Literature Review of Newly Graduated Nurses' Perceptions of Preparation to Provide Palliative Care in Hospitals

Saturday, 28 October 2017

Latrina T. Geyer, MSN
Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, USA

A comprehensive review of existing and evolving substantive nursing knowledge was conducted to first identify background, scope, and significance of caring for seriously ill persons in healthcare. Further, the review of literature sought to identify the education standards, recommendations, guidelines, and competencies in baccalaureate degree nursing programs. Finally, the review of literature sought to explore newly graduated nurses’ perceptions of preparation to use palliative care principles in the care of seriously ill patients and their families in acute care settings. This poster presentation will summarize the comprehensive review of literature and include gaps identified in the literature which should be addressed in future studies.

To identify the significance, scope, and background of palliative care, Google Scholar; CINAHL; PubMed; OVID; and JSTOR search engines and databases were utilized to conduct an exhaustive review of the literature. Further, to determine education standards, recommendations, guidelines, and competencies related to palliative, hospice, and end-of-life care for nursing programs as well as relevant population statistics, online resources were accessed including the American Association of Colleges of Nursing (AACN); The Institute of Medicine (name of The Institute of Medicine changed to The National Academy of Medicine, effective July 1, 2015); the Quality and Safety Education for Nurses (QSEN) Institute; the Hospice and Palliative Nurses Association (HPNA); the Centers for Disease Control and Prevention (CDC); and the United States (U.S.) Census Bureau.

Preparation of nursing students in baccalaureate degree programs to care for individuals receiving palliative, hospice, and end-of-life care is recognized as a global health priority. The AACN (1997) document entitled Peaceful Death: Recommended Competencies and Curricular Guidelines for End-of-Life Nursing Care; The Institute of Medicine’s (2011) document called  The Future of Nursing: Leading Change, Advancing Health; The Institute of Medicine’s (2015) document entitled Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life; and AACN’s (2016) document entitled Competencies and Recommendations for Educating Undergraduate Nursing Students (CARES) represented the most widely referenced documents which articulate the significance of palliative, hospice, and end-of-life care for nursing and healthcare. Additional sources which demonstrated the significance and urgency for nursing practice and nursing research related to end-of-life and palliative care included the National Institutes of Health (NIH) and National Institute of Nursing Research (NINR). End-of-life/Palliative care is listed as one of five NINR-supported research funding priorities for nursing research. Attending to the physical, psychological, spiritual, and population health needs of persons of all ages diagnosed with a chronic, serious, life-limiting illness are fully supported as the responsibilities and priorities of a caring workforce.

In their report on Dying in America (2014), The Institute of Medicine (IOM) addressed the pressing need to improve end-of-life care. The IOM listed four factors burdening the nation’s healthcare system. One such factor was the inadequate numbers of palliative care specialists and too little palliative care knowledge among other clinicians who care for individuals with serious advanced illness. According to the IOM, “although palliative care is well established in most large hospitals and professional education programs, the committee identifies the need for greater understanding of the role of palliative care—by both the public and care professionals—as one of the greatest remaining challenges in the delivery of high-quality end-of-life care” (p. 2). Finally, organizations such as HPNA (2015) and the National Consensus Project (2013) have set standards and recommendations for nursing education. Key focus areas addressed included quality of clinical palliative nursing experiences for nursing students, registered nurses, and advanced practice registered nurses (APRN); utilizations of standard competencies for palliative nursing practice; and improved care of individuals with serious illness by assuring knowledge, skills, and competence of nurses through palliative nursing education.

While there is much documentation on the importance and significance of preparing nursing students to deliver high-quality palliative and end-of-life nursing care, approaches to incorporating palliative nursing and end-of-life care principles into nursing curricula and nursing research is scarcely documented (Adesina et al., 2014, Bassah, 2014; Watts, 2014). Further, Mizell et al. (2014) reported “most nurses are not taught the full scope of end-of-life care in nursing school” (p. 103). These sentiments are echoed in essentially all of the materials covered for this review of literature (AACN, 2008; Bassah, 2014; Bush, 2013; Ek, 2014; Ferrell, et al., 2016; Hermann, 2016; Kelly, 2011; Northam, 2015; O’Shea, 2015; Pfitzinger, 2015).

Also of note in the literature are misconceptions related to palliative care, hospice, and end-of-life that are due in large part to the incorrect use of the terms. The terms palliative care, hospice, and end-of-life are often used interchangeably, in the public as well as by healthcare professionals. Several publications make note of the importance of the distinctions between the terms (O’Shea, 2015; Watts, 2014). This clarification is needful for nursing students. While the populations affected may be the same, clearly defined terms recognize the focus and goals of care for each is uniquely different. An understanding of the role is enhanced by an understanding of the terminology, scope, and standards for each. Further, Perrier et al. (2016) stated, “The growing need and demand for palliative care means that healthcare professionals are expected to provide palliative care as a core part of their practice. In fact, healthcare professionals have an ethical and legal responsibility to ensure quality palliative care across the continuum of healthcare provision” (p. 887).

In several publications, education standards, recommendations, guidelines, and competencies of palliative care and end-of-life care were linked directly to the essentials of baccalaureate and master’s education for nursing programs (AACN, 2008; AACN, 2011; Ferrell et al., 2016; HPNA, 2015; Northam et al., 2015). Key principles of palliative care included pain and symptoms assessment and management; cultural and spiritual considerations; ethical, communication, and quality considerations at end of life; loss, grief, and bereavement; and preparation for and care at time of death (AACN, 2008; Kelly et al., 2011). According to Kelly et al. (2011), palliative nursing care education that prepares nurses to provide competent pain and symptom management and consideration of the “whole person” (p. 193) will greatly improve the quality of care and quality of life.

Recent and relevant research studies have been conducted with undergraduate nursing students at varying stages of their undergraduate nursing program to identify their attitudes, beliefs, and perceptions of palliative care, hospice, and end-of-life education and clinical preparation (Adesina et al., 2014; Goodwin et al., 2013; Henderson et al., 2016; Hold, 2015; Perrier et al., 2016; Osterlind et al., 2016; Verschuur et al., 2014; and Watts, 2014). In a summary of findings, Watts (2014) noted “much has been done internationally to incorporate palliative care into pre-registration nursing education curricula (Ballesteros et al., 2014; Bush, 2012; and Jacono et al., 2011; as cited in Watts, 2014). Although studies have investigated students’ experiences of palliative care education (Ballesteros et al., 2014), there is a dearth of empirical evidence of the effectiveness of education initiatives on professional practice and patient outcomes. Further, Perrier (2016) wrote that “further research is needed on the contribution of such education in the development of competencies and in the access, quality and improvement of palliative care provision in this country” (p. 887). Moreover, Adesina et al. (2016) noted “the literature suggests that many registered nurses (RNs) and nursing students feel inadequately prepared by their nursing education to provide EoLC and emphasizes the need for continuing education in this area of nursing (Dickinson et al., 2007; Hughes et al., 2006; Leighton and Dubas, 2009; and Mutto et al., 2010).

Many studies have documented undergraduate nursing students’ beliefs and attitudes toward care of the dying as well as perceptions and meanings associated with caring for the actively dying in hospice settings. Further, these and other studies question whether undergraduate nursing education is adequately preparing nursing students to provide EoLC” (p. 396). Moreover, what is not known, and is of chief importance in this review of literature, is the impact of theoretical knowledge of palliative care and utilization of palliative care principles in caring for seriously ill patients with life-limiting illnesses in acute care settings.

Healthcare in the United States is greatly impacted by escalating costs associated with advances in technology, pharmaceuticals, skilled care, and life-sustaining treatments. Morbidity and mortality of the U.S. population aged 65 years and over was estimated at 44.7 million according to the 2013 U.S. census. Further, as many acute care hospitals move to outcomes-driven, value-based reimbursement institutions, attention must be given to all areas of the health-illness continuum. Quality of life and outcomes for patients with chronic life-limiting illness are greatly influenced by preparation, experience, and care delivery. A review of the literature indicates palliative care is a concept poorly understood by nurses in non-hospice settings. Moreover, newly graduated nurses who may lack palliative care and end-of-life care nursing preparation, and years of acute care experience may lack competence, confidence, and clinical judgment necessary to improve quality of life outcomes for the seriously ill in acute care settings.