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Original Article

American Journal of Hospice & Palliative Medicine®

2023, Vol. 40(2) 117–121 © The Author(s) 2022 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/10499091221094313 journals.sagepub.com/home/ajh

Improving Critical Care Nurses Perceived Self-Efficacy in Providing Palliative Care: A Quasi-Experimental Study

Christina DeFusco, RN, BSN, CCRN, Auriel Lewis, RN, BSN, and Tanya Cohn, PhD, MEd., RN

Abstract

Background: Palliative care is a service that focuses on quality of life and symptom management. It is particularly important for patients with chronic disease. Palliative care in general is an underutilized service for various reasons. Many nurses have only learned about palliative care from experience and express a need for more education. Purpose: This study focused on educating critical care nurses on palliative care through online training videos. This quasi-experimental study aims to determine if an online palliative care educational program improves critical care nurses’ self-efficacy in providing palliative care. Procedures: The study was conducted using a pre-survey and post-survey that was created with a validated tool called the Palliative Care Self-Efficacy Scale. In between the surveys, the respondents were directed to online education.Main Findings: The overall Palliative Care Self-Efficacy Scale showed a median score of the Palliative Care Self-Efficacy Scale increased from pre education (Md=38) to post-education (Md = 43.5), z = -4.868, p <.001, with a large effect size (r = -.76). Principal Conclusions: The majority of critical care nurses have received some form of palliative care education. Online resources similar to the VitalTalk videos and handouts provide added education and improve perceived self-efficacy in providing palliative care in both psychosocial and symptom management aspects of care. The data suggests that improvements to access to education can be done by employers. Further studies can be done to assess current access to palliative care education in undergraduate nursing programs.

Keywords palliative care, hospice, education, critical care, intensive care, nurse, self-efficacy, multidisciplinary

Introduction

According to the CDC life expectancy was steadily increasing until the COVID-19 pandemic. Since the pandemic life ex- pectancy has declined 1.5 years in 1 year.1 Despite this de- cline, Americans are expected to live to an average of 77.3 years as of 2020 per the CDC.1 This, along with health problems related to the pandemic, means providers are seeing patients with more chronic health problems. Palliative care is a service that can help prolong the quality of life of all people, yet it is an underutilized service, particularly among minorities and those of lower socioeconomic status. The WHO estimates that worldwide about 40 million people need palliative care and only about 14% of those people receive it.2

Palliative care is a specialty focused on improving the quality of life for patients and families that are suffering from chronic disease by providing relief of symptoms and stress. Palliative care not only provides important quality of life services to patients, but it can also be a cost-saving service. It is estimated that 6 billion dollars of annual healthcare

spending could be saved if palliative care was fully integrated into the hospital system.3

Palliative care is a sector of healthcare that can improve the patient experience while saving money, but the challenge is that the topic of palliative care often relates to end-of-life decisions, which can be difficult for healthcare professionals, patients, and families. Nurses, providers, and the entire healthcare team require support and education on this topic so that they feel comfortable with the discussion of options and providing the care. This would in turn allow the patients to feel comfortable and get the best possible care. Formal education for both providers and nurses is lacking. Most medical school programs include end-of-life education more consistent with

Department of Nursing, Simmons University, Boston, MA, USA

Corresponding Author: Christina DeFusco, Department of Nursing, Simmons University, 300 Fenway, Boston, MA 02115-5898, USA. Email: [email protected]

hospice care.4 Hospice care can be a part of palliative care, but it is not 1 of the same. In undergraduate nursing schools, it was found that only 11% of programs offered a palliative care course, and most schools provided “1 or 2 lectures” on palliative care.5

American Association of College of Nursing (AACN) made it a goal in 2016 to increase palliative care education in under- graduate nursing programs.6 Specifically this initiative is re- ferred to as CARES, which stands for Competencies And Recommendations For Educating undergraduate nursing stu- dents, which includes 17 competencies that all nursing students should receive before graduating.6 While this is extremely important, we need to also focus on nurses already practicing. Many nurses have only learned about palliative care from ex- perience and both the nurses and patients deserve more support.

The topic of palliative care is extensive and so is the topic of educating healthcare professionals. This literature review and this study focused on educating nurses because nurses spend the most time at the bedside with the patient and it can be argued that nurses have the best understanding of the patient from a holistic point of view. Nurses can do education with their patients on what palliative care is, what options they have, and be a voice for the patient in discussions with the medical team. According to Aslakson et al,7 palliative care is an integral component of caring for critically ill patients during their entire admission, it should not be introduced only after failed attempts of life-prolonging treatment. Critically ill patients tend to have chronic diseases, and many are experiencing exacerbations, long hospital stays, and readmissions. These are the patients that could benefit immensely from palliative care.

Critical care nurses have the challenge of providing treatment that can be lifesaving, but this environment also lends itself to many palliative care opportunities. Critical care nurses should be educated and confident in palliative care, but this is not the case. In an article published by the American Association of Critical-Care Nurses they state that COVID-19 has amplified the need for integrative palliative care in the critical care setting8. Critical care and palliative care cannot be separated yet palliative care should be integrated into critical care with symptom management protocols, communication frameworks and goals-of-care discussions. The article states that these improvements will decrease burnout and improve patient quality-of-life. In a survey of critical care nurses most respondents perceived palliative care competencies as highly important, but fewer than 40% rated themselves highly competent in any single competency.9 The American Asso- ciation of Critical Care Nurses suggests that both nurses and patients reference CAPC and VitalTalk for information about palliative care.10 VitalTalk is the source for the education that was provided to the nurse participants.

Similarly, Price et al.11 found that critical care nurses had concerns about communication, decision making, and facili- tation of continuity of care concerning palliative care. Nurses that have been practicing for more than 10 years had a sta- tistically significant increase in perceived competency in pal- liative and end-of-life care when compared to nurses that have

been practicing for less than 10 years. They concluded that these findings should guide development of educational pro- grams that address specific unit needs according to the patient population, acuity, and staff characteristics.11 There is little evidence about what the best education strategy is for educating critical care nurses, but as Pesut and Greig12 concluded in their review good outcomes on both knowledge and confidence in palliative care result from a variety of educational content, delivery methods, and duration. In this study an online, in- dependent, and short duration educational program that AACN suggests was evaluated by analyzing how critical care nurses improved their palliative care self-efficacy after completing the education.

Improving the utilization of palliative care requires a mul- tifaceted approach that can perhaps begin with the improvement of the nurse’s comfort with referring a patient and having conversations about palliative care. The research shows that nurses are largely uncomfortable with their level of knowledge about palliative care, which results in low screening and referral rates.9 Therefore, this quasi-experimental study aims to deter- mine if an online palliative care educational program improves critical care nurses’ self-efficacy in providing palliative care.

Methods

This was a quasi-experimental study that was based on a survey conducted before and after the implementation of an educational intervention. The pre-survey and post-survey were created with a validated tool called the Palliative Care Self-Efficacy Scale.13 The educational intervention was 5 videos and two documents from the VitalTalk website (https:// www.vitaltalk.org/topics/nurses-role/). University IRB approval was obtained. Informed consent was obtained from each par- ticipant and participants had the option to answer as little or as many questions as they chose. The researchers decided to not use incomplete data as sufficient complete data sets were available to analyze and create significant results. Almost all of the incom- plete data resulted from participants not completing the post- survey and therefore the data was not useful in our analysis. No identifying personal information was collected from the participants.

Data collection

Sample

A convenience sample of self-identified critical care nurses from Facebook groups was utilized. Based on previous evi- dence by Dehaghani14 a power analysis was conducted for a two-tailed paired t-test with an alpha of .05, a power of 80%, and a calculated effect size of .45 resulting in a needed sample of 41 participants. Nurses with critical care experience were the targets of the study. Demographics collected included: years of critical care experience, critical care specialty, and previous palliative care training. Exclusion criteria included

118 American Journal of Hospice & Palliative Medicine® 40(2)

nurses who were not previously or currently working as critical care nurses. A Qualtrics survey was created using the Palliative Care Self-Efficacy Scale and posted to multiple Facebook pages that focus on critical care nurses.

Palliative care self-efficacy scale

Research data collection was done through an online survey utilizing the Palliative Care Self-Efficacy Scale.12 This scale was based on a four-point Likert scale. Participants completed the 12 questions on the scale before and after completion of the educationmaterial. Questions on the scale are rated as 1 – “Needs further basic instruction”, 2 – “Confident to perform with close supervision/coaching”, 3 – “Confident to perform with min- imal consultation”, and 4 – “Confident to perform independently”.

The 12 questions were divided into two domains – psy- chosocial support and symptom management. The lowest score a participant could obtain was 12 and the highest was 48. Participant ratings of each of the 12 items were then calculated and divided by the total number of questions to reveal an overall self-efficacy score before and after the educational intervention.

The Palliative Care Self-Efficacy Scale has been proven as a valid and reliable tool as evidenced by a study byMason and Ellershaw.15 The scale has a content validity of 1.0, an internal consistency of .67 - .82, and has been utilized in several research studies.16 The overall internal consistency for this study was a pre-test of .908 and a post-test of .939. The in- ternal consistency pre and post were independently analyzed for the psychosocial support questions and was .809 and .861 respectively. The internal consistency pre and post were in- dependently analyzed for the symptom-management based questions and was .909 and .925 respectively. The palliative care self-efficacy scale proved to be a highly reliable tool both as a whole and when broken down into the psychosocial domains and the symptom management domains. This means that there was a sufficient amount of items to capture the concept adequately.

Intervention

The intervention for this study included the implementation of the Vital Talk education videos as well as 2 handouts provided by VitalTalk to further assist in education. The Palliative Care Self-efficacy Scale13 was used as a tool to assess the change in self-efficacy before and after the intervention.

The VitalTalk educational videos were 5 videos that were about 25 minutes total and included topics on Palliative Care: A Bedside Nurse’s Perspective, Palliative Care and ICU Nurses’ Scope of Practice, Communication About Prognosis and Goals of Care: The Nurse’s Role, Nurses are the Bridge: A Family Perspective, and Supporting Each Other: A Physician’s Perspective. These videos were chosen because they informed the participants about the importance of their roles in palliative care and how they can best help their patients.

Data analysis plan

Data was exported from Qualtrics into Excel for review and cleaning. Data was then imported into SPSS 27.017 for data analysis. Descriptive statistics were performed on all demo- graphics and the Palliative Care Self-Efficacy Scale. Due to the lack of normality of the data, the non-parametric Wilcoxon Signed Rank Test was used to compare the total pre and post- Palliative Care Self-Efficacy Scale, psychosocial support subscale, and symptoms management subscale. Statistical significance was determined at the p-value level of .05 or less and effect sizes were calculated.

Results

The total sample size for this study was 40 participants. The mean years of experience were 6.08± 5.72 years of critical care nursing experience with a median of 4 years of experience. Study participants came from a range of critical care back- grounds, many with varied experience with the most common being a cardiac background at 12 (60%) respondents. Of all participants, 36 (90%) reported training in palliative care. The multiple-choice question that inquired about the type of training displayed that the majority of respondents (n = 13, 54.2%) had palliative care training by their employer. Table 1 includes all of the demographics collected.

Pre and post self-efficacy

The pre-test overall score’s median was 38 (32.5, 42.75). For subscales, the medians included a pre-test median on the psychosocial items of 18 (14.25, 19.75) and a post-test median of 21 (18, 23). For the symptom management items, the medians were 21 (18, 23.75) and 22.5 (18.25, 24) respectively. Whereas the post-test overall median score was 43.5 (36, 46). Medians are reported instead of means because after a priori power analysis that was done it was determined that the

Table 1

Past palliative care training, n (%) training 36 (90%) no training 4 (10%)

Past palliative care training, n (%) Online resources sought out by yourself 11 (45.8%) Undergraduate training 12 (50%) Short courses or training provided by your employer 13 (54.2%)

Critical care specialty, n (%) Surgical 11 (55%) Neurology 6 (30%) Cardiac 12 (50%) General 13 (54.2%)

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assumption of normality was not met and the non-parametric alternative was used.

A Wilcoxon Signed Ranks Test revealed a statistically significant improvement in perceived self-efficacy of pro- viding palliative care following participation in the VitalTalk educational videos and documents. The overall Palliative Care Self-Efficacy Scale showed the median score increased from pre- education (Md= 38.0) to post-education (Md= 43.5), z = -4.868, p <.001, with a large effect size (r = .76). The tool was further broken down into psychosocial and symptom management domains. A statistically significant improvement of perceived self-efficacy of providing psychosocial support aspects of palliative care was found following participation in the ed- ucation as the median score on the psychosocial items in- creased from pre-education (Md = 18.0) to post-education (Md = 21.0), z = -4.867, p <.001, with a large effect size (r = .76). Similarly, there was a statistically significant improvement of perceived self-efficacy of providing symptom management aspects of palliative care following participation in the edu- cation. The median score on the symptom management items increased from pre-education (Md = 21.0) to post-education (Md= 22.5) z= -3.861, p < .001, with a large effect size of (r= .61).

Discussion

The purpose of this study was to test whether online education would improve critical care nurses’ self-efficacy in providing palliative care to their patients. Although the majority of the participants had some palliative care education they still improved their perceived self-efficacy in providing palliative care with the VitalTalk education program. This improvement was found in the overall scores as well as scores on the subgrouped domains of psychosocial and symptom man- agement and all of them resulted in a large effect size, sug- gesting a large difference in pre and post-test scores illustrating a high clinical significance. This data is significant to clinical practice because as previous data has displayed nurses feel undereducated in palliative care and our data demonstrates that a short, free, educational intervention can improve nurses’ perceived self-efficacy in providing palliative care. Our data suggests that providing practicing critical care nurses resources like the VitalTalk videos and handouts could result in improvements in nurses’ perceived self-efficacy in providing palliative care, which would hopefully lead to improvement in both patient outcomes as well as nurse’s job satisfaction while providing palliative care.

Furthermore, this study was also conducted in a way that we could try to analyze how critical care nurses are being educated in palliative care topics. The data suggest that themajority of critical care trained nurses have had some palliative care education, most often from their employer. Close to half of the respondents had some palliative care education in nursing school. AACNmade it a goal in 2016 to increase palliative care education in under- graduate nursing education as Thrane5 found that only 11% of

undergraduate nursing programs offered palliative care courses. The data from this study is inconclusive on this topic. It shows that either nursing schools still have to make improvements to their curriculums to include palliative care education or it may also be that respondents from this study completed nursing education before the initiative to include palliative care education in nursing school curriculums started from associations like AACN.

What can be gathered from this data is that employers are playing a major role in educating their employees about palliative care. This is important to bridge the gap in the cases where nurses did not receive training on the topic in school. The data from this study is consistent with findings in theWolf et al.9 study that found that 38% of critical care nurse re- spondents reported no palliative care education in the past two years. These findings add to the evidence that there are still improvements to be made as this number could be closer to 100% if employers did something as simple as requiring their nurses to complete an online training similar to the VitalTalk education program utilized in this study.

Some limitations of this study included a small sample size due to difficulty getting respondents to complete the entire study including the post-education survey, as we did not in- clude the incomplete data in our analysis. However, the final sample size of 40 nearly met the projected needed sample size of 41 participants. Another limitation was the fact that the researchers were unable to verify whether or not the partic- ipant completed all of the education before responding to the post-survey, meaning the fidelity of the intervention could not be assessed. Related to this, another limitation was the pos- sibility of the Hawthrone effect playing a role in how the participants responded to the post-survey. Though the hy- pothesis that providing online education would improve self- efficacy scores was not implicitly provided to the participants, it is clear by the way the study is set up that the researchers were looking for an improvement in scores from the pre-test to the post-test. This could have made participants more likely to score higher on the post-test even if they did not necessarily improve their psychosocial or symptom management self- efficacy in providing palliative care. Many of these limitations relate to the fact that the data was self-reported meaning the data relies on the participants feelings and may be have validity issues. In this study a Likert scale was used which gives quantitative data, but responses rely on how a participant rates their feelings or experience and not actual concrete objective analysis on a participants skill or understanding.

Implications for practice and future research

Future research could involve sampling new graduate nurses that recently completed their entry into practice to further assess how schools are improving their curriculums to include palliative care. The data does not conclusively suggest that undergraduate schools are not providing

120 American Journal of Hospice & Palliative Medicine® 40(2)

palliative care education because the majority of the nurses in this study did not just complete undergraduate education in the past few years, as evidenced by the number of years in practice. It does suggest that in the past schools did not effectively provide this critical education. This is important because past research shows that nurses are largely un- comfortable with their level of knowledge about palliative care, which results in low screening and referral rates.8

Furthermore, palliative care is underutilized and can im- prove the quality of care for patients as well as be cost- saving to the healthcare system.

The data suggest an important implication for practice as there is a continued need to provide palliative care education to critical care nurses in the workplace and an online educational tool can be effective in meeting that need. Palliative care pro- viders, pharmacists, nurses, or social workers from a palliative care team can take part in further educating nurses so that more effective palliative care can reach our patients. This idea leads to an opportunity for future research to analyze the outcomes of other educational structures being used to provide palliative care education to either critical care nurses, a broader population of nurses, or the entire interdisciplinary team as a whole.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, au- thorship, and/or publication of this article.

ORCID id

Christina DeFusco  https://orcid.org/0000-0002-1290-1784

References

1. Center for Disease Control. Life Expectancy in the U.S. Declined a Tear and Half in 2020. Georgia, USA: CDC. https://www.cdc. gov/nchs/pressroom/nchs_press_releases/2021/202107.html. (Accessed August 1, 2021).

2. World Health Organization. Palliative Care. Geneva, Switzer- land: WHO. https://www.who.int/news-room/fact-sheets/detail/ palliative-care. (Accessed July 25, 2021).

3. Center to Advance Palliative Care. Palliative Care Facts and Stats. New York, NY: CAPC. https://media.capc.org/filer_ public/68/bc/68bc93c7-14ad-4741-9830-8691729618d0/capc_ press-kit.pdf. (Accessed July 25, 2021).

4. Sheehan K. Nourish the Roots: The Importance of Palliative Care Education in Medical School. New York, NY: CAPC.

https://www.capc.org/blog/nourish-roots-importance-palliative- care-education-medical-school/. (Accessed July 25, 2021).

5. Thrane S. Online palliative and end-of-life care education for undergraduate nurses. J Prof Nurs. 2020;36(1):42-46. doi:10. 1016/j.profnurs.2019.07.002.

6. Ferrell B, Malloy P, Mazanec P, Virani R. CARES: AACN’s New Competencies and Recommendations for Educating Undergrad- uate Nursing Students to Improve Palliative Care. J Prof Nurs. 2016;32(5):327-333. doi:10.1016/j.profnurs.2016.07.002.

7. Aslakson RA, Randall C, Nelson JN. The changing role of palliative care in the ICU. Crit Care Med. 2015;42(11): 2418-2428. doi:10.1097/CCM.0000000000000573.

8. American Association of Critical-Care Nurses. Pandemic Am- plifies Need for Integrated Palliative Care. CA, USA: AACN. https://www.aacn.org/newsroom/pandemic-amplifies-need-for- integrated-palliative-care. (Accessed March 15, 2022).

9. Wolf A,White K, Epstein E, Enfield K. Palliative care and moral distress: An institutional survey of critical care nurses. Crit Care Nurse. 2019;39(5):38-49. doi:10.4037/ccn2019645.

10. Nelson J. Communicating with Families: Shifting the Focus. CA, USA: American Association of Critical-Care Nurses. https://www.aacn.org/blog/communicating-with-families-shifting- the-focus. (Accessed July 25, 2021).

11. Price DM, Strodtman L, Montagnini M, Smith HM, Miller J, Zybert J, et al. Palliative and end-of-life care education needs of nurses across inpatient care settings. J Cont Educ Nurs. 2017;48(7):329-336. doi:10.3928/00220124-20170616-10.

12. Pesut B, Greig M. Resources for educating, training, and mentoring nurses and unregulated nursing care providers in palliative care: a review and expert consultation. J Palliat Med. 2018;21(S-1):S50-S56. doi:10.1089/jpm.2017.0395.

13. Phillips J, Salamonson Y, Davidson PM. An instrument to assess nurses’ and care assistants’ self-efficacy to provide a palliative approach to older people in residential aged care: a validation study. Int J Nurs Stud. 2011;48(9):1096-1100. doi: 10.1016/j. ijnurstu.2011.02.015.

14. Dehghani F, Barkhordari-Sharifabad M, Sedaghati-kasbakhi M, Fallahzadeh H. Effect of palliative care training on perceived self-efficacy of the nurses. BMC Palliat Care. 2020;19(1). doi: 10.1186/s12904-020-00567-4.

15. Mason S, Ellershaw J. Assessing undergraduate palliative care education: validity and reliability of two scales examining perceived efficacy and outcome expectancies in palliative care. Med Educ. 2004;38(10):1103-1110.

16. Zhou Y, Li Q, Zhang W. Undergraduate nursing students’ knowledge, attitudes and self-efficacy regarding palliative care in China: a descriptive correlational study. Nursing Open. 2020; 8(1):343-353. doi:10.1002/nop2.635.

17. IBM Corp. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp; 2020.

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