Received Date: October 08, 2015 Accepted Date: October 31, 2015 Published Date: November 03, 2015
Citation: Al-Zadjali M, Al Sinawi F, Al Touby S, Al Busaidi M, Al Jardani F (2015) Palliative Care Nursing in Oman; Moving towards Palliative Care Nursing. J Palliat Care Med S5:003. doi:10.4172/2165-7386.1000S5003
Copyright: © 2015 Al-Zadjali 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.
Visit for more related articles at Journal of Palliative Care & Medicine
Oman has witnessed great achievements in the past four decades especially in its healthcare services that has been recognized by the World Health Organizations and many other international organizations. These developments and achievements reduced the infant mortality rate and the incidence of communicable diseases in the country. With these changes, Oman has witnessed demographic and epidemiological changes in its structure leading to increased longevity and increased prevalence of non-communicable chronic diseases. This generated the need for palliative care services in the country with a major role that nurses are required to undertake. Palliative care nurses work with individuals and their families who are suffering from a life-threatening illnesses. They work in order to improve the quality of life of these people through prevention and control of suffering; early detection and thorough assessment, diagnosis and management of pain and other problems associated with their illness whether it is physical or psychosocial or spiritual. They provide care at multiple levels including primary, secondary and tertiary health services. They work with an interdisciplinary team in different care settings. This paper will explore the need for palliative care specialist nursing services in Oman. It will discuss the sporadic efforts that have been put in place in order to establish and integrate such service into the current healthcare system. It will recommend and draw a roadmap for paving the way towards an interdisciplinary collaborative palliative care service to be offered in the country for those who need it in different settings.
Palliative care; Palliative care nursing; Health care
Palliative care aims to provide comprehensive care to patients and careers to relief their pain and discomfort [1-5]. The modern hospice move started from 1967 with the opening of St Christopher’s Hospice, London which was found by Dame Cicely Saunders who was originally a nurse, social worker and later became a physician. The advances in medicine in the 20th century carried with it a failure in healthcare system in serving those who could not be cured. Saunders focused on hospice care, pain and symptom management, emotional, psychological and spiritual support as well as providing multidimensional care to those who are terminally ill and their families. This set the foundation for modern hospice and palliative care practice [4,6].
In 1975, the Canadian surgeon Balfour Mount, one of Saunder’s students started using the term “palliative care” in order to avoid the poor reputation of the word “hospice” in his area of practice. Mount found a comprehensive hospital based service at the Royal Victoria Hospital in Montreal. The services were directed towards non-curative therapy for improving quality of life that included inpatient beds, consultation, home visits and bereavement services .
Today, Palliative care is defined as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” .
The Sultanate of Oman is located in the south eastern corner of the Arabian Peninsula. It shares the borders with the Republic of Yemen, Saudi Arabia and United Arab Emirates (U.A.E.). It is about 309,500 km2  and has a population of around four million and approximately 1.89 (44.4%) millions of those are foreigners . The Omani population is considered to be a young population as about 50% of the population is below the age of 21years and merely 6% of the entire population is 60 years or above . The Omani culture is an ethnically diverse culture. People of Oman speak several different languages with Arabic being the main. Islam is the main religion followed in the country and has a great influence on the culture and lifestyle of the people living in the country .
There have been notable changes in the Omani healthcare system in the past four decades. The country has adopted the national healthcare model. All Omanis and the expatriates who work in governmental agencies receive all the healthcare services free of cost. The availability of services and the advancement in medicine created a great success story in Oman. One of the major achievements witnessed was the decline in the infant mortality rate to 9.5/10000 of the population by the year 2012 . In addition, the life expectancy at birth increased to 76.6 years (Male=74.8 and Female=78.5) . Moreover, the crude birth rate of the country is 3.2 per 1000 individuals and the crude death rate is 32.1 per 1000 individual. Taking these data into consideration, it is thought that the Omani population will double in the next 25-30 years increasing the total population to more than 7 million by year 2050 and as the population continue aging, it is expected that almost 13% of the population will be 60 or above by the year 2050 .
With increased longevity, modernization and changes in the lifestyle it is expected that the burden of non-communicable diseases will increase. According to WHO , 68% of the total deaths in Oman are caused by non-communicable diseases. Around 33% of the deaths are caused by cardiovascular diseases; 10% from Diabetes; 10% from cancer; 2% from chronic respiratory diseases and 13% from other noncommunicable diseases [9,10]. The epidemiological changes that are taking place in the country are calling for services that improve the quality of life of those who are living longer and those with terminal illnesses. One of the main areas to focus on is palliative care. In this context, it is necessary to prepare healthcare professionals who can function competently while providing palliative care to their patients.
Nurses are the main workforce that works with patients with terminal illnesses. Based on the definition of palliative care, palliative care nurses are the nurses who work with individuals and their families who are suffering from life-threatening illnesses. They work in order to improve the quality of life of these people through prevention and control of suffering; early detection and thorough assessment, diagnosis and management of pain and other problems associated with their illness whether it is physical or psychosocial or spiritual. Thus, they need to possess certain specific competencies in order for them to meet the goal of the services they provide.
Based on the definition provided by WHO, palliative care nurses function to relief pain and suffering of their patients; they manage symptoms with appropriate use of medications and therapies; they handle death and dying as a normal process and integrate psychological and spiritual support in their patients care plan. They support patients and their families to live a normal life and accept any distressing complication or situation as it comes by using effective communication skills.
They work in collaboration with a team of other healthcare professionals in order to improve the quality of life of their patients. In functioning in these roles, they should possess some competencies that will enable them to function in these roles in wide range of settings successfully. Several societies, associations and organizations have outlined a number of competencies that a nurse should possess when functioning as a palliative care nurse. Almost all these organizations describe similar competencies as the expected outcome is the same. For example the European Association for Palliative Care (EAPC) has mentioned that the main constituents of the competencies that must be demonstrated by any healthcare professional working with palliative care should be autonomy, dignity, relationship between patient and healthcare professionals, quality of life, position towards life and death, communication, public education, multiprofessional approach and grief and bereavement. Similarly, the Canadian hospice palliative care (HPC) standards in addition to the Canadian Nurses Association’s code of ethics, it includes person and family focused care; comfort; coordination and navigation; quality and safety; leadership and person and professional growth .
Likewise, in Australia, the Competency Standards for Specialist Palliative Care Nursing Practice focused mainly on five main interrelated domains on which the framework was built. These standards were: therapeutic relationships; complex supportive care; collaborative practice; leadership and improving practice . Thus, it is thought that the most common core competencies that a palliative care nurse should possess include: therapeutic communication; functioning in a multidisciplinary team using a multi-professional approach; applying various approaches in grief and bereavement while caring for patient and family; ability to use problem solving and critical thinking skills while assessing, treating and evaluating care delivered to the patient using best available knowledge and skills as well as striving for attaining higher levels of continuing professional development.
There are around 15,627 nurses in Oman . Most of these nurses have a Diploma in General Nursing as a Diploma used to be considered the entry level qualification. However, the vision is now changing to consider a Bachelor in Nursing Science as the basic level of entry. Palliative care is usually taught to these nurses in their curriculum as a concept incorporated into the main courses. In addition, the move towards palliative care nursing in Oman started sporadically and very early. However, the care was integrated into the service and was not mentioned as a separate entity until Oman Cancer Association (OCA), the former National Association for Cancer Awareness (NACA), supported by Ministry of Health and some international partners such as Middle Eastern Cancer Consortium (MECC) the Oncology Nursing Society (ONS), the National Cancer Institute (NCI) and the American Society of Clinical Oncology (ASCO) organized the first basic palliative care course for Omani nurses. This was immediately followed by an advanced training course in palliative care for nurses. The advanced course 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 participants attended this conference from more than 20 different countries around the world .
The basic and the advanced course have trained around 90 nurses. Nurses were introduced to palliative care, pain management, End of Life care, challenges in care for the actively dying, assessment and management of common palliative care issues such as gastrointestinal symptoms, respiratory distress, delirium, wound care and psychosocial realm. They were then taken to the advanced level of training where they were introduced to the main components of palliative care and care implications, state of palliative care across the Middle East, pain assessment and management, symptom clusters in palliative care, management of multiple symptoms in advanced illness, psychosocial aspects of palliative care, and care for the caregiver, ethical and culture issues at end of life, and spiritual aspects of palliative care. These nurses were then sent back to their institutions with an appropriate action plan to be implemented in their respective practice. Multidisciplinary teams were formed in their institutions in order to implement the action plan. The trained nurses raised public awareness and organized several continuing education activities in order to train their colleagues in their institutions.
In addition to training these nurses, the Omani Community Health Nurses were playing an active role in providing culturally oriented family centred care for their patients since 2005. This role was further strengthened by Ministry of Health’s Memorandum of Agreement that was signed with Cardiff University in order to prepare Bachelor prepared community health nurses to provide community healthcare to the patient in Oman . Consequently, 68 nurses graduated from this program as of the end of 2015. Part of the curriculum that is taught to these nurses is Palliative Care preparing them to take an active role in promoting the quality of life of patients who needs palliative care in different community settings.
The move towards palliative care did not stop with just preparing the nurses to function as palliative care nurses; it went further to these nurses preparing the other healthcare workers as well as the public for this role. The graduates of BSc (Hons) Community Health Nursing Practice Program at Oman Specialized Nursing Institute, organized a scientific day in the year 2014 focusing on the importance of palliative care, services provided and the role of multidisciplinary team that provides multidimensional, culturally relevant and family centred care to their patients. Over 300 multidisciplinary participants attended this scientific event. The event was followed by 2-days of public awareness program that aimed to raise public awareness of palliative care, chronic diseases, prevention of complication and the role of community health nurses as palliative care nurses. Further, due to the increased prevalence and incidence of chronic diseases and changes in the epidemiological characteristics of the Omani population, the Ministry has now approved the palliative care program resorting it administratively under the Primary healthcare department. In addition, there are 24 more nurses being prepared to function as community health nurses providing palliative care for those patients who need it in different community settings and the efforts to build a strong system of palliative care are going on.
These efforts of moving towards palliative care can go unnoticed if a clear plan and recommendations were not followed when preparing for the move. Thus, it is considered important to focus efforts on four main areas when planning to move towards palliative care. These areas are: education, service, policy and research.
As the world witness a demand for end of life care, nurses need to be prepared educationally at different levels to be able to take part in providing care for the terminally ill at different stages . Bush  suggests that the undergraduate nursing programs should include a course in palliative care taught by skilled palliative care specialists and includes both theoretical and practical components. According to the European Association of Palliative Care , health professionals cannot receive the same level of training. The roles and responsibilities of healthcare professionals towards both the patient and the team might differ, as does the number and type of patients they come in contact with. Medical practitioners also call for a coordinated palliative care model whereby basic and specialist preparation need to be recognized to help address the growing need of palliative care services .
Palliative care education focuses on the art and science of caring for and relieving the suffering of individuals living with serious chronic, life-threatening and life-limiting illnesses. Preparing a health workforce able to address the growing need for palliative care services can be enhanced by introducing basic palliative care education followed by the advanced specialist palliative care education . Core precepts of pain and symptom management, communication skills, and care coordination for patients with serious or life-threatening illnesses are the key components of the basic level educational preparation for these professionals .
The European Association of Palliative Care  recommends many strategies "beyond the lecture" that can enhance the teaching in palliative care and result in enhanced learning by participants. Diverse methods of teaching are also likely to enable the learner to reflect upon their experiences, beliefs, and values that will also facilitate more effective care giving. In Oman, it is recommended that palliative care education be on the national agenda for the efforts to improve nursing education and services provided by these nurses when care for ethnically diverse population in different settings.
Nurse education in oman
As the European Association of Palliative Care  model is a wellknown model that has been utilized for years in Europe and other places, it is recommended that Oman adopts such a model as a general framework for recommendation of palliative care education at different educational levels in Oman. The context of the specificity of each level is mapped across the health professions education vision of Oman.
Level A: Basic (Undergraduate)
All Bachelor in Nursing programs’ curricula should include a competency related to knowledge of Palliative care. In this, the students should be taught the importance of listening, pain and symptom management, therapeutic communication, ethics, bereavement support and psychosocial care.
Level A: Basic (Post-Graduate)
At this level, all courses to include a competency on application of palliative care approach within the specialty areas wherein the students will learn the multidisciplinary nature of pain and the tools used to guide pain assessment, differing modes of administration of medication to relieve symptoms of pain and adjuvant analgesics and associated side effects. They should also be taught proper handling of physical, psychosocial and spiritual needs of the patients in addition to providing culturally sensitive care and emotional guidance to families in their grief.
Level B: Specialist (Post-Graduate)
Targeted towards nurses who work in specialist palliative care services or in general setting but act as a resource person e.g. oncology nurses, community, elderly, etc., where they will explore the core concepts of palliative care including practice standards, symptom management, communication skills, evidence-based practice, noncancer contexts, bereavement care, psychosocial issues and care and support for carers.
At this level, nurses are also challenged to learn advance pharmacology to manage pain and other symptoms. Thus, case application and small group discussion can be valuable in developing plans of care. Another common aspect of post graduate education is discussion of the many ethical issues involved in palliative care. Nurses are sometimes involved in patient-family discussions regarding advanced directives, withdrawal or withholding nutrition or hydration, and many other complex decisions related to the end of life care. They should be prepared in order to function in this role successfully.
Level C: Nurse practitioner (Masters)
Palliative care nurse practitioners are responsible for palliative care units or provide palliative care consultancy, research or education. Their education is directed towards teaching them about goals of care; assessment and alleviation of complex symptoms relating to care of patients and families experiencing serious life-threatening illnesses. Students taking this specialty analyse the impact of such illnesses on patient, family, community and the health care system, through advance care planning; comprehensive assessment; communicating bad news; pain management; managing depression, anxiety, delirium and sudden illness; withdrawing or withholding treatment and medical ineffectiveness. They also learn about the last hours of living; legal issues; psychosocial issues; gaps in palliative care; elements and models of end-of-life care.
In addition, the availability of resources and barriers to care are analysed within the context of various settings. The leadership role of the advanced practice nurse in palliative care is delineated with emphasis on policy development, protocols, and standards of practice, fiscal management, research utilization, quality improvement, patient advocacy, ethics, social-cultural issues and the role of the nurse leader in the interdisciplinary team. Students participate in professional team meetings, family meetings and patient support groups.
Although training nurses has come a long way in Oman; there is no comprehensive sustainable training for nurses to take the role of a palliative care nurse in Oman. There is a clear need for a comprehensive in-service training program that includes symptoms management especially pain management, psychosocial care, communication, complex decision making and end of life care. Once nurses are prepared for taking this role, there should be a program that raises public awareness regarding palliative care. The Omani healthcare system, like any other systems, should overcome the dichotomy of cure/care and make the palliative care dedicated to promoting quality of life. The misconception that palliative care is only provided at the time of death or dying should be dealt with wisely as palliative care belongs throughout the continuum of care. Palliative care should be started as early as the time of diagnosis of any kind of life threatening diseases. This will enable better coping and quality of life. In addition, there is a need for integrating multidimensional assessment for providing holistic, patient and family centred comprehensive health services. In doing so, using a multidisciplinary approach is recommended.
One of the main dimensions that need to be focused on in order to initiate an organized palliative care system is focusing on policies. In order to have a sustainable palliative care system, palliative care should be integrated into the routine practices in caring for all patients with chronic life threatening diseases. Resources necessary for such a change in the system must be allocated including human resources. In addition, clear policies and guidelines to define the role of a palliative care nurse and the standards of practice must be developed. In order to make the system more organized, a cost effective service model that is readily available to patients in different settings and that is culturally oriented and suites the healthcare system of the country must be employed. To reach to a better state of the art palliative care system, it is advised to develop partnership and benchmarking with national and international institutions for coordinating palliative care efforts.
The advancement and development of any specialty is dependent on a great extent on the quantity and quality of research that expands on the body of knowledge. Similarly, palliative care requires to be put as one of the areas of health research priorities in the Ministry of Health to advance its practice. Multidisciplinary collaborative studies in palliative care should be encouraged. There is a strong need for funding research areas that are related to palliative care such as pain management, service evaluation and impact or outcome of service or training as well as culturally sensitive care provided. In order to support researchers in conducting research in this filed, the system should encourage them to find new sources of funding such as involving pharmaceutical or insurance companies to fund researches related to palliative care. This will not only promote research but will advance the field of palliative care practice in the country.
In conclusion, Oman like any other country is moving towards modernization. Advances in science and modernization affected the way people live, the way they get sick and the way their life ends. In all these situations, what is thought to be important is to maintain a high quality of life. To do so, the new roadmap points towards palliative care nursing.
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals