The Advancement of Palliative Care in Rwanda: Transnational Partnerships and Educational Innovation

Health Care Worker Education for Palliative Care in Africa: Narrative Review

The demand for palliative care for terminally ill patients is rising globally. This review examines the potential of health worker education to enhance palliative care in Africa. A search of PubMed yielded 32 relevant articles published in English from 2013 to 2023 focused on African countries with WHO-categorized palliative care development and health care worker training. The findings underscore the pivotal role of health care worker education in elevating palliative care standards. Targeted initiatives equip health care workers with vital skills in pain management, symptom control, and communication. The integration of palliative care into public health systems is important for the sustainability of end-of-life care for terminally ill patients in Africa and around the world.

Comprehensive scoping review of palliative care development in Africa: recent advances and persistent gaps

Worldwide 56·8 million people need palliative care (PC), and Africa shows the highest demand. This study updates the 2017 review of African PC development, using a scoping review methodology based on Arksey and O'Malley's framework and the PRISMA-ScR checklist. The review was conducted across PUBMED, CINAHL, Embase, government websites, and the African PC Association Atlas, from 2017 to 2023, charting its progress using the new WHO framework for PC Development, which, in addition to Services, Education, Medicines, and Policies, two new dimensions were incorporated: Research and Empowerment of people and Communities. Of the 4.420 records, 118 met the inclusion criteria. Findings showed increased adult specialised services (n = 675), and 15 of 54 countries have paediatric services. Nonetheless, the ratio of services per population mostly remains under 0,10 per 100.000 inhabitants. PC education was included in undergraduate curricula in 29 countries; despite the rise in morphine availability (28 countries), median consumption remains under 3 mg/per capita/year, and 14 countries presented stand-alone policies. Publications on PC development increased, and 26 countries have National PC Associations. Notwithstanding progress since 2017, significant hurdles remain, highlighting the need for ongoing research and policy development to ensure equitable access to palliative care in Africa.

'There is no such word as palliative care for us at the moment': A mixed-method study exploring the perceptions of healthcare professionals on the need for palliative care in Bhutan

Background

The need for palliative care is ever-increasing globally. However, it is least developed or not available in most low-and-middle-income-countries including Bhutan.

Objective

This study was aimed at exploring the perspectives of Bhutanese healthcare professionals on the need for palliative care in the country.

Design

This is a cross-sectional, mixed-method study.

Setting/subjects

The study sites included all levels of healthcare in Bhutan and involved doctors, nurses, physiotherapists, pharmacists, health assistants and Drungtshos (traditional physicians). Data were collected through surveys, focus group discussions and in-depth interviews.

Results

While the majority of the participants were directly involved in taking care of terminally ill and dying patients, only 14% had received some form of palliative care training for a duration ranging from 1 day to 6 weeks. Ninety-five percent of the participants reported that they faced challenges related to lack of palliative care knowledge and skills; limited resources including analgesics; shortage of doctors and nurses and lack of a palliative care team; issues with low illiteracy and financial challenges among patients; and policies and other systemic issues. The qualitative data generated four major themes: past adverse experiences; unique and complex needs for palliative care; challenges faced while caring for terminally ill and dying patients; and the urgent need for palliative care in Bhutan.

Conclusion

Bhutanese healthcare professionals had very limited exposure to palliative care. This study identified a crucial need for palliative care and informs the development of an appropriate palliative care model for Bhutan.

Perceived policy-related barriers to palliative care implementation: a qualitative descriptive study

Background

Ethiopia has a national palliative care guideline, and palliative care is explicitly recognised in the country's healthcare policy and health sector transformation plans. However, palliative care is not fully delivered in the regional public hospitals and primary health care units.

Objective

This study explores perceived policy barriers to deliver palliative care services in rural and regional healthcare settings, which primary healthcare units largely serve.

Design

Face-to-face interviews were conducted in a rural region of Ethiopia.

Methods

Forty-two participants were recruited from a variety of health settings including primary, secondary and tertiary levels across the region. Interviews were conducted with policymakers from the regional health bureau, pharmacists, medical doctors, health officers (clinical officers) and nurses, including chief nursing officers in leadership roles at all levels of healthcare institutions. Data analysed using thematic analysis.

Results

Participants described several barriers related to healthcare policy, including lack of government priority and focus on palliative care; lack of health professionals' awareness of the national palliative care plans and guidelines; and lack of palliative care integration into the existing healthcare system and the national budget. Participants remarked that palliative care services in the region were mainly limited to HIV patients, often managed with external support and, hence unsustainable.

Conclusions

Policy priority and focus is a fundamental component for the provision of palliative care because lack of focus and support from the government have led to inadequate access to palliative care for all in need. Hence, as participants suggested, palliative care should be integrated into all healthcare levels, particularly into the primary health care units and the health extension programme, to facilitate health extension workers to support millions living in rural areas.

Making Advance Care Planning a part of cancer patients' end-of-life care in Rwanda

After the devastating damage inflicted by the 1994 Genocide against the Tutsi, Rwanda made great strides in reconstructing its healthcare system from scratch. Although cancer mortality rates continue to rise, there is still a dearth of qualified healthcare workers for advance care planning (ACP) for terminally ill patients. I will draw on lessons learned through the literature search for the initiation of ACP and reflect on their adaptation to the existing policies, healthcare systems, and workforce in Rwanda. We hope to introduce advance care planning into the clinical package given to patients with cancers in terminal illness and their families in Rwanda. The introduction of ACP by skilled, qualified, and specialized healthcare professionals in Rwanda will help establish a practical ACP strategy at the hospital and in the community to benefit patients and their loved ones for an enhanced quality of life in end-of-life care. There is a need for training, policy-making, and community mobilization for the awareness of ACP.

Socially, Culturally and Spiritually Sensitive Public Health Palliative Care Models in the Lower-income Countries: An Integrative Literature Review

The demand for palliative care (PC) is ever-increasing globally. The emergence of COVID-19 pandemic has further accelerated the need for PC. In the lower-income countries (LICs), where PC need is highest, PC, the most humane, appropriate and realistic approach to care for patients and families affected by life-limiting illness, is minimal or non-existent. Recognising the disparity between high, middle and LICs, the World Health Organization (WHO) has recommended public health strategies for PC within the socioeconomic, cultural and spiritual contexts of individual countries. This review aimed to: (i) identify PC models in the LICs utilising public health strategies and (ii) characterise how social, cultural and spiritual components were integrated into these models. This is an integrative literature review. Thirty-seven articles were included from a search of four electronic databases - Medline, Embase, Global Health and CINAHL. Literature, both empirical and theoretical literature, published in English from January 2000 to May 2021 that mentioned PC models/services/programmes integrating public health strategies in the LICs were included in the study. A number of LICs utilised public health strategies to deliver PC. One-third of the selected articles highlighted the importance of integrating sociocultural and spiritual components into PC. Two main themes - WHO-recommended public health framework and sociocultural and spiritual support in PC and five subthemes - (i) suitable policies; (ii) availability and accessibility of essential drugs; (iii) PC education for health professionals, policymakers and the public; (iv) implementation of PC at all levels of healthcare and (v) sociocultural and spiritual components, were derived. Despite embracing the public health approach, many LICs encountered several challenges in integrating all four strategies successfully.

The Influence of College Entrepreneurship Education System on the Cultivation of Applied Innovative Talents

With China's socioeconomic development, especially in the educational sector, foreign advanced education experience might not be omnipotent for the innovation and entrepreneurship education (IEE) in Chinese colleges. In response to such a difficult context, firstly, this study was conducted to analyze the applied innovative talent cultivation status quo in Chinese colleges under innovation and entrepreneurship. Then, the authors dug into the current situation and the development of IEE-related courses in College S through Questionnaire Survey (QS) and unveiled the efficacy of entrepreneurship environment and conditions, IEE courses, teaching methods, and policy system on the college applied innovative talents cultivation. Finally, the experiment discovered that three problems are prominent when training applied innovative talents in College S: unreasonable talent training process, imperfect education system, and emphasizing theory over practice. The main reason is that the IEE courses are not systematically set up, and teachers are in severely short supply. According to the research outcomes, the corresponding countermeasures and suggestions were proposed for applied innovative talents cultivation in College S. It is concluded that the cultivation of applied innovative talents under innovation and entrepreneurship should be reformed from four aspects: educational concept, educational model, educational policy, and social support, laying a foundation for improving the quality of IEE in Chinese colleges and universities and strengthening the cultivation of applied innovative talents.

Healthcare professionals' views on how palliative care should be delivered in Bhutan: A qualitative study

Palliative care aims to relieve serious health-related suffering among patients and families affected by life-limiting illnesses. However, palliative care remains limited or non-existent in most low- and middle- income countries. Bhutan is a tiny kingdom in the Himalayas where palliative care is an emerging concept. This study aimed to explore the views of Bhutanese healthcare professionals on how palliative care should be delivered in Bhutan. It is a component of a bigger research program aimed at developing a contextual based palliative care model for Bhutan. This is a descriptive qualitative study. Eleven focus group discussions and two in-depth interviews were conducted among healthcare professionals, recruited through purposeful sampling, from community health centres, district hospitals, regional and national referral hospitals, and the traditional hospital in Bhutan. The participants in this study emphasized the need for suitable palliative care policies; education, training and awareness on palliative care; adequate access to essential palliative care medicines; adequate manpower and infrastructure; and a multi-disciplinary palliative care team. Participants confirmed a socially, culturally and spiritually appropriate approach is crucial for palliative care services in Bhutan. Despite palliative care being a young concept, the Bhutanese healthcare professionals have embraced its importance, emphasized its urgent need and highlighted their views on how it should be delivered in the country. This study will help inform the development of a public health-focused palliative care model, socially, culturally and spiritually applicable to the Bhutanese people, as recommended by the World Health Organization.

Support Needs for Bhutanese Family Members Taking Care of Loved Ones Diagnosed with Advanced Illness

Background: Palliative care aims to improve the quality of life of patients diagnosed with an advanced illness and their families. Family members, who often play a central role caring for their very ill loved ones, have significant support needs. In Bhutan, where palliative care is an emerging concept, the needs of family members have not been assessed thus far. Objective: This study explored the support needs of Bhutanese family members caring for their loved ones diagnosed with advanced illness. Design: This is a cross-sectional descriptive study. Setting/Subjects: Study sites included the national referral hospital, the two regional referral hospitals, four district hospitals and Basic Health Units (Grade I and II), spread across Bhutan. Participants were recruited through purposeful and snowball sampling strategies. Data were collected from May to August 2019. The Carer Support Needs Assessment Tools (CSNAT) was used. Results: Despite unforeseen challenges, 46 family members out of 60 identified (77%) participated in the survey. Twenty-three (50%) cared for relatives with advanced cancer and the remainder for loved ones with non-malignant conditions. This study found high support needs among both groups. The priority needs included understanding their relative's illness, managing symptoms, providing personal care, financial aspects, dealing with their own feelings and emotions and knowing what to expect in the future. Conclusion: This study will help inform the World Health Organization recommended public health approach to palliative care modified to the Bhutanese context for enabling a cost-effective intervention to improve the quality of lives of patients and families.

Palliative and End-of-Life Care Self-perceived Educational Needs of Physicians and Nurses in Rwanda

Palliative care access is an urgent and ethical imperative to effectively manage the increasing burden of serious health-related suffering worldwide. Understanding the palliative care educational needs of health care professionals is critical to support evidence-based clinical practice in Rwanda and other low- and middle-income countries. A cross-sectional study was conducted at 5 hospitals in Kigali, Rwanda, to assess the palliative/end-of-life educational needs of nurses and physicians. The End-of-Life Professional Caregiver Survey and a demographic form were used to collect data. Descriptive analyses and independent t tests were conducted. A total of 420 health care professionals participated in the study (response rate, 72%). Participants perceived their knowledge and skills in providing palliative/end-of-life care as low. Those who received palliative/end-of-life care training in the past 5 years, third- and fourth-year residents, and health care providers with 5 years of experience or more had significantly higher (P ≤ .05) mean scores on the End-of-Life Professional Caregiver Survey. Nurses scored higher than physicians in the patient- and family-centered communication (P = .049) and cultural and ethical values (P = .037) subscales. Pain management was identified as an educational need by 77% of participants. Our survey suggests the need for increased governmental investments in palliative/end-of-life care education among nurses and physicians in Rwanda.

International consensus-based policy recommendations to advance universal palliative care access from the American Academy of Nursing Expert Panels

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. On behalf of the Academy, these evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. Through improved palliative nursing education, nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative care nurses worldwide, nurses can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations. Part II herein provides a summary of international responses and policy options that have sought to enhance universal palliative care and palliative nursing access to date. Additionally, we provide ten policy, education, research, and clinical practice recommendations based on the rationale and background information found in Part I. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter.

An Integrative Review of Community Theories Applied to Palliative Care Nursing

The purpose of this integrative review was to appraise the qualitative and quantitative literature for community-level health behavior theory application to palliative care nursing to identify their use and future research implications. To date, there has not been an integrative review of the nursing studies that have used community-level health behavior theory to guide palliative care nursing research. Despite the availability of high-quality care, there continues to be underuse of resources. An integrative review on community-level theory application may provide a more holistic understanding of previous interventions to frame future interventions and research needs. The review was guided by the 5-step framework of Whittemore and Knafl. Relevant literature was searched and appraised. Seven different community-level health behavior theories were found with applications to palliative care nursing, and 16 studies using these theories were identified for discussion. Community-Based Participatory Research was the most used theory. Community-level health behavior theories such as Community-Based Participatory Research have helped build partnerships and activate community resources such as capacity, engagement, and diversity through culturally sensitive training interventions. Further research using these theories in palliative care nursing can realize positive outcomes, particularly in low-income rural areas.

A case analysis of partnered research on palliative care for refugees in Jordan and Rwanda

BACKGROUND

This case analysis describes dilemmas and challenges of ethical partnering encountered in the process of conducting a research study that explored moral and practical dimensions of palliative care in humanitarian crisis settings. Two contexts are the focus of this case analysis: Jordan, an acute conflict-induced refugee situation, and Rwanda, a protracted conflict-induced refugee setting. The study's main goal was to better understand ways humanitarian organizations and health care providers might best support ethically and contextually appropriate palliative care in humanitarian contexts. An unintended outcome of the research was learning lessons about ethical dimensions of transnational research partnerships, which is the focus of this case analysis.

DISCUSSION

There exist ongoing challenges for international collaborative research in humanitarian conflict-induced settings. Research partnerships were crucial for connecting with key stakeholders associated with the full study (e.g., refugees with life limiting illness, local healthcare providers, aid organization representatives). While important relationships were established, obstacles limited our abilities to fully attain the type of mutual partnership we aimed for. Unique challenges faced during the research included: (a) building, nurturing and sustaining respectful and equitable research partnerships between collaborators in contexts of cultural difference and global inequality; (b) appropriate ethics review and challenges of responding to local decision-maker's research needs; and (c) equity and fairness towards vulnerable populations. Research strategies were adapted and applied to respond to these challenges with a specific focus on (d) research rewards and restitution.

CONCLUSIONS

This case analysis sheds light on the importance of understanding cultural norms in all research roles, building relationships with decision makers, and developing teams that include researchers from within humanitarian crisis settings to ensure that mutually beneficial research outcomes are ethical as well as culturally and contextually relevant.

Recommendations to Leverage the Palliative Nursing Role During COVID-19 and Future Public Health Crises

With the daily number of confirmed COVID-19 cases and associated deaths rising exponentially, social fabrics on a global scale are being worn by panic, uncertainty, fear, and other consequences of the health care crisis. Comprising more than half of the global health care workforce and the highest proportion of direct patient care time than any other health professional, nurses are at the forefront of this crisis. Throughout the evolving COVID-19 pandemic, palliative nurses will increasingly exercise their expertise in symptom management, ethics, communication, and end-of-life care, among other crucial skills. The literature addressing the palliative care response to COVID-19 has surged, and yet, there is a critical gap regarding the unique contributions of palliative nurses and their essential role in mitigating the sequelae of this crisis. Thus, the primary aim herein is to provide recommendations for palliative nurses and other health care stakeholders to ensure their optimal value is realized and to promote their well-being and resilience during COVID-19 and, by extension, in anticipation of future public health crises.