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Provision of palliative care education in nursing homes.

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VOL: 102, ISSUE: 05, PAGE NO: 36

Kathryn Mathews, RGN, DN, FETC, Dip Marie Curie Cancer Nursing, Dip Cancer Health Education

Jemma Finch, BA; are both clinical nurse specialists (palliative care) Liverpool Care Pathways Nursing Home Facilitators, Mount Vernon Cancer Network, Middlesex

Palliative care has increased in prominence over the past two decades within health care provision in the UK. Current government initiatives include £6m for additional training in palliative care for district nurses. This has ensured that all these nurses have had the opportunity to improve their knowledge on symptom control and care of dying patients. In contrast, few nursing home staff have had an opportunity for such education. This study aimed to explore the provision of education to nursing home staff across Mount Vernon Cancer Network (MVCN).

Palliative care has increased in prominence over the past two decades within health care provision in the UK. Current government initiatives include £6m for additional training in palliative care for district nurses. This has ensured that all these nurses have had the opportunity to improve their knowledge on symptom control and care of dying patients. In contrast, few nursing home staff have had an opportunity for such education. This study aimed to explore the provision of education to nursing home staff across Mount Vernon Cancer Network (MVCN).

Literature review
Over the past decade, changes in community care policy and changing demography have resulted in an increased admission of older and frailer people to residential and nursing homes in the UK (Laing, 1995). The changing profile of residents has resulted in an increased annual death rate of between 17 per cent and 35 per cent within homes and a corresponding increased demand for staff to provide care for older people with multiple conditions when they are dying (Sidell et al, 1997).

A number of reports and directives have encouraged the application of palliative care principles within non-specialist settings (Department of Health, 2000; National Council for Hospice and Specialist Palliative Care Services, 1997) and for patients with illnesses other than cancer (Addington-Hall, 1998).

Education is suggested as the means by which a palliative care approach can be facilitated in all care settings and several projects have specifically addressed palliative care in nursing homes through the provision of education and training (Dowding and Homer, 2000; Frogatt, 2000; Avis et al, 1999; Sidell et al, 1997).

The complexity of the care environment, the blurred financial responsibility for end-of-life care, the expertise of staff and the wishes of older people themselves all need to be taken into account within educational initiatives (Froggatt, 2001).

In 1997 Sidell et al undertook a two-year study to investigate the management of death and dying in residential and nursing homes for older people. Funded by the DoH the study was based on the assumption that high-quality care should be available to everyone in all settings (Castle, 1998). The authors acknowledged that despite the lack of formal training in palliative care many homes aspired to provide high-quality terminal care.

In many cases, however, palliative care training involved demonstration by one member of staff to another. Most members of staff found it hard to pinpoint the beginning of the terminal phase and few members of staff other than managers understood the term palliative care.

Most managers said their primary goal was to relieve discomfort for dying patients, although on exploration the focus of their concern was limited to physical care such as reducing incidence of pressure ulcers; only 20 per cent raised pain as a major issue. Most staff displayed minimal knowledge of the principles of pain control and many were not familiar with basic pain-relieving measures. Access to palliative care depended on relationships between GPs and staff in the nursing homes and the GPs' views on the appropriateness of palliative care in the residential setting.

While a great deal of emphasis is placed on educating nurses, it is important to remember that the majority of hands-on care is often provided by nursing assistants and ancillary staff. Dowding and Homer (2000) described the organisation of a palliative care study day for health care assistants (HCAs) and highlighted that many vocational and emotional needs were not being met.

A postal survey conducted by Froggatt and Hoult (2002) of 730 community clinical nurse specialists (CNSs) in the UK explored their involvement with nursing homes. It revealed that much of their work was reactive, meeting the direct clinical needs of residents, primarily those with cancer. Lack of continuity of staff in nursing homes was one of the most significant factors affecting developmental work in the homes due to staff shortages, rapid turnover, and work patterns. A lack of commitment by management to support practice development was also cited as a problem in sustaining education.

The majority of the literature appears to favour the use of education programmes and of palliative care practitioners as the means to improve palliative care for residents in nursing homes; however, this alone is insufficient to ensure changes in practice. Froggatt (2001) suggests a collaborative approach is needed to ensure a clear understanding of the nursing-home culture by all relevant professionals (nursing staff, CNSs, managers and GPs) responsible for delivering end-of-life care.

Without the involvement of nursing home owners and managers, future developments will be limited and resources for funding attendance at courses and releasing staff may not be made available. Appropriate interventions can then be designed to promote the integration of palliative care with nursing home practice to ensure the needs of older people at the end of their lives can be addressed.

Methodology
The palliative care nursing home education project was an idea conceived by the MVCN, which formed a steering group of interested parties to oversee the appointment of the researchers and to guide and support them during the study.

A letter was sent to 70 nursing homes explaining the aims of the project. Telephone contact revealed that only 51 were still operating and appointments to visit could only be arranged at 34 of these. However, these gave a reasonable spread of homes over nine PCTs.

A joint visit was carried out to the first three homes to ensure a standardised format to the questioning and interviewing processes. The remaining 31 homes were divided into geographical areas and each was visited by one researcher. A structured interview took place and the managers were encouraged to talk freely about issues.

The researchers also met palliative care education providers within the MVCN.

Results
Data from home managers

A total of 13 homes (38 per cent) had an education programme, 14 (41 per cent) had no programme and seven (20 per cent) did not know whether they had a programme or were in the process of setting one up (Fig 1).

The content of these programmes varied enormously. Some concentrated on statutory requirements such as fire, moving and handling, and food hygiene, while others included a more comprehensive programme for staff development. Only three homes (eight per cent) had a palliative care education programme specifically designed for their own staff provided by an outside agency (hospice/CNS team), while 12 (35 per cent) had access to courses provided by local palliative care teams - although the uptake varied. In addition five managers had a palliative care background and were keen to disseminate their knowledge to staff.

Policies relating to staff attending education or training sessions varied, with 25 (73 per cent) allowing staff to attend courses in working time and seven (20 per cent) expecting staff to go in their own time. The remaining two (five per cent) were unable to answer the question (Fig 2, p37). With regard to funding, 26 managers (76 per cent) said they would fund staff education providing it was relevant to their job, six (17 per cent) said they would not pay and two (five per cent) said they did not know (Fig 3).

The managers/heads of care were then given an opportunity to talk openly with the researchers about the palliative care education they would like to receive in their nursing home if resources were available. The researchers suggested a variety of topics including communication skills, pain control and breaking bad news. The overall response suggested that all aspects of palliative care education would be useful with the exception of spirituality and oncology, which eight managers (23 per cent) thought would be of little value.

Managers were asked to comment on the benefits of on-site training versus a large outside venue with an audience from other nursing homes across the network. On-site training was preferred by 20 managers/heads of care (58 per cent), while 12 (35 per cent) stated they would like their staff to attend a venue away from their work environment. Two (five per cent) had no preference. The main issues appeared to be transport to an outside venue and backfill of staff.

The ethnicity of staff employed by the nursing homes was mixed and some employed overseas nurses undertaking adaptation courses, while others relied heavily on overseas staff on short-term contracts to work as care assistants. Many of the homes therefore employed staff whose first language was not English.

Managers were asked to identify the health care professionals currently providing specialist palliative care within their home. In 20 nursing homes (58 per cent) there was involvement with the CNS/hospice team, nine (26 per cent) had never had any contact with such a team but were aware of their service and five (14 per cent) had no knowledge of the team (Fig 4). In addition, nine homes (26 per cent) had access to the local district nursing service while 25 (73 per cent) reported no contact. Some managers/heads of care stated that they were well supported by other health care professionals such as stoma nurses, continence advisers, wound care specialists and some pharmaceutical representatives. A total of 12 homes (35 per cent) had access to a link nurse and 22 (64 per cent) did not.

Eighteen managers/heads of care (52 per cent) said they had access to the internet. However, in many cases this was via their home computer as workplace computers were restricted. Sixteen (47 per cent) had no access.

In light of the recent guidelines on supportive and palliative care (NICE, 2004), managers/heads of care were asked whether they were familiar with the Liverpool Integrated Care Pathway for Care of the Dying Patient (LCP) and its implications for palliative care practice (Ellershaw and Wilkinson, 2005). Only five (14 per cent) had heard of the LCP while 29 (85 per cent) had no knowledge of it (Fig 5). In addition only four (11 per cent) had heard of the Gold Standard Framework (DoH, 2005) while 30 (88 per cent) had not (Fig 6, p40).

Palliative care education providers
The provision of palliative care education varied greatly between homes. In 2000 the government made £6m available for district nurse palliative care education, which was distributed throughout the UK cancer networks. MVCN disseminated its share of the money to education providers within the PCTs. Some of these providers have extended the education to include nursing home staff.

The results of the interviews highlighted the lack of a clear and coherent policy on nursing home education across MCVN's area. With no clear policy on funding of education or any format on educational objectives for palliative care training across the network a wide disparity in the provision of training has been identified.

Due to the lack of any central data system covering local nursing homes there is little available data on the numbers of patients with palliative care needs. This makes it difficult to target individual nursing homes with specific training requirements.

Discussion
It has become evident through the literature review and the findings of the research that the provision of palliative care education within the nursing home setting requires national attention. The researchers felt that in some cases home managers had limited knowledge of palliative care. In order to comply with the National Care Standards a few appeared to be focusing on obtaining their own management certificate and had therefore little time to coordinate staff training.

Many nursing homes experienced huge problems in recruiting and retaining staff. Since MVCN is in the south east of England, housing prices and the cost of living are high, which impacts on homes' ability to recruit and retain while keeping wages at an affordable level.

English is a second language for many nursing home staff. In one of the homes visited 80 per cent of the HCAs were Romanian and had difficulties communicating with patients and other staff. Since the extension of the European Union (EU) in 2004, many Polish nationals are also joining the nursing home workforce, some with limited English. Provision of palliative care education is therefore difficult to address as the needs of the nursing home staff population are extremely diverse with regard to both level of understanding and cultural background.

Managers were anxious for their staff to receive education, stating they would provide backfill to enable key workers to attend training. However, it was apparent that this was not always the case. On one course places had been booked but participants failed to attend, reporting that staff levels were so low that they were unable to be released from duty. In addition, several nurses attending the study day had fallen asleep during the lectures because they had been on night duty the previous night.

There was mixed response about choice of venue for any education that might be offered. Some managers thought it would be best provided in-house. They said they felt staff would be more likely to attend in-house courses as many neither owned nor drove a car and public transport had its limitations.

The managers also felt they would have some knowledge of what quality of education their staff were receiving if courses were held in-house, and said they might wish to attend themselves. Others thought it would be more beneficial for their staff to attend a full day's training in an out-of-house venue. This would allow them to network with staff from neighbouring homes, contribute towards PREP requirements and 'give the staff a day out'.

Education is the key to the delivery of high-quality palliative care but it has huge implications in terms of time and cost. The question of who pays for education in nursing homes is one of much discussion. Some of the local hospice palliative care teams are independently funded by charities. They see the growing population of large group-owned nursing homes as profit-making businesses and therefore believe they should pay towards their staff training.

Others feel that palliative care should be made available to everyone who needs it regardless of where they are being cared for. With new government initiatives and challenges in palliative care, nursing homes will have to address education funding. Patients in nursing homes should expect to receive the same level of care and services as the rest of the population.

Limitations This study had some limitations due to difficulty in obtaining a comprehensive and up-to-date list of nursing homes and defining the MVCN area. In addition, the researchers were employed for 20 hours a week over a limited period, and therefore could not become involved with complex search or sampling techniques and lengthy interviews with health professionals.

Conclusion and recommendations
A palliative care education programme that is appropriate for nursing home staff needs to be devised and initiated. A programme based on the Liverpool Integrated Care Pathway would ensure the main principles of palliative care were taught and that Key Recommendation 14 of the NICE (2004) guidelines Improving Supportive and Palliative Care for Adults with Cancer was adhered to.

An educational skills and requirements framework should be developed for the different grades of nursing home staff based on the LCP and an achievable programme for its delivery across the network over a defined timescale developed to ensure nursing homes are able to deliver a common standard of palliative care across the network. This would allow a realistic financial strategy to be developed and proper funding to be obtained to meet this key government target to improve supportive and palliative care in the community.

In the short term steps should be taken to make nursing homes aware of the specialist palliative care and support services currently available within the network. This can be achieved through direct contact or by nursing home staff attending various PCT training initiatives. A resource file listing services and contacts should be collated and given to each of the nursing homes in the network's area.

The following recommendations are relevant to any agency seeking to develop initiatives concerning palliative care in nursing homes within the MVCN; they may also be relevant to other cancer networks:

- Any education project should be underpinned by a process of collaboration between the project team and the owners and managers of the nursing homes;

- A framework of educational requirements; (standards and needs) for the various groups of staff working in nursing homes should be identified;

- A group of education providers from across the network should meet to develop a programme to roll out a palliative care education programme for the network based on identified requirements;

- An overall strategy with appropriate funding should be developed to allow achievement of the above aims;

- Education initiatives should initially be directed at registered nurses, as the turnover of health care assistants is high;

- Due to the large numbers of nursing homes in the MVCN area, a link nurse system should be introduced. It is suggested that two members of staff from each nursing home attend the education sessions and then disseminate the information they receive back to their colleagues. A written agreement between the nursing home managers and education providers would help to ensure nurses would be released from duty at the required time;

- The Liverpool Integrated Care Pathway would be an ideal template for an education programme as it incorporates the core principles of palliative care. This could be used in conjunction with the Macmillan Cancer Relief (2004) publication Foundations in Palliative Care: A Programme Offering Facilitated Learning for Care Home Staff (Katz et al, 2004);

- Every nursing home should have a resource file containing palliative care information and contact numbers for advice and support. This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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