Developing and testing an Educational intervention for the Management of Constipation for people with advanced cancer: a feasibility intervention study (DEMCon)
Constipation, Symptom Management, Hospice, Palliative Care, Education
Constipation is a widespread symptom, and significant concern, for people receiving palliative care. It contributes to considerable physical and psychological suffering for both people with a life-limiting condition and their families. Constipation can be difficult to define due to it being both private and subjective. Fragmented approaches to constipation assessment and management within palliative care settings have been reported despite clinical guidelines recommending the inclusion of a comprehensive assessment (Rome III Criteria, complete history, and physical exam) and a balance of strategies for prevention (prescribed laxative therapy) and self-care. There is a dearth of clinical evidence regarding the assessment and management of constipation for people receiving specialist palliative care.
The aim of this research was to develop and test the feasibility and acceptability of a novel educational intervention for health and social care professionals to help them manage constipation in a hospice setting. An incremental, multi-method approach was adopted, in line with the Medical Research Council (MRC) Framework for complex interventions and guidance in end-of-life care research. The study involved four phases. Phases 1) The research team undertook a systematic review and found a lack of standard assessment and management of constipation, with medication being the most used method to treat the condition in a hospice setting. Findings from a review of patient charts (n=150), discussion groups with health and social care professionals (n=6), and interviews with people with a life-limiting condition (n=13) and their family members (n=5) also reported upon a lack of standard assessment, with most being given medication to treat the condition. People with a life-limiting condition and their family members reported that living with constipation impacted upon all aspects of their life, yet medication only responded to the physical aspect leaving their psychosocial needs unaddressed. Phase 2) Based on these findings a six week, online educational program was developed in consultation with an eLearning company and guided by a workshop with key stakeholders including clinicians, academics, educators, clinical managers, patients, families, and members of the public (n=39). This workshop informed both the clinical content and the methods of delivery and evaluation. Phase 3) The educational program was implemented in five hospices across the UK. Phase 4) The final phase sought to evaluate the primary feasibility outcomes, usability, and acceptability of the intervention within a hospice setting using anonymised electronic surveys and focus groups with course participants and telephone interviews with hospice managers/ members of the senior clinical team.
The educational program was delivered to five hospices. In total, 24 nurses, doctors, and pharmacists completed the online programme. Statistically significant improvements were found in staff knowledge, self-efficacy and competency in constipation assessment and management. Feedback from the post-course evaluation survey (n=18) was positive regarding the overall clarity and relevance of the resource. The majority of participants (94%) agreed or strongly agreed that the learning objectives were clear and met, that it increased knowledge and will positively influence clinical practice (94%), and that the content was relevant and delivered at a suitable pace (100%). Feedback from focus groups and questionnaires reported that the educational programme was welcomed, with everyone viewing the content as being relevant to clinical practice and there was evidence of intention to put learnings into practice. Whilst a lack of time for training and technical concerns were reported as barriers, overall, the training was viewed to be a valuable resource to help care for someone with constipation. Research was seen positively by hospice managers and nursing/medical clinical leads. However, it was acknowledged that engaging with research such as this project was only one of many priorities, and due to limited time available, clinical duties were prioritised. The funding of a dedicated research nurse was identified as a key approach to improve research engagement.
How this project will influence future research, policy and clinical practice:
Clinical practice – the development of an online free educational programme for practitioners to guide them in the assessment treatment and management of constipation for people with palliative care needs.
Research – findings from this study highlight an under researched condition within palliative care and the challenges and complexities of treating the condition. This research provides an evidence base from which future research can be based and further evaluative work can be undertaken.
Policy – this research informs the debate on the challenges faced by researchers when engaging practicing hospices in research.
In 2021 the eLearning course, ‘Constipation Assessment and Management in Palliative Care’ was made freely available to all health and social care professionals on the All Ireland Institute of Hospice and Palliative Care Learning Platform. This eLearning course contains 6 short modules, videos, quizzes, case studies, and links to further resources. It takes a minimum of 3 hours to complete and learners can progress through the contents and materials provided independently and at their own pace. To access the course register on The Palliative Hub – Learning Platform. If you need any assistance, contact email@example.com
Study carried out September 2016 – September 2019
Professor Sonja McIlfatrick, Head of School of Nursing, University Ulster (UU).
Dr Deborah Muldrew, Ulster University
Dr Felicity Hasson, Ulster University
This research was supported by a research grant awarded to Professor Sonja McIlfatrick by Marie Curie UK (REF MCCC-RP-16-A20993) and the HSC R&D Office.
The findings from this study have been disseminated through peer reviewed publications and at national and international conferences and events, including the Palliative Care Network’s International Palliative Care Poster Exhibition (2018), a Voices4Care Research Engagement meeting (2018), the Marie Curie Research conference in London (2017 and 2018), the European Association for Palliative Care conference (2017, 2018, and 2019) and the Palliative Care Nurses Australia (2020) virtual conference.
eLearning course (free to access): ‘Constipation Assessment and Management in Palliative Care’
Magazine Article: McIlfatrick, S., (2019). A caring approach to a sensitive issue. The View, Issue 23 (p22). Available at https://issuu.com/brianpelanone/docs/view_edition_-_issuu_53
Graham-Wisener, L, (2018). ‘New research highlights problem of constipation at the end of life’, 23 April, 2018. Available at: https://www.mariecurie.org.uk/blog/constipation-research/190426 (Accessed 2 March 2021)
Hasson, F., Muldrew, D., Carduff, E., Finucane, A., Graham-Wisener, L., Larkin, P., McCorry, N., Slater, P., & McIlfatrick, S. (2020). ‘Take more laxatives was their answer to everything’: A qualitative exploration of the patient, carer and healthcare professional experience of constipation in specialist palliative care. Palliative Medicine 34(8) 1057-1066. Available from: https://doi.org/10.1177/0269216319891584
McIlfatrick, S., Muldrew, D., Beck, E., Carduff, E., Clarke, M., Finucane, A., Graham-Wisener, L., Larkin, P., McCorry, N. Slater, P., & Hasson, F. (2019). Examining constipation assessment and management of patients with advanced cancer receiving specialist palliative care: a multi-site retrospective case note review of clinical practice. BMC Palliative Care 18, 57 (2019). Available from: https://doi.org/10.1186/s12904-019-0436-3
Muldrew, D., Hasson, F., Carduff, E., Clarke, M., Coast, J., Finucane, A., Graham-Wisener, L., Larkin, P., McCorry, N. Slater, P., Watson, M., Wright, E., & McIlfatrick, S., (2018). Assessment and management of constipation for patients receiving palliative care in specialist palliative care settings: a systematic review of the literature. Palliative Medicine, 32 (5).