STARZ-DRP: An Advance Nursing Approach for Palliative Home Care Services

Abstract

Nurses perform a significant role as professional practitioners in the healthcare system, particularly providing the Palliative Home Care Services (PHCS). PHCS is a continuum of medical and social services which support the needs of patients living with chronic medical conditions or severe disabilities. Most of the time, they shall engage with patients and their family members in the absence of physicians or pharmacists. They shall assist them to go through their daily routines with physical help and support. Foremost, they shall help their patients to consume medications as being prescribed. For that reason, they need an advanced approach to assist them to provide a quality and excellent PHCS. Therefore, this article shall highlight a tool is known as STARZ-DRP as a potential modus operandi to maneuver them to make an accurate and quick triaging-decision as well as identify the actual or potential drug-related problems. It is to be hoped that the tool shall enhance the image of nurses as healthcare providers.

1. Introduction

Nursing practice is a critical profession in the healthcare system. Nurses are trained with a particular skill or type of behavior through practice and instruction over a period of time to assist the physicians in many aspects of tasks. Their ultimate role has the intention to reduce the burden of work of the physicians. They shall help the physicians to administer medicines, monitor desired or undesired medical conditions as well as provide sufficient or essential health welfare. Such a course of action acquires the nurses to learn or develop a particular skill, habit, or quality as a way to reflect their image as competent healthcare worker. Therefore, they must gain or acquire knowledge of or skill in a particular task by study, experience, or being formally taught. The process of learning shall maneuver them to integrate the essential knowledge, skills, perception, and behavior into their actual activities [1]. Sometimes, they must take the challenge to move forward from their comfortable way of practice towards more advanced knowledge and skills [2]. It shall benefit them and enhance their image in the healthcare system.

Nurses are having the chance to provide and lead a Palliative Home Care Service (PHCS) as a way to optimize quality of life and mitigate suffering among people with serious and complex illnesses [3]. Their roles in PHCS are well notified in many scientific writing papers [4]. Nonetheless, Sekse et al. noticed that they need additional knowledge and training, guidance, and support to fulfill their role in PHCS [4]. It is because the nurses might have to be in the state of being independent. PHCS is patient and family-centered care that optimizes quality of life by decreasing the suffering of continuum illnesses [3]. Most of the time, the patients might stay at home instead of the hospital. Such a scenario might reflect the absence of regular physician’s attendance or attention. As a result, the nurses should take the responsibility to be key decision maker in the PHCS [5]. To ensure the high standard provision of tailored PHCS to patients with life-threatening illnesses and their relatives, the nurses need all their knowledge of basic nursing with additional and adequate skills. Such knowledge and skills might have the chance to make the nurses ready to deal with the challenges in term of practice, relationship with the patient and family members, and their self-motivation. Furthermore, the PHCS always demands on their role to be in a comprehensive way.

Among the essential knowledge and skills acquired in the PHCS are making a quick and accurate triaging decision [6]. Such a role needs the nurses to perceive the significance, explanation, or cause of triaging action. They must be knowledgeably aware of the character or nature of their patient’s medical condition, particularly the illnesses which acquire immediate medical attention or examination. In addition to that, they must have the skills to identify, prevent, and resolve the actual or potential drug-related problems (DRP) [7]. Moreover, they should aware of their patient’s drug-related needs [8]. The entire mode of action might have the chance to protect their patients from harm and danger of medication use and undesired diseases or condition.

This article shall highlight a potential approach is known as STARZ-DRP to maneuver the nurses to provide an efficient and competent PHCS [9]. STARZ-DRP had demonstrated its ability, capability, competence, and quality to make an accurate and quick triaging decision as well as identify, prevent, and resolve DRPs [10]. Foremost, the tool shall have the chance to assist the nurses to response to their patients’ drug-related needs [10]. Therefore, STARZ-DRP had been acknowledged its values as a potential approach to give professional help and advice to patients in the healthcare system [11]. It is to be hoped that the approach shall enhance the importance, worth, or usefulness of PHCS in eyes of patients, their family members, policymakers, and other healthcare providers.

2. STARZ-DRP

2.1 Essential behavior

Nurses who provide PHCS must act or conduct themselves appropriately in response to a particular situation or practice. Such attitudes ensure they have a desire to perform the exact duties or services. Firstly, they must be ready to engage in providing PHCS. PHCS is constantly carried out at the place where the patient lives permanently. For such scenario, they must also possess the skills to communicate effectively or be involved directly with a member of their patient’s family [12]. Otherwise, the family members might not have the chance to be actively interested in and concerned for the success of PHCS. Furthermore, the patient needs for assistance especially financial support as necessities for PHCS.

In addition to that, they must have considerable skills to communicate with the necessary confidentiality with other healthcare providers [13]. They should share or exchange information, news, or ideas using the principal method of communication which consists of comprehensive words in a structured and conventional mode and conveyed by speech, writing, or gesture [13]. Such communication skills should include or deal with all or nearly all elements or aspects of PHCS. The elements shall ensure the successful conveying or sharing of ideas and feelings by speaking, writing, or using some other mediums. Foremost, it shall make PHCS recognized, familiar, or within the scope of knowledge of patients and other healthcare providers.

They should have the ability to understand and share the feelings of another, particularly with the patients or their family members. Nonetheless, the feelings should be emphasized in the context of empathy. Such course of action shall ensure their feelings are not being bonded with their patients or family members. Moudatsou et al. notified that healthcare providers with high levels of empathy are having the chance to elicit better therapeutic outcomes [14]. The empathetic relationship between nurse and patient shall reinforce the need to complete the drug therapy plan as a way to achieve a desired outcome in the absence of medical or medication errors [15]. As a consequence, it shall enhance the quality of PHCS.

2.2 STARZ-DRP: a tool to provide a PHCS

STARZ-DRP is a simple mnemonic which established to assist the healthcare providers to make an accurate triage-decision as well as identify, prevent, and resolve the actual or potential drug-related problem. STARZ-DRP was developed by a group of clinical researchers from Universiti Sains Malaysia, Malaysia to meet a specified degree which proposed by the philosophy of Pharmaceutical Care (PC) [9]. The philosophy of PC acquires the healthcare providers to response to the patients’ drug-related needs [16]. In addition to that, PC maneuvers them to identify, prevent, and resolve the actual or potential drug-related problems (DRPs) [16]. Such course of action is critical to put in the picture because DRPs shall have the chance to cause someone to be vulnerable or at risk of death or decrease his or her health quality of life. Whereas, an act of reacting quickly or positively to drug-related needs of an individual shall persuade the patient to meet the aims of PHCS as well as enhance compliance behavior towards therapy plan.

STARZ-DRP had involved in the previous study to determine its feasibilities to perform an accurate and quick triaging action as well as exercise a particular ability to proficiency identify, prevent, and resolve DRPs repeatedly or regularly [10]. Foremost, each component in STARZ-DRP was evaluated and estimated by a group of physicians and pharmacists to ascertain its nature, ability, and quality of making a triage-decision and identify the actual or potential DRPs [17]. Therefore, STARZ-DRP is having a chance to maneuver the healthcare provider to be an expert with adequate skill and knowledge in a particular field.

STARZ-DRP (Table 1) consists of the five most significantly original and influential alphabetic characters (S-T-A-R-Z). The first letter, S, represents the patient’s presenting symptoms. The second letter, T, denotes the time of onset and duration of the presenting symptoms. The third letter, A, stands for the associated or related symptoms. The fourth letter, R, stands for recurrence or repeated symptoms. ‘S-T-A-R’ shall maneuver the nurses to evaluate or estimate the nature of patients’ complaints about medical or medication issues. ‘S-T-A-R’ consists of specific questions, particularly in an official context as reflected inTable 1. Lastly, ‘Z’ means zoom into the patient’s medical and medication experience. Carefully guides the nurses to assess and evaluate medical and medication histories. ‘Z’ encourages them to devote their theoretical and practical understanding of clinical knowledge and experience to determine if the medical condition needs either medication or medical attention (Table 1). Therefore, the entire modus operandi of STARZ-DRP must be accomplished successfully as a way to ensure they do not fail to notice, hear, understand and keep in writing essential or critical information. Otherwise, PHCS shall be the absence of degree of excellence, abilities, qualities, or achievements.

Alphabetical character	Description
S	Symptom presentation refers to subjective evidence of health problem perceived by the patient.
T	Time of onset and duration of the present symptoms.
A	Associated symptoms refer to patient symptoms explored and determined by the nurse during the interview. It does not refer to the symptoms presented earlier by the patient. This is done by using the pictorial documentation form. To aid and ease the nurse during the interview, the human body is arbitrarily divided into four regions: (1) Front: the part of the body facing the nurse (asking for symptoms like bloating, heartburn, nausea, vomiting, breathlessness, extra), (2) Back (asking for symptoms like lower and upper back pain, shoulder pain, and neck pain), (3) Upper (head) (asking for symptoms like headache, dizziness, problems with sleep, extra), and (4) Lower (asking for symptoms like numbness in both legs and hands, constipation, and swollen feet). Perhaps, the method is likened to a filtering or screening process to rule out the presence of severe symptoms.
R	Recurrence problem refers to the symptoms have been treated before, precisely when the symptoms recur and persist despite the treatment prescribed.
Z	Zoom into the patient’s medication experience refers to information collected by the nurse related to any medical problems (for example, hypertension, diabetes, hyperthyroid, and extra), medication utilization (for example, use of prescription and non-prescription drugs, and herbal supplements), immunization history, allergies, drug sensitivities, drug side effects, adverse reactions, and the consumption of alcohol, caffeine, and tobacco.

Table 1.

Definition of alphabetical characters in STARZa^,b.

^a

This is not a diagnostic tool, rather it is a format with the purpose of organizing a nurse’s knowledge in a manner that allows him/her to begin identifying the actual and potential DRPs and subsequently referring triage patients to the appropriate healthcare professionals.

^b

The patient’s vital signs will be measured when necessary. At times, the patient’s blood pressure, pulse rate, and body temperature are measured to aid the nurses in assessing the appropriateness of symptoms for self-medication.

Role to determine DRPs is a vigorous action in PHCS [18]. Such activity shall ensure the safety of patients when they start to consume medications [18]. STARZ-DRP is able to maneuver the nurses to identify a wide range of DRPs as notified in Table 2. Nonetheless, they should have adequate knowledge of pharmacological of basic therapeutic as a way to enhance their skill to perform the activities. For that reason, they should attend an accredited training involving those experts who are very knowledgeable about or skillful in identifying, preventing, and resolving DRPs. Furthermore, the trainers shall be a source of information if they want to ascertain something.

Indication	DRP#1: No indication for non-prescription medicine; DRP#2: Uncertainty about the indication of drug; DRP#3: Need for additional therapy
Effectiveness	DRP#4: Inappropriate drug choice; DRP#5: Dose too low; DRP#6: Ineffective therapy; DRP#7: Interference with medical therapy by smoking/alcohol consumption; DRP#8: Lack of understanding of the medication; DRP#9: Monitoring required
Safety	DRP#10: Use of medication to which the patient is allergic; DRP#11: Adverse drug events; DRP#12: Potential drug-disease interaction; DRP#13: Potential drug-drug interaction; DRP#14: Dose too high
Compliance	DRP#15: Problems arising from the financial impact of therapy; DRP#16: Interference with medical therapy by cultural/religious beliefs; DRP#17: Failure of the patient to adhere to labelling instructions; DRP#18: Others

Table 2.

List of DRPs.

Interestingly, STARZ-DRP is able to be used or obtained in a documentation form (see Figure 1 – Pharmacy Self-care Advice Form) [19]. The form eases them to evaluate the nature of the patient’s complaint, a physical or mental feature, medical condition, and medication histories [19]. Such documentation activities shall provide information or evidence that serves as a permanent record for later reference. Furthermore, the course of action ensures the nurses might not fail to include critical information for further detailed examination. Foremost, the documentation form makes sure the nurse and patient have in or be able to bring to one’s mind an awareness of something from the past.

Figure 1.

Pharmacy self-care advice form.

Nurses shall have the chance to put in the picture their conclusion or resolution reached after considering the latter information in a documentation form as reflected in Figure 1. They shall write down their triaging decision if the patient needs a specific medication, referral for urgent medical attention, or further health screening test or examination. In addition to that, they shall draw special attention to DRPs by pointing out them in the form (Figure 2). Such documentation shall help them to evaluate and monitor the effectiveness of their essential actions.

Figure 2.

Drug related problems.

Referral activities can be performed using a form that is reflected in Figure 3. The form shall have the chance to ease them to share or exchange critical information with other healthcare providers, particularly physicians and pharmacists. They can highlight the reason of referral as well as a category of DRPs to make physicians or pharmacists aware of a fact or circumstance. Subsequently, the other healthcare providers are able to take immediate action and behave in a specified way to resolve the medical problem. Such act of referral might have the chance to enhance the good quality and excellent of PHCS.

Figure 3.

Patient referral form.

STARZ-DRP is having the chance to maneuver them to provide an excellent service in PHCS. A step-by-step approach notified in the modus operandi shall help them to make an accurate and quick triaging-decision as well as identify, prevent, and resolve DRPs. Foremost, the official documentation shall have the chance to establish a collaboration working relationship with other physician or pharmacist as a way to improve their patient’s health quality of life.

2.3 Vital signs and symptoms

Nurses must be ready to methodically and systematically assess the essential information to evaluate and determine their patient’s chief complaint. For that reason, they must establish or indicate who or what are the critical signs and symptoms that acquire for immediate medical attention or examination. Table 3 reflects the signs and symptoms that need intervention by the physicians [20].

1.Any chest pain in a patient looking grey, sweating, or ill; 2.Severe pain in the chest, abdomen, head, or ears; 3.Blood loss from any orifice; 4.Increasing breathlessness; 5.Difficulty in swallowing; 6.Tenderness over blood vessels; 7.A history of severe injury, particularly a penetrating injury, or loss of consciousness; 8.Persistent raised temperature, blood pressure, or heart rate; 9.Loss of weight; 10.Anorexia; 11.Yellow skin colour; 12.Ankle swelling; 13.Yellow or green sputum; 14. Yellow or green discharge from penis or vagina; 15.Urinary symptoms; 16.Any menstrual abnormality; 17.Any swelling or lump of any size, including joints; 18.Weakness in arms or legs; 19.Any visual changes

Table 3.

Signs and symptoms that need urgent medical attention.

Among signs and symptoms that are serious to handle themselves are abnormal readings of systolic and diastolic, heart rate, and body temperature (forehead, tympanic, or rectal). In addition to that, too many associated symptoms, frequent emergence undesired symptoms, or too long-suffering of unresolved symptoms notified among the patients might reflect the actual or potential unexpected, undesired, untreated, or unresolved medical conditions. Foremost, it might suggest as potentially harmful or threatening to the patients’ life. For such course of action, they should urgently contact or inform the physician or pharmacist as a way to resolve the condition.

Undesired or unresolved signs and symptoms should be and must be evaluated or estimated its natures if they need for a medication or a medication is the main cause. Such a particular condition requires the nurses to collaborate with the physician and pharmacist to determine an appropriate therapy plan. Their expert skill or knowledge in a particular field might have the chance to resolve the undesired medical condition. For example, the pharmacist might perform a therapeutic drug monitoring test as a potential approach to establish exactly an appropriate dose of a particular medication for an individual patient. The course of action shall ensure the patient is the absence of undesired adverse drug reactions. Foremost, an accurate dose of a medication shall provide an assurance that the patient might gain the benefits of such therapy.

2.4 Drug-related problems

Nurses must identify, prevent, and resolve the actual or potential DRPs among the patients who consume medications. Such a role shall have a chance to magnify the values of PHCS as well as have an effect on the character, development, or behavior of patients towards the service. For example, undesired side-effects or adverse drug reactions shall cause the patients to refuse to consume a specific medication. In addition to that, failure to resolve the medical condition might give rise to an idea that the patient might potentially dispose to agree with the medication’s dosage regimen or its route of administration. For that reason, the nurses should have adequate training to ensure each medication is indicated, safe, and effective [21]. Foremost, they must ensure the patients are complying with the medication’s dosage regimen [21].

Indicated: nurses must be ready to determine if the patients require an additional prescription or non-prescription medication to alleviate or resolve the illnesses or undesired and unexpected medical conditions. They must inform and advise the physician about the justification for the need of such medication. Such course of action shall make sure the medication is having the chance to eliminate disease or relieve them of undesired signs and symptoms.

Effectiveness: each medication must be effective to alleviate or resolve the unwanted medical condition. For that reason, they must collaborate with the physician to carefully choose medication as being the best or most suitable. Afterward, they should monitor and inform the physician about the effectiveness of the medication to resolve the medical problem. For example, they can appraise the physicians of the potential dose is too low for their patients. In addition to that, they should determine if there are other factors that interfere with medication intake to decrease its effectiveness. For example, the consumption of alcohol [22], caffeine [23], and smoking [24] are having the chance to interrupt the effectiveness of some medications. In other words, they can look at closely or with interest their patients on behalf of physicians about desired or undesired outcomes before or after consuming a specific medication.

Safety: all medications must not cause unwanted effects to the patients such as undesired side-effects or adverse drug reactions (ADRs). Undesired side-effects might have the potential to set or serve as a limit to the patients’ daily activities. For example, the patient might feel too sleepy and hard to be awake the whole day after consuming a tablet of Chlorpheniramine. Whereas, ADRs might cause life-threatening if not immediately being treated. For example, there is a tendency for a gouty-patient to experience extremely ADRs such as Stephen-Johnson Syndrome after consuming a tablet of Allopurinol. For that reason, they must ensure each medication is the absence of potential allergic to the patient, ADRs, potential drug-disease or drug–drug interaction, as well as too high dose.

Compliance: the accomplishment of an aim or purpose of the therapy plan determined by the compliance behavior among the patients. Failure to comply with the dosage regimen might have a chance to make the medical condition become worse or even not being well treated. For that reason, they must identify the actual or potential factors which have an effect on the incompliance behavior. For example, the problem that arises from the financial impact of therapy or interference by cultural or religious beliefs might be the factors. Those factors can be eliminated if the patients are well educated about the critical needs of such a therapy plan. Therefore, the nurses must have adequate training as good educator.

2.5 Clinical parameters to monitor

They must also be aware of the facts, information, and skills acquired through experience or education the theoretical or practical understanding of laboratory-based health screening tests [25]. Such a test shall provide comprehensive information in revealing the degree to which the medical problems are in good health. In addition, it shall reflect the effectiveness of certain medications to alleviate or resolve a specific medical condition. For example, the hematology profile might have the chance to reflect the conditions of red blood cells and hemoglobin and their characters. Lack of both substances shall have an effect on the oxygen level in the bloodstreams. Whereas, the renal profile might give consideration to the selection of medications that have less undesired effects on the kidneys. The liver profile shall give a rise to awareness of medications that are potentially harmful to the liver. Lipid profile shall maneuver the practitioner to determine the effectiveness of statin drugs to lower the cholesterol readings. In short, the entire information obtained in the test shall have a chance to assist them towards an excellence way of performing PHCS in the healthcare system.

They should also work jointly with physicians on an activity to determine the effectiveness of the therapy plan through results such as X-Ray [26], Magnetic Resonance Image [27], or else. Such advanced medical technologies are helpful to give an exact topography of internal organs which reflect actual or potential abnormalities. Any findings obtained from the test shall maneuver them to be more focused on providing a specific therapy plan. In addition, it shall ensure the end result obtained from the test shall be the center of interest or activity.

Foremost, they should determine PHCS is able to enhance the health quality of life of their patients. They can utilize EQ-5D questionnaire as a tool to assess the clinical parameter [28]. The tool consists of two parts: (1). descriptive assessment which comprises of five domains—mobility, self-care, usual activities, pain or discomfort, and anxiety or depression, (2). visual analog scale to indicate the general health status with 100 indicating the best health status. Such a tool is easier to use and it is helpful while providing PHCS.

2.6 Barriers

A role to identify, prevent, and resolve DRPs is not well-known in nursing practice. Nonetheless, they should take the responsibility to perform such a role because it has had a chance to keep undesired ADRs from happening. ADRs are potentially life-threatening. For that reason, they must take the role of a medication protector in the absence of physicians and pharmacists. They are ready to take, hold, or deploy the skills to determine DRPs even though the basic training might consume cash and time respectively.

STARZ-DRP which has a chance to maneuver them to identify, prevent, and resolve DRPs was patented under the Copyright Act 1987 by Universiti Sains Malaysia with a reference number is CRLY00004047. It was ethically approved to perform towards patients in the previous studies by Universiti Sains Malaysia—Lam Wah Ee Hospital Joint Committee for Clinical Study Ethics (reference number is USM-HLWE/IEC/2008(0026) and Human Research Ethics Committee Universiti Sains Malaysia Centre for Research Initiatives, Clinical and Health Sciences, Universiti Sains Malaysia Health Campus (reference number is USM/JEPeM/15040145). For that reason, it is essential to officially inform the author if they would like to utilize STARZ-DRP as their modus operandi.

2.7 Perception to STARZ-DRP

STARZ-DRP is having constructive, optimism, or confidence among other healthcare providers such as physicians and pharmacists. Their responses had been published in other scientific journals [29]. For that reason, the approach might have the chance to establish an excellent working collaboration relationship with other healthcare providers. In addition, the experts in the healthcare system had notified STARZ-DRP as a potential approach to make an accurate and quick triaging decision as well as identify, prevent, and resolve the actual or potential DRPs. Foremost, the stakeholders noticed the potential of the approach to assess and counsel patients respectively [29].

3. Conclusion

STARZ-DRP is a potential approach for PHCS to enhance their skills to make a triaging decision and determine DRPs or the needs of their patients. Such course of action shall have the chance to enhance the excellent service of PHCS. Foremost, the approach shall assist them to ensure their patients are having the chance to improve their health quality of life.

Acknowledgments

Dr. Nazri Nordin is a Specialist in the field of Clinical Pharmacy who established the practice of Pharmaceutical Care in Malaysia through evidence-based clinical research while completing his Master of Science in Clinical Pharmacy and PhD in Clinical Pharmacy at Universiti Sains Malaysia, Malaysia. The module which is reflected via a simple mnemonic known as STARZ was patented under the Copyright Act 1987 by Universiti Sains Malaysia (Ref Num: CRLY00004047). It was approved to perform towards patients in the previous studies by Univesiti Sains Malaysia-Lam Wah Ee Hospital Joint Committee for Clinical Study Ethics (Ref Num:USM-HLWE/IEC/2008(0026) and Human Research Ethics Committee Universiti Sains Malaysia, Centre for Research Initiatives, Clinical & Health Sciences, Universiti Sains Malaysia Health Campus (Ref Num: USM/JEPeM/15040145).