Introduction
This is a quality improvement initiative aimed at evaluating the effectiveness of implementing a palliative care assessment tool to enhance the knowledge of nurses working at a long term care facility, in identifying and referring patients for palliative care. In order to address patients who are in need of palliative care, it is vital to identify a tool which allows for early recognition of these patients (Thilini et al., 2018). Palliative care has shown in multiple clinical trials to enhance patient satisfaction, fewer and less intensive hospitalization, less anxiety and depression and shown to be cost saving (Hughes & Smith, 2014). However, palliative care is often not accessible to the patients who would benefit from it. There are many factors contributing to why palliative care is not being provided. These factors include education, lack of time for education, and provider reimbursement. This literature review will examine current research focusing on education and assessment tools for nurses that are used to facilitate referrals for palliative care.
Literature Search Strategy
An internet search of ProQuest Central, Cochrane Database of Systemic Reviews, CINAHL Complete, PubMed Central, and Google Scholar was done to obtain the best available literature to support the PICO question. Also, recommendations from respected authorities such as the World Health Organization and Centers for Disease Control provided information to support the background of the project. The searches were done between February 10 and February 29th 2020. About 19 studies were identified but only 15 were appraised in line with the criteria for appraising research evidence provided by Melnyk & Fineout-Overholt (2017). Of these only 9 will be analyzed for this review. Articles that were included were written in English and published in peer reviewed journals. Some of the search items include palliative care, long term care, assessment tools, and nurses’ knowledge. Due to the limited amount of studies done in the United States, foreign studies were also included in the search.
Palliative Care and Role of Nurses
Meaning of Palliative Care
The National Hospice and Palliative Care Organization (NHPCO) in the United States defines palliative care as the provision of treatment that specifically enhances comfort as well as improving the quality of life of patients and their families when facing issues associated with a life threatening illness (Maclifatricks, 2017). Special measures are used to anticipate, treat and prevent suffering with the goal of optimizing care (Aslakson, Dy & Wilson, 2017). According to the WHO (2018), palliative care is an ethical responsibility of health systems and its integration into the mainstream public health system is essential in improving patient and system outcomes. Chover-Sierra, Martínez-Sabater, and Lapeña-Moñux (2017) pointed out that while palliative care was traditionally given to cancer patients, a more diverse groups of patients increasingly need such care, and has become an essential part in nursing care. Despite of this, palliative care is still rarely accessible to many patients in the United States resulting in suffering on a massive scale (WHO, 2018). This issue has attracted significant research interest, many of which have tried to identify factors that make it difficult for patients to access palliative care.
Role of Health Professionals
Globally, including the United States, health professionals play a major role in the uptake of the recommendation by WHO that palliative care be part of routine care provided in health facilities (WHO, 2018). Nurses, who represent the largest group of health professionals in the United States and the world, have the highest amount of presence with patients and can play a major role in enhancing the use of palliative care (Chover-Sierra et al., 2017). Nurses are positioned to contribute to the provision of holistic person centered care because they spend time with the patients and their families, they help to facilitate communication, provide comfort when patients are dealing with an array of complex emotional problems, offer advice on pain management and other related treatments (Harazneh, 2015; Hughes & Smith, 2014; Lau et al., 2014). Professional nursing care can mitigate the burden and stresses that are experienced by those approaching death. Despite this, research has shown that one of the impediments to application of palliative care is that many nurses do not have the skill, attitude and knowledge to identify and refer patients who need palliative care as timely as possible (Burns &McIlfatrick, 2015; Tan, 2019; Harazneh, 2015; David & Banerjee, 2010; Kassa et al., 2014; Lau et al., 2014; Smets et al., 2018).
Nursing Knowledge Deficit in Palliative Care
According to Liyanage et al. (2019), 51% of patients in developed countries die from chronic illness versus malignant disease. Most patients who pass away usually spend their last couple of months being shifted between the hospital, skilled nursing facility and home. Research has pointed out lack of education in palliative care as one of the barriers for palliative care. According to Cimino et al. (2016), although many health care workers are responsible with caring for patients with chronic illnesses, most only receive a limited amount of palliative care training (Tan, 2019). An exploratory study by Chan et al. (2017) sought to test the tool for evaluating staff readiness to provide palliative care in an outpatient setting. To this end, Chan et al. (2017) developed a 16-item instrument to test the knowledge and preparedness of the nurses for the new initiatives of palliative care. The 16-item tool covered perceived knowledge, skills, and psychological readiness of the nurses in care homes. The study involved 247 care assistants, registered nurses and administrative staff working in four care homes that engaged in the study. The results of the study identified willingness, capability, and resilience as the three subscales with high internal consistency for illustrating the level of preparedness of staff to provide palliative care. This study proposed a tool that care homes can use a brief, valid, and reliable scale for measuring the preparedness of the staff to offer palliative care and end-of-life care. The tool proposed by Chan et al. (2017) is also helpful in determining the knowledge of the staff in a care home because it can identify their concerns and training needs in regards to provision of palliative care.
Long term care nurses need to have the knowledge and skills necessary to identify patients with palliative care need. However, these nurses often do not have the knowledge and a number of strategies have been employed to improve their skills. A descriptive, cross-sectional study by Harazneh et al. (2015) was conducted to make an assessment of palliative care knowledge among nurses at Arab American University. In this study, a convenience sample of 198 nursing students was included and data on palliative care knowledge as well as demographic characteristics was collected. The researchers used the Palliative Care Quiz for Nurses (PCQN) tool to assess nursing students’ knowledge and the combined average score to be less than 50% (40.58%, SD=13.89) (Haranzeh et al., 2015). They also found that palliative care knowledge was independent of age of student, gender and academic level. Although this study was conducted in nursing students, these findings are relevant for the present project as it highlights the importance of considering determinant factors of knowledge and ability of nurses in referring patients for palliative care (Haranzeh et al., 2015; Tan, 2019).
In another study, authors concluded that knowledge about palliative care will help nurses understand the needs of patients, and hence promote the provision of quality evidence based care (David & Banerjee, 2010). The study was conducted in order to assess the level of knowledge about palliative care among oncology nurses in an oncology unit. It also aimed at measuring how the use of an information booklet impacts on their knowledge of nurses. The authors used a conceptual framework that was adopted from the Daniel Stufflebeam’s CIPP (Context – Input – Process – Product evaluation) model. The study was conducted in a cancer hospital in India using the one group pretest-posttest, pre-experimental design. Non probability purposive sampling design was used to identify 100 nurses working at the hospital, who were asked to complete a structured self-administered questionnaire at pretest. An information booklet containing information about palliative care was given to the nurses as an intervention. The baseline questionnaire was administered again during follow up. The results of this study found that the post test scores of the nurses were significantly higher when compared to their pre-test knowledge scores. As such, David and Banerjee (2010) concluded that the booklet with information about palliative care was effective in enhancing the level of knowledge of the nurses. These findings support evidence by others that implementation of palliative care assessment educational information and tools can enhance provision of palliative care. Nurses play a critical role in the implementation of evidence based practice, especially in long term care centers. Being an intervention study, the evidence generated has the potential to impact on patient care. Although, the sample size is small, this study provides a useful evidence of the importance of assessing the knowledge and skills of nurses in care homes (David & Baneree, 2015). Knowledge about palliative care will help nurses understand the needs of patients, and hence promote the provision of quality evidence based care.
Kassa et al. (2014) conducted a cross sectional quantitative study to investigate the knowledge skills and attitude and associated factors with palliative care in nurses who worked in some hospitals in Addis Ababa. The study which was based on the Frommelt Attitude Toward Care of the Dying (FATCOD) had a sample of 365 nurses working in chosen public and private hospitals. The attitude scale was adopted from FATCOD and modified so as to make it fit to Ethiopian context. The practice questions were adopted from different related studies while the he knowledge questions were adopted from the Palliative Care Quiz for Nursing (PCQN) and modified according to the prevailing context of health institutions in Ethiopia. Chi square and logistic regression was performed using SPSS and Epi-Info. It was found that only 30.5% (n=104) had good knowledge about palliative care while 76% (n=259) had favorable attitude towards palliative care. The study further found that nurses who had prior training on palliative care as well as those who worked in the medical and surgical wards tended to have better knowledge. Those who had prior training, were working in medical wards and had a higher education also had more positive attitude towards palliative care. Those working in private hospitals were more likely to be knowledgeable about palliative care compared to those working in governmental hospitals. The majority of respondents did not implement palliative care despite having the knowledge, many indicating that diagnoses were usually done when the patient approached their terminal stages. The conclusion was that while the nurses’ attitude towards palliative care was generally favorable, the general knowledge was below standards. As such, Kassa et al. (2014) recommended that national health policy should give attention to palliative care by incorporating it into the national curriculum of nurse education to enhance the knowledge of the nurses.
Assessment Tools for Palliative Care
Several studies have been conducted to find ways to improve nurses’ skill and ability to assess patients with long term illnesses and identify those who need palliative care. A prospective multicentric study by Molin et al., (2019) was conducted to implement a palliative care assessment tool, PALLIA-10 in order to identify patients for palliative care in comprehensive cancer centers in France. The goal was to enhance the identification and referral of patients who need palliative care. In this study, 840 patients were enrolled from 18 comprehensive cancer centers in 2015. Patients who scored > 3 in the PALLIA 10 questionnaire were recommended for palliative care. Data on prevalence of palliative care need as well as data on demographic characteristics were collected. The decision for Palliative Care (PC) intervention adopted including the overall survival of patients who scored more than 3 was recorded. Logistic regression was performed to determine determinants of palliative care and a cox proportional hazards model was performed to adjust the identified score model for confounding factors. About 70% (n= 479) of the sample scored more than 3 and were referred for palliative care within the next six months. The study underlined the importance of using palliative care assessment tools in identifying care needs in a diverse setting (Molin et al., 2019). It also shows that the PALLIA-10 tool has a high validity and reliability and can be used to improve evidence-based practice and improve the outcomes of long term care patients.
A prospective cohort study by Liyanage et al. (2019) sought to test the accuracy, feasibility and accessibility of two combined tools: the surprise question (SQ) and the Supportive and Palliative Care Indicator Tool (SPICT). The study included 187 patients, and the results showed that the combination of the two tools was effective in predicting palliative care needs, whereas using the SPICT only had marginal effectiveness (Liyanage et al., 2019).
In another study, O’Reilly et al. (2016) implemented a quality improvement initiative in order to develop and investigate the impact of the implementation of the Milford Palliative Care Assessment Tool (MPCAT) on documentation of key patient needs. The (MPCAT) is a comprehensive instrument that involves several evidence-based tools, such as the Pain Assessment Questionnaire for a Patient with Advanced Disease, the Palliative Performance Scale and Index (PPS and PPI), the Blessed Short Orientation Memory Test (SOMCT), the Confusion Assessment Method and Mount Vernon Cancer Network tools (O’Reilly et al., 2016). The intervention took place in a specialist care inpatient unit employed a mixed methods design to make pre and post intervention measurements. The goal was to evaluate the effectiveness, feasibility and acceptability of the comprehensive instrument. As such, O’Reilly et al. (2016) implemented the tool in a specialist palliative care inpatient unit and then monitored its outcome in 6-month and 12-month follow up.
Data was analyzed using both descriptive and inferential statistics. The study found that after the intervention there was an increase in documented evidence of pain assessments (from 71% to 100%). The improvement was sustained even 12 months after the intervention (p< 0.001). There was also a significant increase in the proportion of clinicians who agreed that palliative care domains were comprehensively assessed post-intervention when compared with pre-intervention (88% vs 59% P = 0.01).The number of referrals made in the first 24 hours after assessment increased post-intervention (physiotherapy, P = 0.001; occupational therapy, P = 0.001; social work, P = 0.005; pastoral care, P = 0.005); this was maintained at 12 months. There was a significant increase in the documented evidence of screening for spiritual distress increased from a baseline rate of 23% to 70% at 6 months and to 82% at 12 months (P < 0.001). The conclusion from the study is that the use of Milford Palliative Care Assessment Tool led to a significant improvement in assessment of multiple important aspects of patient need(O’Reilly et al., 2016). The study is supports the DNP project since it shows that implementation of palliative assessment tools can increase referrals for palliative care. It points to the need to measure the sustainability of impacts of interventions implemented to enhance palliative care. The use of assessment tools has the potential of improving patients’ outcomes since the tools have been developed based on research evidence.
Thilini, Mitchell, and Senior (2018) conducted a prospective cohort study in order to test the accuracy and feasibility of the surprise question (SQ) as well as the supportive and palliative care indicator tool (SPINCT) in identifying residents who had palliative care needs. The study which was carried out in residential aged care facilities in Australia used the two tools to screen 187 residents who were at risk of dying within12 months. Follow up data collected 12 months later measured deaths, use of palliative care, hospitalizations, clinical indicators and end of life care. The researchers found that the SPINCT was more sensitive in identifying residents who need palliative care than the SQ tool (Thilini et al., 2018). This study lends support to the DNP project in a number of ways: it also sheds light on the various tools available in assessing palliative care needs and their effectiveness as it compares the SQ and the SPINCT tools. Further, it informs quality improvement projects on the enhancement of palliative care in long term care centers. Finally, the article further supports already existing evidence of the importance of palliative care to the patient, family, care giver and the facility (Thilini et al., 2018).
Limitations
Although the research articles identified for this study provide evidence on the barriers of implementing palliative care as well as some of the assessment tools that can be used in a care home, there is one limitation that can be found in them. The limitation is in regards to the populations of the studies. In all these studies, the researchers focused on patients in care homes. However, it is essential to note that a comprehensive palliative care should also consider the issues that the family and those around the patient are experiencing due to the patient’s illness. As such, these findings do not show how lack of knowledge among nurses as well as the assessment tools accounts for the care that is needed by the family of the patients. This limitation creates a gap in research on palliative care that considers the perspective of the family as well as that of the patient. In this care, the interventions measures or evaluations tools that should be adopted must include the needs of the family and not only those of the patient.
Summary
The literature shows that there is inconsistent application of the recommendations for provision of palliative care in long term care facilities. Nurses and other health practitioners including those working in long term care facilities have demonstrated a lack of awareness of the palliative care or even the existence of the policies that guide the provision of such care. Furthermore, many facilities do not have mechanisms and policies in place to guide the provision of palliative care. Collectively, the identified barriers to palliative care access and provision call for the need for training and implementation of a palliative care assessment tool. It is also apparent in the literature that implementing these tools leads to an improvement in palliative care provision. An intervention that targets nurses working at long term care facilities with the implementation of an assessment tool for identifying and referring patients who need palliative care was identified as a necessary practice change for the project. The DNP project aims at increasing the use of palliative care. It targets nurses in a long term care setting since they play a critical role in enhancing use of palliative care.
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