Palliative care training addressed to hospital healthcare professionals by palliative care specialists: a mixed-method evaluation

As the first result of the training, the meanings shifted from what we denominated “doubt and disagreement” to “knowledge and synergy”. Before the training, the HPs primarily emphasized a lack of specific guidance on PCU activities. They expressed the need to receive basic relevant information on PC, especially its objectives and its procedure, to advice a patient and her/his family about PC provision. The major deterrent was represented by the moment of the patient’s discharge from the hospital to hospice or home care. HPs revealed they needed information about how activate PC provision after hospitalization.

“There needs to be clarity on the figures of reference for health professionals and PCU, the goals of PC, and how PCU works” (FG 3 Ph).

“One of the doubts I have is on when to call in palliative-care medical advice” (FG 1 Ph).

Furthermore, there does not appear to be an official agreement indicating which hospital specialist is responsible for PC patient management. This not only creates obvious delays in requesting and providing assistance but also involves a conflicting decision-making process about treatments. Physicians and nurses, within the same wards, often disagreed on treatments. Participants were not fully aware of the local network, while they were aware of the weakness and the precariousness of their therapeutic programme, mainly when carried out at the patient’s home. HPs saw the risk that the continuity of care might disappear.

“Our opinion was to suspend the treatment since the chances (of survival) were very few, but the specialist wanted to try a last line anyway, despite the patient … being already in desperate conditions. So there is no agreement between us” (FG 1 Ph).

“This is a problem that doctors often cause us … . They often demand things that are impossible to achieve” (FG 2 N).

Once the hospital professionals received training on PC, they became aware of the broader picture and organization of PC, the paths for pursuing its integration within daily hospital activity and its implementation outside hospital structures. Additionally, having a better comprehension of the roles and profiles of the professionals working in this service allowed the other hospital professionals to be more attentive and sensitive in facilitating palliative doctor consultancies.

“It was useful to get a clear definition of the meaning of palliative care, in relation to care and professional roles with them (PCU staff)” (FG 7 Ph).

Having clarified that PC needs can actually be met by the PC specialist once a PC plan is activated led the participants to feel a sense of synergy with colleagues that seemed to facilitate inter-professional relations. The presence of the palliative specialist helped trainees to achieve a new perspective.

“Now, after the training, there is a lot more awareness (on PC), and we can work in line with the medical staff, whereas before, when we had a patient in pain, we were in a situation where no one would take on the final provision for the treatment” (FG 8 N).

“With the introduction of the palliative doctor, we are facilitated in the assistance and decision making by coordination with the palliative doctor” (FG 11 Ph).

The relationship and communication with the patient’s family were reported as particularly strenuous by the professionals. Among the aspects highlighted by the participants were dealing with suffering and incurable conditions, the nature of the information they are in charge of communicating (e.g., poor prognosis, recurrent disease, last line of active treatment, transition from active care to PC) and the underlying issues of communication skills and personal ethics.

“I'm faced with the dilemma: “What should we communicate and how?” “I sometimes ask myself whether I should communicate the diagnosis or not” (FG 7 Ph).

“Since I do not know what the patient's wishes are, I often refer to the family's judgement” (FG 7 Ph).

“Each of us is self-taught in this field, but in reality, there are communication techniques that we absolutely do not know; we lack communication training” (FG 1 Ph).

Participants felt that communication with the family was very problematic and listed some typical situations, such as when the family members cannot accept the fact their relative’s disease is inevitably worsening towards death or when a family member asks to continue a useless therapy.

“It is necessary to help the family understand the meaning of pain therapy in relation to the process of accompanying the patient towards death; many times, the medical staff is forced to resort to a defensive medicine, just because the family are not entirely convinced that this person, in the end, is dying” (FG 5 Ph).

They stressed that this issue remained a critical point despite having undergone the present training course and began planning further training that could help them address their communication needs towards a collaborative approach with PC professionals.

“It is important to organize the approach together with colleagues, with the patient and his/her family, a possible caregiver” (FG 1 Ph).

“Our problems with communication lie largely in the lack of training” (FG 3 Ph).

Participants shifted from what we called “sense of uselessness towards the EoL” to “discovering the ‘treatments’ of the EoL”. In fact, participants felt a sense of uselessness, of ‘having their hands tied’. Before the training, pain was a cause of conflict among nurses and physicians: on one hand, the physicians considered the problem of the patient’s pain already solved, while the nurses thought there was a lack of pain therapy culture. Participants were more sensitive to the patient’s global suffering:

“The problem is precisely the therapy of pain, which perhaps we have not yet understood how it should be done, we see the patient suffering, but sometimes we have our hands tied” (FG 4 N).

“We often ask family members to allow us to give (PC) a try, … for something that will probably prolong the patient's suffering and that brings no apparent advantage to the patient's well-being. So, there is an insecurity that we all have towards these choices” (FG 1 Ph).

The participants discovered the importance of EoL treatments, as they reported a higher sensitivity and attention to the patient at the EoL after training. Nurses recognized that physicians, after the training, were more likely to involve palliative doctors, when before they felt more embarrassed. All the HPs gained a clear understanding of the area of intervention of PC, namely, the response to the needs of the person, even when they could no longer manage the treatment of the disease.

Nevertheless, the problem of identifying psychosocial and spiritual needs remained in both the pre- and post-training FGs.

Participants understood that the intervention of the PC specialist is needed to address the complexity and multiplicity of symptoms and needs that cause suffering in the patient.

“Surely our doctors have become confident enough to call the palliative doctor, and this alone is an important step ahead” (FG 10 N).

“For our work, we should have a greater knowledge of what palliative care is” (FG 9 Ph).

From the “initial perception of the impossibility of meeting and integrating the PC specialists” and being somewhat powerless, participants shifted to an “understanding of the process, which will facilitate PC inclusion in their work”. In fact, the first reaction of the professionals revealed their doubts about the feasibility of PC. The expectations of participants before the training were to receive not only theoretic notions but also concrete proposals they could transfer to the patient’s bedside. The first obstacle was traced back to organizational problems. HPs declared that working schedules were short and that the organization often did not allow a method that was different from the one traditionally intended, where it is the doctor alone who interacts with the patient and the family. Participants thought that more complex approaches, such as those proposed by palliative specialists involving several actors, were challenging to apply.

“I am often involved in the most difficult part of setting up the PC programme and coordinating everyone, from my colleagues to the patient, family, and a possible caregiver” (FG 1 Ph).

“Even doctors, however, are always struggling to involve the palliative doctors. They always wait until the last moment” (FG 4 N).

The participants’ understanding of the organization within the PCU seemed to have facilitated the involvement of the palliative doctor’s consultancies within the care. Participants became aware of the practical possibility of activating PC and showed the need for greater integration of PC specialists within the examined operating units (OUs).

“We should involve palliative specialists more and more, so they can get to know our patients, the dynamics at our department, and grasp the mesh of our organization” (FG 9 Ph).

Still, some HPs perceived organizational boundaries and constraints.

“What we will discover is whether we can implement PC on a practical basis, with the patient. However, in this setting, there is neither the time nor the mindset to use this approach to the patient. Because we are unable to do it... because of the organization” (FG 3-4 N & Ph).

The last theme emerging from FGs regarded the difficulty of the professionals in sustaining, over time, the emotional charge of daily contact with patients and families who have EoL situations.

Following training, professionals in the FGs recognized above all the need to receive psychological support themselves to face complex EoL situations.

“Plus, we don't receive much attention ourselves. In fact, the staff suffer... from an emotional point of view. You deal with it on your own. You can take an individual route, but it's not enough. For years we've been claiming that we need support for the staff” (FG 2 N).

The risk of burden was perceived especially by nurses, who felt they would gradually become unable to help anymore because of the intensity of emotions experienced. HPs reported that they were not able to identify, welcome and process those strong feelings. Both personal development and preparedness were needed to cope with the phenomenon.

“Manage this impact requires the right maturity, and the right preparation; the psychological aspect is important for the family, it is important for the doctor, but it is also important for the nurse and the assistants who are in contact with the patient on a daily basis” (FG 2-6 N & T).

From the post-training FG, the previously highlighted needs and the fears expressed by the participants related to the risks of emotional stress led the way to a precise awareness. It appeared that the requests for help became explicit, even if not yet well circumstantiated: from training to communication to the care for HPs, to emotional support in the management of complex cases. Participants recognized the training as an occasion for discussion and sharing of the most complex problems. The shared search for common solutions could become a support strategy.

“We should establish a mutual-support group. Moments to dedicate not only to the discussion of cases but also of what has caused emotional reactions in the colleagues” (FG 8 -12 N & T).