Australian Standards for Working with the Family in Palliative Care: Experiences from Practice concerning Implementing Organisational Change

The article provides practical experience of the multidisciplinary home hospice care team with organisational change. This change concerns the introduction of Australian standards for patient admission to home hospice care. The aim of the fi rst phase of the research part was to map the current practice of admitting a patient to home hospice care, identify the needs of the team, and prepare the ground for the implementation of organisational change. Based on the obtained data, the team selected and agreed four standards for patient admission. These were implemented in practice in the next phase for a period of three months. The last phase consisted of a joint refl ection upon the implementation process. The presented article describes in detail all the partial phases from the point of view of practical experience. At the end, it presents recommendations from which can be used by other organisations when optimising the progress of work in home hospice care teams.


Introduction
Palliative care is a developing fi eld that is gradually gaining ground as part of the care of clients of health and social services both abroad and in the Czech Republic 2 -and is gradually establishing itself in discourses not only of medical science and ethics, but also of social work. 3 In addition to hospice care, palliative care is increasingly being promoted as a human-centred approach not 1 Th is text is a modifi ed version of the diploma thesis of Naděžda Adámková. It was successfully defended in 2018 at the Department of Management and Supervision, Faculty of Humanities, Charles University: : © Univerzita Karlova, Domácí hospicová péče -možnost využití australských standardů při příjmu pacienta (on-line), available at: https://dspace.cuni.cz/handle/20.500.11956/99678, cited 30 th August 2020. Naděžda Adámková is also the author of the research work and the author of the tables. 10 2020 only in the institutional care environment 4 but also as a type of health / social care provided in the patient/client's home environment. Although palliative care is gradually gaining the attention not only of the professional public but also of the lay public, this approach to human care in the last phase of one's life is still not widespread enough to be considered a commonly available and guaranteed health and social service. 5 Although palliative and hospice care is increasingly being publicised today, many people have no idea what a 'hospice' is. Th e issue of death remains taboo, oft en evoking feelings of anxiety and fear. People are not used to talking about similar topics. Part of the population thinks that the patient belongs to the hospital. However, when treatment is stopped and the patient is sent home by a doctor, panic oft en occurs. Many patients do not have enough information about their next life journey with an incurable disease. Th eir general practitioner should be able to set up basic palliative care. If the care is not manageable at home, the patient is oft en sent back to the hospital. According to research from 2013, 78% of people would like to die at home. Unfortunately, the reality is that almost 60% of people die in hospitals, 20% in nursing homes, and about 20% at home or suddenly outside. 6 Th e fi rst author of the presented text is professionally involved in the fi eld of palliative care as a nurse in a home hospice and as a coordinator of home hospice care. In her opinion, there is room in some areas for a more optimal organisation of team working procedures in her organisation. Th erefore, she tried not only to analyse the process of admitting a new patient to home hospice care but also to implement a change that would lead to a higher quality of client care. Th e presented article describes the practical experience of the multidisciplinary home hospice care team with organisational change. Th e team in the organisation where the research and experimental implementation of the change was originally formed had been created as a small group of volunteers -professionals, health professionals who wanted to help patients who are suff ering at the very end of their lives. Th e team wanted to fulfi l one of patients' last wishes -to die at home in the arms of the love of their own family. Th e team was originally small but due to the increasing demand of applicants for home hospice care it has grown into the current group of about thirty members. In the current team, the eff ective coordination of work is necessary. Otherwise, the resulting chaos could have a negative impact on the quality of care provided. For this reason, the team members themselves have consensually chosen several Australian palliative care standards for pilot implementation. Th e common goal was testing, resp. implementation of a change that would benefi t both patients and the organisation itself. Th e primary purpose was to make the coordination of team work more eff ective and thus to increase the quality of services provided. Th e aim of the fi rst phase of the research part was to map and analyse the current practice of admitting a patient to home hospice care in the researched organisation, to identify the needs of the team, and to prepare the ground for the implementation of organisational change. Based on the obtained data, four standards for the admission of the patient to home hospice care were consensually selected by the team. Th ese were implemented in practice in the next phase for a period of three months. Th e last phase consisted of a joint refl ection upon the implementation process and a collective assessment of whether the experience was benefi cial for the team. Th e presented article describes in detail all the partial phases of this process from the point of view of practical experience. At the end, it presents recommendations which can be used by other organisations when optimising the progress of work in home hospice care teams.

Principles and Standards of Palliative Care
Th e most commonly used defi nition was expressed by the World Health Organization (WHO) which states that Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suff ering by means of early identifi cation and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care: 7 Another concise defi nition is that of the European Association for Palliative Care (EAPC): Palliative care is the active, total care of patients whose disease is not responsive to curative treatment. Relieving pain and other symptoms, and dealing with social, psychological, and spiritual problems is crucial. Palliative care is interdisciplinary in its approach and includes the patient, family and community. Palliative care honours and protects life. It considers dying and death to be a normal process. It does not accelerate nor delay death, though. It strives to maintain the maximum possible quality of life until death. 8 All defi nitions have a common basis, namely the alleviation of suff ering, dignity, maintaining the quality of life for the maximum possible period and all-round support for the patient and his loved ones. At a general level, the standards are a set of recommendations of a general nature. Th ey determine the minimum level of quality of care that should always be kept by facilities providing specialised palliative care. If the standards become part of the contract between the facility and the patient, they become binding. Th e standards represent the basic starting points of hospice palliative care. Th ey are principles, a target group, indications for hospice care, and basic organisational forms. Th e standards also contain a detailed plan of care for the physical, spiritual, mental, and social status. Th ey contain ethical, legal, and cultural aspects of care as well. ' An integral part are personnel standards for in-patient and mobile hospices and material and technical equipment. ' 9 Teams and individuals providing palliative care must be aware of the goals of hospice care. At work, they should use all their abilities, personal qualities, and the art of empathy when communicating with each individual patient. Th ey should also assess and provide the patient with a dignifi ed, professional accompaniment for the rest of his days. Th e essence of care is the quality and satisfaction of patient needs. Th e caring staff tries to gently involve the family and loved ones who are part of the patient's environment. Th e defi nition of quality of life is diffi cult to formulate as it changes throughout life. Professional staff are able to respond to the individual needs of a particular patient in an operative way. 'Th e basic principle for meeting the defi ned goals is frequent communication not only with the patient but mainly with accompanying family members. ' 10 Workers in this fi eld must respect the life values of the patient even if they diff er from the values of other people and their own ones. In general, the division of palliative care into general and specialised palliative care is used at the basic level. Each of them has its specifi c purpose in providing specifi c services. It is mainly about nursing care and fulfi lment of bio, psycho, social services, and providing psychological support to patients and their families. General palliative care should be available in all facilities providing health services (according to the capacities and abilities of a non-specialist health facility) and such 'care should be provided by any health care professional, regardless of his expertise. ' 11 Every health care professional should be able to detect and operatively adapt all processes important for improving the last moments of a patient's life. We call professional interdisciplinary care specialised palliative care. It must be provided by a team of experts whose specialisation, education, and practice allow them to be prepared for providing precisely this care. A professional specialised team is usually a multidisciplinary group consisting of doctors, psychologists, nurses, carers, social workers, physiotherapists, occupational therapists, and clergy. A network of volunteers is oft en used to complement the team. Th e concept of specialised palliative care in the Czech Republic takes several forms: home palliative care -home/mobile hospice, in-patient hospice, palliative care department at in-patient medical facilities, palliative care counselling teams, specialised palliative care clinics, palliative care day-care centres, etc. Home hospice teams provide care in a natural environment 24 hours a day. Availability and complexity are essential for the patient and family. Th ese teams know where to call when needed. In case of such need they can obtain information about everything important, about the patient's condition. Th anks to this system, the team is able to help very quickly in the situation of sudden problems. Th erefore, the home hospice is the most desirable form of patient care. Many of us would like to stay at home at such a time. 'Th e Czech Republic still has reserves in comparison with the world in this regard.' 12 Th e 'hospice' in-patient facility takes care of patients who cannot stay at home. Palliative care departments are being set up in some healthcare facilities, such as hospitals and clinics. Specialised outpatient care is suitable for patients who are still able to come and then go home independently. It usually takes the form of a doctor's offi ce and deals mainly with the treatment of pain. Day-care centres are intended for patients who are still able to visit these centres. Th e staff here off er activities that correspond with the patient's current strength, such as relaxation, exercise, and psychological support in the group of other clients. Outpatient medical facilities are suitable for patients who can easily transport themselves to such a facility, so they are not yet bedridden. In this condition, they can also visit day-care centres. Th ey decide for themselves when they will come and how long they will be able to stay. Th e regularity of their visits depends on the current state and needs. Another important form of assistance in this care is various counselling centres. Th e centres direct patients or their relatives to other existing organisations that will help them in their difficult situation. Th ese can be volunteer centres, medical equipment rentals, various hotlines, and associations specialising in this fi eld.

Admission of the Patient to the Home Hospice
As we deal here with the issue of admitting a patient to the care of a home hospice on a practical level, we will now approach the environment of the implemented project in this chapter. A necessary precondition for admission to a home hospice is the patient's wishes and consent to be taken care of in his home environment. Th e family or loved ones must be able to care for the patient at home. Th e patient's general practitioner should be willing to cooperate, especially in prescribing medications and devices. All participants understand the clinical situation in the same way; they are aware of the fact that the patient is terminally ill. Th e goal of care is to maintain a good quality of life in the home environment. All practical aspects of care are manageable at home, including dealing with acute or critical situations. Th e patient comes into the care of a home hospice at the stage when he no longer knows how to cope with the situation at home and even his loved ones can no longer manage the care themselves. Sometimes it is this serious condition that forces them to apply for home hospice care. Unfortunately, the waiting time is oft en longer and the hospice does not have the capacity to receive the applicant immediately. Th erefore, it is advisable to submit an application in advance even if the patient does not eventually use the service. Th e home hospice team receives the patient most oft en at the time of irreversible or terminal disease. Th e prognosis of the survival of these patients is usually days and weeks, exceptionally months. Th e conditions for the admission of a patient to a home hospice include, in particular, that he suff ers from an incurable disease in an advanced or fi nal stage, has been acquainted with his state of health and has adequately understood his condition. Furthermore, he needs to understand the principles and limits of home hospice care and to agree with care in the home environment. Th e doctor decides on admission based on the categorisation of the patient's health condition. Th e necessary conditions for the admission of a patient to a home hospice include the full information of caregivers about the patient's state of health. Caregivers should, with respect to their abilities, understand the prognosis of the disease, know the limits of home hospice care, and agree to the cooperation with the home hospice team. It is essential that at least one person can take responsibility for the continuous care of the patient.

Research Part and its Goals
Th e research took place in an organisation that provides health and social services in accordance with applicable legislation (that is, in accordance with Act No. 372/2011 Coll., On health services, and Act No. 108/2006 Coll., On social services). Specifi cally, these are residential and outreach services, a day care centre, and social counselling. We are talking about an organisation whose main goal is to provide care for terminally ill and dying patients. Th is service also includes care for loved ones, carers, and family members of the sick. Th e organisation was founded by representatives of the three churches and is based on the humanistic, Christian foundations of Western civilisation. It also represents the meaning of 'agape = unconditional love' of the Father, the Son and the Holy Spirit, which is based on the Bible. Th e main operation of the organisation, an in-patient hospice, was launched in 2008. Its main goal is to provide hospice, palliative care, that is, providing and improving comprehensive hospice care which will not be limited by the place of residence or social status of the patient. It follows the standards of palliative care issued by the Czech Society for Palliative Medicine. Th e aim of hospice care is to alleviate pain, minimise the symptoms of an incurable disease, preserve the dignity of the patient, take care of the patient's mental state, and support the care and accompaniment of his family members or loved ones. Th e general goal of the project implemented within this organisation was to fi nd out the possibilities of optimising the procedure of a multidisciplinary home hospice team. Th is procedure involved admitting a patient to home hospice care while using the Australian standards for working with the family. Th is process consisted of three consecutive parts: (1) analysis and mapping of the patient admission process to home hospice care, (2) participatory implementation of the Australian patient admission standards, and (3) refl ection upon the obtained experience.

Course of Project Implementation, Questions on Methodology
Th e research involved ten members of a multi-professional home hospice care team (two doctors, three social workers, one head nurse, and four nurses). Th e other professions of the team usually are involved with the care only aft er the admission of the patient, therefore, they were not included among the research participants. Th roughout the research, great emphasis was placed on an ethically responsible approach to the respondents; as it was an almost unique project in a relatively small but very specifi c team, we had to ensure that their identity and privacy were protected. A semi-structured individual interview was chosen as the main method of data collection, and a group interview was chosen for the fi nal phase of evaluation of the implementation. Th e research was divided into fi ve basic stages and then into partial steps.

Source: Own processing
In the fi rst stage of the work (phases 1A-1D), the researcher presented the plan of the entire research at a regular meeting of the home hospice team. She gave the team members a translation of the individual Australian standards. Th e team members' goal was to study them and assess their possible suitability for use in their organisation. Th e team members were informed about the time burden that research collaboration would represent for individuals. Related questions were answered during a joint discussion.
In the second stage, individual semi-structured interviews took place. Th ey were focused on the course of the fi rst contact with the patient and his family. During the fi rst interviews, the researcher realised that the questions would need to be adjusted with regard to the assumption of the existence of individual subcultures in the team. Th e fi rst, very coherent group speaking 'the same language' was made up of nurses. Th e second group consisted of doctors and psychologists and the third, most heterogeneous group consisted of social workers, workers in aids rental business, and fi eld workers. Th e aim of this stage was to map and analyse the current process of admitting a patient to a home hospice, identify the needs of the team, and prepare the ground for the implementation of the selected Australian standards.
In the third stage, a discussion took place at a regular meeting of the team. By consensus, it was determined which specifi c standards would be used for testing and which of the team members would be willing to participate in the implementation.
In the fourth stage of the research, a three-month implementation of the selected standards took place. At the same time, the team's discussions took place at regular meetings. Th e positives and negatives of the newly acquired experience were discussed. In the fi ft h stage, aft er the implementation, a group interview of the participating team members was organised.

Stage No. 2 (2A-2D): Analysis of the Patient's Admission to Home Hospice Care
In June and July 2017, individual interviews were held with ten members of the multidisciplinary team. Th e aim of this (research) stage was to fi nd out what the individual possibilities of the patient's fi rst contact (applicant for home hospice care) were with the home hospice care team, and to analyse how the contact would take place.

Respondent's personal procedure when admitting a patient to home hospice care
Th e interviews revealed the usual individual procedure of the respondent when admitting a patient to home hospice care. Almost all the members of the team except one agreed that they had their own, relatively stable system. Th ey are mostly guided by experience from their own practice and, instructed by the mistakes of themselves and their colleagues, they try to bring their own procedure to perfection. Where appropriate, they have taken over the established procedure from their predecessor and it suits them. Th ey have trained in their procedure so that they cannot forget anything signifi cant. Nine respondents follow the guidelines of the organisation for the admission of patients to home hospice care. Only one respondent describes the procedure diff erently: 'I do not have a completely stable procedure, I improvise according to the needs of the team and the situation in the family' (respondent 7).

Respondents' own mistakes when admitting a patient to home hospice care
When asked about the respondents' own mistakes which can complicate the work of others in the team, four respondents state imperfect administration, namely writing data to the electronic system: some missing social data, contacts to relatives, no patient's general practitioner, etc.

Inadequate practices of other members of the home hospice care team
Part of the interview focused on what procedures carried out by colleagues (concerning the patient's admission to home hospice care) are not good and why. Six of the respondents mentioned the need for faster and more operational team cooperation. Th ey are oft en bothered by the lengthy admission process and the resulting time lag for the patient. 'Slow teamwork and low fl exibility due to part-time work contracts' (respondent 2). Four respondents reported an unsatisfactory procedure caused by haste when someone was trying to help as quickly as possible. If it is not possible to correctly estimate the situation during the fi rst visit to the family (that is, whether they will manage the patient's care at all), then there are stressful situations for both the patient and his family and for the home hospice care team. Th e consequences of such an admission are diffi cult. Th ey are solved operatively -usually the patient is transferred to an in-patient hospice.

Proposals for changes for an easier patient admission process to home hospice care
At the end of the interviews, the respondents were asked what would personally help them in the process of admitting a patient to home hospice care. Th e reactions of respondents pointed out the requirement to introduce the rules, methodology, standards, IT system, that is, they required the elements which would clearly determine the optimal course of the admission process. 'Probably some standards about what exactly to ask at the fi rst contact, and also communication with the team about mistakes and about better solutions for issues' (respondent 3). 'Some IT system shared by everyone where I write information and everyone sees it immediately' (respondents 2, 4, 6, and 7 answered similarly). Th ere were many ideas and wishes in the interviews. Some were heard repeatedly. It can be concluded that it would be appropriate to consider the introduction of some changes arising from the needs of respondents. Some also suggested to introduce a valid routine that would support faster operational cooperation of the team between professions -an operation that would be provided by suffi cient staffi ng. In this way it would be possible to respond to the requirements of a multidisciplinary team doctor -nurse -social worker -psychologist without delay. Four of the respondents stated that the certainty of operative consultation with a doctor would help them. Th is represents a fl aw of the home hospice care. Th ere are mainly personnel reasons for this as there is a lack of doctors. Each member of the team has a system for proceeding during the admission of the client to home hospice care. However, these systems are individual, oft en even situational. In fact, they are not guided by any methodology. Th e situational interaction of these individual systems can lead to certain problems which then complicate the work of other team members. It is this moment -agreed by the members of the research team -that could be potentially improved by the implementation of the Australian patient admission standards.

Why the Australian Standards?
Th e question remains regarding the reason why 'the Australian standards for working with the patient's family' were chosen. Th is choice was preceded by a study of the available literature and consultations with experts in the fi eld of hospice and palliative care. Th e main benefi t of this choice was the fact that the Australian standards are intended for all palliative patients regardless of the original diagnosis. Th ey diff er from most other standards issued in Germany, Ireland, Canada, and USA, which are aimed primarily at cancer patients. Given the situation where 'the age structure of the population of the Czech Republic belongs to the European average but will gradually become one of the countries with the oldest population according to statistical criteria' , 13 we must take this outlook of a rapidly aging population into account. In practice, this means that even today it is possible to observe a slight increase in applicants for home hospice care due to geriatric fragility. So far, geriatric patients requiring specialised palliative care do not outnumber cancer patients but we must be prepared for this trend as the care of these patients is diff erent in all respects. Although death aft er a certain age is a foreseeable and natural phenomenon, humans are never prepared for it. Th e multi-professional home hospice care team faces completely different problems in younger cancer patients and older polymorbid patients. For cancer patients, usually at a younger age, the team helps to address the issues of a person aff ected by the disease at a productive age. Oft en there are small children left behind, and unresolved problems. Th e patient oft en deals with the question of why the disease has aff ected him, etc. In elderly geriatric patients, it is necessary to address the correct setting of medication to which patients respond completely diff erently than cancer patients. We perceive a diff erence here in the care of the mental state of a senior and in the provision of quality nursing care. We also see diff erent demands concerning the care of the bereaved, especially if the other partner remains completely alone. On the other hand, seniors tend to have most fi nancial and property issues resolved and do not need help in this area. All of these specifi cs and diff erences of care are well addressed in Australian standards. Th ese are still living, continuously used methods, operatively evolving according to the current needs of patients. Th ey include demographic and cultural aspects of all regions of Australia. Th e standards are published repeatedly in new updated versions. Another argument for using Australian standards is the fact that they are the basis for many other national palliative care societies, including the multinational European Association for Palliative Care (EAPC), in the process of developing palliative care standards and norms in their country.

2020
Th ey are also referred to in palliative care standards in Canada. 14

Australian Standards for Working with the Family
Clinical Practice Guidelines for the Psychosocial and Bereavement Support of Family Caregivers of Palliative Care Patients (paraphrased): 15 1. Once a patient has agreed to receive palliative care, inform the patient that the role of palliative care is also to support their family caregiver(s). Th e family caregiver(s) will be a person(s) whom the patient perceives to be their most important support person(s). Th is may be a family member, partner, or friend, and may not necessarily be his next of kin. 2. Ask the patient to identify the primary family caregiver(s). Where only one family caregiver is identifi ed ask the patient if there is another family member / friend who may be willing to be approached and act as an additional family caregiver. Discuss the patient's preferences for the involvement of the family caregiver in medical and care planning discussions and note this in the medical record / care plan. 3. Confi rm with the family caregiver(s) that they understand the patient has nominated them for this role. Explain the typical role and responsibilities of 'family caregiver' and confi rm they are willing to accept this responsibility and note this in the medical record. Discuss any concerns that the family caregiver may have in accepting this role (including possible confl icts with other family members). 4. Discuss advance care planning with the patient and family caregiver(s) covering any implications relating to the legal responsibilities of the family caregiver(s). 5. Recognise the family caregiver(s) as an important source of information about the patient.
Gather information from the family caregiver(s) about their experience as a support person for the patient, including any information (where pertinent) regarding the patient, which they believe may be important for the health professional team to know about. 6. Explain to the family caregiver(s) what services and resources can be provided by the palliative care service so that realistic expectations are established. 7. Whenever possible, convene a family meeting / case conference, including the patient, if practicable. 8. Conduct a needs assessment with the family caregiver(s). Th is should include psychological and physical health, social, spiritual, cultural, fi nancial, and practical elements. 9. Once the needs of the family caregiver(s) are assessed, develop a plan of action with involvement from the family caregiver(s). Initiate the appropriate interventions as pertinent. 10. Based on discussion with the family caregiver(s), determine the current state of and risk for poor psychological health and/or prolonged grief and plan relevant intervention(s). 11. When appropriate, assist the family caregiver(s) in how to recognise signs that death may be imminent and the potential implications for the patient's care requirements. 12. When death appears imminent, ensure the family caregiver(s) are aware and assess preparedness for death. 13. Confi rm with the family caregiver(s) the type of support they may desire in the lead-up to death (e.g., last hours, days) and/or immediately aft er. 14. Th e interdisciplinary team identifi es a means of communicating with the family caregiver(s) to determine short-term and long-term post-death responses. Potential external bereavement support services are identifi ed, if required. 15. Relevant members of the interdisciplinary team are advised of the patient's death in a timely fashion. 16. As soon as practicable aft er the patient's death, a member of the interdisciplinary team should contact the family caregiver(s) to off er condolences and respond to queries. If death occurred at home, assess the need for a home visit. 17. Contact the family caregiver(s) and other family members (as appropriate) to assess needs at three to six weeks post-death and adapt bereavement care plan accordingly. 18. Develop a preliminary bereavement care plan based on the needs of the family caregiver(s), the pre-death risk assessment, and the circumstances of the death (e.g., unexpected or traumatic). 19. Conduct a follow-up assessment of the family caregiver(s) and other family members (if appropriate) six months post-death. 20. Following the death of a patient, the interdisciplinary team should have a discussion (at an appropriate time) about the quality of care provided to the patient and family caregiver(s) and the nature of the death.

Phase No. 3: Selection of Standards for Implementation (3A, 3B)
Th e interviews included four questions on the Australian standards for family work. Th e attitude of individual members of the home hospice care team to the possibility of using the Australian standards in their own organisation was ascertained. Th e attitudes were mostly positive. Four respondents saw the possibility of testing the standards as a potential benefi t and inspiration. Th ree respondents expected that the possible implementation of the new standards would provide them with knowledge and clearer rules for the admission process. One of the respondents saw this as an opportunity to try inspiring rules which he himself lacks in his work in a team. He said that although the team works in a similar spirit, it does not have such rules offi cially established. With a growing team, he himself would welcome offi cial rules. Especially, new colleagues are confused and need to learn from others -something from everyone, being what suits them best. One of the respondents stated that every point of the Australian standards can be used in the Czech Republic. Th ere is nothing in them that would limit the team. Another respondent believed that 'the use of the Australian standards in the team would be inspiring and bring systematic work' (respondent 10). Th e aim of the individual interviews was, among other things, to fi nd out the mood of the home hospice care team at that moment, to evaluate whether the current way of admitting patients was fully functional, or whether there was a will to think about changes. Th ere was also a need to evaluate respondents' attitudes towards the Australian standards for working with the family and to evaluate their willingness to personally try some of the standards in their own practice. Th e result of the analysis of individual interviews was fi nding out that the team is a compact organism. It cooperates operatively, and is always able to negotiate. Th e fi rst priority of the team is the maximum quality of patient care in all aspects as it is based on the values of hospice and palliative care. Th e team members perceive the space to improve their own set processes in the patient's admission to home hospice care. Respondents are willing to invest their time and energy in implementing Australian standards. Th ey expect benefi ts of inspiration for possible changes to the current admissions process. Th e use of Australian standards in one's own team is perceived by fi ve members as a possible contribution to the optimalisation of the system and order in the process of admitting a new patient. Th ey hope that, thanks to the implementation, they will create a kind of framework for admission which can be used for the entire team. Th ree of the respondents see specifi c positives in focusing on systematic care for mourners from six weeks to six months aft er death. At present, except for meetings of the bereaved twice a year, they deal with it rather intuitively. In Australia, they care for the bereaved to a greater extent than in the Czech Republic. Th ey also discuss their refl ections on mourners, they learn from possible mistakes. Th e team could put more emphasis on that. Two of the respondents see an opportunity in focusing on caring for the family as a whole. Th ey would like to pay more attention to the care of mourners and map the whole situation in the family in detail.
One of the questions in the semi-structured interview asked the respondents to choose four of the Australian standards they would like to try in a real three-month implementation -preferably those that are lacking in the current system of work procedures, that is, the ones that would be most useful and eff ective in their view. Table 3 provides an overview of twenty standards according to how the respondents chose them for possible implementation. In the fi rst line we fi nd the series of numbers of all twenty Australian standards listed above. Th e second line records how many respondents selected a particular standard for implementation. Th e table shows that the respondents chose standards Nos. 2, 9, 18, and 20 the most (namely four times).

Source: Own processing
Th e team members were acquainted with this conclusion of the analysis at the next regular joint meeting of home hospice care. Th is analysis was one of the main indicators for the next implementation process. It was a supporting point for the consensus of the whole team when selecting specifi c Australian standards for the three-month implementation. Th e team members reiterated the standards, discussed their detailed focus, consulted and presented their views, and fi nally made sure that the standards would be used by the team in its actual operation. Th e trial period was set from 1 September to 30 November 2017. Nine out of ten original respondents actively participated in the implementation. One respondent declined to cooperate due to serious time reasons.

Phase Nos. 4 and 5 (4A -5B): Implementation Process and its Refl ection
Th e fourth stage of the research, that is, the implementation phase itself, took place in the period from September to November 2017. During the fi rst month of implementation, 12 admissions to home hospice were realised (during the second month it was 5, and during the third month it was 4). A total of 21 patients were admitted to home hospice care while using elements of the above-selected Australian standards for working with the family. Th roughout the implementation period, the team members addressed regular ambiguities, uncertainties, fears, observations, and positive experiences during regular meetings. Th roughout the implementation period, the team members communicated with each other on an ongoing basis and refl ected upon the ongoing process. One team meeting was then intended for an overall evaluation of the previous experience. Th e experience concerned the implementation of standards for patient admission, including in the form of a group interview. Eight out of nine implementation participants met within the set deadline. All participants actively participated, collaborated, and realistically suggested or argued regarding the experiences they had during the past three months. During the implementation period, which lasted 91 days, 21 patients were admitted to home hospice care. During those admissions, the standards were tested practically. Th e team members appreciated the method of implementation, especially the detailed explanation of the reasons and the method of its implementation, as well as suffi cient time to absorb information about Australian standards. Most participants worked well with the standards and perceived them positively.
On the question of the applicability of standard 2, four respondents were positive, two positive with reservations, and two were negative. However, the team as a whole would welcome the introduction of this standard in their organisation -the team members agreed that it would make it easier for them to work within the team, especially in the area of passing on information about the client / client's family. Negative reactions to this standard included concerns about increased administration and increased time taken. Six participants commented unequivocally positively on the second implemented standard (9). All of them considered it necessary to implement such a standard in the organisation. One respondent considered the introduction of a similar standard to be unnecessary. Th e third standard (18) provoked a lively debate. Th e conclusion was seven positive attitudes toward implementation and one negative, arguing as follows: 'And again, this is about the risk factors. I've had enough. I'm not a clairvoyant. If one wants to predict responsibly the unpredictable, it is like solving the unsolvable. I leave it to the development of the situation in the family' (respondent 2). However, most thought in a similar vein to respondent 7: 'Th is is a harder to grasp but necessary standard. Th e question is what is the best way to grasp it so that it is a usable standard in our country. Especially, it is necessary for measuring the quality of services provided by our team.' Th is standard was therefore also perceived as benefi cial for improving the quality of services provided. Six respondents commented positively on the last implemented standard (20), that is, in favour of its implementation. Respondent 5 responded with reservations: 'I do not share your enthusiasm, I still have a problem with terminology. What exactly is "a good time"? I am in favour of a clear specifi cation, and then I would agree.' And respondent 8 mentioned concerns: 'I'm just worried that we will end up drowning in all those papers. I am in favour of introducing concise, clear, well-arranged, eff ective, and meaningful standards.' Concerning the statements of the respondents, it was clear that the tested standards were perceived positively on a practical level -that is, as benefi cial for better coordination of teamwork and thus for higher quality of services provided. Th e reservations concerned both terminological ambiguities and time-related concerns associated with the implementation of the selected standards. Th e group interview also focused on the possible interest of the team in introducing a change in the fi eld of standards, the incorporation of some of these tried and tested standards into practice. When asked whether everyone was well acquainted with the issue and the intention, and whether they understood the reasons for this possible change, the respondents generally responded in agreement. No one fundamentally opposed -the team members perceived the implementation of the selected standards for working with the family as benefi cial for better coordination of the work of the team as a whole.

Recommendations for Practice, Conclusions
Given that the home hospice team has been actively and genuinely involved in the research, it can be assumed that there is space for real refl ection upon the introduction of change. During the research and implementation process, it has been shown repeatedly that the team is a compact, living organism. It tries to do its best in all circumstances to maintain quality functioning. Based on the results of individual interviews and group interviews, the following recommendations were made -although it is based on the needs of a particular organisation, we believe it could be an inspiration for other multidisciplinary teams, especially those which consider organisational change in order to streamline teamwork and improve service quality:  If an organisation decides to implement change, the whole process needs to be well timed, prepared, and implemented with the right steps so that it has a chance of success. Th e home hospice team is a functioning organism that is sensitive to all stimuli. We perceive that a directive change 'from above' is not appropriate here, for example, in the form of a change in methodology without any consultation.  During the preparatory phase of the change process, we recommend fi nding out the state of the organisation's readiness for the change implementation fi rst. For example, one should use some of the tools 'to analyse the situation and identify the factors that support the process of change (accelerators), and the factors which block it (retarders). Th is is called a force fi eld analysis. Accelerators and retarders have the opposite orientation with diff erent intensities. Aft er assessing their signifi cance, it is possible to decide about the change or stay in the current state. ' 16  We recommend remaining with proven models when compiling a change implementation plan. For example, it would be possible to use the method 'Eight steps of successful transformation of the organisation' . 17 We have already taken the fi rst step of this method within the research, namely the introduction of the idea of change implementation. Th e second step of the method is to build a stable team of the most motivated people. It is necessary to explain to this team what will happen and why, clearly and intelligibly. It is also important to give staff relevant time to receive this information and to check that there has really been enough time. In his method, Kotter also recommends conveying the idea to all employees, elaborating a detailed procedure for implementing changes, and answering all the questions asked. Kotter's fi ft h step is then the implementation itself where it is recommended to set the necessary adjustments according to current requirements. Here, we recommend adjusting the standards into a precise, usable, and eff ective wording for the team. Th e sixth step of the method is to set short-term goals. In this way, it is possible to point out the partial successes of the team, motivate employees to continue the started process with maximum support, and work for a long time to stabilise the change so that the original stereotypical state does not return. Th e seventh step is to consolidate the change achieved so that it becomes an automatic part of the team's work process.  Th e fi nal recommendation is to map out the potential risks that could complicate the successful implementation of the change. It is about fi nding ways to prevent risks or looking for ways to solve problems that could occur. Th e research revealed the team's concerns, especially about the lack of time, insuffi cient staffi ng, stress from the news, and from the fact that employees will not know how to properly understand the change.
Th e fundamental experience we have gained through the implementation of this project is that any process in an organisation, team, or company requires enough time for all processes, even for thinking about the change. Th e process of organisational change related to work procedures, where routine -learned behaviour -is being changed, is an activity for at least a few months, but rather for several years. We self-critically believe that in order to increase the probability of success, it would be appropriate to involve members of the home hospice care team in the research preparation process itself. We believe, based on a collective refl ection at the end of the implementation process, that the incorporation of selected standards has triggered a deeper thinking of multidisciplinary team members on all possible ways to improve, simplify, speed up, and refi ne work coordination -and thus increase the quality of services provided. Th e project presented by us can also be perceived positively: it initiated a collective refl exive process which focused the attention of team members on such important topics as the eff ectiveness of work procedures, quality of services provided, coordination of work in a multidisciplinary team, etc. Th e participation of respondents in the research stimulated their activity in a discussion with other team members who did not directly participate in the implementation, but only observed the resulting eff ect. Respondents were most signifi cantly infl uenced by their own experience with this experiential method. Th e team especially appreciated the time allowed for the individual steps which was needed in order to absorb new information and understand why this is happening. Th e whole process created the feeling that they needed change in the team. Th is is an essential moment for the possibility of success of any change process in an organisation. One of the most important eff ects of the described implementation process is that the team members, through a shared refl ective process, recognised the need for changes in the team. Th ey saw them as benefi cial, and that they save time by eliminating the duplication of tasks, etc. We can answer in the affi rmative about the applicability of Australian standards to other home hospice teams. Th is is possible due to the similarity of procedures and work system which must adhere to the applicable legislation and conditions for the operation of these specifi c services. Th erefore, we can off er the research results as inspiration to other teams across the country. Working in a home hospice can be seen as 'death before me, death behind me' . We would hardly fi nd a more striking slogan characterising this profession. From the point of view of a nurse with six years of hospice care experience, the co-author of the article perceives this service as meaningful and very sought aft er. Promoting humanity and dignity in the fi nal stages of life is the only guarantee of maintaining the maximum quality of life for as long as possible. Although hospice and palliative care in our country does not have a long history, it is certain that its importance will grow as the Czech population is aging.