1. Palliative care orientation & training program for overseas trained nurses

2. Acknowledgements This orientation program was funded by the Rural Health Continuing Education Stream 2 (RHCE 2) program grant from National Rural Health Alliance (funded by the Department of Health) Jennifer Noonan, Bronwen Clayton, Sharyn Meyer, Deb Funcke, Sharyn Cook, Wimmera Hospice Care Registered Nurses, Wimmera Health Care Group Pete Marshall (Manager Grampians Region Palliative Care Consortium) Educators and Nurse Unit Managers across the Wimmera region. Jade Odgers (Manager) and Regina Kendall (Nurse Practitioner) Grampians Regional Palliative Care Team Palliative Care Orientation & training program for overseas trained nurses

3. Wimmera Hospice Care Provides specialist palliative care services to the Wimmera region of Western Victoria Support to clients, carers and their primary health care professional’s Map Reference: www.health.vic.gov.au/regions/grampians/ Palliative Care Orientation & training program for overseas trained nurses

4. Increasing number of overseas trained nurses Many nurses had no or minimal experience in palliative care Many nurses were not familiar with symptom management or opioids 2012 Pilot of a Palliative Care Orientation Program for Overseas Trained nurses in the Wimmera Rural Health Continuing Education (Stream 2) program grant from National Rural Health Alliance (funded by the Department of Health) Ethics approval given by the Wimmera Health Care Group Research committee as a quality improvement project

5. Palliative Care Orientation & training program for overseas trained nurses Literature Review…. Overall literature related to nursing migration is limited – Significant increases (Jeon et al 2007; Wellard et al 2010; Hawthorn et al 2001) Noting that often coming from countries where there are isolated or generalised provision of palliative care (Lynch et al 2011) – Loneliness, isolation, tension between workplace roles and personal cultural values – Nurses with Non English speaking backgrounds experienced difficulty with communication with colleagues, patients and their families, medical language, medication and equipment names and colloquial expressions. Found also to experience unrealistic expectations by local nurses – Need for intervention including mentor programs, support nurses, country specific orientation programs, formal networks as well as informal networks.

6. Palliative Care Orientation & training program for overseas trained nurses 3 Key Learning objectives Cultural awareness of death and dying in Australia and Wimmera Palliative care symptom management; and Supports available to deliver palliative care in the region Target Groups Registered Nurses and Enrolled Nurses employed by health services within the region, and had completed their nursing training overseas Priority given to nurses who had recently registered in Australia

7. Palliative Care Orientation & training program for overseas trained nurses The Program Two Elements: 1. Self Directed learning Package and orientation manual (included PCV podcasts) 2. Cancer Council of Victoria Workshop ‘Responding to Emotional Cues’ Wimmera Hospice Care Nurses available for support by telephone and visits to assist with the package Nurse Managers/Educators at each Health Service partnered and promoted/identified participants

8. Palliative Care Orientation & training program for overseas trained nurses The participants Registered Nurses working in Aged Care and Acute Care 3 Health Services (5 campuses) 35 participated – 25 successfully completed a package – 29 attended a workshop (4 workshops conducted across 3 Health Services)

9. Palliative Care Orientation & training program for overseas trained nurses The participants (continued) 1participant reported that they had cared for palliative care patients in their country of training 1 participant stated “Giving palliative care to dying patients here in Australia is very different from the country where I came from” and “it’s my first time to see subcutaneous syringe driver for pain”

10. Palliative Care Orientation & training program for overseas trained nurses Evaluation Survey pre and post completion of the program assessed: 1. Attitudes about end of life care (Bradley, EH, Cicchetti et al 2000) 2. Confidence in palliative care knowledge and skills (Grampians Regional Palliative Care Team Liverpool Pathway Project) Surveys de-identified Results do not identify individual improvements Self reporting in these cultural groups was also not investigated SurveyNumber pre-survey21 participants (58%) post-survey23 participants (63%)

11. Palliative Care Orientation & training program for overseas trained nurses Evaluation (continued) Statement/QuestionPre survey (n=21) Post survey (n=23) Confident or very confident How confident are you in your knowledge of the facilities available at your health service to dying patients and their families? 19%83% How confident are you as a nurse in assessing & treating the following symptoms in a dying patient? (are over 7 symptoms) 70%95% How confident are you as a nurse in assessing and discussing the dying patient’s wellbeing? 19%74% How confident are you as a nurse in knowing what family care is required after a patient in your care has died? 29%48% Table 1: Pre and Post Survey Confidence

12. Palliative Care Orientation & training program for overseas trained nurses Evaluation (continued) Statement/QuestionPre survey (n=21) Post survey (n=23) Agree or Strongly Agree Hospice care or palliative care generally meets the needs of the family better than conventional care does. 67%83% I feel knowledgeable enough to discuss hospice or palliative care with patients and families. 48%83% Disagree or Strongly Disagree Most patients’ symptoms, such as pain, shortness of breath and nausea are not controlled any better with hospice/palliative care than with conventional care they would otherwise receive. 33%39% Most elderly patients do not want to be told if they are dying. 43%61% Table 2 Pre and Post Survey Attitudes towards Palliative Care:

13. Palliative Care Orientation & training program for overseas trained nurses Evaluation (continued) All participants rated the training as effective, with most ratings being extremely effective or highly effective: ItemRating of extremely or highly effective ‘Quality and information in the self-directed learning package’ 78% ‘Relevance of the program to your workplace’ 91% ‘Usefulness of the course’83%

14. Palliative Care Orientation & training program for overseas trained nurses Evaluation (continued) ‘It was just wonderful - I did not expect it be that very interesting’ ‘The role play gave me opportunities to practice new phrase/lines. Now I feel more confident to deal with angry/depressed/anxious patient’s’ ‘The brilliant part of the workshop is that role play made things easier to understand. The role play really helped to find where I am as a nurse.’ ‘ I would like to attend more programs like this’

15. Palliative Care Orientation & training program for overseas trained nurses Lessons Learnt Follow up of completed packages difficult. Specifically developed overseas trained nurse’s workshop on communication skills that identifies Australian cultural issues. Ongoing support. Further palliative care education opportunities were sent out with the Certificates of Completion. Wimmera Hospice Care staff reported improved rapport and contact from nurses across the region. Cultural training for Hospice staff

16. Palliative Care Orientation & training program for overseas trained nurses 2014 and beyond… Expansion of pilot across Grampians Region and Wimmera commenced June 2014 Funded by the Grampians Region Palliative Care Consortium

17. Palliative Care Orientation & training program for overseas trained nurses Conclusion Improved cultural awareness of death and dying in palliative care in Australia for overseas trained nurses Overall positive response from participants, educators and managers Developed and improved relationships between participants and Wimmera Hospice Care Key to the success was the support of the RHCE grant, collaboration between the Wimmera Hospice Care team, Grampians Regional Palliative Care Team, and managers and Clinical educators across the 3 Health Services involved.

18. Palliative Care Orientation & training program for overseas trained nurses References Bradley, EH, Cicchetti, Fried R, Rousseau D, Johnson-Hurseler R, Kasl S, Horwitz S. Attitudes about care at the end of life among clinicians: A Quick, Reliable, and Valid Assessment Instrument. Journal of Palliative Care 2000 16(1): p 6-14 Brunero, S, Smith J, Bates E. Expectations and experiences of recently recruited overseas qualified nurses in Australia. Contemporary Nurse 2008; 28: 101-110. Deegan J, Simkin K. Expert to novice: Experiences of professional adaptation reported by non-English speaking nurses in Australia. Australian Journal of Advanced Nursing. 2010; 27 (3):31-37 Hawthorne L. The globalisation of the nursing workforce: barriers confronting overseas qualified nurses in Australia. Nursing Inquiry 2001; 8:4 213-229 Jeon Y-H, Chenoweth L. Working with a culturally and linguistically diverse (CALD) group of nurses. Collegian 2007; 14:1 16- 22. Klein, P. Freedom from Pain. (online). Available: http://english.aljazeera.net/programmes/peopleandpower/2011/07/2011720113555645271.html. (Accessed 20 th March 2014) http://english.aljazeera.net/programmes/peopleandpower/2011/07/2011720113555645271.html Konno R. Support for overseas qualified nurses in adjusting to Australian nursing practice: a systematic review. International Journal of Evidence Based Healthcare 2006; 4: 83-100 Lynch T, Clark D, Connor S. Mapping levels of palliative care development: a global update 2011. Worldwide Palliative Care Alliance. Wellard SJ, Stockhausen LJ. Overseas trained nurses working in regional and rural practice settings: do we understand the issues? Rural and Remote Health 2010; 10:1458. (online). Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1458 (Accessed 20 th March 2014) http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1458