The palliative care education needs of nursing home staff

BACKGROUND: Palliative care is delivered in a number of settings, including nursing homes, where staff often have limited training in palliative care. AIM: We explored the level of palliative care knowledge among qualified staff delivering end-of-life care in nursing home settings, to inform the development of an appropriate education and training programme. DESIGN: An audit of the educational needs assessment was performed using an anonymous postal questionnaire sent to 528 qualified nursing staff within 48 nursing homes. FINDINGS: In total, 227 questionnaires were returned giving a response rate of 43%. Results indicated that less than half the sample had obtained formal training in the area of pain assessment and management and less than a quarter had obtained training in non-malignant conditions. Registered nurses in this study reported a lack of awareness of palliative care principles or national guidelines. CONCLUSION: Qualified nursing home staff agree that palliative care is a valuable model for care in their setting. There are clear opportunities for improvement in nursing home care, based on education and training in palliative care. Results also support the need for enhanced liaison between nursing homes and specialist palliative care services.     

Dementia palliative care: A multi-site survey of long term care STAFF’S education needs and readiness to change

Many people with dementia reside in long-term care, where limited staff knowledge of dementia palliative care has been identified, along with poor awareness that a palliative approach can assist in identifying unmet care needs. Evidence-based guidance in palliative care for people with dementia is available however, implementing this guidance requires staff engagement and a tailored educational approach. This pre-implementation situational analysis informed a tailored staff education intervention to support the implementation of national guidance on dementia palliative care in long term care. Using a cross-sectional study design, underpinned by the Consolidated Framework for Implementation Research, survey data were collected on site profile, staff demographics, learning needs, and readiness-to change at three residential care sites for older people in Ireland. In total, 69 staff (predominantly nurses and healthcare attendants) completed the surveys. Medication management and management of pain were the most frequently identified learning needs. Staff were confident in their ability to implement change but de-motivation and powerlessness were substantial factors as only one-third of staff were “ready for change”. Staffing levels, managing risk during change and perceived reluctance in others were common barriers. These results informed an educational intervention to address the specific care context, staff learning needs and barriers to change prior to implementation.     

Developing palliative care practice in the community

The inadequacy of some areas of palliative care provision was acknowledged in the NHS Cancer Plan (DoH 2000). Many patients would prefer to die at home, but only one quarter are able to do so because of the lack of community or specialist palliative care teams in some parts of the country. The Lancashire and South Cumbria Cancer Services Network developed an initiative to meet the educational and training needs of practitioners delivering palliative care in the community.     

Provider perspectives on palliative care needs at a major teaching hospital

Jericho Metropolitan Hospital (JMH) is a major Australian teaching hospital which lacked a designated palliative care service at the time this study was conducted. A questionnaire addressing palliative care service needs, and educational and support needs of staff, was sent to 267 multi-disciplinary oncology staff at JMH. A response rate of 83% was achieved. Staff identified a number of palliative care needs that were being particularly poorly addressed by existing services. These included: spiritual support, cultural needs, grief and bereavement support, pleasant surroundings, adequate privacy and facilities for families. The majority of respondents identified the following issues as critical problems in palliative care provision: lack of a designated palliative care service, lack of palliative care education of staff, unmanageable caseloads and inadequate physical facilities for the provision of care. Only 24% of respondents reported having had any palliative care education, and 92% of respondents expressed a need for further education. The majority of respondents (79%) expressed a need for improved staff support. There was a significant association between perceived need for improved support and professional discipline (chi2 = 31.33, P < 0.002), with medical staff being significantly less likely than other staff groups to report a need for improved support. Overall, the health providers surveyed identified major deficiencies in the provision of palliative care to cancer patients at JMH and in the palliative care education and support for staff caring for terminally ill cancer patients. The findings support the need for a designated palliative care service at JMH to improve the standard of care of dying cancer patients, and the need for improved palliative care education and support for staff.     

Palliative care in nursing homes: exploring care assistants' knowledge

Aim.  To explore the level of palliative care knowledge and to identify educational needs of care assistants (CAs) working within a nursing home context.
Background.  In the United Kingdom (UK) many patients at the end-of-life are admitted to (or reside in) nursing homes, where they receive care from unqualified CAs who have little formal training. Mandatory training in specific skills to meet palliative care needs are absent.
Method.  Questionnaire to CAs in 48 of 91 private nursing homes in one UK region.
Findings.  A population of 1135 CAs were targeted with a response rate of 45% ( n  = 508). A high proportion of CAs in this sample required information about the philosophy and principles of palliative care. Results support the need for an educational initiative to improve palliative care in nursing homes.
Conclusion.  Although recognized as a common place of death for older people, CAs are often unprepared to provide end-of-life care to nursing home residents. It is recommended that attention be given towards developing the skills and knowledge of this staff group.     

A needs assessment for southern Manitoba physicians for palliative care education

Recent calls for increased palliative care education of physicians and a need to improve the effectiveness of palliative care delivery in rural areas are the stimuli for this study. The needs assessment evaluated educational needs and preferences of physicians practicing in three Regional Health Authorities in southern Manitoba in 2000, as well as semi-structured interviews with health care workers in seven rural communities. Physicians report their knowledge of symptom management issues as adequate, although for other issues in palliative care such as bereavement, psychosocial aspects of dying, and professional issues, they have less confidence. Physicians prefer learning through case studies, lectures, and self-directed learning, in settings close to their community, on the weekend. Qualitative analysis from the semi-structured interviews revealed themes related to the role of physicians in rural palliative care: i) a need for physician education, ii) physician participation within the palliative care team, and iii) physician involvement in patient-centered care.     

Medical education in end-of-life care: the status of reform

Deficiencies in education about end-of-life care are widely recognized, both in the "formal" or structured curriculum, and in the "informal" curriculum (the culture in which students are immersed as they learn medicine). Numerous approaches to addressing these deficiencies have been identified. These approaches include developing palliative care leaders; improving curricula; creating standards and a process for certification of competence; creating and enhancing educational resources for end-of-life education; faculty development; growing palliative care clinical programs as venues for education; textbook revision; and creating palliative care fellowship training opportunities. Current efforts in these areas are reviewed, and barriers to their implementation are highlighted.     

A needs assessment for a palliative care curriculum

To ensure the success of a new curriculum at an institution, information about the educational needs of learners, available resources, and potential obstacles needs to be systematically collected and analyzed prior to the development and implementation of the actual curriculum. This process, known as needs assessment, is important in the development of palliative care training for internal medicine residents, because internal medicine has only recently begun to address these issues in a formalized way and palliative care is a relatively new topic in medical education and clinical medicine. Therefore, institutional issues and resistance, lack of knowledge and appropriate attitudes among trainees and faculty, and a paucity of educational models for individual internal medicine training programs present potential obstacles. Although curricula that have been developed by national organizations can serve as “guideposts,” these documents are unable to address the specific needs and culture of an individual institution. This paper outlines a systematic methodology of needs assessment for palliative care curricula at individual institutions that could be applied to the development and implementation of palliative care training for different groups of learners. An institution-specific needs assessment was developed based upon the findings of a systematic literature review and interviews with experts in palliative medicine and medical education. The following methods were utilized: 1) an anonymous survey; 2) focus groups; 3) topic rankings; and 4) individual interviews. The needs assessment revealed the following educational, clinical, and institutional information: 1) interns had very little exposure to palliative care in medical school; 2) there was no formalized system for formal education and clinical exposure; 3) tremendous interest in palliative care education existed; 4) patients, families, physicians, and nurses perceived a need to improve the quality of palliative care; and 5) there are several political, logistical, and resource (time and financial) obstacles that needed to be addressed. An institution-specific needs assessment is an important part of the successful development and implementation of any new curriculum for medical residents and was specifically necessary for our palliative care program. As a result of the needs assessment process, a curriculum consisting of ten units of case-based and problem-based teaching was successfully implemented.     

The challenges and opportunities in providing end-of-life care in nursing homes

Approximately 20% of deaths in the United States occur in nursing homes. That percentage is expected to increase as the population continues to age. As a setting for end-of-life care, nursing homes provide both challenges and opportunities. This article examines factors that impede the delivery of high-quality end-of-life care in nursing homes, such as inadequate staff and physician training, regulatory and reimbursement issues, poor symptom management, and lack of psychosocial support for staff, residents, and families. In addition to discussing hindrances to providing end-of-life care, this article explores characteristics of nursing homes and their staff that support the care of terminally ill residents. Also included is an overview of models for delivering end-of-life care in nursing homes, including provision of hospice services, specialized palliative care units, and consultation services. Finally, this article discusses educational programs and current educational initiatives to enhance end-of-life care in nursing homes.     

Development of a rural palliative care program in the Calgary Zone of Alberta Health Services

Specialized rural models of palliative care are greatly needed to address the challenges rural communities face in providing palliative care services and to ensure that their unique strengths and needs are considered. In late 2005, a Rural Palliative Care Program was developed to support primary care providers in delivering palliative care to patients in rural communities outside of Calgary, Alberta, Canada. The program was grounded in the needs of individual communities, incorporated integral roles for local champions, and adopted pre-existing, accepted rural structures and processes. Needs and gaps in rural palliative care service delivery were identified and prioritized. The following actions were taken to address the top six priorities: 1) more accessible palliative care education opportunities with a rural focus were provided to health care professionals; 2) linkages with rural and urban resources were strengthened and access to specialists and procedures was improved; 3) strategies were implemented to improve psychosocial support for patients and families; 4) resources were developed to facilitate rural home deaths; 5) opportunities were expanded for education and utilization of volunteers; and 6) a mobile specialist consultation team was developed to support rural health care professionals and their patients in their rural communities. In its first four years, the team consulted on 640 patients, nearly three-quarters of whom died in their rural communities. Rather than imposing an urban outreach strategy, the development of a rural-based program through respectful engagement of local providers has proven to be crucial to the success of this rural palliative care program.     

End-of-life Nursing Education Consortium (ELNEC) Training Program: improving palliative care in critical care

The integration of palliative care in critical care settings is essential to improve care of the dying, and critical care nurses are leaders in these efforts. However, lack of education in providing end-of-life (EOL) care is an obstacle to nurses and other healthcare professionals as they strive to deliver palliative care. Education regarding pain and symptom management, communication strategies, care at the end of life, ethics, and other aspects of palliative care are urgently needed. Efforts to increase EOL care education in most undergraduate and graduate nursing curricula are beginning; yet, most critical care nurses have not received formal training in palliative care. Moreover, educational resources such as critical care nursing textbooks often contain inadequate information on palliative care. The ELNEC-Critical Care program provides a comprehensive curriculum that concentrates on the requirements of those nurses who are working in areas of critical care. Extensive support materials include CD-ROM, binder, Web sites, newsletters, textbooks, and other supplemental items. The ultimate goal is to improve EOL care for patients in all critical care settings and enhance the experience of family members witnessing the dying process of their loved ones.     

End-of-Life Nursing Education Consortium. Geriatric Training Program: improving palliative care in community geriatric care settings

Recent studies of end-of-life care in nursing homes and other long-term care settings point to a significant need to improve care. The End-of-Life Nursing Education Consortium (ELNEC)-Geriatric Training Program is an important educational initiative to advance palliative care and end-of-life education for licensed nurses and nursing assistants. The ELNEC-Geriatric Training Program prepares nurses as educators and leaders to improve the quality of end-of-life care in geriatric care facilities. This article presents evaluation data from the 2007 pilot ELNEC-Geriatric Training Program and follow-up evaluation of the "train-the-trainer" model to disseminate comprehensive palliative care education in geriatric settings.     

Palliative care philosophy in care homes: lessons from New Zealand

Increasing numbers of people are dying in care homes yet little is known about the nature and quality of their deaths. The limited research available suggests that there is a need to promote a philosophy of palliative care that is not confined to the terminal phase of life. However, adopting such an approach appears to be inhibited by a lack of understanding, education and training, as well as continuing reluctance to discuss issues of death and dying in an open and honest way. Drawing on data from a large convenience sample of caregivers in New Zealand, this article argues for a reappraisal of the way in which care homes view death and dying and advocates the more widespread adoption of a palliative care philosophy.     

Palliative care curriculum development: a model for a content and process-based approach

To ensure its success, a new curriculum has to meet the needs of learners, patients, and the institution. A review of the literature indicates that despite a tremendous need for palliative care services and a lack of appropriate knowledge and attitudes among physicians, few palliative care curricula for medical residents have been developed. Most are developed by national organizations, and as a result can not meet the individual needs of different institutions. This paper outlines the process of developing a palliative care curriculum in the context of available institutional resources that meets the learners' needs. The development of a curriculum can be divided into four phases: needs assessment, curricular design, implementation, and evaluation. Content (curricular content, instructional strategies and available resources for the curriculum and the developmental process) and process (methods through which the curriculum is developed and institutional issues are addressed) issues that are pertinent to the successful completion of each phase are discussed. Two hypothetical institutions are used to illustrate relevant issues. Methods that have been successfully used to develop residency curricula are discussed.     

Raising the profile of care home nursing through collaborative working

AimTo explore the innovative educational practices of two care home teams based in the United Kingdom (UK). Both homes aimed to provide education and developmental opportunities so that they could further deliver effective nursing care to residents. Through such practices, the care homes sought to enhance nursing career development and improve workforce retention.Meeting the long-term care needs of older people remains a challenge and the nursing workforce need to be adequately supported to deliver effective care. Employers have an important role in supporting the educational and developmental needs of nursing staff so that they can fulfil their challenging roles.ConclusionUsing several approaches to nursing education and development, the care homes described in this Discussion Paper were able to show positive impact. Considering the care home workforce shortage and employability churn, it is hoped these ideas can offer inspiration to others in the sector.     

Educational opportunities in palliative care: what do general practitioners want?

It is important to support general practitioners (GPs) in maintaining and developing their palliative care skills as most of the final year of a patient's life is spent at home under the care of the primary health care team. The training needs and uptake of GPs have been explored, but little is known about how GP educational preferences vary. The aim of this study was to explore the current educational preferences of GPs in different geographical locations as part of an evaluation of an educational intervention. The methods used included postal questionnaires sent to 1061 GPs. Results from 640 (60%) of GPs revealed that half (51%) wanted education in symptom control for non-cancer patients. More inner-city GPs wanted education in opiate prescribing (43%), controlling nausea and vomiting (45%), and using a syringe driver (38%) than their urban and rural colleagues (26%, 29% and 21%, respectively). Increased educational preference and increased difficulty in accessing information was associated with reduced confidence in symptom control. To maximize educational uptake it will be important for educational strategies to be developed and targeted according to variations in demand, and in particular to respond to the need for palliative care education in symptom control for patients suffering from advanced non-malignant disease.     

New directions in palliative care education

In the past, palliative care education in the United Kingdom has tended to be patchy and ad hoc, rather that systematic and comprehensive. Recently the picture has begun to change, and this paper identifies and discusses three areas where developments are occurring. Firstly, educational provision has become more comprehensive and systematic, so that the needs of staff in all care settings and at all levels of practice and experience are now being addressed. Secondly, palliative nursing curricula that draw on research into the problems of nurses working with dying patients and the dimensions of the supportive role are now being developed. Thirdly, a number of initiatives are underway to assure the quality of palliative care education. Two of those initiatives concern the preparation, support and evaluation of educational roles and the development of educational research programmes.Presented as an invited lecture at the 4th International Symposium: Supportive Care in Cancer, St. Gallen, Switzerland, 24–27 February 1993     

Developing palliative care practice in nursing and residential care homes: the role of the clinical nurse specialist

The development of practice is but one aspect of Clinical Nurse Specialists' (CNSs) work, and a number of factors act to shape the extent to which CNSs are able to work with and develop practice with nursing and residential care homes. A postal survey of 730 community CNSs in palliative care working in the UK was undertaken to explore the involvement of these nurses with nursing and residential care homes. Much of the focus of the involvement was reactive work meeting the direct clinical needs of residents, primarily with cancer. Although the CNSs perceived that there were some educational and care deficits in these care settings, the amount of proactive work undertaken to improve practice was limited. The development work undertaken was focused on educational initiatives and establishing link nurse systems. There is potential to develop palliative care practice in nursing and residential care homes through practice development initiatives.     

Developing rural communities' capacity for palliative care: a conceptual model

The population in Canada and other developing countries is aging, increasing the need for palliative care services. In rural communities, care of dying people is normally provided by health care professionals as part of a generalist practice, not by palliative care specialists. Despite a lack of specialists and resources, some rural communities have developed local palliative care programs. The goal of this research was to conceptualize rural communities' process of developing palliative care programs using a theoretical perspective of community capacity development. Data were from nine focus groups of interdisciplinary rural health care providers who provided palliative care in seven provinces/territories of Canada. The outcome is a theoretical model that conceptualizes the process of developing palliative care programs in four sequential phases: antecedent community conditions, a catalyst, creating the team, and growing the program. The activities of each phase are outlined. This research offers practical and theoretical knowledge to guide practitioners and planners seeking to develop palliative care programs in other rural communities.