Compassion and collaborative practice are individually associated with high quality healthcare. When combined in a compassionate collaborative care (CCC) practice framework, they are reported to improve health, strengthen care provision, and control health costs. Little is known about how to integrate and measure CCC, yet it is fundamentally applied in palliative and end-of-life care settings. This study aimed to identify quality indicators of CCC by systematically reviewing and synthesizing the current state of the palliative and end-of-life care literature.
An integrative review of the palliative and end-of-life care literature was conducted using Whittemore and Knafl's method. Donabedian's healthcare quality framework was applied in the data analysis phase to organize and display the data. The analysis involved an iterative process that applied a constant comparative method.
The final literature sample included 25 articles. Patient and family-centered care emerged as a primary structure for CCC, with overarching values including empathy, sharing, respect, and partnership. The analysis revealed communication, shared decision-making, and goal setting as overarching processes for achieving CCC at end-of-life. Patient and family satisfaction, enhanced teamwork, decreased staff burnout, and organizational satisfaction are exemplars of outcomes that suggest high quality CCC. Specific quality indicators at the individual, team and organizational levels are reported with supporting exemplar data.
CCC is inextricably linked to the inherent values, needs and expectations of patients, families and healthcare providers. Compassion and collaboration must be enacted and harmonized to fully operationalize and sustain patient and family-centered care in palliative and end-of-life practice settings. Towards that direction, the quality indicators that emerged from this integrative review provide a two-fold application in palliative and end-of-life care. First, to evaluate the existing structures, processes, and outcomes at the patient-family, provider, team, and organizational levels. Second, to guide the planning and implementation of team and organizational changes that improve the quality delivery of CCC.
Since the early 2000s, there has been generalized concern over the decreasing state of compassion in health systems across developed countries [1, 2]. Defined as "the recognition, empathic understanding of and emotional resonance with the concerns, pain, distress or suffering of others coupled with motivation and relational action to ameliorate these conditions" . Not only is it viewed as a guiding foundation for ethical practice among healthcare professionals and organizations, but also as a cornerstone of quality healthcare by patients, families, clinicians, and policy makers [4–7]. Emerging evidence shows a relationship among compassionate care, improved patient outcomes and enhanced provider well-being [6, 7]. Despite efforts, compassion remains elusive in many organizations and care settings, and is poorly conceptualized  and empirically understood . According to a recent scoping review of the compassion healthcare literature, there is a lack of patient and family data to inform the body of literature . Looking beyond patient and family perspectives and into the team and organization is further required to understand their influence on values and practices .
Collaborative practice has numerous definitions, but the majority agree that it involves multiple disciplines of healthcare team members who work with patients and families to achieve common goals through processes, such as shared communication and decision-making [10–12]. It is a practice model whose core domain involves a patient and family-centred approach . Collaborative practice has been shown to improve health outcomes in and across care sectors and settings [12, 13], and is linked with higher accessibility to care, better chronic disease management, patient safety, and healthy workplaces [11–13]. Despite a growing body of literature, the integration of collaborative practice continues to lag behind in many healthcare settings .
As an exception, palliative and end-of-life care settings are places where compassionate patient and family centered care is the priority of the interprofessional (IP) team. This led us to theorize that compassion is the lever or 'missing antecedent' for fully operationalizing and sustaining collaborative practice in end-of-life care settings . Compassion is a foundational value underlying the modern hospice movement [16–18], and a core concept of palliative care. It involves a holistic approach in which IP care providers support patients and families throughout diagnosis, disease stages, death and bereavement . Compassion is also considered a marker of spiritual care, a facilitator for ameliorating existential suffering towards end-of-life , and an enabler of an integrated patient-centered approach . Nevertheless, there is no robust evidence that describes how to systematically promote and improve the quality of compassionate collaborative care (CCC) in palliative or hospice care settings.
In 2014, the Schwartz Center for Compassionate Healthcare and the Arnold P. Gold Foundation convened an expert panel to recommend timely steps for integrating compassion and collaboration . Panel members included patients, family members, advocates, clinicians, health profession educators, licensure and accreditation agency representatives, funders, and administrators. The Compassionate Collaborative Care Model and Framework was identified as a vehicle for improving health and experiences of care while controlling health-related costs . Making CCC the standard of care in every healthcare organization and patient encounter was agreed upon as the ultimate vision for excellence in healthcare [3, 21]. Although the report identifies the major attributes and provider skills associated with CCC, it provides few steps for its assimilation into healthcare teams, settings, and organizations. Therefore, greater understanding of organizational culture and system change processes is essential . Without this knowledge, teams and organizations will remain continually challenged to integrate and measure the impact of compassionate collaborative care.
Measuring the quality of care and services through indicators, including patient and family satisfaction, has become increasingly important. According to Schuster and colleagues, key indicators can be measures of structure, process, and outcome, classified according to type of care, function, and modality . For certain conditions, treatments or patient populations, indicators without evidence, based solely on professional consensus, may be all that is feasible . Because growing evidence suggests that practicing with compassion leads to better outcomes [6, 7, 24, 25], it is important to understand the nature of CCC and its quality indicators. As CCC is philosophically and fundamentally applied in palliative and end-of-life care, this body of literature is theoretically appropriate for examination.
The aim of this study was to identify quality indicators of CCC by systematically reviewing and synthesizing the current state of the palliative and end-of-life care literature.
Compassionate collaborative care (CCC) is a process through which caregivers from different professional and non-professional backgrounds work together with patients and families to deliver care that recognizes, understands and responds to concerns, pain, distress, or suffering, with the aim to promote positive patient-family, team, and organizational outcomes across healthcare settings.
The following online databases were searched for relevant key terms: Medline, CINAHL, ProQuest, and PubMed. Numerous search terms were used in various combinations. These terms were identified from a preliminary review of the literature and author expertise, and included the following algorithm: (interprofessional OR interdisciplinary OR multidisciplinary OR transdisciplinary) AND (collaboration OR cooperation OR practice OR team work OR teamwork OR care OR caring) AND (compassion or empathy or sympathy) AND (hospice OR palliative OR end-of-life OR end of life). Truncation and wildcard symbols were applied to maximize retrieval of related reports.
Inclusion criteria were as follows: peer-reviewed, published in English, original research, systematic review, literature review, case study, conference proceedings, or position statements. The settings of interest were acute care, hospice palliative care, and long-term care. Given the conceptual nature of the review, there was no limit on publication date. We excluded studies that did not meet the inclusion criteria reported above. Studies conducted in home or community settings were also excluded given the heterogeneity in their structures and processes.
The literature search produced a total of 296 citations. The removal of 22 duplicates left 274 citations for title and abstract screening. Two hundred and eighteen articles were rejected during title and abstract screening. This number included one article (dated 1987) that was not accessible from library and digital sources. The title and abstract screening process produced 56 articles that were eligible for full manuscript screening. During the full manuscript review phase, 31 articles were rejected, resulting in a final literature sample of 25 articles. Outcomes of the literature search and screening procedures are reported in Fig. 1.
Both authors independently screened each title and abstract and documented their recommendation to include or exclude. When screening the titles and abstracts of each citation, we maintained a constant focus on the aim of the review and the question: "Does the article potentially address structures, processes or outcomes of compassionate collaborative care for patients at end-of-life of any age group in acute care (any unit), tertiary care (hospice, palliative care) or long-term care?" Upon comparing the independent screening results, disagreements were thoroughly discussed until agreement was reached to include or reject. Following this phase, full manuscripts were retrieved and the same strategy was applied for inclusion/exclusion. Articles that did not meet inclusion criteria were eliminated from literature sample. Characteristics of the literature sample are reported in Table 1 .
Although not required in an integrative review , the articles were appraised for quality. We believed this was necessary for users to be able to interpret the usefulness and transferability of the review findings to practice and policy . We used the qualitative and quantitative criteria of Letts et al.  and Polit and Beck , respectively to assess the rigour of each study. The articles were then ranked on a scale of 1 (weak) to 5 (strong) based on the presence or absence of evidence to support the criteria. Six articles reflected research studies (5 = qualitative; 1 = mixed methods). We retrieved one meta-synthesis of the qualitative literature, and two quality improvement (QI) program evaluations. Sixteen documents reflected non-research articles that included position/consensus statements (n = 4), case study reports (n = 2), literature reviews (n = 2), and narrative summaries of Schwartz Rounds (n = 8). Given the nature of these reports and lack of reliable appraisal tools, these articles did not undergo quality appraisal. Nevertheless, they were considered low forms of evidence . Two of the qualitative studies were scored as moderately-high (score = 4). The remaining articles were scored between 1 and 3. The weak scores reflect studies that lacked comprehensive literature reviews and clear reporting of design and methods. Although there is criticism about inclusion of low quality of studies in systematic reviews, these concerns largely relate to the bias associated with meta-analyses . Given the lack of research in this area, including all studies that met inclusion was necessary to understand this phenomenon.
The process by which data analysis and synthesis was conducted is displayed in Fig. 2. It involved an iterative process that applied a constant comparative method  throughout data abstraction, reduction, display, conclusion drawing, and verification stages . We continually focused on the research question and the adopted conceptual definition of compassionate collaborative care throughout the analysis. The process involved two phases: (1) literature abstraction and (2) data reduction and display. To achieve consistent coding and categorization of the data, the researchers met weekly to compare and agree on the attribution of the data.
'Structure' denotes the attributes of settings where care occurs. It refers to health system characteristics that affect the ability to meet the health care needs of individual patients, families, or a community. Structural indicators describe the type and amount of resources used (i.e. staff, clients, money, beds, supplies, buildings) in order to answer whether care is provided under favorable or unfavorable conditions to good care.
'Process' denotes what is actually done in giving and receiving care. Processes are a series of inter-related activities undertaken to achieve objectives. Process indicators measure the activities and tasks in patient episodes of care. For some researchers, seeking care and carrying it out are also viewed as process indicators.
'Outcome' describes the effects of care on patient and/or population health status. These may include knowledge improvement, changes in behavior and ultimately, satisfaction with care. Outcome indicators are states of health or events that follow care and should be evidence-based.
The data from phase one were further abstracted into Table 2 for reduction and display across the patient-family-provider, the team, and the organization levels. Numerical codes (1 through 9) were attached to each data point to support the reliability and consistency of the data analysis. As the analysis proceeded, the cell descriptors were refined to best fit the data . The data were further reduced into sub-categories within each of the cells. This also involved a rigorous and iterative process of comparing data points within each cell to all other data in each cell.
Three pivotal factors to high-quality EoLC in care homes: advance care planning (ACP), multidisciplinary communication and work, dignified and compassionate care. ACP as a useful trigger for beginning communication with residents and other care professionals. Strong leadership can motivate compassionate care.
Policy Statement / Pediatric Palliative Care-Pediatric Hospice Care (PPC-PHC) Guidelines based on published observational studies, expert opinion, and consensus statements.
Hospital culture, mores and beliefs impact the experiences of older dying pts. Bracketing out time provision of psychological care.
team approach, recognition of cultural differences, integration of family into care of the dying, memory packets or boxes, support groups, resource lists and information, remembrance ceremony, continued contact with family, staff education and development, program evaluation and feedback.
The hospice environment provides physical-psycho-social-spiritual care as a therapeutic community, and reflects compassion. The hospice team core values include communication at all levels and development of sense of community. There is awareness of how the environment influences care (attention to details, minimum noise, soft background music, common meal area, garden homelike, supportive, family).
Social and spiritual events (Happy Hour, Memorial Service) provided a sense of community. Needs of resident prioritized over paperwork.
Strong personal foundations are complemented by firm professional supports. Team includes the patient's family, nurses, social workers, physicians, and other professionals and volunteers who "cocoon" the dying. Hospice nurses are collaborators, valuing, seeking, and offering support to the IP team. For nurses, is important to develop a sense of the abilities of others on the hospice team.
Processes involve active planning, ongoing support from relatives, friends and the team as resources described as "circles of strength", being honoured and cared for by the team; patient and family involvement in decisions; open and direct communication; promoting self-care; proactive and timely referrals; IP mentoring. Outcomes include intimacy, happiness after diagnosis, hope, changing relationships and perspectives, enhanced spirituality.
Patients expected caregivers to listen to needs and respect wishes. Care involved tremendous integration and teamwork between patient, family, nursing, palliative care, and pharmacy. The team considered the best place for the patient to die taking into account family wellbeing. Having a safety net is important to protect a dying patient from acute suffering. Support from, consultation and collaboration with other providers improved pain management. Family perceived making the right decision and felt like part of the team. Positive outcomes included protocol development for use of barbiturates for intractable suffering. Spiritual peace was achieved for family, friends and staff. Team education is needed to address ethics of the "double effect".
The team worked with the family to proceed through fertility treatments, pregnancy, and birth. Instilling hope and helping patients address difficult questions, and make decisions is a significant part of care. The team works together to decide to continue or cease treatment. Acknowledging the patient's positive impact on the caregiver's life.
Implementing Schwartz Rounds requires commitment by hospital administration, human resources and formalized planning. Reflecting on the emotional aspect of care enhances caregivers' ability to deal with a similar situation in the future. Rounds provide support towards empathic practice of medicine (i.e. reflection, self-monitoring, processing emotion and coping with its effects).
Unanticipated outcomes: patient-centered changes in institutional policy or practice; greater use of palliative care teams/enhanced palliative care services; improved linkages among hospital services to better meet the needs of veterans with mental health disorders and substance abuse; discussion among staff about advanced illness and palliative care issues.
Participants emphasized communication, partnership, having the right attitude and the team as being "what saves all of us". The rounds provide spaces for connecting with the team and learning about the patient as an individual. Reported positive outcomes included reduced burnout and stress, ability to recognize stress and burnout in self and others, improved coping and teamwork and team support.
The team was viewed as an extended family. Caring involves honouring the personal relationship, meeting patient's needs as survivors, and realizing the need to sacrifice. Processes included: phone calls, bereavement care programs (sending cards, memorial services, saying good-bye to patient, family, friends), bereavement rounds for staff. Family valued receiving phone calls, cards and letters.
Discussion centred around several topics: care decisions, sharing prognosis and options, maintaining supporting patient wishes, mobilizing transition to hospice care, saying good-bye, team communication, commitment and working relationships. Positive outcomes were allowing "different family members to establish their own relationship with team members… members of the team [were able] to share the sadness and the challenges of working with the family and to 'hold' the emotion that these cases evoke".
The document integrates a "Call to Action". The model emphasizes adherence to a biopsychosocial-spiritual model of care that is practised by all members of the healthcare team. Self-awareness, ongoing interdisciplinary team communication ensures that patient and family have comprehensive compassionate plan of care. Compassionate presence involves intention, openness, connections with others, and comfort with uncertainty. It is relationship-centred, not agenda-driven. It enriches the work of each healthcare professional richer through collective action.
Organizational policies should promote spiritual compassionate care across the organization, at the bedside with patients and families, in staff relationships, and at all levels of leadership. It has potential to transform and heal all parties.
The grief program involved all units, departments, disciplines, leaders and volunteers. Timing and training were provided.
Surveillance data were collected. The team benefited from increased teamwork and morale, knowledge about others' expertise, knowledge about advocacy, and patient and family care in the terminal phase.
Frequency of referrals, conferences and meetings increased.
The integrated treatment model was driven by collaborative healthcare guidelines and a mission statement: The mission statement was: 1) to reduce suffering created by the effects of cancer on patients and loved ones; 2) to work with patients and their families to diminish stress and channel all available resources toward health, healing, and quality of living; 3) to provide ongoing support to staff and physicians; 4) to strengthen and support the physician/ patient relationship, and 5) to relieve staff and physicians of lengthy and/or complex psychosocial patient interventions. Proximity, accessibility and availability of the therapist enabled frequent team communication, a whole person approach, assessment of patient and family complex needs, resources, goals (lifestyle, faith, sexuality, grief). It supported crisis prevention and management. Outcomes were collective action, team shared learning, team satisfaction with care delivery, patient reduction in suffering, improved quality of life, and increased hope and perceived agency for patient and family.
Patient values, expectations, choice and cultural tradition, and patient dignity must be respected. The case exemplifies attendance to the patient physical and emotional comfort, evidence-based practice, shared decision making, family information needs. Team crisis care was available. Bereavement care was available before and after death. Compassionate care was coordinated across care settings and facilitated by IP referrals, transitions in care, and participation in important family events. An individualized, holistic care plan addressed the person's priorities and contributed to perceived hope.
Connection with patients and family members goes beyond just doing the job. A sense of community is appreciated by family. A quick response by the team was seen as "giving reassurance, pulling out all the stops and going the extra mile" to support a family's wellbeing. Patients and caregivers expressed satisfaction with care that was seen to be "engaging", sometimes humorous, and "genuine".
Multidisciplinary team but specific reference to physician, social workers and nurses.
Families value speaking during meetings, continuity of the care team, timely communication, sharing sorrow, and being informed of changes in the care plan. Parents want to feel supported regardless of their decisions. Every team should exercise compassionate, individually tailored, and non-judgmental care including respectful treatment of the body. Respect can also be given through verbal and emotional support of family and co-workers. Shared decision-making should be viewed as a multidisciplinary process. The team should help parents feel that the right decision has been made. Compassionate care demonstrated through assistance with religious rites, funeral support, bereavement care.
Interdisciplinary morbidity and mortality sessions or small group debriefings may help reduce the heavy emotional stress.
A narrative summary of the synthesized findings with exemplar data sources is also consistent with Whittemore and Knafl's integrative review method . It is presented in the results section.
The overarching categories and sub-categories that reflect key indicators (structure, process, outcomes) of CCC at the individual, team, and organizational levels are displayed in Table 3.
Based on data from 19 of 25 articles, our analysis revealed 'patient and family centeredness' as the primary structure for CCC across the individual, team, and organizational levels [37–55]. Overarching structural values were: a) empathy [39, 43, 46, 49, 54, 56–58], b) sharing [40, 46–48, 52, 53, 55, 56, 59], c) respect [37, 42, 44, 46, 47, 53, 55, 56, 59], and; d) partnership [37, 40, 42, 44, 46, 47, 49, 52–54, 59, 60]. Further to these findings, empathy, sharing, respect, and partnership are values that must be structurally present for CCC to evolve. In the literature sample, the act of co-suffering, or suffering alongside a patient and family, is demonstrated through compassionate presencing [48, 49, 57], as well as recognizing and acting on the presence of patient-family suffering [39, 43, 46, 54, 56–58].
"You need to know that the people caring for you, whether they can or can't help you with your disease, honor you for who you are and care about you" .
Sharing is manifested when patients, families, and caregivers relate care concerns and preferences [52, 55, 56], learning needs , decisions [47, 53, 55], and care experiences [46, 47, 59]. Respect involves careful attention to the patient's physical and bodily needs [55, 56], patient and family wishes , and verbal and emotional support for patient and family members [55, 56], as well as team members [37, 42, 46, 47, 59]. Finally, partnership involves forging formal and informal connections between patient, family, the team, organization, and external agencies or resources [37, 40, 42–44, 46–49, 52–54, 59, 60]. Partnerships among patients, families, and providers involve a shared journey [49, 59] that is not agenda driven and transcends sectors and settings .
Patients and families value, need, and expect holistic and continuous care across the continuum [38, 39, 41, 49, 52, 55] that is supportive, non-judgemental and equitable [51–55].
"Family member: I never felt like we weren't part of your team… You always validated our thoughts and feelings... that's so important to hear because we have to live with that [decision]" .
Promoting and protecting dignity emerged as another important element of supportive care among patients and families [39, 43, 53, 56].
"You [the patient] need to know that the people caring for you, whether they can or can't help you with your disease, honor you for who you are" .
With regard to providers, the analysis revealed personal and professional commitment [38, 42, 47, 58] as a prominent structure.
"If I don't do it from the heart, then the care isn't good…I really don't know what it is like to die" .
"Sometimes it's learning from the family. Sometimes we're not the expert. 'You know your mother. You understand your culture…Help us…so that it's meaningful for all of us' .
Attributes of CCC at the team level include shared values, skills, and resources. Teams must value authentic relationships [47, 50, 52, 56], a shared team commitment [42, 47, 56, 60], and a holistic approach that supports bio-psychosocial-spiritual care [40, 41, 44, 49, 58].
"When a resident dies and they leave the home…the staff will line the corridors to say cheerio to them and that includes domestic staff, kitchen staff, everyone…I always go with the undertakers because I want to make sure that the person I'm looking after is still being looked after" .
Skills at the team level are relational [49, 52, 54], and involve active listening [48, 49], leadership [50, 51, 56, 61], advocacy [51, 56], reflection and self-awareness [39, 43, 46–48, 59–61]. According to our analysis, human resources and time are key structural indicators at the team level. In particular, the literature sample supports an IP team approach in delivering CCC [37, 39, 40, 43–52, 54, 55, 58, 59]. Time and shared spaces for planning, sharing, and debriefing are essential to support CCC among teams [46, 47, 51, 52, 55, 59, 61].
"…time needs to be allocated for this initiative to work, and it needs to be integrated into staff professional development as opposed to being a forum that can be attended only if staff have spare time" .
Nine articles revealed structural indicators within organizations that support CCC [37, 40, 50, 52, 54, 56, 58, 59, 61]. Three of those articles emphasized how a shared mission and vision for CCC can be influential in driving organizational programs and activities [51, 52, 61]. The organizational culture should be inclusive [56, 59] of all staff "from porters to executive directors" . Leadership is essential for championing and supporting the planning [56, 61], and policies that promote IP patient and family-centred care may support CCC integration [40, 50, 56].
"Organizational policies should promote and support spiritual compassionate care at the bedside, in the boardroom, and in staff relations" .
Finally, adequate organizational resources are required for patient and family programs [37, 40, 52], IP staffing and support across the institution [40, 52, 59, 61], and compassionate spaces for patients and families [54, 58] as well as staff [56, 60].
"We try to create a home-like rather than an institutional environment…. When everything is right, we're sending a message that we do care…" .
Three overarching processes emerged at the individual, team, and organizational levels. These are: 1) communication [40, 43, 45, 46, 49, 52, 55, 56, 58, 61], 2) shared decision-making [39, 44, 45, 47, 53, 55] and 3) goal setting [37, 43, 44, 46–49, 51, 52, 56, 58, 60]. Not only do these processes bridge all levels, our analysis suggests that they may enable several CCC sub-processes among patients, families, teams, and organizations.
"The more formal venues, such as the rounds or the chemo meetings, are not just meetings where we talk about what therapy someone's on, they become, "Oh my God. She is 38. She has two kids and she has cancer" .
SCR provides a venue for sharing the emotional work of caring with other carers [43–48, 60, 61], and this sharing can support CCC.
"For the responsible and empathic practice of medicine, health-care providers have to engage in the routine process of reflecting, self-monitoring, processing emotion, and coping with its effects; tasks that are quite challenging without support. We have found the Rounds help to provide that support" .
Our analysis revealed three sub-processes in organizations that support CCC: 1) strategic planning [39, 51, 61], 2) policy development [37, 46, 56, 61], and 3) program development and evaluation 39, 40, 44, 49, 51, 52, 58, 61]. For example, palliative and end-of-life expertise was integrated in a U.S. pediatric hospital through strategic planning and development of a Compassionate Care Network . In several instances, development of programs began with institutional pilot projects, such as the 3 Wishes Project , an integrated psychosocial treatment team , grief programming , and memorial services [40, 58]. These organizational processes may support the achievement of outcomes that are reported in the next section.
Satisfaction and development emerged as the two overarching outcomes across all three levels. Knowledge and behavioral development occurred across the individual and team levels, whereas satisfaction emerged as a prominent outcome among patients, families, teams, and organizations.
Our analysis suggests that indicators of development and satisfaction may be evidenced by integrating the structures and formal processes that are described in the preceding results, however empirical study is required.
Indicators of patient-family knowledge and behaviour development include engagement in self-care [43, 61], enhanced patient-family coping [43, 44, 48, 52, 61], reduced fear and depression [48, 52, 60], and improved quality of life . Patient satisfaction is reflected through "being known" [39, 43] holistically [39, 43, 49] by others on the care team. Finally, when compassion and collaboration are integrated in end-of-life care, patient and families report satisfaction with overall care delivery  and provider relationships [43, 44, 46, 52, 54].
"This service is very important because of the intensity by which fear, love, anger, grief, stress, and loss overtake you. By giving compassion and tools to cope, patients and families are helped to love one another and stay connected. This is vital to making the process a healing one" .
Provider satisfaction is associated with the achievement of patient end-of-life care goals, [43, 44, 46, 48, 49, 56, 58, 60], including spiritual peace [49, 60], pain and symptom management [43, 44, 48], and the provision of patient-family support across the continuum of care through bereavement [46, 58].
"Both cure and healing fall within the responsibility of the health care profession. I think doctors and nurses offer the most powerful kind of healing possible when they really care about someone. You weren't just a pro doing what you had to do. You went beyond being technically competent" .
Finally, the ability to engage in self-care and self-compassion are additional prominent indicators of provider satisfaction [42, 56, 60, 61].
"One must acknowledge the losses, accept the pain, strive to move beyond the grief, and then be willing to embrace new relationships guaranteed to include more loss" .
Knowledge development, behavioral development, and team satisfaction are the main team outcomes. Quality indicators of team knowledge development include expertise in managing complex end-of-life care [42–44, 51], including pain management [43, 44, 47, 51], and ethical decision-making . Team behavioral development outcome indicators are: effective IP communication [42, 45, 51, 60], a collective purpose [39, 42, 47, 49, 60], strengthened team relationships [39, 43, 47, 49, 50, 60], and enhanced team coping 39, 47, 60, 61].
"The synergy between all those interacting with the patient enhances the overall care and wellbeing of the patient. But it also makes the work of each individual healthcare professional richer in that the contribution of each healthcare member to the treatment plan potentiates each individual contribution. The wholeness is more than the sum of its parts" .
According to our analysis, team satisfaction is evidenced through role fulfillment [44, 45, 48, 51, 56] and positive teamwork experiences associated with collectively achieving the patient-family goals of care [43–45, 51, 53].
"It's really important to bring someone out of the world. I think it's a real privilege to do it. After they have passed away – changing them, laying them out and everything, putting the flowers on and seeing their family's reactions when they see them like that – it makes you feel really proud of what you do" .
The findings suggest two main organizational outcomes, the first of which is organizational development. It can take the form of innovative programs, partnerships, and patient-centered changes in policy and practice [37, 40, 44, 46, 50, 51, 56, 61]. Examples of quality indicators include: evidence-based pain management protocols , institutional advance care planning procedures , spiritual care programming [50, 58], integrated acute care and community palliative teams [37, 51, 61], staff education and development [40, 51], Schwartz Rounds [60, 61], bereavement rounds [46, 51], and family bereavement care [39, 46, 51, 58].
"Findings indicate high levels of engagement and intentionality about building community…equally important was the benefit of interdisciplinary exchange and understanding. Participants reported that the sessions increased their capacity to provide palliative care and integrate it into care on the units where they practiced. Participants in each [bereavement care]session identified specific new learning that would influence their clinical practice" .
Secondly, indicators of organizational satisfaction that include reduced healthcare provider burnout and compassion fatigue emerged from several articles [42, 51, 56, 60, 61].
"The thing that keeps you going, even in the middle of a busy, frustrating day is when you can't help all of the patients, is being able to connect with people. That is the only thing that keeps me coming back every day [clinical nurse practitioner]…I've been here…for about four years and have seen incredible changes. I've been thinking about how you survive in a place like this that keeps growing and growing and getting busier and busier every year…The goal for the day can be that you'll connect someone…I hear the positive perceptions that patients have of their care providers…The regular newsletter "Hotline" occasionally publishes encouraging letters from patients. Reading these makes you feel really good because they identify the people that the patient had come into contact with [social worker]" .
This integrative review was motivated by our shared practice experiences, and the voices of researchers, clinicians, and educators who advocate CCC as an essential component of healthcare quality [3, 62, 63]. To that direction, our work builds on the CCC Model and Framework  to promote operationalization of CCC in a way that is meaningful and measurable for patients and families who receive end-of-life care, as well as teams and organizations who provide end-of-life care.
To achieve this purpose, our integrative review process entailed an analysis and synthesis of the published literature related to CCC and end-of-life care over the last twenty years (1996 to 2016). Among the sample of 25 articles, less than one-third were published in the last five years. This finding indicates that CCC is an emerging field that has yet to receive the necessary attention by the scientific community, despite international calls for more compassionate care [3, 5, 63, 64]. The country of origin for the overwhelming majority of articles was the US (n = 17), followed by four Canadian articles, three from the UK, and one from Iran. This is not surprising as similar literature sample characteristics were reported in a recent scoping review of compassion  and a palliative care meta-analysis .
Patient and family-centered care was a dominant finding across the literature sample, and as such, we emphasize it as an overarching structure and key quality indicator of CCC. Patient and family-centered care is defined as "working 'with' patients and families, rather than just doing 'to' or 'for' them", and it should take place in all settings and across all care levels . At end-of-life, patients must be at the core of all end-of-life care processes, and families recognized as care team members, and not merely "visitors" . Achieving a patient and family-centered care delivery model requires an extreme culture shift from a historic provider-driven model to one that involves patients and families in quality of care initiatives. This culture shift from passive, trusting and compliant patients, to engaged and empowered team members requires acquisition of a specific set of patient-centered care competencies . However, according to critical social theory, integration of patient-centered care into health care organizations is frequently hindered by the inherent knowledge and power of healthcare providers . According to our analysis, it also requires a sharing of values among patients, providers, teams, and organizations [37, 39, 40, 42–44, 46–49, 52–60].
The overarching structural values of empathy, sharing, respect, and partnership emerged across all ages of patients (infants through old age), and in acute care settings (NICU, ICU), tertiary care (hospice, palliative), and long-term homes/continuing care facilities. The same values were also revealed within North American, UK, and Iranian contexts. These findings are again not surprising, as the quality of patient-family and care provider relationships is fundamental to the social mission of hospice and palliative care [53, 58, 69, 70]. The structural values identified in this review are also reflected in the IPFCC's four core concepts of patient and family-centered care, namely: respect, information sharing, participation and collaboration . Empathy, although lacking in IPFCC's concepts, is commonly accepted as a value in hospice and palliative care . It is also often used as a synonym for compassion, although conceptually different . Compassion extends empathy beyond merely understanding and acknowledging another's experience, to include actions that are motivated by love and acts of kindness .
Communication, shared decision-making, and goal setting are three overarching processes that can support CCC. Acknowledging the abilities of other team members, as well as their contributions, is of great importance to engaging these processes . In end-of-life care, the IP team includes the patient and his or her family, physicians, nurses, social workers, and the many professionals and non-professional volunteers who "cocoon" the dying patient . The inclusion of patients and families expands previously accepted definitions of IP collaboration that only included professional caregivers . Collaborating with, valuing, seeking, and offering support to this extended IP team are all important attributes of CCC. The team seeks communication at all levels, and understanding of how the environment influences care  to integrate meaningful processes, such as honoring dying patient wishes, humanizing the environment, offering tributes, facilitating family reconnections, rituals and observances, and "paying it forward" . More formal IP team processes include care conferences, rounds, advance care planning, and are listed as quality indicators of CCC. A significant finding from this review is the value of formalized team rounds, and their impact on provider self-care and emotional regulation [43–48], with SCR being an exemplar case of CCC.
Eight articles reported narrative summaries of SCR with great richness and depth in dialogue [33–48, 60, 61], and poignant descriptions of each healthcare provider's unique perspectives and contributions to the IP care plan. SCR are multidisciplinary forums where HCPs come together to discuss and process emotionally and ethically complex care issues . In these rounds, reflection on the emotional aspect of care strengthens a provider's ability to deal with similar situations in the future, providing support towards empathic practice . For palliative and end-of-life care, SCR provide an ideal milieu for promoting compassion and IP teamwork among attendees. According to Manning and colleagues, SCR are very well received by healthcare professionals . Moore and Phillips report improved attendee insights into psychosocial aspects of patient care, teamwork, and less clinical isolation . Issues raised by staff during SCR center around three concerns: (1) staff uneasiness with a patient's decision for continuing or discontinuing a therapeutic regime, (2) verbalizing the need to say goodbye to a patient at end-of-life, and (3) going through the emotions elicited by the death of a patient with whom a provider identified and bonded . Unexpected positive outcomes include patient-centered changes in institutional policy or practice, greater use of palliative care teams/enhanced palliative care services, and discussion among staff about advanced illness and palliative care issues . Implementing SCR requires human resources, advanced planning, and commitment by institutional administration [59, 61].
Development and satisfaction emerged as overarching outcomes at the individual, team and organization levels. Outcomes such as self-care, dignity, self-compassion, holistic care provision, therapeutic patient-provider relationships, and goal achievement [43, 44, 48, 49, 52, 56, 61] are important indicators for evaluating quality care among patients, families, as well as professional and non-professional caregivers. Examples include "giving voice to the family", and promoting family involvement in the caring process . Several of these outcomes can be measured to evaluate quality. For example, the Patient Dignity Inventory is a reliable and valid measure for measuring dignity-related distress at end-of-life . Walker and colleagues recently developed and tested a scale to measure patient perspectives of holistic and integrated care . The McGill Quality of Life Questionnaire is widely used among individuals with advanced disease and at end-of-life .
Key indicators of team development include interdependency and synergy [39, 47, 49, 52, 60, 61]. This finding is not surprising as these concepts are attributes of IP collaboration . According to the American Academy of Pediatrics guidelines, children's hospitals should have dedicated interdisciplinary pediatric palliative care and hospice care (PPC-PHC) teams . These teams provide integrated multimodal care (cure seeking, life-prolonging, comfort-enhancing, quality-enriching), facilitate clear and compassionate discussions, and support families and staff beyond the end-of-life period . A recent systematic review by Mulvale and colleagues reveals that interrelated 'gears' at the macro, meso, micro and individual levels are critical considerations for IP collaboration . Although focused on primary care, Mulvale's findings are similar to those of this review in that dedicating human resources, setting a common vision, attending to formal and social processes, and valuing the contributions of team members are highly recommended actions. Continuous improvement activities, such as quality audits and regularly scheduled team meetings, are equally important to understanding how policy and organizational contexts affect the ability of teams to collaborate effectively . According to the gears model, collaboration should extend beyond the team itself to include policy-makers, organizational leaders, team leaders and individual professionals .
Our findings draw attention to environmental factors at all three levels that can enable or hinder CCC, and are congruent with the recently published compassionate care flow model by Tierney et al. . This study examines how compassionate care is delivered to patients with type 2 diabetes within a range of healthcare settings . This model demonstrates that mere intention to providing compassionate care is not enough. Rather, working within an environment that supports compassionate practice is perhaps more important. The flow of compassionate care can be enhanced by defenders (i.e. empathizing with patient, supportive colleagues, professional autonomy, faith, controlling own emotions) and/or depleted by drainers (i.e. competing agendas, time and resource limitations, negative emotions). Compassionate care is learned within the work environment, and shaped by the influence of colleagues, patients and organizational demands and expectations . Nevertheless, the extent to which an organization can modify provider behavior, and enhance CCC performance is under debate . Regardless, our findings complement previous research which suggests that organizations and systems can enable rather than impede compassionate, high quality healthcare [1, 2]. Main enablers include: 1) resource allocation and policy setting focusing on the needs of patients/families and caregivers (professionals and non-professionals), 2) valuing and recognizing compassionate caregivers and organizations, 3) supporting providers to manage the emotional stress of caring, and to diminish personal or moral distress, and burnout, 4) forming partnerships with patients and families, 5) educating providers, patients, and families about the attributes and benefits of CCC, and 6) developing flexible QI processes to implement and continuously improve compassionate care .
When conducting the analysis, commitment and support were coded with high frequency at the individual and team levels. The importance of ongoing support from relatives, friends, and the team as resources, described as "circles of strength" and having "a safety net" emerged as exemplars [43, 44]. Nevertheless, there were wide variations in how these indicators were reported. Given the subjectivity, these indicators need to be interpreted from a clinical perspective. That is, when discussing goals of care, a meaningful ongoing assessment should occur. The following practical and powerful question for patients and families should be routinely asked: "How can I and/or the team demonstrate commitment to you and how can I / we support you in your journey?" Our analysis also suggests that individual practitioners and teams require ongoing organizational support; the attributes and processes of support should be systematically assessed and implemented by institutional leaders.
Several strategies to promote and engage individuals, teams, and organizations in CCC were discussed in the sample articles. Among them, the Comprehensive Pediatric Bereavement Program is characterized by a team approach, recognition of cultural differences, integration of family into care of the dying, support groups, resource lists and information, remembrance ceremonies, continued contact with family, staff education and development, program evaluation and feedback . The most documented strategy, SCR, is developed and sponsored by the Schwartz Center for Compassionate Healthcare . The Schwartz Center supports individual organizations to implement SCR through providing educating and training programs in compassionate care. The Schwartz Center's "Compassion in Action Webinar Series" teaches participants how to sustain compassion and collaboration in healthcare while sustaining one's well-being . Presenters teach some of the concepts and skills that are essential components of the CCC model in ways that are meaningful to patients, families and providers. For example, the 2017 webinar series includes CCC training at the organization and systems level.
Because the required skills to deploy empathy and compassion are not routinely taught nor systematically assessed and evaluated across the continuum of learning and practice , targeted measures and policies that reinforce humanistic values, such as kindness and compassion, are important in healthcare institutions and in healthcare education [5, 81]. Recently, a UK educational institution introduced SCR in undergraduate medical education . Medical students perceived SCR to support their self-reflection, insight and emotional processing . Challenges include training, cost, optimal timing, and participation [59, 61, 74, 81].
At the organizational level, the use of indicators allows for ongoing monitoring of health care quality, setting the basis for quality improvement (QI) and prioritization in the healthcare system . Rushton and team evaluated four QI initiatives at a U.S. Children's Hospital that included: 1) the establishment of a Compassionate Care Network that spanned all units of the institution, 2) institutional palliative care rounds, 3) patient care conferences, and 4) bereavement debriefing . The above QI initiatives can enable CCC, however both top-down and bottom-up organizational commitment and support must be enacted . As highlighted in the IMPACT study, the use of quality indicators to drive improvements in palliative care settings is determined by the organization's orientation towards continuous improvement. Furthermore, sustainability is determined by the perceived value of the QI package which can differ across settings (i.e. specialist palliative care vs. generalist care). Finally, 'top-down' engagement approaches were reported to be less effective .
We assert palliative and end-of-life care as the 'gold standard' for operationalizing CCC. Given that palliative care should begin once a life-limiting condition is diagnosed [19, 70], the majority of patients and families who access healthcare can benefit from CCC. The findings of this review can be applied by institutions and systems implementing and maintaining a culture of CCC as part of QI, accreditation and/or magnet status projects.
Our study validates the work of the Schwartz Center for Compassionate Healthcare and the Arnold P. Gold Foundation whose visual representation (Fig. 3) shows how person-family-centered care can be achieved when compassion and collaboration intersect and are supported within the family, community, education and healthcare systems . In addition, our work contributes to the understanding of the quality indicators within each system, with exception of the community and educational systems. It indicates how the CCC approach can optimize patient-family and provider outcomes, such as satisfaction with care and satisfaction with providing care, respectively. Although our analysis did not reveal key indicators related to staff turnover, it is reasonable to hypothesize that reductions in burnout/compassion fatigue will positively affect provider and staff retention .
As previously highlighted, the usefulness and applicability of the review's findings outside of facility-based end-of-life care cannot be assured. The community requires in-depth exploration, with Compassionate Communities representing an opportunity for comprehensive understanding. 'Compassionate Communities' or 'Compassionate Cities' are examples of CCC that are applied using a public health approach to comprehensively address end-of-life care at the community level . Now expanding across the globe, 'Compassionate Communities' engage citizens to partner with HCPs and others to meet the holistic healthcare needs identified by patients and families . As more of these communities evolve, evaluation of the fit of the quality indicators in the community setting will be interesting and may increase its utility.
Reliable and valid indicator measures will be required to measure quality outcomes of CCC. 'The Schwartz Center Compassionate Care Scale' is a new instrument that measures patients' perceptions of compassionate care provided by hospital physicians . It is unknown if the scale has been tested in end-of-life care settings, and the instrument does not provide a level of team engagement in CCC. With the growing debate on the ability to measure CCC, experts urge the inclusion of compassionate care elements in national surveys of patient experience using standardized protocol items . Sinclair's team is actively developing a patient-reported instrument to measure compassionate care, and this work will support the advancement of CCC within teams and organizations . Although patient and family satisfaction with healthcare is a quality indicator valued by most organizations, policy and institutional decision-makers are primarily driven by economic and high quality clinical data. Future work is needed to evaluate the benefits of CCC on costs, efficiencies, staff turnover and retention. Evaluation will be challenged by the complexity of the concept. Randomized controlled studies remain the bedrock of evidence-based practice, and their application in evaluating complex interventions can be fraught with challenges . Pragmatic trials and mixed methods studies may be more feasible to generate the strength of evidence needed to change practice and policy .
Our review adds to the existing body of knowledge and builds on the recent work and recommendations of several professional organizations and experts [3, 6, 7]. It overcomes the limitations identified by Gaertner et al. by providing an in-depth analysis of a complex phenomenon . With regard to the review process, rigor was supported through a comprehensive search strategy, using explicit inclusion and exclusion criteria. Two authors independently reviewed each citation and abstract, and a database was developed 'a priori' to support the organization and sharing of data. The authors met and reviewed their assessments and decisions, and came to consensus for all discrepancies.
This review is limited by a largely US literature sample, and the focus was end-of-life care. Therefore, the findings cannot be generalized beyond this population. There were no studies that explicitly examined the quality indicators of CCC as a primary outcome. The overall quality of the literature sample was weak since over two thirds reflected position/consensus statements, case studies, literature reviews and SCR reports which could not be appraised. Inter-rater reliability for the abstract reviews was not calculated. The usefulness of the quality indicators outside of end-of-life care settings will be contingent on the organization's structures and processes. Future studies and pilot implementation are required to further refine the key indicators.
Compassionate collaborative care (CCC) is an emerging, complex concept. Although limited by a lack of strong empirical evidence, it is of growing importance for healthcare quality. This integrative review suggests that CCC is inextricably linked to the inherent values, needs and expectations of patients, families and healthcare providers. Communication, shared decision-making and goal setting comprise the overarching processes, while development and satisfaction are overarching outcomes. These findings may be applied to facilitate the assessment and evaluation of existing structures, processes, and outcomes at the patient-family, provider, team, and organizational levels, and guide the planning of team and organizational changes to achieve the essential quality indicators for CCC. Given the growing numbers of individuals who require quality end-of-life care [19, 84], this review provides a synthesis of the evidence for clinicians, administrators, and policy makers wishing to maximize the delivery of CCC in palliative and end-of-life care settings.
We appreciate the support from Shereen Jonathan, Lisa Hamilton, and Madison Broadbent, undergraduate baccalaureate nursing students at the University of Windsor, who assisted with article retrieval and compiling reference lists.
The full datasets used and/or analyzed for the current study are available from the corresponding author on reasonable request. The literature sample summary and reduced data are included in this published article (Tables 2 & 3).
KP developed and conducted the search strategy, provided substantive expertise, extracted and screened articles, analyzed and synthesized the data, drafted the manuscript.
AM conceived the study and abstraction framework, extracted and screened articles, analyzed and synthesized the data, drafted the manuscript. Both authors read and approved the final manuscript.
Not applicable (integrative review study).
Government of Canada. Healthy workplaces. https://www.canada.ca/en/health-canada/services/health-care-system/health-human-resources/strategy/healthy-workplaces.html. Accessed 20 Sept 2016.
Canadian Interprofessional Health Collaborative (CIHC).A national interprofessional competency framework. https://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf. Accessed 15 Sept 2017.
World Health Organization (WHO). Department of Human Resources for Health. Framework for action on interprofessional education and collaborative practice. 2010. Ref #: WHO/HRH/HPN/10.3 http://www.who.int/hrh/resources/framework_action/en/. Accessed 26 June 2017.
Barrett J, Curran V, Glynn L, Godwin M. CHSRF synthesis: Interprofessional collaboration and quality primary healthcare. Ottawa: Canadian Health Services Research Foundation. 2007. Available at: http://www.cfhi-fcass.ca/Migrated/PDF/SynthesisReport_E_rev4_FINAL.pdf. Accessed 19 July 2017.
Bankston K, Glazer G. Legislative: Interprofessional collaboration: What's taking so long? OJIN. 2013;19(1). doi:10.3912/OJIN.Vol18No01LegCol01.
World Health Organization (WHO). (2017). WHO definition of palliative care. http://www.who.int/cancer/palliative/definition/en/. Accessed 26 June 2017.
The Arnold P. Gold Foundation. Gold Foundation Launches Triple C Initiative to Promote Compassionate, Collaborative Care. http://www.gold-foundation.org/newsroom/blog/gold-foundation-launches-triple-c-initiative-to-promote-compassionate-collaborative-care/. Accessed 26 June 2017.
Letts L, Wilkins S, Law M, Stewart D, Bosch J & Westmorland M. Critical review for qualitative studies (version 2.0); 2007. https://srs-mcmaster.ca/wp-content/uploads/2015/05/Guidelines-for-Critical-Review-Form-Qualitative-Studies.pdf. Accessed 20 July 2017.
Institute for Patient and Family-Centred Care (n.d.) Patient and family-centred care. http://www.ipfcc.org/about/pfcc.html Accessed 13 July 2017.
The Schwartz Center. Schwartz Center Rounds. 2016. http://www.theschwartzcenter.org/supporting-caregivers/schwartz-center-rounds/. Accessed 26 June 2017.


Learn from your peers! In Dr. Bergeron's April vlog, she shares what Head Start and Early Head Start programs across the country are learning, planning, and doing to serve families experiencing homelessness. She asks programs to be sure their Program Information Reports (PIRs) accurately identify families' living situations and offers guidance about the McKinney-Vento definition. Dr. B also answers questions about home-based services for families experiencing homelessness.


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The Dow Left These 2 Stocks Behind
Rich Duprey, The Motley Fool, AOL.com
Jun 7th 2012 1:41PM
The Dow Jones Industrial Average soared 286 points, or 2.4%, yesterday as it looked probable not only that "Helicopter" Ben Bernanke would make it rain with yet another round of quantitative easing, but that his peers in Europe were going to begin a massive stimulus to bail out their defunct financial system as well. Some stocks missed the memo and absolutely crashed yesterday. Here is a look at some of the companies that fell hardest.
Sleep on it
Shocking as it may seem -- well, the market was shocked by it, at least -- sellers of specialty mattresses have a hard time pushing product in a recession. Tempur-Pedic (NYS: TPX) rolled over yesterday, losing half its value after reporting that it expects revenues to fall next quarter and keep dropping throughout the year. Competition for its specialized foam mattress is growing, and analysts forecast that it doesn't have the moat they thought it did and will lose share in the market.
That caused other mattress makers to drop as well, though none took nearly the drubbing Tempur-Pedic did. Select Comfort (NAS: SCSS) -- the maker of the uber-expensive Sleep Number beds -- and Mattress Firm lost more than 20% of their value while Sealy (NYS: ZZ) was down a more modest 5% on the day.
It was just two weeks ago that shares of mattress stocks were springing up after the International Sleep Products Association said that the number of mattresses shipped posted a year-over-year 6.6% increase in April. Perhaps that should have been a warning sign instead that traditional mattresses might be more popular (and affordable) than their high-priced specialty competitors.
Select Comfort, however, did recently report its own earnings, which showed a 36% increase in sales on a 34% jump in comps. Though 88% of those rating the mattress maker on Motley Fool CAPS do see it outperforming the broad market averages, the low two-star (out of five) rating they've assigned it suggests they think you'll sleep better if you put your money elsewhere.
Tell me on the Select Comfort CAPS page or in the comments section below whether you agree its business is firming up, and then add the Sleep Number purveyor to the Fool's free stock tracking service to see how dreamy it can be.
Alternative-energy specialist FuelCell Energy (NAS: FCEL) was another one that was recently riding a wave of investor sentiment higher, only to have its hopes dashed on the shoals of a sour quarterly report. But it was its own second-quarter numbers that did it in, as revenues fell 15% from a year ago, and it continued to report losses, albeit narrower ones than last year.
The profit picture was actually better than analysts anticipated, and FuelCell said it was able to grow the gross margin line because of restructuring it had done. And that's promising, because this was the first quarter in the last five that didn't show year-over-year revenue rising.
Unlike the mattress industry, where the entire sector rolled over, both Ballard Power and Plug Power seemed unaffected by FuelCell's results.
The alt-energy provider's backlog was also higher than last year's -- though, as Fools know, backlog doesn't always neatly translate into revenues. Yet it's important to note that the pending business doesn't include the recent memorandum of agreement signed with South Korean steelmaker POSCO (NYS: PKX) for 120 megawatts of power.
I'm in agreement with CAPS member slohariw that FuelCell's "earnings forecasts seem achievable," and with POSCO funneling it business regularly, it should snap back from this fall. But you can have your say on whether the fuel cell specialist's future is still bright in the comments section below, and then add the company to your watchlist to see whether that backlog business gets any bigger.
Ready for a resurrection
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At the time this article was published Fool contributor Rich Duprey holds no position in any company mentioned. Click here to see his holdings and a short bio. The Motley Fool owns shares of Tempur-Pedic International. Motley Fool newsletter services have recommended buying shares of Select Comfort. The Motley Fool has a disclosure policy. We Fools may not all hold the same opinions, but we all believe that considering a diverse range of insights makes us better investors. Try any of our Foolish newsletter services free for 30 days.

redpajama_set_name: RedPajamaCommonCrawl


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Happy to share screen space with Rajinikanth, says Akshay Kumar
THE ASIAN AGE. | LIPIKA VARMA
Published : Dec 9, 2018, 12:05 am IST
Updated : Dec 9, 2018, 1:08 am IST
Akshay kumar on his films, South Indian filmmakers and why he does't mind working in multi-starrers.
Akshay Kumar is one actor who has always attempted to perform and produce films with a message. Films such as Padman, Toilet: Ek Prem Katha and Air Lift amongst others doesn't help solve our own problems, but makes society a better place to live in, he feels.
Akki who has been associated with South Indian makers like Priyadarshan and Prabhudeva is all happy to have shared the same screen space with the iconic Rajnikanth in the much awaited film 2.0 directed by Shankar. The actor shared his thoughts in a conversation with Lipika Varma.
On what he learned from Rajnikanth
When I met him for the shooting, I came to know that he's a Maharashtrian and speaks in Marathi. I spoke to him in Marathi. Even if you give him a tiny line to speak as a dialogue and perform as well, he makes it so stylish and full of swag. An ordinary line becomes an extraordinary line. I asked him how he does it. His style mantra is what I learnt from him throughout the film.
On the arduous process of Make-up for 2.0
The make-up process took three and half hours. Three people use to be around me. This was the toughest make-up I have ever had to go-through — it was practically third degree as the suit was thick and they would apply feathers.
When I removed the suit I would smell of sweat as there were no exit points for my sweat to ooze out. I could not eat as my body would bloat. Hence I was kept on liquid diet. I was kept in an AC cage. I could not move about. The cage would be pushed around. I felt like a bird who was allowed to come out and then put back in the cage. If I was out of this AC cage — the makeup would come off. I sat in for 38 days and I know what I went through. I am a very patient man but I have become more patient. They kept a bed ready so that I could lie down at times. After three days I was advised to take rest for a day. I had worn lenses which were thick and bigger than my eye ball. I suffered conjunctivitis one day but they took care of it. My eyes had turned red but that was bound to happen. The eye doctor was on the sets so were other doctors present to take care of my health.
On playing the antagonist role for the first time ever
If I am playing a negative role, it's a reel character. I don't think anyone will feel that having played a negative character I am like a villain in real life as well. They know I am not a negative human being. I am playing a character and only time will tell what I am doing. I know Amrish Puri did so many negative roles but people came and met him with a lot of love.
On roles in earlier films especially written for villains
I have been a fan of filmi villains like Amrish Puri, Danny, Ranjeet saab, Madan Puri, Jeevan and Ajit. Nowadays there are no villains, and no roles are specially written for them. Manoj Bajpayee and Nawazuddin are playing different roles. There is no set image. Everyone is playing different roles. If I get any character even if it is for just 15 minutes to perform on reel, I will certainly do it. I don't mind doing roles in a four-hero or five-hero film. I am doing a film Mission Mangal which has five heroines. No one asked what the other's role is. Everyone wants to be part of a good film. I am glad to be a part of a big film like this — it's one of the most expensive films in India. In Hollywood, actors do a lot of different roles, the trend is seeping in here.
On being replaced by Arnold Schwarzenegger
I come from a background where I didn't get roles. I don't care whom the role was offered to first. I am doing the film and I enjoyed doing it. Being associated with a film of such huge stature and that too technically well made, I would not mind even being director's fourth choice. I only care for good and appealing content. I have always tried to make films with high content even from my own production house. Audience mind has been opened in a vast way. They have so much choice on internet, cell phones and television. There is so much space for good content and now is the time to take risks and Shankar has done it.
On Being associated with South films
It's not the first time I am doing a South film. I had done a Kannada film Vishnu Vijaya directed by Keshu Ramsay in 1993. I have interacted and worked with many south Indian technicians and directors. I have done a lot of films with Priyadarshan and Prabhu Deva.
They work at a fast pace. They don't waste our time. They don't come late. They have better technologies. They try and upgrade themselves with latest technologies. In this film you will see that the mobile turns into a human form — when it walks, you will hear the sound from below the seat you are sitting in the cinema hall. The idea is to experience new technologies.
On South Indian film makers
For me 2.0 is a bigger film than Hollywood, though Hollywood makers have big budgets and no budgetary constraints.
In comparison to them, films by our South Indian makers is made with great content. They have a different and alluring vision, which are also technically great films in a meager budget. Surely, Hollywood makers won't be able to make a film on such scale with such a meager budget. South film makers are ready to take risks and make our country proud for making a world standard film.
On content oriented scripts from his Production house
I have always believed in content. My films will tell great stories. I am doing Kesari which is in the war and action zone now. I want to get into such new forms of making new films. Even Mission Mangal is an interesting film, but I can't talk about it.
On being a disciplinarian
I have been taught discipline from childhood. I have carried on the system. I don't take myself for granted. I do not like to waste anyones time. I can do things on time. If I don't take others for granted it means I am not taking my work for granted. Thus I always believe in time management. Look! We have been taught to reach school on time. If we are late we are marked late and at times may be rusticated from school. Thus I ask a question to everyone here. When because of the pressure of being rusticated, we always reached to school on time, why can't we simply follow the rule we have been taught during our school days….to always be on time?
Tags: akshay kumar, rajinikanth
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Barroso is elected to chair the 1st Panel of the Brazilian Supreme Court in 2023
By Lachlan Williams
Luís Roberto Barroso, minister of the Federal Supreme Court (STF), was elected on Tuesday, Dec. 6, to chair the 1st Panel of the Court in 2023.
Historically, the vote chooses the oldest member of the Panel who has not yet served as president.
However, Barroso was elected by acclamation, which is when the choice is unanimous among the ministers that make up the STF collegiate.
"Having the company of Your Excellencies has been an encouragement in this hard journey that we have chosen," said the Justice. "But we must joyfully fulfill the missions that life gives us."
Barroso will . . .


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Home » All About Us » Introducing Our Patrons: Camara Fearon
Introducing Our Patrons: Camara Fearon 2
15 May, 2017 in All About Us / Home / News by Natalie
The third and final of our new patrons is the supremely talented CAMARA FEARON.
Camara is a 20 year old multi-instrumentalist, singer, songwriter, musician, mentor, Presenter, actress and ardent Charity worker. A Multi-Award winner, she was even honoured at our very own Dr. John Roberts CBE QC 10th Annual Achievements Awards', receiving the inaugural STEVE McQUEEN CBE AWARD which was presented to her by the mother of the 12 Years a Slave director.
To list some of Camara's immense achievements so far:
At 10 years old performed at the Hackney Empire, where she was given a standing ovation.
She has performed at Sadler's wells Theatre with full orchestral and choir backing directed by Tim Steiner.
Life Changers Award 2010
Word4weapons Award 2012
LBWF Leaders Award 2014
Angel Foundation Award 2015
Lead vocalist at The Royal Albert Hall accompanied by full orchestra and band.
She was the first female/black youth to play 'Last Call' Trumpet solo at 11/11 Memorial service in LBWF.
Was the first non famous person to have her song lyrics in print in the Jack Petchey Foundation diary distributed to thousands of schools.
Camara was for 4 years, in the cast of 'The JA Story' a much renowned educational factual musical about Jamaica's people and its history which was written and produced by JD Douglas who also wrote Black Heroes Hall of Fame. The production toured the UK and by the 3rd successive year on the production Camara was elevated to principle singer, actress and dancer as well as being the official vocal coach at just 16 years of age. Considering she has had no professional training it can only be put down to hard work.
Invited to the House of Commons, where she performed one of her own penned songs called STAND UP MY PEOPLE. This event celebrated the Achievements and Contributions of Black and Ethnic minorities in LBWF.
She was a member of London Symphony Orchestra's Next Generation project for exceptionally talented musicians playing the trumpet and was also chosen to sing with the orchestra.
She has performed internationally and was a guest artist for the late ' Dr Myles Munro on his successful Motivational tour in Ghana.
Camara is an ambassador to eight organisations/charities including Through Unity and extending some charities in helping those in desperate need abroad.
Winning a prestigious SPIRIT OF LONDON 'Achievement through Music Award' Camara has been part of the successful mentoring workshops run in schools all over London organised by SOLA.
In March 2016 Camara won the Wise Women Award for the Most Outstanding young Christian women making a difference from within the Church and the Community
Is a regular at City Hall as a guest speaker and performer at International Womens Day hosted by Jennette Arnold
Since the age of ten, Camara has been heavily involved in the Anti-gun and knife crime campaigning in area's asking people to stand up against the crime, inviting gang members to believe in themselves and to give education another try.
In January 2014 Camara was given the opportunity to become and is now a columnist in an national/international monthly online newspaper called 'The Phoenix Newspaper', her column is called 'Camara's Spotlight' where charity matters and inspirational people are given recognition for their positive achievements.
After completing her A levels in 2015 she was headhunted and immediately offered a part time job with Word4Weapons in partnership with Ascension Trust as a PA Co-ordinator overseeing Weapon Bins in London and the Midlands, also running school mentoring workshops. Camara believes that God has truly been faithful as this has allowed her to work on her music and do his work.
We all can agree that Camara is an excellent role model, and it is a true gift for the kids and young people of Descendants to have someone so close to their peer group as a source of inspiration. Welcome Camara – we are all looking forward to working with you!
For more on Camara:
www.camaraofficial.com
www.youtube.com/camaraofficial
www.linkedin.com/CamaraOfficial
Camara (aka mizzcamara for websearch)
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2 thoughts on "Introducing Our Patrons: Camara Fearon"
Chima Luke Okafor September 8, 2017 at 6:00 am
So blessed to know this very talented young lady. May God continue to bless her
Margaret Noel November 19, 2017 at 4:32 pm
Yes she is a truly wonderful young Woman. Descendants is blessed to have her on board.
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Amongst other things, the credit crunch is also triggering currency fluctuations in the Pund Sterling and the US Dollar. As people may already know, the euro is getting stronger and stronger vs the Pound.
That is good news for those of us who buy books as book prices are often just euro equivalent of the sterling price. And sometimes a bit less. So I was able to buy Wrath of a Mad God on Saturday in O'Mahonys for €20.99 which is a bit less than the exchange rate would suggest. €20.99 is £16.47 at current rates, and the recommended retail price for the book is £18.99. So not too shabby.
UPDATE to correct figures from €22.99/£17.93 to €20.99/£16.47 for even cheaper books.
This entry was posted on Tuesday, March 25th, 2008 at 8:39 am	and is filed under Uncategorized. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.


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Q: create an array or list with different element sizes python I would like to create an array or list with different element size however, I got the output not as expected with a word array written in the middle of the array as in the following:
import numpy as np
lst_2=np.array([1,2,np.repeat(3,3),2],dtype="object")
print(lst_2)
#Output is=[ 1 2 array([3,3,3]) 2]
#lst_2 should be = [1,2,3,3,3,2]......

please any help or suggestion

A: You are mixing lists and numpy arrays. I presume what you want to achieve is a numpy array that looks as follows:
import numpy as np
lst_2=np.concatenate([np.array([1,2]), np.repeat(3,3),[2]])
print(lst_2)

Output:
[1 2 3 3 3 2]

Alternatively you can also use the following if you want a list:
lst_2 = [1,2] + list(np.repeat(3,3)) + [2]

The plus operator here stands for concatenation of two lists. Whereas the plus operator stands for elementwise addition in case of numpy arrays.

redpajama_set_name: RedPajamaStackExchange


We receive a report that one of Dr. E's workers is angry because one of the cameras on the roof is broken and he is blaming the Occupiers for this. We have no knowledge of how this could have happened but decide, in order to keep the peace, we will pay for the damaged camera. We will notify Dr. E of this asap. We are committed to maintaining good relationships with all workers and neighbors.
We discuss options for use of a space we have been offered which can be rented out to bands for practice sessions and also possibly used for Occupy benefits. People take on tasks.
We plan to have a BBQ at the camp in a few weeks. We will invite the workers and neighbors to attend. Plans will be finalized at the next G.A.( 6-16-12 6pm at the camp).


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Born: December 11, 1928
Died: January 30, 2014
11:00 a.m. Wednesday, February 5, 2014, at the United Methodist Church in Sutherland.
Rev. Kwang Song David Orthmann
CASKET BEARERS
Visitation will be at the church one hour prior to the service.
Piano ~ Joel Orthmann Vovalists ~ Andrea Orthmann Lindsay DeKok
Waterman Cemetery Sutherland
Betty L. Jensen
Betty Louise Fogelman, the daughter of Malcolm and Sarah (Husted) Fogelman, was born in O'Brien County, Iowa on December 11, 1928. She was raised in the Sutherland area and graduated from Sutherland High School with the Class of 1946. On June 24, 1949, she was united in marriage to Alfred E. Jensen at the Sutherland United Church of Christ. They raised their five children in Sutherland. Betty and Al enjoyed dance and card clubs and spent many hours fishing down at the river. She was an avid bowler and held various offices in the American Legion Auxillary and Eastern Star. She spent many hours babysitting with her grandchildren and great-grandchildren. She was a member of the Sutherland United Methodist Church. In June of 2006, after living most of their married life in Sutherland, Al and Betty downsized into a small apartment in Paullina,IA. In September of 2012, they moved to the Prairie View Campus in Sanborn, IA. Following Al's death on April 22, 2013, Betty moved to the Sutherland Care Center. She passed away there, surrounded by family, on January 30, 2014, at the age of 85. She was preceded in death by her parents, her husband, daughter Sherri and her husband, Tom Nelson, grandson Todd Nelson, great-grandson Damen Dau, two sisters and their husbands, Marion and Don Johnson and Marilyn and Paul Braunschweig, and nephew Gary Johnson. Left to cherish her memory are her children, Julie (Dennis) Dau of Granville,IA, Dale (Janelle) Jensen of Kansas City, MO, Andrea (Joel) Orthmann of Marcus, IA, and Jim (Dawn) Jensen of Sutherland,IA; 12 grandchildren and 25 great-grandchildren; a brother, Burdette (Faith) Fogelman of Webb, IA; in-laws, John (Helen) Jensen, Doris Jensen and Paul Jensen; many nieces and nephews, other relatives and friends.
Greenwood Funeral Home
216 South 2nd Street | Highway 59 South | Cherokee, Iowa 51012 | 712-225-4886
100 Eagle Avenue | Marcus, Iowa 51035 | 712-376-4886


For the Sake of the Children | Character Trailers | Fly on the Wall Productions | Video. Documentary. Multimedia.
For the children and grandchildren of the thousands of Japanese Americans held in internment camps, the memories of survivors were rarely even discussed. Many of our characters in For the Sake of the Children are therefore sharing their experiences for the first time. Watch these videos to learn more about how the legacy of the internment has made an impact on their personal stories.


An interesting closure on the top makes this box look silly. But maybe that's just how you want it.
An innovative and practical way of separating glass bottles in a box.
Shapes can be cut into the box, giving you extra branding and showing off your product.
Have some fun – just about anything can be created using cardboard.


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Home » LATICRETE SALESPERSON PROMOTED
LATICRETE SALESPERSON PROMOTED
Bernadette "Bernie" Anderson
BETHANY, CT - Laticrete, a global leader in the manufacturing of innovative systems for the installation of stone and tile, has announced the promotion of Bernadette "Bernie" Anderson to Regional Sales Manager for the Oregon region. Anderson signed on with Laticrete in 2008 as the Senior Architectural Specialist for the same territory, and will now lead all Laticrete sales initiatives for Alaska, Northern California, Oregon, Utah, Idaho, Montana, Wyoming and Western Canada. Anderson will now report to Ron Nash, the North American Director of Sales at Laticrete.
"Bernie has an extensive background in sales management with a proven track record that will help her be successful in her new role," said Nash. "She's extremely smart and aggressive, and we plan to see some great things happen under her leadership."
In her previous role as Laticrete Senior Architectural Specialist, Anderson worked closely with architects, specifiers and design professionals to promote the benefits of the Laticrete warranty program. Anderson has extensive experience in the stone and tile sector after serving as District Sales Manager for Master Tile West in Northern California prior to joining Laticrete. At Master Tile West, Anderson developed an architectural sales program targeting high-end custom home builders, and served in a similar capacity for four years at Bedrosian Tile & Marble.


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The Homeless Gospel Choir
Normal (2017)
A-F Records
Reviewer Sean Crawford
The Homeless Gospel Choir has always been one of the most compelling folk punk acts of the last few years. Singer songwriter, Derek Zanetti, caught my ear after 2014's I Used To Be So Young with his clever lyrics and relatively dynamic instrumental arrangements (at least, as far as folk punk goes). He struck an interesting balance between retaining that undeniably folk punk aesthetic, and adding a strong punk edge in the production as well as his energy.
Normal seems to be a transitional moment The Homeless Gospel Choir; while the majority of the record revolves around the standard Homeless Gospel Choir sound, the main event seems to be the handful of tracks on which Zanetti tests the waters in louder instrumental arrangements. While standard drums, bass, and electric guitar arrangements have been utilized on other Homeless Gospel Choir tracks, they still seemed to retain a very stripped back feel. Normal, on the other hand, will often go straight up pop punk; its title track sounds like the Menzingers, but twenty years younger, and "1983" sounds like a b-side from the latest Anti-Flag project (and I wouldn't be surprised to find that they had some involvement with the writing or production on this track, given its release on A-F Records, and Derek's relationship with the band).
The more subdued tracks on Normal seem to be lacking some of the sharp lyrical wit that I've come to expect from the band. This record sees the Homeless Gospel Choir straying away from politics, for the most part, and taking more of an introspective approach to lyrics, the notable exception being "Everyone". "Everyone" encapsulates everything I loved about the I Used To Be So Young, and it probably wouldn't have felt too out of place in its tracklist. It uses a simple and easy to follow structure to deliver subtly cynical, but simultaneously well spoken lyrics over a dynamic arrangement of instruments, which helps to set apart the Homeless Gospel Choir from other generic contemporary folk punk acts.
"Depression" is the other lyrical highlight of Normal, and has the quality of self deprecating humor that you might expect from the likes of Jeff Rosenstock. Other than that, the lyrics on Normal aren't bad by any means, but they fail to live up to the standard that Zanetti has set with his past efforts, and with the minimalism of The Homeless Gospel Choir's instrumentation, the lyrics really have to take center stage. In turn, tracks like that don't contain compelling lyrics or bombastic instrumentals, such as "6th Grade" and "Sometimes" feel a bit empty and unfinished, and grow stale with repeated listens.
Normal is definitely indicative of a new era of The Homeless Gospel Choir, and it's too soon to say whether that's for better or for worse, but this is a decent record, with a handful of great moments that you'll definitely want to check out if you're a fan of the band's previous work.
The Lillingtons: Project 313 [EP]
Foo Fighters: The Colour and the Shape


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Joshua Robert Akers Photograph Collection, 1915-1917
The Joshua Robert Akers Photograph Collection consists of eleven photographic prints collected by alumnus Akers that depict group shots of Oregon Agricultural College (OAC) students, all of which feature Akers. Akers graduated from OAC in 1917 with a BS in agriculture.
Images from this collection have been digitized and are available in Oregon Digital
Akers, Joshua Robert
ID: P 244
Extent: 0.07 cubic feet
11 photographs; 2 oversize boxes
The Joshua Robert Akers Photograph Collection consists of eleven photographic prints collected by alumnus Akers that depict group shots of Oregon Agricultural College (OAC) students, all of which feature Akers. The groups portrayed in the images are identified as the OAC Cadet Band and the Arcadia Club. Among the photographs is a panoramic print of the OAC Band at the 1915 Panama Pacific International Exposition in San Francisco, California.
Images from this collection have been digitized and are available in Oregon Digital.
Hailing from Portland, Oregon, Joshua Robert Akers studied agriculture at Oregon Agricultural College and graduated with a bachelor's degree in 1917. During his time at OAC, Akers was involved with the Arcadia Club, the Cadet Band, the OAC Chemists Society, and the College Orchestra. For the Cadet Band he played french horn. Akers went on to work for the aluminum industry in a number of facilities throughout the United States: Illinois, Pennsylvania, Kentucky, and South Carolina. For his administrative role in managing an aluminum plant during World War II, Akers received recognition by the U.S. Department of Defense for his civilian contribution to the war effort. Akers died in 1965. Author: Karl McCreary
Statement on Access: Collection is open for research.
Statement on Description: The panoramic photograph of the Cadet Band was originally described as a part of Harriet's Photograph Collection and was later transferred to this collection when more images were received from the donor.
Preferred Citation: Joshua Robert Akers Photograph Collection (P 244), Oregon State University Special Collections and Archives Research Center, Corvallis, Oregon.
Acquisition Note: These photographs were donated in two transfers to the former University Archives in 2002 by Murray Akers, Joshua Robert Akers' son
Acquired: 2002.
Finding Aid Revisions: This finding aid replaces information about the collection that was placed online in 2012.
Collection Material Type: CLD
College students--Oregon--Corvallis.
Oregon Agricultural College--Alumni and alumnae.
Oregon Agricultural College--Bands.
Oregon Agricultural College--Students.
Panama-Pacific International Exposition (1915 : San Francisco, Calif.)
Other images of Oregon Agricultural College students during the 1910s can be found in collections such as: the Armond C. Taylor Photograph Collection (P 139); the Fred Henshaw Photograph Album (P 305); the Willetta Moore Photograph Album (P 269); and the J. Llewellyn Spriggs Photograph Album (P 285). Images of the OAC Cadet Band can also be found in the OSU Band Photographs (P 104). Other views of students in the Arcadia Club are available in the Harriet's Photograph Collection (P HC).


Maureen Mitchell joined GE Asset Management (GEAM) in 2009 as president, Institutional Sales and Marketing, and in 2011 was promoted to president of Global Sales and Marketing. With over 25 years' experience in the investment management industry, including 20 in sales, Maureen has built a distinguished career. She previously spent 10 years with Bear Stearns Asset Management as a senior managing director.
A two-time Business 100 honoree, Maureen is a graduate of City College of New York with a graduate degree from Fordham University, and is a member of the GEAM board of directors and the board of directors of GE Investment Distributors, Inc., as well as a director of GE Asset Management Limited, a London-based GEAM subsidiary. She has also held board positions with nonprofit organizations.
Born and raised in New York City, Maureen is a first-generation Irish American with roots in Sligo, where her father worked as a lobsterman before immigrating to the U.S. with her Galway-born mother. She has two daughters, both of whom have traveled throughout Ireland with their mother.


A short journey through equity investments as social systems based on Ian's experience as a therapist. The group can get a taste of what he will be talking about here. It will be suitable for everyone— not only folks who dabble in the markets!
Ian Miller is a New York based psychoanalyst consulting in the field of investment psychology. He is a principle in the Accord Advisory Group; and will be beginning this visit to Australia with a talk in Melbourne called, "Blaming BP", about stock market reaction to the 2010 Deepwater oilspill.
Emotion at work is an emotive issue. If we are to believe what we read, organisations are rational places focused on task driven activities conducted in passion free (or potentially passion free) environments – that is unless those passions have been sanctioned by management as important for the delivery of the organisation's goals. Emotion is either 'good' or 'bad' – the former associated with job satisfaction and the latter with stress. Yet we don't attend or return from work in a feelings neutral manner. We tell stories of relationships; we articulate how work 'feels'; we are often required to demonstrate particular feeling. Organisations are emotional and emotion generating environments and attending to the emotional climate of organising can reveal rich intelligence about how systems function – so why are we afraid that organisations will collapse if emotion remains unmanaged?
Annette Clancy is an organisational consultant and psychotherapist from Ireland who currently lives in New York. She has a particular interest in the unconscious life of organisations i.e. what goes on 'under the surface' and emotion at work in particular. She is currently researching a PhD in organisational behavior and is looking at 'disappointment' in the workplace. Prior to starting her consulting firm http://www.inter-actions.biz she was an arts and cultural manager in Ireland. She can be found on twitter @annetteclancy. Annette was recently interviewed by the Australian Financial Review.
Organisations often think that a particular technology is the solution to all knowledge management (KM) problems. However, technology is only one element of KM. This presentation will look at the use of online collaboration tools and Intranets in a company size of 500+ employees. It will explore how technology is not the only thing needed in successful KM, but also the involvement of people, the strength in process, and the quality of content.
Nicole Punsalan is currently undertaking her Masters in Knowledge Management at the University of Technology Sydney.