BACKGROUND: End-of-life discussions are associated with improved quality of care for patients. In the UK, the General Medical Council outlines a requirement for medical graduates to involve patients and their families in discussions on their care at the end-of-life. However medical students feel ill-equipped to conduct these discussions.
METHODS: In 2018, Sheffield Medical School introduced a small group role-play session on end-of-life discussions for all final year medical students. Scenarios were devised to improve confidence in the following learning domains: communicating prognosis with patients and family; ascertaining patient's goals, values and preferred place of death; discussing escalation of treatment, discussing do not attempt resuscitation orders, care in the dying phase of illness and pre-emptive prescribing. Evaluation was conducted over 16 weeks with a before and after questionnaire. Students rated their confidence in the above learning domains on a Likert-style scale and explained their ratings in free-text boxes.
RESULTS: There was a 76% response rate to the questionnaire and analysis showed statistically significant improvements in confidence across all learning domains following the session. Qualitative analysis of free-text responses showed that prior to the sessions, students expressed low confidence due to lack of experience and fear of upsetting patients. After the session students felt they had gained skills but expressed persistent anxiety and a desire for further practice.
CONCLUSIONS: Our innovation suggests that the opportunity to experience end-of-life discussions through role-play can significantly improve students' confidence in conducting these conversations. However, repeated sessions are likely necessary for students to feel prepared upon graduation.
Background: Palliative care is a patient-centred, integrated approach for improving quality of life for both patients facing life-threatening illnesses and for their families. Although there has been increased interest in palliative care for non-cancer patients, the palliative care competency of nurses who care for non-cancer patients has rarely been investigated. This study described the palliative care knowledge, attitude, confidence, and educational needs in nurses who care for patients with congestive heart failure, stroke, end-stage renal disease, and end-stage liver disease; explored the relationships between those variables; and identified factors affecting nurses’ palliative care confidence.
Methods: A cross-sectional, descriptive, correlational design was employed; data collection was conducted at a tertiary hospital in Seoul, Korea. Nurses who were working in general wards and intensive care units (N = 102) completed valid and reliable self-administered questionnaires. Descriptive statistics, frequencies, independent t-tests, one-way ANOVA, Pearson’s correlations, and multiple regression were conducted to analyse the data.
Results: Nurses’ palliative care knowledge level was low (9.73 ± 2.10; range = 0–20) and their attitude toward palliative care was moderate (87.97 ± 6.93, range: 30–120). Knowledge was significantly correlated with attitude (r = .29, p = .003). Nurses were highly confident in pain and symptom management but demonstrated high educational needs for managing human and material resources to provide palliative care. Previous training in hospice, palliative, and EOL care was a significant and modifiable factor that affected nurses’ confidence (std. ß = 0.25, p = .010).
Conclusions: To facilitate high-quality palliative care for non-cancer patients and families, nursing education programs should be developed to address nurses’ knowledge level, confidence level, and educational needs. This study provides relevant information that can be utilised to develop palliative care educational programs for nurses who care for non-cancer patients.
BACKGROUND: This quantitative study aimed to analyse the relationship between knowledge and nurses' self-confidence (or self-efficacy) in applying palliative care (PC) in the intensive care unit (ICU). This study was a correlational study with a cross-sectional approach. The sampling technique used was total sampling, and the sample included all nurses who were actively working at the general hospital in Bandung, West Java, Indonesia, during the study. There were 127 people in total. Data were collected using questionnaires. The Pearson correlation test was used for bivariate analysis. The results of univariate analysis showed that the majority of respondents had high self-confidence but had less knowledge related to PC in the ICU. Based on the results of the bivariate analysis, there was a significant relationship between knowledge and self-confidence variables. The results showed that a high number of respondents had less knowledge in implementing PC in the ICU. Therefore, familiarisation sessions and training related to this are needed, focusing on nurses' beliefs in their abilities.
BACKGROUND: Many domiciliary care workers have reported low confidence and isolation when delivering end of life care in patients' homes. Project Extension for Community Healthcare Outcomes (ECHO) is an initiative that has demonstrated success in increasing confidence and knowledge of end of life care in UK nursing home and community hospice workers, but it has not been evaluated with domiciliary care workers.
AIM: To test the acceptability of Project ECHO to domiciliary care workers as a means of increasing their knowledge of, and confidence in, delivering palliative care, and its effectiveness in reducing their isolation by developing a community of practice.
METHOD: A service evaluation, involving one domiciliary care agency delivering care in the community, was conducted from May 2018 to April 2019. The participants were 25 home care workers who were employed by the agency. Participants were invited to attend an event at which gaps in their knowledge were identified, and a curriculum of learning on the Project ECHO programme was developed. The learning involved 12 educational sessions over 12 months, with each session teaching a different component of palliative care. Questionnaires were completed by the participants before and after the educational sessions to assess their effect. In addition, a focus group was conducted with four of the participants.
RESULTS: Comparison of the questionnaires completed before and after participating in the education sessions revealed an increase in self-reported knowledge across all 12 topics of the curriculum and an increase in confidence in seven of the 12 topics. However, attendance across the 12 sessions was variable, with no more than nine being attended by any one participant.
CONCLUSION: Palliative care education for domiciliary care staff using ECHO methodology was well received, relevant and accessible, and may have the potential to improve self-assessed knowledge and confidence. However, finding an ideal time for as many staff to attend as possible may be challenging.
The legality of euthanasia and assisted suicide (AS) and nature of regulations of these practices remain controversial and the subject of lively debate among experts and the general public. Our study investigates attitudes and behaviours towards AS among older adults in Switzerland where the practice of AS has a relatively long history and remains rather unregulated. We aim to explore how individuals' preferences regarding their end of life, as well as individuals' trust in institutions involved in the practice or control of AS are associated with attitudes and behaviours towards AS. We analyse nationally representative data of adults aged 55 and over from wave 6 (2015) of the Survey of Health, Ageing and Retirement in Europe (SHARE) in Switzerland (n = 2,145). While large majorities supported current legal arrangements around AS in Switzerland (81.7%) and stated that they could consider AS for themselves under certain circumstances (61.0%), only a minority either was a member of a right-to-die organisation already (4.9%) or stated they were likely to become a member of such an organisation (28.2%). Stated preferences for control over the end of life and for maintaining essential capabilities at the end of life showed a positive association with AS-related attitudes and behaviours, whereas preferences for feeling socially and spiritually connected, as well as for not being a burden displayed a negative association with our outcomes. Higher levels of trust in one's relative were positively associated with both support for the legality of AS and potential use of AS. A positive association was also found between trust in the Swiss legal system and support for the legality of AS. By contrast, trust in religious institutions displayed a negative association with all five AS-related attitudes and behaviours. Similarly, trust in healthcare insurance companies was negatively associated with potential use of AS. Taken together, older adults were generally supportive towards current practices regarding AS. This approval appears to be closely related to individuals' preferences and, at different extends, to trust in social and public institutions with regard to end-of-life issues, which is relatively high in Switzerland.
BACKGROUND: The General Medical Council expects medical graduates to care for dying patients with skill, clinical judgement and compassion. UK surveys continually demonstrate low confidence and increasing distress amongst junior doctors when providing care to the dying.
AIM: This systematic review aims to determine what has been evidenced within worldwide literature regarding medical undergraduate confidence to care for dying patients.
DESIGN: A systematic electronic search was undertaken. Data extraction included measurements of baseline confidence, associated assessment tools and details of applied educational interventions. Pre/postintervention confidence comparisons were made. Factors influencing confidence levels were explored.
DATA SOURCES: MEDLINE, CINAHL, EMBASE, ISI Web of Science, ERIC, PsycINFO, British Education Index and Cochrane Review databases were accessed, with no restrictions on publication year. Eligible studies included the terms 'medical student', 'confidence' and 'dying', alongside appropriate MeSH headings. Study quality was assessed using the Mixed Methods Appraisal Tool.
RESULTS: Fifteen eligible studies were included, demonstrating a diversity of assessment tools. Student confidence was low in provision of symptom management, family support, and psycho-spiritual support to dying patients. Eight interventional studies demonstrated increased postinterventional confidence. Lack of undergraduate exposure to dying patients and lack of structure within undergraduate palliative care curricula were cited as factors responsible for low confidence.
CONCLUSION: This review clarifies the objective documentation of medical undergraduate confidence to care for the dying. Identifying where teaching fails to prepare graduates for realities in clinical practice will help inform future undergraduate palliative care curriculum planning.
PROSPERO REGISTRATION NUMBER: CRD42019119057.
Les relations avec les autres sont complexes et potentiellement conflictuelles en fonction de la place ou du rôle qu'il va nous être donné de jouer dans telle ou telle circonstance. Du fait de schémas comportementaux et affectifs chargés en émotion, il est difficle pour la raison d'arriver à faire la part des choses. De plus, la raison, même lorsqu'elle analyse et tente de discerner objectivement se retrouve vite impuissante pour comprendre les situations paradoxales.
La confiance est un concept qui illustre parfaitement, toute l'emprise émotionnelle de l'être humain et tous les vains mais non nécesaires efforts de la raison à cerner la réalité d'une situation. Nous avons isolé quelques qualités "supérieures" qui permettent de sentir ce qu'est la confiance et ainsi de trouver la voie d'une relation pacifiée avec l'autre en dépit de l'hostilité du contexte. Il s'agit notamment de la réciprocité, de la spontanéité, d'une sincère humilité mais aussi de la considération de l'unicité de chaque personne.
Background: Research has indicated that clinical staff in long-term care often lack self-confidence in palliative care delivery, particularly at the end of life.
Goals: (a) To examine the contribution of age, palliative care education, palliative care work-related experience and psychological empowerment to palliative care delivery confidence and (b) to explore the social reality shaping those factors for long-term care staff.
Design: Explanatory sequential design.
Setting: Twenty long-term care facilities in two district health boards in New Zealand.
Participants: Phase 1:139 clinical staff. Phase 2:46 clinical staff who provided care in the last month of a residents' life.
Methods: Phase 1: Cross-sectional survey. Phase 2: Individual semi-structured interviews.
Results: Phase 1: Previous experience (ß = .319) and psychological empowerment (ß = .311) contribute most to predicting an increase in palliative care delivery confidence. Phase 2: Four factors underlay palliative care delivery confidence, (a) mentorship by hospice nurses or colleagues (b) contextual factors (organisational culture, resources and experience), (c) maturity and (d) formal education.
Conclusion: Organisational leadership should use multiple strategies (e.g. power-sharing, increased opportunities for mentorship) to improve staff palliative care delivery confidence.
Implications for Practice: This study adds to the literature in understanding the predictors of palliative care delivery confidence specific to long-term care staff. The results indicate that educational interventions must be contextually appropriate to achieve sustainable improvements in palliative care confidence and ultimately in resident care at the end of life.
INTRODUCTION: Many children are born with life-limiting illnesses. Medical decision-making for these children by caregivers is complex and causes significant psychosocial distress, which can be partially alleviated by effective communication with medical providers. In order for providers to support caregivers, this study explores how caregivers make decisions regarding the medical care of their terminally ill children.
METHODS: Semistructured interviews were conducted among caregivers of terminally ill children. Participation was voluntary and confidential. The institutional review board approved the protocol. Transcripts were read and coded by 2 authors using inductive, concurrent analysis to reach thematic saturation and generate common themes.
RESULTS: Nine interviews were completed, discussing the care of 10 children. Caregivers described decision-making as impacted by their relationships with medical providers of 2 distinct types-trusting and nontrusting. Trusting relationships were notable for a longitudinal relationship with medical staff who empowered caregivers and treated the patient primarily as a child. Nontrusting relationships were noted when the medical team objectified their child as a "patient" and appeared to withhold information. Also, nontrusting relationships occurred when caregivers felt frustration with needing to educate health-care providers about their child's illness.
CONCLUSION: Decision-making by caregivers of terminally ill children is complex, and supporting families in this process is a critical role of all medical providers. A trusting relationship with medical team members was identified as an effective tool for well-supported decision-making, which can potentially alleviate the suffering of the child and distress of the caregivers during this emotionally charged time.
Context: Providing patient care at the end of a patient's life is a humbling and sacred experience for both patient and provider. Without a truthful and meaningful conversation about end-of-life care preferences, the care that is delivered may not be the care that the patient prefers.
bjectives: Determine if there is a relationship between level of training, confidence, and presence of decisional conflict in making an accurate prognosis for 2 standardized cases. Additionally, we evaluated the correctness of the prognosis as measured against survival outcomes for patients with similar diagnoses.
Methods: Decisional conflict was measured with the SURE tool, a validated 4-item tool that has been used in assessing for the presence of decisional conflict.
Results: Following analysis of data, it was found that providers with no decisional conflict were much more likely to be attendings with more than 5 years' experience. Providers were more conflicted overall when confronted with a case with a more grave prognosis. It was determined that providers with a lower level of training were more likely to have decisional conflict.
Conclusions: Provider confidence increases and decisional conflict decreases as one increases their level of training. However, the degree in which the provider is correct in their prognosis does not change as one increases their level of training. These findings have broad implications on patients, providers, and the health-care system.
Background: Project ECHO™ (Extension for Community Healthcare Outcomes) is a form of online interactive teaching, which has gained international traction. This project evaluates the effectiveness of an ECHO-delivered palliative care education program for the South Dublin region of Ireland. Our aim was to measure project success by quantifying gains in staff confidence.
Methods: The educational program consisted of 10 interactive sessions over a five-month period on palliative care topics ranging from pain management to advance care planning. Twenty nursing homes took part in the education program. Of these, a subgroup of six nursing homes were randomly selected for assessment. Likert scale-based questionnaires assessed staff confidence before and after each lecture and assessment was repeated at least six weeks postlecture. Five of the 10 sessions were assessed in this way. Other characteristics such as staff role and years of experience were also collected.
Results: Twenty nursing homes and 353 staff participated in the education sessions. Of the 6 nursing homes chosen for assessment, an average of 42 questionnaires were returned per session (n = 211), representing 83% of attendees at these 6 selected nursing homes. Seventy-seven percent of questionnaires were successfully followed up for six weeks. Average confidence increased by 27% pre- to postlecture (6.4 [SD = 1.4] to 8.1 [SD = 2.1], p < 0.005). Confidence gains persisted at six weeks; 8.1 of 10 (SD = 1.4), with no significant drop-off (-0.01/10, p = 0.95). All staff groups (nursing vs. non-nursing) exhibited equal confidence gains (nursing gain of 27%, non-nursing gain 22%, p = 0.16), and all confidence gains persisted at six weeks.
Conclusion: This interactive, novel, training program significantly improved nursing home staff confidence in managing palliative care situations, and this confidence was sustained at least six weeks after the sessions.
BACKGROUND: Around the world, many paramedics are authorised to withhold or terminate resuscitation. Research indicates this can be a challenging part of their role. Little is known about graduating paramedic student confidence, concerns and learning in this area.
METHODS: An online cross-sectional survey of students nearing completion of a paramedic degree in New Zealand, including piloting of a newly-developed confidence scale.
RESULTS: Seventy-two participants reported varying exposure to termination of resuscitation and patient death. Participants felt most confident providing technical procedurally-based care and least confident with non-technical skills. Participants' greatest concerns included making 'the right call', supporting grieving family, controlling emotions and encountering conflict. Clinical exposure with supportive mentoring, clinical simulation, peer reflection and resolved personal experience with death, were considered most useful for professional development.
CONCLUSIONS: Exposure to termination of resuscitation and management of the scene of a patient death is variable amongst graduating paramedics. Novice paramedics may benefit from opportunities to observe and rehearse non-technical skills including delivering death notification and communicating with bystanders and bereaved family. The Confidence with Resuscitation Decision-Making and Patient Death Scale has favourable psychometric properties and utility as an outcome measure for future research in this area.
OBJECTIVES: Having early discussions with seriously ill patients about their priorities and values can improve their peace of mind and family outcomes during bereavement; however, physicians and medical students report feeling underprepared to hold serious illness conversations. We evaluated the impact of the Serious Illness Care Program clinician training workshop on medical learners' knowledge of comfort and confidence in holding such conversations.
METHODS: Eligible learners were penultimate- or final-year medical students or first-year residents of generalist programs (Family Medicine, Internal Medicine). Learners participated in a 2.5-hour workshop involving reflection on serious illness discussions, didactic teaching and demonstration of the Serious Illness Conversation Guide (SICG), role play with standardized patients, direct observation, and feedback from experts. Participants completed pre- and post-intervention questionnaires with Likert-type scale and open-ended questions, which were analyzed using paired t tests and qualitative content analysis, respectively.
RESULTS: We enrolled 25 learners. The intervention was associated with an increase in knowledge (P < .001) and self-efficacy (P < .001). All learners reported gaining new skills, with a majority specifically identifying a framework for structuring serious illness conversations in the qualitative analysis (n = 14, 56%). Participants stated the workshops would improve their comfort in holding serious illness conversations (n = 24, 96%), and that it would be valuable to integrate the workshops into their formal curricula (n = 23, 92%).
CONCLUSIONS: Training on the use of the SICG is novel for medical students and first-year residents and associated with the improvement in their knowledge of and perceived capacity to hold serious illness conversations. This study suggests that the integration of SICG training into medical curricula may have educational value.
BACKGROUND: Trisomy 13 and trisomy 18 are common life-limiting conditions associated with major disabilities. Many parents have described conflictual relationships with clinicians, but positive and adverse experiences of families with healthcare providers have not been well described.
AIM: (1) To investigate parental experiences with clinicians and (2) to provide practical recommendations and behaviors clinicians could emulate to avoid conflict.
DESIGN: Participants were asked to describe their best and worse experiences, as well as supportive clinicians they met. The results were analyzed using mixed methods.
SETTING/PARTICIPANTS: Parents of children with trisomy 13 and 18 who were part of online social support networks. A total of 503 invitations were sent, and 332 parents completed the questionnaire about 272 children.
RESULTS: The majority of parents (72%) had met a supportive clinician. When describing clinicians who changed their lives, the overarching theme, present in 88% of answers, was trust. Parents trusted clinicians when they felt he or she cared and valued their child, their family, and made them feel like good parents (69%), had appropriate knowledge (66%), and supported them and gave them realistic hope (42%). Many (42%) parents did not want to make-or be part of-life-and-death decisions. Parents gave specific examples of supportive behaviors that can be adopted by clinicians. Parents also described adverse experiences, generally leading to conflicts and lack of trust.
CONCLUSION: Realistic and compassionate support of parents living with children with trisomy 13 and 18 is possible. Adversarial interactions that lead to distrust and conflicts can be avoided. Many supportive behaviors that inspire trust can be emulated.
BACKGROUND: Equipping midwives and nurses with confidence to provide bereavement care to parents who have experienced a perinatal loss is vital and impacts on the efficacy of the care received by grieving parents. In education and clinical practice environments there are shortages of bereavement care questionnaires specifically designed to measure midwives' and nurses' confidence and psychosocial factors that impact on their confidence to provide bereavement care.
AIM: The purpose of the study was to develop a valid and reliable perinatal bereavement care confidence scale (PBCCS).
METHODS: The PBCCS was developed in 4 phases. Phase 1: Questionnaire development, 44 questions were formulated from the literature. Phase 2: Face and content validation of the PBCCS by an Expert Panel. Phase 3: A pilot study was conducted and included 10 cognitive pre-testing interviews and test-retest reliability assessment with a cohort of 26 midwives. Phase 4: Construct validity was assessed using factor analysis with 277 midwives and nurses. In order to avoid confusion with terminologies, the term midwife was used for both nurses and midwives who provided care to bereaved parents and participated in the study. Internal consistency reliability measurement was assessed with Cronbach's alpha. Ethical approval of the study was obtained from four maternity hospitals in Ireland.
RESULTS: The PBCCS has 43 items. Bereavement care knowledge (15 items, 3 sub-scales). Bereavement care skills (9 items, 2 sub-scales). Self-awareness (8 items, 2 sub-scales). Organisational support (11 items, 2 subscales). The internal consistency reliabilities ranged from 0.753 to 0.871 except for one subscale 0.663.
CONCLUSIONS: The PBCCS is a valid and reliable tool with good psychometric properties which can be used to measure midwives' confidence and the psychosocial factors thatimpact on their confidence to provide bereavement care.
L'entrée en institution d'un sujet exige de ce dernier ainsi que sa famille et ses proches d'accorder un peu de confiance pour se laisser accompagner dans les soins par les soignants. Accorder sa confiance ne se fait pas sans heurts, maladresses, malentendus, conflits qui donnent cependant aux soignants et aux résidents la possibilité de trouver des points d'aménagements, des stratégies à mettre en oeuvre où chacun trouverait sa place. Passer par le conflit permet de dialectiser et d'envisager une issue, une résolution. Cependant nous sommes au coeur d'une époque où le conflit n'est parfois qu'apparence, un bruit sourd, réduit à des positions univoques, des certitudes exprimées qui empêchent la dialectique, même inconfortable, de s'installer.
Nous ne sommes pas épargnés par la rencontre de ce phénomène dans nos EHPAD et au travers de ces deux exemples cliniques, il s'agit de rendre compte du barrage fait au conflit.
Plus que le conflit, ce qui peut être problématique, voire destructeur, c'est son mode de résolution et surtout le cadre dans lequel celui-ci se déroule. Si l'environnement est dédié à la défiance, le conflit peut être problématique. En revanche, si c'est la confiance qui prédomine alors les différents interactants savent qu'il se situe dans un cadre bienveillant et, dès lors, si les arguments échangés sont bien à discuter, ils ne portent pas en eux de charge délétère.
BACKGROUND: Advance care planning (ACP) is an essential skill for clinicians, yet trainees feel inadequately prepared to conduct ACP discussions. Optimal teaching methods and timing are unknown.
AIM: We designed a curricular intervention to expose second-year medical students to the process of ACP, aiming to improve their ACP knowledge and confidence.
DESIGN: The intervention consisted of a case-based workshop facilitated by a physician experienced in ACP ("facilitated ACP workshop"), which was added to an existing multifaceted ACP curriculum (longitudinal senior mentor program including multiple visits with a volunteer older adult, completion of an electronic ACP learning module and reflective writing exercise). The control group received the existing ACP curriculum only, while the intervention group received the existing curriculum plus the facilitated ACP workshop. Both groups completed an ACP knowledge assessment and confidence survey at the conclusion of the curriculum.
SETTING/PARTICIPANTS: Two consecutive classes of second year medical students, single academic hospital.
RESULTS: No statistically significant differences in ACP knowledge or confidence were seen post-intervention. Overall confidence with ACP tasks remained relatively low despite a multifaceted ACP curriculum.
CONCLUSIONS: Future studies should investigate longitudinal, experiential ACP learning, and seek to optimize ACP teaching strategies and timing.
Despite the frequency, complexity, and intensity of communication that occurs between nurses, patients, and families, palliative care nurses often struggle with end-of-life communication. The primary goal of this quality improvement project was to increase nurse confidence and satisfaction engaging in end-of-life communication following the implementation of the COMFORT model; the secondary goal was to improve patient-family satisfaction with care provided in the palliative care unit. Fourteen palliative care nurses attended a 4-hour course to learn the tenets of the COMFORT model and practice through role-play exercises. A repeated-measures design was used to measure nurse confidence and satisfaction precourse, postcourse, and 3 months postcourse. A between-subjects pre-post design was used to compare family satisfaction survey scores in the 3-month period before versus the 3 months after implementation. Analysis revealed a statistically significant increase in all measures of nurse confidence and satisfaction from precourse to postcourse and from precourse to 3 months postcourse. There was no statistical difference between the family satisfaction survey scores before versus after training, although survey results were generally high at baseline and most respondents rated palliative services with the best possible response. This project demonstrates that COMFORT model training increased confidence and satisfaction of palliative care nurses engaged in end-of-life communication and demonstrates potential for use in other clinical areas that do not specialize in end-of-life nursing (eg, critical care) but find themselves in need of the communications skills to address end-of-life care.
The purpose of this project was to explore how registered community nurses experienced providing holistic end-of-life care and how having a structured end-of-life care pathway plan would help develop their knowledge and skills, particularly in respect of communication and their ability and confidence in providing evidence-based compassionate care. For some practitioners there exists a lack of confidence surrounding end of life care, which can result in nurses' reluctance to become involved and avoid engaging in those 'difficult conversations'. Following implementation, early reviews from practice suggest that incorporating the 19 steps of the plan into the delivery of community-based care at end of life has enhanced practice and patient experience.