Staffing a Palliative Care Service

Job Descriptions

No matter how small the service, it is essential to prepare a job description for each post. This should be prepared before advertising the post, ready to be given to all interested in it. It is not a legal contract but may be referred to in any subsequent contract, thus making it binding on all parties.

Size and description of staff

Nurses: It is often said that an in-patient palliative care service should aim to have a ratio of 1 nurse: 2 patients round the clock.  This is seldom achievable and may be too high a ratio, as well as impossible to achieve / afford. Nevertheless the essence of palliative care staffing is as many nurses : patients as possible. Useful as they are there should be sufficient general nurses not to have to reply on untrained nursing auxiliaries for the bulk of the caring.

In an in-patient unit more nurses are needed at night than in a general hospital because that is when patients most need companionship.

The number of nurses needed to staff a community palliative care service depends on

An urban service where the nurses have cars to visit in designated areas 1 nurse can usually care for 20 patients at home at one time. In a rural community where homes are widely scattered and distance long the ratio may be nearer 1 nurse: 5-10 patients

Doctors:  Because it is expensive to employ a doctor it is tempting for a new service to try to manage without one, or to employ one for a few hours each week, principally to write prescriptions. It is possible but highly undesirable, to run a service with minimal medical input. Worldwide it has been shown that palliative care develops better, public and professional acceptance of it grows more rapidly, and palliative care gains professional recognition sooner if a service has a whole time doctor, someone who devotes all his/her time to palliative care. This is not because doctors are more important or more effective than nurses. It is because doctors seem to listen more to other doctors, are more prepared to follow their advice, and give their advice more thought than if it had come from a nurse, highly qualified as she may be.

The number of doctors needed depends on

 

Some of these can be time-consuming, especially if travelling is involved visiting patients or other hospitals.

Other clinical staff: This may include 

Ideally a comprehensive service needs all of them but the financial implications make this impossible.  It is better to attract them as part-time staff, or as volunteers, each working for a few hours each week at pre-arranged times. Alternatively people like social workers can sometimes be shared with local social work departments, enabling greater co-operation and continuity of care for some of the clients.

Qualifications and experience

Basic professional qualifications are essential; trying to save money by employing untrained personnel is a short-sighted policy and will damage the image of the new service.

Doctors and nurses who will work in a community service should have experience and (if available) qualifications in community care.  Without that it will take a long time for them to be accepted by other doctors and nurses working in the community.

Previous experience in palliative care whilst desirable is often not feasible in a country / town where there are few if any such services.  Such experience can be gained (see later)

Those starting new services often assume that all that staff need is an interest in, and a commitment to, palliative care, wrongly assuming that all the necessary knowledge and skills can quickly be gained as the work progresses.  This is not true.

Senior Staff

It is highly desirable that the senior doctor, senior nurse and the manager / director/ chief executive have experience working in palliative care as well as being experienced in their own discipline. This cannot be over-stated.

Doctor: The background of the senior doctor is not as important as his / her experience in palliative care. They most commonly come from general practice / family medicine or oncology, from anaesthesiology (pain relief services) or occasionally from psychiatry. 

Nurse: General nursing training, as well as palliative care training,  are essential as is experience of / training in management of a health care unit such as a small hospital or polyclinic.

Community nursing experience is useful but not essential if the new palliative care service is to have a community outreach

Teaching experience is useful but not essential

Chaplain / Pastoral Care Worker: A small service / unit can use local clergy of the different faiths. As the service grows it will be desirable to employ a chaplain, supported by a chaplaincy advisory committee. It might be possible to recruit one who has had postgraduate training in hospital pastoral care in one of the many courses now available, especially in the USA and UK.

Appointment and induction

Each position should be advertised, all those interested given the information they need about the post, the  proposed service as well as an opportunity to see any buildings and possibly to serve for a trial period  Interviews should be conducted in accordance with employment law.

Induction is critically important. The longer the better but less than a week of talks, demonstrations, questions and answers will never be sufficient.

The topics that must be covered in the induction process must include:

It is helpful if talks / demonstrations are given by as many members of staff and management as possible, each dealing with their own areas of expertise, giving the newcomers a chance to get to know them in the informal atmosphere of induction.

Where possible it is helpful for both newcomers and established members of the staff when the service has been running for some time to visit other palliative care units / services to see how they operate and hear of problems they have encountered and dealt with.

Appraisals

No matter how small the service it is vital that all staff have regular appraisals by their line manager, when they must be given opportunities to discuss their work and any problems they are encountering.

Staff Support

Those starting a new service often assume that the work itself will be so stressful that sophisticated support systems need to be put in place. However research has shown that the principle cause of stress in palliative care is not the dying, death and distress but the personalities of those engaged in it.

 The causes of stress include:

 

Though some new services make use of psychologists or counsellors experienced in stress management most agree that

 

Gaining professional training and experience

When a new service is set up in a country where there are already palliative care services doctors and nurses (and professionals allied to medicine) should be able to go there and gain experience.

In many countries there are now excellent short and long courses for all the professionals involved. [See the websites of IAHPC, Hospice Information and Help the Hospices]

There are books on palliative care for all levels of experience and qualifications, including case-based manuals. [See Recommended Readings]

Education and tutorial staff

So important is it that every doctor and nurse is taught the principles of palliative care (whatever their specialty and wherever they work) that every new service / unit should plan to have an educational component to its work from the outset.

The accommodation may be a room or a lecture hall or suite of rooms. The staff may be a part-time tutor (nurse or doctor) or a full department of lecturers and supporting staff. What matters is that from the start of any service someone must be designated as education officer / tutor/ teacher and money is budgeted for salary and modest equipment

If the decision to become involved in education and training of other doctors, nurses and clergy is not made when the service is being planned or is in its infancy, it will be extremely difficult to find the accommodation, staff and money to develop it later  Sadly, some trustees and sponsors are reluctant to fund education believing that the service is primarily there for the care of today’s patient.. In many parts of the world if such education and training is not made available in the palliative care services, no-one else will offer it.

Pension / Superannuation Arrangements

Before starting any service it must be determined what pension provisions should be made for staff. 

Whatever arrangements are made all members of staff must be provided with full details and kept up-to-date with any changes in the scheme