We conducted a mixed-method design service review in five phases to evaluate whether this technological resource could help. These five implementation phases are described below.
PHASE 1- patient/carer engagement event
At the start of the project, Velindre NHS Trust’s patient/carer group were asked to comment on whether they considered videos, as a medium, to be appropriate for the purpose of conveying the key areas for this topic. The Patient/Carer Liaison Group (PLG) consisted at the time of enquiry of 24 individuals with either a background as a cancer patient, or as a current or past carer of someone with cancer. The hospital trust also has a patient and carer information and support co-ordinator, who was instrumental in setting up this meeting. Patients and carers unanimously agreed that these videos would be important and of high value and were very supportive of the TalkCPR project. Patient/carer representatives in our hospital felt it was important that healthcare professionals approach this topic not as a formulaic process, but that they respect this as one of the most important conversations the patient and carers may have in their disease journey. They also felt that conveying a message that other measures, like antibiotics, chemotherapy, blood products, emergency fluids would not be left unconsidered, merely because of the presence of a DNACPR form. It was felt important by the group to convey this and that it would provide reassurance to patients. A Driver Diagram to further refine these aims and interventions was created (Fig. 1).
PHASE 2- baseline exercise and aspirations
In response to the aims collated and set out in Phase 1, the TalkCPR Implementation group, consisting of clinicians, patients, nursing staff, resus officers and a psychologist, evaluated the patient/carer suggestions and noted key aspirations for the TalkCPR project. The main author, Dr. Mark Taubert suggested the campaign name “Talk CPR” and the Twitter hashtag #TalkCPR and this name was unanimously agreed upon. An additional meeting with the chair of the patient group and a film production team was held, and also included a psychologist, a resuscitation officer, an oncologist, a palliative care nurse and the chair of the national Do Not Attempt Cardiopulmonary Resuscitation steering group.
The key aim that was agreed on, as part of this baseline review, was outlined as follows:
Two key drivers emerged during this baseline exercise. Patients and healthcare practitioners felt it was important to:
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Increase doctor/nurse confidence in having DNACPR discussions, for example how to approach these conversations with patients and what to focus on.
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Encourage patients/carers affected by palliative, life-limiting illness in Wales to approach their clinical team about the issue of CPR/DNACPR.
All meetings were minuted and consensus was sought on what should emerge as content for the videos. The question: “What should the goal of this video information project be?” was asked at the start of the meetings, and all participants were asked to give their views. Aspirations were written down and then altered by participants until everyone was content that they represented what they considered most informative. From this, four aspirational interventions were agreed upon by the patients and healthcare professionals on the TAlkCPR group:
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DNACPR advice videos including ‘Top Tips on DNACPR communication’ to be made available in all Welsh health boards and trusts via Intranet, email and communications teams
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Promote videos and TalkCPR website as a resource area for healthcare professionals who want more information on details of DNACPR in Wales
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Make videos available to healthcare professionals via online and offline means, in order to share them with patients/carers and to supplement face-to-face discussions about this important topic
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Develop a strategic campaign to make videos widely accessible to general public, including on Youtube, Twitter, Facebook, charity websites and on television. Make videos smartphone compatible, but also develop resources that do not require internet access.
PHASE 3- design
Before creating the videos, the team also set out a process map on how DNACPR videos should be accessed and when (Fig. 2). Help to design the project around video production was obtained from the End Of Life Care coalition for Wales ‘Byw Nawr/Live Now’, Welsh Government, the End Of Life Care board for Wales who agreed funding for this project, and the Bevan Commission, who listed this as an exemplar project for Wales. Website and App design was co-ordinated by the Digital Legacy Association and the Welsh NHS IT services.
Framing what would trigger using this technology resource in the patient/carer journey, the following was agreed on by the project team:
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At appropriate time, patient/carer may wish to discuss appropriateness of potential future DNACPR decision- CPR’s chances of success, likely outcomes, what CPR involves.
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And/or: At appropriate time, doctor/nurse/healthcare practitioner may wish to bring up topic of DNACPR in a palliative care situation- including chances of success, likely outcomes, what CPR involves.
A healthcare practitioner (HCP) could discuss with a patient/carer that CPR would or would not have likelihood of success in a given situation, and explore the individual’s view on this topic. If appropriate, a suggestion could be made to write a DNACPR form and keep with patient/carer at all times, as per NHS Wales DNACPR policy. In addition, the healthcare professional should offer the patient/carer some thinking time before sharing their views, and offer TalkCPR website/videos as a resource to improve understanding and consent. This could be accessed via a webpage on patient’s/carer’s own computer device or on a video media pad left at house or by the hospital bed.
PHASE 4- video production and website design
Over a period of 4 months, patients, carers, healthcare professionals and a video production company (Gingenious) created English language and Welsh language videos to inform anyone viewing these films what Cardiopulmonary Resuscitation (CPR) in life limiting and palliative illness involved. Scripting and production took 4 months in total, with a further post-production period of 2 months. Videos were hosted on the TalkCPR website (Additional file 1: Image 1). A Welsh language version of the TalkCPR website (Additional file 2: Image 2) was created http://talkcpr.cymru. Lightweight video media pads were produced, and had videos pre-loaded onto them, in order for healthcare professionals who wanted to bring videos to patients/carers in areas with less Wi-Fi or data access to still be able to do so. Videos were also produced for the hard of hearing (Additional file 3: Image 3), and an audio version for the visually impaired was also created.
PHASE 5- evaluation strategy
Surveys were created to evaluate the videos. The aim was to establish whether videos were seen as a meaningful change and how acceptable and sensitive they were. Three sets of results are presented:
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A survey given to 25 nurses measuring pre- and post TalkCPR video viewing impact metrics (n = 25)
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A survey given to 15 junior doctors measuring pre- and post TalkCPR video-viewing impact metrics (n = 15)
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A summary of a hospital patient/carer focus group session (n = 14)
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A survey to evaluate TalkCPR video media pads with 100 healthcare professionals (n = 100)
The 25 nurses were participating in a palliative care update day, and came from many areas of hospital and community healthcare, including intensive care and district nursing. The hospital junior doctors were at that time job-rotating to Velindre NHS Trust. Survey questions for doctors and nurses can be viewed in Fig. 3.
Nurses and doctors filled in the questionnaire (baseline survey), then watched the TalkCPR videos and then filled in the questionnaire again (post intervention survey) on a separate sheet of paper, to measure if there had been any change in views and confidence after watching videos. They scored from 0 to 10 (0 = not ready at all, 10 = very ready).
We conducted a focus group session with the Velindre NHS Trust patient/carer liaison group. TalkCPR videos were presented to the Patient/Carer Liaison Group (PLG) at Velindre NHS Trust in December 2015. Fourteen members of the patient/carer group were present. Notes were taken during the meeting. Comments and suggestions were captured. Participants were asked a number of pre-prepared questions, for instance on the acceptability of the videos and whether they evaluated the videos as appropriate for viewers. Eight outcomes were eventually agreed on after discussion.
TalkCPR video media pads survey: A survey was completed by 100 healthcare professionals in NHS Wales (25 GPs, 25 junior doctors, 25 nurses, 25 hospital consultants) to look at usability of light weight video media pads, onto which the TalkCPR videos were pre-loaded and ready to view at the click of a button. A short film of the video catalogue being used can be viewed here: https://www.youtube.com/watch?v=5Zw9mD3K0pU.
A questionnaire was designed in order to evaluate the video media pad product amongst healthcare professionals. Input was received from a clinical psychologist with expertise in questionnaire design. From the questionnaire it was aimed to attain the following information:
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1.
The role of the person
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2.
How often they typically discuss DNACPR (0–3 / 3–6 / 6–10 / 10+ x per year)
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3.
Whether they thought the video booklet would facilitate DNACPR discussions (Yes/No)
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How useful they thought patients/carers would find the video booklet (Yes/No)
Any nurse, junior doctor, consultant or General Practitioner working in Wales was entitled to take part and evaluate this video book product. Healthcare professionals were initially contacted via email, asking them to take part and were then met face-to-face, at which point they watched the videos on the video book, before finally filing in the survey.
Four sets of results were obtained from the following professional groups: