Palliative care education and training is provided at different levels by numerous organisations that include UCT, HPCA and individual hospices.

Importantly, the palliative medicine courses at UCT have become an accessible alternative to courses offered by universities outside of South Africa. Pioneered by Liz Gwyther, who became the first physician in South Africa to be trained in palliative medicine, she explains how the course became established:

Out of the palliative medicine course that Ilora Finlay and Fiona Rawlinson were running [at the University of Wales], I started looking at the possibility of teaching it here in South Africa, because it was really very expensive to do it in the UK. Apart from the travel, the tuition fees were way above what we pay at our medical schools. So we looked at whether I could initiate the course at the University of Cape Town with the support of the University of Wales. I was really fortunate in that Professor JP van Niekerk who was the dean at the faculty of health sciences at UCT, is currently the chairperson of the Hospice Palliative Care Association, and he was my champion at UCT . I was in discussion with Ilora in Wales, and with Ralph Kirsch, who heads the department of medicine at UCT, and he employed me on a retainer of 500 rand a month to develop the course.

I came back from a second meeting in Wales with all the plans and the curriculum and ready to roll, and was told that, you know, you must put it into the dean’s circular, it has to be passed by the UCT senate and the rest of it, and there was one further dean’s circular for the year. So I put together my motivation for the postgraduate programme in palliative medicine; we put it in the dean’s circular, and it was accepted like on the turn. So we enrolled our first cohort of students: 23 doctors who were currently working in hospices either part-time or full-time, and we started in the January [2001]. So, having been employed on a retainer in April [2000], put it in the dean’s letter in November, we were up and running in January. And I was just so naïve, I just thought that this kind of happened, but now that I’m in the University I get colleagues saying, ‘How on earth did you get your course approved so quickly?’ In fact the accreditation from the course with the South African Qualifications Authority only came through about three months before our first exams were written. But at least now we have about 60 doctors who are qualified and another 50 or so who are actually in the programme at the moment, and it’s developed from being a diploma in palliative medicine to the degree in palliative medicine with the research component, which is where I started with my research interest.⁶³

National statistics relating to education and training collected by HPCA and disseminated at the AGM in Rustenburg are to be found in Tables 11-13; they concern courses, workshops and talks given under the HPCA umbrella.⁶⁴

Table 11 Training courses, 2003-2004

Table 12 Training workshops, 2003-2004

Table 13 Talks and presentations, 2003-2004

André Wagner speaks about his role in the development of hospice organisations – and the people within them - and how training has been supported by the introduction of a development fund (Table 14):

We have specific funders in South Africa who contribute money; and they want that money to go towards development, so that’s why we have the hospice development fund. And we identified development areas - like developing your boards in the area of being competent governing body members, or developing the fund-raising capacity within the hospice, developing the manager in areas of organisational development, or general hospice management - so that’s what the fund is for, to develop.

The fund of course is very small so we need to, in some cases, try and benefit a whole region. If one hospice identifies a need we go back and say ‘but can’t the whole region benefit from it because then we save money?’ The fund covers all areas: it covers patient care; education; fund-raising; and public relations; as well as organisational development, so it is about developing skills in all those areas. For me it’s quite important to get people developed with quality development opportunities, so I would encourage hospices to make use of recognised tertiary institutions instead of getting someone that would not be able to give them a certificate for what they’re doing. So because we’re not able to pay market related salaries, at least we’re able to develop people so that should they make a job change, which we don’t encourage and which we don’t want of course, then at least then they’ll have added skills and capacity to go into a new job. So that’s what the hospice development fund is about; and it doesn’t make provision for capital items like buying computers and buying a car and buying a property but it is about developing our staff; and people don’t have to pay back, they have to work back.

One of the new things that I’ve implemented because of the development needs of our managers, is the Hospice Palliative Care Association bursary fund which at this stage is just in the field of organisational development: where a staff member can get a bursary to study at a university or a college but on a part-time basis. They don’t have to pay anything; we pay for the tuition, all they have to do is pass. If they fail they need to pay back or they need to pay for the repetition of that specific subject - or subjects – themselves; and then they just need to work back the exact number of years that they’ve had support for.

And that’s one that I’m really promoting at the moment because we’re getting young people into hospice which is a new thing, and which is exciting - getting younger people that are not retired and who just need to work to supplement their pension – it’s people who want to have a career in hospice. So it’s to develop them and really make sure that they get a recognised qualification at the end of that activity.⁶⁵

Table 14 Requests to HPCA for expertise in development areas

Source: HPCA SA Annual National Statistics 2003-2004

Kath Defilippi outlines the significance of a new association with the Council of Health Services Accreditation for Southern Africa (COHASA)

The modus operandi is to first get our own hospice house truly in order, and what’s very exciting, I think, is that we are linking accreditation to mentorship, so that we’re going to have that back-up of this interdisciplinary, team that includes people with human resource and management experience and interest and skills to support hospices, and to get them into the programme of accreditation. Our aim is to move hospices along as fast as possible to the place of full accreditation, but to do it in a non-threatening, supportive way. And then, in order to be a mentor hospice and a mentor, not only as I mentioned to hospices but to other organisations, and very importantly to department of health organisations, we believe that to fulfil that function effectively a hospice should have full accreditation. And so, so that’s what we’re really very excited about at the moment. There’s a lot of hard work ahead and probably some resistance, but hopefully not too much.

HPCA have partnered with COHSASA who are a very professional outfit - COHSASA stands for the Council of Health Services Accreditation for Southern Africa - and they are internationally recognised. And so HPCA have signed a formal Memorandum of Understanding with COHSASA and together we’ve developed hospice standards of care, which is wonderful for us, but it’s also very good for them because in fact they have acknowledged that in some ways we have improved their standards.. So it’s been a real win-win situation. We’re very excited at the fact that COHSASA have just trained quite a large group – there were 24 of us – as what they call ‘surveyors’ and we’ve done one mock survey in a big group and now we’re about to embark on piloting our draft standards in conjunction with the senior surveyor from COHSASA, who will be with a group of us. And then all the people who did the survey training are invited to go along with COHSASA to accredit hospices as an observer and in fact will be evaluated by the very experienced COHSASA team. So, we just believe that it’s a quantum leap that we’ve taken in terms of really working towards quality care, and the fact that we’re having it linked to mentorship is what’s going to make it achievable and we’re confident that it’s really going to happen. ⁶⁶

At the hospice level, Marisa Wolheim speaks of how the spiritual dimension of care is a central feature of staff training at Hospice in the West:

When we train people we try and encourage spiritual - not religious – caring; because I think when you go into a patient’s home who is dying, and they’re so afraid, and you see it in their eyes, you can look past the wound and you can look past the smell and you can talk to that spirit and that god that is within them. There’s something that links, and they just know, and everything else becomes less important. And it’s such a great opportunity to help people to recognise that our soul and our spirit is part of us all the time, but so often we leave it ’til the last minute. So it’s a matter of creating awareness as we go along, to the living and the dying. I think everything that hospice is now, our dying patients have taught us and they are the most valuable lessons and teachers we have. ⁶⁷

Elizabeth Scrimgeour⁶⁸ illuminates this spiritual domain from the perspective of the patient. In a detailed piece of research, she focuses on the development of what is termed ‘sacred spaces’ – that which evokes awe and reverence due to its association with spiritual or religious experience. Terminal illness, she suggests, is a sacred experience and presents qualitative evidence based on patient narratives:

The patients also talked about experiencing the warmth and nurturing of the God of Grace through visits from friends, the church community, being pain-free and going to day-care. They also find God in flowers, the visits from hospice, sunshine or a back rub. All these aspects are part of and indicative of the spirit or spirituality that makes life worthwhile and engenders a sense of wellbeing. The patients’ spirituality or spiritual experiences with the community and the environment encourages the patients to feel included and worthwhile as part of the body of God. Angie and Margaret experienced their lives as being worthwhile and contributing to the body of God - as contributing to the well-being of their communities when they could share about their illness experiences with their church members. They experienced contributing to the understanding of others about serious illness and identified various coping mechanisms helping to make others more sensitive to the plight of those who are ill. Both Angie and Margaret said that they were pleased that they could contribute in some way to making the illness experience easier for both carers and those who are ill.⁶⁹