Research
Palliative approach education for rural nurses and health-care workers: a mixed-method study Barbara Pesut, Gail Potter, Kelli Stajduhar, Richard Sawatzky, Barbara McLeod and Karly Drabot
Background: The aim of this mixed-method study was to evaluate the outcomes of an educational intervention in a palliative approach for rural nurses and health-care workers (HCWs) using a team-based method. Methods: Pre- and post-test measures using the Palliative Care Nursing Self-Competence (PCSNC) scale and the Self-Perceived Palliative Care Knowledge instrument were used to evaluate learning outcomes. Participant post-test scores were also compared to normative provincial data. Findings: At post-test, HCWs showed statistically significant improvements across 7 of 10 domains in self-perceived competence and 6 of 12 domains in self-perceived knowledge; all scores were equivalent to or better than provincial normative data. Nurses’ self-perceived knowledge showed statistically significant improvements in 3 of 12 domains; all post-test scores were equivalent to provincial normative data. Qualitative data indicated improvements in familiarity with the resources available for palliative care and in communication among the nursing team. Conclusion: An educational intervention can improve the competence and knowledge of rural HCWs and nurses in a palliative approach. Key words: Hospice and palliative care nursing l Nursing education research l Home health aides l Chronic disease l Rural nursing l Palliative approach This article has been subject to double-blind peer review.
A
For author affiliations, see Box 1. Correspondence to: Barbara Pesut [email protected]
142
n ageing population with complex chronic illness requires nurses to be confident providing care for those on a dying trajectory. With the majority of people dying outside of specialised palliative care units, there is increasing emphasis on a palliative approach to care (Stajduhar, 2011). A palliative approach emphasises the important role that primary palliative care plays in relation to specialist palliative care (Quill and Abernethy, 2013). The supportive principles of palliative care are applied early in the disease trajectory and adapted for those living with life-limiting chronic illnesses across contexts of care (e.g. hospital, residential and home care). This study focused on an educational intervention in a palliative approach for rural nurses (registered nurses and licensed practical nurses) and
health-care workers (HCWs) (home health aides, nursing care assistants or residential care aides).
Literature review A scoping review of palliative care education revealed the challenges of designing rigorous evaluative studies to examine learning outcomes (Pesut et al, 2013). The evidence to support whether or not palliative educational programmes are meeting their intended outcomes is limited. Further, although there is a need for palliative education across the spectrum of care providers, there are particular cohorts for which the need is of higher priority. In Canada, rural nurses are working with populations that are older and ageing proportionately faster than their urban counterparts (Dandy and Bollman, 2009), with a higher burden of chronic illness (Canadian Institutes for Health Information, 2006). Rural nurses provide palliative care without a specialist palliative team to assist with complex pain and symptom management or complicated psychosocial, spiritual and family issues. Many feel under-prepared to provide palliative care, and opportunities for ongoing palliative education are limited (Kaasalainen et al, 2011; Pesut et al, 2012; Pesut et al, 2013). Education in a palliative approach is particularly relevant for rural nurses, because it adapts palliative care knowledge to the rural context where there is limited access to specialised palliative care services and where nurses care for individuals throughout their disease trajectory. HCWs are another group for which palliative education is of high priority, as they provide direct care to the ageing population. A stressor for HCWs is a lack of preparedness for the complexity of palliative care (Denham et al, 2006; Carlson, 2007; McDonnell et al, 2009; Devlin and McIlfatrick, 2010). The term ‘HCWs’ in this paper refers to unregulated providers who provide care in residential care facilities and the home. In different contexts they are referred to as home health aides, nursing care assistants or residential care aides. In the US, the number of home
© 2015 MA Healthcare Ltd
Abstract
International Journal of Palliative Nursing 2015, Vol 21, No 3
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Research
health aides is expected to increase as much as 69% from 2010 to 2020, with a replacement number of 837 000 persons over that period (US Bureau of Labor Statistics, 2014). In Canada, there is a lack of knowledge about HCWs (Canadian Nurses Association, 2008), which makes it difficult to make informed decisions about their optimal integration into the health workforce. However, challenges with sustaining a home-health workforce, and the increasing complexity of home care clients have led to recommendations for better preparation of home health workers (Canadian Healthcare Association, 2009). A recent study in Ontario suggested that while HCWs felt well-prepared for their role in general, 51% indicated that they needed more training in palliative care, and 63% felt a need for further training in chronic disease management (Lum et al, 2010). Several studies have reported gains in self-perceived competence and knowledge as a result of palliative education for HCWs (Dryden and Addicott, 2009; Phillips et al, 2011; Morris, 2011). However, there is limited published research that evaluates educational interventions designed to include nurses and HCWs, while adapting the curriculum to their roles and scopes of practice. The palliative approach educational intervention in this study included rural nurses and HCWs in joint education.
Aim The aim of this mixed-method study was to evaluate the outcomes of an educational intervention in a palliative approach for rural nurses and HCWs using a team-based method.
Methods This study used a mixed-method convergent parallel design (Cresswell and Plano Clark, 2011). Quantitative and qualitative data were collected concurrently, analysed separately and then compared to interpret and triangulate the study findings.
© 2015 MA Healthcare Ltd
Setting The study was developed through the work of iPANEL, a team based in British Columbia, Canada that is exploring ways in which a palliative approach can better meet the needs of those living with life-limiting chronic illness. The context for this study was two co-located rural communities with populations under 10 000 with no specialist palliative care services.
Participants Nurses and HCWs were recruited to participate in the educational workshop using flyers, email
International Journal of Palliative Nursing 2015, Vol 21, No 3
Box 1. Author affiliations Barbara Pesut, Associate Professor of Nursing, Canada Research Chair in Health, Ethics and Diversity, University of British Columbia; Gail Potter, Nursing Faculty, Selkirk College, British Columbia; Kelli Stajduhar, Professor School of Nursing and Centre on Aging, University of Victoria and Research Scientist, Fraser Health Authority End of Life Program, Fraser Health, British Columbia; Richard Sawatzky, Associate Professor and Canada Research Chair, Trinity Western University, British Columbia and Research Scientist, Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute; Barbara McLeod, Hospice Palliative Care Clinical Nurse Specialist, Fraser Health and Adjunct Professor, School of Nursing, University of British Columbia; Karly Drabot, Research Coordinator, University of British Columbia, Okanagan, Canada.
and word-of-mouth at their places of work. The workshop was provided without cost to participants. Participants received a $100 honorarium from research grant funding for participating in the study to help offset lost employment wages when attending the workshop.
Ethical considerations Ethical approval for this study was obtained from the ethics review boards of the University of British Columbia and Interior Health, the British Columbia Health Authorities.
Study period This study took place between October 2012 and March 2013. The curriculum was delivered in a 1.5-day workshop followed by monthly 2-hour education sessions over a period of 4 months, offered through on-site and distance learning formats. The workshop and follow-up sessions were offered twice to facilitate participation.
Intervention An expert rural nurse educator developed the workshop programme by adapting a specialised palliative curriculum to the rural context, and the scopes of practice of both nurses and HCWs (Potter et al, in press). Curricula addressed the common dimensions of palliative care practice: pain, other physical symptoms, psychological needs, social needs, spiritual needs, needs related to functional status, ethical and legal issues, interprofessional collaboration and communication, personal and professional issues, and last hours of life. A palliative approach was emphasised by adapting supportive palliative principles to various chronic illness trajectories such as cancer, organ failure, frailty and dementia within the primary context of rural nursing. For example, symptoms in the last year of life for commonly occurring chronic illnesses were presented. The workshop included didactic content and case study discussions, provided to nurses and HCWs together, along with breakout sessions that adapted content to the different scopes of practice. For example, pain assessment and management principles were provided to the groups jointly, followed by advanced pharmacology for
143
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Research
nurses and non-pharmacological interventions for HCWs. The monthly education sessions focused on case studies provided by the instructor and practice challenges generated by the participants.
Data collection Participants completed pre-test measures at the beginning of the workshop and post-test measures at the conclusion of the education. Participants were also invited to participate in a semi-structured telephone interview about their learning. Demographics Participants answered demographic questions addressing age, gender, professional designation, length of time in current role, location of clinical practice (both current and previous) and personal experience caring for a loved one with a life-limiting illness, as shown in Table 1. Each participant completed the Frommelt Attitude toward Care of the Dying scale (FATCOD); a 30-item scale designed to measure nurses’ attitudes towards caring for dying persons and their families (Frommelt, 1991). Possible FATCOD total scores range from 30 to 150, with higher scores indicating a more positive attitude. Palliative Care Nursing Self-Competence Scale (PCNSC) The PCNSC and palliative care knowledge tool were used to evaluate participants’ self-perceived competence and knowledge prior to the workshop and at the conclusion of the education. The PCNSC (Desbiens, 2011; Desbiens and Fillion, 2011) evaluates self-perceived competence in ten dimensions of palliative care. Each dimension includes 5 items rated using a 6-point Likert scale from 0 (not at all capable) to 5 (highly capable) (50 items in total). Each dimension score is obtained by taking the average of the responses to the five corresponding items. Originally created for palliative care nurses, this measure was adapted for the purposes of a provincial survey to assess self-perceived competence in a palliative approach among nurses and HCWs who provide care for those with chronic life-limiting illnesses in settings that do not specialise in palliative care. This provincial survey (conducted during 2012 by iPANEL (iPANEL, 2014)), was designed to obtain baseline descriptive data about nurses’ and HCWs’ integration of a palliative approach, included 114 randomly selected health-care settings drawn from a list of all eligible settings in British Columbia. Different versions of the PCNSC were used for nurses and HCWs, to ensure that the questions were compatible with their different scopes of practice. Using data from
144
this survey (n=1468), construct validity pertaining to the 10-dimensional structure of the PCNSC was supported by the results of a confirmatory factor analysis conducted within each group of care provider. Measurement variance analyses provided support for the two versions (one for nurses and one for HCWs) of the instrument (unpublished findings). These validated versions were used for this study. Self-Perceived Palliative Care Knowledge instrument This 12-item knowledge instrument asks participants to rate their knowledge in providing palliative care on a 5-point Likert item from 0 (inadequate) to 4 (more than adequate) for 12 knowledge dimensions. There is one item for each of the 10 PCNSC dimensions, plus two additional items pertaining to disease management and loss and grief support. This face-valid instrument was designed for purposes of the provincial survey (iPANEL, 2014).
Data analysis Quantitative data were entered, cleaned and analysed using predictive analytics software SPSS (version 21.0). Paired-sample t-tests were conducted to evaluate the differences between preand post-test self-perceived competence. In the absence of a control group, our sample’s self-perceived competence scores were compared with the provincial norms using normative comparisons (Kendall et al, 1999). Normative comparisons use significance testing to determine whether the means of the treatment group are different to those of the normative group and equivalency testing to determine whether the range of closeness between the means falls within one standard deviation (SD). Positive educational outcomes occur if pre-test scores are below that of provincial norms and post-test scores are comparable or above provincial norms. Wilcoxon signed-rank tests were conducted to compare pre- and post-test differences between the self-perceived palliative care knowledge items. Self-perceived knowledge was also analysed by dichotomising items into ‘inadequate’ (a score less than 2 on the 5-point scale) or ‘adequate’ (a score equal to or greater than 2 on the 5-point scale) and calculating frequencies of selfreported inadequate knowledge. Initially, outcomes were analysed for the sample as a whole, and then for each group (nurses and HCWs) separately. Independent analyses of the groups revealed that many of the statistically significant gains were made primarily by HCWs. As such, results are reported by groups.
© 2015 MA Healthcare Ltd
❛ The PCNSC ... evaluates self-perceived competence in ten dimensions of palliative care...❜
International Journal of Palliative Nursing 2015, Vol 21, No 3
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Research
Table 1. Demographic information for study sample and provincial normative sample Rural sample
Provincial sample (iPanel, 2014)
Nurses (62.9%)
Health-care workers (37.1%)
Nurses (62.5%)
Health-care workers (37.5%)
≤25
13.6
–
7.9
3.4
26–35
27.3
23.1
22.8
14.1
36–45
27.3
15.4
21.0
25.7
46–55
13.6
46.1
28.0
36.0
56–65
18.2
15.4
18.9
18.4
>65
–
–
1.4
2.4
Female
95.5
100
90.5
88.3
Male
4.5
–
9.5
11.7
10
13.6
25.0
Acute
18.2
–
41.6
–
Residential
18.2
61.5
49.1
85.3
Community
4.5
–
9.3
14.7
Multiple
45.5
38.5
–
–
No work experience (new graduate)
13.6
–
–
–
Age (%)
Gender (%)
Years in current role
Not collected
Location of practice
Experience caring for family with life-limiting chronic illness Yes
27.3
61.5
Not collected
Not collected
No
72.7
38.5
Not collected
Not collected
Not collected
Not collected
Frommelt Attitude Toward Care of the Dying (FATCOD) scale score Mean score
4.34/5
4.27/5
Demographic information is presented in percentages. Percentages for provincial sample represent ‘weighted’ population estimates based on the information provided by the sample of 1433 participants (902 nurses and 531 HCWs). Study sample n=35 (22 nurses and 13 HCWs).
Qualitative interview data were digitally recorded, transcribed, checked for accuracy and analysed within qualitative data analysis software NVivoQSR (version 9.0) using qualitative description (Sandelowski, 2010).
© 2015 MA Healthcare Ltd
Findings In total, 22 nurses and 13 HCWs (n=35) participated in the educational workshop; 18 nurses and 12 HCWs returned completed post-tests, resulting in a total of 30 participants included in the repeated measures analyses. As this was a rural sample, participants worked across multiple sites of care, and, therefore, had a range of experience with palliative care in various contexts.
International Journal of Palliative Nursing 2015, Vol 21, No 3
Table 1 provides the demographic data for the sample and for the provincial sample against which normative comparisons were made. FATCOD results indicate that this sample had a high level of comfort with caring for the dying, with scores comparable with those reported after an educational intervention in previous studies (Frommelt, 1991; Frommelt, 2003).
Changes in self-perceived competence in providing a palliative approach to care Table 2 shows the changes in self-perceived competence between pre-test and post-test across the ten domains of the PCNSC. Spiritual
145
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Research
Table 2. Changes in self-perceived competence as measured by the Palliative Care Nursing Self-Competence Scale Nurses
Health-care workers
Competence dimensions
Pre-test mean (SD)
Post-test mean (SD)
Pre-test mean (SD)
Post-test mean (SD)
Physical needs: pain
3.39 (0.72)
3.73 (0.68)
3.61 (0.86)
4.13 (0.54)*
Physical needs: other symptoms
3.76 (0.70)
4.01 (0.67)
3.80 (0.85)
4.18 (0.65)
Psychological needs
3.45 (0.70)
3.50 (0.76)
3.53 (0.77)
3.88 (0.63)
Social needs
3.14 (0.83)
3.46 (0.82)
2.84 (0.87)
3.45 (0.68)
Spiritual needs
2.92 (0.86)
3.33 (0.75)
2.75 (1.31)
3.98 (0.61)*
Needs related to functional status
3.84 (0.70)
3.97 (0.84)
3.47 (0.88)
4.25 (0.54)**
Ethical and legal issues
3.13 (0.71)
3.52 (0.70)
3.18 (1.24)
4.20 (0.55)*
Inter-professional collaboration and communication
3.77 (0.92)
4.07 (0.89)
3.21 (1.06)
3.95 (0.81)*
Personal and professional issues related to nursing care
3.88 (0.89)
4.04 (0.76)
3.51 (0.93)
4.23 (0.61)**
Last hours of life
3.87 (0.70)
3.98 (0.70)
3.58 (0.92)
4.47 (0.53)**
All dimensions measured on a 5-point scale; * p
Palliative approach education for rural nurses and health-care workers: a mixed-method study Barbara Pesut, Gail Potter, Kelli Stajduhar, Richard Sawatzky, Barbara McLeod and Karly Drabot
Background: The aim of this mixed-method study was to evaluate the outcomes of an educational intervention in a palliative approach for rural nurses and health-care workers (HCWs) using a team-based method. Methods: Pre- and post-test measures using the Palliative Care Nursing Self-Competence (PCSNC) scale and the Self-Perceived Palliative Care Knowledge instrument were used to evaluate learning outcomes. Participant post-test scores were also compared to normative provincial data. Findings: At post-test, HCWs showed statistically significant improvements across 7 of 10 domains in self-perceived competence and 6 of 12 domains in self-perceived knowledge; all scores were equivalent to or better than provincial normative data. Nurses’ self-perceived knowledge showed statistically significant improvements in 3 of 12 domains; all post-test scores were equivalent to provincial normative data. Qualitative data indicated improvements in familiarity with the resources available for palliative care and in communication among the nursing team. Conclusion: An educational intervention can improve the competence and knowledge of rural HCWs and nurses in a palliative approach. Key words: Hospice and palliative care nursing l Nursing education research l Home health aides l Chronic disease l Rural nursing l Palliative approach This article has been subject to double-blind peer review.
A
For author affiliations, see Box 1. Correspondence to: Barbara Pesut [email protected]
142
n ageing population with complex chronic illness requires nurses to be confident providing care for those on a dying trajectory. With the majority of people dying outside of specialised palliative care units, there is increasing emphasis on a palliative approach to care (Stajduhar, 2011). A palliative approach emphasises the important role that primary palliative care plays in relation to specialist palliative care (Quill and Abernethy, 2013). The supportive principles of palliative care are applied early in the disease trajectory and adapted for those living with life-limiting chronic illnesses across contexts of care (e.g. hospital, residential and home care). This study focused on an educational intervention in a palliative approach for rural nurses (registered nurses and licensed practical nurses) and
health-care workers (HCWs) (home health aides, nursing care assistants or residential care aides).
Literature review A scoping review of palliative care education revealed the challenges of designing rigorous evaluative studies to examine learning outcomes (Pesut et al, 2013). The evidence to support whether or not palliative educational programmes are meeting their intended outcomes is limited. Further, although there is a need for palliative education across the spectrum of care providers, there are particular cohorts for which the need is of higher priority. In Canada, rural nurses are working with populations that are older and ageing proportionately faster than their urban counterparts (Dandy and Bollman, 2009), with a higher burden of chronic illness (Canadian Institutes for Health Information, 2006). Rural nurses provide palliative care without a specialist palliative team to assist with complex pain and symptom management or complicated psychosocial, spiritual and family issues. Many feel under-prepared to provide palliative care, and opportunities for ongoing palliative education are limited (Kaasalainen et al, 2011; Pesut et al, 2012; Pesut et al, 2013). Education in a palliative approach is particularly relevant for rural nurses, because it adapts palliative care knowledge to the rural context where there is limited access to specialised palliative care services and where nurses care for individuals throughout their disease trajectory. HCWs are another group for which palliative education is of high priority, as they provide direct care to the ageing population. A stressor for HCWs is a lack of preparedness for the complexity of palliative care (Denham et al, 2006; Carlson, 2007; McDonnell et al, 2009; Devlin and McIlfatrick, 2010). The term ‘HCWs’ in this paper refers to unregulated providers who provide care in residential care facilities and the home. In different contexts they are referred to as home health aides, nursing care assistants or residential care aides. In the US, the number of home
© 2015 MA Healthcare Ltd
Abstract
International Journal of Palliative Nursing 2015, Vol 21, No 3
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Research
health aides is expected to increase as much as 69% from 2010 to 2020, with a replacement number of 837 000 persons over that period (US Bureau of Labor Statistics, 2014). In Canada, there is a lack of knowledge about HCWs (Canadian Nurses Association, 2008), which makes it difficult to make informed decisions about their optimal integration into the health workforce. However, challenges with sustaining a home-health workforce, and the increasing complexity of home care clients have led to recommendations for better preparation of home health workers (Canadian Healthcare Association, 2009). A recent study in Ontario suggested that while HCWs felt well-prepared for their role in general, 51% indicated that they needed more training in palliative care, and 63% felt a need for further training in chronic disease management (Lum et al, 2010). Several studies have reported gains in self-perceived competence and knowledge as a result of palliative education for HCWs (Dryden and Addicott, 2009; Phillips et al, 2011; Morris, 2011). However, there is limited published research that evaluates educational interventions designed to include nurses and HCWs, while adapting the curriculum to their roles and scopes of practice. The palliative approach educational intervention in this study included rural nurses and HCWs in joint education.
Aim The aim of this mixed-method study was to evaluate the outcomes of an educational intervention in a palliative approach for rural nurses and HCWs using a team-based method.
Methods This study used a mixed-method convergent parallel design (Cresswell and Plano Clark, 2011). Quantitative and qualitative data were collected concurrently, analysed separately and then compared to interpret and triangulate the study findings.
© 2015 MA Healthcare Ltd
Setting The study was developed through the work of iPANEL, a team based in British Columbia, Canada that is exploring ways in which a palliative approach can better meet the needs of those living with life-limiting chronic illness. The context for this study was two co-located rural communities with populations under 10 000 with no specialist palliative care services.
Participants Nurses and HCWs were recruited to participate in the educational workshop using flyers, email
International Journal of Palliative Nursing 2015, Vol 21, No 3
Box 1. Author affiliations Barbara Pesut, Associate Professor of Nursing, Canada Research Chair in Health, Ethics and Diversity, University of British Columbia; Gail Potter, Nursing Faculty, Selkirk College, British Columbia; Kelli Stajduhar, Professor School of Nursing and Centre on Aging, University of Victoria and Research Scientist, Fraser Health Authority End of Life Program, Fraser Health, British Columbia; Richard Sawatzky, Associate Professor and Canada Research Chair, Trinity Western University, British Columbia and Research Scientist, Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute; Barbara McLeod, Hospice Palliative Care Clinical Nurse Specialist, Fraser Health and Adjunct Professor, School of Nursing, University of British Columbia; Karly Drabot, Research Coordinator, University of British Columbia, Okanagan, Canada.
and word-of-mouth at their places of work. The workshop was provided without cost to participants. Participants received a $100 honorarium from research grant funding for participating in the study to help offset lost employment wages when attending the workshop.
Ethical considerations Ethical approval for this study was obtained from the ethics review boards of the University of British Columbia and Interior Health, the British Columbia Health Authorities.
Study period This study took place between October 2012 and March 2013. The curriculum was delivered in a 1.5-day workshop followed by monthly 2-hour education sessions over a period of 4 months, offered through on-site and distance learning formats. The workshop and follow-up sessions were offered twice to facilitate participation.
Intervention An expert rural nurse educator developed the workshop programme by adapting a specialised palliative curriculum to the rural context, and the scopes of practice of both nurses and HCWs (Potter et al, in press). Curricula addressed the common dimensions of palliative care practice: pain, other physical symptoms, psychological needs, social needs, spiritual needs, needs related to functional status, ethical and legal issues, interprofessional collaboration and communication, personal and professional issues, and last hours of life. A palliative approach was emphasised by adapting supportive palliative principles to various chronic illness trajectories such as cancer, organ failure, frailty and dementia within the primary context of rural nursing. For example, symptoms in the last year of life for commonly occurring chronic illnesses were presented. The workshop included didactic content and case study discussions, provided to nurses and HCWs together, along with breakout sessions that adapted content to the different scopes of practice. For example, pain assessment and management principles were provided to the groups jointly, followed by advanced pharmacology for
143
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Research
nurses and non-pharmacological interventions for HCWs. The monthly education sessions focused on case studies provided by the instructor and practice challenges generated by the participants.
Data collection Participants completed pre-test measures at the beginning of the workshop and post-test measures at the conclusion of the education. Participants were also invited to participate in a semi-structured telephone interview about their learning. Demographics Participants answered demographic questions addressing age, gender, professional designation, length of time in current role, location of clinical practice (both current and previous) and personal experience caring for a loved one with a life-limiting illness, as shown in Table 1. Each participant completed the Frommelt Attitude toward Care of the Dying scale (FATCOD); a 30-item scale designed to measure nurses’ attitudes towards caring for dying persons and their families (Frommelt, 1991). Possible FATCOD total scores range from 30 to 150, with higher scores indicating a more positive attitude. Palliative Care Nursing Self-Competence Scale (PCNSC) The PCNSC and palliative care knowledge tool were used to evaluate participants’ self-perceived competence and knowledge prior to the workshop and at the conclusion of the education. The PCNSC (Desbiens, 2011; Desbiens and Fillion, 2011) evaluates self-perceived competence in ten dimensions of palliative care. Each dimension includes 5 items rated using a 6-point Likert scale from 0 (not at all capable) to 5 (highly capable) (50 items in total). Each dimension score is obtained by taking the average of the responses to the five corresponding items. Originally created for palliative care nurses, this measure was adapted for the purposes of a provincial survey to assess self-perceived competence in a palliative approach among nurses and HCWs who provide care for those with chronic life-limiting illnesses in settings that do not specialise in palliative care. This provincial survey (conducted during 2012 by iPANEL (iPANEL, 2014)), was designed to obtain baseline descriptive data about nurses’ and HCWs’ integration of a palliative approach, included 114 randomly selected health-care settings drawn from a list of all eligible settings in British Columbia. Different versions of the PCNSC were used for nurses and HCWs, to ensure that the questions were compatible with their different scopes of practice. Using data from
144
this survey (n=1468), construct validity pertaining to the 10-dimensional structure of the PCNSC was supported by the results of a confirmatory factor analysis conducted within each group of care provider. Measurement variance analyses provided support for the two versions (one for nurses and one for HCWs) of the instrument (unpublished findings). These validated versions were used for this study. Self-Perceived Palliative Care Knowledge instrument This 12-item knowledge instrument asks participants to rate their knowledge in providing palliative care on a 5-point Likert item from 0 (inadequate) to 4 (more than adequate) for 12 knowledge dimensions. There is one item for each of the 10 PCNSC dimensions, plus two additional items pertaining to disease management and loss and grief support. This face-valid instrument was designed for purposes of the provincial survey (iPANEL, 2014).
Data analysis Quantitative data were entered, cleaned and analysed using predictive analytics software SPSS (version 21.0). Paired-sample t-tests were conducted to evaluate the differences between preand post-test self-perceived competence. In the absence of a control group, our sample’s self-perceived competence scores were compared with the provincial norms using normative comparisons (Kendall et al, 1999). Normative comparisons use significance testing to determine whether the means of the treatment group are different to those of the normative group and equivalency testing to determine whether the range of closeness between the means falls within one standard deviation (SD). Positive educational outcomes occur if pre-test scores are below that of provincial norms and post-test scores are comparable or above provincial norms. Wilcoxon signed-rank tests were conducted to compare pre- and post-test differences between the self-perceived palliative care knowledge items. Self-perceived knowledge was also analysed by dichotomising items into ‘inadequate’ (a score less than 2 on the 5-point scale) or ‘adequate’ (a score equal to or greater than 2 on the 5-point scale) and calculating frequencies of selfreported inadequate knowledge. Initially, outcomes were analysed for the sample as a whole, and then for each group (nurses and HCWs) separately. Independent analyses of the groups revealed that many of the statistically significant gains were made primarily by HCWs. As such, results are reported by groups.
© 2015 MA Healthcare Ltd
❛ The PCNSC ... evaluates self-perceived competence in ten dimensions of palliative care...❜
International Journal of Palliative Nursing 2015, Vol 21, No 3
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Research
Table 1. Demographic information for study sample and provincial normative sample Rural sample
Provincial sample (iPanel, 2014)
Nurses (62.9%)
Health-care workers (37.1%)
Nurses (62.5%)
Health-care workers (37.5%)
≤25
13.6
–
7.9
3.4
26–35
27.3
23.1
22.8
14.1
36–45
27.3
15.4
21.0
25.7
46–55
13.6
46.1
28.0
36.0
56–65
18.2
15.4
18.9
18.4
>65
–
–
1.4
2.4
Female
95.5
100
90.5
88.3
Male
4.5
–
9.5
11.7
10
13.6
25.0
Acute
18.2
–
41.6
–
Residential
18.2
61.5
49.1
85.3
Community
4.5
–
9.3
14.7
Multiple
45.5
38.5
–
–
No work experience (new graduate)
13.6
–
–
–
Age (%)
Gender (%)
Years in current role
Not collected
Location of practice
Experience caring for family with life-limiting chronic illness Yes
27.3
61.5
Not collected
Not collected
No
72.7
38.5
Not collected
Not collected
Not collected
Not collected
Frommelt Attitude Toward Care of the Dying (FATCOD) scale score Mean score
4.34/5
4.27/5
Demographic information is presented in percentages. Percentages for provincial sample represent ‘weighted’ population estimates based on the information provided by the sample of 1433 participants (902 nurses and 531 HCWs). Study sample n=35 (22 nurses and 13 HCWs).
Qualitative interview data were digitally recorded, transcribed, checked for accuracy and analysed within qualitative data analysis software NVivoQSR (version 9.0) using qualitative description (Sandelowski, 2010).
© 2015 MA Healthcare Ltd
Findings In total, 22 nurses and 13 HCWs (n=35) participated in the educational workshop; 18 nurses and 12 HCWs returned completed post-tests, resulting in a total of 30 participants included in the repeated measures analyses. As this was a rural sample, participants worked across multiple sites of care, and, therefore, had a range of experience with palliative care in various contexts.
International Journal of Palliative Nursing 2015, Vol 21, No 3
Table 1 provides the demographic data for the sample and for the provincial sample against which normative comparisons were made. FATCOD results indicate that this sample had a high level of comfort with caring for the dying, with scores comparable with those reported after an educational intervention in previous studies (Frommelt, 1991; Frommelt, 2003).
Changes in self-perceived competence in providing a palliative approach to care Table 2 shows the changes in self-perceived competence between pre-test and post-test across the ten domains of the PCNSC. Spiritual
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Research
Table 2. Changes in self-perceived competence as measured by the Palliative Care Nursing Self-Competence Scale Nurses
Health-care workers
Competence dimensions
Pre-test mean (SD)
Post-test mean (SD)
Pre-test mean (SD)
Post-test mean (SD)
Physical needs: pain
3.39 (0.72)
3.73 (0.68)
3.61 (0.86)
4.13 (0.54)*
Physical needs: other symptoms
3.76 (0.70)
4.01 (0.67)
3.80 (0.85)
4.18 (0.65)
Psychological needs
3.45 (0.70)
3.50 (0.76)
3.53 (0.77)
3.88 (0.63)
Social needs
3.14 (0.83)
3.46 (0.82)
2.84 (0.87)
3.45 (0.68)
Spiritual needs
2.92 (0.86)
3.33 (0.75)
2.75 (1.31)
3.98 (0.61)*
Needs related to functional status
3.84 (0.70)
3.97 (0.84)
3.47 (0.88)
4.25 (0.54)**
Ethical and legal issues
3.13 (0.71)
3.52 (0.70)
3.18 (1.24)
4.20 (0.55)*
Inter-professional collaboration and communication
3.77 (0.92)
4.07 (0.89)
3.21 (1.06)
3.95 (0.81)*
Personal and professional issues related to nursing care
3.88 (0.89)
4.04 (0.76)
3.51 (0.93)
4.23 (0.61)**
Last hours of life
3.87 (0.70)
3.98 (0.70)
3.58 (0.92)
4.47 (0.53)**
All dimensions measured on a 5-point scale; * p
