Palliative Care Education: Does it Influence Future Practice

It is generally recognised that there is a need for nursing education to incorporate palliative care education within undergraduate programs in order to meet the professional and personal demands made upon nurses when providing end of life care [1,2]. Whilst historically, palliative care was confined to patients with cancer, it has now become a form of care offered to patients experiencing an incurable chronic disease [3]. With an ageing population it is expected that an increasing number of patients will require palliative care in a variety of settings including, a person’s own home, nursing homes, hospices, and virtually every clinical setting within acute care [4]. Nurses play a pivotal role in palliative and end of life care [5] and such care is recognised as being largely provided by nurses [6]. However, for this care to be effectively delivered requires nursing curricula to include discrete palliative care topics in order to help nursing students to be better prepared to assist palliative patients and their families [5]. *Corresponding author: Tony Bush, RMIT University, Nursing & Midwifery, PO Box 71, Bundoora, Victoria 3083, Australia, E-mail: tony.bush@rmit.edu.au Received December 07, 2011; Accepted April 21, 2012; Published April 24, 2012 Citation: Bush T (2012) Palliative Care Education: Does it Influence Future Practice. J Palliative Care Med 2:113. doi:10.4172/2165-7386.1000113 Copyright: © 2012 Bush T. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Background: It is generally recognised that there is a need for nursing education to incorporate palliative care education within undergraduate programs in order to meet the professional and personal demands made upon nurses when providing end of life care [1,2]. Whilst historically, palliative care was confined to patients with cancer, it has now become a form of care offered to patients experiencing an incurable chronic disease [3]. With an ageing population it is expected that an increasing number of patients will require palliative care in a variety of settings including, a person's own home, nursing homes, hospices, and virtually every clinical setting within acute care [4]. "Nurses play a pivotal role in palliative and end of life care" [5] and such care is recognised as being largely provided by nurses [6]. However, for this care to be effectively delivered requires nursing curricula to include discrete palliative care topics in order to help nursing students to be better prepared to assist palliative patients and their families [5].
It is anticipated that the majority of patients in need of palliative care will depend on student nurses and graduate nurses who, whilst not experts, are nevertheless familiar with the principles and practice of palliative care [1,7]. The dependency will arise because of a perceived shortage of nurses with expertise in palliative care.
Traditionally nurses have not received adequate education in the care of the incurably ill patient and nursing education has not been seen to be sufficiently effective in preparing student nurses to care for this class of patients [8]. However, nursing students reported increased satisfaction with their ability to deliver end of life care when end of life education and palliative nursing care had been adequately provided within their nursing education [9,10]. Improvements in nursing students' knowledge and clinical competence were reported to be related to the inclusion of palliative care education within nursing programs and accordingly it has been recommended that palliative care education is included in the basic nursing curriculum [11,12]. The Australian Government has addressed the need for the inclusion of palliative care in all disciplines of health care through the funding of Palliative Care Curriculum for Undergraduates, PCC4U Project.
Currently, there is a paucity of Australian evidence to identify whether the teaching of palliative care subjects can influence a nursing student's perceived clinical competence in the provision of fundamental palliative care practices.

The Study
Aims: The aim of this research study was to determine if the completion of a Oncology and Palliative Care elective course aided a group of undergraduate nursing students in the clinical provision of palliative care. The course is offered to Year 3 students of the Bachelor of Nursing program and is held for 3 hours each week within Semester 2. The Oncology content constituted 70% of the course whilst the Palliative Care content constituted 70% of the course and consisted of a selection of palliative care problems and related treatments, together with psychosocial, ethical and spiritual concerns often encountered in palliative care. A considerable part of the Palliative Care material was guided by PCC4U outlines and recommendations.

Design
A descriptive/explorative mixed methods study was conducted which consisted of two phases. This paper presents the results from the phase one.

Questionnaire and sample:
In the first phase a questionnaire was sent to 70 third year nursing students at a Victorian University who had recently completed the Oncology and Palliative Care Course. The questionnaire was developed specifically for the study and used a Likert scale with provision for qualifying comments (Appendix). It elicited information about the reasons for selecting this course, how much the specific topics influenced students' perceived ability to care for a person who is incurably ill, whether students would elect to work in palliative care following the completion of this course and how much influence the various teaching processes played in assisting the students' understanding of palliative care practices. Comments were also sought regarding the amount of influence played by each of these categories in determining the students' responses.
In the second phase a group of third year students from the same cohort were selected to participate in a Focus Group discussion on the most effective ways of teaching palliative care.
Ethical permission: A low risk Human Research Ethics approval was granted by the Sub-Committee of the School of Health Sciences and formal written consent was obtained from the participants.

Results
From a cohort of third year students who undertook the oncology and palliative care course, 70 students were randomly selected from an enrolled cohort of 109 students and 51 (73%) students returned the completed survey. The demographic characteristics of study participants included 7 male and 44 female with 25 participants within the age group 20-25, 11 participants within the age group 26-30 and 15 participants over the age of 31. These numbers were a fair representation of the 3 rd Year nursing cohort. All participants (100%) indicated that the Oncology and Palliative Care course influenced their perceived ability to be clinically competent in the facilitation of palliative care (43% indicated moderate degree, 57% large degree). No respondent indicated less than a moderate degree and was instrumental in determining overall that the course had succeeded in its aim of aiding undergraduate students in the clinical provision of palliative care.
The participants were asked about their reasons for undertaking the course. Seven participants (14 %) cited some form of personal experience (i.e. someone known to them who was diagnosed with cancer or experiencing a terminal illness) that prompted them to undertake the course. The remainder of comments focused on why participants felt the course was important for nursing (Appendix). All comments were positive such as stated by (S27) "Palliative care should be a core unit as it teaches special skills that could be used in all areas of nursing". Other influential variables that were mentioned included the lecturer's influence (S6), course resources (S25), benefits of doing the assignment (S37), and the benefits of the take home exam (S38). The main theme in the remainder of responses outlined how the course as a whole provided clear insights into the provision of palliative care, as evidenced by (S7) "the knowledge (of palliative care) gained in this course is relative to so many areas of nursing and has given me a good clinical foundation to use throughout my nursing career".
Eleven participants (22 %) indicated that they were positively influenced by the course in requesting a placement within a palliative care/oncology setting. However, eight (16 %) commented that requests for placement had already been submitted before undertaking the course, and 12 participants (22%) noted that they were not influenced by the course in this decision because they had (i) already worked in a palliative care/oncology setting, and (ii) previously decided on an alternative setting for placement respectively.
Twenty-six participants (50 %) felt the course had positively influenced them to apply for a clinical position in a palliative care/ oncology setting, either immediately, or in the future as illustrated by (S42) "At the beginning of the Bachelor of Nursing course I would have never considered working in palliative care. Through undertaking the oncology and palliative care course my perspective has changed and I would consider working in that area later in life".
While two participants (4%) commented that they had always wanted to work in palliative care and for that reason the course did not influence them. A further four (8%) felt that palliative care was not the right area for them, as exemplified by (S32) "I think that caring for people who are dying and the issues they encounter would not be something I would be good at dealing with so I'm not keen to work in this area".
Twenty-five participants (50%) commented that the course influenced their attitude about oncology and palliative care, including making a choice to work in the area. Examples of these comments included, "I feel I have found my interest and niche in nursing." (S42) and "this course influenced me to take a more serious interest in palliative care to the extent that I want to make a career path out of it" (S38). ''Prior to undertaking the course end of life care was a deeply unpleasant task that I preferred not to think about…I am now of the opinion that providing palliative care is challenging and highly rewarding" (S5).
Eight (16%) said they did not want to work in the area, but still spoke favourably about the course as noted by (S43) "I have other areas of interest, but I thoroughly enjoyed the course and do believe I will use knowledge gained from it".

Discussion
More females than males indicated a higher appreciation for the inclusion of palliative care within the undergraduate program. Similarly it is not evident why more female students than males were influenced by the inclusion of affective palliative care subjects whilst the males were more influenced by the more traditionally scientific domains of oncology in determining their ability to clinically care for someone who is incurably ill. Certain nursing specialities are highly technical and these domains have a history of being within the masculine domain. Further, it has been argued that men gravitate to speciality areas that have a minimum of touch and it's probable that the males don't perceive palliative care to fall into that category [13]. The females however, might have selected the domains of loss, grief and bereavement, as this was viewed as being more representative of care and caring than oncology and so reflected their understanding of nursing as a 'caring profession' [14]. Paradoxically a greater number of males requested a rotation through a palliative care setting following the completion of the Course. Whilst it is not possible to determine why this was so, insights into the decision making can be gleaned from some of the qualitative comments made by the male students, such as that identified by (S5) in Results. The ratio of female to male respondents probably represented the usual gender mix of students within the total nursing student population. However, there was no difference by gender among the cohort in relation to their capability of providing palliative care where all participants indicated that they were clinically capable of providing palliative care following the completion of the course. Thus, it can be inferred that there is a strong relationship between the learning and understanding of palliative care principles and practices with clinical capabilities.
The students also indicated how the course had a positive influence on their learning of palliative and end of life nursing care. As well, the majority of students pointed out that they would consider applying for a position in palliative care even though they had not previously considered this prior to commencing the course. This was a very similar finding to Mallory [8] who inferred that appropriate education can have a positive effect on nursing students electing to work with people with an incurable illness.
The students remarked on the positive influence a good lecturer had on their learning of challenging and complex topics by sharing with them real life clinical scenarios. These comments about the scenarios were supported by the literature which clearly indicates that students learn from "hearing stories about actual clinical events" [15] and was reflected in this study where the majority of students commented very positively on the use of current clinical experience situations that the lecturer provided them with, as a way of exploring palliative care topics. Rosser [11] also found that effective teaching of palliative care was greatly influenced by having a qualified and clinically current teacher in this field of study and emphasised that palliative care should be taught as a discrete core subject in an undergraduate nursing curriculum. Opportunities for high levels of interaction with peers and the lecturer was considered conducive to learning especially when combined with hearing stories of actual clinical experiences from the lecturer. These factors have been identified as being integral to successful learning [15,16] and helped to provide the students with a sense of clinical competence in the provision of palliative care.
This study was primarily interested in determining if exposure to formal classes in palliative care influenced students' assessment of their skills preparation to provide such care in a clinical setting. Whilst it appears that this question was answered it would be unwise to generalise these findings to a larger population due to the number of participants involved in the study. Subsequently any future research will need to focus on future cohorts of undergraduates who have completed the Course in order to replicate this study's findings. Similarly a further focus might be on the effect of this course in determining students' clinical preferences upon graduation.
Nurses have an important role to play in the provision of palliative care and end of life care [5,17]. Approximately 77,000 people each year are diagnosed with a terminal illness in Australia and given that most of these people will require skilled nursing care, it is important for nursing curricula to include end of life care to allow nurses to respond effectively to the needs of those persons with an incurable illness [18]. However, there is a lack of discrete content in palliative care within undergraduate nursing programs that is linked to the absence of discrete teaching by expert teachers resulting in poorly prepared nurses who are not clinically capable of providing palliative care [11,18]. It is hoped that the education resources provided by PCC4U will aid in the inclusion of palliative care as a discrete course within undergraduate nursing programs. This study's findings reinforced the importance for students to have an opportunity to explore specialised topics within a single program and how this opportunity encouraged them to participate in learning that underpinned their clinical practices. A moderate percentage of students chose to undertake this course due to personal experiences with incurably ill people and may indicate a pre-existing personal interest in palliative care and that they viewed this particular course as being able to provide them with a deeper theoretical knowledge that could be translated into clinical skills. The findings of this study clearly indicate that this group of third year nursing students appreciated the opportunity to undertake a course in palliative care. They enrolled in the course with varied expectations of the outcomes and in general they appreciated what the palliative care course offered them.

Limitations
It is acknowledged that it is not possible to generalise the findings to the total population of third year students and thus the results should be treated with caution yet a 73 % return rate arguably indicates the third year students' perceptions of the importance of the palliative care course to their clinical practice. As well, it is not known if the findings would be restricted to a Year 3 cohort of student nurses and what findings might arise with a different cohort of nursing students. Similarly there is the possibility of a favourable bias towards palliative care given that the students selected themselves for the elective course.

Conclusion
Whilst demands for nurses with palliative care capabilities are likely to increase over the forthcoming years it appears that a major part of ensuring that nurses are clinically able to provide such care depends on their having participated in a discrete palliative care learning program that will equip them with the specific skills underpinning palliative care practices. Our findings suggest that nursing students believe that a discrete course in palliative care should be a core component of an undergraduate nursing program and that they are very receptive to learning that is considered to be relevant to practice, actively engages them in learning and provides them with opportunities to explore topics outside of their prescribed material. These findings have implications for ensuring that any similar course in palliative care is conducted by skilled lecturing staff and that nursing students have access to appropriate clinical placements in palliative care to further enhance the students' clinical capabilities.