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Fast-track palliative care training to bridge the theory-practice gap

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Health care professionals often lack time to reflect and develop their practice after academic study. This was a problem for nurses in Northallerton who had undertaken educational modules in palliative care. As a result, Hambleton and Richmondshire Primary Care Trust’s specialist palliative care team developed a fast-track palliative care training programme.

Abstract

VOL: 100, ISSUE: 12, PAGE NO: 38

Chris Ward, MA, BSc, RGN, is nurse consultant for adult palliative care, Hambleton and Richmondshire Primary Care Trust, Northallerton

Majella Wright, BSc, RGN, was formerly Macmillan clinical nurse specialist, Friarage Hospital, Northallerton

 

Health care professionals often lack time to reflect and develop their practice after academic study. This was a problem for nurses in Northallerton who had undertaken educational modules in palliative care. As a result, Hambleton and Richmondshire Primary Care Trust’s specialist palliative care team developed a fast-track palliative care training programme.

 

 

The programme was set up in 2000. It gives nurses and allied health care professionals an opportunity to study and to consolidate their knowledge through clinical experience with the support of mentors from the palliative care team. Students observe patients in various palliative care settings and contribute to their care and to the support of carers.

 

 

After completing the programme they undertake a project that involves changing their own team’s practice in an aspect of palliative care. This enables them to translate theory in to practice.

 

 

Background to the programme
The palliative care team recognised that nurses lacked time to incorporate academic theory into daily practice. There was also a need to develop nurses’ palliative care skills to meet the requirements of a number of policy documents (Department of Health, 1999; 2000a; 2000b; 2000c; National Institute for Clinical Excellence, 2003).

 

 

The training programme was developed around the needs of patients, students and the primary care trust (PCT). The trust spans a geographical area of 1,000 square miles and has a population of about 118,000 people. The rural nature of the area means providing an equitable service to the whole population is a challenge but both the team and the PCT support the concept of providing palliative care ‘as close to home as possible’.

 

 

The team gained approval to develop the programme from North and East Yorkshire Workforce Development Consortium and received approximately £18,000. This paid for staff replacement, travel expenses, administrative support and the purchase of specialist publications.

 

 

Training aims and objectives
The programme was designed to develop a skilled workforce in palliative care and to bridge the theory-practice gap. Its objectives were to enable students to:

 

 

- Appreciate the principles and practice of palliative care;

 

 

- Assess the palliative care needs of patients and carers;

 

 

- Undertake reflective practice;

 

 

- Develop skills in the management of symptoms;

 

 

- Appreciate the role of various organisations in the provision of palliative care;

 

 

- Provide leadership within their team;

 

 

- Implement a change in practice.

 

 

Setting up the programme
Patient needs

 

 

Evidence suggests that most patients wish to die in their homes if their circumstances permit (NICE, 2003; DoH, 2000b). Whether or not this wish is fulfilled often depends on the primary health care team having the skills to provide effective palliative care. It also depends on ward staff understanding the importance of timely discharge planning and knowing what level of support will be available to patients and carers.

 

 

The fast-track programme aimed to equip students to ensure patients and their carers would have a choice regarding place of death, and that they would be supported in making this choice.

 

 

Staff needs
The Calman Hine Report (Expert Advisory Group on Cancer, 1995) stated that all professionals who care for people with cancer should be appropriately trained. However, The NHS Cancer Plan (DoH, 2000b) recognised that cancer education had received insufficient funding and stressed the need to rectify this situation. The Nursing Contribution to Cancer Care (DoH, 2000a) highlighted the importance of succession planning and of developing career pathways for professionals from all disciplines providing cancer care. The fast-track programme was therefore developed for all nurses and allied health professionals.

 

 

The NHS Cancer Plan (DoH, 2000b) also recognised that underfunding in the NHS had resulted in staff being overworked. The palliative care team realised that it would be necessary to remove students from their normal workplace during the programme. Students were therefore required to obtain consent from their line managers in order to be seconded to the palliative care team for a month.

 

 

Structure of the programme
A training programme was agreed (Box 1) and it was decided to limit student numbers at any one time to three. In addition to the four-week secondment, students also had to undertake a project that would involve changing and/or improving an aspect of practice relevant to palliative care in their workplace. Negotiating the project had a number of benefits - it enabled the students to gain support from their line managers and ensured that the project would be achievable and valuable both for themselves and the organisation.

 

 

The project was to be undertaken over a period of six months. It would provide experience of project management, change management, and the evaluation of the effects of the change. Students were required to present the project to line managers, trust executives, and the palliative care team. Project details were then disseminated throughout the trust in order to facilitate the sharing of good practice.

 

 

Management of training schedules
The programme has been undertaken by 14 nurses to date. They came from a variety of settings including community nursing, chemotherapy, community hospitals, and acute hospital wards.

 

 

Acceptance on to the programme was dependent on line manager approval. Student selection was based on performance in the academic module and an assessment of the proposed project. Initial meetings were held with prospective students and line managers.

 

 

Students completed a baseline knowledge questionnaire to assess their competence. This focused particularly on symptom control and management of palliative care. Learning objectives were set and issues of secondment, mentoring, and optional placements were discussed. Issues such as staff replacement and funding were also addressed with line managers.

 

 

Students were given detailed timetables of their clinical placements. For the optional week they chose to undertake a variety of placements. One student decided to look at mesothelioma in more detail, another spent a week observing palliative care provision at the Royal Marsden Hospital, and a third worked with lymphoedema specialists in Dorothy House Hospice.

 

 

They were also encouraged to develop local networks and to work with HIV specialists and chemotherapy, radiotherapy and complementary therapy services.

 

 

Students working in secondary care were encouraged to work alongside their community nursing colleagues in order to develop an appreciation of palliative care provision in primary care.

 

 

Evaluation of the training programme
Evaluation has been a fundamental principle in streamlining the programme to meet the needs of students, palliative care teams, and significant organisations.

 

 

For the first four cohorts, students were asked to complete knowledge questionnaires and semi-structured taped interviews were held to ascertain their views on the benefits of the programme and how it could be improved. Members of the palliative care team were invited to give written reports expressing their views on the content, the administration, and the management of the programme.

 

 

Evaluation now consists of an informal interview with the programme coordinator after the four-week placement, and completion of the knowledge questionnaire. The programme is also evaluated through the presentation of the projects.

 

 

In order to ascertain the retention and development of learning, students complete the knowledge questionnaire again one year after finishing the programme. Without exception all have retained their knowledge and some have continued to improve.

 

 

Comments from the students
All students have found the programme to be a positive experience. Negative comments have drawn attention to the unpredictability of palliative care. Students often had to ‘wait around’ while practitioners dealt with telephone calls or unexpected situations. Travelling long distances to placements and hospices, though acknowledged to be unavoidable, has also been identified as a difficulty.

 

 

Several nurses have commented on the benefit of having time away from their usual duties to concentrate on palliative care. One said: ‘It’s given me time to reflect and think about what we do for our patients.’

 

 

A common theme throughout students’ feedback has been a significant increase in confidence and a desire to develop skills and to put knowledge into practice. One nurse highlighted this saying: ‘I look after palliative care patients and sometimes I shy away from discussing their problems. I hope I’m going to have more confidence with this now.’

 

 

Another nurse commented on how the training had altered her view of palliative care: ‘It was incredible and very humbling to actually see that these people are living. They are not dying, they are living and they are loving every day.’

 

 

Working in palliative care can be challenging both on a personal and professional level. The programme gives students time, ‘space’, and support to enable them to develop greater self-awareness. One said after completing the programme: ‘I know now where I’m going, and what I can give to others.’

 

 

Results of the programme
The ward and community teams to which the students belonged felt that the programme had increased their knowledge of palliative care and that they were now a valuable resource within the team. One student had not undertaken academic study for some time and the programme clearly motivated her to challenge not only her own practice but also that of others. It also gave her the confidence to consider further academic study.

 

 

The projects have been a fundamental part of the programme and have undoubtedly contributed to changes in practice (Box 2). One such change is the addition of an information pack for bereaved relatives. This is financed by ward-donated funds and is given to families when they return to collect the deceased’s belongings.

 

 

One community nurse has developed an interest in mesothelioma and is now a link between her PCT and national mesothelioma nurses group. The programme has brought about many tangible changes, improving the care of patients who have palliative care needs and that of their families.

 

 

Advantages and disadvantages
Overall the programme was considered an overwhelming success. However, it presented several challenges. It is time-consuming to coordinate and organise. And initially it placed heavy demands on a small team of three Macmillan nurses who invariably had someone shadowing them for the period of the secondment.

 

 

Patients and carers were accommodating and supportive of the programme. They made no negative comments but both the Macmillan nurses and the students felt that occasionally conversations were guarded. It was suggested that patients might not always have wanted a third person sitting in on their conversation. This is now less of an issue as the team has expanded and students are not seeing the same patients every time.

 

 

Releasing staff from the workplace is always difficult, particularly with staff shortages and heavy workloads. It was hoped that funding staff replacements would alleviate the pressures on students’ workplaces. However, more often than not positions remained uncovered as no suitable replacements could be found.

 

 

Gauging the scheme’s success
While the programme has presented challenges, these have been outweighed by its benefits. The palliative care team and PCT are particularly impressed with students’ creativity and ability to develop practice that positively impacts on patient care.

 

 

The overall aim of the programme was to enable students to feel more confident in practising palliative care, however, it has also contributed to succession planning. Of 14 nurses who undertook the programme, six have received promotion and one student from the first cohort has been appointed as a Macmillan nurse within the team and now acts as coordinator for the programme.

 

 

The programme is recognised as being an innovative and practical approach to enhancing learning and developing evidence-based care. It has received a North Yorkshire NHS Modernisation Award and has been used as the foundation for a district nurse training programme developed by Cancer Care Alliance for Teesside, South Durham and North Yorkshire Palliative Care. The palliative care team also won the Nursing Times Cancer Nursing Award 2003, which has enabled them to publicise the programme at a national level.

 

 

The future
The programme continues to evolve to meet stakeholders’ needs. The team plans to improve its assessment of competence and hopes to make the programme more appealing to allied health care professionals.

 

 

There are also plans to extend the programme to include nurses from care homes and to attract nurses working within mental health and learning disability teams. It is anticipated that by the end of 2004 all community nursing teams will have a team member who who has undergone either the fast-track training programme or the Cancer Care Alliance Palliative Care District Nursing training programme.

 

 

A member of the team was recently appointed nurse consultant in adult palliative care, which involves linking up with universities and influencing education provision. Students currently gain credits for the academic module. Enabling them to gain academic credits for their secondment and project work is a goal and developing links with York University may be one way of achieving this.

 

 

Finally it is hoped that this innovative yet simple approach to bridging the theory-practice gap can be shared and built upon for the future. The programme demonstrates tangible improvements in the care of this very vulnerable group of patients.

 

 

Chris Ward was part of the palliative care team that won a Nursing Times Award 2003 for Cancer Nursing.

 

 

For details of this year’s NT awards visit www.nursingtimes.net

 

 

This article has been double-blind peer-reviewed.

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