Palliative care for non-palliative nurses

An ageing population means palliative care is no longer a specialised field – but training is lagging. By Amie Larter

In 2011, according to the Australian Bureau of Statistics, 14 per cent of the Australian population was aged 65 years and over. By 2056, this percentage is forecast to rise to 23-25 per cent.

As the population ages, a greater number of patients will require palliative care throughout their hospital admission. There is growing concern that this increase will put extreme strain on existing palliative care resources.

According to Yvonne Luxford (right), CEO of Palliative Care Australia, palliative care has traditionally been considered a speciality area focused largely on patients with cancer.

“This is an idea we really need to break down,” she says. “I think it probably started out being largely oncology based; but it has certainly moved on from that.

“The other misunderstanding is that palliative care is about terminal care. Of course it incorporates terminal care, but it is much broader than that. It’s perfectly normal these days for palliative care to be taking place at the same time as active care.”

The idea of palliative care is evolving and there is increasingly a recognition that not all services can be provided by palliative care specialists.

“We need to upskill our generalists to ensure that they are better able to meet the needs of an ageing population,” Luxford says. “We really need to get our district nurses, GPs and probably practice nurses better skilled in palliative care, as well as in recognising that a patient is dying. It is not always something that people are identifying.”

Linda Magann, a palliative care clinical nurse consultant, agrees and notes that palliative care is available to all patients, not just those with malignancy. In fact, there has been increasing evidence of its benefits to patients with a non-malignant diagnosis such as heart, renal and respiratory failure.

“Palliative care services should be most involved in those patients with complex pain or symptoms, and therefore all nurses should be skilled in caring for patients with end-stage disease,” Magann says.

Patients with life-limiting illnesses can be found on any ward in the acute hospital setting. There is a drive to improve efficiency in this area to combat future pressures on a system that is already dealing with tightened budgets and a shortage of skilled staff.

This coincides with evidence suggesting patients in acute hospital settings do not routinely die comfortably or with dignity, and that nurses outside of the oncology setting need guidance with the care of patients who have a palliative diagnosis.

“Palliative care is available at any stage of the patient’s life-limiting illness where they need pain and symptom management or psychological support,” Magann explains. “Nurses often require reassurance and guidance with the medications used in the palliative care setting and with pain and symptom management.”

The palliative care team at Sydney’s St George Hospital is thinking ahead, and has appointed a palliative care clinical nurse educator (CNE). The role provides clinical nurses working in a non-palliative setting point-of-care support and education in the management of patients requiring palliative care.

“Palliative care remains a challenging area for nursing practice and upskilling the nursing staff will improve care,” says palliative care CNE Victoria Tait.

According to Tait, the main role of the CNE is to “assess the knowledge and attitudes of the nursing staff working in the aged care, cardiology and respiratory wards”. The CNE will implement an education program and provide both formal and real-time teaching for nurses.

Tait believes that a lack of understanding and education is why palliative care has been a difficult area for nurses.

“For nurses working in the acute hospital setting, this change of philosophy from active to palliative care can be very challenging,” Tait says. “Nurses on the wards may well be caring for three patients having active treatment and one palliative-care patient whose needs are just as great, but for whom the goal of care is comfort and dignity rather than a cure.”

The team at St George Hospital, with assistance from Professor Ritin Fernandez from the Centre for Evidence-based Initiatives in Health Care, have embarked on a project to understand the knowledge and attitudes of nurses working in non-palliative care wards. They believe this is imperative for the development of education programs.

Analysis from the research has revealed nurses have a positive attitude towards palliative care but have large gaps in knowledge. These mainly relate to pain and symptoms, communication with patients and families, ethical decision making and end-of-life care.

The team is now designing an interactive educational program to address these gaps.

A nurse’s perspective

Nursing Review spoke to Kristine Tobin, clinical nurse educator for aged care from St George Hospital, about training for nurses in non-palliative settings.

NR: What preconceived attitudes (if any) do nurses have towards palliative care for patients?
Kristine: They believe it is only relieving physical pain; that it is the end and that it is negative. Some think that you can kill someone by giving them morphine (actually a very common idea amongst newer nurses).

NR: What areas of palliative care do you need more training in?
Kristine: Symptom management and communicating with the families and loved ones of the patients.

NR: How and why would nurses benefit from further training in palliative care?
Kristine: The nurses I work with deal with it all the time, and are often required to be advocates for the patients and prompt medical staff and families that it is time for a palliative approach.

In my experience, nurses are so focused on disease processes and trying to reverse them that they fail to be realistic and incorporate the patient in the process.

Palliative-care training would help them focus on the whole patient; not just physical aspects but psychological and spiritual. In my area (aged care), our patients have so many co-morbidities and underlying illnesses that we have to consider, a palliative approach should often be considered even if it isn’t for the acute issue we are treating them for at the time of admission. Most of my staff don’t understand this concept and require a lot of education around it.

NR: What are some of the challenges in an environment where one minute you could be providing active treatment for patients, then the next more palliative care?
Kristine: Staff require coping strategies for the emotional side of this as they find it difficult to deal with themselves and then have to support patients and families. The staff also find it difficult to come to terms with plans that include a palliative-type approach when they are still required to do things for the patients that they link with active treatment – for instance vital signs, intravenous antibiotics. They definitely struggle with differentiating between palliative care for a patient imminently dying and for someone who is not.

NR: How do you think training in palliative care for non-palliative nurses will benefit patients?
Kristine: Training gives nurses the ability to assess patients at a deeper level and a better understanding of patients’ needs holistically. It makes nurses more aware of patients’ wishes and insight into their own needs. Nurses are better able to care for patients requiring active treatment because they are better able to communicate and take a person-centred approach to care.

NR: Why would hospitals benefit from running such a program?
Kristine: It would give support to CNEs, who have to focus on immediate educational problems. Such a program would complement educational programs already in place by giving nurses that holistic view of patient care. A palliative-care training program also supports nurses by giving them skills of assessment and symptom management, which they can apply to all patients.

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