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Editorial
Palliative care nursing education
Australian and Canadian challenges
Linda Kristjanson
Professor, Faculty of Nursing, RMIT School of Nursing, Edith Cowan University, WA
Elizabeth Manias
Lecture, RMIT University, Faculty of Biomedical and Health Sciences and Nursing, Bundoora West Campus VIC
Tony Bush
Faculty of Nursing, RMIT School of Nursing, Edith Cowan University, WA
Article Text
Historically, nurses have been involved in the provision of palliative care. Nurses have played various roles in the developing of palliative care, offering leadership, support and focus for the movement. Some medical practitioners, such as Professor Ian Maddocks at Flinders University, advocate that nurses take charge of palliative care teams. However, despite this type of support for palliative care nursing and a continued involvement in palliative care, nursing has lagged behind other disciplines in the development of palliative care nursing education curricula. This underdeveloped educational foundation has contributed to difficulties in defining the role of the nurse in palliative care.
Palliative care involves a holistic approach to the terminally ill person. It addresses their physical, psycho-social, spiritual, and emotional needs. Within each of these areas arise unpredictable, complex issues that would confound many practitioner. Recent research indicates a need for all health practitioners to be well prepared to provide the care necessary to meet the complexity of patient demands in palliative care settings (Uyeda, Farrell, Schneider, et.al. 1997). However, many nurses feel inadequately prepared. This is not surprising given the fact that undergraduate palliative care nursing education is almost non-existent within the Australian context. Without formal palliative care education, nurses can flounder both professionally and personally.
Palliative care is now provided in a range of care settings. Over recent years, palliative care has moved from hospice setting to more mainstream areas such as domiciliary care, nursing homes and hospital (Manias, 1998). The degree of distinctiveness or integration of palliative care services within these settings varies widely. The ideal palliative care model requires a cohesive multi-disciplinary team approach, where health professionals are able to support one another as well as the terminally ill person and his or her family. The extent to which this team work exists also differs, making provision of palliative care more challenging. Nurses who endeavour to provide palliative care in a range of palliative care contexts might find themselves struggling for practice knowledge, as they attempt to define their roles with respect to the knowledge and roles of other team members.
An essential element of palliative care nursing education is a strong research base. As palliative care nurses undertake research that better articulates their practice and examines clinically relevant research questions, this knowledge should be integrated into undergraduate and post-graduate nursing curricula. The findings reported in this issue by Aranda and Kelso (1997) in their article, 'Nurse gate-keeping in palliative care: Exploring the tensions', point to the need for palliative care nursing education at the undergraduate level and underscore the importance of interdisciplinary palliative care training.
Most Australian nursing education is dependent upon the commitment of individual lecturers who have expertise in palliative care. To date, formal palliative care nursing preparation is limited to graduate courses; any other experience is gained through on the job exposure. Patently, the preparation is inadequate; particularly as current literature repeatedly identifies the need to prepare undergraduate nurses to at least a safe level of practice. Many medical curricula have included formal education in palliative care for a number of years (Ashby, 1998); Buchanan, Millership, Zalcberg, et. al. 1990). Interestingly, in some universities, experienced palliative care nurses provide training and share their expertise in these medical programs. Nurse academics and students acknowledge that palliative care may be important; however, they argue that existing Australian nursing curricula are overloaded. Nonetheless, a re-valuation of priorities is urgently required. At this point, it is interesting for us to compare the Australian situation to the Canadian context.
Palliative care nursing education challenges are best understood within the social context that surrounds care of the dying. Despite increased public awareness of issues relating to death, Canadians remain in large part, a death-denying culture. The Canadian Cancer Society slogan, 'Cancer Can Be Beaten', might communicate a belief that individuals should fight to get well and that the 'correct' way to die is to continue to struggle towards a cure. This value may have insidious effects on the ways in which Canadian society provides for and supports dying and the emphasis, or lack thereof, placed in nursing curricula on palliative care content.
A recent Canadian survey of practicing physicians and nurses reported a number of palliative care education needs (Samaroo, 1996). Priority education needs identified included: pain and symptom management, family support, communication and ethical issues.
Canadian nursing educators have embraced palliative care training to a limited extent. The degree to which specific theory and clinical practice is part of undergraduate nursing curricula, varies from province to province (Copp, 1994). Canadian research revealed that a specific palliative care unit offered to undergraduate nursing students, was more successful in reducing death anxiety and death avoiding behaviours than an 'integrated curriculum approach' (Degner & Gow, 1988a, 1988b). Despite these findings, most undergraduate nursing programs continue to 'scatter' palliative care nursing content throughout the program, rather than offering this content as a separate unit (Cohen, Bultz, Clarke, et. al. 1996).
A number of Canadian postgraduate nursing courses allow nurses to focus their studies in the area of palliative care. However, no formal specialty status has been awarded to Canadian palliative care nurses, and opportunities for advanced clinical training in these courses are minimal.
A glaring omission in most nursing curricula is the absence of paediatric palliative care content. Specifically, nursing education related to paediatric symptom assessment, symptom management and in particular, pain management for children, is sorely lacking (Liben, 1996; McGrath & Finley, 1996).
With respect to continuing education, a recent survey of palliative care nurses revealed that educational needs was the second most important professional issue identified. This issue was preceded only by the need to develop standards of palliative care practice (Kristjanson & Balneaves, 1995). Clearly there are many needs for further Canadian palliative care nursing education at undergraduate, graduate and continuing education levels.
The issues raised in the Australian and Canadian contexts challenge our thinking and prompt us to ask important questions. Where is nursing headed given the predicted increase in palliative care patients in the mainstream setting? Why do nurse academics agree with the need to include palliative care in nursing curricula, yet appear to do little about it? What formal preparation is provided for nurse academics who teach palliative care programs?
There are usually two types of care situations that warrant inclusion in the curriculum of any health professional. The first is that the situation is so life-threatening that if the health professional does not recognise it and know how to respond, the results will be serious. In the second case, the care experience is so common that most health professional will eventually encounter the situation. Clearly, care of the dying fits into this latter category. As changes in Australian demographics will occur, more and more Australians will require supportive end-of-life care which will be provided in a range of care settings. It is essential therefore that nurse academics re-assess current curricula and include palliative care content in undergraduate nursing education so that nursing graduates of the future are prepared to meet the challenges that lie ahead.
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