This article has Open Peer Review reports available.
A qualitative evaluation of the impact of a palliative care course on preregistration nursing students’ practice in Cameroon
© Bassah et al. 2016
Received: 20 October 2015
Accepted: 10 March 2016
Published: 31 March 2016
Current evidence suggests that palliative care education can improve preregistration nursing students’ competencies in palliative care. However, it is not known whether these competencies are translated into students’ practice in the care of patients who are approaching the end of life. This paper seeks to contribute to the palliative care evidence base by examining how nursing students in receipt of education report transfer of learning to practice, and what the barriers and facilitators may be, in a resource-poor country.
We utilised focus groups and individual critical incident interviews to explore nursing students’ palliative care learning transfer. Three focus groups, consisting of 23 participants and 10 individual critical incident interviews were conducted with preregistration nursing student who had attended a palliative care course in Cameroon and had experience caring for a patient approaching the end of life. Data was analysed thematically, using the framework approach.
The results suggest that nursing students in receipt of palliative care education can transfer their learning to practice. Students reported recognizing patients with palliative care needs, providing patients with physical, psychosocial and spiritual support and communicating patient information to the wider care team. They did however perceive some barriers to this transfer which were either related to themselves, qualified nurses, the practice setting or family caregivers and patients.
The findings from this study suggest that nursing student in receipt of palliative care education can use their learning in practice to provide care to patients and their families approaching the end of life. Nevertheless, these findings need to be treated with some caution given the self-reported nature of the data. Demonstrating the link between preregistration palliative care education and patient care is vital to ensuring that newly acquired knowledge and skills are translated and embedded into clinical practice. This study also has implications for advocating for palliative care policies and adequately preparing clinical placement sites for students’ learning and transfer of learning.
Palliative care education is gradually being incorporated into preregistration nurse training programs, particularly in resource-rich countries [1–5]. This is important to ensure that generalist nurses can respond to increasing needs for palliative and end of life care, and use the palliative approach in their everyday encounter with patients approaching the end of life [2, 6–8]. Some studies reporting the development, implementation, and evaluation of the impact of palliative care education with preregistration nursing students have been published. A modified systematic review  and an integrative review  of this evidence suggests that palliative care education has a positive impact on nursing students’ attitudes towards care of the dying patient and, to some extent, on their palliative care knowledge and self-perceived competence in palliative care. Although this is encouraging, it is still not known whether these competencies are eventually translated into behaviors that can lead to improvements in patient and family experiences of care, and care outcomes. This paper seeks to contribute to evidence about the education of preregistration nursing students in palliative care by examining how students in receipt of palliative care education in Cameroon report transfer of learning to practice, and what they perceive as the barriers and facilitators of this learning transfer, in a resource-poor context.
Registered nurses are the mainstay of the care of the dying, and as such should be competent and confident in palliative care . Yet there is evidence of the lack of palliative care competencies among registered nurses and nursing students, internationally [1, 17, 18]. In Cameroon, some palliative care seminars for registered nurses have been delivered through partnership between local institutions and international collaborators and some nurses have travelled to other countries to undertake a palliative care specialization course [13, 19]. However, these educational approaches are expensive and not accessible to every nurse in Cameroon. Davies and Higginson (2004)  have argued that it is unrealistic to address the scale of needs for palliative care by expanding the specialist workforce; improving the education of healthcare professionals at the undergraduate level is potentially a more feasible strategy . With this in mind, a palliative care course was developed for preregistration nursing students in Cameroon.
The palliative care course
The palliative care course was a 30 h classroom based course underpinned by the experiential learning theory. The course was developed via: a modified systematic review of the literature , review of core curricula developed by international organizations [21–23], consultations with palliative care nurses and nurse educators in Cameroon, and consultation with expert palliative care educators and researchers in the UK.
Summary of palliative care course content and facilitators
Module I: Introduction to the principles and practice of palliative and end of life care
Palliative Care I (Concepts, meanings and principles, the need for Palliative care, international developments in palliative care
Lead author and a palliative care nurse
Palliative Care II (the need for palliative care in Cameroon, palliative care models, palliative nursing skills)
Lead author and a palliative care nurse
Module II: Communication skills and Breaking Bad News
Communication in palliative care
Nurse educator with communication skills training
Breaking bad news
Basic principles of HIV/AIDS counselling
Palliative care nurse
Module III: Pain and other symptom management
Pain and pain assessment
Pain management I (pharmacologic)
Palliative care nurse
Pain management II (non-pharmacologic)
Palliative care nurse
Other symptom management I
Palliative care nurse
Other symptom management II
Palliative care nurse
Module IV: Psychosocial, spiritual, and ethical issues in palliative and end of life care
Psychosocial, ethical and legal issues in palliative care
Nurse educator, with experience in teachings about ethical and legal issues in nursing
Module IV: Dying and death; loss, grief and bereavement management
Dying, dead and after dead care
Palliative care nurse
The palliative care nurse in loss grief and bereavement management
Palliative care textbooks and manual available to course participants
• Becker, R. (2010) Fundamental Aspects of Palliative Care Nursing. 2nd ed. Cromwell Press: Trowbridge
• Kinghorn, S. and Gaines, S. (2007) Palliative Care Nursing: Improving End of life Care. Churchill Livingstone: Edinburg.
• Payne, S. Seymour, J. and Ingleton, C. (2008) Palliative care nursing: principles and evidence for practice. 2nd ed. McGraw-Hill: Open University Press.
• Mari Lloyd-Williams (2008) Psychosocial Issues in Palliative care. 2nd edn. New York: Oxford University Press,
• Qneschuk, Hagen and McDonalds (2012) Palliative Medicine: A case based manual. 3rd edn. Oxford: Oxford University Press
• Wittenberg, Goldsmith, Ferrell and Ragan (2013) Communication in Palliative Nursing
• Goldman, Hain and Liben (2012) Oxford textbook for palliative Care for children. Oxford: Oxford University Press
• Renzenbrik (2011) Caregiver stress and staff support in illness and bereavement. New York: Oxford University Press
• McSherry (2008) Making sense of Spirituality in nursing and healthcare practice
• Regnoid D and Regnard (2011) A guide to symptom relieve in palliative care 2nd edn. Oxford: Radcliffe Publishing
• Vadivelu, Urman and Hines (2011) Essentials of pain management. Springer.
• Knapp, Madden and Fouler-Kery (2012) Pediatric palliative Care: the global perspective. Springer.
• Peter Hudson and Shiela Payne (2009) Family Carers in Palliative care
• Manroe and Payne (2011) Death, Dying and social differences. 2nd Edn. New York: Oxford University Press.
Students started their regular nurse training placement the week following the completion of the palliative care course, either in the medical, surgical, paediatric, outpatient or the haemodialysis units of a regional hospital. They practised under the supervision of their regular placement mentors. It was anticipated that students would encounter patients with palliative care needs during their placements, raising questions about whether they could apply their learning to the care of these patients and their families.
Describe Cameroonian preregistration nursing students’ report of the transfer of their palliative care learning to practice during placement.
Identify the facilitators and barriers to this transfer perceived by the students
Examine what claim can be made about the perceived impacts of palliative care education on preregistration nursing students’ practice during placement.
This paper reports a component of a longitudinal quasi-experimental single group pretest-posttest study that employed both quantitative and qualitative methods of data collection and analysis. In the first phase of the study the palliative care course described above was developed. In the second phase, the course was delivered to second and third year nursing students. In the third phase, an evaluation of the impact of the course on students’ palliative care knowledge, self-perceived competence and confidence in palliative care and transfer of learning to practice was conducted using: a pretest/posttest survey, focus groups and individual critical incident interviews. This paper presents findings from phase 3 of the study that explored students’ transfer of their learning to practice and the facilitators and barriers to learning transfer that they reported (Fig. 1).
Focus Group and Individual Interview guide
Focus Group Guide
• Before participating in this course what did you know about palliative care?
• What where your expectations when you registered for the course?
• How did your experience of this course compare with your expectations?
• Is there anything else you would have loved to learn from this course?
• How did your participation in this course benefit you?
• How did you use your learning from this course in practice during placement?
• What do you think have been influential in enhancing your learning in this course
• What did not quite work well during the course?
• How do you think your experience of this course could be improved?
Critical Incident Individual Interview Guide
• Can you describe the events or circumstances that led to this incident?
• Can you describe the role you played in this incident?
• Can you describe others who were involved in the incident and the role they played?
• What was the patient outcome?
• What do you think facilitated the care you provided in this incident?
• What barrier (s) prevented you from providing palliative care in this incident?
• What did you find most challenging in providing care to patients who require palliative care.
The individual interviews explored this transfer in-depth and were conducted using the critical incident technique (Fig. 1). This technique, developed by Flanagan in 1954 is a set of procedures for collecting direct observations of human behavior in such a way as to facilitate their potential usefulness in solving practical problems. Critical incidents are considered any observable human activity that is sufficiently complete in itself to allow inferences and predictions to be made about the person performing the act. This technique has also been widely used in nursing research [26, 27]. Critical incidents in this study were any encounters students reported with patients with life-threatening conditions and their families. Students were asked to narrate any incidences they could remember and to describe where they encountered these patients, what they could do or could not do for the patients and the facilitators and barriers they encountered to palliative care provision.
An interview guide (Table 3) was employed to encourage students to report behavioural descriptions, and where necessary, probes and prompts were used to elicit more information from the students. These interviews were started 2 months after the course, as soon as students had completed their placement, to facilitate recall of their experiences with patients and their families who were approaching the end of life during placement [26, 28]. The focus groups and interviews were all conducted in classrooms on the University campus. The focus groups were moderated by the lead author with a research assistant as note taker and lasted between 46–69 min. The individual interviews were also conducted by the lead author and lasted for an average of 30 min. All the interviews and focus groups were tape recorded and transcribed verbatim.
The study participants were volunteer second and third year nursing students of the pilot University whom we judged had relevant clinical practice experiences with patients in need of palliative care thus facilitating the use of the experiential learning strategy. Compared to fourth year students, the other target group that could have been considered, these students were on campus for appropriate periods of time and timetabling of the new course could be adequately managed.
The total number of nursing students in the second and third year class of the pilot University, who were potential participants of this study, was 83. Sixty-nine of these students voluntarily registered for and started the course, but only 64 completed all five sessions of the course (Table 1). Of the 64 students who completed the course 23 (35.9 %) took part in the focus groups, 7 (30.4 %) males and 16 (69.6 %) females. Twelve (52.2 %) of them were from the 2nd year class and 11(47.8 %) from third year. One third year student did not show up for the focus group. Ten (15.6 %), of the 64 students, participated in the individual interviews, 3 (30 %) males and 7 (70 %) females. Two (20 %) of these students were from the second year, while 8 (80 %) were from the third year.
First, the volunteer sampling strategy was used to recruit students for the course (Fig. 2).
Second, a simple random sampling technique, via balloting of students’ course registration numbers , was employed to recruit the focus group participants. This strategy was to enhance recruitment of a representative sample, which could allow sufficient exploration and detection of consensus within and across the focus groups, and ultimately increase reliability of results [30, 31].
Third, the critical case purposive sampling strategy  facilitated the recruitment of students for the individual critical incident interviews. This was conducted as follows:
○ In the first place, students who mentioned during the focus groups that they came across patients with life threatening conditions were noted and later invited for individual interviews to explore this in-depth.
○ In addition, the lead author visited the students in the classroom, and also made random phone calls to course participants, to inquire if they had experienced caring for patients with life-threatening/chronic conditions during placement. Students who attested to this were then invited for an individual interview, to explore the experience in-depth.
Preliminary thematic analysis of the focus groups enabled the recruitment of some students for the individual critical incident interviews. Data obtained from the individual critical incident interviews were read several times in order to become familiar with it. This process enabled the classification of the critical incidents and identification of critical interactions. The data were then categorised, as suggested by Flanagan (1954) , into location of experience and type of patient encountered, what they could or could not do for the patients and the facilitators and barriers they encountered to palliative care provision, and other useful characteristics.
In the second stage, a thematic analysis was conducted using the framework approach . The data was coded and classified into main themes and subthemes, and used to develop a coding frame that was applied to the rest of the interviews. Although we developed and employed a thematic framework in coding the data , we were open to themes that emerged, based on the narratives of research participants. Thus constant examination, re-examination and comparison of interview transcripts was undertaken to identify any new themes and ensure rigorous analysis of students’ reported use of their palliative care learning in practice. The findings from the focus were integrated with that from the individual critical incident interviews to enhance data richness and depth of inquiry . Qualitative interview transcripts were imported into the qualitative analysis software package, QSR Nvivo 10 , for data management, coding and analysis.
Ethical approval to conduct this study was obtained from the University of Nottingham Medical School Ethics Committee and the University of Buea Institutional Review Board, prior to commencement. Prior to participation in this study, students were provided with an information sheet about the study and they voluntarily gave their consent to take part in the study.
The critical incident analysis yielded a total of 26 critical incidents, with an average of 2 incidents per student. Students reported encountering a wide range of patients with life-threatening and chronic conditions like HIV/AIDS, cancer, kidney disease, diabetes and hypertension, cardiovascular and respiratory diseases. Most of the patients encountered were adult or elderly patients. Some of these patients had no family members present.
Themes and subthemes
Students’ reports of how they implemented their learning in practice
1. Encountering patients and diagnosing the need for palliative care
2. Communicating with patients, their families and the wider care team
3. Assisting with physical care needs
4. Providing psychosocial and spiritual care
6. Avoiding difficult interactions.
Facilitators of palliative care learning transfer to practice
1. The palliative care nurse
2. Supportive nurses and family caregivers
Barriers to the transfer of palliative care learning to practice
1. Being a student
2. Qualified nurses
3. The practice setting
4. Patients and family caregivers
Students’ report of how they implemented their learning in practice
Students’ report of the transfer of their palliative care learning to practice in this study is described through six subthemes: encountering patients and diagnosing the need for palliative care, communicating with patients, their families and the wider care team, assisting with physical care needs, providing psychosocial and spiritual care, reflecting, and avoiding difficult interactions.
Encountering patients and diagnosing the need for palliative care
“…when I saw her [an HIV/AIDS patient] lying helpless on the bed and without a family caregiver, although I was just passing around, I decided to talk with her… her look made me become empathic.” [Individual interview, Participant 1]
“She had HIV/AIDS ….[her] mother who was the carer [but] was kind of scared of her because of the changes that had occurred on her body. And there was no money to even buy the prescribed drugs and even the nurses in the hospital were like not paying attention to her. So she was lonely and kind of abandoned. When we were allocating patients to students one morning in the hospital, everybody [nursing student on internship] was like running away from her and unfortunately she fell on me” [Individual Interview, Participant 4].”
“The relatives were complaining to me that lately they have been talking to him and he does not respond and he spends the whole time sighing” [Individual interview, participant 10].
“… She was HIV+ and was at the advanced stage. She was hospitalized there for more than three weeks… She also had other conditions… the bed sheets were wet and dirty. So when I saw it I thought it was time to apply the knowledge I acquired during the palliative care course. So the first thing I did was that I asked the nurse if she has had a bath, and the nurse told me no, that her daughter was supposed to do it, but she did not do it. So I planned to give her the bed bath, and I did so” [Individual interview, Participant 6].
“She was HIV+, she was wasted, [her] condition was really getting worse every day. So I saw that palliative care will be really good for her” [Focus group, Participant 9].
Communicating with patients and the wider care team
“…I learned that in palliative care we never say there is nothing we can do! When I sat and reflected on that, I asked myself what I can do for this patient. The only thing that was at my disposal was communication. I thought of active listening and how to communicate through talking. So that was what helped me. I went back to her, I paid attention to her, I was patient when she was talking, looking at her and trying to understand her” [Individual Interview, participant 4].
“Whenever there was a problem, I will always report to the nurses and even the doctor and share with them…and I was updating them on a daily basis…and representing the patient’s interest to them” [Individual Interview, participant 9].
“They constantly called me and ask whether there was hope for their father. To be candid, I told them the truth…I could say the truth firmly but with much softness” [Individual interview, Participant 5].
Assisting patients with physical care needs
“I assisted her in performing her activities of daily living, with the hygiene I was there, to make up her bed, to help her with the sizth bath, and at times, I administered some medications” [Individual interview, Participant 2].
“There was this patient, he was seriously in pain, and I asked the doctor, if there was nothing they could do about it, He said that no, he had been on so many analgesics that prescribing another one right now is not really a good idea. They wanted to prescribe Trabar [A narcotic analgesic, indicated for moderate to moderately severe pain], but I said she was really in pain… because we talked about that [during the palliative care course], the morphine, that when the pain was chronic, we had to start that one, but I don’t know” [Individual interview, Participant 5].
Providing psychosocial and spiritual care
“…when the young boy saw the father as we were cleaning (his wound) he started crying… after doing the cleaning, I had time to talk with him, to encourage him… like taking time to explain his father’s condition to him… considering his father’s health records, his condition was not changing, despite the medications that were being given. So with this, with the knowledge I had during the seminar [palliative care course], I knew that with this type of conditions, they can go home if they have a carer at home. So I asked the son if they have a close person at home, that is a nurse or someone who can offer nursing care…And then I also told him to collaborate with the nurses and that if he had any concerns, he can talk with the nurses and express his concerns” [Individual Interview, participant 10].
“…the patient was terminally ill with HIV…The patient had been in the hospital for three months and after two months, the relatives left that patient…we were concerned…We spoke with the patient… I consulted the charge nurse. The charge nurse said that is the problem they had been facing with this patient. But up to that time, they had not contacted the social service. So that is the proposal we gave. The charge nurse then went to the social service and the social service had to come in to call the patient’s family… the person came the following morning… So after that, we helped the patient to arrange his bed, we cleaned him and we handed the matter with the social service” [Individual interview, Participant 3].
“…he said he thinks he wants to be in a Christian hospital, he wants to be where they will pray for him…So it was a bit difficult because the surgeon was absent so I went further and asked him if he needed any man of God to pray for him. He accepted and fortunately through one of our classmates, I asked her to call their pastor, and their pastor came and prayed for him. Immediately after, he could speak, and he got up on his bed and sat. And then after the pastor left, he went back to his bed and in less than one hour he died… I must say I actually saw an aspect of spirituality manifested” [Individual interview, Participant 3].
“…it actually struck me because if I were the one, lying on that bed, I don’t know whether somebody will do that to me…I think it’s really significant to me” [Individual interview, Participant 2]
Avoiding difficult interactions
“…but er, I spoke to her without mentioning death, death, death, or making her to know that she had an incurable disease or was in an advanced stage of the HIV/AIDS” [Individual interview, Participant 1].
Facilitators of palliative care learning transfer to practice
The palliative care course
“…I remember encountering so many incidences before we started the course but after the course, I realized that my approach was different, because I gained some knowledge” [Individual interviews, participant 3]
“Before the palliative care course, I had once worked in the intensive care unit…So when I did this course, I reflected back and I really saw that there were many things which I could have done at that time for them, but which I did not have that knowledge to do” [Focus group, Participant 15].
“…What was peculiar from the palliative care course that I learned is that; in palliative care we never say there is nothing we can do! When I sat and reflected on that, I asked myself what I can do for this patient. The only thing that was at my disposal was communication…”[Individual interview, Participant 4].
Supportive nurses and family caregivers
“The nurses were encouraging me to go on with the procedure. They assisted me and they were telling me how to give the bed bath” [Individual interview, Participant 6].
“One of things that facilitated the care was the carers [family caregivers]. They were collaborative” [Individual interview, Participant 9].
Barriers to the transfer of palliative care learning to practice
Being a student
“…so my big challenge was the issue that I am a student, and it limited me a lot” [Focus group, Participant 20].
“I came across somebody with a life-threatening condition, but I did not know how to really go about it” [Focus group, Participant 8].
“…they [nurses] told us that there are more important things to do and that there are patients that are there that can easily recover, we should take care of them, that that man has been there for 2 months and nothing is changing” [Focus group, Participant 20]
“…in addition to what [name of student withheld] is saying, what I also discovered is that the nurses in our setting know little or nothing about palliative care, so what I know and what they know actually differs. What I know about palliative care, they know little or nothing about that. So it’s as if I should also transfer the knowledge to them or teach them also, so that we can care for these patients” [Focus group, Participant 13]
The practice setting
“There are really barriers for example there is no particular setting where they place people with palliative care needs. So you have to come first of all and identify that this one is an incurable case, so the fact that there are no particular places for them, so there are no particular nurses or personnel allocated to them. So we find that we are dispersed to give care to everybody at the same time, so you can’t really concentrate on those dying patients because you have other patients in the ward you need to care for. So the fact that they do not have a particular place for them is really a challenge because you sometimes have the will to help them, but you don’t have the time to do it” [Individual interview, Participant 5]
“…the hospital setting, especially where we go for practice, is already made in such a way that nurses have some fix things that they do, each morning, each afternoon, each evening or every time, they have a specific thing that they do… but it is not routine for you to see a nurse giving palliative care, even when the case is really advanced” [Focus group, Participant 16].
Patients and family caregivers
“we went there to clean his wound and he was always looking sad, so I tried to ask him how he was feeling, he could actually talk just that he could not move, but he made a harsh sound that actually scared me, like he did not want to talk, he was not just willing to cooperate, so I found it very difficult to break the wall that he had built around him, so I ended up not doing anything” [Focus group, Participant 19].
“…when I tried to discuss this with her sister, I saw that from her own idea of palliative care, she thought that palliative care was mainly for people that are dying, if somebody is going there it means the person is going to die. So for them they had a very big hope, they did not see their sister dying; they knew that she will recover and live normally. So for me, with this I had a problem implementing my knowledge” [Focus group, Participant 9].
“Her drugs, palliative care also deals with drugs that she could not provide” [Individual interview, Participant 7]
This qualitative evaluation of the impact of a palliative care course on preregistration nursing students’ practice in Cameroon suggests that nursing student in receipt of palliative care education can use their learning in practice to provide care to patients and their families approaching the end of life. Students reported recognizing patients with palliative care needs, providing patients with physical, psychosocial and spiritual support and communicating patient information to the wider care team. There were, however, some barriers pertaining to the students themselves, qualified nurses, practice settings and to the patients and family caregivers, that hindered this learning transfer, as perceived by the students.
These findings need to be interpreted within the context of self-reported practice data. The use of retrospective critical incident interviews in this study could have resulted in distorted perceptions and sub-conscious editing of the incidents . Moreover, students’ memory could be imprecise or some incidences might not have been reported . Although some commentators have reasoned that researchers should be ‘confident in the ability of research participants to tell their story’ (, p. 306), studies in nursing have shown that direct observation of practice might yield more valid results [38, 39]. Direct observations can therefore be used to explore nursing students’ transfer of their palliative care learning to practice.
In addition, what is reported, at first sight, all sound like some ‘good nursing care’ which can be provided by any student nurse with a similar level of nurse training in Cameroon, irrespective of whether he/she took part in the palliative care course. It is also not clear whether and to what extent their behavior had changed after participating in the palliative care course, and how the observed behavior relates to the palliative care education received. We agree with other commentators that it can be quite challenging disentangling palliative care skills from routine nursing care skills in general practice settings , and measuring the direct or indirect impacts of education on practice .
However, a critical analysis of these students’ experiences portrays some key features of their reported practice, which could suggest they were using generalist palliative care competencies [7, 22, 23]. Some examples include being able to identify patients who needed palliative care, recognizing the need and advocating for morphine for a dying patient in severe pain, providing psychosocial support to family caregivers and educating them on patient care, and advocating for social support for a patient who had no family caregiver present. Moreover, some students reported that their learning from the palliative care course was a facilitator of the care they provided. In addition, these students, both in the focus group and individual interviews, self-evaluated their practices with dying patients, and said their post-course practices were comparatively better. Other studies have documented positive self-reports from nurses about the influence of a palliative care course on their practice, although these have involved qualified nurses rather than nursing students [41–43]. Therefore, although we cannot claim that the reported transfer to practice has come solely from students’ learning on the palliative care course, given the potential hidden value of these students’ nurse training course and of their interactions with patients, nurses and other members of the healthcare team it is a reasonable hypothesis to make. Further research of a different type would be needed to explore further; the only way to do this conclusively would be through a randomized controlled trial.
In reporting the implementation of their palliative care learning to practice, the students in this study recounted providing psychological support and said they found this more straightforward than other forms of palliative care support. This is an interesting finding that needs further examination in future research. Moreover, despite the palliative care course, the students still reported some avoidance behaviour and expressed a lack of competence and confidence to provide palliative care in some instances. Avoidance behaviour has been reported in other studies with preregistration nursing students [44, 45] and suggests the importance of not regarding palliative care education as a ‘one time’ endeavour. An effective model should incorporate plans for refreshers, support and mentorship post training and as students advance in their career as nurses [46, 47]. This is important particularly when students have not developed the confidence that can enhance their palliative care practice or when enthusiasm about and learning from the course may have waned.
Based on the findings from this study we can say that a number of barriers may prevent these students from transferring their palliative care learning to practice, and thus hinder the consolidation of learning and the learning of new skills. In this study, nursing students reported struggling with the lack of support from qualified nurses in the practice setting and lack of resources and policy for palliative care, while implementing their learning. They equally said it was challenging implement learning when the family was death denying or the patients were difficult. These resonate with previous findings from studies with practitioners and seem to confirm the claims that the integration of the palliative care philosophy in non-specialist palliative care settings can meet with resistance if staff attitudes, values and organizational frameworks are not clarified . Some commentators have recommended educating health professionals, policy makers, and the general public about palliative care, and advocating for adequate palliative care policies and drugs as some ways of overcoming these barriers [48–50]. In view of these therefore, nurse educators need to: address the values that underpin care both at an individual and organizational level, educate placement sites and mentors about palliative care and how they can support students’ placement learning, lobby for palliative care policies with hospitals, as well as educate family caregivers and the general public to create their awareness and possibly gain their support for palliative care practice. These might to some degree improve on student nurses’ palliative care learning and learning implementation in clinical practice.
Though it is important to demonstrate how palliative care education is effective in improving preregistration nursing students” palliative care competencies, it seems the greater measure of the effectiveness of this education is how students integrate these competencies in solving real problems with patients and their families who require palliative care. The findings from this study suggest that students can use their learning from a palliative care course in practice, although with some barriers. These barriers generally relate to the lack of awareness about palliative care amongst qualified nurses, other healthcare providers, patients and family caregivers, as well as to the lack of resources for palliative care in the health care system. Demonstrating the link between preregistration palliative care education and patient care outcome is vital to ensuring that newly acquired competencies are translated and embedded into clinical practice. This study also has implication for advocating for palliative care policies and adequately preparing clinical placement sites for students’ learning and transfer of learning. This can go a long way to improve on palliative care provision in resource-poor countries.
This research is part of a PhD thesis funded by the Life Cycle Studentship of the University of Nottingham, United Kingdom. We are grateful to the University of Nottingham for providing this studentship. The input and support of colleagues and teachers are much appreciated.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Bassah N, Seymour J, Cox K. A modified systematic review of research evidence about education for pre-registration nurses in palliative care. BMC Palliat Care. 2014. doi:10.1186/1472-684X-13-56.PubMedPubMed CentralGoogle Scholar
- Cavaye J, Watts JH. An Integrated Literature Review of Death Education in Pre-Registration Nursing Curricula: Key Themes. Int J Palliat Care. 2014. doi:10.1155/2014/564619.Google Scholar
- Johnson A, Chang E, O’Brien L, Nursing the dying. A descriptive survey of Australian undergraduate nursing curricula. Int J Nurs Pract. 2009;15:417–25.View ArticleGoogle Scholar
- Dickinson GE, Clark D, Sque M. Palliative care and end of life issues in UK pre-registration, undergraduate nursing programmes. Nurse Educ Today. 2008;28:163–70.View ArticlePubMedGoogle Scholar
- Wee B, Hughes N. Education in Palliative Care Building a Culture of Learning. Oxford: Oxford University Press; 2007.View ArticleGoogle Scholar
- Frey R, Gott M, Neil H. Instruments used to measure the effectiveness of palliative care education initiatives at the undergraduate level: a critical literature review. BMJ Supportive & Palliative Care. 2012;3:114–9.View ArticleGoogle Scholar
- Becker R. Fundamental Aspects of Palliative Care Nursing: an evidence based handbook for student nurses. 2nd ed. London: Quay Books; 2010.Google Scholar
- Shipman, Gysels, White, Worth, Murray, Barclay, Forrest et al. Improving generalist end of life care: national consultation with practitioners, commissioners, academics, and service user groups. BMJ. 2008; 337:a1720.Google Scholar
- Ddungu H. Palliative Care: what approaches are suitable in developing countries? Br J Haematol. 2011;154:728–35.View ArticlePubMedGoogle Scholar
- Harding R, Higginson IJ. Palliative care in sub-Saharan Africa. Lancet. 2005;365:1971–7.View ArticlePubMedGoogle Scholar
- Hunt J. Palliative Care in Resource-Poor Countries. In: Payne S, Seymour J, Ingleton C, editors. Palliative care nursing: principles and evidence for practice. McGraw-Hill: Open University Press; 2008. p. 680–94.Google Scholar
- Association APC. Cameroon: Country Profile. 2012. http://africanpalliativecare.org. Accessed 18 January 2013.Google Scholar
- Human Rights Watch: Submission to the Human Rights Committee regarding Cameroon’s Fourth Periodic Report. 2009. https://www.hrw.org/news/2009/08/26/submission-human-rights-committee-regarding-cameroons-fourth-periodic-report. Accessed 21 February 2013.
- Stjernsward J, Foley K, Ferris F. The Public Health Strategy for Palliative Care. J Pain Symptom Manage. 2007;33:486–93.View ArticlePubMedGoogle Scholar
- Ingleton C, Gardiner C, Seymour J, Richards N, Gott M. Exploring education and training needs among the palliative care workforce. BMJ Supportive & Palliative Care. 2013. doi:10.1136/bmjspcare-2013-000233.Google Scholar
- Wallace M, Grossman S, Campbell S, Robert T. Integration of end-of-life care content in undergraduate nursing curricula: student knowledge and perceptions. J Prof Nurs. 2009;25:50–6.View ArticlePubMedGoogle Scholar
- Gott M, Seymour J, Ingleton C, Gardiner C, Bellamy G. 'That's part of everybody's job': the perspectives of health care staff in England and New Zealand on the meaning and remit of palliative care. Palliat Med. 2012;26:232–41.View ArticlePubMedGoogle Scholar
- Cavaye J, Watts JH. End-of-life education in the pre-registration nursing curriculum: Patient, carer, nurse and student perspectives. J Res Nurs. 2012;17:317–26.View ArticleGoogle Scholar
- Millington L. Initiators course strengthens palliative care services in Francophone Africa. 2012. http://www.ehospice.com/africa/Default/tabid/10701/ArticleId/1439. Accessed 20 January 2013.
- Davies E, Higginson I. The Solid Facts: Palliative Care. Copenhagen: World Health Organization; 2004.Google Scholar
- End-of-Life-Nursing Education Consortium (ELNEC): History, Statewide Efforts and Recommendations for the Future. 2012, Advancing Palliative Nursing Care, Available from,.http://www.aacn.nche.edu/elnec/publications/ELNEC-Monograph.pdf. Accessed 19 January 2013.
- European Association for Palliative Care: A guide for the development of Palliative Care Nurse Education in Europe. 2004. http://www.eapcnet.eu. Accessed 19 January 2013.
- African Palliative Care Association Palliative Care Core Curriculum: Introductory Course in Palliative Care. 2012. http://africanpalliativecare.org. Accessed 19 January 2013.
- Lavy V. and Wooldridge R: Palliative Care toolkit: improving care from the roots up in resource-limited settings. 2008. http://www.helpthehospices.org.uk. Accessed 20 January 2013.
- Lavy V: Palliative Care toolkit: Trainers Manual. 2009. http://www.helpthehospices.org.uk. Accessed 20 January 2013.
- Schluter J, Seaton P, Chaboyer W. Critical incident technique: a user’s guide for nurse researchers. J Adv Nurs. 2008;61:107–14.View ArticlePubMedGoogle Scholar
- Bradbury- Jones C, Tranter S. Inconsistent use of the critical incident technique in nursing research. J Adv Nurs. 2008;64:399–407.Google Scholar
- FitzGerald K, Seale NS, Kerins CA, McElvaney R. The critical incident technique: A useful tool for conducting qualitative research. J Dent Educ. 2008;72:299–304.PubMedGoogle Scholar
- Procter S, Allan T, Lacey A. Choosing the right approach: Sampling. In: Gerrish K, Lacey A, editors. The research Process in Nursing. New Jersey: Blackwell Publishing ltd; 2010. p. 142–57.Google Scholar
- Krueger RA, Casey MA. Focus groups: A practical guide for applied research. 4th ed. Thousand Oaks, CA: Sage; 2009.Google Scholar
- Kitzinger J. The methodology of focus groups: The importance of interaction between research participants. Sociology Health and Illness. 1994;16:103–21.View ArticleGoogle Scholar
- Flanagan J. The critical incident technique. Psychol Bull. 1954;51:327–58.View ArticlePubMedGoogle Scholar
- Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117.View ArticlePubMedPubMed CentralGoogle Scholar
- Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.View ArticleGoogle Scholar
- Lambert SD, Loiselle CG. Combining individual interviews and focus groups to enhance data richness. J Adv Nurs. 2008;62:228–37.View ArticlePubMedGoogle Scholar
- QSR International: NVivo 10. http://www.qsrinternational.com/products_nvivo.aspx
- Sharoff L. Critique of the critical incident technique. J Res Nurs. 2008;13:301–9.View ArticleGoogle Scholar
- Larson EL, Aiello AE, Cimiotti JP. Assessing nurses’ hand hygiene practices by direct observation or self-report. J Nurs Meas. 2004;12:77–85.View ArticlePubMedGoogle Scholar
- Al-Wazzan B, Salmeen Y, Al-Amiri E, Abul A, Bouhaimed M, Al-Taiar A. Hand hygiene practices among nursing staff in public secondary care hospitals in Kuwait: self-report and direct observation. Med Princ Pract. 2011;20:326–31.View ArticlePubMedGoogle Scholar
- Hedges C, Wee B. Evaluating a Professional Development Programme. BMJ Support Palliat Care. 2014;4:A76.View ArticleGoogle Scholar
- Loftus LA, Thompson E. An evaluation of a palliative care course for generic nurses. Int J Palliat Nurs. 2002;8:354–60.View ArticlePubMedGoogle Scholar
- Waldron M, Hasson F, Kernohan WG, Whittaker E, McClaughlin D. Evaluating education in palliative care with link nurses in nursing homes. Br J Nurs. 2008;17:1078–83.View ArticlePubMedGoogle Scholar
- Hughes PM, Parker C, Payne S, Ingleton MC, Noble B. Evaluating an education program in general palliative care for community nurses. Int J Palliat Nurs. 2006;12:123–31.View ArticlePubMedGoogle Scholar
- Leighton K, Dubas J. Simulated Death: An Innovative Approach to Teaching End-of-Life Care. Clinical Simulation in Nursing. 2009;5:e223–30.View ArticleGoogle Scholar
- Birkholz G, Clement PT, Cox R, Gaume A. Students self-identified learning needs: A case study of baccalaureate students designing their own death and dying course curriculum. J Nurs Educ. 2004;43:36–9.PubMedGoogle Scholar
- Gamondi C, Larkin P, Payne S. Core competencies in palliative care: An EAPC White Paper on palliative care education—Part 1. Eur J Palliat Care. 2013(a);20:86–91.Google Scholar
- Gamondi C, Larkin P, and Payne S. Core competencies in palliative care: An EAPC White Paper on palliative care education—Part 2. Eur J Palliat Care. 2013(b);20:140–145.Google Scholar
- Webster R, Lacey J, Quine S. Palliative Care: A Public Health Priority in Developing Countries. J Public Health Policy. 2007;28:28–39.View ArticlePubMedGoogle Scholar
- Reville B, Foxwell AM. The global state of palliative care—progress and challenges in cancer care. Ann Palliat Med. 2014;3:129–38.PubMedGoogle Scholar
- Rajagopal MR, Twycross R. Providing palliative care in resource-poor countries. 2009. http://www.paliativossinfronteras.com/upload/publica/PROVIDING-PALLIATIVE-CARE-POOR-COUNT-TWYCROS.pdf. Accessed 17 March 2013.