Paediatric palliative care: Is it all about communication?-quality improvement project to assess and address background knowledge and training needs of a department

Abstract

Context This quality improvement project took place in a district general hospital paediatric department. The target population was all doctors in training, consultants, ward nurses and community nurses. Problem Across the general paediatric team, many people feel poorly equipped to look after life limited and life threatened children, often preferring to ‘leave it to the specialists’. However, these children are regularly admitted to the general paediatric ward during acute illness and cared for as an inpatient requiring everyone to have basic skills and understanding of the principles of palliative care, and experience in dealing with some of the more difficult communication topics. There were sometimes ‘mixed messages’ or differing language used with these families by staff unfamiliar with these cases, and a heavy reliance on the tertiary centre or specialist, meaning patients and families were often left waiting. Assessment of problem and analysis of its causes A questionnaire was sent to all acute ward nurses, community nurses, consultants and junior doctors working within the paediatric department. Information gathered included current experience, level of confidence in a range of core palliative care areas such as breaking bad news, symptom management, parallel planning, and knowledge of local guidance and support available. This enabled us to develop a study day specifically targeted at some of the more challenging concepts for non-specialists. Intervention A Regional Paediatric Palliative Care Study day was designed using targeted areas as highlighted from the questionnaire. It included interactive communication scenarios using the ‘goldfish bowl’ technique with professional actors, and seminars on organ donation, hospice involvement, symptom management, the patient/parent perspective and ACPs/DNACPRs. Study design Quality improvement project. Strategy for change All those who had shown interest were invited to attend the study day, and it was advertised regionally to ensure a good mix of levels and experience. The study day was held approximately 2 months after the initial questionnaire. The results of the initial questionnaire were presented as the premise for the content of the study day. Measurement of improvement A post-course questionnaire was sent out after attendance to ascertain the efficacy of the study day, and to develop any changes that may be required to deliver it again in the future to a different cohort of attendees, and also to explore any further training needs that may be addressed with a second, more advanced day for the current attendees. Effects of changes Overall pre-course, there were low confidence levels with advance care plans and DNACPR discussions, hospice involvement and symptom management. These areas were addressed by the study day, and post-course attendees commented on how useful the communication scenarios, symptom management and seminars had been in improving their confidence in managing children with life limited/life threatened children. Lessons learnt We tried to cover too many topic areas within a single study day, therefore leaving attendees wanting more detail in some areas. It may be better to run it as a two-day study course, but with the days six months apart to allow participants to use the skills and knowledge learnt on the day and then feed back to the group. Unfortunately there were limited numbers of consultants available to attend the communication scenarios, which may have been helpful to provide experience and balance. Adaptations to timings of the training day are being assessed to encourage more consultant attendees. Message for others The confidence levels and knowledge base around many aspects of paediatric palliative care for non-specialist nurses and doctors can be improved by a targeted study day. Please declare any conflicts of interest below.