Staff training and education

In Australia, 35% of all deaths among people aged over 65 years occur in residential aged care facilities (RACFs). [1] The recent COVID-19 pandemic has also led to increased death rates in this care setting. [2] Residential aged care staff, therefore, require a level of competency in managing palliative care needs and in communicating with people’s families. [3, 4] These include skills in managing distressing symptoms, such as pain and breathlessness, and being able to discuss end-of-life matters confidently to help people plan for their future. [4] Staff also need to know when hospitalisation can be avoided, [4] when more specialist skills and knowledge are required, and how to access these services. [5]

Residential aged care facilities are complex environments that can create specific challenges for providing quality palliative and end-of-life care to older people. [5] Residents often have higher levels of multimorbidity, dementia, frailty, and functional disabilities than older people living in the community which can make it difficult to recognise when a person is nearing the end of life. [5] The skill mix of the residential aged care workforce is also unique. In Australia, 70 per cent of the residential aged care workforce are direct care workers, an unregulated workforce, supervised by a small number of registered nurses. [6] These workers deliver most of the direct ‘hands on’ care provided to residents, assisting with personal care, eating and often being called upon to offer social and emotional support. [6] They are well-positioned to understand residents’ care needs and recognise any changes in mental or physical health. [6] Despite having a central role in caring for residents up until their death, direct care workers have often not been shown how to assess the palliative care needs of the people they care for. [2, 7]  As RACFs are not hospitals, staff and residents can be isolated from medical care services and their timely provision. Staff, especially those without clinical skills, may find it difficult to communicate with health professionals about residents’ healthcare needs. They may also be required to be involved in challenging decisions regarding patient care after hours. [5]

Palliative and end-of-life care training has been identified as an educational need of growing importance for home care workers as well as direct care workers in residential aged care. [8] Home care workers spend a lot of their time providing emotional and social support to their clients, in addition to personal care. [9] As home care services enable more older Australians to age and die in their own homes, home care workers will need to be able to assess and manage the palliative care needs of their clients and be part of their care as they are dying. [10] Despite this, there currently appear to be few training programs specifically tailored to this group. [9, 10]

Australian competencies for aged care staff at all levels are specified in the National Palliative Care Standards (Level 1 capabilities). [3] However, these competencies cannot be acquired without regular, ongoing training and education, which staff may not have access to, or the opportunity to participate in. [5]  The limited staff and resource budgets under which RACFs operate are unlikely to foster opportunities for staff to attend fee-based training programs within work time. [11] The high rate of turnover in this workforce might also frustrate efforts to provide ongoing training for competence in palliative and end-of-life care. [5, 6]

This evidence theme on palliative care and end-of-life training and education for aged care staff is a summary of one of the key topics identified by a scoping review of the palliative care research. If you need more information on this topic, try using one of the PubMed searches below.

We identified four systematic reviews exploring staff training and education in palliative care and end of life. [2, 4, 5, 12] These reviews focused on the quality and characteristics of existing programs, [2, 5] the factors that encourage or constrain staff access to palliative care education, [2, 4, 12] and the impact of staff training on residents’ quality of life, quality of death, and burdensome transitions to acute care near the end of life. [4] All four reviews were specific to residential aged care and its workforce.

Characteristics of staff palliative care training and education programs

Traditionally, the main educational approaches offered to staff have included face-to-face lectures, group workshops, and scenario-based learning. However, e-learning, blended learning and reflective practices, while less common, [5] appear to be gaining in popularity. [2] Few training approaches appear to offer a range of educational approaches. [5] It is also not clear from many published reports if the education initiatives they describe are based on evidence-based practices or national standards for training. [2]

There is little evidence showing that staff training and education in palliative care leads to higher quality end-of-life experiences for people in residential aged care, [5, 12] owing to only a small number of studies evaluating the effect of training on resident care or resident/family satisfaction with that care. [2, 4, 5, 12] Most research tends to focus instead on staff satisfaction with the training they receive or their evaluation of its impact on their knowledge, attitudes, or confidence in delivering end-of-life care. [2, 5] This information is often obtained using unvalidated surveys or questionnaires, and few studies follow up to see if these self-reported changes translate into actual changes in staff care practices or patient outcomes. [2, 5]

Overall, education initiatives vary widely in approach and appear to be brief, one-off events, rather than part of a culture of continuing professional development. [5] The number of teaching sessions attended as part of any program is consistently low, suggesting that within many programs the complex topics of palliative care and end of life are covered only superficially and would be unlikely to change staff behaviour and attitudes. [5]

Outcomes of training on residents and their families

Of the few studies investigating the impact of training on resident outcomes, most focus on improvements in residents’ quality of life, quality of care, quality of death, and resident/family satisfaction with care. [4, 5] Many of these studies relied on family members completing surveys after the resident’s death rather than directly observing or questioning the resident. [2] They also used a wide range of assessment tools to report an inconclusive impact on resident quality of life, quality of death, and satisfaction with care, and mixed findings on rates of hospitalisations. [4]

Facilitators and barriers to staff education and training

The main factors that appear to promote staff participation in, and ownership of, training in palliative care and end of life include:

• Engagement and support from managers and leaders as a matter of policy [2, 12]
• Time specifically allocated to attending training [12]
• Face-to-face training approaches [12]
• Content and mode of delivery tailored to the needs of the organisation [12]
• Participation of staff at all levels [2]
• Good, supportive relationships across work teams within the facility [2]
• Low staff turnover [2]
• Clearly outlined staff roles and responsibilities [2]
• The use of learning contracts or mutual goal setting as part of the training [12]
• Staff willingness to disseminate new knowledge to other staff [12]
• Ongoing opportunities to implement new knowledge gained. [12]

Most reviews reported barriers to the implementation and continuation of education and training. These include:

• Lack of staff time to attend training [2, 12]
• High turnover of staff and of the administrative staff responsible for organising training [2, 12]
• An aged care facility culture that avoids conversations around palliative and end-of-life care [2]
• Staff reluctance or lack of confidence in participating in end-of-life care [2]
• Staff uncertainty as to their roles and responsibilities in proving palliative and end-of-life care [2, 12]
• Management perception that staff already have the required skills and knowledge [12]
• Lack of trust, understanding, and communication between professional groups within the RACF or with staff from outside the organisation such as visiting general practitioners [2]
• A lack of opportunities for self-reflection or staff discussion after training has occurred [2]
• Insufficient physical space and access to resources such as computers with reliable internet connection for training onsite. [12]

Several reviews included in this evidence theme highlighted concerns about the methods used in some of the studies and rated the overall quality of the current evidence as very low. [2, 5] This reduces the degree of certainty we might have about the benefits of current staff training and education programs in palliative care. For example:

• What the training involved and how its outcomes were evaluated were often poorly described. [5]
• Training was often delivered as one component within a large complex study. This makes it difficult to assess the independent effects of the training on resident/family outcomes. [4]
• Most studies involve only a small sample of participants which makes it difficult to draw any firm conclusions about the effectiveness of a particular approach. [5]  
• Few studies investigated if the reported changes achieved by the training were sustained over time. [5]

• Seek out education and training opportunities to learn more about palliative care and increase your knowledge, skills, and confidence in providing care at the end of life. This may be online via some of the quality e-learning modules offered by PEPA and palliAGED (see suggested resources below)
• Invest time in keeping palliative care knowledge and skills up to date.

• Convey to staff the importance of palliative care as an organisational priority by providing management support for staff training opportunities.
• Consider focusing on core competencies as a matter of priority, clearly linking them to the organisation’s goals or key performance indicators.
• Ask staff to identify their learning needs before delivering or commissioning training to increase the likelihood of training meeting the needs of the specific setting and trainee group.
• Provide staff with opportunities to use and sustain their new knowledge after training.
• Allocate staff with protected time within work hours to attend training.
• Establish a well-resourced space with computers and internet access for staff to participate in online learning in the workplace.
• Pay for staff to attend outside training programs where possible.
• Acknowledge staff participation in training as an organisation by awarding certificates or continuing professional development points.

1. Australian Institute of Health and Welfare. Interfaces between the aged care and health systems in Australia--where do older Australians die? [Internet]. AIHW; 2021 [cited 2022 Oct 10]. Available from: https://www.aihw.gov.au/getmedia/56c1f616-8b2c-493e-8e1c-2db5083ad59d/aihw-age-106.pdf.aspx.
2. Iida K, Ryan A, Hasson F, Payne S, McIlfatrick S. Palliative and end-of-life educational interventions for staff working in long-term care facilities: An integrative review of the literature. Int J Older People Nurs. 2021;16(1):e12347.
3. Palliative Care Australia. National Palliative Care Standards, 5th ed. Canberra, ACT: Palliative Care Australia; 2018.
4. Lamppu PJ, Pitkala KH. Staff training interventions to improve end-of-life care of nursing home residents: A systematic review. J Am Med Dir Assoc. 2021;22(2):268-78.
5. Anstey S, Powell T, Coles B, Hale R, Gould D. Education and training to enhance end-of-life care for nursing home staff: A systematic literature review. BMJ Support Palliat Care. 2016;6(3):353-61.
6. Norling T, Donovan H. Palliative care education for care workers in aged care: A scoping review. Collegian. 2022.
7. Karacsony S, Chang E, Johnson A, Good A, Edenborough M. Assessing nursing assistants' competency in palliative care: An evaluation tool. Nurse Educ Pract. 2018;33:70-6.
8. Pavloff M, Labrecque ME. Continuing education for home care nurses: An integrative literature review. Home Healthc Now. 2021;39(6):310-9.
9. Herber OR, Johnston BM. The role of healthcare support workers in providing palliative and end-of-life care in the community: A systematic literature review. Health Soc Care Community. 2013;21(3):225-35.
10. Tsui EK, Wang WQ, Franzosa E, Gonzalez T, Reckrey JM, Sterling MR, et al. Training to reduce home care aides' work stress associated with patient death: A scoping review. J Palliat Med. 2020;23(9):1243-9.
11. Evenblij K, Ten Koppel M, Smets T, Widdershoven GAM, Onwuteaka-Philipsen BD, Pasman HRW. Are care staff equipped for end-of-life communication? A cross-sectional study in long-term care facilities to identify determinants of self-efficacy. BMC Palliat Care. 2019;18(1):1.
12. Manson J, Gardiner C, McTague L. Barriers and facilitators to palliative care education in nursing and residential homes: A rapid review. Int J Palliat Nurs. 2020;26(1):32-44.