Workshop I: Diagnosing and Treating Problems in Palliative Care

Professional training differs from fundamental education, where knowledge holds value in and of itself. In a professional environment, we train individuals to achieve specific work-related outcomes.

Training is necessary in two main cases:
1)A problem needs resolving – for example, staff are performing specific tasks incorrectly or not adequately, and we aim to change that.
2)Something new needs to be implemented. The work is already going well, but we wish to enhance the quality or efficiency.

Through examples, we’ll demonstrate that solving a work-related issue or challenge does not rely solely on employees’ knowledge and skills. If we overlook other contributing factors, training may not yield the expected results and could prove ineffective.

Situation
Right after the New Year, I received a call from a colleague—the deputy head of HR at a large multidisciplinary hospital in Moscow. Their hospital was urgently establishing a new palliative care unit and needed to train staff immediately: ‘Let’s start tomorrow!’

Solution
We provided our existing programmes:

• For nurses, a 36-hour in-person course.
• For doctors, a blended learning course totalling 72 hours.

Result
The courses were successful. Doctors and nurses participated actively, completed the assessments, and provided excellent feedback on the programmes. The head of the unit noticed that the training was valuable.
Then I discovered that, after the training, three of the twenty-six nurses resigned. We decided to investigate what occurred.

Reasons
1) Staff were not informed about what palliative care entails.
When they were transferred to the new unit, no one explained the nature of the work. During the training, they suddenly realised:

• Their work would involve a significant amount of hands-on patient care.
• They were accustomed to administering IVs and injections, but did not expect hygiene and personal care to be part of their responsibilities.
• The topic of death proved to be more emotionally complex than they had anticipated.

2)The unit was inadequately equipped.
When they arrived at our training centre, they noticed modern hoists, functional hospital beds, and comfortable care equipment. However, their unit had none of this. I overheard one nurse say to a colleague in the hallway: ‘Well, sure, they’ve got everything here—but we’ve got nothing… How are we supposed to work?’

3)Staff shortages.
After completing our programme, the nurses understood just how much relies on the quality of their work in palliative care—and how many responsibilities rest on the nursing staff. When there aren’t enough hands available, it becomes challenging to provide quality care. Some simply felt overwhelmed by the workload.

Conclusion
Consequently, there was a disconnect between expectations and reality. Staff recognised what was necessary to deliver quality palliative care, but their hospital did not provide those conditions. They were given the tools, but had no means to use them.

Outcome—three nurses quit immediately after the training.
Does this mean the training was ineffective? No.
Does it mean the problem wasn’t merely a lack of knowledge? Yes!
If working conditions had been addressed beforehand, the job’s specifics clearly explained, and the unit properly prepared, the outcome might have been very different.

Situation
We observed that in our organisation, doctors occasionally prescribed unnecessarily high initial doses of morphine for dyspnoea. In Russia, there are no official clinical guidelines on morphine dosing for breathlessness. Sometimes, physicians would commence treatment with high doses, even when unnecessary.

Solution
We decided to develop an internal protocol for managing dyspnoea. We outlined diagnostic and treatment algorithms, clearly defined when and in what doses morphine should be prescribed, and conducted training sessions for doctors.

Result
We reviewed whether clinical practice had changed a few months after the training. The situation had improved. However, unjustified high-dose prescriptions of morphine still occurred. Why?

Reasons

1. Not all doctors internalised the new information. Some simply did not retain the material, while others did not take the changes seriously. In some departments, there was a lack of oversight to ensure compliance with the new protocols.
2. Resistance from nurses.

One doctor shared the following story: ‘I prescribe a starting dose of 2.5 mg. But the nurse says to me: — Doctor, why bother? Now you’ll have to use an insulin syringe, record the ampoule usage… It’s such a hassle! Let’s just go with 5 mg, like we always do.’ This doctor stood her ground and didn’t alter the order. However, not every physician is willing to challenge an experienced nurse. The team’s influence can be quite substantial when there are 10 doctors and 30 nurses in a unit.

Conclusion
We trained the doctors, but we overlooked the role of nurses in the process. We should have also provided additional training for the nursing staff, emphasised the importance of correct starting doses, and offered clear instructions. Training the doctors without engaging the nurses proved insufficient.

Situation
We were introducing the use of slide sheets into nursing practice—special sheets made of smooth fabric that assist in moving patients with limited mobility.

Solution
The training was successful. Each department sent a team, including the head nurse, to share their knowledge with their colleagues.

Result
Two months later, we found that in many departments, the slide sheets had still not been used.

Reasons
The main issue was a delay in procurement. Government purchasing processes are slow. When we conducted the training, we assumed that the slide sheets would already be available on the wards or would arrive in the next few days, but procurement was delayed. We assumed, but never verified it.

Poor coordination between the training department and the procurement team adversely affected the actual outcome. By the time the slide sheets finally arrived, staff had already forgotten how to use them. Consequently, the training was wasted and had to be repeated.

Conclusion
We failed to synchronise the training with the delivery of materials. We should have ensured that the staff had the necessary tools available by the time they were trained in using them.

Now, let’s examine a few positive examples—cases where we accurately diagnosed a genuine workplace issue that was unrelated to a lack of knowledge among staff and, therefore, did not waste time on unnecessary training.

Situation
A medical director approached me and said:
‘We urgently need a training session on how to use portable oxygen concentrators. Doctors don’t know how to operate them, so they’re not prescribing them to patients.’

Solution
We first decided to verify that a lack of knowledge was indeed the cause of the problem.
We spoke with the doctors. They did know how to use the concentrators. The real issue was that the demand for the devices exceeded the supply, and doctors were concerned about receiving complaints if they refused requests. Therefore, they simply avoided mentioning the possibility of providing them.

Some doctors expressed concerns like:
‘Yes, we have concentrators—but not many. Who should get them first? If a patient wants to leave the city, is that a valid reason? Or should they go to someone who’s stuck at home and can’t breathe without one?’

The core of the problem was the lack of clear criteria for distribution. What doctors required wasn’t training on how to use the device, but a protocol—a set of prioritisation guidelines.
So that’s exactly what we developed.

Result
The practical issue was resolved.

Conclusion
Had we merely delivered the training, it would have had no impact, as the core of the issue resided elsewhere.

Situation
The head of the department approached us:
‘We need training for the dispatchers in the palliative care service. We listened to some of the calls and realised that while they do answer patients’ calls, they don’t provide clear information. Not all of them introduce themselves, they are not always polite, and they don’t seem willing to help. We have established work protocols, but they are not being followed.’ At first, the idea seemed straightforward: if protocols exist, then dispatchers simply need to be trained to follow them. However, we decided to dig deeper.

Solution
We identified several root causes behind the dispatchers’ behaviour:

1. Lack of quality control. No one was consistently reviewing calls or providing feedback to the dispatchers. They were aware that their calls could be monitored, but this occurred infrequently, making it easy to ‘slip through.’
2. Hiring without consideration for key personal qualities can be problematic. Politeness, empathy, and a genuine willingness to help are difficult to instill through training. If a person doesn’t possess these qualities from the outset, no amount of training will compensate for it. However, recruiters were unaware that these traits were critical for dispatcher roles and did not screen for them during the hiring procedure.

Result
Rather than jumping straight into training, we suggested implementing a comprehensive quality control process first: assigning someone to review calls regularly, providing ongoing feedback to the staff, and incorporating empathy and customer focus into the recruitment criteria. Only after these changes would training be effective.

Conclusion
If we had held a training session prior to implementing these changes, it would not have led to any genuine results.

To successfully solve any problem, we must first ‘collect history’—that is, understand what the problem is. Then, based on that specific problem, we select appropriate measures rather than merely launching into training for the sake of training.
If we want training to bring practical benefits, we first need to answer key questions:

1. What specific work-related problem are we solving?
2. What additional measures, beyond training, are required?
3. How should training be integrated into a comprehensive solution to the problem?

If we ignore these factors, training becomes a futile activity.

Today, that’s precisely what we’re focused on—learning how to diagnose organisational problems, clearly define them, identify the root causes, and develop a range of solutions.

In our second workshop, scheduled for 29 March, we will proceed to the next stage:

1. How can we use a proper understanding of the problem to design learning content?
2. How do we ascertain who needs to be trained, how, in what format, and at what time?
3. What conditions must be established for the training to yield genuine results rather than remain merely theoretical?

It’s not enough to confirm that training is necessary; we also need to understand what other actions must occur for it to be effective. Because if training is conducted in isolation from real issues, it loses its significance and simply fades into the void, as we’ve seen in some of the examples presented.

Have you ever faced a situation where doctors and nurses in a hospice lack the knowledge needed to diagnose and treat pressure ulcers?

I see that many in the chat are replying ‘Yes.’

However, this is a trick question. A lack of knowledge, on its own, is not the real issue. The true problem lies in the consequences that arise from this lack of understanding.

For example, we conduct a quality audit and find that 70% of patients with pressure ulcers show no improvement after three weeks of treatment, or worse, their ulcers worsen instead of healing. This presents a measurable problem that we can influence. Perhaps it’s not merely a lack of knowledge.

The issue may lie elsewhere. We managed pressure ulcers effectively on our own. However, planning the procurement of wound care supplies was a different matter. The procurement department attended a meeting and stated:  ‘Colleagues, it’s difficult for us to plan the budget for purchasing wound dressings. We see that consumption levels in our branches (we have 13 in the organisation) vary significantly, even though the number and condition of patients are roughly the same.’

In one branch, specific dressings are actively used, and there is a growing demand for more. In another branch, the same dressings expire and are discarded. The result is inefficient budget expenditure.

In this case, the issue was not only that the staff were unaware of which dressings to use or how to apply them. The root cause lay in the lack of a unified standard for diagnosing and treating pressure ulcers, along with differing levels of staff knowledge.

Typically, the initial causes that spring to mind are superficial. A useful technique for exploring further is the ‘why cascade.’ Keep asking yourself ‘why’ until you uncover the root causes of the issue:

1. Why do staff lack knowledge about wound dressings?—Because there are many types of dressings, and their brand names often change.
2. Why do the brand names change frequently?—Because that’s how the procurement system is set up: tenders, changing suppliers, and different countries of origin.

While we cannot alter the procurement system, we can still address the issue. It is vital to establish a clear and user-friendly classification for wound dressings and to train staff to recognise dressings not by their brand names but by their mechanisms of action. Additionally, it is essential to train department heads and senior nurses responsible for procurement first, followed by the remaining staff.
If we had merely conducted a training session on dressings, the issue wouldn’t have been resolved. The true solution is to develop and implement a unified standard, and then train staff according to that standard.

Consider the results of your analysis and make suitable decisions.
Identifying Causes or Solutions to Problems (Participants’ Work)

Problem
In Latvia, several registered medications are not purchased or stocked in adequate quantities, necessitating orders from neighbouring countries. Virtually no reserves exist within the country, resulting in patients sometimes having to wait for their medication. For example, fentanyl in low-dose patch form—not every patient requires it, but when it is necessary, it must be ordered and awaited. It’s not a global problem, but it’s a significant one.

Cause
The market is small. There are few consumers, and not all of them require opioids. Purchases are not made in advance.

Solution
The current solution is a ‘manual’ one—there is a pharmacy that, based on personal agreements, has consented to stock a small supply of such medications. However, what will happen if the pharmacy management changes and the new director decides not to procure rare medications?

Conclusion
This is an example of an unstable solution. Today, someone is willing to support the system; tomorrow, they may not. In such instances, systemic solutions are required—for example, changes in the national procurement system, rather than merely one-off agreements with a single pharmacy.

How should training address the issue of medication availability?
Suppose we are developing a training programme on pain management for doctors in Latvia. What aspects should we pay attention to?

1. Specific forms of medication are not available at short notice.
2. Doctors must know how to substitute an unavailable medication.
3. If the required medication does not arrive for a week, the doctor must select an alternative.

When developing training programmes, it is essential to consider real-life conditions, such as the availability of medications and the specifics of the procurement system.

Problem
Doctors either refrain from prescribing opioids or prescribe them in inadequate doses.

Cause
Due to opiophobia, doctors are hesitant to prescribe these medications, and their lack of knowledge leaves them unsure of how to prescribe them correctly. This is a prevalent issue in many countries.

Comment from a participant
I am currently the head nurse of a palliative care department. For the three years preceding my transition to palliative care, I served as head nurse at a large outpatient clinic with nearly 60,000 registered patients. I was responsible for distributing prescription forms for home use, and uncovered other reasons behind the issues with opioid prescribing:

1. Inadequate training of medical residents and first-year doctors leads to their unfamiliarity with the pain scale, a lack of understanding of the steps involved in pain management, and unawareness of the full range of available medications.
2. Delayed assignment of ‘palliative’ status to patients. In our region, palliative status carries a stigma. Once a patient is labelled ‘palliative,’ it becomes more difficult for them to access treatments such as chemotherapy, radiotherapy, and others. Doctors hesitate to assign this status because they understand it will complicate the patient’s access to care. This isn’t merely a pain management issue—it reflects a broader problem within the palliative care system.

Problem
As mentioned earlier, there is a problem: young doctors, recent graduates, do not prescribe pain relief.

Causes

1. Gaps in education. Universities do not devote sufficient attention to this topic. Doctors study pharmacology, but it may take years before they need to apply it in practice. By the time a doctor begins clinical work, they often forget this information.
2. Fear and lack of motivation. A doctor may know how to prescribe pain relief but may be hesitant to do so. They might avoid prescribing it out of fear of making a mistake or facing repercussions. In the past, there was anxiety over criminal liability for losing an ampoule or tablet. Although this concern is now outdated, it lingers among many doctors.
3. Bureaucracy. The procedure for prescribing opioids is complex. It is easier to bypass it entirely than to endure endless formalities. In some organisations, management explicitly prohibits opioid prescriptions.

‘Why Cascade’

1. Why don’t doctors prescribe opioids?
2. — Because they are afraid.
3. Why are they afraid?
4. — Due to their fear of criminal prosecution in the past.
5. Why does that fear still exist?
6. — Because no one made it clear that the penalties have been repealed.

Problem
Ambulance teams must frequently respond to calls from palliative patients at home because the medications prescribed by doctors are ineffective.

Causes
1)Incorrect prescriptions.
— Young doctors lack knowledge in prescribing pain relief.
2)Doctors neglect to prescribe breakthrough pain medication in advance.
— There is no quality control system for prescriptions.
3)Patients misuse medications.
— The doctor failed to provide clear instructions.
— The patient or their relatives exhibit opiophobia.

Problem
One common issue we encounter is the belief among doctors that opioids should not be prescribed more than three times a day. This myth lacks any legal or clinical foundation, yet doctors persist in adhering to it. Consequently, patients remain under-medicated for pain.

Causes

1. Some doctors believe that prescribing morphine more frequently will lead to addiction.
2. Others fear legal repercussions.
3. Some recall hearing this during medical school but cannot locate the original source.

Solution

1. Doctors must be informed that the frequency of opioids should match the individual needs of the patient.
2. It is important to rely on international clinical guidelines.
3. Legal departments should issue official statements confirming that there are no restrictions.

Problem
Many patients and their families fear that opioids lead to addiction, withdrawal symptoms, or hasten death. An additional factor is religious belief. For instance, in Islamic tradition, the use of intoxicating substances is forbidden. Some patients perceive morphine as a narcotic and thus feel it violates their religious principles. Consequently, patients endure pain while refusing treatment, or their families prohibit the use of pain relief. Even some doctors are reluctant to prescribe opioids.

Cause
This is not a medical issue but a sociocultural barrier.

Solution

1. Collaborate with religious leaders to hold public lectures explaining that opioid prescriptions do not violate religious doctrine.
2. Develop informational materials for patients and their families.

It may seem that everyone understands: education is not a magic pill that solves all problems. However, the process of analysing issues, identifying root causes, and diagnosing reasons is challenging and time-consuming. That’s why people often attempt to bypass it. No one wants to delve into the deeper causes because ‘training is easy.’ There’s a training centre, there’s a programme—we’ll just train everyone, and the problem will go away. But in reality, the causes may be entirely different. That’s why we must first understand what problem we are solving, then identify its causes, and only after that find ways to resolve it, including training.

1. Choose a problem that is relevant to your organisation or country.
2. Complete the ‘problem passport’ using the suggested template.
3. Submit it to PACED by 1 March.
4. Join our WhatsApp chat—it will include links to the problem passport template, the webinar presentation, and announcements of upcoming events.