Recommendations for palliative care training in Jordan were first proposed in an unpublished report on assessing need for palliative care for cancer patients in Jordan completed in 1986, by two UK nurses from the charity Macmillan Cancer Relief.³⁵ In 1992, concerned health professionals began actively to develop the concept of palliative care services and training in Jordan. Most Jordanian healthcare professionals, who had completed post graduate education in the USA or UK, were already aware of the concepts of palliation and end of life care. In 1993 the Al Malath Foundation was established, not only to set up the first home hospice service, but also with a commitment to education for people in the community and for healthcare professionals within Jordan.³⁶

Al Malath Foundation

The Al Malath Foundation is committed to both public and professional education. Director of Al Malath, Rana Hammad explains:

‘We serve the community in three ways: patient care is one way, education and training is the other channel we work at. I went round the country for courses, presentations, panel discussions, from sophisticated conferences down to sitting with lay women on the floor and talking about sadness and grief, and the wisdom of God, for example. Two structured courses at the University for: medical students, nursing students, social workers. The third area is support groups and supporting the care givers in the hospitals. They should be empowered. They should be trained on grief, loss, spiritualities, emotional well-being, understanding, empathy, communication, knowing the value of the work.

We got a hospice social worker who was a volunteer through the American Peace Corps. She stayed with us for two years, and the first year she got to understand the culture and the needs of the patient, the second year with us we together developed a manual, and she trained the nurses. They trained each other. So they interacted in a way which she knows the needs of those patients and they know the culture. Eventually people will get to know what palliative care is, it is not about skills because it’s there, we can study and we can learn those skills, we can learn how to calculate, we can learn how to assess, but it’s about attitude. So the majority of my training programs are about shaping the attitudes, empowering them, make them understand the value of this work; and then when it comes to knowledge, it’s there.

I have a one-day program, and I have two-day program for pain management, and I have a two-week program that I develop for the Ministry of Health; and I have some tailored programs, it depends on the needs, for example, the social workers when they come and they want to talk about the social-psychological emotional aspects of cancer care.’³⁷

World Health Organisation (WHO)

The World Health Organisation has been actively involved in supporting the development of services and promoting education and training at Al Basheer Hospital and at KHCC. In June 2004, Dr Jan Stjernsw ä rd of WHO announced:

‘All medical and nursing schools are committed to introducing palliative care into their undergraduate education and six palliative care courses, supported by an international faculty and bedside practice, are budgeted for over the coming three years.’

In March 2004 an introductory training course in Amman ran with 32 participants (9 physicians and 23 nurses). In March 2005 introductory and advanced courses ran with 70 participants - physicians, nurses and pharmacists, (including 2 Iraqi doctors), of which 22 participants had returned to completed the advanced course. The advanced group had some class based training instruction and also did interactive bedside work in small groups discussing cases at 2 clinical sites, KHCC and Al Basheer Hospital; seeing a large number of patients, initially practising assessments. In Autumn 2005 the course following the training model ‘Education on Palliative and End of Life Care ‘EPEC’ (Train the Trainers)’ ran in collaboration with colleagues from San Diego Hospice and the Hospice of the National Capital Region, USA, and Dr Stjernswärd.³⁸

An important aspect of the training was addressing health professionals’ opioid phobia, by the trainers teaching physicians how to write an opioid prescription, and then witnessing patients improving and wanting to go home. It was shown to be vital to train the pharmacists on attending the course. For example, Al Basheer pharmacists initially were horrified at the dosages proposed until the improvements in patients’ pain and well being was demonstrated. The training includes sessions on specific symptom management, how to disclose prognosis, how to avoid burnout and about other symptom management e.g. dyspnoea, and withholding fluids and nutrition. The training hospitals and trainers have worked with the religious leaders, who have announced a new fatwa allowing the prescribing of opioids and the appropriate withholding of fluids and nutrition.

King Hussein Cancer Centre (KHCC)

In 2003, the Ministry of Health, supported by the WHO and with members of KHCC and other hospitals, formed an education committee. Since 2004 the committee has aims of the committee has been to establish a palliative care education and training programme for interested health professionals and training for medical and nursing students.

The director of nurse training at KHCC and chairperson of the KHCC training committee, Ahmad Al Khateib explains that KHCC was designated to be the training center for palliative care and pain relief in Jordan, and later on to be a regional training centre. KHCC has been chosen because it is a pioneer hospital in the region offering palliative care services and has the facilities and resources to develop these services. KHCC is supported by the World Health Organisation (WHO), which have donated funds to cover courses twice a year.³⁹ Ahmad Al Khateib explains how the courses (and educational plans) are expanding and attracting participants from different institutions in Jordan and other health professionals from neighbouring countries:

‘Now we have the second palliative care training program, conducted in our centre; one introductory course for three weeks, and we have around 50 people now on this course who are physicians, pharmacists and nurses, from different institutions [ in Jordan]. We have physicians coming from Iraq and the plan is to have physicians from Syria, from Palestine. We have five international faculty members here at this moment conducting the second part of training course, and the same time an advanced training course. We are going to have at least three day workshop starting in March (2006), designed to provide some sort of education for the faculty; the teachers from school of medicine, school of nursing ... helping them to orient about the concept of palliative care and helping them to integrate the concept of palliative care and pain relief in the undergraduate curriculum for school of medicine and school of nursing'.

Ahmad echoes the WHO observation that one major difficulty in developing the palliative care is that there is:

‘sensitivity of physicians towards prescribing narcotics … I think that we need to educate the health care providers and to try to change their perception about palliative care and morphine and to understand palliative care.’⁴⁰

As part of the development of the training programmes, Dr Amal Bandak, director of the KHCC hospice team and her colleagues, have compiled a draft manual and guide for training and hospice team development.⁴¹

Since 2004, with the help of Carol El Jabari, director of the NGO Patient’s Friends Society based in Jerusalem, education in the community has been developed by establishing a self-help group for women with breast cancer, which provides regular training sessions in preventative and supportive care. There are now around 13 women regularly attending the group.⁴²