Chapter 6
The professional workforce and its development
6.1
This chapter will examine the composition of the professional palliative
care workforce and its ability to meet the needs of the ageing population. It
will begin by considering the role of palliative care specialists, including
doctors, nurses and occupational therapists. Ways to improve and support
workforce education and training in palliative care, including through
scholarships and funding arrangements, will be discussed. Finally the chapter
will look at the scope for changes and enhancements to the current healthcare
curriculum and the need to embed awareness of palliative care more broadly
across the health workforce (including in general practice) will also be
covered.
The palliative care workforce profile and challenges
6.2
The committee heard evidence of the need for capacity building within
the palliative care workforce. The following section provides an overview of
the current workforce profile, the concept of multidisciplinary teams and
future workforce challenges. It also looks at different workforce roles
including specialist physicians and nurses as well as occupational therapists
and general practitioners.
6.3
Most information the committee received about workforce was in relation
to specific professions or roles. The Victorian Healthcare Association's
submission noted that 70 per cent of the total palliative care workforce was
over 40 years of age and that almost 35 per cent is over 50 years of age.[1]
6.4
In relation to aged care workers, Ms Wendy Porter, Residential Care
Manager, Western Australia, for Aged and Community Services Australia, told the
committee that the aged care workforce would need to treble over the next 30 to
40 years 'and a large proportion of that workforce will need generalist skills
in a palliative approach to care'.[2]
Ms Angela Raguz, General Manager, Residential Care for HammondCare, also
commented that a shift in perception was needed to make aged care a more
desirable area in which to specialise:
It is about how we get those experts to come on board and to
move beyond that view: 'Oh, it's aged care—that's a bit daggy. I don't want to
spend time in aged care.' For young doctors and nurses it is not the sexiest
part of the industry to select. So it is about getting it within undergraduate
training, looking at training people on the ground in the nursing homes across
a broad scale. And it is not just about setting up distinct units, even though
that is an ideal. It is about lifting the bar across the whole of aged care, be
it in people's homes or in facilities.[3]
6.5
Professor Patsy Yates, President Elect of Palliative Care Australia,
told the committee that addressing workforce issues in palliative care entailed
not only providing education opportunities and up-skilling the existing
workforce, but also being 'bold and brave in looking at new and innovative
models that might actually be more sustainable in addressing the future that we
are going to face in terms of increasing demand'. For example, the role of
nurse practitioners has been successfully implemented in the palliative care
environment, although not yet to a consistent degree, particularly in aged and
community care settings.[4]
6.6
At a public hearing, Mr Trevor Carr, Chief Executive of the Victorian
Healthcare Association, also illustrated the broad challenges to the palliative
care workforce profile over coming decades:
I think that in aged care and some elements of palliative
care—so moving aside from the science of palliation to the emotional welfare
side of palliation—there is a tremendous opportunity for people to specialise
in this sort of area, just as there is for people, through TAFE VET qualified
education, to specialise in home care type services. So our view is that we
need to be moving towards that. There is no dataset that I have seen recently
that suggests that in 20 years time we are going to have anywhere near the
university qualified clinical profile that we have today, so that leaves us
with two choices: either we change the models of care and the range of people
providing them or we become more aggressive importers of clinicians—and
generally that is not a good solution because of a range of issues, not least
of which is: what does that leave in the countries that you are actually taking
them from?[5]
6.7
The committee heard that the palliative care workforce needed to be based
around multidisciplinary team approaches, supported by appropriate funding
models. Multidisciplinary teams include specialist palliative care physicians
and nurses, general physicians, general practitioners, nurses, psychologists,
occupational therapists and carers.[6]
The Australian Nursing Federation described 'new and emerging roles' within
palliative care teams which include palliative psychological medicine
specialists, general practitioners with special interests in palliative care,
caregiver network facilitators and advanced practice roles such as palliative
care consultants in physiotherapy or pharmacy.[7]
The Pharmacy Guild of Australia's submission stated that community pharmacists
should be integral members of all interdisciplinary palliative care teams 'as
good palliative care depends enormously on teamwork and effective symptom
control'.[8]
6.8
Mr Trevor Carr, Chief Executive of the Victorian Healthcare Association,
argued that the multidisciplinary team approach had not been achieved due to
the constraints of current funding drivers.[9]
He emphasised the 'proof of concept' around the nurse practitioner[10]
model for palliative care, particularly medication management:
The early conceptualisation of nurse practitioners in
Australia was that nurses would have access to billing through the MBS. Whether
we use that mechanism or not, we need to break down the barrier to ensure that
practitioners who have clinical skills and the understanding of the drivers of
the need for care for that particular care model have access to delivering and
designing care for the consumer, rather than it being a professionally
demarcated decision based on funding models.[11]
Palliative care medicine
specialists
6.9
The committee heard that currently there are around 160 to 200
palliative care physicians nationally,[12]
although data does not indicate whether they are full-time equivalents and the
estimates do vary. When asked how many palliative care physicians there should
be per 100 000 population, Associate Professor Rohan Vora told the committee
that the Australian and New Zealand Society of Palliative Medicine (ANZSPM)
advocated a figure of one per 100 000.[13]
The Royal Australian College of Physicians estimated that the current supply of
palliative care doctors was approximately half of the ratio recommended by the
ANZSPM.[14]
Palliative Care Australia's submission stated that 1.5 palliative care
physicians per 100 000 would be the preferred ratio.[15]
6.10
The Royal Australasian College of Physicians (RACP) gave evidence that
there was an undersupply of specialist palliative care medicine physicians. Dr
Leslie Bolitho, President of the RACP, commented on some of the key workforce
challenges for palliative care:
We have to also take into special consideration the rural,
remote and culturally sensitive communities, including Indigenous health, and
children and adolescent palliative care is another specific area requiring
attention. We see the federal government specialist training program and the
potential of tele-health's role in the training and supervision of trainees and
provision of services to our patients as a step in the right direction. Many of
the members of this committee will be familiar with the dual training pathways
which the college is promoting in order to address underprovision of specialist
services in rural areas. While this model currently focuses on general medicine
paired with other specialties, there is potential that this could also include
palliative care services in the future.[16]
6.11
Dr Yvonne McMaster, a retired palliative care doctor, described to the
committee the critical and highly specialised role of palliative care
physicians, who look after not only the patient's physical symptoms but a range
of other complex needs:
How do you help people deal with all the practical, emotional
and spiritual problems they face at the end of life? What can help when the
going gets tough is regular contact with highly competent, reliable clinicians
who can guide the patient on a well-trodden path—well trodden for the
clinicians but new and scary for the patient. We walk the path with the person
and their family, and it helps. As ANZSPM, the Australian and New Zealand
Society of Palliative Medicine, say in their excellent submission to you, they
'listen to the spirit of the patient' and attend to 'the multiple fears,
concerns and regrets that proximity to mortality entails'. Some doctors or
nurses are able to do this on their own; many need the help of a
multidisciplinary team. Palliative specialists also have a role in encouraging
wise decision-making regarding appropriate practice goals: whether to persist
in trying to prolong life in the face of serious side-effects of treatment or
to focus mainly or wholly on improving quality.[17]
6.12
Dr McMaster stated that the current palliative care workforce was deeply
demoralised. She described a 'tremendous contraction' in the New South Wales
workforce over the last 15 years and advocated better pay as well as specific
Medicare item numbers for palliative medicine to better recognise the work
undertaken by specialists, which would help to attract more people into the
workforce:
It has been so sad to see that services which were
flourishing and people coming in were very interested to do palliative medicine
are not doing as much now.
...They are not paid as well as procedural specialists
of course but they can be better recognised in pay. There could be specific
item numbers such as the geriatricians have. They have a very good item number
for a very complex assessment. There could be item numbers like that for palliative
medicine, because most of palliative medicine is complex assessments.[18]
6.13
Associate Professor Mark Boughey, Co-Deputy Director of the Centre for
Palliative Care, told the committee that nationally the number of doctors
wanting to train as a specialist in palliative medicine was on the rise:
The positions around Australia are increasing. As a
membership, we have over 250 fellows in Australia who would be considered
specialists in palliative medicine. That does not mean they are all actively
practising.
We have a two-pronged approach in the training process. The
chapter allows for people who have had training in any other clinical specialty
to come in and retrain as a palliative medicine specialist or we can have
people going by the direct route as a physician going on to be a specialist.
There is also the capacity to do a six-month diploma in clinical palliative
medicine. You get bidirectional training of GPs, geriatricians, respiratory
physicians and other people who are in the medical arena for whom palliative
care becomes important to them.[19]
6.14
Associate Professor Boughey also observed that for those who choose to
work in palliative care, 'financial reward does not tend to factor into it'.[20]
6.15
The committee discussed the need for paediatric palliative care
specialists with Dr Jenny Hynson of the Australia and New Zealand Paediatric
Palliative Care Group. She noted that while the demand for such specialist
positions was not likely to be great, she spoke of the need for a system that
would be sustainable into the future.[21]
Palliative care nurses
6.16
Nurses will be the main carers for most people who are dying, regardless
of care setting.[22]
Ms Angela Raguz, General Manager, Residential Care of HammondCare, told the
committee that the aged care sector does not currently have a lot of palliative
care trained nurses:
In fact, in aged care, your ratio of registered nurses to
direct care staff is, in a good nursing home, one registered nurse for probably
25 residents. In some nursing homes you may have one registered nurse looking
after 70-odd residents.[23]
6.17
The Australian Nursing Federation (ANF) explained the benefits of having
certified specialist palliative care nurses working in the provision of
palliative care. While registered nurses, within their scope of practice, can
provide palliative care and can administer prescribed medicines, specialist
palliative care nurses have expertise in the palliative requirements of people
as they progress through their illness:
So, as far as scope of practice goes, all nurses can provide
palliative care and they determine their own scope of practice. They are
responsible and accountable for the care that they provide, and they would only
provide care to their level of competence. So they look for support and
expertise from other health practitioners where they determine that that is not
their scope of practice any further. Where we have nurses who have
qualifications in palliative care, they are providing a greater level of care
according to their competence, right up to the point where they are a nurse
practitioner.[24]
6.18
Ms Catherine Pigott, Member of the ANF, explained the role of specialist
palliative care nurses further, particularly in providing information to the
family of the patient about what is happening and why:
Some of the things that we would be doing around medication
in particular would be providing information to the patient and the family
about why that medication has been started—particularly around morphine; people
have a number of different myths about morphine, so it gives them information
about why they might be on morphine—what we are doing, why we have changed it
from perhaps oral medication to syringe driver medication, what is happening
with the person, why things might be changing and why we might be having a
different type of medication or perhaps no medication. We would add an adjuvant
medication if they have a different type of pain. That is what the nurse's role
is: to talk to the patient, and particularly the family, about what is
happening with the person, why things are changing, where we are going, what to
expect and what sort of side effects to look for when we administer the
medication—because people might be a little bit nervous if we give them some
morphine, but in fact what is happening, of course, is that their body is
deteriorating and that is what they are dying from, not from an overdose of
morphine. So it takes a lot of education, a lot of information provision and a
lot of family support for us to be able to do that, and that is where your
specialty nurse knowledge comes in particularly.[25]
6.19
The ANF told the committee that there were slightly in excess of
330 000 nurses and midwives in Australia[26];
however, the ANF also stated it was difficult to estimate the numbers of nurses
with palliative care qualifications in the Australian workforce. This was
because there is no regulatory requirement to have a palliative care
qualification to be able to work in the area:
Ms Pigott:...It is a similar thing to cancer nursing in that
people can say that they are a specialist palliative care nurse, but that does
not necessarily mean they have the education completed...
Ms Bryce: Some obviously have experience from having done
further education in continuing professional development. Others have a formal
postgraduate qualification up to master's level. So there is quite a variance
in the preparation for working in the area of palliative care. There is no
regulatory requirement to have a palliative care qualification in order to be
able to work in palliative care, because there is such a range of care that is
provided.
Ms Coulthard: Good basic general nursing care is palliative
care, so the specialist add-on of knowledge of medications and knowledge of
specific clinical care for palliative care does not deny that most nurses are
already able to provide good palliative care. There is also a range of nurses
who have developed good clinical skills through clinical work and who have had
very little extra training or education.
Senator MOORE: But there is no regulation.
Ms Coulthard: No.[27]
Occupational therapists
6.20
The committee also heard from occupational therapists who described
their role in palliative care as a 'newer' development. Their focus is 'looking
at how people actively live until they die'.[28]
This includes self-care activities such as showering and dressing, home and
domestic duties, community activities, work and leisure/recreational
activities.[29]
According to Ms Deirdre Morgan, Senior Occupational Therapist, Palliative Care
for Peninsula Health:
Palliative care was developed initially as a service to
provide terminal care. With advances in health care and people living for
longer now, people have palliative care for a much longer period of time. They
are living for much longer with impaired function, much longer at home with families,
where the burden is greater. So we are newer in the palliative care sphere
partly because of the changes and medical advances.[30]
6.21
Some of the main workforce issues raised with the committee by
occupational therapists were:
- the lack of community occupational therapists in most community
palliative care services;
-
the current workforce structure having a medical, nursing and
supportive care focus, influenced by symptom control and psychospiritual
support, with less of a focus on enabling people to participate in everyday
activities; and
- a distinct lack of broader allied health input to provide
holistic care including physiotherapy, speech therapy, social work and
psychology.[31]
The rural workforce
6.22
The committee heard that getting enough palliative care staff to work in
rural and regional areas was always going to be a challenge. Dr Yvonne McMaster
advocated a scheme which would create incentives for palliative care
specialists to practise in rural areas:
I believe that we could really do something dramatic in the
country if we advertised overseas and got people in the rural towns. They would
then have to have a rotating registrar coming from city practices backwards and
forwards every term, and all those young doctors doing palliative medicine
would have the experience of country life because attracting people to the
country has been hard.[32]
6.23
Professor Katherine Clark of Catholic Health Australia emphasised the
need for hubs of palliative care specialists to ensure there is adequate care
and support right across Australia:
We cannot have specialist hospices and specialist clinicians
in every small hamlet across Australia. Our country is too vast and our
population is too sparse. We cannot have that, so we need formalised agreements
between different parts of Australia and we need to ensure that the hub is
upskilled and adequate enough to provide support that does not become
burdensome to that unit, so we can promise care to all Australians who require
it.[33]
6.24
Similarly, Mr Peter Cleasby, President of Palliative Care New South
Wales, stated that it was unrealistic to expect a palliative care specialist to
be available in every country town or even major regional town. However, he
outlined to the committee some concerns about the availability of palliative
care doctors, despite the presence of excellent palliative care nurses
servicing rural communities:
We have struggled in New South Wales. There was a time when
we had one specialist trained palliative care doctor outside the
Newcastle-Sydney-Wollongong metropolitan basin; there was only one for the rest
of the state and she was up in Lismore. There are now two between Newcastle and
Lismore and there is no-one west and there is still no-one south. So specialist
palliative care physicians in regional and rural New South Wales is a
significant issue still not addressed. That is part of our major workforce
issue. In most of those rural and regional areas we currently have fabulously
experienced and appropriately trained specialist palliative care nurses doing a
great service. There are limitations to their services. As the presenter in the
session before us said, nurses cannot prescribe so they have to rely on another
prescriber to accept the thoughts that they are offering and to act upon them.
Those rural nurses, who are, as I say, the backbone of good palliative care in
those areas, have themselves expressed concern about succession planning. Many
of them are older, nearing the end of their career, and the system is not
allowing opportunities for people to be trained up to replace them. That is a
major concern in New South Wales about how one is going to go about doing that
when budgets are so tight.[34]
The role of general practitioners
6.25
The committee heard views about the role of general practitioners (GPs)
in palliative care. As primary care physicians, the role of the GP has changed
significantly over time. Gone are the days when home visits and after-hours
consultations were commonplace. Dr Yvonne McMaster said the expectations that
GPs become heavily involved in end-of-life care were too high as they are so
busy.[35]
6.26
Ms Angela Raguz, General Manager, Residential Care for HammondCare,
commented that 'we do struggle to get GPs who have the knowledge and the
expertise to be able to deal with people at the end of their life well'.[36]
Dr McMaster also made the observation:
A proportion of the GP workforce is made up of overseas born
and trained doctors with no palliative care knowledge or understanding or
willingness to take advice from specialist palliative care nurses—'You make too
much fuss about dying; you have to expect to suffer', one nurse was told.
Another nurse wrote, 'GP competence in palliative care in rural areas is vital
but sadly lacking.'[37]
6.27
The Australian Nursing Federation observed that in many rural
communities, GPs themselves are not easily accessible. Its submission outlined
a number of other concerns in relation to GPs and appropriate provision of
palliative care:
...General Practitioners with an interest and specialty in
palliative care are rare in rural and remote areas. There is sometimes a
disinclination for General Practitioners to participate in the process of
teamwork in delivery of quality palliative care, in particular due to lack of
understanding of current principles of palliative care; and a focus only on
pain management. It is fair to say that General Practitioners in rural areas
have issues similar to nurses in accessing education and professional
development. Further, General Practitioners are often unavailable on weekends
and after hours, leading to unnecessary hospitalisation of patients requiring
care which would be deemed by a palliative care team nurse to be uncomplicated
palliative care.[38]
6.28
The South Australian government noted workforce limitations in general,
and mentioned GP availability in particular:
One of the impediments to increasing the capacity of primary
health care providers is inadequate funding and staffing to meet increasing
demand. The ability for general practitioners in particular to provide visits
to patients at the end of their life in their home or in a residential care
facility is currently limited.[39]
In this case, the issue appeared to be not the GP workforce
in general, however, but the capacity to visit palliative care patients 'in
place'.
6.29
Associate Professor Deborah Parker, Director of Blue Care Research, told
the committee about a study she conducted where GPs were encouraged to attend a
palliative care case conference. About 50 per cent of residents in aged care
facilities who had been given a prognosis of less than six months to live had
their GP attend a case conference. She explained:
This study specifically focused on the use of case
conferences and engaged the GPs with well-organised timeslots, coordinated by
the nurses and a clear process to be followed to ensure that time limits were
adhered to and that the GPs could claim, using the EPC [Enhanced Primary Care]
Medicare items. In this instance, with this support of a well-funded research
project, we can achieve the 50 per cent of GPs coming to a palliative care case
conference for residents. You can imagine what the norm is when that sort of
support is not available. I can tell you that the incidence of getting a GP to
come to a residential-care facility to conduct a palliative case conference is
almost non-existent. This project showed significant improvements in family
satisfaction and resident outcomes.[40]
Education and training in palliative care
6.30
The committee heard from witnesses that education and training for the
palliative care workforce could be improved in some crucial areas. This could
occur as part of both undergraduate and postgraduate training of healthcare
workers, as well as through continuous professional development of both
specialists and the broader health profession. Improvements in training and
education could also be achieved through increased Commonwealth funding for
training and places and scholarships.
6.31
Professor Patsy Yates, President Elect of Palliative Care Australia,
described the 'ad hoc' approach to education in palliative care over the last few
decades:
More recently in Australia we have a recognition that people
are dying in all sorts of areas of our communities and in our health services
and so we need to have all health professionals prepared with at least some
capability in providing end-of-life care. In Australia we have gone some way in
understanding that and trying to tackle the issue of getting it integrated into
undergraduate programs. There has been some progress but still there is a great
difference across the country in how that is taken up.[41]
6.32
Qualification and skill levels must be improved to ensure that
palliative care in Australia is supported by an appropriately skilled
workforce. Mr Nicolas Mersiades, Senior Aged Care Adviser for Aged and
Community Services Australia, argued:
There is a lot more work to be done to ensure that the
qualifications and the skill levels of staff are adequate to deliver a
palliative care approach and that there is also ready access to specialist
information and advice where needed in those cases where symptom management is
much more complex.[42]
6.33
Palliative Care Nurses Australia advocated for palliative care education
for all health professionals, including Indigenous health workers and personal
carers in the aged care setting at both undergraduate and postgraduate level.[43]
Commonwealth funding for workforce
training
6.34
When questioned as to how the Commonwealth Government supports training
for the aged care workforce, the Department of Health and Ageing (the
department) explained to the committee a range of initiatives to address
training requirements. Since 2007, more than $252 million has been invested in
more than 41,800 aged care training places:
Included as part of these training places is education to
improve the palliative care skills and knowledge of people working in aged
care. This includes understanding the needs of people approaching the end of
life, understanding the palliative approach to care of people and their family,
and developing and implementing a care plan for people at the end of life.
Support also includes funding for people working in aged care
to undertake specific units from the palliative care skill set. The skill set
comprises a set of training units and enables people working in aged care to
gain targeted skills that can be transferred readily into their caring role.[44]
6.35
The department also noted that it provides funding through the
Encouraging Better Practice in Aged Care initiative to 'support the uptake of
evidence-based, person-centered and better practice in aged care'. This initiative
focuses on improving staff knowledge and skills and resource development. Three
projects funded under this initiative are specifically targeted at encouraging
a palliative approach in residential aged care:
1. A good death in residential aged care: optimising the use
of medicines to manage symptoms in the end-of-life phase.
2. ...Encouraging best practice palliative care in residential
aged care facilities from rural and remote communities.
3. The implementation of a comprehensive evidence-based palliative
approach in residential aged care.[45]
6.36
In addition, the department stated it was supporting the development of
a program to look at 'appropriate models of practice for aged care nurse
practitioners':
The program aims to test and evaluate a range of financially
viable practice models that can be implemented across both home care and
residential aged care settings. In this program nurse practitioners are working
in a range of clinical specialties, including palliative care, to assist in
improving the care of older people.[46]
6.37
The recently announced Commonwealth aged care reform package includes
$1.2 billion for a Workforce Compact to be implemented over four years from
July 2013. The government says that this is aimed at improving the capacity of
the aged care sector to attract and retain staff through higher wages, improved
career structures and enhancing training and education opportunities.[47]
6.38
The ANZSPM called for Commonwealth funding for accredited positions for
training in palliative medicine.[48]
Its submission stated:
To meet the future workforce need it is imperative that more
doctors are trained in the specialty of Palliative Medicine. Currently a major
rate limiting step is the funding of positions by State and Territory
governments. A minority of positions are funded through the STP [Specialist
Training Program].
Accreditation of training positions is performed
independently by the RACP (Royal Australasian College of Physicians) Palliative
Medicine Education Committee. As such, there are more accredited positions than
there are trainees. To increase the number of Palliative Medicine Specialists
for the future ANZSPM proposes that funding is provided according to numbers of
accredited positions, rather than on the basis of historical allocations,
usually to public hospitals.[49]
6.39
Some other issues raised by witnesses in relation to Commonwealth
support for training included:
-
calls for funding of Commonwealth training places to match
assessments by Health Workforce Australia of future palliative care workforce
needs, both generalist and specialist[50];
and
- the level of workforce support and training being provided by the
Commonwealth to allied health professionals. This equated to around $12.5
million per year across Australia according to Mr Rod Wellington, Chief
Executive Officer of Services for Australian Rural and Remote Allied Health
(SARRAH). Mr Wellington observed that this was far less funding for support and
training than what is provided to general practitioners and nurses.[51]
Training and scholarships for
nurses
6.40
Palliative Care Nurses Australia (PCNA) and the ANF appeared before the
committee to discuss qualifications and training options for post-graduate
study in palliative care nursing.
6.41
The ANF described undergraduate nursing courses as having 'a very full
curriculum', noting the optional Palliative Care Curriculum for Undergraduates
program (mentioned in further detail below). For the specialist palliative care
nurse, there are a number of graduate certificates, graduate diplomas and
masters degrees that are run by institutions such as the Australian Catholic
University, Edith Cowan University, La Trobe University and the University of
Melbourne.[52]
6.42
Professor Jane Phillips noted that postgraduate palliative care nursing
qualifications were expensive to obtain and particularly prohibitive for many
nurses.[53]
Ms Catherine Pigott, Member of the ANF, outlined the costs of postgraduate
study:
Ms Pigott: The cost of them ranges. For a graduate
certificate you are talking between $5,000 and $10,000. Around $6,000 and
$7,000 is the average mark for a graduate certificate in university. For a
graduate diploma it would be double that. For masters it is variable depending
on whether it is masters by research or masters by coursework.
CHAIR: It is expensive, in other words.
Ms Pigott: For nurses, yes.[54]
6.43
Mr Jason Mills, National Committee Secretary for PCNA, described his
nursing training at the University of Canberra and his graduate year in
Victoria:
In the curriculum where I studied palliative care was not an
elective and it was not a core unit, per se. It was embedded within a subject
of chronic illness ... [T]here is discrete representation and it does differ
across the university sector across the different states. For example, some
universities have a subject on spiritual care whereas others do not.[55]
6.44
He told the committee that he decided he wanted to be a palliative care
nurse after volunteering in a hospice. He also spoke of encountering a passion
among his fellow students to pursue palliative care but also then coming across
a systemic resistance to this desire in his graduate year:
... among the cohort that I studied with, my peers, I did see
that flame being sparked within the subject. It was very well articulated in
the course and I witnessed it amongst my peers. I was pleasantly surprised that
there was within the future generations of nurses a passion there if it were
given a chance to be linked. In my graduate year I in some ways met some
resistance. There seems to be a perception, which perhaps stems from a society
with the view of protecting young people from death, that we need to shield
people from it. That runs counter to it; it is not so productive. I came across
the view in many forums that you should not and cannot work in palliative care
until you have at least ticked off five or six years in general medical
surgical nursing. I was a little shocked at that because that was the whole
reason that I wanted to become a nurse.[56]
6.45
Mr Mills told the committee he received a competitive scholarship from
the Victorian Government which was administered through Palliative Care
Victoria to do his graduate certificate in palliative care. The scholarship was
worth about $2,600 and the course itself was about $7,500.[57]
6.46
Access to funding for further education in palliative care is
complicated by the breadth of the healthcare sector and competition for the
same pool of funding. PCNA suggested to the committee that dedicated funding be
set aside, which 'would go a long way to nurturing the future workforce in
palliative care'.[58]
PCNA's submission recommended dedicated scholarship funding for postgraduate
studies in palliative care on a national level, rather than palliative care
clinicians competing for the generic and highly competitive Postgraduate
Nursing and Allied Health Scholarship and Support Scheme (NAHSSS):
Many clinicians wanting to further their clinical knowledge
and develop advanced practice skills in palliative care are consistently
missing out on funds through the generic NAHSSS. This results in frustration
and disillusionment regarding any higher education aspirations such clinicians
may have held. Such barriers to further education ultimately impede quality
improvement of clinical staff practising in a dynamic environment of
evidence-based practice (with an everchanging evidence base) and adversely
affect bedside care of palliative patients.[59]
6.47
PCNA also called for recognition of the specialist skills acquired by
palliative care nurses:
We recommend creation of a credentialling program to
recognise specialist palliative care nurses and a national rollout of the
existing competency standards for specialist palliative care nurse.[60]
6.48
The ANF also discussed with the committee the issue of postgraduate
scholarship funding for nurses to gain further qualifications in palliative
care. However, the shortcomings of these current arrangements were noted (the
ANF has made representations to the Department of Health and Ageing to have
scholarship funding increased).[61]
The ANF also cited the difficulty for staff to get time off to actually
undertake intense further studies. Workforce shortages in regional areas make
this particularly difficult. For rural and remote area nurses, postgraduate
study can be hard to access, so continuous professional development is usually
undertaken through short courses, including through online education.[62]
Other training issues
Better training of aged care staff
6.49
The committee heard concerns about the level of training in palliative
care principles being provided to staff working in aged care. For example, Dr
Yvonne McMaster pointed to the urgent need for training by palliative care
specialists on symptom control and end-of-life care for nursing home staff. She
described the situation in nursing homes as 'Dickensian':
Some of the most difficult cases—you have been hearing about
dementia today—are managed by the least trained staff: little girls with six
weeks training and no concept of real care. Yet it seems that these places are
to be the new hospices and the now hospices are to become only acute short-stay
facilities. This attempt to save state funds and shift costs onto the
Commonwealth should be resisted to the death.[63]
6.50
Alzheimer's Australia called for mandatory training and support for
staff of aged care facilities in relation to artificial nutrition, hydration,
antibiotics, pain management, hospitalisation, resuscitation, differences in
cultural values and beliefs around dying, advanced care directives and the law.[64]
Training in oncology
6.51
Associate Professor Frances Boyle, Former Executive of the Medical
Oncology Group of Australia, told the committee that specialist palliative care
doctors and nurses needed to be integrated at every level of cancer care in
Australia. This would entail making oncology training positions available which
is currently difficult to do:
If we are talking about an expansion of the palliative care
workforce, we have got to do our bit to make sure that those training positions
are available at our end to pull them in so that, if they are going to be
involved earlier in the care of cancer with patients, they need to know more
about chemotherapy, more about radiotherapy, and they need to be involved in
communication training with our trainees, not just on their own. So we would be
certainly very willing to look at methods to increase access to training. For
instance, at our hospital, which is a private hospital, we have put in an
application for an extended settings job to rotate the palliative care trainees
into. Like everybody else, we are waiting to find out what happens about that
funding, but certainly there are an increasing number of oncology units in
Australia that could be providing some training for palliative care physicians.[65]
The palliative care curriculum
6.52
The committee heard from witnesses that the curriculum studied by those
entering the health workforce needs to include education in quality end-of-life
care. Ongoing support through continuing professional development is also
required.[66]
The committee was pleased to hear about current programs and training modules
in palliative care—specifically the Palliative Care Curriculum for
Undergraduates and the Program of Experience in the Palliative Approach.
6.53
Palliative Care Australia (PCA) explained to the committee that working
in palliative care needed to be made an attractive career choice for doctors,
nurses and allied health professionals.[67]
Dr Yvonne Luxford, Chief Executive Officer of PCA, noted that exposure to
palliative care in undergraduate training was required to cultivate this
interest among health professionals. She explained that the College of
Physicians includes practitioners of palliative medicine, but noted that
palliative care is not taught across the curriculum.
6.54
Dr Luxford told the committee about a government-sponsored program
called PCC4U—Palliative Care Curriculum for Undergraduates[68]—which
'has some reach into the various undergraduate curriculums of health
professionals, but not nearly enough'.[69]
Professor Jane Philips, Professor of Palliative Nursing at the University of
Notre Dame, noted that the PCC4U curriculum is embedded within her university's
three year nursing degree and that medical schools and allied health school are
also able to utilise content from that program, allowing emerging clinicians to
be exposed to palliative care.[70]
6.55
The committee also heard about PEPA—the Program of Experience in the
Palliative Approach.[71]
Offered as postgraduate informal education, PEPA is supported by the Department
of Health and Ageing and is aimed at educating health professionals who do not
have specialist palliative care expertise but who have an interest in the area.[72]
PEPA is also targeted to Indigenous health workers, with location-specific
resources to account for different palliative care needs around Australia.[73]
Enhancing knowledge and awareness
of palliative care in the health curriculum
6.56
Palliative Care Nurses Australia suggested enhancement of the
undergraduate health curriculum by embedding palliative care principles,
through programs such as PCC4U. While noting the 'crowdedness' of the
undergraduate curriculum, PCNA stated that palliative care should be a basic
component of all health professional curricula and also called for the
establishment of professional mentor programs.[74]
6.57
When asked how many universities around Australia have a chair of
palliative care, the Centre for Palliative Care responded that there were five
or six.[75]
Dr Yvonne McMaster told the committee that medical students need to be inspired
by 'charismatic palliative care specialists of the highest calibre' in teaching
hospitals:
That is what catches the attention of the students and
attracts them to the specialty. Universities must teach palliative medicine,
and the teachers must be able to inspire young people to go into a specialty
where they can really make a difference to people's lives and wellbeing.[76]
6.58
Associate Professor Andrew Cole, Chief Medical Officer for HammondCare,
expressed worry about how little of the curriculum for the training of health
professionals is devoted to end-of-life care:
All of us are most concerned about the very small amounts of
clinical teaching time given to healthcare students—medical, nursing and allied
health—as they learn about end-of-life care compared with, for example, the
time given to learning about the care of infants and children. In my own
university [University of New South Wales], the medical students would spend a
term in each of first, second and third years learning about beginnings, growth
and development and they would spend about a week learning about palliative
care and care at the end of life. At Sydney University, they spend about half a
day.[77]
6.59
Associate Professor Mark Boughey explained that the Centre for
Palliative Care, an academic research and education centre at the University of
Melbourne, encourages early exposure to palliative medicine:
Prof. Boughey:...we are then going into the hospitals and
trying to encourage intern placements, junior doctors and early trainees so
they get an exposure. They may never go to palliative medicine but they get an
exposure about what palliative care and palliative medicine is all about that
they can carry into whatever area they go.
Senator FIERRAVANTI-WELLS: Would that be at
undergraduate level?
Prof. Boughey: It depends on the priorities of any
university. Somewhere like Melbourne University that we are associated with has
moved to a postgraduate model. They have about a two-week program built into
two separate parts of their four-year course. They have taken a fairly serious
approach to palliative care being part of that training.[78]
6.60
In comparison to training offered at other institutions, a two week
program may be seen as quite substantial:
Some other universities may only have a few hours or a few
lectures in a six-year period. That is not to say that palliative care does not
get mentioned in the disease profile of all the training; it is just the
specialist area where the people who work in palliative care have access to
students. In many ways medicine is more organised than nursing, allied health
or other areas of training. I do not think in occupational therapy or
physiotherapy it is actually part of the undergraduate training. Once you get
away from medicine, it falls off quite precipitously in Australia. There is
nothing to say there is a minimum standard in training for students in this
area, even though it is so much a part of our work.[79]
6.61
According to Associate Professor Boughey, there are different needs for
workforce development depending on the health professional:
At the moment we might have nurses who have had a great deal
of experience but that experience is not recognised in a structured way so
that, say, a young graduate nurse can be told: 'This is your career. If you
want to become a career specialist in palliative care, these are the stepping
stones to move towards it.' It is much more organised in the medical field. For
a psychologist who wants to work in the area there is not really any training
pathway other than being experienced in death and dying, which does not
necessarily mean that they have had the training.[80]
6.62
Associate Professor Boughey cited the success of a palliative care
training program in Victoria which has encouraged promising workforce
developments:
To give an indication: their program was set up five years
ago—there was a two-year pilot and then three years into the program—and it has
gone from having only five or six trainees in palliative care medicine to about
35 positions and 17 trainees. That is significant growth in a three-year period.
It is all because we have centralised, coordinated, brought the trainees
together and provided value-added education. We are getting people move to
Victoria from interstate, whereas before we had to move to other parts of
Australia because our training requires us to do certain terms that were not
available in Victoria. It is an interesting model. Queensland is taking up a
view that they want to develop a similar program and process to keep their
trainees in Queensland. So things are happening but it is on a state-by-state
basis at the moment.[81]
Committee view
6.63
The committee strongly endorses the interdisciplinary and team-based
models of care about which it received evidence, and noted the importance of
nurse-led teams in providing care in this sector. These multidisciplinary teams
need to be effectively resourced and well trained.
6.64
The committee recognises that the palliative care workforce must be
properly equipped with the knowledge, skills and experience to provide high
quality end-of-life care to people with terminal illnesses, as well as to their
families and carers. The committee heard that through enhancements to the
health workforce curriculum, in both undergraduate and postgraduate settings, a
broader awareness of the principles of palliative care will become more greatly
embedded within the health system and not just among specialist palliative care
providers. The committee believes it is important that such awareness be
developed in the healthcare community, so that health practitioners refer patients
to specialist palliative care in a timely manner; patients get the most
appropriate care; and the healthcare system is not used inefficiently through
patients with palliative care needs being inappropriately placed in acute care
settings.
6.65
The committee understands the critical role played by nurses in
providing quality palliative care. Greater opportunities for nurses to develop
their knowledge and specialise in palliative care nursing through postgraduate
education should be pursued. The committee sees merit in the creation of a
dedicated scholarship fund to assist nurses aspiring to gain postgraduate
qualifications and considers that the Commonwealth Government should establish
such a fund.
Recommendation 9
6.66
The committee recommends that medical workforce training include being
educated about existing pathways to specialist palliative care, ensuring that
this care is applied effectively to best meet patient need.
Recommendation 10
6.67
The committee recommends that the Australian government create an
ongoing and dedicated national scholarship fund for postgraduate studies in
palliative care nursing.
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