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Pre-Service Orientation and Training

All staff without previous experience in modern palliative care, about to start work in a new hospice / specialist palliative care unit will need orientation and training in two subjects:

• Modern palliative care- principles and practice
• The new unit – how it will operate

Modern palliative care – its principles and practice

• The principles of holistic care of the terminally ill
• Setting goals – discussing realistic goals, how to achieve, how to record.
• Team caring, clarifying and blurring of traditional roles, mutual respect and support
• The general principles of symptom diagnosis and relief
• Pain control – diagnosis, assessment, analgesic ladder, modern analgesics, routes of administration, dispelling opioid myths and misunderstandings
• All other common symptoms encountered in end stage malignant and non-malignant conditions
• The place of intravenous infusions, parental feeding, blood transfusion and invasive investigations in palliative care
• Emotional care – causes of distress, diagnosis, pharmacological approaches, psychotherapeutic approaches, family conferences
• Social issues - diagnosis, management approaches, the needs of relatives.
• Spiritual / existential issues – expressions of suffering, fear or doubt, the role of pastoral care workers, searching for meaning. Cultural and religious differences.
• Grief and bereavement – features of, preparation for, counselling.
• Relatives, including children, needs of, support of.
• Staff stress and “burn out”
• Ethical issues – confidentiality, resource allocation, euthanasia and PAS, research, patient’s competence, “right to die”, power of attorney.
• Emergencies encountered in palliative care and how they area dealt with.

The need for this aspect of preparation to be clinical and practical rather than theoretical and academic cannot be sufficiently stressed. Each new staff member must be left in no doubt that the unit will aim for the highest possible standard of care, something that is achievable when everyone works as a team.
Experience has shown that most professionals coming into this work feel that they know much of it already, only to be surprised at how little they know and must now learn. Again, experience suggests that teaching mixed professional groups (e.g. doctors and nurses) can be profitable and, some sessions conducted by both a doctor and a nurse, are a timely reminder of the mutual dependency and valuable cooperation possible in palliative care.

The new unit – how it will operate

All new staff members should be in possession of the Staff Handbook before coming to these tutorials. The aim of the classes is to familiarise them with how the unit will be operated on a daily basis. The topics will include

• Where the patients will come from (home, hospital, care home, nursing home etc)
• Pre-admission assessment by a palliative care doctor or nurse
• The commonest conditions they will suffer from (malignancy, cardiac, neurological)
• What investigations and treatment they may already have had
• The spectrum of suffering likely to be seen
• What the patients may know of their condition and what additional information they may want on entering the palliative care unit.
• How crucially important information about the patient and/or relatives will be made known to team members who need updates.
• How care staff will be updated on new clinical developments and information about patients
• How the patient will be met at the hospice / PCU door and made to feel welcome.
• How the relatives will also be welcomed and arrangements made for them to see around the unit and meet staff, see where they can go for peace and quiet, a shower or a light meal.
• What will happen as death approaches and when the patient actually dies, the role of the nurse / doctor at that time
• Death certification, guidance to relatives, handing over possessions, saying goodbye.
• Other palliative care units / services in the same city or town
• The relationship between the new unit and pre-existing ones
• The different departments of the new unit and how they will relate to each other
• community palliative care service
• day unit
• hospital consultation service
• bereavement service
• educational work of the unit – who will the students be, will they see patients, who will teach them, how will this affect the patients, will they be able to refuse…

The Staff Handbook

Each hospice / palliative care unit must produce its own handbook to be given to every member of staff whether they work at the bedside or in the background, whole time or part-time It will not be the same as the Useful Information for Patients and Visitors Booklet which will be described later. The two will have several sections in common however.
Staff need to know about the following, not listed in any priority-

• Roles of different members of staff
• Uniforms, who wears what and when
• The importance of name badges
• Times of duty shifts
• Visiting times and their durations for different patients
• Patient and staff mealtimes and arrangements
• Availability and use of alcohol by patients and visitors
• Regulations about smoking by patients and visitors
• Giving information about patients (phone and in person)
• Radio, TV, and computer games for patients (and visitors if permitted)
• Visiting by children and how they are welcomed and assisted (if needs be)
• Visiting by pets
• Volunteers in and near the patients’ care areas
• Food being brought in by visitors
• Flowers being brought in or sent after funerals
• Laundering of patient’s clothes
• Security for patients’ and staff possessions
• The crucial importance of hygiene and preventing cross infections
• Medication regimens, record keeping.
• Medications brought in by patients and their relatives.

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