Providing end-of-life care in a hospital is challenging, because hospital care is typically focused on prolonging life. Several studies have described the unmet needs of patients dying in hospitals, such as poor symptom control and insufficient communication [1–6]. Gaps in end-of-life care have been identified, e.g. the lack of awareness of approaching death, and shortcomings in healthcare professionals’ knowledge of and skills in palliative care [1–8]. To date research on end-of-life care in hospitals has been mainly descriptive, focusing on the characteristics of care, identifying problems and suggesting possibilities for improvement. In a literature review, Al-Qurainy et al. (2009) proposed improvement strategies: integration of palliative care services in the hospital to enhance caregivers’ attention for the transition of treatment goals; increase of palliative care knowledge among healthcare professionals; and improvement of prognostication, advanced care planning and communication . However, experimental studies on quality improvement interventions in end-of-life care in the hospital are scarce, partly due to methodological challenges in health services research in general and in the field of palliative care in particular. Many results of studies on quality improvement interventions are thus affected by concerns about the validity and reliability of data, due to e.g. limitations of the design, selection bias, inaccurate measurements and confounding [7, 10–14]. To evaluate the effects of changes in palliative care structures and processes on patient outcomes, innovative experimental research is needed [7, 15–21].
In the Netherlands most in-hospital deaths occur on wards that lack specific palliative care expertise. Innovations to improve the quality of end-of-life care in the hospital have to be disseminated to all these wards and to be integrated in the whole hospital care system . This process of quality improvement seems to be comparable to innovations in other fields of hospital health care, such as infection prevention, and tissue and wound care. To address these problems, networks of specialized nurses, such as infection control link nurses have been implemented in many hospitals. Only few studies have evaluated the effects of these link nurses’ networks, but the results were promising [22–26]. Some work has been done on networks of palliative care nurse champions in the UK, and evaluations indicated that champions’ self reported knowledge on palliative care, and confidence in collaborative working had increased [27–30]. In the Netherlands a few hospitals have recently started such a network. The empowerment of hospital nurses in being an ambassador of palliative and end-of-life care and in the dissemination of palliative care knowledge and skills could contribute to the quality of care of patients dying in the hospital [31–33]. This implies the translation of knowledge and skills from palliative care experts via the network of nurse champions to the wards. The translation of knowledge is a complex process, partly because various types of knowledge (e.g. explicit and tacit) are involved, and it has to be received by various persons in various contexts. Therefore such translation requires various teaching skills . Transfer of theoretical knowledge by experts to ward nurses easily conflicts with nurses’ daily practice; nurses may decide that it is irrelevant, or that implementation is impossible [35, 36]. A network of ward based nurse champions, as intermediates between palliative care experts and ward nurses, is expected to improve the results of education. Nurse champions are probably more dedicated to palliative care than other nurses and have more insight in the culture and processes on their wards than the experts. It is thus probably easier to adapt the educational programme to prior knowledge, beliefs, attitudes, and educational needs of the champions than of all nurses on all the wards, and the content of the programme will easier be experienced as meaningful when champions can connect it to the context in which they work [34, 37].
Education and training of health care professionals will only be successful when it leads to improved practice and decision making [38, 39]. In palliative care this means timely identification of patients in need of palliative and end-of life care, timely referral to palliative care experts, collaboration between patients, family and the medical team, the use of guidelines and appropriate working procedures, and knowledge of palliative care and symptom management on the clinical wards [8, 40–43]. Being a resource and role model for their colleagues, nurse champions can contribute to improved quality of palliative care, when they have sufficient clinical experience, improved knowledge of palliative care, improved teaching capacities, and acquired authority towards managers and colleagues. [25, 28]. Still, rigorous evaluation of the effects of nurse champions on the outcome of care is necessary. In this article we describe the study protocol of the PalTeC-H project: a study on understanding and improving Palliative and Terminal Care in the Hospital by implementing a palliative care network of nurse champions.