Background
As populations age, “home” at the time of death for a growing number of older people will be long-term care facilities [
1]. In addition, older people in long-term care are more likely to live with complex co-morbidities and experience illness within the context of existing physical or mental impairment [
2,
3]. As one of the most disadvantaged and vulnerable groups in industrial societies, older people in long-term care facilities are thus at a greater risk of receiving care at the end of life that does not adequately meet their needs [
4]. The increasingly complex needs of long term care residents and the fact that a large number of older adults will die while long-term care makes it essential that services have processes in place to facilitate quality palliative and end of life care. Long-term care in New Zealand is synonymous with residential aged care. The level of care provided is based on need and includes rest home care (support but not 24 h nursing/medical care), hospital-level care (24-h nursing/medical care), dementia care and psychogeriatric care [
5].
The New Zealand Health Needs Assessment for Palliative Care conducted under the auspices of the Palliative Care Council concluded that almost all long-term care facility residents would require palliative care at the end of their life [
6]. Furthermore, 50% would benefit from specialist palliative care advice and support, while the other 47% could be managed by the long-term care facility, given the capabilities and resources to provide a generalist level of palliative care [
7].
Within the context of this study, long-term care staff refers to registered nurses and health care assistants (non-health professional support workers) directly involved in the care of residents.
Research has indicated that registered nurses in long-term care facilities are often unprepared to provide palliative care [
8]. For example, they feel ill-equipped to undertake Advance Care Planning (ACP), [
9] a process of discussion and shared planning for future health care that assists the individual to identify their personal beliefs and values and incorporate them into plans for their future health care [
10]. There is also evidence that long-term care facility staff (both registered nurses and health care assistants) feel inadequately supported in coping with multiple bereavement experiences [
11]. Addressing the palliative care knowledge and skills deficit, as well as the emotional readiness of long-term care facility staff is therefore of critical importance to delivering quality palliative care [
7,
12,
13].
However, a major challenge continues to be the translation of educational interventions to the reality of the long-term care environment [
14]. The negative impact of burnout on education uptake and the lack of consideration of organisational factors (e.g. low staffing levels, time pressures) may present obstacles to sustainable change [
15,
16]. Furthermore, conflicts may arise between hospice as an organization and long-term care facilities hindering the delivery of quality care [
17]. The provision of complex, quality health care requires effective relationships among multidisciplinary team members, as well as the ability to learn together and adapt to change [
18‐
21].
Education initiatives developed to date have focused on short training programs concentrating on the traditional “chalk and talk” format [
22,
23]. However, there is minimal evidence that nurse and support staff knowledge gained from this format is sustained in the long term [
14]. Adults learn best from direct experience [
24]. As quoted from Confucius “Tell me, and I will forget. Show me, and I may remember. Involve me, and I will understand.” It is within this context that the need for a new model of education delivery has been identified that supports “hands-on” learning which is a vital component of the sustained transfer of new knowledge into practice [
25].
The Supportive Hospice Aged Residential Exchange (SHARE) intervention provides a means to package and systematically support knowledge exchange between hospice palliative care nurse specialists and long-term care facility direct care staff (registered nurses, health care assistants). Hospice palliative care nurse specialists are defined as registered nurses with a recognized palliative care qualification [
26] Although hospice involves in-patient services, hospice palliative care nurse specialists also provide care in the community including to residential aged care residents [
27]. The goal of SHARE is to improve palliative care delivery [
28]. Palliative care in this paper is defined as an approach to care that improves the quality of life of patients and their families for those facing a life-threatening illness [
29]. It involves care across the duration of the resident’s illness [
29]. End-of-life care is incorporated into palliative care, although the timeframe differs in that it is typically limited to the last few months of life [
30]. SHARE implementation involved weekly visits by one of three palliative care nurse specialists from two local hospices to twenty local long-term care facilities.
SHARE components. The SHARE model included: 1) a records review and assessment of the goals of care of residents identified as having palliative care needs by the palliative care nurse specialist and facility RN, using the Clinical Frailty scale [
31] and Supportive Palliative Care Indicators Tool [
32]; 2) palliative care nurse specialist and RN reciprocal clinical coaching; 3) role modelling of advance care planning conversations with RN’s; 4) palliative care education planning and 5) debriefing following a resident death with the facility RN’s, and to a lesser degree with HCA’s [
28]. Evidence indicates that these methods can achieve sustained knowledge transfer [
32‐
34]. (Table
1). SHARE was implemented and evaluated in 20 long-term care facilities, for 1 year in two district health boards. Each palliative care nurse specialist was assigned a subset of the 20 facilities to visit weekly.
Table 1
Components of the SHARE model (Frey et al., 2017)
Records Review |
The identification of residents who would benefit from a palliative approach was completed through a records review conducted by the hospice palliative care nurse specialist in conjunction with a registered nurse (RN) from each facility. The review included an assessment of resident palliative care need using the Supportive Palliative Care Indicators Tool [ 31] and the Clinical Frailty Scale [ 32]. The purpose of the review was to provide the basis for ongoing monitoring of resident palliative care need and to create a “Goals of Care” plan for those on the registry. |
Clinical Coaching and Role Modelling |
This was a reciprocal process of shared learning between palliative care nurse specialists and long-term care RN’s and healthcare assistants (HCA’s). In partnership with HCA’s, RN’s and General Practitioners (GP) the palliative care nurse specialists worked to develop and update a “Goals of Care” plan to reflect new or changing palliative care needs. This consultation was made in partnership with the RN and HCA present to provide opportunities for clinical coaching, role modelling and development of clinical knowledge. |
Palliative Care Education Planning |
The palliative care nurse specialist worked together with RN’s and HCA’s to discuss the specific learning needs in each facility identifying the priorities for staff. A programme of education was be developed that was unique to that facility and complimented the current education provided by the two hospices. |
Debriefing |
Debriefing following resident deaths was offered facilitated by the palliative care nurse specialist in collaboration with a senior RN from the facility. This service provided an opportunity to acknowledge the emotional impact of end of life care. It also provided an opportunity to reflect on the care provided. |
The goal of the larger SHARE evaluation was to determine if the intervention was contextually appropriate and sustainable. This study forms
Phase One of the larger SHARE evaluation and explores the palliative care nurse specialists’ views and experiences regarding the benefits and barriers to SHARE implementation in long-term care facilities. The effective implementation of any educational intervention is dependent on the perceptions and interpretations that both mentors and students bring to the encounter [
33]. While there are studies focusing on the impact of palliative care interventions on residents, clinical staff and families [
34‐
37] little research has dealt with the perceptions of the facilitators [
38]. An individual’s perceptions of experience directly influence their subsequent motivation [
39]. It would seem important that the perceptions of the palliative care nurse specialists delivering SHARE be examined.
Discussion
A number of factors supported the educational intervention, Supportive Hospice Aged Residential Exchange (SHARE) as perceived by the three hospice nurses. In the first instance, the relationship that the palliative care nurse specialists forged with facility registered nurses, health care assistants as well as facility managers appeared to have a huge bearing on the success of the uptake of the learning. Developing a connection and acceptance of the specialist nurse specialist was key – i.e. that the palliative care nurse specialist needed this relationship to be developed in order to feel her role was effective. Indeed, previous research has indicated a relationship between improved student outcomes and the development of a trusting teacher-student relationship [
44]. Having a dedicated palliative care nurse specialist visiting on-site regularly allowed the registered nurses to build a key relationship, encouraging them to share the gaps in their knowledge, as well as to ask for support in working with families. Comments on the personal support that the palliative care nurse specialist gave indicate that along with providing specialist palliative care knowledge, they became a source of comfort for many stressed registered nurses. Trust has also been associated with increased sharing and collaboration [
45]. In fact, trust and collaboration reinforce each other [
45]. Ongoing contact between the parties (in this instance, palliative care nurse specialists, registered nurses and health care assistants), creates the opportunity to increased trust, leading to enhanced motivation to learn [
46]. This increased motivation, in turn, supports a willingness for continued collaboration. In other words, with ongoing contact, the palliative care nurse specialist gained acceptance within the facilities and was in turn welcomed as part of the “staff family”. The development of a trusting relationship where registered nurses felt “safe” to ask for help with caring for residents with palliative care needs was a key component of the SHARE model. Relationships between staff (RN’s, HCA’s) and facility managers were also key to palliative care nurse specialists’ perceptions of improved resident and family care. Previous research has indicated that the quality of the relationships and communication among staff members is a key predictor of health care quality [
47].
Drawing on Lave and Wenger [
48], learning within long-term care facilities is a situated and collaborative activity, a process of participation in “communities of practice.” Learning is context-bound, shaped by the sociocultural practices of the organization. Indeed, research indicates that setting, activities, and artifacts also play a key role in learning, particularly in tasks that require higher-order knowledge [
49]. According to Billet [
49], “the adaptability of the knowledge that has been learned is premised upon its discernible applicability to particular situations” (p. 389). Findings also point to evidence of reciprocal learning with palliative care nurse specialists gaining new knowledge and understanding during the interactions with registered nurses and health care assistants.
Previous research has indicated that mentoring is linked to personal and professional development for mentors [
50]. Palliative care nurse specialist mentors appeared to have expanded their knowledge of gerontology as well as their understanding of long-term care registered nurse perspectives [
51]. In essence, the palliative care nurse specialists and the registered nurses in the long-term care facilities developed a peer-learning partnership – a reciprocal learning relationship between parties of equal status who share a common goal [
52]. Findings indicated that interactions as part of the SHARE role increased the palliative care nurse specialists’ respect for the care provided by the facility as well as their own knowledge and skill to care for frail older people. The partnership thus facilitated knowledge exchange between the palliative care nurse specialists and registered nurses and health care assistants with the goal of improving palliative care delivery within the long-term care facilities. This, in turn, helped to establish a trusting relationship built on mutual respect [
53].
Evidence from the hospice logs indicated both a recognition of improved communication about changes in a resident’s condition with family members. Excellent palliative care occurs when interdisciplinary team members communicate effectively and collaborate on care plans [
34]. Therefore, it is necessary for all health care providers (including health care assistants) to become more effective at interpersonal communication and collaborative skills [
54]. Mentoring by palliative care nurse specialists appears to have enhanced interpersonal communication skills for registered nurses. Barriers to communication persisted, however, particularly in relation to the initiation and documentation of advance care plans for residents. There is a significant relationship between advance care plans and quality of dying [
55] as well as a relationship between the care received at end of life and patient preferences [
56]. As in previous research, lack of willingness to document palliative care need may stem from prior uneasiness with discussing advance care plan related issues with residents or families [
57].
The level of reference to staff turnover, insufficient staffing, and staff changes was highlighted by hospice nurses and represented a barrier to SHARE implementation. Low staffing levels and the associated time pressures can create barriers to the uptake and application of new knowledge [
58]. Previous research has indicated a staff preference for interactive, hands-on, applied learning [
59] making the physical presence of the palliative care nurse specialists even more significant in sharing knowledge and practice. Furthermore, traditional training and education methods in palliative and end of life care have previously required registered nurses to leave the clinical environment to attend study days and training sessions [
60] creating more staffing pressures for long-term care facilities. In contrast, SHARE does not pull registered nurses away from the bedside and therefore does not require “more time” to attend teaching sessions. Nevertheless, the continued staff turnovers presented a challenge to the establishment of trusting relationships between the palliative care nurse specialists and new staff registered nurses. Such challenges require the development of skills on the part of palliative care nurse specialists to create genuine connections, even in brief encounters. Such skills can result in greater trust and opportunities for teamwork to develop [
61].
Strengths and limitations
The findings and consequent discussion are based solely on the perceptions and observations of the hospice nurses. The views and opinions of others involved in the evaluation, such as the long-term care facility registered nurses, managers, and residents, have not been included. However, because the logs were maintained over the course of a year, emerging patterns were revealed which may not have been observable with other methods. Furthermore, both contextual and recall biases were significantly reduced as logs were created as events unfolded [
62].
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.