Palliative Care Nursing – looking back to where it started and where it is now
A blog post written by Kate Swetenham, Nursing Director of Palliative Care Projects at SA Department for Health and Wellbeing
When I started nursing I trained in a paediatric hospital under the apprenticeship model. Six weeks was spent in study block prior to entering the hospital wards as a novice student nurse to start putting the theory into practice. My entry into the world of nursing started with learning the fundamental tasks and with that I was taught about ‘basic nursing care’. This was the act of attending to the needs of patients that addressed activities of daily living. There was focus on taking notice of the patient and observing patterns of behaviour. This was a fundamental skill for a paediatric nurse as children cannot tell you what is wrong and the skill of problem solving resided in interpreting their behaviour and working in partnership with their parent or caregiver.
Communication, feeding and nutrition, hygiene, mouth care, eye care, bladder and bowel care, bed making and recording vital signs of temperature, pulse and respirations underpinned what was referred to as ‘basic nursing care’. Technical skills such as wound dressings, nasogastric tubes, indwelling catheters, Intravenous therapy and working with machines that went beep were saved for the next study block as we progressed through the training program and gained a stripe on our nurses’ cap to indicate the next level of proficiency.
There were great rewards in progressing through each study block and developing our technical skills. A new skill equated to increasing status on the ward as someone who could be trusted with a more complex patient. It was not until I finished my General Training in 1987 and was working in the Cystic Fibrosis ward that I reconnected so firmly with my basic nursing care skills. While I had developed proficiency in the much sought after technical aspects that equated to being a ‘good competent nurse’ the skills I required in this ward were highly developed ‘soft skills’ of communication, empathy, observation, care and being able to stay in a place of distress and be a source of strength to parents as they prepared to lose their child to this dreadful disease. I did not realise it at the time but I was a palliative care nurse then.
It would be 15 years before I started to actually work in a designated palliative care role. I had worked in paediatrics, adult medicine, surgery and oncology before arriving at a Hospice to work. On arrival to Hospice I was impressed by the practice of palliative care nursing. Hospice nurses had a calmness that underpinned a level of care I had not seen for such a long time. Nothing was too much and every effort to ensure the patient was included in all decision making and the family understood what was happening was what I remember most about this time in my career.
Hospice nurses might be moving quickly through the corridor seeking a buddy to check an opioid medication, but as soon as they entered the patient room the pace slowed immediately, the tone of voice was calm and confident and the medication was administered after a thorough assessment of pain along with education as to how they may feel after receiving the medicine and the bell placed in the patients’ hand in the event they needed the nurse.
Hospice nurses naturally engaged in ‘rounding’ something that was introduced as a concept for more acute areas in recognition that if a nurse popped their head in frequently this reduced the number of patient falls and increased patient satisfaction with the care.
This may not sound that special but this was the point of difference patients and their families continually reported back from their experience in Hospice. “The nurses know me, they know what I need, they treat me with respect and nothing is too much trouble”.
The Hospice nurses were often accurate in their predictions of prognosis. They recognised deterioration swiftly and prepared families as the changes emerged. The psychosocial aspects of care are highly developed in an experienced palliative care nurse. They know how to explore patient distress, and how to ask open ended questions that encourage rapport and trust in the care relationship.
These skills are often considered ‘soft’ because we engage in conversation daily and people mistake it for something that comes naturally. The courage it takes to sit with a vulnerable human being as they explore what their living and dying means, to sit with their tears and distress and to provide them a safe place to open up cannot be underestimated.
Soft skills underpin really tough work. It is emotionally draining as a nurse to expose yourself to suffering daily. Job satisfaction has to be found in other ways. Your patient is unlikely to recover and return home being free of the ailment that brought them into hospital. Instead as a nurse you take your job satisfaction in the small things. Making someone comfortable on a shift, washing someone’s hair in bed, giving them a hot towel sponge and hearing them relax and tell you how much they enjoy it.
For nurses considering palliative care a clinical mentor is very helpful. My mentor reminded me of the importance of my ‘soft’ skills in basic nursing care and supported me into courageous patient encounters. As my career in palliative care developed so did palliative care resources. CareSearch and End-of-Life Essentials have provided a vehicle to undertake education and skill development at any time of the day or night as these resources are freely available online. It is very helpful to have best practice role modelled as palliative care is not a set of tasks to be undertaken but is a philosophy and approach to care.
For people to experience a good death those around them need to be supported by clinically competent and psychosocially brave clinicians who skilfully shepherd them through the process.
Kate Swetenham, Nursing Director of Palliative Care Projects at SA Department for Health and Wellbeing