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Dealing with death

Australian nurse educators are working to embed palliative care training firmly in undergraduate nurse programs, putting us ahead of some other countries. Megan Stoyles reports.

The growth in the ageing population in developed countries and their growing numbers in acute and aged care is forcing a rethink of undergraduate nurse education to integrate palliative care content throughout the nursing curricula in Australia.

Barriers limiting the integration of palliative care content into the undergraduate curricula traditionally included an overcrowded curriculum, limited access to specialist palliative care clinical placements, and a general reluctance to allow students to engage with a frail and vulnerable patient population.

Inadequate palliative care education among nurses caring for a terminally ill or dying resident or patient has been associated with inappropriate communication, lack of compassion and avoidance of the patient, as well as increased patient and family anxiety.

To improve the palliative care capabilities of the growing health and aged care workforce, the Department of Health and Ageing in 2005 began funding the development of the 'Palliative Care Curriculum for Undergraduates' (PCC4U) Program, led by Professor Patsy Yates of Queensland University of Technology.

The PCC4U online competency-based program now has four modules: principles, communication, assessment and optimisation. Course materials and desired graduate capabilities revolve around communication, appreciation of diversity, assessment principles, management of clinical issues, and reflection and self evaluation regarding the care of people facing life limiting illness, grief and loss, and changing goals of care.

By now, 20 out of the 38 Australian universities that have schools of nursing with undergraduate nursing courses are implementing PCC4U, with a further eight planning to adopt it over the next 12 months.

Dr Susan Lee, a senior lecturer in the palliative care research team, and master of nursing course leader at Monash University, is using the materials "widely".

"We have an undergraduate elective designed for year 2 students from any health science discipline. The unit runs in two semesters per year with up to 100 students per year across nursing, occupational therapy, midwifery and other disciplines," she says.

Students who wish to follow this unit up can also undertake elective clinical studies in palliative care in their following year, says Lee.

"In addition, we are using the PCC4U materials in a short course we have developed in partnership with the Gippsland region palliative care consortium. The aim of the collaboration was to build capacity in the region for the provision of a palliative approach in any health service.

"Participants in this program- registered and enrolled nurses, personal carers, service managers, and diversional therapists; come from acute, community and aged care facilities in regional, rural and remote towns," she says.

Lee says it is hoped that in 2012 the short course will be offered more widely.

Similarly, Dr Jane Phillips, professor of palliative nursing in the School of Nursing at the University of Notre Dame (UNDA) outlines how palliative care content, including PCC4U, has been"embedded" at all levels of its three year undergraduate nursing program.

She says the development of the UNDA nursing curriculum is underpinned by the PCC4U recommendations that all health professionals achieve key graduate capabilities. Among them is the ability for effective communication in the context of an individual's responses to loss and grief, existential challenges, uncertainty and changing goals of care.

They must also gain an appreciation of, and respect for, the diverse human and clinical responses of each individual throughout their illness trajectory, as well as an understanding of the principles for assessment and management of clinical and supportive care needs. Finally, they must gain the capacity for reflection and self evaluation of one's professional and personal experiences.

"Palliative care content has been both vertically and horizontally integrated by spiralling it across the entire nursing curricula," explains Phillips. "This allows the teaching of palliative care to be undertaken in many contexts across the curriculum at both the pre-clinical and clinical level.

"Throughout the undergraduate course various modes of delivery, such as lectures, tutorial, clinical practice units and palliative care clinical placements are used to engage nursing students in the palliative care learning experience, utilising PCC4U, EdCaN and Cancer Learning resources."

In addition to the palliative care content, second year students are also required to demonstrate their palliative competencies in the 'Acute Care Nursing' unit discussion, she says.

Phillips says that, as many nursing students will be confronted with death and the care of the dying during their first clinical placement, it is essential they have adequate clinical and emotional preparation so their first placement is a positive experience.

"Nursing students need to be well prepared so that on graduation they have good communication techniques to be able to readily identify and package the information that each patient and family requires it in a manner that best suits the patient's unique needs and circumstances.

"The co-location of medical and nursing students on the UNDA Sydney campus adjacent to Australia's oldest hospice means that the University is ideally placed to explore the potential for interprofessional palliative care education," she says.

Ahead internationally
With its efforts to incorporate palliative care firmly into undergraduate nursing programs Australia is moving ahead of some of its peers.

For example, the Canadian Association of Schools of Nursing is now testing new ways to include more palliative care training in undergraduate nursing programs, after a survey of 91 nursing schools revealed many inadequately prepare graduates to deal with death and dying.

According to the Canadian Medical Association Journal, a two-year project will pilot models for integrating new palliative care competencies into existing curriculum and accreditation standards in a bid to improve graduate readiness to deal with both the physical and emotional demands of terminally ill or dying patients.

The competencies - which cover practical skills, such as pain and symptom management, and 'soft' skills, such as "knowing how to be with suffering" - were developed after a survey conducted by the association in 2007 found existing programs offered little instruction and hands-on training in end of life care.

"Programs cover bits and pieces of things related to palliative care, but most of the time it depends on the knowledge and willingness of the instructor to talk about that connection as they're going through the module," says Darcee Bidgood, president of the Canadian hospice and palliative care nurses group, told CMAJ. She said this is often because the instructor lacks the resources or confidence to tackle death and dying.

"Some young nurses are lucky enough to find mentors to walk them through a situation and give them the space and guidance to process it emotionally, but in most non-palliative settings it's a case of sink or swim," she said.

Under the new competencies, nursing students will be asked to demonstrate self-care, communication and the ability to "recognise and attend to meaning in suffering," in addition to providing more practical care to the patient.

"It's about giving them space around the whole death and dying issue, so they can reflect, look after themselves and in some cases grieve," said Bidgood.

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