Relevance of Palliative Care Training in Nursing Practice - Literature review Example

Relevance of Palliative Care Training in Nursing Practice Palliative care is professed as an effective method of quality care for alleviating pain of terminally ill patients, as it promotes both the physical and psychological well-being of the patient and family. This is attained through multidisciplinary care teams. Even though much scientific advances have been made in medical care for treating people with progressive and fatal diseases, yet efforts to prepare health professionals to confront the needs of dying patients have begun only recently with the propagation of palliative care. Palliative care has generally been linked with end-of-life care of cancer patients, but considering its effectiveness in reducing suffering of patients and their family the concept has now been extended to include non-cancer population as well. “Dying patients need to be assured that their destiny lies in the hands of well trained, multi-disciplinary, professional team because often the dying are no longer capable of caring for themselves and their rights.” (Gronemeyer, et al 2005, p.1). Hence, effective implementation of palliative care will be possible only through adequate training and grooming of health care providers. Since nurses interact most with patients and act as intermediaries between other health care providers and patients and their family members it is imperative that addressing training needs of nurses is crucial for success of palliative care program. As such, an attempt has been made to analyze select articles related to experimental models of palliative care and training strategies relevant to nursing practice. Method: University of Wollongong Library’s electronic resources were searched for locating relevant articles. Though Google scholar has larger volumes of articles, considering the fact that Proquest data base covers specific nursing related peer reviewed journal articles, search was limited to Proquest database only. The basic search question used was ‘Palliative care’, which retrieved 7982 articles from Proquest. Further search of the data base for ‘medical sciences-Nursing and allied health sources’ short listed number of articles to 130. When the results were limited to full text documents of scholarly journals 23 articles have been retrieved. Five articles with different area of coverage, such as (1) Nurses’ perceptions around providing palliative care for long-term care residents with dementia; (2) Providing pediatric palliative care through a pediatric supportive care team; (3) Using high-fidelity simulation to educate nursing students about end-of-life care; (4) Enhancing meaning in palliative care practice: A meaning-centred intervention to promote job satisfaction; and (5) Spiritual development of nursing students: Developing competence to provide spiritual care to patients at the end of life. Since large volumes of research articles (303,000) have been retrieved from Google scholar using the catch phrase ‘Palliative care’ and only 5 articles have to be selected for literature review it has been decided to search Proquest data base and cover palliative care experiences in two challenging areas, such as pediatrics and geriatrics (dementia), and three articles covering innovative training approaches; Nurses’ perceptions around providing palliative care for long-term care residents with dementia The study conducted by Kaasalainen et al (2007) explores nurses’ perceptions around providing palliative care for long-term care (LTC) residents with dementia, using a qualitative descriptive design. The inspiration for this study was the unprecedented increase in aged care population with cognitive impairment and identification of ‘many barriers to optimal palliative care in LTC homes’ in Canada. Dementia is a progressively degenerating physical condition leading to gradual loss of cognitive abilities. It is pointed out that there are several barriers related to quality terminal dementia care and palliative care for residents with dementia is ‘suboptimal’. This is because health care providers have higher workload demands, limited training and education, and also there is failure to implement a timely end-of-life care plan. Kaasalainen and team have conducted their study in three LTC facilities in southwestern Ontario, Canada after obtaining ethics approval from concerned ethics review board (2007). They have used ‘criterion sampling’ to ensure representation of registered nurses, registered practical nurses, and personal support workers who worked in dementia care and/or general units at each of the three LTC facilities and the focus group was held on site at each institution for the convenience of the participants. A semi-structured interview guide, with questions that have been ‘adjusted and modified to pursue various theoretical issues that arose as the interviews progressed’, was used to conduct this qualitative study. All the communications that transpired during the interview have been digitally recorded and transcribed verbatim and nonverbal communications have been noted by a second moderator. A ‘template organizing style of interpretation’ by assigning special code to the data was developed and qualitative software program ‘N-Vivo’ was used to manage the data. It is further stated that ‘the team used a number of approaches to ensure rigor in this study’ for avoiding possible thinking biases about palliative care in LTC. By regular review discussions of research team and obtaining multiple opinions of participants the findings of the study were refined and an audit trail was done to ensure dependability of conclusion. The study found that the main goals of participant nurses were facilitating a “good death” for patients with and without dementia; ‘having dementia made the dying experience unique for each resident’ and lack of awareness that the dementia patients were dying created additional challenges for nurses; and educating and training nurses in pain management and bereavement skills for consoling and removing guilt feeling of the family members of patients under palliative care was another area of support required by nurse practitioners. Most important finding of the study was need of nurses to take time to care and grieve themselves because attending multiple demands of dementia unit, which is not conducive to providing effective palliative care, was more challenging. Kaasalainen et al (2007), based on study findings and work of others, conclude that ‘both supportive and educational initiatives are needed for families as well as for the nurses themselves who care for dying residents’ and ‘the addition of an advanced practice nurse (APN) can facilitate and improve palliative care processes’. They acknowledge that ‘relatively small sample size of focus groups’ limits efficacy of study findings and including other stakeholders would enrich data. It is suggested that further research with a larger sample size using a grounded theory approach ‘could result in the development of a theoretical model describing these relationships in a more comprehensive manner.’ This study substantiates the relevance of high quality palliative care not only in dementia patients under LTC but for terminally ill patients suffering from other maladies also. Providing pediatric palliative care through a pediatric supportive care team: Chronic life-threatening conditions may put children under considerable suffering and premature death, even as we expect children to live longer. Jennings (2005) in the article titled ‘Providing Pediatric Palliative care through a pediatric supportive care team’ published in ‘Pediatric Nursing’ propose that “the devastating effects associated with the death of a child can be lessened by providing palliative care’ (Jennings, 2005). According to the American Academy of Pediatrics (AAP) ‘Palliative care seeks to enhance quality of life in the face of an ultimately terminal condition. Palliative treatments focus on the relief of symptoms (…) and conditions that cause distress and detract from the child’s enjoyment of life’ (Jennings, 2009). Providing pediatric palliative care is more challenging as health care needs of children differ from adults and existing end-of-life care designed for adults does not fit in the caring of children. The article narrates the success of pediatric palliative care initiative at St. John Hospital (SJH) at Detroit, Michigan, a 600-bed, non-profit, community hospital, utilizing established staff and services. The Pediatric Palliative Care Committee constituted at SJH was entrusted with analyzing the existing standard of care for children with life-limiting illnesses and chartering effective pediatric palliative care based on established guidelines as well as educating healthcare providers about the new comprehensive pediatric palliative care principles. The committee, headed by a pediatric oncologist certified in palliative care, comprised specially trained, inter disciplinary team. While child’s medical care was managed by pediatrician, clinical nurse specialist/nurse practitioner provided direct patient car, and the primary nurses coordinated interdisciplinary activities. Social workers, nurse care managers, pharmacists, dietary counsellors, spiritual care services, and child life specialists were also involved at various levels of the activity. The focus of the Supportive Care Team was ‘support, quality care, and ensuring continuity of care for the child and family from the hospital to outpatient visits, home, and school’ (Jennings, 2009). The activities, begun with a consultative service model of care, involved patient referral and assessment, continuing education for all concerned staff, and bereavement skill training. Even though there were no specific reimbursable palliative care services, with the concerted efforts of dedicated health care professionals the mission was accomplished successfully. Through the case study of a 16-year old child, diagnosed with acute lymphoblastic leukemia (ALL) at 9 years of age, who was diagnosed ‘relapse, no further curative treatment indicated’ the efficacy of pediatric palliative care approach has been narrated by Jennings (2005) in this article. How the palliative care team strived to accomplish last wishes of Jane, the child suffering from ALL, without causing much suffering either to the patient or her family members is insightful and true example of humane aspect of palliative care. This article once again establishes the positive aspect of palliative care that ‘builds staff confidence and satisfaction’ and dispel ‘fear of caring for children with life limiting illnesses’. (Jennings, 2009). (3) Using high-fidelity simulation to educate nursing students about end-of-life care: End-of-life (EOL) care is more challenging and stressful experience nurse practitioners are exposed to. In the article titled ‘Using high-fidelity simulation to educate nursing students about end-of-life care’ by Smith-Stoner (2009) it is proposed that providing nursing students with chance to practice pre and postmortem care in a clinical skills lab aided with high-fidelity simulations will prepare them to face stressful situations of end-of-life care. It is projected that “[s]imulators provide an effective bridge between the unknown of caring for a dying person and developing the skills necessary to facilitate a meaningful death experience for patients and their families.” (Smith-Stoner 2009, p.1). Though there is wide variety of educational models, a conceptual model, called “Silver Hour”, that provides ‘guidance in developing evidence-based and patient-centred care simulations’ has been developed by the author to guide and provide meaningful learning experience. It is stated that Jeffries’s Nursing Education Simulation Framework (NESF) (2007) has been used to develop the actual simulation. Course plan and selected learning objectives for end-of-life care has been narrated sequentially with focus of teaching, training activities, learning objectives, and components of scenario involved in Tables 1 and 2, which are well laid out and easy to understand. Simulation, using a manikin and the simulator equipment, is run by an instructor who acts as resources person. Student preparation and their responses during simulation and debriefing help to asses the effectiveness of the scenario. Though the tool is projected to have ‘good psychometric properties and has been used in a variety of pilot projects’ an evaluation of the scenario is crucial to establish its significance in nursing education. Even though the technology has many physical limitations, Smith-stoner (2009) suggests that “incorporating EOL care into simulation practice and research is essential if nursing education is to promote quality experiences for dying patients and their families.” Observations made by Smith-stoner (2009) in this article, based on experimental research and evaluation, will act as driving force for development of interactive teaching methods incorporating best practices. Enhancing meaning in palliative care practice: A meaning-centred intervention to promote job satisfaction Fillion and colleagues (2006) in their article titled ‘Enhancing meaning in palliative care practice: A meaning-centred intervention’ has attempted to introduce a new meaning-centred psycho-educational group intervention that aims to increase job satisfaction and quality of life to nurses engaged in palliative care. They have adopted Frankl’s ‘existential therapeutic approach, called logotherapy’ as the basic tenet for this intervention (Fillion et al 2009). It is alleged that palliative care nurses are exposed to emotional and occupational stresses associated with their work, because frequent encounter with terminally ill patients and their family members compounded with workplace stress are unmanageable. Fillion et al hypothesize that their three section article will create ‘framework and strategies for alleviating nurses’ burden of care, reduce stress, and increase their work satisfaction’ (2006). Adequate explanations related to workplace stress, how to cope with such stress, development and validation of interventions, and future course of action have been included in the article. Rationale and objectives of the study have been supported by more recent literature reviews and situations leading to stressful working conditions, particularly emotional stress in palliative care nursing, have also been elaborated. Next, concept of coping strategy and interventions in palliative care nursing, based on self-care strategies and intervention propounded by Frankl’s existential approach, are discussed. The description of three basic avenues under logotherapy substantiates the validity of the approach for adoption in palliative care, since ‘[l]logotherapy may provide concrete ways to help nurses find meaning and become conscious that meaning is a strong motivation for living, leading to lesser psychological distress.’ (Fillion et al 2009). Further, the program strategy has been tested in a select group of cancer patients with advanced disease that has been validated with the help of expert group composed of multidisciplinary experts in palliative care, nurses, physician, psychologist, and social worker. After pilot testing, using validated intervention through trained palliative care nurses, the feed-backs have been analyzed to make modifications and adjustments to the program. Facilitators, who are licensed psychologists, have also been trained to help them experience the ‘humanistic-existential approach’ and prepare them as skilled group leaders of the new program. A training manual was also developed. The participants were introduced to the new program through progressive session activities that instilled self confidence to pursue ‘search for meaning’ and equip participants with tools that will help them transform the stress they may experience at work. Though further research is proposed, it is suggested that this innovative meaning-centred intervention for palliative care nurses developed by Fillion et al (2009) have ’potential to contribute to the betterment of nurses’ quality of life and satisfaction and, indirectly, to the quality of care they provide.’ This article may be termed as experimental research paper, as it attempts to introduce a new approach in palliative nursing care. It is an innovative approach and further qualitative research is proposed by the authors. Since it is an attempt to find out new strategy suitable to enhance nurses’ competence through improving stress coping skills it will be irrelevant to criticize this article like other research articles. Spiritual development of nursing students: Developing competence to provide spiritual care to patients at the end of life Since nurses spend more time with their patients than other health care workers and studies have shown increased importance of providing spiritual care at the end of life, it is proposed that “spiritual needs of patients must be recognized as a domain of nursing care.” (Mitchell, Bennett & Manfrin- Ledget, 2009). The article published in Journal of Nursing Education by Mitchell et al (2006) is an attempt to address this unique area that has least coverage under classroom topics in nursing education according to Meyer (2003). Through case study-based examples, similar to teaching strategies recommended by Pimple et al (2003 cited by Mitchell et al 2006), this article attempts to provide ‘nursing faculty with tools that may be used to develop spiritually knowledgeable nursing students who can overcome barriers to providing spiritual care to end-of-life (EOL) patients.’ Mitchell et al (2006) hypothesize that ‘[s]piritual competence results in the professional and personal growth of students and healing for patients’, because spirituality is intrinsically interwoven into the web of patient care. Since nursing students are found to be unsure to make spiritual assessments it is suggested that ‘care mapping’, which is termed as ‘metacognitive approach to engendering critical thinking and synthesis in nursing students,’ will help them link theory and practice (Beitz, 1998, quoted by Mitchell et al, 2006). Main advantage of care mapping is that it encourages holistic view of patients and allows nursing students to ‘focus on the patient, rather than on the illness.’ It is achieved through spiritual self-assessment, development of spiritual assessment skills, and development of a plan of care using care mapping by nursing students. The case studies quoted in this article support the relevance of developing spiritual need assessment skills by nurses providing EOL care. Conclusion: An analysis of few articles related to palliative care, with special emphasis to nursing practice, revealed that it has more potential for relieving pain and suffering of terminally ill persons, whether young or old, and their family members. Adequate training and preparation of health care providers, particularly nurses, through innovative methods will ultimately lead to quality health care with complete job satisfaction. “Palliative care is comprehensive in affirming life and regarding dying as a natural process” and a well trained palliative health care team will assure efficient and effective quality care (Palliative care: improving the quality of care for patients with chronic, incurable musculoskeletal conditions a consensus document, n.d.). Reference Fillion, L et al. 2009, Enhancing meaning in palliative care practice: a meaning-centered intervention to promote job satisfaction: existentialism, meaning and logotherpy, Palliative & Supportive Care, vol.4, no.4, p.333, ProQuest, viewed 25 May 2009, http://proquest.umi.com.ezproxy.uow.edu.au/pqdweb?index=12&did=1456931351&SrchMode=1&sid=7&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1243038344&clientId=20901 Fillion, L et al. 2009, Enhancing meaning in palliative care practice: a meaning-centered intervention to promote job satisfaction, Palliative & Supportive Care, vol.4, no.4, p.333,ProQuest, viewed 25 May 2009, http://proquest.umi.com.ezproxy.uow.edu.au/pqdweb?index=12&did=1456931351&SrchMode=1&sid=7&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1243038344&clientId=20901 Gronemeyer, R etal 2005, Helping people at the end of their lives: hospice and palliative care in Europe: foreword by Gerda graf, LIT Verlag Berlin-Hamburg- Munster, viewed 25 May 2009, http://books.google.com/books?id=9j-ibAjzBTgC&pg=PA83&lpg=PA83&dq=palliative+care+%22dissertation%22+site:org&source=web&ots=j5Ltkpq_2I&sig=_ymxorhnWer39ijIN0qAAdY0u10&hl=en&sa=X&oi=book_result&resnum=1&ct=result Jennings, P D 2009, Providing pediatric palliative care through a pediatric supportive care team, Pediatric Nursing, vol.31, no.3, p.195, ProQuest, viewed 25 May 2009, http://proquest.umi.com.ezproxy.uow.edu.au/pqdweb?index=18&did=859511641&SrchMode=1&sid=7&Fmt=4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1243039285&clientId=20901 Kaasalainen, S et al 2009, Nurses’ perceptions around providing palliative care for long-term care residents with dementia, Journal of Palliative Care, vol.23, no.3, p.173, ProQuest, viewed 25 May 2009, http://proquest.umi.com.ezproxy.uow.edu.au/pqdweb?index=9&did=1380280401&SrchMode=1&sid=7&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1243038344&clientId=20901 Mitchell, D, Bennett, M J & Manfrin- Ledget, L 2009, Spiritual development of nursing students: developing competence to provide spiritual care to patients at the end of life: abstract(summary), Journal of Nursing Education, vol.45, no.9, p.365, ProQuest, viewed 25 May 2009, http://proquest.umi.com.ezproxy.uow.edu.au/pqdweb?index=15&did=1121916271&SrchMode=1&sid=7&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1243039285&clientId=20901 Palliative care: improving the quality of care for patients with chronic, incurable musculoskeletal conditions a consensus document: statement of the problem n.d., Naon: National Association of Orthopaedic Nurses: Advancing the Art and Science of Orthopaedic Care, viewed 25 May 2009, http://www.orthonurse.org/portals/0/images/PDF/PalliativePosition.pdf Smith-stoner, M 2009, Using high-fidelity simulation to educate nursing students about end-of-life care, Nursing Education Perspective, vol. 30, no. 2, Proquest, viewed 25 May 2009, http://proquest.umi.com.ezproxy.uow.edu.au/pqdweb?index=0&did=1711957381&SrchMode=1&sid=7&Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1243039285&clientId=20901 Read More