In this episode of the Care to Learn Podcast, we sit down with Steve Pitman, an incredibly experienced palliative care nurse. Steve speaks beautifully about his guiding nursing and education principles, emphasising the importance of understanding the unique context of each individual for whom we care…

Podcast Transcript

Wayne: From Ausmed Education, hello and welcome to episode eight of the Care to Learn Podcast series. I’m Wayne Woff and each month I sit down with interesting and influential professionals working within healthcare and education.

In this episode we’re extremely excited to be sitting down with Steve Pitman, a Nurse Practitioner Candidate with the East Hume Region Palliative Care Service. Steve is an incredibly experienced nurse and he speaks beautifully about why we must work to provide contextualised and individualised care, particularly in the palliative care setting.

In today’s episode we’ll discuss how mentorship can be used to enhance the translation of new knowledge into practice; the importance of soft skills within palliative care; the critical role of education and support of clients and families; and finally, why it’s essential to better incorporate care workers into care planning discussions for clients.

So, let’s get into it.

Welcome, everybody, to today’s episode of the Care to Learn Podcast. It’s great to have Steve Pitman here with us today, welcome to you Steve.

Steve: Thank you very much.

Wayne: We’ll kick off today as we traditionally do by letting you tell the audience a little bit about yourself – your personal and professional background, your journey – just to kick us off today.

Steve: Sure, so, I came into nursing quite late – in my late twenties. I was your typical twenty-something year old bloke going from job to job, not knowing what to do career-wise. I actually went into palliative care volunteer training and I enjoyed that so much that I thought, ‘oh yeah this could be interesting’. So, I went into nursing with a palliative care bent right from the very start. I’ve always had a passion for palliative care.

I did my nursing and then a graduate year, and then went straight into working for a community specialist palliative care team. And then I transitioned into clinical nurse speciality and clinical nurse consultancy. A very strong component of that was education in terms of supporting primary health care providers who provide palliative care.

Wayne: We’ve got that similarity in that I started my nursing career a little bit earlier than yours, but I very quickly established that I wanted to work in aged care. So, it was very much for me, similarly to you, that you found a clinical area that you were passionate about and wanted to do.

You touched on education there, Steve, your passion for education and interest in education has been a thread throughout your career since commencement?

Steve: Yes absolutely, and I think it’s in the nature of how palliative care is set up in the sense that that majority of the palliative care is actually done by the primary health care providers. So, as specialist providers, sometimes we’re a bit of a blow-in – we come in and put in our two bobs worth in terms of complex symptom issues or complex cases and even complex ethical issues. We’re quite often working with the primary health care providers in that space which almost lends itself to mentoring and education and so forth. It seems to be almost a natural extension of that speciality role.

Wayne: And in teaching about palliative care what would you consider to be your key pillars or foundation principles that you work off?

Steve: I think in terms of education the thing that I’m becoming increasingly passionate about is the mentorship. There’s only so much you can actually do in terms of presentation of clinical expertise. It’s about the application of those clinical skills that’s where the rubber hits the road.

The nature of my education is that we’re talking about terminal conditions all the time, but one terminal condition we don’t often talk about is death by PowerPoint. So, trying to avoid that and trying to get people into a reflective and a contemplative space where they can really start to think about the application of that knowledge in their day-to-day work, that for me is where I try and put the emphasis in my education.

Wayne: It’s something we’ve discussed before in these podcasts – it’s not just about knowledge, it’s not just about information, it’s about the ability to translate and apply.

The other thing I wanted to touch on was the balance between what we might call the ‘soft skills’ – of communication, negotiation, mediation – in that palliative care space, and the clinical skills. Do you think that it’s important that both of those are addressed with providers and individual staff?

Steve: Absolutely. We did a research project in New South Wales around an online learning package for palliative care – we did pre and post-tests on knowledge and confidence, and then followed them up six months later. What we found was that there was definitely a measurable increase in confidence and knowledge pre- and post-test.

Six months down the track they still retained the knowledge, but we couldn’t say the same thing about confidence. So, we can have the content, but what we need is the application as well.

At the workshop today, I’m going to quote one of your facilitators, she was quoting Oscar Wilde and she said, ‘the job of education is not to fill the pail, it’s to light the fire underneath it’. So, it’s really about developing that capacity to enable people to apply the knowledge.

Wayne: And just digging a little bit further into that space of what is often referred to as the soft skills, the one I want to pick up on in our discussion today is that of listening. How important would you consider that to be in the space of palliative care?

Steve: Absolutely, it’s one of the most necessary skills – the ability to sit down and shut up. It’s that quote of, ‘we’ve got two ears and one mouth for a very good reason’.

It’s recognising that in healthcare there definitely is a power imbalance there, between clinician and patient and family. The ability for patients and family to set their own agenda is so important. We’re going into homes and asking about their pain, their bowels and all this sort of stuff and it might not actually be the most pertinent thing they’re concerned about.

Wayne: It’s that ability to constantly remind yourself of the individual circumstance that presents with each and every person isn’t it?

Steve: Absolutely. Every situation is contextual, and it is consideration of each individual and their family care givers as well.

Wayne: I think here on our podcast we might change the word individualised with context. And context which clearly takes in the individual person – the client, the patient, whatever tag we’re going to use. What surrounds that person; whether they’re isolated; whether they’re in a rural setting, a metropolitan setting; the number of active family members. All of those things build up that context don’t they?

Steve: Absolutely. We had a physician by the name of Eric Cassell who has written a book called The Nature of Suffering, and I saw him speak at a palliative care conference. He gave an example of a 74-year old presenting to the emergency department with pneumonia, and his question was: what caused that patient’s pneumonia? Of course the standard accident and emergency answer is bacteria. So, what do we do? Sputum cultures, chest x-rays, put him on antibiotics, retrieve them and send them home.

Then [Cassell] took it to the next step and said, ‘what if I told you he had rheumatoid arthritis in his knees and he lives in a two-storey flat? What caused his pneumonia?’ Is it access to nutrition? Is he sitting in a recliner chair with a simple cold, and he’s not able to mobilise to it develops into pneumonia? Is he socialising – is he going down to the local bowls club like he used to?

Then [Cassell] takes it one step further and he says, ‘what if I told you that his wife died a year ago? What caused his pneumonia?’ Is it loss and grief? Is it depression? Is it social isolation?

We treat disease very well. We don’t necessarily treat people very well, I don’t think. Contextual and individualised are very important in palliative care.

Wayne: As you say, it’s hugely important in palliative care because you are, without overselling it, talking about a person’s life as opposed to a young, fit individual with a fractured leg. The context around that, and the complexity is a lot less. We need to recognise that every day we’re in palliative care, the multi-layered nature of the work that we do.

In terms of information, education and then translation to practice – what do you see as some of the barriers to that translation to practice of information that is clearly out there in a lot of different forms?

Steve: Going back to that Oscar Wilde quote, I think we’re very good at filling the pail. But lighting the fire underneath is a completely different ballgame. I think where the gap lies is in that mentorship.

The early proponents of evidence-based medicine said that it was so much richer than just the research-based evidence. Of course, the research is our major pillar in terms of evidence-base, but they also postulated that it was the individual patient’s circumstances, as you rightly said. They also said that it was the clinician’s wisdom too. They talk about it in medicine in terms of clinical decision-making and so forth, and in nursing we talk about it as nursing intuition.

Interestingly, the Ancient Greeks used to have a very similar division of knowledge. The used to talk about episteme, which was the root word for epistemology. That was the research component. They talked about techne which was the knowledge that enabled the craftsmen to craft their pots and so forth. Then they had this word, phronesis, which literally translates as practical wisdom. Practical wisdom aligns itself well with that nursing intuition.

So, what did the Ancient Greeks say about that? They said that the components of phronesis are: hindsight. So, reflective practice and being able to look back on our clinical experiences and allowing that to inform us into our future. Foresight - anticipatory care planning for palliative care patients, for example. Making sure that they’ve got their alternative sub-cutaneous medications ready to go when they’re approaching the end of life, instead of it being three o’clock on a Saturday night with no access to a GP. We talk about compassionate care and really investing yourself in a person’s suffering and circumstances. Eloquence and being able to articulate our clinical case – when we’re advocating with a GP for adequate pharmacology for someone who is approaching end of life, let’s do it in a way that is eloquent so that we can really develop our clinical case. Prudence was the other component of practical wisdom – getting away from the binary yes or no. We’re working with people, so the palette is much richer than just the black and white.

Wayne: For our listeners, I think that’s a terrific summation in terms of the shades and the colour palette as you referred to it as. You couldn’t find a clinical speciality, in my mind, that needs it more than palliative care and I think you’ve painted a terrific picture there.

I’ll just pick up on one thing that you touched on lightly: professional missteps or mistakes. From an educational point of view how important is it to look and analyse those things? You touched on it with the word ‘hindsight’ and what we can learn from previous situations. From an educational point of view, do you think it’s incredibly important that we’re willing to be honest and say, ‘we didn’t do this well, we need to do better next time and we need to learn’?

Steve: Absolutely. I touched on death by PowerPoint as a terminal condition, and the other terminal condition that we haven’t spoken about it expertosis. If I get to a situation where I believe I know everything there is to know about palliative care, it’s time to resign.

I think it’s that thing of, when you’re in a workshop or seminar situation, it’s about appreciating that everyone brings their own wisdom to the table. Enabling people within that workshop space to be able to be self-reflective and bring some of those experiences to the table is really important.

I’m open and honest about some of the mistakes I’ve made as well. What I try to do is fragment my presentations between the theoretical and the reflective, breaking things up with case studies and case scenarios. Then giving people the opportunity to drop the theoretical and be able to reflect in groups as well. It is about being open and honest about our clinical experiences.

The lady who mentored me in palliative care, in my first week one of the first things she said to me was, ‘it’s okay Steven, we bury our mistakes in palliative care’.

Wayne: Indeed, indeed. The final discussion point I had down today was around the education of clients and families, and support for them. Firstly, just to get your take on the need for that, and secondly what we’re doing in regard to the education of professionals on their ability to educate and support families.

Steve: Who does palliative care? As nurses, we’re actually going in to people’s lives for a very brief moment in time. In the community setting we’re going into the house for one hour a day at the most. At the end of the day it’s the family care-givers who are providing the palliative care. So, the education of family is absolutely essential.

It comes back to being able to appreciate context – to be able to sit down with family and appreciate where they’re coming from and where their complexity lies.

Wayne: And you raise a great point that in a community setting, in somebody’s home, they are doing a hell of a lot of that hands-on palliative care work. My background and experience is mainly in residential care where you can get the reverse scenario – families feel hesitant about getting involved in some of the practical aspects. I was always of a mind to encourage and facilitate that so that they didn’t completely detach from the process; and again, you’d need to craft that according to family situations.

It’s quite a difference between the two settings, whether it be in-home or residential?

Steve: Yes, I’d agree. In-patient hospital as well. The example I’d like to give there is that there was a 104-year old who was in an intensive care unit in renal failure – so, she’s dying – and the daughters were jumping up and down and saying, ‘do anything you can. Can’t you dialyse her?’ Interestingly the treating physician asked the daughters, ‘when was your last experience of somebody dying in your family?’ And they said, ‘1956, when our father died’.

As health professionals sometimes we have a lack of appreciation for the fact that this is the first time for many people they will have actually seen somebody die. Being able to be brave and talk people through the dying process – what does your dying look like? – I think that’s a very important part of the family and care giver education as well.

Even the patient. Sometimes I’ll sit down with the patient and I’ll say, ‘do you want to know what the last few weeks of your life are going to look like?’ And if they want to go there, the most important thing that I’ve done there is to actually ask permission. If they give me permission, and I lay the cards down on the table about what their dying process might look like, you’ll quite often just see the relief because it takes away some of that uncertainty and that fear of what dying looks like.

Wayne: I think it’s a fabulous point you make about asking family members when the last time they experienced, within close friends or family, a death. The answer that you gave in that anecdote would have absolutely floored me, and I’ll certainly add it to my list for future reference if I ever find myself in that situation again.

To the second part of the question looking at educating and supporting families, what’s your take on the need to educate professionals about that space and how would you approach it?

Steve: I’ve heard some people say, ‘it’s not really my role to have those difficult conversations’. But, you raise the example of the PCA in residential aged care, for instance. When they’re showering a resident with COPD who’s got refractory dyspnoea and they say, ‘I’d rather be dead now than have to go through this suffering’. We’ve got to empower our carers to be able to deal with those sorts of difficult conversations too. No matter what discipline or what sort of experience or background you come from, you are going to be privy to some of those really intimate conversations, I think. It’s empowering people with, we said it earlier, that permission to just stop, sit down and listen. You, as the clinician, are medicine, and empowering people to be the medicine in that situation is really important.

Coming into that is also self-care and recognising that when we witness suffering, we suffer as well. Being able to look after self in that situation is an important part of that mentoring process as well.

Wayne: And I think you make a hugely important point that I’m passionate about, with the growth of the group of staff who look after particularly older people – personal care workers, assistants in nursing, whatever title they have. We have to remember the importance of the education for them in moments like that. We tend to educate senior clinicians very well, but [PCAs/AINs] have a hugely important role to play and have a right to have the support and the information they’ll need. They can get the most difficult questions because they’re doing the most direct care and the most intimate care – the showering, assisting with meals, pressure care and whatever else. They need that empowerment, so it’s great to hear you mention that.

Steve: It’s also recognising the role that they play in terms of, say, physical assessment too.

I was in a situation where one of our senior nurses was talking to the aged care facility manager about somebody’s pain for about 20 minutes, and then it was decided that we go and see the resident. I said, ‘no, stop. Wait. Let’s talk to the PCA. The PCA has been doing the bed mobilisation, the showering, they’ve actually witnessed the pain and witnessed what they’re like during those vulnerable moments. We need to tap into that source of wisdom.’

Wayne: Your point there about tapping into all the resources we have, and sometimes we just flat-out forget that. I’ve heard stories of people documenting in aged care where the reference point is one or two people in terms of what are the care needs, how are they presenting, what’s the background, mobilisation etc. And often they can miss the people who know the most. You raise that beautifully.

Now, traditionally we’ve got three questions that we close with. The first question is, what’s one thing you’ve learnt in the past month that has really stuck with you personally?

Steve: In the last month? That’s going to be a tough one. Go to the second question and I’ll come back to that one.

Wayne: What’s your favourite personal learning tip?

Steve: For learning, it’s the phone-a-friend. If I stop phoning friends, I stop learning.

Again, the lady who mentored me through palliative care, she’d been working in palliative care for over 12 years before I started, and she used to ring me up and say, ‘what do you think about this, Steven?’ And I thought, ‘what are you asking me for? You know this much better than I do.’

She was doing two things: one was, she was mentoring by stealth and getting me up to speed by asking my opinion. And the other, she taught me a very valuable lesson: always bounce things off of colleagues.

Nothing replaces that multidisciplinary engagement and collegial engagement in terms of complex clinical situations. I’ll always see something that you don’t. Learning is about that collegial support, and that engagement in a considered way, I think.

Wayne: And you may have already leapt to the answer of the third and final question: what’s the best piece of advice that you’ve ever received about continuous learning?

Steve: It’s that engagement of that practical wisdom – the phronesis. It’s being able to engage the application of knowledge in the moment. Even in a workshop situation, you can still achieve that to a certain degree. Can you teach practical wisdom? I don’t think you can, but you can learn it. You can also provide situations through which people can start on that reflective journey.

A really good example would be in the communication module that I do in palliative care, the very first image I show is the People’s Choice Award for the Archibald Prize of 2012, which is a self-portrait by an artist by the name of Jenny Sages. It’s a portrait of her in a grief situation after she’d lost her husband 12 months prior. The look on this woman’s face is just incredible.

I put that up and I say, ‘what do you want to do?’ You’ll get this plethora of different answers: I want to give her a hug; I want to give her a cup of tea; I want to leave her alone; I just want to sit beside her. So, it gives us an opportunity to then start reflecting as a group about what is useful to say in that situation. This woman has just lost her husband of 40-plus years. This is a loss that she’s never going to get over. For us to look for the platitudes, they’re not particularly helpful.

That reflective practice journey where you can start getting people to think about how they would deal with situations in the moment, you can achieve that in a seminar/workshop context I think.

Wayne: Wonderful. So, what’s one thing you’ve learnt in the past month that has stuck with you?

Steve: I’m going to quote your facilitator again, I think that’s a great quote. With education, it’s not our task to fill the pail, it’s to light the fire underneath. When she said that today I thought, ‘that’s it’.

Wayne: Perfect close to our discussion today, Steven. Once again thanks for joining us on our Care to Learn Podcast, it’s been terrific to have you here and have a great conversation.

Steve: It’s a pleasure, thank you so much.