Growth in the number of older adults is widely documented and the associated increase in morbidity is already having implications for palliative care.
In England, 19% of all deaths take place in the long-term care sector, with projections suggesting that this will rise by a further 17% by 2030. However, care home staff often lack confidence in being able to meet the needs of dying residents and the dying trajectory of older people is often characterised by a ‘lack of certainty’, common in chronic long term conditions.
The importance of hospices transferring their knowledge and best practice to other care settings has been widely recognised, including in the End of Life Care Strategy.
The project begins
After working at Oakhaven Hospice as a staff nurse for nine years, I was appointed educational practitioner to lead a project aimed at increasing capacity in the delivery of end of life care.
The purpose of this project was to use ‘situated learning’ to provide education, training and support in palliative and end of life care for staff working in residential and nursing homes within our catchment area.
Situated learning is learning that takes place in context in which it is to be applied – in this case, residential and nursing homes. Studies have suggested that improving end of life care in the long-term care sector is achievable by increasing the confidence and capacity of staff through education and support while they are caring for dying residents2,3.
It should also be noted that situated learning happens ‘naturally’ outside the work of this project across many of the services our hospice is able to provide. For example, as community nurses and doctors engage with staff in hospital and as hospice at home staff work alongside carers in patients’ homes.
Initially letters were sent to all 43 residential and nursing homes within our catchment area, inviting them to take part on the project, followed-up by a phone call and introductory meetings with staff.
By questioning the staff, the specific areas of education they would like can be identified. Using a combination of a questionnaire to assess perceived confidence, informal interviews and my own observations I am able to build a picture of their educational and supportive needs and therefore design an intervention accordingly. It is also necessary to take into account potential barriers to providing educational initiatives within the long term care setting, such as pressures of work and lack of available time, and structure the sessions accordingly.
How the project has evolved
To date, the project has involved 410 nurses and care assistants from 28 residential care and nursing homes. Examples of how situated learning has worked include:
- Working alongside staff in providing end of life care.
- Education sessions on a variety of topics such as an overview of palliative and end of life care, pain assessment in dementia, symptom control, communication, syringe drivers, caring for the dying or more specifically related to an individual resident’s needs.
- Reflective debriefing after the death of a resident or critical incident.
- Storytelling. This is widely recognised in literature as important for professional practice as it can depict important characteristics of end of life care and is ultimately vital in combining both the contrasting ‘art’ and ‘scientific’ theories of knowledge.
A model has been developed for the situated learning project to reinforce its ‘on-going’ principles and goal of producing ‘lifelong learners’.
Alongside the situated learning sessions, I run a well-attended six-weekly ‘link nurse’ meeting for care home staff that include updates and news but ultimately providing discussion and support as a group.
Having an email database of homes that have been involved in the project means I am also able to regularly send them updates and information, especially useful for those unable to attend the meetings.
Currently we are also piloting a checklist that has been designed for use when a resident is being discharged from hospital and back into their care.
Individual projects are evaluated using a questionnaire where usefulness of the session is scored 1-10, but delegates are also asked to leave comments such as ‘list key elements learned from today’s event’ and ‘what could have been improved’. The evaluations have made pleasant reading with the majority scoring 9/10 and leaving comments such as; “The support from Oakhaven regarding end of life and the regular meetings are immensely useful”, “I believe the sessions have helped me to have a better understanding of recognising end of life care situations” and “I certainly will feel more confident when talking to relatives of a dying resident.”
The situated learning project has been running for just over two years. Although initially funded by a grant from the local health authority, the success of the project means that it was continued after this funding had ended. The project has evolved over the last two years and we have already expanded into domiciliary care agencies.
Building sustainable relationships with the care homes and agencies within our community has been a fundamental aim of this project and the education department look forward to the future opportunities this project will present!
- Phillips J, Davidson P, Jackson D and Krtistjanson L. Multifaceted palliative care intervention: aged care nurses’ and care assistants’ perceptions and experiences. Journal of advanced nursing 2011; 62(2) 216-227
- Brazil K, Brink P, Kaasalainen S, Kelly M and McAiney C. Knowledge and perceived competence among nurses caring for the dying in long-term care homes. International journal of nursing 2012; 18 (2): 77-83
- Stillman D, Strumpt N, Capezuti E and Tuch H. Staff perceptions concerning barriers and facilitators to end of life care in nursing homes. Geriatric nursing 2004; 26(4): 259-264
Jennifer Caine is a staff nurse and educational practitioner at Oakhaven Hospice in the New Forest and is currently studying for an MSc in clinical leadership in cancer, palliative and end of life care at the University of Southampton.
For more information on this project, you can contact Jenny at firstname.lastname@example.org