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Rural nurses’ self-rated knowledge and skills in pain, medication, symptom and emergency management in community-based palliative care: A cross-sectional survey
The assessment and management of pain and symptoms in community-based palliative care patients is a measure of quality in palliative care to indicate the quality of palliative care. Studies have identified rural community-based nurses are not always confident in this area of practice.
Aim
To identify rural community-based nurses’ strengths and gaps in palliative care knowledge and skills regarding pain, symptom and emergency management and to determine correlates of deficient knowledge.
Methods
A cross-sectional study design was used. An electronic questionnaire was emailed to 165 community-based nurses in Gippsland, Australia. Participants rated their palliative care knowledge/skills on a five-point Likert scale ranging from ‘No knowledge’ (1) to ‘Can teach others’ (5) on the following topics: pain (2 items), medication (14 items), symptoms (26 items), palliative care emergencies (12 items) and assessment tools (2 items). For each item classified as a gap or consolidation, associations between nurse characteristics and no/basic knowledge were assessed using univariable and multivariable binary logistic regression.
Findings
Overall, 122 nurses (response rate = 74%) completed the questionnaire. Seventy-one percent of items were identified as practice strengths. Strengths included pain (2/2), medication management (11/14), and symptom management (22/25). Twenty-nine percent of items were identified as gaps and consolidations. Gaps and consolidations related to management of opioid medications, symptom management of delirium, and the recognition and management of rare emergency situations within palliative care.
Discussion
This study found that lack of experience and formal training in palliative care were associated with gaps in knowledge.
Conclusion
This study found that lack of experience and formal training in palliative care were associated with gaps in knowledge. Targeted interventions such as training and peer mentoring have the potential to address identified gaps in rural community-based nurses... palliative care knowledge/skills and, ultimately, improve the care of palliative patients.
Symptom control and personal care form the cornerstone for measuring quality in palliative care. Australian data from the Palliative Care Outcomes Collaboration (PCOC) reveal significant gaps in management of pain and symptoms in community-based care.
What is already known
While some palliative care nursing competency tools have been developed for general palliative and home-based care, no such tools have been developed with rural nurses, who have a different scope of practice to metropolitan-based nurses to identify areas of training and education needs. We developed and validated a Palliative Care Skills Matrix Questionnaire (PC-SMQ) to identify strengths and gaps in rural nurses’ knowledge of providing community-based palliative care.
What this paper adds
The PC-SMQ can be used by rural nurses, managers and health services to systematically identify palliative care practice strengths and gaps, with a view to planning future CPD activities. This study found that lack of experience and formal training in palliative care led to significant gaps in palliative care provision in the areas of symptom control and pain management.
1. Introduction
In 2014, World Health Assembly passed the first global resolution calling upon the World Health Organization (WHO) and member states to ensure equitable access to palliative care (
). Palliative care is an approach to care which aims to improve the quality of life of a person diagnosed with a life-threatening or terminal illness through the appropriate assessment and treatment of pain, physical symptoms, and psychosocial and spiritual needs (
). Palliative care can be provided at stage of illness or age and includes family, carers or significant others. End-of-life care (EOL), which is also provided through palliative care services, focuses on the last few weeks and days of a person's life, the person's death and bereavement care for family/carers. In Australia, palliative and EOL care are provided in hospitals, hospices (either in hospital or community-based facilities), residential aged care facilities and at a person's home (Palliative Care Australia). In rural areas, however, many palliative care services are provided in community and home-based care, through community health and hospital-in-the-home programs (
), there is geographical variation in the distribution of the nursing workforce. In 2018, only 1.1% of the nursing workforce worked in a designated palliative care role, most of whom (72.1%) worked in major cities (
). Furthermore, rural areas have a higher proportion of enrolled nurses (EN) (>20%) and nurses aged over 50 years (45.3%) compared to corresponding Australian averages (15.8% and 39%, respectively) (
). The qualifications and scope of practice of Enrolled Nurses (EN) and Registered Nurses (RN) is different. In Australia, an EN has completed a two-year Diploma of Nursing and works under the direct and indirect supervision of a RN. A RN has completed a 3-year Bachelor of Nursing undergraduate degree and has a wider scope of practice in providing specialised nursing care and patient assessment, supervision of staff and organisational management roles (
), rural and remote areas will need to ensure they not only have enough nurses with the necessary knowledge, skills and competencies to effectively meet the needs of palliative care patients, families, and carers.
Multiple studies have highlighted the need to increase nurses’ training in many aspects of palliative care provision (
Patient-reported outcome measurement of symptom distress is feasible in most clinical scenarios in palliative care: an observational study involving routinely collected data.
International Journal for Quality in Health Care.2021; 33: mzab075
found nurses providing home-based care in a rural setting felt rewarded in these roles, but experienced geographical and professional isolation, feared they lacked necessary palliative care skills, and expressed frustration working with insufficient supplies and medical advice. These gaps in knowledge, and workforce-related issues, have the potential to impact on symptom control and personal care provided to palliative care patients by rural nurses; two cornerstone indicators for measuring quality in palliative care (
). Australian data from the Palliative Care Outcomes Collaboration (PCOC) reveal significant gaps in management of pain and symptoms in community-based care (
found knowledge, pain and symptom management were priorities for further education of palliative care nurses. Furthermore, assessment and management of various emergencies (
). Multiple studies have also found that confidence and positive attitudes towards palliative care practice increase with further education and training (
Self-perceived competence of nurses and care aides providing a palliative approach in home, hospital, and residential care settings: a cross-sectional survey.
Development and validation of scales for attitudes, self-reported practices, difficulties and knowledge among home care nurses providing palliative care.
), no such tools have been developed with rural nurses. Rural nurses’ scope of practice may differ from that of metropolitan-based nurses and should be explored with tools designed with, and for, rural nurses. To address this gap, we developed a Palliative Care Skills Matrix Questionnaire (PC-SMQ) to identify strengths and gaps in rural nurses’ knowledge of providing community-based palliative care (
). This study aimed to use the PC-SMQ to identify rural community-based nurses’ knowledge and skills regarding pain, medication, symptom, and emergency management to palliative care clients and families in home-based palliative care and to determine correlates of deficient knowledge. Our research questions were:
What are rural community-based nurses’ knowledge strengths and gaps in pain, medication, symptom, and emergency management in community-based palliative care?
What characteristics of rural community-bases nurses are associated with gaps in knowledge in pain, medication, symptom, and emergency management?
2. Methods
A cross-sectional study design was used. We undertook an online survey of nurses working in community-based palliative care in Gippsland, Australia in 2019. Nineteen health service managers in the region emailed the survey on behalf of the researchers to eligible nursing staff. Each manager calculated the number of staff members in their health service who met the eligibility criteria. Across the 19 services, there were 165 eligible staff members. Participants indicated consent after reviewing a written description of the risks and benefits of participation. Study procedures were approved by Monash University Human Research Ethics Committee (project ID: 14172).
The 123-item PC-SMQ was used to measure nurses’ self-rated knowledge and skills against six National Palliative Care Standards, national health service standards in safety and quality, and palliative care-specific screening and assessment tools (
Australian Commission on Safety and Quality in Health Care. (2015). National Consensus Statement: Essential elements for safe and high-quality end-of-life care. Retrieved from Sydney:.
). For each item, nurses rated their knowledge and skills on a five-point Likert scale: (1) No experience, (2) Basic knowledge; (3) Can do skill with supervision; (4) Can perform independently; (5) Can teach others. This scale was based on Benner's (
Demographic: age, gender, role, years of experience in palliative care, years of experience in current role, palliative care education and training.
2
Clinical practice supports: self-care tools, scope of practice, clinical supervision modalities, local, and national practice frameworks and guidelines.
3
Screening and assessment tools.
4
Standards of practice:
•
Standard 1: Assessment of needs
•
Standard 2: Developing a care plan
•
Standard 3: Caring for carers
•
Standard 4: Providing care––care of the dying person
•
Standard 5: Transition within and between services
•
Standard 6: Grief support
This paper reports results for the 56 items about pain management (2), medication management (14), symptom management (26), palliative care emergencies (12), and assessment tools (2).
Demographic variables and responses to PC-SMQ items were analysed by calculating frequencies and percentages. We used a set of rules to classify nurses’ self-reported knowledge into strengths, consolidations, or gaps:
·
If >25% of an item's respondents rated their capability as ‘no knowledge’ or ‘basic knowledge’, then this item was classified as a ‘gap.’ Gaps should be the main focus for CPD.
·
If >25% of an item's respondents rated their capability as ‘can do skill with supervision’ and the question has not been identified as a ‘gap,’ then this item was classified as a ‘consolidation.’ These areas can be improved upon and should also be included in CPD.
·
If >50% of an item's respondents rated their capability as ‘can perform independently’ or ‘can teach others’, and the question has not been identified as a ‘gap’ or ‘consolidation,’ then this item was classified as a ‘strength.’ No immediate CPD is required, although advanced learning opportunities may be beneficial (Table 1).
Associations between participant characteristics and each outcome—no or basic knowledge of each palliative care standard—were assessed using binary logistic regression (BLR). First, univariable BLR models (with one participant characteristic variable per model) were fitted. This involved calculating univariable odds ratios (UORs) and corresponding 95% confidence intervals (CIs). Subsequently, for each knowledge outcome, Hosmer and Lemeshow's (
) purposeful selection method was used to build a parsimonious multivariable BLR model (with multiple participant characteristic variables per model) adjusting for one or more factors, with the theoretical confounding factor age retained in models regardless of statistical significance (
). Parsimonious multivariable models were built through this approach as the sample size of 122 could not simultaneously support all covariates of interest. If no factors were associated with a particular palliative care standard outcome in the multivariable setting, then a final multivariable model was not built and results were not reported. Where appropriate, multivariable modelling involved calculating multivariable odds ratios (MORs) and 95% CIs. If the 95% CI surrounding a given UOR or MOR excluded 1.00, then the association between the covariate and no/basic knowledge of the particular palliative care standard was considered statistically significant at the 5% level. All analysis was performed in SPSS Version 25 (SPSS Inc., Chicago, IL, USA).
3. Results
Overall, 122 nurses (response rate = 74%) completed the questionnaire. Eight-seven percent worked as RNs, 64% were aged ≥45 years, 58% had ≥5years’ palliative care experience and 63% worked in small organisations with <5 personnel (Table 2). A follow up was sent to increase response rate with no positive result.
Table 2Participant characteristics.
Characteristic (N = 122)
n
%
Age (years) 18–24
2
2
25–34
21
17
35–44
18
15
45–54
49
40
≥55
29
24
Missing
3
2
Gender Female
114
93
Male
5
4
Missing
3
2
Role RN
106
87
EN
16
13
Experience in palliative care (years) <1
9
7
1–4
43
35
5–9
29
24
≥10
41
34
Formal palliative care training Yes
49
40
No
31
25
Not answered
42
34
Service size Small (<5 staff)
77
63
Medium (5–10 staff)
30
25
Large (>10 staff)
15
12
n, numerator; N, denominator; RN, registered nurse; EN, enrolled nurse; %, percentage.
One gap and two consolidations were identified in the management of medications (Fig. 2).
Opioid rotation: In the univariable setting, the EN role was associated with significantly higher odds of no/basic knowledge of opioid rotation while ≥10 years’ experience and formal palliative care training were associated with significantly lower odds of no/basic knowledge of opioid rotation (Table 4). Neither of these three factors were found to be significantly associated with opioid rotation knowledge in the multivariable setting.
Table 4Factors associated with no or basic knowledge of the management of opioids in the palliative care setting.
Statistically significant at the 5% level in univariable setting as well as in the multivariable setting with adjustment for age (multivariable odds ratio = 6.88, 95% confidence interval = 1.98–23.9).
a Statistically significant at the 5% level in the univariable setting.
b Statistically significant at the 5% level in univariable setting as well as in the multivariable setting with adjustment for age (multivariable odds ratio = 6.88, 95% confidence interval = 1.98–23.9).
Opioid equivalency/conversion: The univariable odds of no/basic knowledge of opioid equivalency/conversion were significantly higher for the EN role and significantly lower for those with ≥10 years’ experience (Table 4), although these associations were nonsignificant in the multivariable setting.
Opioid metabolism: The EN role was associated with significantly higher odds of no/basic knowledge of opioid metabolism in both univariable and multivariable (age-adjusted MOR = 6.88, 95% CI = 1.98–23.9) models (Table 4). Relative to those with <5 years’ experience, participants with 5–9 and ≥10 years of palliative care experience had significantly lower odds of no/basic opioid metabolism knowledge in the univariable setting (Table 4), although these associations were non-significant in the multivariable setting.
3.4 Symptom management
There were three consolidations regarding managing delirium symptoms and one gap in the use of the delirium screening tool (Fig. 2).
Using delirium screening tool: Formal palliative care training was associated with significantly lower odds of no/basic knowledge of how to use the delirium screening tool (Table 5); however, this association was non-significant when adjusted for age.
Table 5Factors associated with no or basic knowledge of delirium screening and management in palliative care patients.
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age (multivariable odds ratio = 6.23, 95% confidence interval = 1.91–35.5).
a Statistically significant at the 5% level in the univariable setting.
b Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age (multivariable odds ratio = 6.23, 95% confidence interval = 1.91–35.5).
Nonpharmacological and pharmacological management of delirium: The EN role was associated with significantly higher odds of no/basic knowledge of nonpharmacological and pharmacological management of delirium (Table 5); however, only the association with nonpharmacological management was significant when adjusted for age (MOR = 6.23, 95% CI = 1.91–35.5).
Recognition, assessment or management of delirium: None of the factors assessed here were associated with no/basic knowledge of recognition, assessment or management of delirium in the univariable and multivariate setting (Table 5).
3.5 Palliative care emergencies
Eight gaps and one consolidation were found in recognising and managing the following emergencies: catastrophic haemorrhage, spinal cord compression, hypercalcemia in malignancy, superior vena cava (SVC) obstruction and seizures (Fig. 2).
Recognising spinal cord compression: Number of years’ experience was associated with lower odds of no/basic knowledge of recognising spinal cord compression in the univariable setting and the multivariable setting with adjustment for age (5–9 years: MOR = 0.29, 95% CI 0.10–0.87; ≥10 years: MOR = 0.19, 95% CI = 0.06–0.58; Table 6). Relative to the RN role, the EN role was associated with higher odds of no/basic knowledge of recognising spinal cord compression in the univariable (Table 6), but not multivariable, setting.
Table 6Factors associated with no or basic knowledge of recognising palliative care emergencies.
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Recognise spinal cord compression’: 5–9 years’ experience = 0.29 [0.10–0.87], ≥10 years’ experience = 0.19 [0.06–0.58]; MORs and 95% CIs for ‘Recognise hypercalcaemia in malignancy’: EN = 5.67 [1.53–21.0], 5–9 years’ experience = 0.31 [0.10–0.90], ≥10 years’ experience = 0.17 [0.05–0.53]; MORs and 95% CIs for ‘Recognise superior vena cava obstruction’: 5–9 years’ experience = 0.26 [0.09–0.74], ≥10 years’ experience = 0.16 [0.06–0.48]; MORs and 95% CIs for ‘Recognise catastrophic haemorrhage’: EN = 4.41 [1.20–16.3], ≥10 years’ experience = 0.22 [0.06–0.74]
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Recognise spinal cord compression’: 5–9 years’ experience = 0.29 [0.10–0.87], ≥10 years’ experience = 0.19 [0.06–0.58]; MORs and 95% CIs for ‘Recognise hypercalcaemia in malignancy’: EN = 5.67 [1.53–21.0], 5–9 years’ experience = 0.31 [0.10–0.90], ≥10 years’ experience = 0.17 [0.05–0.53]; MORs and 95% CIs for ‘Recognise superior vena cava obstruction’: 5–9 years’ experience = 0.26 [0.09–0.74], ≥10 years’ experience = 0.16 [0.06–0.48]; MORs and 95% CIs for ‘Recognise catastrophic haemorrhage’: EN = 4.41 [1.20–16.3], ≥10 years’ experience = 0.22 [0.06–0.74]
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Recognise spinal cord compression’: 5–9 years’ experience = 0.29 [0.10–0.87], ≥10 years’ experience = 0.19 [0.06–0.58]; MORs and 95% CIs for ‘Recognise hypercalcaemia in malignancy’: EN = 5.67 [1.53–21.0], 5–9 years’ experience = 0.31 [0.10–0.90], ≥10 years’ experience = 0.17 [0.05–0.53]; MORs and 95% CIs for ‘Recognise superior vena cava obstruction’: 5–9 years’ experience = 0.26 [0.09–0.74], ≥10 years’ experience = 0.16 [0.06–0.48]; MORs and 95% CIs for ‘Recognise catastrophic haemorrhage’: EN = 4.41 [1.20–16.3], ≥10 years’ experience = 0.22 [0.06–0.74]
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Recognise spinal cord compression’: 5–9 years’ experience = 0.29 [0.10–0.87], ≥10 years’ experience = 0.19 [0.06–0.58]; MORs and 95% CIs for ‘Recognise hypercalcaemia in malignancy’: EN = 5.67 [1.53–21.0], 5–9 years’ experience = 0.31 [0.10–0.90], ≥10 years’ experience = 0.17 [0.05–0.53]; MORs and 95% CIs for ‘Recognise superior vena cava obstruction’: 5–9 years’ experience = 0.26 [0.09–0.74], ≥10 years’ experience = 0.16 [0.06–0.48]; MORs and 95% CIs for ‘Recognise catastrophic haemorrhage’: EN = 4.41 [1.20–16.3], ≥10 years’ experience = 0.22 [0.06–0.74]
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Recognise spinal cord compression’: 5–9 years’ experience = 0.29 [0.10–0.87], ≥10 years’ experience = 0.19 [0.06–0.58]; MORs and 95% CIs for ‘Recognise hypercalcaemia in malignancy’: EN = 5.67 [1.53–21.0], 5–9 years’ experience = 0.31 [0.10–0.90], ≥10 years’ experience = 0.17 [0.05–0.53]; MORs and 95% CIs for ‘Recognise superior vena cava obstruction’: 5–9 years’ experience = 0.26 [0.09–0.74], ≥10 years’ experience = 0.16 [0.06–0.48]; MORs and 95% CIs for ‘Recognise catastrophic haemorrhage’: EN = 4.41 [1.20–16.3], ≥10 years’ experience = 0.22 [0.06–0.74]
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Recognise spinal cord compression’: 5–9 years’ experience = 0.29 [0.10–0.87], ≥10 years’ experience = 0.19 [0.06–0.58]; MORs and 95% CIs for ‘Recognise hypercalcaemia in malignancy’: EN = 5.67 [1.53–21.0], 5–9 years’ experience = 0.31 [0.10–0.90], ≥10 years’ experience = 0.17 [0.05–0.53]; MORs and 95% CIs for ‘Recognise superior vena cava obstruction’: 5–9 years’ experience = 0.26 [0.09–0.74], ≥10 years’ experience = 0.16 [0.06–0.48]; MORs and 95% CIs for ‘Recognise catastrophic haemorrhage’: EN = 4.41 [1.20–16.3], ≥10 years’ experience = 0.22 [0.06–0.74]
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Recognise spinal cord compression’: 5–9 years’ experience = 0.29 [0.10–0.87], ≥10 years’ experience = 0.19 [0.06–0.58]; MORs and 95% CIs for ‘Recognise hypercalcaemia in malignancy’: EN = 5.67 [1.53–21.0], 5–9 years’ experience = 0.31 [0.10–0.90], ≥10 years’ experience = 0.17 [0.05–0.53]; MORs and 95% CIs for ‘Recognise superior vena cava obstruction’: 5–9 years’ experience = 0.26 [0.09–0.74], ≥10 years’ experience = 0.16 [0.06–0.48]; MORs and 95% CIs for ‘Recognise catastrophic haemorrhage’: EN = 4.41 [1.20–16.3], ≥10 years’ experience = 0.22 [0.06–0.74]
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Recognise spinal cord compression’: 5–9 years’ experience = 0.29 [0.10–0.87], ≥10 years’ experience = 0.19 [0.06–0.58]; MORs and 95% CIs for ‘Recognise hypercalcaemia in malignancy’: EN = 5.67 [1.53–21.0], 5–9 years’ experience = 0.31 [0.10–0.90], ≥10 years’ experience = 0.17 [0.05–0.53]; MORs and 95% CIs for ‘Recognise superior vena cava obstruction’: 5–9 years’ experience = 0.26 [0.09–0.74], ≥10 years’ experience = 0.16 [0.06–0.48]; MORs and 95% CIs for ‘Recognise catastrophic haemorrhage’: EN = 4.41 [1.20–16.3], ≥10 years’ experience = 0.22 [0.06–0.74]
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Recognise spinal cord compression’: 5–9 years’ experience = 0.29 [0.10–0.87], ≥10 years’ experience = 0.19 [0.06–0.58]; MORs and 95% CIs for ‘Recognise hypercalcaemia in malignancy’: EN = 5.67 [1.53–21.0], 5–9 years’ experience = 0.31 [0.10–0.90], ≥10 years’ experience = 0.17 [0.05–0.53]; MORs and 95% CIs for ‘Recognise superior vena cava obstruction’: 5–9 years’ experience = 0.26 [0.09–0.74], ≥10 years’ experience = 0.16 [0.06–0.48]; MORs and 95% CIs for ‘Recognise catastrophic haemorrhage’: EN = 4.41 [1.20–16.3], ≥10 years’ experience = 0.22 [0.06–0.74]
a Statistically significant at the 5% level in the univariable setting.
b Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Recognise spinal cord compression’: 5–9 years’ experience = 0.29 [0.10–0.87], ≥10 years’ experience = 0.19 [0.06–0.58]; MORs and 95% CIs for ‘Recognise hypercalcaemia in malignancy’: EN = 5.67 [1.53–21.0], 5–9 years’ experience = 0.31 [0.10–0.90], ≥10 years’ experience = 0.17 [0.05–0.53]; MORs and 95% CIs for ‘Recognise superior vena cava obstruction’: 5–9 years’ experience = 0.26 [0.09–0.74], ≥10 years’ experience = 0.16 [0.06–0.48]; MORs and 95% CIs for ‘Recognise catastrophic haemorrhage’: EN = 4.41 [1.20–16.3], ≥10 years’ experience = 0.22 [0.06–0.74]
Managing spinal cord compression: The EN role was associated with higher odds of no/basic knowledge of managing spinal cord compression while ≥10 years’ experience and formal training were associated with lower odds of no/basic knowledge of managing spinal cord compression (Table 7). The association between the EN role and no/basic knowledge of managing spinal cord compression remained significant when adjusting for age and years’ experience (MOR = 4.98, 95% CI = 1.38–18.1). Furthermore, when adjusted for age and role, ≥10 years’ experience was associated with lower odds of no/basic knowledge of managing spinal cord compression (MOR = 0.23, 95% CI = 0.08–0.69). Neither 5–10 years’ experience nor formal training were significantly associated with knowledge of managing spinal cord compression in the multivariable setting.
Table 7Factors associated with no or basic knowledge of managing palliative care emergencies.
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
a Statistically significant at the 5% level in the univariable setting.
b Statistically significant at the 5% level in the univariable setting as well as in the multivariable setting with adjustment for age ± another factor significant in the multivariable setting for that outcome (multivariable odds ratios [MORs] and 95% CIs for ‘Manage spinal cord compression’: EN = 4.98 [1.38–18.1], ≥10 years’ experience = 0.23 [0.08–0.69]; MORs and 95% CIs for ‘Manage hypercalcaemia in malignancy’: 45–54 years of age = 0.29 [0.09–0.97], 5–9 years’ experience = 0.31 [0.11–0.90], ≥10 years’ experience = 0.27 [0.09–0.81], formal training = 0.35 [0.13–0.96]; MORs and 95% CIs for ‘Manage superior vena cava obstruction’: 5–9 years’ experience = 0.19 [0.06–0.57], ≥10 years’ experience = 0.30 [0.10–0.89], formal training = 0.36 [0.14–0.93]; MORs and 95% CIs for ‘Manage catastrophic haemorrhage’: EN = 6.36 [1.72–23.5]; 5–9 years’ experience = 0.31 [0.10–0.99], ≥10 years’ experience = 0.23 [0.07–0.76]; MOR and 95% CI for ‘Manage seizures’: EN = 8.35 [2.30–30.3].
Recognising and hypercalcemia in malignancy: ENs had higher odds of no/basic knowledge of recognising hypercalcemia in malignancy relative to RNs, and this association maintained significance when adjusted for age and years’ experience (MOR = 5.67, 95% CI = 1.53–21.0; Table 5). Five-to-nine and ≥10 years’ experience was each associated with lower odds of no/basic knowledge of hypercalcemia recognition; these associations remained significant when adjusted for age and role (5–10 years: MOR = 0.31, 95% CI = 0.10–0.90; ≥10 years: MOR = 0.17, 95% CI = 0.05–0.53). Formal training and age (35–44 and ≥55 years) were associated with lower odds of no/basic knowledge of hypercalcemia recognition, although neither were significant in the multivariable setting (when formal training was adjusted for role, age and years’ experience, and age was adjusted for role and years’ experience; Table 6).
Managing hypercalcemia in malignancy: The 45–54-year-old and ≥55-year-old age groups were associated with lower odds of no/basic knowledge of managing hypercalcemia in malignancy (Table 7), although only the 45–54-year-old age group was significant when adjusting for years’ experience and formal training (MOR = 0.29, 95% CI = 0.09-0.97). Participants with 5–9 and ≥10 years’ experience had higher odds of no/basic knowledge of managing hypercalcemia in malignancy, both in the univariable setting and the multivariable setting adjusting for age and formal training (5–9 years: MOR = 0.31, 95% CI = 0.11–0.90; ≥10 years: MOR = 0.27, 95% CI = 0.09–0.81). Formal training was also associated with lower odds of no/basic knowledge of managing hypercalcemia in malignancy in the univariable setting and the multivariable setting adjusting for age and years’ experience (MOR= 0.35, 95% CI = 0.13–0.96; Table 7).
Recognising SVC obstruction: Five-to-nine and ≥10 years’ experience were associated with lower odds of no/basic knowledge of recognising SVC obstruction in the univariable setting and the multivariable setting when controlled for age (5–9 years: MOR = 0.26, 95% CI = 0.09–0.74; ≥10 years: MOR = 0.16, 95% CI = 0.06–0.48; Table 6). While an EN role and formal training were associated with higher and lower odds, respectively of no/basic knowledge of recognising SVC obstruction in the univariable setting (Table 6), neither of these characteristics were significant in the multivariable setting.
Managing SVC obstruction: Five-to-nine and ≥10 years’ experience was associated with lower odds of no/basic knowledge of managing SVC obstruction in the univariable setting and the multivariable setting with adjustment for age and formal training (5–9 years: MOR = 0.19, 95% CI = 0.06–0.57; ≥10 years: MOR = 0.30, 95% = CI 0.10–0.89). Formal training was also associated with lower odds of no/basic knowledge of managing SVC obstruction in the univariable setting and when adjusted for age and years’ experience (MOR = 0.36, 95%CI = 0.14–0.93). The 45–54-year-old age group was associated with lower odds of no/basic knowledge of SVC obstruction management in the univariable analysis (Table 7); however, this was non-significant in the multivariable setting.
Recognising catastrophic haemorrhage: Age (45–54 and ≥55 years) and experience (5–9 and ≥10 years) were associated with significantly lower odds or no/basic knowledge of recognising catastrophic haemorrhage. However, only ≥10 years’ experience was a significant correlate of recognising catastrophic haemorrhage when adjusted for age and role (MOR = 0.22, 95% CI = 0.06–0.74). In the univariable setting, the EN role was associated with 3.14 and 4.86 times higher odds of reporting no/basic knowledge of recognising and managing catastrophic haemorrhage, respectively. These associations remained significant when adjusted for age and/or years’ experience (recognising: MOR = 4.41, 95% CI = 1.20–16.3; managing: MOR = 6.36, 95% CI = 1.72–23.5; Tables 5 and 6).
Managing catastrophic haemorrhage: Five-to-nine and ≥10 years’ experience was significantly associated with lower odds of no/basic knowledge of managing catastrophic haemorrhage when adjusted for age and role (5–9 years: MOR = 0.31, 95% CI = 0.10–0.99; ≥10 years: MOR = 0.23, 95% CI = 0.07–0.76). The 44-54-year-old age group was associated with lower odds of no/basic knowledge of managing catastrophic haemorrhage in the univariable analysis (Table 7), but was non-significant when adjusting for role and years’ experience.
Managing seizures: Relative to the RN role, the EN role was associated with significantly higher odds of no/basic knowledge of managing seizures. This association remained significant when adjusted for age (MOR = 8.35, 95% CI = 2.30–30.3; Table 7).
4. Discussion
Our study found rural nurses were highly knowledgeable in dealing with most issues regarding pain, medication, symptoms and emergencies in a community palliative care setting. These included assessing and managing nausea and vomiting, dyspnoea, fatigue, breathlessness, urinary retention and constipation. Knowledge gaps related to managing opioid medications, managing delirium symptoms and recognising and managing rare emergency situations within palliative care emerged as knowledge gaps and areas for knowledge consolidation. These gaps were largely associated with lack of relevant experience, formal palliative care training and type of nursing role.
Knowledge gaps in managing opioid medications may reflect the scope of practice of nurses, who are not routinely involved in selecting and prescribing opioids (
). Other studies have identified similar findings regarding nurses’ limited confidence in the use of EOLopioids and assessment and management of breakthrough pain to provide adequate pain and symptom relief. Sometimes pain relief was withheld due to legal concerns about hastening death (
also found rural community-based nurses reported concerns about medication safety issues such as a lack of awareness of medications that a nurse can initiate, knowledge and training regarding cytotoxic medications handling and errors associated with the use of dose administration aids.
While we identified a need for rural nurses to consolidate their knowledge in recognising, assessing, and managing delirium as well as the pharmacologically and nonpharmacologically managing delirium, using the delirium screening tool to assist with these processes was classified as a knowledge gap. Delirium management in palliative care patients is important as psychoactive/potentially sedating medication use, older age, comorbidities and cognitive impairment may precipitate delirium (
). Deficits in delirium assessment knowledge have been found in studies of generalised nursing cohorts and nurses working within specialised palliative care services (
). Using a validated delirium assessment tools can help support and guide nurses’ practice in identifying and initiating management of suspected delirium. As our study found participants without palliative care training and the EN role to be associated with a knowledge gap in using the delirium screening tool, undertaking further education is a first step in addressing this knowledge gap.
Most gaps in our study related to recognising and managing acute, potentially severe and life-threatening emergencies in palliative care. These emergencies, whilst infrequent, require prompt and effective management to reduce harm, distress and unwanted hospitalisations (
A study of the incidence and management of admissions for cancer-related symptoms in a District General Hospital: the potential role of an acute oncology service.
). Clinical experience was a significant correlate of greater knowledge in recognising and managing palliative care emergencies. While various studies have examined preparedness for emergency care and the competency of medical and nursing staff in emergency departments (
), there is a paucity of published research on community-based nurses’ experiences and preparedness for emergency care. While providing clinical education in recognising these emergencies is one strategy to address this gap, with the infrequent nature of these emergencies, clinicians may not retain the relevant knowledge if it is not used regularly in clinical practice.(
). It may be beneficial to stratify the palliative care workforce to support less experienced clinicians with access to mentoring by more experienced/highly specialised palliative care nurses.
Our study was limited by the use of a self-assessment tool to gauge knowledge and clinical skills. However, past studies have validated the use of self-reported knowledge and performance tools in nursing and palliative care settings (
Self-perceived competence of nurses and care aides providing a palliative approach in home, hospital, and residential care settings: a cross-sectional survey.
Development and validation of scales for attitudes, self-reported practices, difficulties and knowledge among home care nurses providing palliative care.
). Self-reflection and evaluation are part of nursing registration and supported by the Nursing and Midwifery Board of Australia. A limitation of our study population is the relatively high number of RNs compared to ENs. This may have led to overestimated self-assessments of ability due to perceptions of greater knowledge and experience in practice areas. Furthermore, the small number of ENs led to relatively wide 95% CIs around estimates of effects of role on knowledge. Finally, we acknowledge our study was conducted in one geographical region and may not be transferable to other rural settings, which may have different nursing and palliative care workforce issues and palliative care outcomes. This survey could be expanded to other rural regions to build a bigger picture of the rural nursing workforce strengths and gaps in this area of practice.
Overall, our study found rural community-based nurses were confident in their palliative care knowledge and skills across 71% of PC-SMQ items related to pain, medication, symptoms, and emergency management. The PC-SMQ can be used by rural nurses, managers and health services to systematically identify palliative care practice strengths and gaps, with a view to planning future CPD activities. This may ensure rural community-based nurses receive skills-based training which can enhance the care provided to, and meet the needs of, patients, families and carers in community-based palliative care.
5. Conclusion
This study found that lack of experience and formal training in palliative care were associated with gaps in knowledge. Targeted interventions such as training and peer mentoring have the potential to address identified gaps in rural community-based nurses... palliative care knowledge/skills and, ultimately, improve the care of palliative patients.
Authorship contribution statement
ER drafted the manuscript, ML did the analysis, all other authors contributed to the writing and editing of the manuscript.
Funding
Dr ER and HK received part funding to conduct this work from the Gippsland Region Palliative Care Consortium.
Ethical statement
Study procedures were approved by Monash University Human Research Ethics Committee (project ID: 14172).
Conflict of Interest
None.
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A study of the incidence and management of admissions for cancer-related symptoms in a District General Hospital: the potential role of an acute oncology service.
Patient-reported outcome measurement of symptom distress is feasible in most clinical scenarios in palliative care: an observational study involving routinely collected data.
International Journal for Quality in Health Care.2021; 33: mzab075
Self-perceived competence of nurses and care aides providing a palliative approach in home, hospital, and residential care settings: a cross-sectional survey.
Development and validation of scales for attitudes, self-reported practices, difficulties and knowledge among home care nurses providing palliative care.
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