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Competence development in palliative care in Norway: A description and evaluation of a postgraduate education program in palliative care in Drammen, Norway
Published online by Cambridge University Press: 04 April 2005
Abstract
Objective: The aim of the present study was to evaluate competence development in palliative treatment, nursing and care in students (n = 25) undergoing a two-year postgraduate education program in palliation at a university college in Norway.
Methods: A questionnaire was handed out on five occasions during the education period.
Results: Results showed that the students rated their competence level as between some competence and good competence before entering the course. However, the competence level rose throughout the course period, and at the end of their education most of the students perceived themselves at a very good or extremely good competence level.
Significance of results: Statistically significant differences in all questions measuring competence in palliation were found on all occasions. Further studies are needed to confirm the effect of education on students' perceived competence development and whether it has a positive impact on clinical practice.
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- © 2004 Cambridge University Press
INTRODUCTION
Norway, with four and a half million inhabitants, is sparsely populated, and palliative care is therefore not easily comparable with other Scandinavian or European countries. Following the Second World War, the Norwegian National Welfare State was established, anchored on equality of rights for all citizens, with health and social services provided as public services free of charge, irrespective of economic and/or social status. The hospice movement in England and Canada influenced the development of palliative care, which has a relatively short history in Norway. The first Governments White Paper on The Treatment and Care for the Terminally Ill and Dying was published in 1984 (Norges offentlige utredninger (NOU), 1984). It stated that the care of the terminally ill and dying had been a neglected area. In 1999, a second White Paper concerning palliation (Norges offentlige utredninger (NOU), 1999) described palliative treatment and care both in Norway and in the other Nordic countries. This document stressed the need for better organization of services, and increased focus on research, education, and legislation. In 1999, The Nordic Association for Palliative Care arranged a multidisciplinary conference to discuss development of minimum recommendations for education in palliation in Scandinavia. Results from this initiative were presented during 2003 as mono- and multidisciplinary programs, similar to programs developed by The European Association for Palliative Care (EAPC). Differences in national levels of education complicate development of a common postgraduate curriculum in Scandinavia. Iceland was previously the only Nordic country to provide a university-based Bachelor of Nursing program. Three-year basic nursing programs have been provided for students after high school, and higher nursing education has been available at universities in Norway for many years. It is however, only since 2003 that nursing faculties provide a Bachelor of Nursing program. Faculties of Health at Norwegian university colleges now provide a wide range of multidisciplinary postgraduate programs. The course described in this article is the first Scandinavian multidisciplinary postgraduate program of 60 European credit transfer systems (ECTS) that includes both theoretical and practical components.
Competency in the area of palliative care resides in the ability to serve the needs of the terminally ill and dying and their relatives in such a way that they may achieve the best possible quality of life (NOU, 1999). With the rising incidence of cancer and with more terminally ill patients wishing to be cared for at home, there is a growing need in society for health carers, skilled in palliation. There is evidence that pain control is often insufficient. Part of the problem is that physicians and nurses often lack knowledge of methods for assessment and treatment of cancer pain, and may have rigid beliefs and attitudes (Franks et al., 2000). However, the main barriers identified in the provision of palliative care, beside inadequate education and training of staff, are lack of resources, environmental factors, and conflicts between professionals in the management of residents (De Bellis & Parker, 1998).
Health and social care professionals have described lack of competence and confidence in many aspects of palliative care, and have recognized the need for increased educational opportunities, where new skills can be acquired and existing knowledge consolidated. The need for palliative programs, which can enhance health care providers' competency, is well documented (Charlton & Smith, 2000; Ellerton & Curran-Smith, 2000; MacDonald et al., 2000; Ury et al., 2000).
Redressing these omissions has led to the development and growth of educational programs in palliative care (Koffman, 2001). Earlier, education programs focused on specific areas related to palliative care such as pain and symptom control management and communication. However, now the emphasis is placed on the provision of holistic multiprofessional and uniprofessional courses, dedicated to enhancing the quality of palliative care (Chippendale, 2001). Studies have found that education in palliative care impacts health providers' knowledge and attitudes substantially, and makes a difference to practice (Wilkinson et al., 1999; Bauwens et al., 2001; Kenny, 2001).
To document the effect of broader education programs in palliative care, it is important to evaluate many aspects, among them the process of how the students perceive their competence development throughout courses in palliative care. Therefore, the aim of the present study is to evaluate competence development in students undergoing postgraduate education in palliation from the students' perspective. Competence development is seen in relation to factors of importance in palliation, such as competence in integrating theory and practice, competence in performance, and competence in cross professional collaboration.
The following research question was asked: How do students report competence development throughout a two-year postgraduate education program in palliative treatment, nursing, and care for terminally ill and dying?
A POSTGRADUATE EDUCATION IN PALLIATION—COURSE DESCRIPTION
The postgraduate course was aimed at personnel with a background in health care and/or social welfare. It was interdisciplinary, part-time, ran over a two-year period, and consisted of eight 1-week sessions. Theory accounted for 60% and practical work for 40% of the course, which covered five core topics, structured around four perspectives (see Table 1). Life span, cultural perspectives, and research were also integrated in all course components. Details of the curriculum can be found at www:hibu.no.
Course content
In between theory sessions, students continued in their normal employment. They worked on a range of assignments, of both a theoretical and practical nature, related to the current course topic. An innovative aspect of this course was the provision of clinical guidance for all students. Permanent groups of five or six students were established during the first study week. The groups met every second week during the first and second semesters, every third week during the third semester, and once a month during the last semester. The aim of the compulsory clinical guidance was to provide experienced health professionals with the opportunity for in-depth reflection over their practice, and to stimulate integration of theory in their development of competency in palliation. The qualitative data from this evaluation study of student experiences of clinical guidance was presented at The European Association for Cancer Education Conference in Sweden, June 2003.
Learning Strategies
All students were experienced health professionals. In acknowledgement of the principles of lifelong learning, learning strategies stimulated active participation (Gulbrandsen & Forslin, 1997; Dalland, 1999; Schei & Gulbrandsen, 2000). In addition to a traditional teaching approach in the form of topic lectures, dynamic and holistic teaching methods were used to increase students' awareness of thoughts, feelings, and body reactions, for example, music, role-play, drawing, fantasy, reflection, and existential statements. Students themselves were responsible for building and adapting acquired knowledge to their own conceptual framework, regardless of profession and place of employment. The students were given the opportunity to gain new experience as they alternated between theory and practice. These experiences gave a basis for reflection and increased insight during the clinical guidance sessions.
MATERIALS AND METHODS
Design
The present study has a prospective follow-up design with five measurements: one on commencement of studies to provide baseline data, then after 6 months, 12 months, 18 months, and at the end of the education program. No suitable validated questionnaires were available to enable collection of data in response to the aims of the study. The questionnaire was developed by the authors, aimed at tapping the students' perception of their competence development. Students were asked to evaluate their competence in relation to the following: insight into palliation, ability to use theory in practice, action competence, professional role, and cross professional collaboration. Students were asked to rate their competence in all areas both in relation to patients and significant others (see Table 2).
An overview of the questions asked, on commencement, at 6, 12, 18 and 24 months, to evaluate competence development in palliative care from the student perspective
Sample
The sample in the present study consisted of 25 students from the whole of Norway, who in 2000 were recruited from both hospital and community health services to the two-year postgraduate education program in palliation care. Students were given oral and written information concerning the aims of the study and of their right to refuse or withdraw from participation at any time. Refusal to participate in the study had no influence on the faculties' evaluation of student performance. All students gave free and informed written consent to participate. A staff member, not connected to the course, was responsible for providing each student with a contact number to ensure anonymity throughout the study. This staff member was responsible for collection of all questionnaires; the authors were at no time present during data collection.
Statistics
Data were analyzed using the SPSS for Windows (version 10.0) software (SPDD, Inc.). Descriptive analyses were used to shed light on the characteristics of the sample and the competence development process. To assess the statistical significance of the competence development in this group of students, a paired t test was performed between the first and the second measurements, the first and the fifth measurements, and the third and the fifth measurements.
RESULTS
The sample consisted of 24 women and 1 man. The mean age of the sample was 44 years (SD 7.8) with a range from 31 to 62 years. They were all nurses. Thirty-two percent (n = 8) had other postgraduate education. Forty eight percent (n = 12) reported more than 15 years of work experience after completing nursing education. Sixty percent (n = 15) of the sample had personal experiences related to terminal illness and dying.
As seen from Table 3 the students rated their level of mean competence in palliation within all areas before the education started between 2 (indicating some competence) and 3 (indicating good competence). Most students rated some competence or good competence before they entered the program.
Mean values and SD for the five measurements of the students' evaluation of competence development
Looking at the pattern of change, one can see a gradual increase in the mean value from the first to the last registration. At the end of the course the students rated their mean competence as being 3.8 to 4.4, indicating a very good competence level. At the end of the program, between 60% and 70% of the students' rated their competence as very good and 20–30% rated it as extremely good.
Between the first registration (before entering the education program) and the last registration a paired sample t test showed significant changes on a 0.000 p level within all questions measuring competence development. However, one can see a statistically significant increase in the students' perception of competence in all items already after 6 months (second registration). The mean differences from the first to the last registration ranged from 1.4 to 1.7, and indicated similar developments in the different areas of competence in palliation.
DISCUSSION
A variety of courses in palliative care have been available in Scandinavia during the last decade. The program evaluated in this study however is unique, both in length and content, and is the first to publish data concerning a Scandinavian program in palliation that includes theory and practice as obligatory course components. The present study has shown that students undergoing a holistic postgraduate education program in palliative care reported a statistically significant increase in their own evaluation of competence development throughout the course. Kenny (2001) performed a similar multiphase study among students attending hospice education in England. Although the module studied was shorter both in theory and practice, and Kenny's evaluation design differed from the method chosen in this study, the findings are comparable. The students reported feeling more confident, skilled, and knowledgeable in caring for patients and their relatives. Other studies have also focused upon competence development in relation to education in palliative care issues and found similar results (De Bellis & Parker, 1998; Ferell et al., 1998; Frogatt, 2000).
Results show that the students perceived themselves as increasingly better at integrating theory and practice throughout the education program. These findings may suggest that the students become better able to reflect upon their own and others' practice, and thereby become more competent in knowledge-based decision making in the clinical field. Rolfe (1993) suggested that new knowledge does not necessarily result in changed practice. On the other hand, Busch (1999) states that health personnel need a theoretical framework to enable them to relate to their daily working lives, and to organize what they hear and experience. Further, Hagström et al.(1998) suggested that there is a clear connection between the patients' experience of trust and security and the competence of health professionals. A study by Dyson (1997) found that gains in knowledge and positive attitudes should influence the quality of care in practice. This study supports these views. Although the data collection in this study only relates to the students' subjective experience of competency development, results show that the program, which highlighted integration of theory and practice, provided the students with the opportunity to gain insight into palliation. The results show that students, on entering the program, evaluated their competence between some and good competence. On completion of the program, they rated their competence between very good and extremely good in relation to patients, significant others, their own professional role, and their ability to collaborate in the cross professional field of palliation.
Studies suggest that basic education of health professionals does not provide the knowledge, attitudes, and skills necessary to identify the needs of dying patients and their families (Seligman et al., 1999; Llamas et al., 2001). Stirling et al. (2000) point out that the history of palliative medicine as a speciality is one of vision and compassion, and a practice that has developed out of experience rather than evidence. Forty-eight percent (n = 12) of the students in this study reported more than 15 years of work experience after completing nursing education. Sixty percent (n = 15) of the sample had personal experiences related to terminal illness and dying. These findings may suggest that the students' self-evaluation prior to commencement of studies was based upon personal experience, as suggested by Stirling, and that the students were unaware of their lack of knowledge and skills prior to commencement of the postgraduate education.
Results show that the changes in competence increased already after 6 months and further increased throughout the course, more or less similarly for all items. This similar competence development may be due to the learning strategy process of the present education program. The course aimed to provide students with a variety of learning challenges within a holistic and dynamic framework where the core topics of the course were simultaneously focused. The core topics presented during each study week were further explored in study groups throughout the course. Obligatory tutorials every 14 days during the first year, at 3-week intervals during the first half of the second year, and once a month during the last 6 months gave students the opportunity to reflect upon their practice in the light of new knowledge.
In Norway nurses have dominated interest in the field of palliative care since the 1980s, when palliation and the ideals of hospice began to be addressed in this country. This may explain why all applicants for this course came from the nursing field, although the program was developed as a multidisciplinary course. This study describes the development of palliative competence from the students' perspective, but it fails to provide subjective data from patients and their relatives who have experienced the students' expression of this competence in practice. In addition, no data has been accumulated from other health professionals regarding their experience of the postgraduate students' competency development. Further studies are needed to show whether or not postgraduate education in palliative care really has a positive impact on clinical practice. In addition, studies are required to identify which pedagogical methods are best suited to ensure the development of competency in palliative care.
CONCLUSION
The present study has shown that students undergoing a holistic postgraduate multiprofessional two-year education program in palliative treatment, nursing, and care reported a statistically significant increase in their own evaluation of competence development throughout the course. Further studies are needed to look upon the effects of this kind of education on practice. It may be noted that the students from the first Scandinavian program to integrate theory and practice during a two-year postgraduate course have, on completion of their studies, influenced the development of palliative care. Students were recruited from the whole of Norway, from both hospital and community health care settings. Several of the students now have central roles in the organization of palliative services and in the development of standards for palliative care in Norway.
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Course content
An overview of the questions asked, on commencement, at 6, 12, 18 and 24 months, to evaluate competence development in palliative care from the student perspective
Mean values and SD for the five measurements of the students' evaluation of competence development
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