‘Necessity is the mother of invention’: Specialist palliative care service innovation and practice change in response to COVID-19. Results from a multinational survey (CovPall)

Background: Specialist palliative care services have a key role in a whole system response to COVID-19, a disease caused by the SARS-CoV-2 virus. There is a need to understand service response to share good practice and prepare for future care. Aim: To map and understand specialist palliative care services innovations and practice changes in response to COVID-19. Design: Online survey of specialist palliative care providers (CovPall), disseminated via key stakeholders. Data collected on service characteristics, innovations and changes in response to COVID-19. Statistical analysis included frequencies, proportions and means, and free-text comments were analysed using a qualitative framework approach. Setting/participants: Inpatient palliative care units, home nursing services, hospital and home palliative care teams from any country. Results: Four hundred and fifty-eight respondents: 277 UK, 85 Europe (except UK), 95 World (except UK and Europe), 1 missing country. 54.8% provided care across 2+ settings; 47.4% hospital palliative care teams, 57% in-patient palliative care units and 57% home palliative care teams. The crisis context meant services implemented rapid changes. Changes involved streamlining, extending and increasing outreach of services, using technology to facilitate communication, and implementing staff wellbeing innovations. Barriers included; fear and anxiety, duplication of effort, information overload and funding. Enablers included; collaborative teamwork, staff flexibility, a pre-existing IT infrastructure and strong leadership. Conclusions: Specialist palliative care services have been flexible, highly adaptive and have adopted low-cost solutions, also called ‘frugal innovations’, in response to COVID-19. In addition to financial support, greater collaboration is essential to minimise duplication of effort and optimise resource use. ISRCTN16561225 https://doi.org/10.1186/ISRCTN16561225


What is already known about the topic?
• • Specialist palliative care services are part of a whole healthcare system response to COVID-19 which involves services working collaboratively with each other and with other external health care organisations in response to the pandemic. • • Services need to make practice changes in response to the global pandemic.

What this paper adds
• • Specialist palliative care services responded rapidly to COVID-19 in both planning for change and then adapting to needs and requirements. • • Services often relied on 'improvisation', 'quick fixes' and 'making do' when responding to the COVID-19 crisis.

Implications for practice, theory or policy
• • In addition to financial support, greater collaboration is essential to build organisational resilience and drive forward innovation, by minimising duplication of effort and optimising resource use. • • The effectiveness and sustainability of any changes made during the crisis needs further evaluation.

Background
The COVID-19 pandemic, and the healthcare service response to this, is an example of a so-called 'wicked problem', constantly changing, difficult to define and with multiple interdependencies 1 ; what the army would call a VUCA situation: 'volatile, uncertain, complex and ambiguous'. 2 Adaptations, flexibilities and innovative practices are necessary 3 in this crisis context. This includes innovative responses of healthcare systems, where hospice and palliative care services are an integral part of such a response to the COVID-19 pandemic.
The term innovation can have multiple meanings and be discipline specific. 4 Broadly, innovations are the tools used by organisations to influence or respond to environmental change and can encompass both radical and incremental innovation. 4,5 In healthcare, innovation has been defined as; 'a novel set of behaviours, routines, and ways of working that are discontinuous with previous practice. . .and that are implemented by planned and coordinated actions' (p.582). 6 A more ubiquitous definition, also used in healthcare, 7,8 defines innovation more broadly as 'an idea, practice or object that is perceived as new' so a change in practice may be novel even if the same approach has been used elsewhere (p.12). 9 In crisis management, innovation can incorporate 'improvisation', [10][11][12][13] which involves organisations using, adjusting and recombining existing resources, structures and processes to manage the impact of a crisis. 14 In this paper, the term innovation is used as a broad umbrella term that includes 'improvisation' and practice change.
Practice changes that may be regarded as innovations against these definitions are likely to be required and seen in response to COVID-19, especially with rapidly shifting priorities, new learning about the disease, potential shortages of drugs and equipment, and adjusting to workforce pressures and redeployments. 15 A large number of deaths have been associated with COVID-19 so there is need to understand the role specialist palliative care services play in providing end of life care in this context. 16 Commentaries indicate an initial rapidity of service changes with reports of new staffing and service delivery models, virtual care and addressing shortages all in the context of infection control procedures and heightened fear and anxiety. [17][18][19][20][21] It is imperative that we consider which might be sustained as part of a 'new normal', and which may quietly fall away, 22,23 with a focus on a learning mindset. 24 In this context, it is important that there is wide learning about how hospice and palliative care services have responded to the COVID-19 pandemic, so that effective innovations can be rapidly shared, and preparations made for future care, including second or third waves or other pandemic or emergency situations. 25

Aim
To map and understand specialist palliative care services innovations and practice changes in response to the COVID-19 pandemic. This paper is part of the wider CovPall study that aims to understand the breadth of the multinational specialist palliative care response to COVID-19, 26 including clinical palliative care of those with COVID-19.

Design
An online multinational cross-sectional survey of hospice and specialist palliative care providers. This study is reported according to the STROBE 27 and CHERRIES 28 statements.

Population and setting
Inpatient palliative care units, hospital palliative care teams, home palliative care teams and home nursing services were eligible to provide data, from any country (see Supplemental materials for definitions).

Sampling and recruitment
The aim of the recruitment strategy was to receive responses from all hospice and specialist palliative care services. Information was widely disseminated through key collaborators (e.g. Hospice UK, Marie Curie Care, Sue Ryder Foundation, European Association of Palliative Care), contacts through publicly available service directories, information provided on institutional websites, personal networks, and via the social media channels of investigators and key collaborators. Potential participants could contact the study team to receive a participant information sheet and link to complete the survey online. The clinical lead or their nominee completed the survey.

Data collection
REDCap was used to securely build and host the online survey with closed and free text survey responses (see Supplemental materials for the full survey). Sites could enter the data online directly (with a pause and return function), be sent the survey as a word document via email to complete and return electronically, or request to answer the survey questions via telephone or video conferencing with a member of the study team. Multiple questions with free-text response options within the survey addressed relevant areas for this analysis, and are presented in Table 1.

Data analysis
Anonymised data were exported to SPSS (for quantitative analysis using descriptive statistics, frequencies, proportions and means) and NVivo 12 (for analysis of free-text comments using a qualitative framework analysis approach). 29 Continuous variables were expressed as means (SD) and medians (IQR) and categorical variables as counts and percentages. Missing data were not imputed. An analytical framework was initially developed by LD and CW through familiarisation with the data, the framework was then applied to the free text data and refined, as appropriate, during the analysis process. LD and CW used analytical memos and charting to aid interpretation of the data.

Findings
The survey was open to responses from 23/04/2020 to 31/07/2020. Responses were received from 458 respondents: 277 UK, 85 Europe (except UK), 95 World (except UK and Europe), 1 missing country. The response rate could details will open) Please give details Question 6.9-6.10: Please tell us about the change in practice or innovation that you think has been most successful to your working. Why is this? Question 6.11: What would you say were the most important things that made this possible? Question 6.12: Please list any other important changes/innovations you have made not be calculated as the survey denominator was unknown. Table 2 reports data on the characteristics of responding services and answers to the survey questions explored in the findings below (see Supplemental materials for details of services offered before the pandemic discussed in the findings below).
The overarching categories identified in the analysis included 'the crisis context', the changes made (streamlining access, extending services, increasing outreach, using communication technology and implementing innovations for staff wellbeing) and the enablers and barriers for change (see Figure 1). These were identified from services responding from across the world, and often where they provided care across a range of different service types. As discussed previously, the term innovation is used as a broad umbrella term that includes 'improvisation' and practice change. Exemplar data extracts for each category and subcategory are presented in Table 3 and in the narrative below, along with supporting quantitative data.

The crisis context
All services had to change, often rapidly, to prepare for, and respond to, the anticipated and actual impact of the COVID-19 pandemic. Services often initiated changes that had been previously considered but rejected or resisted.

Streamlining access to specialist palliative care services
Specialist palliative care triage and assessment/single point of access The pandemic led to changes in how referrals to services were received, assessed and managed, both initially and on an ongoing basis. This included, for example, proactively seeking referrals, loosening or tightening referral criteria, such as not accepting patients for respite care, and the use of telephone advice lines: Ongoing telephone support would also be provided for those patients who were unable to attend outpatients or day therapy services because of restrictions. Services wanted to reassure patients and family carers that 'the care is still here, it just looks different' (participant 42, UK, adult, home palliative care team).

Extending current specialist palliative care services
Inpatient bed management 41.3% of services who had changed in response to COVID-19 reported changes in inpatient beds in their service with 27.6% reporting an increase in bed numbers. This was often in situations where dedicated beds previously did not exist, or else increasing capacity by using space in flexible ways: *Included data from the one missing country in the numerator and denominator.

+
Includes data from the one missing country in the denominator.    Some also reported that inpatient bed numbers stayed the same, decreased and that additional beds were not always needed.

Support in the community
55.3% of services that had changed due to COVID-19 said there had been changes in how they provided support for patients in their own home with 40.6% saying the number of patients needing support at home had increased. There was a shift in patient need from the inpatient to the community setting in some areas: Medical and nursing shift patterns were sometimes adjusted to accommodate the increase in out of hours provision. Some services reported that routine hours of working had resumed in their locality.

Bereavement services
36.7% of respondents reported that they were providing slightly more or a lot more bereavement support than before the pandemic with 41.2% offering about the same. Some were offering support to those not directly under the care of the specialist palliative care service, including to nursing home staff, and educating others on how to provide bereavement care: 'reorganising the family support team to work virtually and provide more education and support to wider groups outside of the hospice. e.g support for staff outside of the hospice on how to support someone with bereavement.' (participant

194, UK, adult, inpatient palliative care unit/home palliative care team/home nursing services)
Services were starting to see referral numbers pick up and were planning for the anticipated increase in those requiring bereavement support as a result of the pandemic.

Management of medicines and medication administration
The pandemic led to changes in how medicines were managed with routine practices and processes adapted to reduce infection risk and unnecessary visits, such as single use syringe drivers and specialist palliative care professionals administering medication in services where this was not norm. New processes were set up to improve access to symptom control medication:   33.8% of services who had changed how they provided support for patients in their homes said they changed how medicines were given in the community. In those areas where policies were not already in place, policies were developed to support carer administration of subcutaneous medication and/or routes of administration were changed to oral.

Specialist palliative care 'outreach' into the hospital
Hospital specialist palliative care teams often shifted from a responsive to a proactive model of care as patients with COVID-19 could deteriorate and die rapidly and some of those providing direct care lacked end of life care experience. Teams proactively engaged with clinicians in areas where COVID-19 patients were being cared such as intensive care units, emergency departments and respiratory wards. They focused on; developing and disseminating COVID-19 symptom control guidelines, providing symptom control advice, supporting colleagues with complex treatment escalation or withdrawal decisions, visiting patients as necessary, and providing end of life care training and support including how to communicate with relatives over the telephone. Training and guidelines needed to be brief and rapidly developed:

Using communication technology
Services were forced to adopt the use of technology so that some clinical services could continue to operate. Patients could decline inpatient admission or face-to-face visits as they were fearful of contracting the virus and were concerned about the visiting restrictions. Some clinical staff, including those who were shielding, worked from home when able, to maintain social distancing.

Using communication technology with patients and family carers
Prior to COVID-19, only 21.6% of services used telehealth/video support/e-learning for clinical care with 83.7% of services that changed due to COVID-19 reporting that they were using virtual technologies with patients and families a lot more or slightly more during the pandemic. Generic digital platforms were used for communication such as Zoom, Skype, WhatsApp and Facebook. Hospice day therapy services were also provided off site using this technology such as complementary therapies via Skype and 'Time to create' via a Hospice YouTube channel. There were also reports of telemedicine being used, electronic care plans and applications to facilitate symptom assessment, virtual ward rounds and admission assessments: Lack of closeness and human contact were reported as issues with remote working. Volunteer befriending, bereavement support and hospice day therapy services were also provided by telephone.

Virtual visiting
The A less costly and simpler strategy was the use of postcards for e-mail and telephone messages from relatives to be given or read out to patients.

Using technology to facilitate communication between healthcare professionals
84.4% of services that changed in response to COVID-19 reported that they were using virtual technologies (e.g. zoom/teams etc.) with colleagues a lot more than before the pandemic. It was used to facilitate communication within specialist palliative care teams, across specialist palliative care services and with generalist clinicians and external partner organisations. Respondents felt the benefits included increased efficiency by reducing travel time, keeping the team connected and up to date with the everchanging situation as well as helping to facilitate the support process: 'firstly the support we gave our teams on a daily level. we realized they were leaving their family at home to visit patients and we perceived that as a vulnerable situation to many team members. we compiled a extensive reaching out plan to all the teams on an individual, sectorial, regional and nationwide level with phone support and zooms by

Enablers and barriers to change
Changes in practice occurred in a crisis context and in some instances this accelerated changes that had been previously planned or hoped for: Respondents identified several factors that they felt enabled the imposed changes to be implemented swiftly into clinical practice. These included; pooling of staffing resources, staff flexibility (both a willingness and a need to be flexible), strong leadership, collaborative teamwork (within and between specialist palliative care services and with other generalist palliative care providers) and having a pre-existing IT infrastructure: A lack of access to basic IT equipment such as cameras, microphones or laptops, poor Wi-Fi or internet connection and there being too many digital platforms was a barrier to change. The need to implement remote working rapidly meant there was no time for training and staff could lack confidence and be unfamiliar with the technology but needed to learn quickly. Emergency COVID-19 funding was available but the sustainability of out of hours services without adequate funding was raised as an issue: Changes were also being implemented at a time of heightened patient, family carer and healthcare professional anxiety and fear and when services needed to handle and digest ever changing information which one respondent described as an 'infodemic' (participant 107, UK, adult, inpatient palliative care unit/hospital palliative care team/home palliative care team). There was also evidence of effort duplication with services producing their own guidelines, procedures and policies.

Main findings
Hospice and specialist palliative care services had to implement changes rapidly to respond to the anticipated and actual impact of the COVID-19 pandemic. Changes in practice involved streamlining, extending and increasing outreach of services, as well the use of communication technology and innovations for staff wellbeing. A number of barriers and enablers to change were evident such as patient, family carer and healthcare professional fear and anxiety, duplication of effort, pooling of staffing resources and collaborative teamwork.

What this study adds
Changes seen do not reflect the standard literature on the diffusion of innovations. 6,9 Standard forms of innovation require planning and funding, often impossible when responding to an unforeseen event like the COVID-19 pandemic. 10,11 As discussed in the introduction, the term improvisation rather than innovation has been used in crisis management, [10][11][12][13] as organisations are required to be creative by using, adjusting and recombining existing resources, structures and processes to manage the impact of a crisis. 14 In these circumstances, resistance to change is limited as there is an acceptance that 'normal' rules no longer apply and a collective identity develops, as seen in this study, with clinicians no longer working in professional silos and previously resisted technology being used. 11 Whilst used in a different context, such limited resistance to change resonates with Klein's concept of the 'shock doctrine' 30 in which extreme crises (such as COVID-19) pertain the power to 'shock' systems and, in doing so, shake up socio-cultural norms to the extent that new changes -that may have been previously resisted -can be made quicker and easier than usual. In this study, services had to rely on a 'quick fix', 'making do', being flexible and thinking in a frugal way. So called 'frugal' or 'Jugaad' innovation can challenge standard definitions of innovation. 31 The aim is to provide low cost solutions to problems in environments that have resource constraints, 32,33 and has been used in healthcare in economically disadvantaged communities, 34 including in the context of palliative care. 35 Specialist palliative care services demonstrated considerable flexibility and 'frugal' innovation, and will continue to play an important role in managing the impact of the COVID-19 pandemic. 36,37 Organisations need to build flexible and resilient systems so they can be responsive to the ongoing crisis, including threats to their income as a result of an economic downturn, and any future increases in infection rates. Both national and international collaboration, and coordinated action is required to optimise resource use and avoid duplication of effort, particularly in relation to training, policies, and guideline development, while maintaining high standards of care. This need for greater collaboration was highlighted in a recent review that found a dearth of comprehensive international COVID-19 guidance on palliative care for nursing homes. 38

Strengths and weaknesses of the study
This study is a large multinational survey of specialist palliative care services response to the COVID-19 pandemic. Free text responses provided useful insights into how and why services made changes to their routine ways of working in response to the crisis. The survey was completed by service leads so the findings may present an overly positive view of the changes made and may not reflect the views of other practitioners working within the services taking part in this study. Negative aspects of the changes made may also not have been captured due to the wording of questions in the survey. More detailed survey responses were also generally provided by those who were native English speakers. Many respondents worked within services that provided care across multiple settings. The way in which the survey was created meant that it was not always possible to distinguish between services and settings in the free text comments. The number of paediatric services included in the survey was low so the results may not be representative of children's services.
Data were collected at a single time point so how useful and sustainable the changes were has not been captured. A successful frugal innovation or improvisation may be retained but may not be useful unless there is a similar future crisis. 13 Changes in practice may lead to unethical practices and negative outcomes as resource scarcity may, in some instances, simply undermine the quality of care. 11 The challenge of implementing remote clinical consultations rapidly during the pandemic with limited resources, for example, has been raised 39 and how sustainable changes are beyond the pandemic without the necessary infrastructure being in place has been questioned. 40 This issue is particularly pertinent to palliative care where funding for services in some countries relies heavily on charitable funding. Further qualitative case study research is planned to explore in greater depth how services responded to the pandemic and why they did or did not implement particular changes into practice, including a more in-depth exploration of the enablers and barriers to change, and whether changes were sustained and viewed as effective.

Conclusion
Specialist palliative care services have responded rapidly to the COVID-19 pandemic. Services have demonstrated considerable flexibility and relied on 'frugal innovation' when responding to the crisis. Enablers to change included collaborative teamwork, pooling of staffing resources, staff flexibility, a pre-existing IT infrastructure and strong leadership. In addition to financial support, greater collaboration is essential to build organisational resilience by minimising duplication of effort and resource use. The effectiveness of any changes made during the crisis needs continued evaluation.