From hospice to hospital: compassionate care for all

Public confidence in hospital care has plummeted, amid serious failings in patient care, as highlighted earlier this year by the Francis report and again over the summer with the publication of the long awaited reports on the Liverpool Care Pathway and the Keogh review. However, one area of the healthcare sector where patient satisfaction remains high is hospices.

‘There is much hospitals can learn from hospice colleagues when it comes to treating patients with compassion and respect’

Hospices provide care that is compassionate and highly personalised. This care focuses on providing a holistic assessment and response to patients’ multi-faceted needs and those of their families.

In the National Bereavement Survey from the Office for National Statistics, published earlier this year, hospice staff were rated significantly higher than hospital staff in their demonstration of dignity and respect for patients and relatives: 84 per cent “always” did this among hospice doctors and 82 per cent of hospice nurses, compared with 59 per cent for hospital doctors and 52 per cent for hospital nurses.

At this critical time for the NHS, there is much that hospitals can learn from their hospice colleagues when it comes to treating patients with compassion and respect. Indeed, hospices are already working with hospitals, care homes and other providers of end of life care to share their strong ethos of person centred care and drive up standards in other settings.

New values

Quality End of Life Care for All (QELCA) is an education programme, designed originally by St Christopher’s Hospice in London, to be delivered by hospices for nurses working in other healthcare settings.

It was set up in direct response to a request from a local acute hospital for bespoke training for the ward managers of a medical and elderly care unit due to concerns about inadequate skills in end of life care. Issues included poor communication with patients and relatives and lack of recognition of the needs of dying people and their families.

‘Nearly a third of programme participants said at the beginning of the programme that looking after “palliative” patients was not part of their role’

By using role-modelling, both in practice and in the classroom, person focused care that mirrors the values of palliative/end of life care − as articulated by the hospice movement − the aim of the QELCA programme is to empower generalist nurses to return to practice equipped to make a sustainable difference to the experience of patients dying in hospitals and their relatives or carers.

Following its initial local success, a national pilot of QELCA was set up last year. This involved 21 hospices working with 17 acute trusts between April 2012 and April 2013, with a total of 137 acute nurses participating. Staff from all the hospices involved were trained by St Christopher’s to deliver the programme and were provided with course resources, support and supervision.

During the programme, acute nurses spend five consecutive days at their local hospice working in small groups. They are offered a first hand experience of observing and being alongside experienced palliative care nurses as they deliver care to patients and their families at the end of life. This is combined with classroom discussion and reflection facilitated by specialist palliative care nurses and then followed by six months of “action learning” where agreed action strategies for personal, team and organisational change are implemented.

Better communication skills

All the nurses who participated in the programme pilot reported subsequent positive changes in their clinical practice. The main changes were: a marked improvement in their own communication skills − and also improved communication with their colleagues and other healthcare providers; greater knowledge of the drugs used in end of life care; and greater emotional engagement in addressing the needs of patients and their families.

The latter was the most notable change, demonstrated in the nurses’ increased sensitivity to the experiences of patients and families. There was a clear shift from preoccupation with knowledge and skills in pre-course questionnaires to a concern for more person centred care, expressed in evaluation data collected at the end of programme.

‘Opportunities to learn from other settings where patient satisfaction is high should be maximised’

Bringing hospital staff into a hospice environment to observe care and compassion in practice, in conjunction with a safe classroom environment where any negative attitudes and fears could be challenged, was key to the success of the programme. Many participants described the opportunity to observe hospice care as a “light bulb moment” that reawakened their sense of why they had decided to become nurses in the first place and reinforced why it was important to bring both their professional skills and human kindness to the role.

Nearly a third of programme participants said at the beginning of the programme that looking after “palliative” patients was not part of their role. However, following the programme a majority of nurses recognised that issues of death and dying relate to patients not necessarily identified as requiring specialist palliative care, such as the frail elderly or those with advanced chronic long term conditions. They now recognise their role as nurses is to apply a palliative approach to the care of these patients.

In addition, those who attended the QELCA programme appeared re-energised about their leadership role, particularly if they held management responsibility, and returned to the workplace equipped with new ideas and renewed motivation.

Positive changes in practice

In addition to changes in the attitudes and approach of the nurses, there were also widespread practical changes. These include:

• Creating a “bereavement resource box” − with information for relatives and bereavement cards
• Setting up a space for staff to have 10 minutes for a period of calm and reflection
• Using a butterfly symbol to indicate to all staff that a patient is dying in a ward or bay area
• Introducing a pocket size checklist outlining the procedure following a patient death
• Providing screens in ward areas to maintain privacy and dignity
• Making any necessary changes to the environment, including setting up a relative’s room
• Running joint training sessions between hospices and hospital specialist teams

The positive changes emerging from the pilot programme are immensely encouraging. They have demonstrated how hospices have an important role to play in driving standards of care in hospitals and are capable of provide significant training resources for hospital staff.

At a time when there is a real need to improve patients’ experience of care, opportunities to learn from other settings where patient satisfaction is high should be maximised.

Heather Richardson is national clinical lead at national hospice charity Help the Hospices