How many times in your palliative or hospice nursing practice have you said, "If only the doctor had talked to this patient about his illness," or "Why didn't they refer sooner?" or "Nurses in the acute care setting just don't get it when it comes to palliative care." I must admit, I am guilty of expressing my views on more than one occasion about what a terrible job those "other" healthcare professionals do when it comes to providing care at the end of life. In addition to being aware of how poor our colleagues are at providing palliative care, as a former hospice clinician and administrator, I am also acutely aware of the impact the nursing shortage has had on our profession. The question then becomes, do we sit and lament about the shortfalls of the healthcare system, or do we take action and do our part to improve end-of-life care? My personal feeling is that lamenting satisfied my need for martyrdom but did little to improve palliative care or hospice nursing.
Seattle, like many other communities, has its challenges when it comes to providing quality end-of-life care. However, I firmly believe that our medical and nursing programs have recognized their current end-of-life curriculum deficiencies and are taking steps to correct them. In 2004, the University of Washington School of Medicine will incorporate a clerkship in palliative care for all fourth-year medical students. Starting in August 2003, one of our local internal medicine residency programs incorporated a month-long hospice rotation into the curriculum for its third-year residents. At least 4 different area nursing schools (3 RN, 1 LPN) now provide didactic lectures on palliative care once per quarter. Three of those schools also allow both graduate and undergraduate students to have an option for a clinical experience in hospice. Finally, the large county hospital, which is operated by the University of Washington, has hired a palliative care specialist/educator to work with staff and families in the hospital's 7 critical care units. These examples show me that "those people who just don't get it" really want to learn.
Given the community needs related to better end-of-life care and the response of our academic programs to attempt to meet at least some of those needs, I was recently surprised when a hospice supervisor indicated that she did not know if her staff would be able to accommodate any more students (medical, nursing, or residents). She believed that they were just too busy and having an extra learner might place too much stress on the nurses. As I inquired further, several nurses said they were too busy to "have a student with them." If we, as the experts in palliative and hospice nursing, are not willing to provide training, then who will? My argument is that as experts in our field and advocates for better end-of-life care, we have a duty to provide education and training. Education is everyone's job!
I acknowledge that there are some nurses who are good clinicians but are not as effective as teachers. In those cases, having them precept a student or physician might have the opposite effect, leaving all involved individuals unsatisfied. I would argue that those folks are few and far between and that as nurses we all teach, both informally and formally, everyday to patients, families, and professional colleagues. It is also important to remember that if the goal is to teach true hospice and palliative care, then students should be given the opportunity to experience all disciplines, not just nursing. Nursing is but one piece of hospice and palliative care. Our professional colleagues in social work, spiritual care, bereavement, nutrition, and medicine should also share in the education responsibility.
Of course, we would not want to leave administration out of the education equation. Administrators in hospice and palliative care programs must also recognize and support the need for education. Examples of this support include paying staff for developing and giving lectures to academic programs (not just the weekly marketing lunch to the physician's office), preceptor pay differentials, and actively forming alliances with local schools and residency training programs. There are some hospice administrators who do not support any academic teaching unless it directly affects their census; fortunately, these shortsighted profit-driven people are the exception, not the rule. Resident physicians become attending and community-based physicians who make hospice referrals to programs with which they are familiar. Nurses seek out employment in programs where as students they had a positive experience. The old saying of "what goes around, comes around" applies here.
It is easy to get caught up in the cycle of disempowerment. We lament instead of educate about how patients get little or no hospice or palliative care because healthcare providers are not knowledgeable about our practice, which leads to decreased job satisfaction. Then we lament about our increased workloads, which result, in part, from our nursing peers having not been exposed to the wonderful work we do and, therefore, not actively seeking positions in our field. We all have a choice: we can be empowered to make a difference through education, or we can moan about how hard we work and how poorly others are at providing end-of-life care.
By now, you must be asking yourself if I put my money where my mouth is. I am happy to say the answer to that question is an overwhelming yes. First and foremost, I am blessed (and always have been) with an employer who supports the need for better end-of-life care. That support is demonstrated by their willingness to provide me with time to attend HPNA board meetings, participate in conference calls, and write educational materials. In addition to national work, I give a 2-hour palliative care lecture at 4 different schools of nursing once every quarter, I cofacilitate palliative care rounds for resident physicians twice per month, and I never turn down a request for a talk or lecture on hospice or palliative care. As an experienced palliative care and hospice nurse and advocate for improved end-of-life care, I absolutely believe it is our responsibility to educate our peers. In the lament vs. educate scenario, I would encourage you to choose to educate. Although it does not lend itself to martyrdom, it is much more rewarding in the long run.
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Guest Editorial