Educating nurses to care for the dying in Hong Kong: a problem-based learning approach

Palliative care education and its effectiveness: a systematic review

BACKGROUND

Palliative care education (PCE) is an important public health approach to palliative care and is crucial to improving its utilisation. The present study aims to develop a comprehensive understanding of PCE and its effectiveness.

METHOD

A systematic review approach, including narrative synthesis, was used to review qualitative and quantitative studies published in the English language between January 1969 and January 2019, focussing on PCE programs.

RESULTS

Thirty-nine research studies were included in the systematic review. The target audience of the included studies were mostly healthcare professionals, followed by family caregivers. Definitions of death and palliative care, symptom management and communication were leading themes in the reviewed PCE programs. The educational resources used in PCE programs were mainly self-developed teaching materials, with some programs utilising eLearning resources. The included PCE programs were effective in improving knowledge, attitude and confidence in palliative care and the satisfaction of participant learning experience.

CONCLUSION

PCE is a useful tool to improve knowledge of, confidence in and attitudes towards palliative care amongst healthcare professionals and carers. To make palliative care a public health issue, PCE should be expanded to the public and policy-makers.

Effectiveness of problem-based learning on the professional communication competencies of nursing students and nurses: A systematic review

The objective of this systematic review was to estimate the effectiveness of problem-based learning (PBL) in developing the professional communication competences of nursing students and nurses. We have searched PubMed, EMBASE, MEDLINE, PsycINFO, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, and VIP Database for Chinese Technical Periodicals to identify all the English and Chinese language studies that used PBL to determine the effectiveness of developing professional communication competences of nursing students and nurses. Then two reviewers independently assessed eligibility and extracted data. Quality assessment using the Cochrane Collaboration's risk of bias tool for randomized controlled trials and Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) for quasi-experimental studies. A total of 12 studies were included, all of which were inclined to low bias. Eleven articles showed that PBL developed the communication skills of nursing students or nurses, while only one article revealed no significant difference between PBL and the traditional method. Owing to differences in experimental design and the method and duration of intervention, some of these studies combined PBL with other methods, and the evaluation tools were different. This systematic review cautiously supports the outcomes of PBL compared with traditional learning.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is the third update of a review that was originally published in the Cochrane Library in 2002, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress, which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of HCPs working in cancer care and in improving HCP well-being, patient health status and satisfaction.

SEARCH METHODS

For this update, we searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid, Embase via Ovid, PsycInfo and CINAHL up to May 2018. In addition, we searched the US National Library of Medicine Clinical Trial Registry and handsearched the reference lists of relevant articles and conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In updated versions, we limited our criteria to RCTs evaluating CST compared with no CST or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real or simulated people with cancer or both, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects method. For continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 17 RCTs conducted mainly in outpatient settings. Eleven trials compared CST with no CST intervention; three trials compared the effect of a follow-up CST intervention after initial CST training; two trials compared the effect of CST and patient coaching; and one trial compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists, residents, other doctors, nurses and a mixed team of HCPs. Overall, 1240 HCPs participated (612 doctors including 151 residents, 532 nurses, and 96 mixed HCPs).Ten trials contributed data to the meta-analyses. HCPs in the intervention groups were more likely to use open questions in the post-intervention interviews than the control group (SMD 0.25, 95% CI 0.02 to 0.48; P = 0.03, I² = 62%; 5 studies, 796 participant interviews; very low-certainty evidence); more likely to show empathy towards their patients (SMD 0.18, 95% CI 0.05 to 0.32; P = 0.008, I² = 0%; 6 studies, 844 participant interviews; moderate-certainty evidence), and less likely to give facts only (SMD -0.26, 95% CI -0.51 to -0.01; P = 0.05, I² = 68%; 5 studies, 780 participant interviews; low-certainty evidence). Evidence suggesting no difference between CST and no CST on eliciting patient concerns and providing appropriate information was of a moderate-certainty. There was no evidence of differences in the other HCP communication skills, including clarifying and/or summarising information, and negotiation. Doctors and nurses did not perform differently for any HCP outcomes.There were no differences between the groups with regard to HCP 'burnout' (low-certainty evidence) nor with regard to patient satisfaction or patient perception of the HCPs communication skills (very low-certainty evidence). Out of the 17 included RCTs 15 were considered to be at a low risk of overall bias.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving HCP communication skills related to supportive skills and to help HCPs to be less likely to give facts only without individualising their responses to the patient's emotions or offering support. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', the mental or physical health and satisfaction of people with cancer.

The impact of a 'Critical Moments' workshop on undergraduate nursing students' attitudes to caring for patients at the end of life: an evaluation

AIMS AND OBJECTIVES

To evaluate the impact of an educational workshop on nursing students' attitudes to caring for dying patients.

BACKGROUND

The quality of end-of-life care education provided in preregistration nursing programmes has been criticised. The lack of attention to the emotional content results in nursing students feeling ill-prepared to care for the dying and bereaved. This article reports the findings of a study conducted to evaluate the impact of an educational workshop on undergraduate nursing students' attitudes to caring for patients at the end of life.

DESIGN

A pre- and postintervention survey was used to determine nursing students' attitudes and feelings concerning end-of-life care prior to and following their involvement in an educational workshop.

METHODS

Third-year undergraduate nursing students completed two questionnaires incorporating the Frommelt Attitude Toward Care of the Dying Scale, before and after attending a 'Critical Moments' workshop.

RESULTS

The data revealed a statistically significant increase in positive attitudes to end-of-life care amongst the respondents. Free text responses confirmed the development of positive attitudes and indicated that the workshop was regarded as a valuable learning opportunity.

CONCLUSIONS

Workshops that use case studies based on 'real-life' episodes of end-of-life care can provide an effective learning opportunity that significantly improves the attitudes of nursing students to caring for the dying.

RELEVANCE TO CLINICAL PRACTICE

Identifying emotional labour is an important stage in the development of emotionally intelligent nurses. It may reduce the risk of occupational stress, burnout and potential withdrawal from nursing practice in the longer term. Timing, expert facilitation and peer support are important considerations for an educational workshop that aims to enable nurses to remain healthy whilst delivering high-quality care to patients and their relatives near the end of life.

End of life care education, past and present: a review of the literature

BACKGROUND

Research on end of life care education suggests that undergraduate nursing students are largely unprepared to provide end of life care to dying patients and their families. Although there have been attempts to address the issue of lack of preparedness, little is known on how to improve this.

LITERATURE REVIEW AIMS

To examine how end of life care education has been delivered to undergraduate nursing students and to critically discuss the research on modes of delivery and teaching strategies.

REVIEW METHODS

An extensive literature search on end of life care education in the undergraduate nursing curriculum was conducted in CINAHL, Mosby's Index, Cochrane Database, Scopus, Eric via Proquest, and Medline. 18 research papers published between 1984 and 2012 that met the selection criteria are included in the review.

FINDINGS

Findings of these 18 articles are reported under two main themes: Modes of End of Life Education Delivery and End of Life Care Education Initiatives.

CONCLUSION

This review highlights issues with end of life care education and suggests that end of life care simulation is an innovative strategy that may help to prepare undergraduate nursing students to provide quality end of life care.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is an updated version of a review that was originally published in the Cochrane Database of Systematic Reviews in 2004, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses have been proposed and are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether CST is effective in improving the communication skills of HCPs involved in cancer care, and in improving patient health status and satisfaction.

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2012, MEDLINE, EMBASE, PsycInfo and CINAHL to February 2012. The original search was conducted in November 2001. In addition, we handsearched the reference lists of relevant articles and relevant conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In this updated version, we limited our criteria to RCTs evaluating 'CST' compared with 'no CST' or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real and/or simulated patients with cancer, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects model and, for continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 15 RCTs (42 records), conducted mainly in outpatient settings. Eleven studies compared CST with no CST intervention, three studies compared the effect of a follow-up CST intervention after initial CST training, and one study compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists (six studies), residents (one study) other doctors (one study), nurses (six studies) and a mixed team of HCPs (one study). Overall, 1147 HCPs participated (536 doctors, 522 nurses and 80 mixed HCPs).Ten studies contributed data to the meta-analyses. HCPs in the CST group were statistically significantly more likely to use open questions in the post-intervention interviews than the control group (five studies, 679 participant interviews; P = 0.04, I² = 65%) and more likely to show empathy towards patients (six studies, 727 participant interviews; P = 0.004, I² = 0%); we considered this evidence to be of moderate and high quality, respectively. Doctors and nurses did not perform statistically significantly differently for any HCP outcomes.There were no statistically significant differences in the other HCP communication skills except for the subgroup of participant interviews with simulated patients, where the intervention group was significantly less likely to present 'facts only' compared with the control group (four studies, 344 participant interviews; P = 0.01, I² = 70%).There were no significant differences between the groups with regard to outcomes assessing HCP 'burnout', patient satisfaction or patient perception of the HCPs communication skills. Patients in the control group experienced a greater reduction in mean anxiety scores in a meta-analyses of two studies (169 participant interviews; P = 0.02; I² = 8%); we considered this evidence to be of a very low quality.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving some types of HCP communication skills related to information gathering and supportive skills. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', patients' mental or physical health, and patient satisfaction.

Undergraduate nursing students caring for cancer patients: hermeneutic phenomenological insights of their experiences

BACKGROUND

The care of patients suffering from cancer and especially those facing the death trajectory appears to be complex and demanding not only for student nurses but for professional nurses as well. The educational models often used in nursing require students to face challenging care scenarios, sometimes with minimal or no supervision and guidance. These "worst case scenarios" can be traumatic experiences that can leave the student hopeless and disappointed of themselves and in many cases can "scar" their subsequent professional career. The literature demonstrates that this can be the result of the students' ill-preparation to care for cancer patients and deal with death and dying. The purpose of this study was to interpret the students' experiences of coming face-to-face with cancer care during their clinical placements.

METHODS

This is a hermeneutic phenomenological study influenced by the ideas of the French Philosopher Paul Ricoeur. Based on this philosophical enquiry the interpretation process included three stages: 1) naïve reading, 2) structural analysis and 3) comprehensive understanding. Data were collected through reflective/narrative diaries from the 4th grade undergraduate (pre-registration) nursing students practicing at oncology, hematology, pediatric oncology departments and hospices. Diaries of twelve students met the inclusion criteria and were included in the interpretation process. The study took place during January and May 2011.

RESULTS

The interpretation yielded the following themes: a) Being part of the center's life, b) Being sympathetic, c) Being confronted by others, d) Being self-reflective, e) Being trapped in the system, f) Being caring towards the family and g) Being better in clinical practice.

CONCLUSIONS

The students emphasized the need for appropriate preparation both at a theoretical and at a clinical level, as to better confront situations involving death and dying as well as learning techniques for crisis management. The students perceived the importance of adopting a policy that is both patient and family-centered in order to provide better care.

Stressors in the ICU: a comparison of patients' and nurses' perceptions

AIMS AND OBJECTIVES

The aim of the study was to compare the stressors as perceived by patients in an intensive care unit (ICU) against those of nurses on the basis of their perceptions of patients' stressors.

BACKGROUND

Getting admitted to an ICU is viewed as a stressful event by patients. However, numerous studies have indicated that nurses do not always accurately perceive the stressors of their clients. Therefore, it is important for nurses to know what seems most stressful from the patients' perspective so that appropriate nursing measures can be directed towards minimising such stressors.

DESIGN

Survey.

METHODS

As a convenience sample, 60 patients and 54 critical care nurses were recruited. The Intensive Care Unit Stressor Questionnaire (Chinese) (ICU-CSQ) was used to collect the perceptions of stressors by the patients. Nurses were also asked to rate the items in the said questionnaire according to how they believe patients would rate them.

RESULTS

In every comparison, nurses evaluated the items to be significantly more stressful than patients did. Overall perceived stress levels of nurses were also significantly higher than those of their patients (z = -8.78, p < 0.001).

CONCLUSIONS

Nurses tended to rate the items as more stressful than did the patients, perhaps over-emphasising the stressful nature of the ICU. The findings also highlight the importance of cultural beliefs on the perceived stress levels among the Chinese population.

RELEVANCE TO CLINICAL PRACTICE

Findings in this study have strong implications in clinical practice, especially in a critical care setting. Nurses must attempt to identify and endeavour to cope with the situations that patients listed as most stressful. Moreover, attention must be drawn towards measures aimed at relieving the stress of patients by taking into account their cultural values so that culture-specific interventions for reducing their stress can be established.

Compartilhando o processo de morte com a família: a experiência da enfermeira na UTI pediátrica

A morte é um evento presente no cotidiano das enfermeiras que trabalham com crianças em UTI. Este estudo teve como objetivo compreender a experiência da enfermeira no cuidado da criança e da família que vivenciam o processo de morte. O referencial teórico adotado foi o Interacionismo Simbólico e, como referencial metodológico, o Interacionismo Interpretativo para análise das narrativas biográficas das sete enfermeiras que participaram da pesquisa. Os eventos que marcaram a história das enfermeiras neste cenário foram: DEPARANDO-SE COM A MORTE DA CRIANÇA, PROJETANDO-SE NO PAPEL DE MÃE e PROMOVENDO A DESPEDIDA. Os dados analisados possibilitaram a compreensão da experiência das enfermeiras ao cuidarem da criança e sua família durante o processo de morte.

Developing communication competency in the context of cancer: a critical interpretive analysis of provider training programs

We conducted a critical interpretive analysis of 47 studies from the Cochrane Review of the communications training literature to capture the empirical indicators used to judge provider communication competency and to describe how the indicators were characterized in the context of a cancer care system. Of the 47 studies reviewed, few showed any resemblance to recommendations from two international consensus conferences of experts in the communication research field. Some of the challenges in moving forward with cancer-related communication skills involve deciding what we want people to learn, providing learning across various experiences, identifying learning models, and finding alternate ways of motivating people to learn. Once core competencies are clearly articulated, we can determine the best approaches for developing cancer-specific training programs.

Problem-based learning: ancient Chinese educational philosophy reflected in a modern educational methodology

Problem-based learning (PBL) has been widely adopted as a strategy by nurse educators all over the world. Many studies have been carried out to examine its process and outcomes. There are few studies discussing the relevance of PBL to students with different cultural background. This study reports the experiences of Chinese students in Hong Kong using PBL and explores if their experiences were compatible with the educational philosophy documented in traditional Chinese literature. The phenomenological approach was used in the treatment of data. The informants were students enrolled in the post-registration nursing degree programme at a university in Hong Kong during 1997-1998. A total of 94 journals were included in the analysis. Seven main themes emerged from the phenomenological analysis. They were the integration of knowing and doing, critical reflection and debate, individuality of learning, self-motivated learning, critical inquiry and independent thinking, timeliness of instruction and cooperative learning. This study provides evidence to show that PBL is an approach that is compatible with the Chinese way of learning. The result of this study shows that aspects of the modern PBL process harken back to an ancient Chinese learning philosophy that underpins Chinese learning today.

Communication skills training for health care professionals working with cancer patients, their families and/or carers

BACKGROUND

Research suggests communication skills do not reliably improve with experience. Considerable effort is dedicated to courses improving communication skills for health professionals. Evaluation of such courses is important to enable evidence-based teaching and practice.

OBJECTIVES

To assess whether communication skills training is effective in changing health professionals' behaviour in cancer care with regard to communication/interaction with patients.

SEARCH STRATEGY

We searched CENTRAL (Cochrane Library Issue 3 2001), MEDLINE (1966 to November 2001), EMBASE (1980 to November 2001), PsycInfo (1887 to November 2001), CINAHL (1982 to November 2001), AMED (1985 - October 2001), Dissertation Abstracts International (1861 to March 2002) and EBM Reviews (1991 to March/April 2001). Reference lists of relevant articles were searched. Three further studies were detected in November 2003.

SELECTION CRITERIA

Randomized controlled trials or controlled before and after studies of communication skills training in cancer health professionals, measuring changes in behaviour/skills using objective and validated scales.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials and extracted data.

MAIN RESULTS

Of 2824 references, 3 trials involving 347 health professionals were included. One provided an intensive 3 day course then assessed oncology doctors interacting with 640 patients; a second provided a modular course then assessed role plays with oncology nurses; the third was modular and assessed outcomes with clinical and simulated interviews and patient questionnaires. In one trial, course attendees used more focused questions (probability < 0.005), focused and open questions (p = 0.005), expressions of empathy (p < 0.005) and appropriate cue responses (p < 0.05) at follow up than non-attendees. No significant differences were found between attendees and non-attendees for leading questions. From baseline to follow up, attendees had significantly different changes in rates of leading questions (p < 0.05), focused questions (p < 0.005), open questions (p < 0.05) and empathy (p = 0.005). The only observed significant difference in the second trial was that trained doctors controlled the follow-up interview more than untrained doctors (p < 0.05). Neither studies found differences in summarising, interrupting and checking. The third trial found trained nurses used more emotional speech than untrained counterparts, particularly regarding anxiety and distress. Patients interviewed by trained nurses used more emotional terms, but no differences emerged in questionnaires.

REVIEWERS' CONCLUSIONS

Training programmes assessed by these trials appear to be effective in improving some areas of cancer care professionals communication skills. It is unknown whether this training would be effective if taught by others, nor the comparative efficacy of these programmes.

Death, dying, and the ICU nurse

Death is a natural progression from life. Most nurses will be exposed to the physical and emotional effects of this experience as they care for a dying patient. The nurse is taught how to provide support for the patient and family as they proceed through the stages of grief. Often, however the nurse may not realize his or her own need to grieve.

Communication skills training for health care professionals working with cancer patients, their families and/or carers

BACKGROUND

Research suggests communication skills do not reliably improve with experience and considerable effort is dedicated to courses improving communication skills for health professionals. The evaluation of such courses is of importance to enable evidence-based teaching and practice.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of health professionals in cancer care with regard to communication/interaction with patients.

SEARCH STRATEGY

We searched CENTRAL (Cochrane Library Issue 3 2001), MEDLINE (1966 to November 2001), EMBASE (1980 to November 2001), PsycInfo (1887 to November 2001), CINAHL (1982 to November 2001), AMED (1985 - October 2001), Dissertation Abstracts International (1861 to March 2002) and EBM Reviews (1991 to March/April 2001). Reference lists of relevant articles were searched.

SELECTION CRITERIA

Randomized controlled trials or controlled before and after studies of communication skills training in cancer health professionals, measuring changes in behaviour/skills using objective and validated scales.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Although 2822 references were considered, only two trials involving 232 health professionals were included. One provided an intensive three-day course then assessed oncology doctors interacting with a total of 640 patients; the other provided a modular course then used role plays with oncology nurses for skill assessment. In one trial, course attendees used more focused questions (34% increase, probability < 0.005), focused and open questions (27% increase, p = 0.005), expressions of empathy (69% increase, p < 0.005) and appropriate responses to cues (38% increase, p < 0.05) at follow up than non-attendees. No significant differences were found between attendees and non-attendees in use of leading questions. From baseline to follow up in the same study, attendees had significantly different changes in rates of leading questions (relative risk 0.72, p < 0.05), focused questions (Relative Risk 1.25, p < 0.005), open questions (RR 1.17, p < 0.05) and empathy (RR 1.50, p = 0.005). The only significant difference in observed communication skills in the second trial was that the trained group were more in control of the follow-up interview than the untrained group (p < 0.05). Both studies investigated differences in summarising, interrupting and checking but found none.

REVIEWER'S CONCLUSIONS

The training programmes assessed by these trials appear to be effective in improving cancer care professionals communication skills. It is not known whether the training would be effective if taught by other educators, nor has any trial compared the efficacy of both programmes.

Evaluating the use of developmental action inquiry in constructing a problem-based learning curriculum for pre-registration nursing education in Hong Kong: a student perspective

BACKGROUND

Developmental action inquiry (DAI) was chosen as the change strategy for introducing problem-based learning (PBL) in a pre-registration nursing programme. The central task was to transform the tutor and student participants to become collaborators in this curriculum reconstruction project.

AIM

This paper expounds the way in which the action inquiry was constructed and in light of students' feedback analysis, the way in which PBL has made a difference in student learning was evaluated.

DESIGN

Taking into consideration the change context and different group characteristics, the DAI was conducted in terms of two dynamically interlinked circles that formed partnerships between PBL core group members and tutors, and between tutors and students in coconstructing knowledge useful for PBL curriculum development.

FINDINGS

The findings of the student evaluation questionnaire reveal that the majority of students felt PBL made a difference to their expectations of self, the student group and the teacher role in creating a facilitative environment to enhance learning. However, there was a significant difference among individual student group responses. The students' positive and negative PBL experience in self-learning, tutor-student interaction, and group-learning were identified as crucial factors contributing to these group variations.

CONCLUSION

The evaluation findings show that a paradigm shift from teacher-centred to student-centred learning, from valuing self-learning to co-operative group-learning, and from theory-based to practice-based learning occurred among the students. DAI was found to be an effective change strategy for transforming participants to become collaborators in searching for useful knowledge and coconstructing the PBL learning context.