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The 1960’s represented a period of tremendous social change in the United States. Both federal and state governments developed and implemented social welfare programs designed to meet the needs of Americans of all ages, including the aging population. Nursing homes were constructed across the country to provide housing and care for the growing numbers of aging individuals with increasing medical needs who could no longer maintain themselves independently in the community.

The 1970’s witnessed exciting medical and psychological research which attempted to explain the increasing incidence of cognitive decline among the aging demographic segment. Technological advances made more precise research possible. Research revealed that many forms of cognitive decline are age-related and add to the physical and psychological decline of those afflicted. In more recent years, the word “dementia” became the umbrella term that describes cognitive and memory disorders which result in eventual death. Dramatically increasing numbers of individuals suffering with dementia became residents of nursing homes.

The 70’s also saw the birth of a new philosophy of care for the terminally ill called hospice. Hospice, in providing compassionate comfort care for those at the end of life, challenged concepts of aggressive care based in the medical model found in hospitals and other health care facilities. After an initially difficult period, hospice care has now been successfully integrated into the care offered in many nursing homes.

The 1990’s were the years in which the concept of palliative care grew out of the philosophy of hospice. Originally developed to provide care for persons suffering from terminal diseases like cancer, hospice is less able to address the care needs of those afflicted with the more enduring, yet terminal, dementias. In more recent years, palliative care has been identified as an excellent approach to providing long term, non-aggressive, compassionate, comfort care for dementia sufferers, including those who reside in nursing homes. The challenge currently facing the nursing home community is learning how to implement palliative care programs in their individual facilities.

In the early 2000’s, research conducted by Schervier Nursing Care Center (SNCC) revealed that there were deficiencies in knowledge of palliative care among nursing home administrators, management and staff and that these deficiencies were impeding the development of palliative care programs in many nursing homes. In 2006, the newly created Schervier Center for Research in Geriatric Care, a part of SNCC, created a Consortium with four other nursing homes and applied to the New York State Department of Health - Dementia Grants Program (NYS DOH) for funding to correct these deficiencies and help bring about the creation of viable palliative care programs in nursing homes throughout New York State. The Consortium members include: Andrus-on-Hudson Nursing Care Center in Hastings-on-Hudson; Cabrini Center for Nursing and Rehabilitation in Manhattan; Kings Harbor Multicare Center and Morningside House Nursing Home, both in the Bronx.

NYS DOH agreed to fund a program of research and education, the goals of which included: 1) development and implementation of palliative care assessment tools; 2) strengthening the palliative care programs within the consortium nursing homes and eventually throughout New York State; 3) development of educational curricula to address identified needs for palliative care education for nursing home staff; and 4) delivery of these educational materials through in-service presentations for administrators, management and staff of the Consortium member facilities. Subsequent to this work, curricula were reviewed and revised using feedback received from 2,616 participants in 215 in-service presentations, and compiled into a Training and Resource Manual, copies of which have been distributed to every nursing home throughout New York State. The Consortium will complete its work in May, 2008, but will remain a resource for anyone needing information or assistance regarding palliative care. Publication of a scholarly article describing this work is pending.

This Training and Resource Manual represents the realization of the Consortium’s work. Initial analysis of evaluation data indicates that participants found the curricula to be relevant, and their level of knowledge on material presented improved significantly.

The goal of the training program found in this Training and Resource Manual is to provide education materials regarding palliative care for nursing home administrators, management, trainers and staff. The materials are presented in a ready-to-use, easily accessible, compact form. The Manual is divided into seven training modules:

● Understanding Dementia

● Palliative Care

● Culture, Spirituality and Religion

● Advance Directives

● Pain and Pain Management

● Teamwork and Care Planning

● Creative Approaches

Following completion of individual training modules, participants will complete a Post-Test, the results of which will assist administrators and management of the individual nursing home to determine if the education goals of the module have been met. At the discretion of the individual nursing home, a Reaction Survey may also be provided to participants so they can rate the course content, methods of instruction, the presenter and the learning environment.

The training program is designed as seven modules, the titles of which are shown above. The length of each module varies, depending on the topic addressed. Although not required, it is suggested that the modules be presented in the order provided, because some modules build on knowledge gained from earlier modules. Two of the modules, namely “Pain and Pain Management” and “Creative Approaches to Dealing with Dementia” have such density of material that it is advisable to present each of them in two parts, each of which would be approximately one hour in length. Of course, for nursing homes with well developed palliative care programs, individual modules may be presented as discrete entities for the enrichment of previously educated staff. These facilities may also choose to excerpt specific portions of modules to fill in knowledge gaps depending on the background and competence of the participant group.

Because much of the information is didactic, that is, presented in lecture format, participants may be seated at tables in small groups or seated in a classroom configuration.

Interaction and participation between/among the trainer and individual/all participants is encouraged primarily through a dialogue structure, and “brainstorming” is the primary exercise format used. Participants are continually asked to respond to questions that require reasoning, experience-based knowledge, and personal opinion. Several large group exercises are included to reinforce new material presented.

Within each training module, information is divided into segments containing specific information. Each segment begins with one or more objectives to be met, followed by the methodology to be used to reach the objective(s), and materials and equipment needed for that segment.

Estimated time is shown for each module. Time needed for each module will vary, depending on the size of the group and the amount of participation. Based on time constraints encountered in some Consortium facilities, some modules presented in this manual were modified by a particular facility for presentation in as little as 45 minutes. In other facilities, where ample time existed for training, participant involvement in dialogue has resulted in presentations taking longer than times suggested.

The Trainer’s Manual is the primary component of each modular curriculum. In addition, there are several auxiliary components. The main auxiliary component of each module is the Participant Handbook, which is comprised of:

The methodology section of the Trainer’s Manual illustrates the manner in which the PowerPoint presentation and the Appendix materials would be interwoven in the curriculum delivery to maximize participation and understanding. The methodology section is arranged in bulleted lists to facilitate this integration.

Although PowerPoint projection provides excellent graphic support, hard copies of the PowerPoint presentation should be provided by nursing home trainers to their own staff members if LCD projectors and laptop computers are not available at the individual nursing home.

The Participant Handbook is designed to encourage learning during in-service trainings and also to be used as a reference by participants following the trainings.

Transparencies for use with overhead projectors may be made from the PowerPoint presentation which is included on the CD that accompanies the Training and Resource Manual and which is discussed below.

In addition to all hard-copy materials provided in the Training and Resource Manual, the above referenced CD contains the entire contents of the Training and Resource Manual in electronic form. The CD can be used to provide:

Hard copies and electronic versions of the Post-Test and Reaction Survey are also included as auxiliary components and should be completed by participants in order to evaluate the effectiveness of the trainings.

It is important for trainers to thoroughly familiarize themselves with the Trainer’s Manual and the Participant Handbook prior to delivery of the trainings in order to utilize them effectively.