Michelle Buono, Nurse Prescriber and Macmillan End of Life Education Nurse/Clinical Nurse Specialist, Palliative Care Team, West Suffolk NHS Foundation Trust, Bury St Edmunds, Michelle.firstname.lastname@example.org
The author, a member of the palliative care team at West Suffolk NHS Foundation Trust (WSFT), created a WSFT Integrated Learning in Palliative Care (ILPC) model developed from a research study comprising 1-week shadow placements between services for six registered nurses (RNs) based at WSFT’s Macmillan unit and six RNs based at St Nicholas Hospice Care’s (SNHC) Sylvan ward.
The hospice is situated within the hospital grounds in Bury St Edmunds, although separate from the main hospital. The primary aim of the study was to evaluate a peer-learning initiative for RNs working in both acute wards and palliative care settings. An action research approach was used, which allowed the RNs taking part to give feedback from their own nursing practice perspective, when working with palliative care patients and those requiring end-of-life care. This article focuses primarily on the evaluation of end-of-life care practice.
Key concepts of the study
Staff working in acute wards, emergency departments and assessment units in hospitals all care for palliative and end-of life care patients. The study promoted peer learning by allowing acute RNs and hospice RNs to learn from each other. It aimed to enable the RNs to gain knowledge and understand the differences and similarities of acute ward and hospice practices (Michaelsen et al, 2004; Millis, 2010).
Peer learning encompasses several learning practices. In this study, collaborative learning was undertaken in practice as the shadowing process between acute and hospice RNs demonstrated learning initiated through collaboration in small groups. Michaelsen et al (2004) and Millis (2010) suggested that greater retention of information is gained this way. RNs working on each shift shared ideas and educated the shadowing RN regarding end-of-life care, sharing how they would manage any complex symptom issues as they arose, within their own acute or hospice organisation.
Patients with advanced disease and limited life expectancy often present with complex issues. Integrated learning is a process to help the learner (shadowing RN) make connections between skill concepts and experiences, which can be applied when working with challenging and complex symptoms in end-of-life care (Resources for Rethinking, 2020). Work-integrated learning is a process of learning in collaboration with others who work in similar fields of practice (Resources for Rethinking, 2020). It enables sharing of ideas about what works well and not so well, in this case with patients nearing the end of life, looking at ‘real life’ situations in patient care. Therefore, it was anticipated that the shadowing would offer work-based learning in practice and an opportunity for sharing transferable skills between acute RNs and hospice RNs.
Shadowing offers opportunity to draw from multiple sets of clinical skills, from those RNs facing similar challenges, although working in a different clinical environment. It allows the sharing of experiences to accelerate the learning process. Specific areas of learning, such as complex symptom management in end-of-life care, can be addressed in this way, contributing to a deeper understanding of these issues (Resources for Rethinking, 2020).
Action research is a way of providing rich live data, as it happens, from those involved. Francis (2013) and Titchen (2015) suggested that this method is often adopted by health researchers, as a method to promote innovative change and developments in practice. It was chosen for this study to enable participatory involvement, which may be seen as emancipating and empowering for the individual. It offered the RNs the chance to be a part of the learning process and grow professionally (Harrison, 2006; Francis, 2013; Titchen, 2015; Dobson, 2017). The study benefitted from RN provision of honest, real-time feedback about work-related issues. Research supports the theory that nurses often provide the best feedback, because they are familiar with the process of reflection (Moon, 2004; Harrison, 2006; Kemmis and McTaggart, 2008).
Research is a significant part of hospital and hospice work. This study is an example of the hospice and hospital joining forces to promote new action research and learning to benefit patient care.
The medical model of patient care adopted by many clinicians does not always allow for a holistic approach (Dobson, 2017). Palliative care experience and end-of-life training received by professionals can differ greatly from one ward to the next. O’Connor et al (2016) and Bloomer and O’Connor (2012) suggested that nurses working in acute care units, such as intensive care, require significant training in end-of-life care. Dobson (2017) argued that learning about end-of-life care is essential in acute care, to ensure that RNs have the skills to provide holistic care.
This research study recognised the importance of holistic learning in end-of-life care, for all nursing disciplines, particularly those working on acute wards, often staffed by inexperienced and newly qualified nurses who may be lacking in these skills (O’Connor et al, 2016; Dobson, 2017).
Authors such as Wood and Salter (2013), Dobson (2017) and Weng et al (2017) have recognised that there is learning to be gained by shadowing in hospices, because these are environments where nurses gain an abundance of experience, knowledge and skills in caring for patients nearing the end of their lives.
Box 1. Strategic documents
■ Ambitions for Palliative and End of Life Care: A national framework for local action 2015-2020 (National Palliative and End of life Partnership, 2015)
■ One Chance to Get it Right: One year on report (Department of Health (DH), 2015) ■ Our Commitment to End of Life Care (DH, 2016)
■ End of Life Care for Adults: Service delivery (National Institute for Health and Care Excellence, 2019)
■ Palliative and End of Life Care Strategy (West Suffolk NHS Foundation Trust, 2015)
Both wards involved in the study deal with complex symptom issues where end-of-life care is often part of the daily routine for RNs; thus, supporting the relevance of the research from a practice perspective (Bryman, 2015).
For the purposes of the study, the author, a Macmillan Educator based with the WSFT palliative care team, was instrumental in arranging and attending meetings with both the hospital and hospice human resources (HR) departments to enable agreements for a joint process, making it easier for RNs to move between the two organisations.
WSFT and SNHC produced a joint honorary contract form and a streamlined certificate of good standing form. This simplified the honorary contract process, where a contract allows an RN to shadow and/or work for a limited period in a different organisation, such as the hospice or hospital.
National and local policies were highlighted in the proposal for the study as strategic drivers (Box 1). These promote the use of initiatives to make improvements in end-of-life care. The author recognised that an integrated approach to learning would offer strategies in line with current government and local recommendations.
Aims and objectives
The aim of the study was to evaluate a peer-learning initiative for RNs in both acute and palliative care. The study explored how best to obtain cohesive, collaborative working and meaningful learning between services, to support staff learning and enhance the experience of palliative and, predominantly, end-of-life care for patients and their families.
The objectives for the RNs are set out in Figure 1.
The study evaluated a peer-learning initiative from the perspectives of six acute and six hospice RNs, who all took part in the nurse shadowing project over a 6-month period from January to June 2018.
Action research was used as a means of integrating the study into current practice (Denscombe, 2007). The nurses were recruited at team meetings and, due to high levels of engagement, were chosen on a first-come-first-served basis (Bryman, 2015). RNs gave permission for personal details to be shared between organisations and, for the purposes of the study, HR teams at WSFT and SNHC communicated directly, once ward managers had completed relevant paperwork. Timings werenegotiable when working ‘shadow’ shifts, dependent on ward rotas and staff availability. Hours worked were agreed between each ward and ward manager.
A cycle of obtaining constant feedback proved to be responsive in gaining ‘buy-in’ from those involved to form a ‘bottom-up’ process to establish real personal perspectives for beneficial change.
Data collection tools
Questionnaires, evaluation forms, reflective diaries, email and verbal feedback were used to collect data to evidence new learning from practice.
Figure 1. Feedback data from the study Figure 2 Objectives of the study
Questionnaires were given to each shadowing RN and completed on the first day of the 1-week shadow placement. This measured the RNs’ understanding of the aims and objectives of the study and identified what RNs hoped to achieve. Each RN and their ward mentor were also asked to complete an evaluation on the final day of shadowing. The evaluation form was designed to measure the impact and learning acquired during the study. Not all RNs submitted a diary, although email proved valuable for receiving feedback from busy nurses. Four RNs returned reflective diaries, eleven returned evaluation forms and five RNs returned reflective accounts by email (Figure 2). Triangulation of data identified strengths and areas for change.
Positive findings: acute RNs
Among the positive findings reported by the six acute RNs was the opportunity to observe more holistic assessments undertaken with patients and their families in the hospice. The acute RNs reflected that more time and having only eight inpatient beds in the hospice was a factor, enabling greater depth of assessment, family contact and consistency of care. Acute RNs reported that the shadowing offered opportunities to compare different ways of working and to learn from specialist teams, such as family support teams, bereavement services and community specialist nurses. Greater understanding of the hospice services meant acute RNs were more likely to refer patients to the service. They also gained increased understanding of symptom management in end-of-life care. RNs reported that a main benefit of the shadow placement was greater understanding of how to deal with some of the complex needs of dying patients.
The acute hospital RNs therefore reported that they had gained:
■ Greater knowledge of holistic assessments ■ Confidence increased in end-of-life care giving ■ Enhanced understanding of emotional/family support.
The study offered the opportunity to gain understanding of the medications (Figure 3) used across both organisations to assist acute and hospice RNs when managing complex symptoms such as:
■ Nausea and vomiting ■ Agitation and restlessness ■ Secretions.
Positive findings: hospice RNs
Hospice RNs reported that shadowing allowed opportunities to build their confidence when dealing with more acute symptom management issues and instilled enthusiasm to complete intravenous (IV) learning packages and start practising IV administration and blood transfusions. The study enabled hospice RNs to complete the hospice’s RN Competency Area 3: ■ Spend 4 days shadowing within another clinical setting
■ Demonstrate knowledge of the pharmacology indications, contraindications, routes and dosages of drugs commonly used at the end of life.
The hospice RNs’ main gains from the study were:
■ Acute skills refreshed ■ IV competencies completed ■ Blood transfusion updates.
An important area in which hospice RNs could gain knowledge was in the management of oncological emergencies in hospital such as:
■ Neutropenic sepsis
■ Spinal cord compression
■ Tumour lysis syndrome
■ Superior vena cava obstruction.
Hospice RNs also developed relationships with acute care colleagues so they knew whom to contact if they needed advice or support with an aspect of patient care such as caring for a patient with a tracheostomy.
Positive findings: both groups of RNs: Both groups reported improved knowledge and understanding of medications used for symptom control (Figure 3).
The main learning themes reported by the nurses in the study are set out in Figure 4, showing that key learning objectives were achieved by all RNs. Particularly of note was the feedback relating to improved confidence and understanding of managing complex symptom issues, end-of-life care giving and the sharing of good practice.
Figure 3. Symptom management medications used across both organisation
The study offered both sets of RNs the opportunity to spend time working alongside others who tackle similar challenges. Additionally, acute and hospice RNs acknowledged that the shadowing would count as part of their continuing professional development required for revalidation.
Findings from both acute and hospice RNs acknowledged the amount of rota changes and swapping of shifts at ward level that the study involved. Shadowing RNs were not always placed with a named nurse or mentor and there was sometimes a lack of knowledge about the study on the wards. Feedback from RNs indicated that time was an issue for completing reflective diaries. Therefore, the author devised a simplified version in the form of an email reflective account form.
Limitations of the study included the small participant population and the low survey response rate. It was disappointing that only four RNs completed a reflective diary, because it was part of the main data for the action research. However, email reflections were received from five RNs, as well as verbal feedback, and eleven evaluations containing reflective accounts were returned.
Figure 4. Main themes reported by nurses in the study
Discussion and recommendations
Feedback from RNs highlighted that the opportunity to spend a full week shadowing colleagues was a unique opportunity, particularly because it is often difficult to obtain study leave. However, opinions varied on the length of placement, because four RNs reported that they would have liked longer placements and two RNs reported that they felt a week was too long. Meetings between the author and hospice and hospital ward managers led to the decision that a 2-day placement was more likely to be utilised as a working model, rather than 5-day placements, due to the potential difficulties of gaining time away from the RNs’ own clinical environment. As a consequence, for future practice, the ILPC model developed by the author was amended to offer 2-day shadow placements.
To enable valuable learning, professionals are asked to identify their individual objectives with line managers before taking part in the new ILPC model. From the study results, these could be to:
■ Update knowledge and skills
■ Gain and improve competencies
■ Expand professional networking
Benefits of the new ILPC model
Managers can offer acute care nurses and acute end-of-life ward champions the opportunity to shadow at the hospice
■ Managers can encourage new staff/those with little end-of- life care experience to take part ■ During annual appraisals managers can encourage staff to participate as part of planning new
learning for the coming year
■ Support and advice are available from the Macmillan Educator.
The main changes to the model (following feedback from the study) were:
■ Simplifying the honorary contract form
■ Reduction in the length of shadow placement from 1 week to 2 days ■ Reflective diaries reorganised into a concise email reflection form.
Outcomes for shadow placement participants
■ Breaking down barriers to achieve greater understanding of each other’s roles ■ Opportunities for completion of clinical and ward-related competencies
■ Sharing best practice
■ Greater understanding of complex symptom-control issues
■ Promoting familiarity of a variety of palliative care settings ■ Optimising transferable skills.
With an increasingly ageing population, the demand for more end-of-life care training is expected to increase over the next 20 years (Dobson, 2017). Therefore, learning initiatives such as the new ILPC model should provide accessible new approaches for learning, to meet the changing demands in health care for patients and their families.
Palliative care is a challenging and demanding work area that relies on effective communication and teamwork for unified professional care to be achieved (Sleeman, 2013; Sleeman and Collis, 2013; Dobson, 2017). Increasingly, nurses and other clinicians are becoming involved in delivering end-of- life care, no matter which ward or area of practice they may work in (Dobson, 2017).
The study was designed to initiate new actions to improve holistic learning in clinical environments (Kemmis and McTaggart, 2008). However, this will only be achieved if educational opportunities are easily accessible and made use of by health professionals (Firn et al, 2016; O’Connor et al, 2016). Time constraints and poor staffing issues are no justification for allowing professional development and opportunities for new learning to be ignored. The author developed the new ILPC model as a result of the study, as part of new training and educational initiatives offered by the WSFT palliative care team.
The study highlighted learning resources readily available within WSFT and SNHC to integrate learning around good end- of-life care, to improve communication links and collaborative working within both settings (Department of Health, 2015; Dobson, 2017; Weng et al, 2017; National Institute for Clinical Excellence, 2019).
A core principle for those working in palliative care is to ensure that RNs working with adult patients in any clinical setting provide ‘best practice’ general holistic palliative/end of-life care for patients and families. The study offered the opportunity for RNs from SNHC to complete competencies and gain appreciation of patient experience and pathways when in hospital (Francis, 2013; Titchen, 2015). The ILPC model enables flexibility to meet individual learning needs. It provides ward managers with a model for upskilling RNs (which can be discussed at appraisals), and ensures learning opportunities for RNs to increase confidence and competencies, within acute or hospice settings.
It should be recognised that outpatients, emergency departments, day surgery and clinics need to extend skills and knowledge in recognising patients who may be deteriorating or dying. A holistic approach to care should be offered, for all patients, no matter what clinical setting, or department they attend (Firn et al; 2016; O’Connor et al, 2016). All RNs should act on these assessments, so medications are made available if symptoms occur or worsen, and to ensure that families are made aware of the prognosis, to help patients gain the end-of-life care that they would wish for.
The Macmillan Educator post, sponsored by Macmillan originally as a 2-year end-of-life education nurse project, was extended for a further 2 years due to learning initiatives such as the one devised from this study.
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■ A plethora of research supports the need for education and training opportunities to be readily accessible and available in the fundamental principles of holistic palliative care
■ Accessible learning initiatives such as the Integrated Learning in Palliative Care Model provide a straightforward option for professional development
■ Developing relationships with professional colleagues in acute settings was identified as a key benefit to the hospice, for example, knowing whom to contact for advice/support for a patient with a tracheostomy
■ Understanding services provided by other organisations, such as the hospice, enabled acute care nurses to refer families to these services
CPD reflective questions
■ Think about whether this model of learning could be introduced in your own area of practice
■ What learning objectives could be achieved by taking part in a similar shadow placement in your
own hospice/acute organisation?
■ Consider whether this model of learning could change or improve your practice