Background: Palliative care is an important but often overlooked component of primary care. In Myanmar, early emergence of palliative care is being seen, however no formal community-based services yet exist. Present challenges include resource scarcity and inadequate education and training.
Aim: Our goal was to improve understanding and approach towards palliative care by GPs in Yangon.
Method: An initial survey was performed among 42 GPs in Yangon, Mandalay, and Meiktila in March 2019 demonstrating a gap in current training needs and willingness by GPs for this to be improved. A 2-day workshop, the first ever of its kind, was subsequently designed and held for 20 local GPs, consisting of interactive seminars delivered in Burmese.
Results: Improvement in knowledge and confidence were used as measures of success. A true/false-style quiz was distributed pre- and post-workshop demonstrating a mean total score improvement of 15%. Self-reported confidence rating scores regarding confidence when: 1) managing palliative patients; 2) providing holistic care; and 3) breaking bad news, increased by a mean of 25%.
Conclusion: The greatest outcome from this workshop, by far, was the enthusiasm and awareness it generated, support was even gained from the President of the Myanmar Medical Association despite his initial reservations about developing this area. Ultimately, the workshop behaved as an advocate for the introduction of a regular palliative care lecture into the local Diploma in Family Medicine curriculum; it also spurred a group of GPs to further this work and turn the workshop into a regular teaching event.
Background: Advance care plans (ACP) provide patients the opportunity to communicate their goals and wishes for future care.
Local problem: A retrospective case note review of 50 inpatient deaths in 2017 confirmed a doctor had discussed expected death in 90%, however only 2% had an ACP.
Methods: Patients appropriate for ACP were identified on a single geriatrics ward. Interventions were implemented with monthly data collection. Patients with an ACP were followed prospectively. The initiatives were subsequently applied across six geriatrics wards.
Interventions: Interventions included improved identification of patients appropriate for ACP, doctor education and improved communication to general practitioners and healthcare providers.
Results: Before initiation of interventions on the pilot ward, ACP was completed for 38% of appropriate patients; this increased to a mean of 78.6% over 4 months post-interventions. During the pilot, 44 patients had an ACP. Of those discharged, 75% avoided readmission over the following 6 months. After applying the interventions across all geriatric wards, ACPs increased to a mean of 81.2% and was maintained 12 months later at 72%.
Conclusions: The initiatives formed a structure to promote the use of ACP on the wards. Care plans focused on individualising care and effective communication resulted in reduction of readmissions.
Context: During the course of March and April 2020, New York City experienced a surge of a 170,000 coronavirus disease 2019 (COVID-19) cases, overwhelming hospital systems and leading to an unprecedented need for palliative care services.
Objectives: to present a model for rapid palliative care workforce expansion under crisis conditions, using supervised advanced psychiatry trainees to provide primary palliative services in the acute care and emergency setting.
Methods: In response to the New York City COVID-19 surge, advanced psychiatry trainees at New York-Presbyterian Columbia University Irving Medical Center were rapidly trained and redeployed to a newly formed psychiatry-palliative care liaison team. Under the supervision of consultation-liaison psychiatrists (who also served as team coordinators), these trainees provided circumscribed palliative care services to patients and/or their families, including goals-of-care discussions and psychosocial support. Palliative care attendings remained available to all team members for more advanced and specialized supervision.
Results: The psychiatry-palliative care liaison team effectively provided palliative care services during the early phase and peak of New York City's COVID-19 crisis, managing up to 16 new cases per day and provided longitudinal follow-up, thereby enabling palliative care specialists to focus on providing services requiring specialist-level palliative care expertise.
Conclusion: by training and supervising psychiatrists and advanced psychiatry trainees in specific palliative care roles, palliative care teams could more effectively meet markedly increased service needs of varying complexity during the COVID-19 crisis. As new geographic regions experience possible COVID-19 surges in the coming months, this may serve as a model for rapidly increasing palliative care workforce.
Background: No studies have explored the pain resource nurse curriculum in the hospice setting. This curriculum offers a structured method to teach pain management to nurses.
Aims: The purpose of this study was to examine the effect of implementing a modified pain resource nurse curriculum on nursing knowledge in a community hospice agency.
Methods: A modified and condensed version of the pain resources nurse curriculum was presented to community hospice nurses during two educational sessions. A pre-test–post-test assessment was conducted using a modified version of the Nursing Knowledge and Attitudes Survey Regarding Pain tool to assess knowledge growth from the educational sessions.
Findings: For educational session 1, average correct responses rose slightly from the pre-test to the post-test. However, this increase was not found to be statistically significant. For educational session 2, average correct responses rose an average of 2.6 points. This increase was found to be statistically significant.
Conclusions: Based on this pre-experimental study, there is evidence that the pain resources nurse curriculum can provide an instructional framework for teaching hospice nurses. However, further study is needed, including a more rigorous design.
Although there is an increased need for delivery of bereavement care, many health care providers in acute care hospital settings feel inadequately prepared to deliver quality grief support, have lack of time, and have inexperience in provision of bereavement care. As a result, although families would like health care providers to offer bereavement support, they are inadequately trained and susceptible to burnout, resulting in families not having their needs met. The purpose of this qualitative study was to uncover the social process occurring in a bereavement education workshop titled "How to Care, What to Say" offered to health care providers. The goal of the workshop was to improve delivery of care for the dying and their family by providing holistic care to the family before, during, and after the death of a loved one. Past grief workshop participants who cared for the bereaved were interviewed, and data were analyzed and synthesized using constructivist grounded theory. Individual interviews and focus group data revealed participants' perceptions, learnings, and potential integration of the workshop into practice. The overarching theory of providing bereavement care that emerged from the data is "a relational process of understanding knowledge, self-awareness, moral responsibilities, and advancing grief competencies of providing holistic grief support."
PURPOSE: Patients with advanced cancer often have a poor understanding of cancer incurability, which correlates with more aggressive treatment near the end of life (EOL). We sought to determine whether training oncologists to elicit patient values for goals-of-care (GoC) discussions will increase and improve these discussions. We explored its impact on use of aggressive care at EOL.
METHODS: We enrolled and used block randomization to assign 92% of solid tumor oncologists to 2-hour communication skills training and four coaching sessions. We surveyed 265 patient with newly diagnosed advanced cancer with < 2-year life expectancy at baseline and 6 months. We assessed prevalence and quality of GoC communication, change in communication skills, and use of aggressive care in the last month of life.
RESULTS: Intervention (INT) oncologists' (n = 11) skill to elicit patient values increased (27%-55%), while usual care (UC) oncologists' (n = 11) skill did not (9%-0%; P = .01). Forty-eight percent (n = 74) INT v 51% (n = 56) UC patients reported a GoC discussion (P = .61). There was no difference in the prevalence or quality of GoC communication between groups (global odds ratio, 0.84; 95% CI, 0.57 to 1.23). Within 6 months, there was no difference in deaths (18 INT v 16 UC; P = .51), mean hospitalizations (0.47 INT v 0.42 UC; P = .63), intensive care unit admissions (5% INT v 9% UC; P = .65), or chemotherapy (26% INT v 16% UC; P = .39).
CONCLUSION: Use of a coaching model focused on teaching oncologists to elicit patient values improved that skill but did not increase prevalence or quality of GoC discussions among patients with advanced cancer. There was no impact on high care utilization at EOL.
Background: Nurses are involved in providing end-of-life care for end stage individuals and their self-efficacy is one of the key factors bearing on such care. The purpose of this study was to determine the effect of palliative care on perceived self-efficacy of the nurses.
Methods: this is a quasi-experimental study with pretest-posttest design. Sampling was randomized and included 40 individuals. The intervention consisted of palliative care training for four sessions, each lasting 45 min. Data were collected using demographic and perceived self-efficacy questionnaires completed before and after the intervention. Data were then analyzed by SPSS 16 software using descriptive and inferential statistics.
Results: The mean age of the participants was 38.6 and their work experience was 14.25 years. The majority of the participants were female (85%) and had a bachelor level of education (92.5%). The findings showed that “perceived self-efficacy”, “psychosocial support” and “symptom management” improved significantly after intervention (p < 0.05).
Conclusion: Based on the results, palliative care education has the potential to increase nurses’ perceived self-efficacy. Since all members of the health care team Including nurses play an important role in providing palliative care, nursing managers can take an effective step to maximize the capacity of nurses by planning and supporting training in this regard.
Evidence of quality of life improvements in patients with advanced-stage cancer has spurred a move towards early integration of palliative care into the outpatient setting. As discussed herein, meaningful and sustained improvements in timely access to palliative care requires commitments to funding, encouraging integration and routinizing referral across care settings. More palliative medicine training positions as well as broader education of clinicians and the public about the benefits of palliative care throughout the disease course are also needed.
Coronavirus disease 2019 (COVID-19) has brought a tsunami of suffering that is devastating even well resourced countries. The disease has wreaked havoc on health systems and generated immense losses for families, communities, and economies, in addition to the growing death toll. Patients, caregivers, health-care providers, and health systems can benefit from the extensive knowledge of the palliative care community and by taking heed of long-standing admonitions to improve access to essential medicines, particularly opioids for the relief of breathlessness and pain.
Background: Providing end of life care (EoLC) is an important aspect of primary care, which reduces the risk of hospital admission for most patients. However, general practitioners (GPs) seem to have low confidence in their ability to provide EoLC. Little is known about an adequate volume and kind of training in EoLC among GP trainees.
Methods: We performed a before-after comparison in all post-graduate GP trainees who were registered in the vocational training program (KWBW VerbundweiterbildungPLUS). They were offered participation within a two-day seminar focussing on palliative care in 2017. Those who attended the seminar (intervention group I) completed a paper-based questionnaire directly before the intervention (T1) and 6 months after (T2). None-attendees (group C) were also asked to fill out the questionnaire once. The questionnaire covered previous experiences in palliative care, self-assessment of competencies in EoLC in the organisation of patient care as well as in control of symptoms, attitudes towards death and caring for dying patients and questions about GPs’ role in EoLC.
Results: In total, 294 GP trainees (I: n = 219; C: n = 75) participated in the study. Of those, more than 90% had previously gained experience in EoLC mainly during vocational training in the hospital rotation. Around a third had previously gained competencies in EoLC in medical school. Between groups I (T1) and C no significant differences were observed in socio-demographic characteristics, pre-existing experience or overall expertise. At T2, 75% of participants of group I declared they have extended their competencies in EoLC after the intervention and 70% classified the intervention as helpful or very helpful. Overall, they rated their competencies significantly higher than at T1 (p < 0.01). In detail, competencies in organisation of EoLC and competencies in handling of symptoms significantly improved (p < 0.01). Due to the intervention, 66% could reflect their attitudes towards dying, death and grief and 18% changed their attitudes. Group I highlighted palliative care as one of GPs tasks (Likert 4.47/5, SD 0.75).
Conclusions: The intervention fostered personal competencies, understanding and self-confidence in EoLC among GP trainees. This is crucial for the aim to broadly provide EoLC.
Background: The population of older adults with chronic kidney disease (CKD) is increasing and nephrologists need education on the principles of geriatrics and palliative care to effectively care for this population.
Objectives: Our objective was to develop and deliver a curriculum to interprofessional clinicians caring for older adults with CKD. The aim of this curriculum would be to improve knowledge of the principles of geriatrics and palliative care.
Design: We have previously developed a curriculum on geriatrics and palliative care targeted toward primary care teams. In this project, we used an interdisciplinary steering committee to modify the curriculum for nephrology teams.
Setting: This curriculum was delivered in a live grand rounds setting and was recorded and made available via online platform for virtual learning.
Participants: The 6-session curriculum was delivered to 611 live and online learners between January 2018 and April 2019, with more than half of the participants (n = 317) completing more than 1 session. Participants came from a variety of disciplines including medicine, nursing, pharmacy, and social work.
Results: Participants had a high rate of agreement with the statement that the curriculum met learning objectives, with live participants having stronger agreement. Participants reported that the activity would change their practice behavior by calling palliative care earlier, as well as improving their communication skills.
Conclusion: Interprofessional collaboration can result in improved learning around the management of patients with CKD or end-stage kidney disease.
Context: The disparity between gaps in workforce and availability of palliative care (PC) services is an increasing issue in health care. To meet the demand, team-based PC requires additional educational training for all clinicians caring for persons with serious illness.
Objectives: To describe the educational methodology and evaluation of an existing regional interdisciplinary PC training program that was expanded to include chaplain and social worker trainees.
Methods: From 2015 to 2017, 26 social workers, chaplains, physicians, nurses, and advanced practice providers representing 22 health systems completed a two-year training program. The curriculum comprises biannual interdisciplinary conferences, individualized mentoring and clinical shadowing, self-directed e-learning, and profession-focused seminar series for social workers and chaplains. Site-specific practice improvement projects were developed to address gaps in PC at participating sites.
Results: PC and program development skills were self-assessed before and after training. Among 12 skills common to all disciplines, trainees reported significant increases in confidence across all 12 skills and significant increases in frequency of performing 11 of 12 skills. Qualitative evaluation identified a myriad of program strengths and challenges regarding the educational format, mentoring, and networking across disciplines.
Conclusion: Teaching PC and program development knowledge and skills to an interdisciplinary regional cohort of practicing clinicians yielded improvements in clinical skills, implementation of practice change projects, and a sense of belonging to a supportive professional network.
A growing body of research has examined modalities for delivering palliative care education; however, we know little about education and training preferences of VA interdisciplinary Palliative Care Consult Teams (PCCT). In the BEACON II study, we explored training preferences of PCCTs from 46 Veterans Affairs Medical Centers (VAMCs) participating in either a multisite webinar or a small group, in-person workshop. We interviewed participants by telephone seven to eight month post-training. In all, 75.9% preferred in-person education and training, including 78.9% of workshop participants and 73.1% of webinar participants. Respondents described in-person training as fostering learning through the following processes: (1) active engagement and focus, (2) interaction and networking, (3) meaning-making and relevance, and (4) reciprocity and commitment. Although it is not possible for Web-based palliative care education programs to replicate all aspects of the in-person learning experience, building experiential, interactive, meaningful, and reciprocal components into Web-based education may help shift preferences and make interdisciplinary team-based palliative care education accessible to a larger audience.
Caring for the dying patient can be stressful for nursing students. The purpose of this study was to describe a multimodal educational intervention designed to improve nursing students' attitude toward care of the dying patient and the family. Sophomore nursing students participated in an interactive end-of-life (EOL) lecture and simulation. A quasi-experimental, pretest/posttest design with a convenience sample was used for this study. Frommelt Attitudes Toward Care of the Dying version A was used to measure attitudes toward care of the dying patient before and after educational intervention. In addition, students were given an open-ended questionnaire to reflect on their perceptions of the EOL experience and a demographic questionnaire. A paired t test revealed a statistically significant difference between the pretest and posttest (t50 = 3.1, P = .003) on the Frommelt Attitudes Toward Care of the Dying, suggesting that students gained a more positive attitude toward caring for the dying patient. Three themes emerged from the content analysis and included knowing what to say and how to offer presence, becoming emotionally prepared, and learning skills to comfort. The use of lecture and simulation allowed students to assimilate the knowledge and affective skills needed to provide quality EOL care.
BACKGROUND: Insufficient knowledge of radiotherapy among hospice and palliative medicine (HPM) physicians is a barrier to providing optimal palliative care. We sought to assess the impact of a palliative radiotherapy curriculum on the knowledge, attitudes, and practice behaviors of HPM fellows at a single institution.
METHODS: We implemented a palliative radiotherapy didactic course for HPM fellows. The course consisted of three one-hour lectures and a guided tour of the radiation oncology suite. Anonymous pre-post was performed using descriptive statistics with P values calculated using the Wilcoxon rank-sum test with continuity correction.
RESULTS: All eligible fellows completed the questionnaires. Prior to the course, all fellows agreed that possessing a working knowledge of palliative radiotherapy was important yet lacked confidence in this domain. Fellow-reported confidence increased significantly on post-course assessment, as did the mean score on objective knowledge assessment. This increased knowledge was retained on longitudinal evaluation at three months. The curricular intervention also impacted fellow-reported practice behaviors and attitudes. In the three months following the intervention, fellows were more likely to refer patients for palliative radiotherapy, more likely to collaborate with radiation oncologists, and more likely to view radiation oncologists as members of a comprehensive palliative care team.
CONCLUSIONS: This feasibility study suggests that a brief curricular intervention can impact HPM fellows' knowledge about, attitudes towards, and practice behaviors associated with the use of radiotherapy in the palliative management of advanced cancer patients.
AIMS: To evaluate how a structured interactive two-day education programme for clinical nurses on end-of-life (EOL) care for older people affects nurses' attitudes and knowledge.
DESIGN: Non-randomised controlled trial.
METHODS: Nurses were recruited separately for intervention and control groups. The intervention group assisted older patients with EOL care and recruited patients for the programme. To prevent sampling bias, control group nurses were recruited from a facility with numerous EOL care opportunities. The intervention was a two-day educational programme. Using valid and reliable scales, we evaluated the attitudes (total score range: 26-130) and knowledge (total score range: 0-51) of the intervention group four times (pretraining, post-training, 3 months, 6 months) and the control group three times (baseline, 3 months, 6 months) between January 2016 and April 2017. Analysis of covariance examined both groups' score changes at 3 and 6 months while adjusting for confounding factors.
RESULTS: Participants were 338 nurses caring primarily for older people (intervention group: 164; control group: 174); 142 responded at all measurement points. The change in mean value of the attitude scale from baseline to 3 months (differences in the groups' attitude scores = 7.33; 95% CI = 2.43-12.24; p = .004) and 6 months (differences in groups' attitude scores = 5.77; 95% CI = 0.17-11.37; p = .044) was greater in the intervention group. Moreover, the mean knowledge scale score change from baseline to 3 months was greater in the intervention group (differences in groups' knowledge scores = 5.74; 95% CI = 4.07 to 7.39; p < .001). There was no evidence of a change in this score between baseline and 6 months.
CONCLUSION: The programme improved nurses' medium- to long-term attitudes and knowledge. Thus, it may help nurses enhance the quality of care they provide.
IMPLICATIONS FOR PRACTICE: A two-day educational program improves nurses' medium- to long-term attitudes and knowledge on end-oflife care. For quality end-of-life care for older people, a structured and evidence-based educational program should be provided to nursing staff.
BACKGROUND: The aging of populations is rapidly accelerating worldwide. Especially, Japan has maintained the highest rate of population aging worldwide. As countermeasures, the Japanese government prioritized the promotion of local comprehensive care systems and collaboration in medical care and social (long-term) care. Development of a system to connect medical and social services in the community is necessary for the increasing older people, especially for the people in the stage of end of life.
OBJECTIVE: This study aimed to assess the effect of a multidisciplinary end-of-life educational intervention program on confidence in inter-professional collaboration and job satisfaction among health and social care professionals.
DESIGN: a cluster-randomized controlled trial.
SETTING/PARTICIPANTS: Three professional groups (home care nurses, care managers, and heads of care workers) in an urban area participated in this trial.
INTERVENTION: We implemented a multidisciplinary end-of-life educational intervention program comprising two educational workshops and an educational booklet to support multidisciplinary care for end-of-life patients during the 7-month study period.
MAIN OUTCOME MEASURE: Confidence in improved interactions among professionals and job satisfaction were assessed with the Face-to-Face Cooperative Confidence Questionnaire and the Minnesota Satisfaction Questionnaire at T1 (before intervention) and T2 (7 months after the intervention).
RESULTS: In total, 291 professionals participated in this study (experimental group n = 156; control group n = 135). Multivariate regression analyses showed significant between-group increases on all of seven subscales in participants' face-to-face cooperative confidence over the study period; no effect was evident regarding job satisfaction.
CONCLUSIONS: A multidisciplinary end-of-life educational intervention program increased confidence in multidisciplinary collaboration among health and social care professionals.
AIM: To describe Israel's development of the palliative care advanced practice registered nurse as a foundation for the development of the advanced practice registered nurse role in other specialties.
BACKGROUND: Palliative care centres on alleviating physical, emotional, social and spiritual distress associated with life-limiting illness. In 2009, Israel introduced the palliative care advanced practice nurse role, that is, registered nurses with specialized training in palliative care, to address increasing palliative care needs.
INTRODUCTION: While there has been investment in its development, full implementation of the advanced practice nurse has not yet been achieved.
METHODS: In this qualitative descriptive study, we conducted a document analysis (n = 11) and key informant interviews (n = 11), extracted themes using qualitative content analysis and triangulated data sets.
RESULTS: Documents reflected growing palliative care needs and uniform requirements for advanced practice nurse training. Interviews uncovered a perceived lack of awareness of palliative care, the need for increased role definition and practice authority for advanced practice nurses, and barriers to entry and training for this role.
DISCUSSION: Findings highlight ongoing needs in palliative care and advanced practice nursing and a trajectory of growth.
CONCLUSIONS: The challenges Israel faces in implementation of the palliative care advanced practice nurse role inform development of other advanced practice nursing roles in Israel and other countries.
IMPLICATIONS FOR NURSING PRACTICE: Streamlining training pathways and resolving scope of practice issues will assist in implementation of advanced practice nursing roles.
IMPLICATIONS FOR HEALTH POLICY: Our data offer targets for policymakers advocating the advanced practice nurse role, including training requirements and scope of practice.
OBJECTIVE: Patients' desire to die (DD) is rarely discussed in palliative care (PC) due to health professionals' (HPs) feeling of uncertainty. The aim of the study was to develop and evaluate a training to increase HPs' self-confidence in responding professionally to patient's DD and to assess the feasibility of this approach.
METHODS: The training course was developed via focus groups and relevant literature and refined with an advisory board. An evaluation design was developed to evaluate training outcomes and to examine feasibility. To assess self-confidence, knowledge, skills, and attitudes: (1) standardized surveys were applied at T1 (before training), T2 (directly after), and T3 (3 months later), and were analyzed by descriptive and non-parametric statistics; and (2) participants' open feedback was summarized by content.
RESULTS: A two-day multi-disciplinary training was developed to improve self-confidence via diverse teaching methods. Twenty-four HPs from general and specialized PC were participated. Via self-rating on Likert scales at three time points, improvements were seen at T1, T2, and partly remained at T3, especially in the overall item of self-confidence in communicating with patients about their DD (means: 4.3. at T1, 5.7 at T2, and 5.9 at T3; on a 7-point scale with 1 = lowest value and 7 = highest value). Fewer improvements were found in skills (using different approaches) and attitudes (feeling less helplessness). Open feedback revealed a high appreciation for the training, especially the composition of participants, the role-play, and the overall increase of awareness of the topic.
SIGNIFICANCE OF RESULTS: The developed training on addressing DD meets a need and was perceived by the participants to be of added value. Future research should measure training effects with a validated instrument, including more participants, diverse participant groups, and a control group. Effects on patients should be assessed.
The need to improve access to palliative care across multiple settings and disease groups has been identified. This requires equipping health care professionals from many different professions, including physicians and nurses, among others, with basic palliative care competencies to provide a palliative care approach. Pallium Canada's Curriculum Development Framework supports the development, deployment, and dissemination, on a large scale, of multiple courses targeting health care professionals across multiple settings of care and disease groups. The Framework is made up of eight phases: (1) Concept, (2) Decision, (3) Curriculum Planning, (4) Prototype Development, (5) Piloting, (6) Dissemination, (7) Language and Cultural Adaptation, and (8) Ongoing Maintenance and Updates. Several of these phases include iterative cyclical activities. The framework allows multiple courses to be developed simultaneously, staggered in a production line with each phase and their corresponding activities requiring different levels of resources and stakeholder engagement. The framework has allowed Pallium Canada to develop, launch, and maintain numerous versions of its Learning Essential Approaches to Palliative Care (LEAP) courses concurrently. It leverages existing LEAP courses and curriculum materials to produce new LEAP courses, allowing significant efficiencies and maximizing output. This article describes the framework and its various activities, which we believe could be very useful for other jurisdictions undertaking the work of developing education programs to spread the palliative care approach across multiple settings, specialties, and disease groups.