Hospice nurse reflections on a palliative care educational intervention in long-term care: An inductive content analysis


 Abstract
Background: Older people in long-term care facilities are at a greater risk of receiving care at the end of life that does not adequately meet their needs, yet staff in long-term care are often unprepared to provide palliative care. The objective of the study was to explore hospice nurse experiences regarding the barriers and facilitators to the implementation of a palliative care educational intervention, Supportive Hospice Aged Residential Exchange (SHARE) in 20 long-term care facilities.
Methods: Reflective logs (465), recorded over the course of the yearlong SHARE intervention by the three hospice nurses, who were the on-site mentors, were qualitatively analyzed by two researchers utilizing inductive content analysis.
Results: Categories emerging from the logs include the importance of relationships, knowledge exchange, communication, and the challenges of providing palliative care in a long-term care setting.
Conclusion: Evidence from the logs indicated that sustained relationships between hospice nurses and staff as well as reciprocal learning were key factors supporting the implementation of this palliative care educational intervention. Challenges remain however in relation to staffing levels, which further emphasizes the importance of hospice presence as a point of stability.

the long-term care facility, given the capabilities and resources to provide a generalist level of palliative care. (3) Research has indicated that staff in long-term care facilities are often unprepared to provide palliative care.(4) For example, they feel ill-equipped to undertake Advance Care Planning (ACP) (5), 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 (Ministry of Health. (6) There is also evidence that long-term care facility staff feel inadequately supported in coping with multiple bereavement experiences. (7) Addressing the palliative care skills deficit of long-term care facility staff is therefore of critical importance to delivering quality healthcare in this setting . (3,8,9) However, a major challenge continues to be the translation of educational interventions to the reality of the long-term care environment. (10) 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. (11,12) Furthermore, conflicts may arise between hospice and long-term care facility staff hindering the delivery of quality care. (13) 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. (14)(15)(16)(17) Education initiatives developed to date have focused on short training programs concentrating on the traditional "chalk and talk" format. (18,19) However, there is minimal evidence that staff knowledge gained from this format is sustained in the long term.(10) Adults learn best from direct experience. (20) 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. (21) The Supportive Hospice Aged Residential Exchange (SHARE) intervention provides a means to package and systematically support knowledge exchange between hospice staff and long-term care facility clinical care staff on-site at the facility, with the goal of improving palliative care delivery. (22) The SHARE model is supported by research evidence indicating that that clinical coaching, role modelling and debriefing provided by specialist palliative care nurses can achieve sustained knowledge transfer.(23-25) SHARE implementation involved the identification of residents who would benefit from a palliative approach through a review process conducted by a hospice nurse in conjunction with a facility nurse. (22) The purpose of the review is 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. The review process is outlined in Figure 1.
[Insert Figure 1 here] SHARE was implemented and evaluated in 20 long-term care facilities for one year in two district health boards. The goal of the larger evaluation was to determine if the intervention was contextually appropriate and sustainable. This study explores the hospice nurses' views and experiences regarding the barriers and facilitators to the implementation of SHARE in long-term care facilities.

Methods
The objective of the study was to explore hospice nurses' views and experiences regarding the barriers and facilitators to the implementation of a palliative care educational intervention (SHARE) in long-term care facilities. The study forms part of a larger yearlong mixed methods evaluation of SHARE in 20 long-term care facilities.

Participants
All of the hospice nurse specialists were female and between 40 and 55 years of age. Two hospice nurse specialists had between six to ten years of experience in age care while the third had over eleven years of experience. Given the small number of contributors, identifiers for quotes have been omitted to maintain the confidentiality of both the hospice nurses and the facilities.

Process
The extensive reflective logs, recorded over the course of the yearlong SHARE intervention by the three hospice nurses, who were the on-site mentors, were qualitatively Higher order headings were refined as the analysis process progressed through in-depth discussions between DB and RF. The names of the categories were selected based on their ability to represent the overall sense of the logs. Sub categories were identified through the process of abstraction.

Results
Four categories were isolated. These categories included connections, knowledge exchange, communication, and challenges. Categories and subcategories are portrayed in [Insert Figure 2 here] Relationships A common topic from all the logs was the building of relationships -of facility staff with residents, and with families, connections among facility staff, and for hospice nurses, the importance of building a strong connection with the facility staff in order to build trust.

Relationships between hospice nurses and long-term care facility staff -The establishment
of relationships between the hospice nurses and long-term care facility staff, helped develop a sense of both trust and understanding of the role and scope of hospice in the care of residents. Having a dedicated hospice nurse visiting regularly allowed the staff to build a key relationship, and encouraged them to share the gaps in their knowledge as well as to ask for support in working with families.
SHARE helped the long-term care facility team and myself developing a better rapport. Relationships among staff members -Opportunities for staff participation in activities encouraged socialization between staff members and between staff and residents. These activities provided a mutual feeling of "family" that fostered the development of collaborative relationships, a key prerequisite for SHARE success.  Early palliative care need identification -The logs also provided evidence of better documentation of residents with palliative care needs. Better identification allows for proactive care planning before the terminal stage.

It was clear which facility did want to involve residents 'family.' When Nurse Manager
When I was preparing for the resident's information for a research report, I realised that all recent deceased residents were enrolled onto Palliative Care Register.
Barriers -Communication problems persisted in some facilities particularly in relation to future care documentation. The hospices nurses in the SHARE study documented practices that they found troubling concerning palliative care and especially unnecessary hospital admission.

A new nurse was on duty and there were no clear easy to access guidelines in residents
notes about her future plan of care. Therefore, by default, she went to the hospital where she spent 24 hours, was commenced on oral antibiotics and then returned to the facility.
Challenges of providing palliative care in a long term care setting Key themes reflected throughout the logs included the detrimental effects of resource constraints and increasing staff turnovers. These factors not only influence palliative care education and delivery but also staff well-being.

Staff turnover, & under-resourcing -The level of reference to staff turnover, insufficient
staffing & staff changes (especially RNs coming in from overseas who use the long-term care sector to bridge into work in district health boards) is troubling. This, in turn, led to very challenging circumstances in which to provide staff education in a traditional classroom sense, making the physical presence of the hospice nurses even more significant in sharing knowledge and practice between the long-term care facilities and the hospice nurses.

Lead clinical nurse in the Dementia Unit has left. Find this unfortunate as she appeared to
us to be very knowledgeable in the care of those with dementia. They do not have someone to replace her as yet.
The continuing staff shortages serve as a further indicator of the need for an alternative to traditional didactic methods of teaching. Staff shortages translate into a lack of staff available to attend sessions, as indicated in the following reflection:

Even CCM [clinical charge nurse manager] A could honestly share that she was constantly orientating a new group of nurses. They were not in any shape to take on [education]
training at all.

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 hospice nurses forged with facility staff appeared to have a huge bearing on the success of the uptake of the learning. Developing a connection and acceptance of the hospice nurse by staff was key -i.e. that the hospice nurse 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.(28) Having a dedicated hospice nurse visiting on-site regularly allowed the staff 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 hospice nurse 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. (29) In fact, trust and collaboration reinforce each other. (29) Ongoing contact between the parties (in this instance, hospice nurses and staff), creates the opportunity to increased trust, leading to enhanced motivation to learn. (30) This increased motivation, in turn, supports a willingness for continued collaboration. In other words, with ongoing contact, the hospice nurse gained acceptance within the facilities and was in turn welcomed as part of the "staff family".
The development of a trusting relationship where nurses felt "safe" to ask for help with caring for residents with palliative care needs was a key component of the SHARE model.
Relationships among staff members were also key to hospice nurse 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. (31) Drawing on Lave and Wenger (32), 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.(33) According to Billet (33) "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 The level of reference to staff turnover, insufficient staffing, and staff changes was highlighted by hospice nurses. This led to very challenging circumstances in which to provide staff education in a traditional didactic format. (18,19) Low staffing levels and the associated time pressures create barriers to the uptake and application of new knowledge.
(43) Previous research has indicated a staff preference for interactive, hands-on applied learning (44) making the physical presence of the hospice nurses even more significant in sharing knowledge and practice. Furthermore, traditional training and education methods in palliative and end of life care have previously required nurses to leave the clinical environment to attend study days and training sessions (45) creating more staffing pressures for long-term care facilities. In contrast, SHARE does not pull staff away from the bedside and therefore does not require "more time" to attend teaching sessions.
Hospice nurses work alongside care staff supporting and coaching as they work and may, in fact, support care staff to provide better care.

Recommendations
In the first instance, findings indicated that one-off education is not sufficient to promote sustained learning. Long-term care facility staff benefit most from hospice nurses being present and demonstrating a willingness to exchange ideas. The frequency of the visits is vital to the long-term success of the intervention. (46) It was also very noticeable in the log accounts how often the hospice nurses were working with newly employed registered nurses -nurturing new relationships, sometimes every week. Dealing with high staff turnover in long-term care will require hospice nurses to constantly invest in developing new connections with nursing staff, which are based on mutual respect of the knowledge, and skills each person brings to the relationship. (47) The creation of genuine connections, even in brief encounters, can result in greater trust and opportunities for teamwork to develop. (47) Finally, given the turnover in the workforce, findings from this study highlight the need for a palliative care orientation package for new residential care staff, which can be used as a supportive tool alongside the mentoring, coaching and reciprocal learning, principles which underpin SHARE. The package, while providing information on palliative care delivery, will supply crucial links for new staff to the SHARE staff nurse and hospice nurse contacts (representing palliative care knowledge integration into practice).

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 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. (48)

Conclusion
The overall impression of the hospice nurses was that SHARE has improved communication between staff and residents and staff and families and alerted registered nurses to be vigilant in assessing the palliative care needs of their residents on a regular basis. Furthermore, evidence from the logs indicated that the more hospice nurses interacted with long-term care facility staff, the better the knowledge base for the hospice nurse and the residential care staff. Challenges remain however in relation to staffing levels and support the need for innovative education initiatives that do not demand additional staff time. Engaging with nurses at the bedside using SHARE principles along with supportive palliative care educational resources for staff needs further development.

Declarations
Ethics approval and consent to participate   Categories and sub-categories identified within the log texts