VOL: 98, ISSUE: 12, PAGE NO: 34
Rosaleen Bawn, RGN, BSc, DPSN, is a Macmillan clinical nurse specialist in palliative care;Terry Matthews is clinical development facilitator, Huddersfield Royal InfirmaryApalliative care link nurse group was set up at Huddersfield Royal Infirmary six years ago with the aim of enhancing nurses' skills and fostering the delivery of quality care to patients and their families.
Apalliative care link nurse group was set up at Huddersfield Royal Infirmary six years ago with the aim of enhancing nurses' skills and fostering the delivery of quality care to patients and their families.
The group now has 25 nurses, grades D to G, who meet once a month. At the beginning of each year it identifies training needs which determine the content of the year's programme. Attendance has been varied. Occasionally numbers are low, but as the group has become more established attendance has greatly improved.
A recent audit of 20 nurses in the group revealed that 80% attended the sessions in their own time. The barriers to attendance were as follows: 36% said that their off-duty timetable made it difficult for them to attend any courses, while a further 37% said that busy clinical settings had not allowed them to attend.
What is not in doubt is the nurses' motivation to attend courses. Rather than miss sessions or put colleagues under increased pressure, members of the group were prepared to attend in their own time. In a climate of poor staffing levels, stressful working conditions and an ever-increasing demand for nurses to spend more time on courses and continuing education, the results of this audit are thought-provoking.
There is no doubt that nurse education is a high priority in the field of cancer care, as it is throughout the health service. The Nursing Contribution to Cancer Care (Department of Health, 2000) says that all nurses, not only those specialising in the field, should have sufficient knowledge and skills to be competent and confident in dealing with people affected by cancer. The NHS Cancer Plan (DoH, 2000) states that it is important to make better use of the skills of existing staff and that investing in staff through education and development is crucial. Improving the Quality of Cancer Services (DoH, 2000) also advocates that all health care professionals involved in cancer care receive appropriate training and continuing professional development.
The Calman-Hine report (DoH, 1995) suggested that education should be an important function of specialist practitioners. Lloyd-Williams (2001) says the key to extending the provision of palliative care is education and the sharing of knowledge. Stjernsward (1996) comments that the provision of palliative care education is the responsibility of service providers.
Setting up the link-nurse group
In 1996, after a new Macmillan nursing service had been set up at Huddersfield Royal Infirmary, it became apparent that there was an urgent need for staff to be provided with information on palliative care. The link-nurse group was set up in the hope that it would resolve this situation.
Managers were asked to identify nurses, possibly through an individual performance review process, who would fit the criteria to become a palliative care link nurse. These specified that they should:
- Be a general nurse;
- Have a specific interest in palliative care;
- Have a commitment to attend and disseminate information to colleagues;
- Have good communication skills.
Many patients cared for by Macmillan nurses are in residential or nursing homes, so in 1998 staff from local nursing homes were invited to join the group. This resulted in representation from six homes. Before they became involved there had been little in the way of palliative care education in nursing homes.
The move follows a shift in the 1980s towards staff in nursing homes providing palliative care to patients with a non-malignant diagnosis. Nursing homes now provide palliative care to older people with a diagnosis other than cancer, and this usually involves caring for residents until their death.
It has been suggested that delivering palliative care can be stressful, which may be because nurses feel ill-prepared for their role. Although education is considered an integral part of the work of palliative care teams, there is little evidence to indicate the effect it has on practice (Macleod et al, 1994). However, Kenny's study (2001) established that palliative care education does make a difference to practice.
In 2000, four years after the link-nurse group had been set up, an audit was carried out in line with recommendations by Higginson (1993), who commented on the importance of the regular auditing of services. The aim was to measure the effectiveness of the education delivered to the palliative care link-nurse group and to determine whether it enabled the development of competent practitioners.
Palliative care education sessions held over one year were evaluated. A total of 20 link nurses were sent questionnaires, of which 15 (75%) responded. The five questionnaires not returned reflected the fact that some nurses had moved areas and could therefore no longer be considered link nurses.
The length of time each nurse has been a member of the group is shown in Table 1. At the beginning of each year the group identified learning needs through discussion and brainstorming. Subjects covered in the education programme included:
- Symptom control - pain, nausea and vomiting, dyspnoea;
- Different cancers;
- Breaking bad news;
- End-of-life issues;
- Complementary therapies;
- The role of the Macmillan nurse;
- Different religions/beliefs;
- Mouth care.
Barriers to attendance
When link nurses were asked if they found it difficult to attend sessions, 67% said 'yes', 20% said 'no' and 13% said 'sometimes'. It is noticeable that 80% attended in their own time. Table 2 lists their reasons for not attending.
Nurses were asked how the knowledge obtained from group sessions was disseminated to colleagues and team members. A total of 57% said they held ward meetings and one nurse held teaching sessions. Most (86 %) said they had developed a resource file, and some used both resource files and ward meetings to pass on the information.
To establish qualitative data, the respondents were asked what they would change about the sessions. Fourteen (or 93%) said they would not change anything about the sessions while one nurse wanted more time for discussion.
When asked: 'What do you enjoy most about the sessions?' the responses fell into the following three main categories:
- The group itself: 'relaxed atmosphere'; 'informal and relaxed'; 'feel able to speak when you want to'; 'always of interest and stimulating';
- Improving knowledge: 'opportunity to update'; 'learn new ideas and new information'; 'always something relevant to practice'; 'keeping up to date';
- Sharing: 'sharing ideas'; 'sharing experiences'; 'getting information from other areas'; 'knowing who to contact in difficult situations and being more likely to refer to Macmillan nurses'; 'knowing Macmillan nurses are available for support and supervision'.
When asked how becoming a link nurse had changed their practice, the comments were favourable and included: 'I feel more confident in my palliative care skills'; 'I feel I have more knowledge to change practice on the ward'; 'I have been able to advise others'; 'I have referred more patients with a non-malignant diagnosis'; 'I am more confident now and can discuss my new knowledge in meetings'.
The audit will be repeated annually to enable the educational content to be reviewed regularly and assessed. A copy of the audit and the information gathered was circulated to managers to encourage their continued involvement and keep them up to date. Letters were also circulated to ward sisters and followed up with informal discussion.
To complement the link-nurse programme, a one-day link-nurse conference is being organised later in the year. Nurses from a neighbouring trust, with which the trust we work for recently merged, have been invited to attend. Nursing and medical colleagues in specialist palliative care services will address delegates on a variety of topics, including 'Specialist palliative care: what it is and is not'; 'Cross-boundary working: link nurse as change agent'. There will also be workshops on symptom control and complementary therapies.
To boost the nurses' skills at disseminating information, a presentation skills session was introduced as part of the link-nurse programme. Following on from this, the group will put together a poster and present it at the conference.
A shadowing programme was also introduced, whereby members of the link-nurse group shadow a member of the specialist palliative care team, consolidating new information and gaining a greater insight into the specialist role. Nurses worked with a Macmillan nurse or spent a day at the hospice. Initial feedback from this programme has been positive.
The audit results suggest that the palliative link nurses have benefited from the programme and that it has made a difference to their practice. They enjoyed the sessions and their confidence increased, although the difficulties they face in trying to attend sessions during work time have been highlighted. The programme has motivated several staff to continue their palliative care education and register for further training, with some taking diploma courses.
Nurses who may be thinking about introducing such an initiative should be aware that keeping the programme interesting and stimulating to meet the needs of an ever-changing group of staff is a challenge.
However, the results of this audit have been encouraging. As has been noted, one of the roles of the clinical nurse specialist is to take responsibility for palliative care education, which ultimately leads to the delivery of quality care for patients and their families. As MacGuire (1990) comments: 'All programmes must ultimately be able to show that they have had a favourable impact on the health status of the population served by the learner.'
We believe that this audit shows that the link-nurse system can address educational needs. The evidence presented, in particular the qualitative data, suggests that nurses have become better equipped to care for patients with palliative care needs and their families. Through the programme, some have gained the confidence to take the initiative and change and improve practice.