Developing palliative care competencies for the education of entry level baccalaureate prepared Canadian nurses.

Educational preparation of health professionals for Palliative and End of Life Care (PEOLC) is inadequate, and nurses are no exception. In 2004, the Canadian Association of Schools of Nursing struck a Task Force to develop PEOLC competencies to address this issue. The development of national PEOLC nursing competencies involved a multi-step, emergent, interactive, and iterative process. An overarching principle guiding this process was building national consensus about the essential PEOLC specific competencies for nurses among experts in this field while simultaneously generating, revising, and refining them. There have been three stages in this iterative, multi-step process: 1) Generating a preliminary set of competencies, 2) Building a national consensus among educators and experts in the field on PEOLC specific competencies for nurses, and 3) Refining the consensus based competencies for curriculum development. Ongoing follow up work for this project is focusing on the integration of these competencies into nursing curricula.

Dying and death within the culture of long-term care facilities in Canada.

AIM AND OBJECTIVE: To identify the influence of the culture in Canadian long-term care facilities on the awareness of impending death and initiation of a palliative approach to care for residents aged 85 years and older. BACKGROUND: Many long-term care residents die after long, dwindling dying trajectories, yet palliative care is often not provided until within a few hours or days of death. DESIGN: Focused ethnography. METHODS: Data were collected in three long-term care facilities in south-central Ontario, Canada, through interviews with residents, family members and staff members, observation, artefact review and a focus group. Data were analysed using a constant comparative technique. RESULTS: Four cultural influences on the awareness of impending death and consequent initiation of a palliative approach to care were identified: (i) the care demands in long-term care facilities and the resources available to meet these demands; (ii) the belief that long-term care facilities are for living; (iii) the belief that no one should die in pain; and (iv) the belief that no one should die alone. CONCLUSIONS: Commonly held beliefs about the role of long-term care facilities and what is viewed as acceptable care in them mediated the acknowledgement of dying. Late initiation of palliative care was the consequence. In addition, the contextual factors of a low staff-to-resident ratio and reduced staff preparation for palliative care were also influential for a delayed response to dying. IMPLICATIONS FOR PRACTICE: Because strongly held long-term care cultural beliefs underlie care, more timely palliative care for long-term care residents is likely to require the development of an understanding that living and dying are not dichotomous, but rather unfold together from admission until death. Enhanced staff-to-resident ratios and staff training on palliative care will also be necessary to permit long-term care facility staff to focus beyond the currently expected day-to-day care of living residents to provide high-quality end-of-life care throughout the often protracted decline to death for residents of long-term care facilities.

Awareness of impending death for residents of long-term care facilities.

AIM: To explore awareness of impending death for very old persons in long-term care facilities. BACKGROUND: The trajectories of decline that are associated with chronic progressive diseases in advanced old age have few prognostic markers. Consequently, it is difficult to determine when to start palliative or end-of-life care. DESIGN: Mixed methods. METHODS: Data were collected in three long-term care facilities in Canada. Statistical data were subjected to basic descriptive analysis. Qualitative data were collected using methods commonly associated with ethnography including interviews, focus groups, observations and artefact review. Constant-comparative analysis of qualitative data occurred as data were collected. RESULTS: A 2-stage layered awareness of impending death was identified: first generalised and then clinical awareness. Generalised awareness was characterised by an understanding of human mortality and an understanding of the person's nearness to the end of an expected lifespan. Care routines and use of resources were not influenced by this early awareness. Clinical awareness of impending death was later acknowledged when health status changes suggested that death was likely within a few hours or days. The care then changed substantially to palliative in nature. CONCLUSIONS: Despite an awareness that death occurs naturally at the end of a long life and/or long illness, a serious decline towards death was not noticed or acknowledged until the last few hours or days of life, thus limiting palliative care to late-stage pain and symptom management. IMPLICATIONS FOR PRACTICE: Although this late-stage awareness of impending death is arguably the first necessary step for a change in nursing homes to a palliative-oriented approach to care for people who are nearing death in late life, timely acknowledgement of the potential for death is needed to facilitate improvements in care for residents of long-term facilities.

An educational innovation to foster evidence-informed practice.

This article describes an innovation in baccalaureate nursing education that is intended to assist in the preparation of nursing students for careers in which evidence-informed practice is an imperative. The innovation involves the combination of central aspects of the internationally recognized Registered Nurses' Association of Ontario Best Practice Guidelines Program with existing curricular goals and themes in a baccalaureate nursing program at a small university in southern Ontario in Canada.