Context Central to appropriate palliative care management in hospital settings is ensuring an adequately trained workforce. In order to achieve optimum palliative care delivery, it is first necessary to create a baseline understanding of the level of palliative care education and support needs among all clinical staff (not just palliative care specialists) within the acute hospital setting.
Objectives The objectives of the study were to explore clinical staff: perceptions concerning the quality of palliative care delivery and support service accessibility, previous experience and education in palliative care delivery, perceptions of their own need for formal palliative care education, confidence in palliative care delivery and the impact of formal palliative care training on perceived confidence.
Methods A purposive sample of clinical staff members (598) in a 710-bed hospital were surveyed regarding their experiences of palliative care delivery and their education needs.
Results On average, the clinical staff rated the quality of care provided to people who die in the hospital as ‘good’ (x̄=4.17, SD=0.91). Respondents also reported that 19.3% of their time was spent caring for end-of-life patients. However, only 19% of the 598 respondents reported having received formal palliative care training. In contrast, 73.7% answered that they would like formal training. Perceived confidence in palliative care delivery was significantly greater for those clinical staff with formal palliative care training.
Conclusions Formal training in palliative care increases clinical staff perceptions of confidence, which evidence suggests impacts on the quality of palliative care provided to patients. The results of the study should be used to shape the design and delivery of palliative care education programmes within the acute hospital setting to successfully meet the needs of all clinical staff.
- Education and training
- Cultural issues
- Terminal care
- Hospital care
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The key to appropriate palliative care management in hospital settings is ensuring an adequately trained workforce.1 Within New Zealand, in line with other developed countries, the need to improve ‘generalist’ palliative carei management is well recognised.2 ,3 Within the acute hospital setting, the vast majority of health professionals provide at least some care for persons with life-limiting illnesses as an integral part of their role. It is therefore vital to ensure that clinical staff are provided with palliative care-related educational opportunities and resources to competently meet the needs of these patients.
International studies have identified that generalists often feel ill-equipped to manage patients’ palliative care needs and, in particular, struggle with identifying when a palliative approach may be appropriate.4–6 Research has also indicated a failure among health professionals to identify treatment goals, an unwillingness to engage in planning and negotiation, as well as deficiencies in skills and confidence in communication of issues related to death and dying with patients and families—all of which are core competencies in effective palliative care delivery.7–11 Moreover, integrating palliative care into the acute environment is both complex and challenging.12 Clinical staff within the acute setting, a context traditionally associated with the delivery of curative treatment, may not perceive palliative and end-of-life care provision as a priority.2 ,13 This may negatively impact the quality of palliative care delivered. A recent study identified a significant gap between policy recommendations for palliative care management by non-specialists and actual practice in English hospitals; education and training were highlighted as essential to closing that gap and ensuring an appropriate transition to a palliative approach to care was initiated.5 Similar recommendations have also been made by a number of other studies.4–6 ,14
Such recommendations are in line with wider policy goals in New Zealand,3 the UK,15 Australia,16 USA17 ,18 and Canada.19 However, the true extent of the need for education and training within the generalist palliative care workforce is unclear. In order to achieve optimum palliative care delivery, it is first necessary to create a baseline understanding of the level of palliative care education need among all clinical staff (not just palliative care specialists) within the acute hospital setting. With this goal in mind, the objectives of the present study were to examine, within the context of the largest acute hospital in New Zealand, clinical staff perceptions concerning: the quality of palliative care delivery and support service accessibility, the quality of palliative care delivery and support service accessibility, previous experience and education in palliative care delivery, perceptions of their own need for formal palliative care education, staff confidence in palliative care delivery and the impact of formal palliative care training on perceived confidence.
A descriptive cross-sectional design was selected to analyse the differences in a set of dependent measures.
A purposive sample of clinical staff members (598) in a 710-bed hospital were recruited through targeted emailsii by hospital management, advertisements through the staff e-magazine and snowball sampling procedures.iii
The hospital has in place a 14-member specialist palliative care service for inpatients and a small outpatient clinic. The team does not provide community services. A pilot advanced care planning programme was recently introduced within renal and palliative care services, with the intention of subsequently rolling out the programme across the hospital.
Data collection instrument
A web-based questionnaire informed by a systematic review of the literature of pre-existing tools20 ,21 for assessing the views of clinical staff regarding the provision of palliative care, including the palliative care education needs of staff members, was used. The tool included items adapted from two recent palliative care education needs assessments: (1) the National Audit of End-of-Life Care in Hospitals in Ireland22 and (2) the National Audit Office Value for Money study on End of Life care.23 The questionnaire contained both open and closed questions pertaining to staff palliative experience, service accessibility, perceived delivery confidence, educational needs and format of training required. Adapted items retained the response format as originally designed to allow for comparison of results with other studies and to lessen the possibility of response set bias.24 The questionnaire was divided into sections by topic and included:
Clinical Staff Perceptions of Palliative Care Provision—Staff perceptions of the quality of care for patients who died in the hospital was measured by a single 6-point item which ranged from 1 ‘very poor’ to 6 ‘excellent’.22
Service Accessibility—Respondents were asked to consider their level of access to 10 palliative care support services on a scale from 1 ‘inadequate’ to 10 ‘adequate’.22 Each item was scored individually. Combining individual responses to items created a global measure of perceived accessibility (Service Accessibility scale). Higher scores reflected a perception of greater accessibility to palliative care services (range 10–100). Information on the validity and reliability of the summative Service Accessibility scale can be found in online supplementary appendices A and B. A de novo open-ended item was also included concerning desired additional support services. Responses were condensed into meaningful categories.
Staff Experience—Clinical staff were asked to estimate the percentage of patients whom they cared for who were in the last 12 months and who would have been eligible for end-of-life care as well as the percentage of their time which was devoted to caring for patients in the last 12 months of life.23 Both of these questions required a numeric response. Clinical staff were also requested to estimate: the percentage of their end-of-life patients who would have benefitted from a palliative approach, the percentage of these patients with whom they had discussions on the subject of their approaching death and the percentage of patients for whom they had discussed end-of-life care management with professional colleagues.23 Responses to these three items were recorded in the following five categories: (1) none, (2) 1%–25%, (3) 26%–50%, (4) 51%–75% and (5) 76%–100%.
Staff Educationiv—Respondents were asked if they had received any formal palliative care training in a yes/no dichotomous question.22 This was followed by open-ended questions on the length of the course and the identity of the provider of the course.22 Qualitative data generated from these items were subjected to content analysis.24 Responses with identical or similar meaning were combined into meaningful categories. Willingness of clinical staff to participate in formal palliative care training was queried. Responses followed a dichotomous yes/no format. Suggestions for the content to be included in the formal training were also requested. Responses were also categorised based on the similarity of responses.
Staff Perceived Confidence—Participants were asked to rank how prepared they felt about caring for a patient with a life-limiting illness on a scale from 1 ‘completely unprepared’ to 4 ‘completely prepared’.23 Given the general nature of these items, a 4-point scale was selected to reduce error based on the argument of Chang25 that more response options may introduce error when respondent groups (eg, nurses, physicians) have differing frames of reference. Staff members also rated their confidence on a scale from 1 ‘not confident at all’ to 10 ‘extremely confident’ in the delivery of three palliative care-related tasks: (1) identifying when a palliative approach should begin; (2) deciding when a referral to specialist palliative care services should be made; and (3) providing palliative care. The three items were combined to create a summative scale of overall Confidence in Palliative Care Delivery. Scores for the scale ranged from 3 to 30. Higher scores indicated greater perceived confidence (see online supplementary appendices A and B).
The questionnaire also included the Cross-Cultural Confidence in Palliative Care Delivery scale (CCPCD) (Frey, Powell and Gott, 2012, unpublished data). The scale, also drawn from items included in the Irish National Audit,22 is designed to measure the respondents’ confidence in palliative care delivery to Maori, Samoan, Chinese and NZ European patient groups.v
The 44 items are each ranked on a 1–5 Likert type scale (ranging from 1—not at all comfortable to 5—completely comfortable). Scores for the summative scale ranged from 44 to 220. Higher scores indicated a greater perceived confidence (see online supplementary appendices A and B).
Reliability and Validity—Nine experts (from medicine, nursing, palliative care, epidemiology, gerontology and specialist palliative care) reviewed the preliminary version of the questionnaire for content validity. The questionnaire was further pilot-tested using cognitive interviewing techniques with six health professionals to assess the face validity of the instrument. Psychometric properties for the scales outlined above can be found in online supplementary appendices A and B.
All of the composite scales (Accessibility, CCPCD, Palliative Care Delivery Confidence) were checked for internal consistency (Cronbach's α). Convergent validity was established using the Experiences with End-of-Life scale.28 ,vi A Cronbach's α of 0.82 for this 3-item scale was recorded in the current study. Discriminant validity was established by correlating the measures with the Responding Desirably 16 (RD-16).31 ,vii Reliability for the RD-16 as estimated by Guttman's method, split halves and Kuder–Richardson methods produced reliabilities larger than 0.60.32 Split half reliabilities in the current study were 0.40 and 0.64, respectively.
This research used data from phase II of a larger project examining potentially inappropriate admissions/treatment of patients with palliative care needs, administered by researchers in the School of Nursing at the University of Auckland. Ethical approval was obtained from both Northern X and the relevant district health board. Informed consent was obtained before completion of the anonymous online questionnaire.
Quantitative data were coded into SPSS. Both descriptive (frequencies, mean, mode, SD) and inferential statistics appropriate to the level of measurement (χ2, t tests, Spearman's rviii) were employed. Qualitative data from the small number of open-ended questions surrounding requested palliative care support services were analysed by content analysis to identify recurrent themes which were condensed into meaningful categories.
A majority of the participants were nurses 50.8% (304/598). Of these, 18.1% (108/595) were members of senior nursing staff. Physicians comprised 32.1% (192/598) of the sample (consultant doctors 10.9% or 65/595, non-consultant doctors 18.4% or 110/595, clinical director—senior medical officer, resident medical officer, medical officer of specialist scale—2.8% or 17/595). The remainder of the sample included allied health professionals and members of the technical workforce (eg, renal technicians, pharmacists): 14.8% (88/595) (table 1).
Palliative care service quality and support service accessibility
The overall quality of care provided to people who die in the hospital was reported by health professionals as ‘good’ (x̄=4.17, SD=0.91).
Respondents also rated the level of access to 10 hospital palliative care support services. Cross-cultural palliative care training received the lowest rating in terms of accessibility (x̄=3.84, SD=2.21) while access to interpreter services recorded the highest mean score (x̄=7.43, SD=2.30). The clinical staff recorded an overall mean score of 50 (SD=17.71) for the Service Accessibility scale (table 2). Access to community resources was the most frequently requested (n=88) additional support service (figure 1).
Clinical staff palliative care experience and education
On average, the 598 participants reported that 18.9% (SD=22.3) of their patients were in the last 12 months of life. Consistent with this result, the 598 clinical staff members also reported an average of 19.3% (SD=23.0) of their time was spent caring for end-of-life patients. Clinical staff members recorded categorical responses concerning the percentage of patients: (1) who would benefit from a palliative approach, (2) with whom they had discussed end-of-life care and (3) about whom they had discussed care management with colleagues. In all, 266 of 598 clinical staff members selected the category of 1%–25% as indicative of the number of patients who would have benefited from a palliative care approach.ix Regarding communication, 187 of 598 respondents discussed end-of-life care plans with colleagues for a majority of these patients (76%–100% category). In contrast, most of the 198 of 598 respondents discussed end-of-life care with only a small number (1%–25% category) and 129 of 598 had no end-of life discussions with these patients (figure 2).
Turning to formal palliative care training,x 118 of 598 (19.7%) of participants had undertaken courses. However, 73.7% of respondents reported that they would like formal training. Palliative care training durations reported (n=84) ranged from less than 1 day (14.3%) to over a year (20.2%). The most frequently reported course length (26.2%) was 1 day or less (table 3).
Clinical staff members (n=381) most frequently mentioned three topics to be included in formal palliative care training: care of the dying (12.3%), pain management (11.8%) and symptom management (11.5%) (table 4).
Perceived confidence in palliative care delivery
Participants reported (1–4 scale) how prepared they felt, both professionally and emotionally, to care for a patient with a life-limiting illness. Respondents recorded mean scores of 2.83 (SD=0.66) for professional preparedness (n=598) and 2.38 (SD=0.64) for emotional preparedness (n=211), respectively. Clinical staff also rated their confidence in the delivery of three palliative care-related tasks from 1 (not confident) to 10 (extremely confident). The mean confidence scores were as follows: (1) identifying when to begin (x̄=6.02, SD=2.20); (2) referral to specialist palliative care (x=6.43, SD=2.31); and (3) providing palliative care (x̄=5.91, SD=2.33). The Confidence in Palliative Care Delivery mean scale score was 18.37 (SD=6.03).
Confidence in dealing with palliative care patients from diverse cultural backgrounds was assessed using the CCPCD scale (Frey, Powell and Gott, 2012, unpublished data). The mean score for the CCPCD scale was 133.5 (SD=33.9).
Impact of formal palliative care training
Independent samples t tests indicated that respondents with formal palliative care training had significantly higher mean scores for professional preparedness (x̄=3.21, SD=0.55) in comparison with those without formal training (x̄=2.72, SD=0.66) (95% CI 0.34 to 0.60). Likewise, clinical staff with formal palliative care training recorded significantly higher mean scores for emotional preparedness (x̄=2.83, SD=0.37) in comparison with those without formal training (x̄=2.29, SD=0.64) (95% CI 0.31 to 0.75). Independent t tests also indicated significant differences in total confidence scores in the delivery of three palliative care tasks between those respondents with formal palliative care training (x̄=22.19, SD=4.69) and those without formal training (x̄=17.43, SD=5.95) (95% CI 3.7 to 5.8). In terms of cross-cultural palliative care delivery confidence, independent sample t tests indicated that clinical staff with formal palliative care training had significantly higher mean cross-cultural confidence scores (x̄=149.93, SD=30.54) in comparison with those respondents without formal palliative care training (x̄=129.65, SD=33.56) (95% CI 12.3 to 28.2). The results suggest that formal palliative care training increased perceived confidence in palliative care delivery.
The effect of the length of the formal palliative care course on participant confidence was also measured. Results of Spearman's r rank order correlations indicated that for those participants with formal palliative care training (n=118), there was a significant positive relationship between length of training and measures of perceived confidence in palliative care delivery (table 5).
Practice and service accessibility
Using categorical response format: (1) none, (2) 1%–25%, (3) 26%–50%, (4) 51%–75% and (5) 76%–100%, clinical staff reported the percentage of patients with whom and about whom they had discussions concerning managing end-of-life care. In comparison with those participants without formal palliative care training (n=480), participants with formal training (n=118) had reported end-of-life discussions with a greater percentage of their end-of-life patients (χ2 (4)=30.78, p=0.000) and also had reported discussions with colleagues about managing end-of-life care for a larger proportion of their end-of-life patients (χ2 (4)=14.09, p=0.007). The results of an independent t test also indicated that clinical staff with formal palliative care training had a significantly higher mean Service Accessibility Scale score (x̄=58.12, SD=17.8) compared with clinical staff without formal palliative care training (x̄=47.35, SD=16.8) (95% CI 6.7 to 14.7).
The present study highlights inadequate palliative care education as a major concern at the time the study was conducted. Only 19.7% of respondents reported having any formal palliative care training, although 73.7% believed they would benefit from increased palliative care knowledge and/or skills. This lack of formal training may impact on the quality of care delivered. Previous research indicates that inadequacies in the palliative care training of health professionals can contribute to less-than-optimal care provision.34 Clinical staff in the present study with formal palliative care training had end-of-life discussions with a greater percentage of their end-of-life patients, and had discussions with colleagues about managing end-of-life care for a larger proportion of their end-of-life patients compared with clinical staff lacking formal palliative care training. A lack of confidence in palliative care knowledge and skills, as reported in the studies’ results, can also be seen as an indicator of potential areas for concern regarding the level of palliative care knowledge and skills among the hospital clinical staff. Previous research has indicated that lack of confidence in one's abilities can negatively impact on performance.1 ,30 Research by Brazil et al,35 although focused on nursing home residents, also found that a major predictor of quality care provision to dying patients was a nurse's level of confidence in discussing issues of death or dying with family.
Although much has been written concerning the impact of palliative care training on clinical staff confidence and competence,36 as well as a large amount of research concerning the content or type (eg, classroom, seminar, e-learning) of palliative care education, a review of the literature has failed to uncover research dealing specifically with the impact of the amount of training on clinical staff confidence or competence. Although the present research indicates the positive impact on clinical staff of courses of even short duration, the research also highlights the benefits of longer courses. Evidence from educational research on the impact on performance of course length is mixed showing that shorter courses can either benefit student performance or make no significant difference.35 ,37
In terms of palliative care service needs, the results highlight variability in perceived accessibility of services with clinical staff with formal palliative care training recording higher scores for perceived accessibility. These variations in perceived accessibility along with suggested additional palliative care services can be viewed as areas that the clinical staff members believe are in need of improvement. This interpretation is consistent with the results of a previous study of health provider perceptions of palliative care support needs.38 In particular, support services related to culture were emphasised as an area in need of increased support mechanisms.
Limitations and recommendations
Respondents to this survey represented a convenience sample and were non-randomised and non-uniform across the hospital under study. Non-responders, including most consultant doctors, may have potentially biased the results. Possible explanations for this lowered response rate among physicians vary. Previous research has demonstrated that doctors, particularly specialists, are more likely to respond to a personalised approach.39 In addition, research indicates that internet surveys produce significantly lower response rates in comparison with mail surveys for this group.40 Conducting this survey retrospectively without a pretest for comparison requires some caution when drawing conclusions. Furthermore, it could also be argued that responses to some questions may have been shaped by the desire to demonstrate the quality of care provided. This possible source of bias could have been counter-balanced by a perception of the survey by respondents as a forum to advocate for additional supports. Despite these potential sources of bias, the results demonstrate the impact of formal palliative care training on clinical staff confidence. It is recommended that the questionnaire be administered at other acute hospitals across New Zealand and internationally to gain a broader understanding of the palliative care education needs of healthcare professionals.
The acute care environment, patient characteristics and the healthcare professional's confidence in the ability to deliver palliative care effectively all impact on the provision of optimum care. The timely recognition of the need to change trajectory to a palliative approach is vital to achieving appropriate care. One way to enhance this goal is through the development and enhancement of interdisciplinary palliative care education within the hospital setting. Continued commitment to the development of staff education and support would be an effective method to address the challenges identified in the present research. On a broader level, a strong case has been made for the significant impact that formal palliative care training can have on clinical staff confidence in care delivery. The results of this research provide information regarding the key role played by multidisciplinary palliative care education within the New Zealand context in improving the quality of care of patients with palliative care needs.
We would like to thank all study participants and HRC Committee members for their assistance in the development and dissemination of the questionnaire.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online appendices
Contributors All authors were involved in the conception, design and implementation of the research. RF, MG and DR were involved in the data analysis and interpretation, and drafting of the paper. All authors were involved in the review and approval of the final article for publication.
Funding The study was funded by the Health Research Council of New Zealand (reference: 10/815).
Competing interests None.
Ethics approval Ethical approval was obtained from the Auckland Region Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
↵i ‘Generalist palliative care’ has been defined as ‘palliative care provided for those affected by life-limiting illness as an integral part of standard clinical practice by any healthcare professional who is not part of a specialist palliative care team…. It is provided in hospitals by general ward staff, as well as disease specific teams – for instance oncology, respiratory, renal and cardiac teams.’2
↵ii Emails disseminated to all hospital staff are prohibited by hospital policy.
↵iii 925 questionnaires were distributed, 600 completed questionnaires were returned and two questionnaires were disqualified based on respondent role (non-clinical).
↵iv Previous research by Sullivan et al26 reporting the results of an educational intervention indicated measureable improvements in confidence in palliative care delivery for physicians and nurse educators.
↵vi Originally designed by Smith et al29 and modified by Billings et al,28 the Experiences with End-of-Life scale30 is designed to record the frequency of observation and performance of end-of-life healthcare tasks. Frequency in this context is defined as measure of experience. Billings et al28 reported a Cronbach's α of 0.69.
↵viii Spearman's r rank order correlation was chosen as the appropriate statistic to examine the relationship between perceived confidence and course length, as length of course was measured at the ordinal level.
↵ix Based on the New Zealand Ministry of Health definition of palliative care as ‘Care for people of all ages with a life-limiting illness which aims to: 1) optimise an individual's quality of life until death by addressing the person's physical, psychosocial, spiritual and cultural needs and 2) support the individual's family, whanau, and other caregivers where needed, through the illness and after death.’33
↵x Formal palliative care training was defined as the reported amount of palliative care workshops, seminars, short courses and/or degree programmes undertaken by the clinical staff.
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