Received date March 01, 2013; Accepted date March 04, 2013; Published date March 06, 2013
Citation: Silbermann M, Al-Zadjali M (2013) Nurses Paving the Way to Improving Palliative Care Services in the Middle East. J Palliative Care Med 3:e125. doi:10.4172/2165-7386.1000e125
Copyright: © 2013 Silbermann M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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In January 2012, the Ministers of health of the Gulf Cooperation Council (GCC) met in Muscat, Oman to respond to the UN General Assembly Political Declaration on the Prevention and Control of Non- Communicable Diseases (NCDs) . “The regional strategy details what the six (GCC) countries will be doing to tackle NCDs during the next years in terms of reducing people’s exposure to causative risk factors and improving services to prevent and treat these leading health problems”, said Dr. Ahmed Al-Saidi, Omani Minister of Health who chaired the meeting . One month later, MECC together with the Oncology Nursing Society (ONS) and the Omani National Association for Cancer Awareness (NACA) organized the first palliative care course for Omani nurses . As a direct follow up to that course earlier in February this year, the Middle East Cancer Consortium (MECC) jointly with the Oman Cancer Association (OCA), the Oncology Nursing Society (ONS), the National Cancer Institute (NCI) and the American Society of Clinical Oncology (ASCO) organized an advanced training course in palliative care for nurses which was followed by a research day on palliative care in the community and an international workshop on palliative care for the geriatric oncology patient. Over 600 attendees from the following countries took part in these events: USA, Egypt, Jordan, Palestine, Israel, Cyprus, Turkey, Iraq, Pakistan, Morocco, United Arab Emiratis, Saudi Arabia, Lebanon, Qatar, Yemen, Sudan, France and Oman.
Unlike most developed countries, the majority of Middle Eastern cancer patients are diagnosed with advanced stage disease . For these patients, the only realistic treatment option is pain relief and palliative care.
When pain is reduced, so is, at least, some of the distress associated with the illness. In the Middle East, health-care workers are worried that, even they prescribe responsibly, opioid painkillers lend themselves to misuse. However, the comfort of seriously ill patients cannot be sacrificed for fear of it. Though some patients may be beyond hope of cure, they are not beyond care .
Unfortunately pain relief drugs are not widely available, and there are still regulatory and pricing obstacles ; and in most developing countries palliative care is not as yet recognized as an essential component of cancer treatment . A major issue as related to the provision of palliative care throughout the trajectory of a malignant illness is the inadequate training for both healthcare professionals and the general public about its necessity and importance. By and large, palliative care is yet to be valued as an integral part of community and hospital patients care in most Middle Eastern countries.
This year’s training course in palliative care which was a direct continuation of the basic course a year ago, was at a very high professional level and brought the trainees abreast the most modern and updated protocols of cancer care; and especially at the end-of-life stage. In addition to the physical impairments such as pain, nausea, vomiting, constipation, breathing difficulties, great emphasis was given to emotional-psychological issues that accompany the advanced stage of the disease. Also, social and community aspects were dealt along with cultural elements that are important to the Muslim patient. The Omani nurses shared this year’s advanced course with senior nurses from other Middle Eastern countries such as: Saudi Arabia, Egypt, Iraq, Jordan, Palestine, Turkey, Cyprus, Abu Dhabi, Qatar and Pakistan; which provided them with an exceptional opportunity to exchange ideas, impressions and opinions; which brought about new genuine professional relationships.
A brand new topic which was introduced in this year’s program was the Mind-Body Exercises. These were conducted by world experts from the USA, and focused on the promotion of self care among nurses working in palliative care both in hospitals and communities. These exercises taught nurses ways and modes to dissociate themselves from daily stresses and tensions in order to enable them to pursue their tasks despite being in one of the most stressful occupations in the health profession. In many countries, nurses working with cancer patients and their families have to leave their workplace due to burnout and depression. The Mind-Body sessions clearly indicated to the participants that they need to take good care (emotional and physical) for themselves since this has a positive effect on both their professional careers as well as personal life.
The origins of palliative care lie in the areas of spirituality and nursing, rather than medicine, yet it encompasses an enormous stressful impact on the caregivers-especially nurses; and it is the responsibility of the supervisors: head nurses, directors of cancer institutions and others to see to it that their personnel be relieved of their ongoing strains and stresses by arranging regular social events for their entire staff such as parties, joint vacations in nature, cookouts etc. Further, it is also recommended that nurses be recognized and praised from time to time for their efforts and achievements.
A significant cultural barrier to the delivery of palliative care in the region is the fact that the public still considers this kind of care with giving up on life, rather than providing quality of life when suffering terminal illness . Therefore, it became clear that trying to translate therapeutic approaches from Western cultures which are deathdenying societies may be problematic in non-western societies, and particularly non-christian cultures; since many of the assumptions that underlie the approach to suffering and death in the West are cultural, based on values and beliefs of Western Europe .
The course this year devoted time to the educational aspects of new nurses in Oman. With the transformation from Diploma in General Nursing to a Bachelor in Nursing Science, palliative care principals and applications will be initially offered as an elective course in the new curriculum, with the hope that with time it will be incorporated into the core-curriculum in the Omani Faculties of Nursing.
The overall objectives of this year’s course was to identify promising candidates who will in the future serve as the nucleus of local champions who will be responsible for the development and establishment of new palliative care services within hospitals as well as in the communities.
While hospitals are for the most part caring for the acute stage of the disease, community health care professionals care for the chronic stage. This implies different approaches of treatments; yet in both cases, nurses serve as the pivot person for such therapies. Since most cancer patients as well as cardiac, renal or respiratory afflicted patients spend long terms at home, special attention should be given to community nurses, who spend more time than anyone else with patients and their families, and thereby serve as a major link in caring for these patients.
Therefore, nurses caring for people with cancer in the community must be proficient in symptom management and discussions with patients and their families on care management and planning. Moreover, the nurse’s home visit contributes so that the patient and his family do not feel abandoned, as they have developed strong bonds with the community nurse .
However, be it in the hospital or the community qualified nurses will need to attain leadership training in order to enable them to carry out their mission in the most successful fashion. It is for this reason that the Omani Cancer Association together with ONS and MECC will carry out leadership courses for those nurses assigned to responsible positions in the Omani palliative care system.
Modern medicine and health care need a strong research element incorporated into their ongoing schedules. This is paramount in order to secure high professional standards of services. The participants in the advanced palliative care course were offered a research day whereby methodological approaches for nursing research were demonstrated and discussed, along with communication skills.
As mentioned above, the nursing profession in Oman is turning from a vocational into academic discipline. This substantial change will need in the near future a cadre of nurses with advanced academic education i.e., Master and Doctorate degree in Nursing. The Omani palliative care initiative will include this important aspect in its overall program, since those nurses with advanced studies and degrees will form the future leadership of Omani nursing in general and in palliative care in particular.
Cancer, once an enigma, is now the second leading cause of death worldwide, after cardiovascular disease. It is also increasingly on the rise in the developing world, where it is rising at a faster rate than population growth. In the Middle East, in particular, cancer cases will outpace population growth by a rate of almost two to one. It is, therefore, an issue that should be prioritized . Solutions to the current state of affairs are not necessarily implementable to all Middle Eastern countries and the GCC states can lead derivation of population-specific approaches that could have effects throughout the region; and the key challenges are: Human capacity and training . Training of nurses about care of patients at the end of their lives drew attention in many Middle Eastern countries. As already indicated above, most cancer patients reaching the end-of-life stage choose to die in their familiar and comforting home. Therefore, reflection and learning about end-of-life care should be part of ongoing practice through multidisciplinary meetings, joint learning with general practitioners and seeking feedback from patients and carers . In training of nurses on end-of-life care, high priority should be given to the development of devices that improve the quality of life in those with terminal illness. For example, drainage of ascites at home is now possible with a peritoneal catheter system, which enables management of ascites at home rather than needing paracentesis in hospital. The adoption of such devices could enable many more patients to receive palliative care at home, protected from the unnecessary burden of inconvenience of hospitalization . Providing the highest quality of end-of-life care should be a fundamental part of all physicians and nurses’ training and continuing professional development, whether in hospital or in the community.
Ideally, the nurses’ expertise of palliative care and symptom management should be continuously integrated with the tumordirected treatment, as they are part of a larger team including medical and radiation oncologists, family physicians, pediatricians and other health-care personnel. Oncology expertise is also needed in home care situations, thus, community nurses should be acquainted with it .
Since 2005, the Omani Community Health Care Nursing Program has been active in providing family centered and culturally relevant care to patients in the community. In 2012, the Omani Ministry of Health signed a memorandum of understanding with Cardiff University to empower its Community Health Nurses with scientific knowledge and evidence based practice skills by awarding them a Bachelor Degree as a stepping stone to move to a specialist level. The Oman Nursing and Midwifery Council are now developing health care standards of practice for these nurses. The above program is currently in the process of negotiation with the Ministry of Health to be approved as a national service .
In summary, in order to reach the level of mainstream health care in the field of palliative care, regional training initiatives could promote that objective, similar to that that was recently undertaken by the Omani Cancer Association; fully realizing that one model of care does not meet every patient’s needs, as the caring nurse has to take into account the relevant ethical, legal and cultural factors .
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