German Nursing Home Professionals' Knowledge and Specific Self-Efficacy Related to Palliative Care

Abstract

Background:

In Germany, more and more terminally ill patients spend their last days of life in nursing homes, and this presents a challenge for these institutions. Even though palliative care is a growing domain in health care, no quantitative in-depth evaluations of the status quo in nursing homes has been conducted so far in Germany, partly because of lacking measuring tools.

Objective:

This study used a new questionnaire to assess German health care professionals' theoretical knowledge of palliative care and their perceived self-efficacy. Both variables have been proven to be indicators for the quality of the implementation of palliative care in nursing homes.

Methods:

We used the Bonn Palliative Care Knowledge Test (Bonner Palliativwissenstest, BPW) questionnaire to measure knowledge of palliative care in the domains of medicine, care, and psychosocial care and to measure self-efficacy relating to palliative care.

Results:

Care workers (N=130) in five nursing homes in the region of Aachen in western Germany answered the questionnaires. The results show low knowledge (on average 52.8% correct answers) and self-efficacy relating to palliative care, although work with dying people is their daily challenge. While general knowledge correlated with work experience, a negative correlation of specific self-efficacy with age and working experience was observed.

Conclusions:

Lower self-efficacy of care workers experienced in palliative care probably implies that the difficulty of palliative care skills is underestimated by inexperienced care workers. Palliative care training is urgently needed to improve knowledge and self-efficacy. Guidance to assist care professionals involved in palliative care in nursing homes needs to be developed and provided.

Introduction

Professional care for severely ill and dying patients is an important challenge for health care systems in modern societies. Although providing adequate care at the chosen place of death is a core element of palliative care, a growing number of persons have to die in nursing homes as demographic and cultural changes dissolve traditional family structures and diminish support from family or friends. Institutional changes in residential care facilities providing care for the dying are necessary, as this area has been neglected over years.^1,2 Little research has addressed end-of-life care in German nursing homes. In a qualitative survey, nine residents described multidimensional needs and a desire for self-determination.³ Another qualitative study explored the concept of dignity in nursing home residents.⁴ An assessment of the present situation in nursing homes and the nurses' knowledge on palliative care would help to identify deficits and to tailor educational programs to the daily work.

In Germany, so far only semistructured interviews or nonstandardized questionnaires have been used to evaluate ongoing projects. We have developed a specific test instrument to allow quantitative pre-post evaluations.⁵ This study presents the results of testing 130 health care professionals in six German nursing homes before the initiation of a palliative care training program.

Methods

Six nursing homes in the region of Aachen in western Germany that were scheduled for a model program for implementation of palliative care agreed to participate in a longitudinal survey on knowledge and self-efficacy in palliative care. Nursing staff was asked to complete the Bonn Palliative Care Knowledge Test (BPW) before the initiation of the program. In November 2010, 290 questionnaires were sent out to the nursing homes. Within one month, 130 questionnaires were returned from six nursing homes, yielding a response rate of 44.8%.

Assessment tool

The BPW is a 38-item questionnaire assessing specific knowledge of palliative care (23 items) and specific self-efficacy (15 items). Self-efficacy is the measure of one's own ability to complete tasks and reach goals. Specific self-efficacy was tested with questions on self-perceived ability to perform palliative care skills such as assessing pain intensity, performing appropriate mouth care, recognizing complex needs of a dying resident, or integrating cultural aspects of death and dying in their care of severely ill patients. Self-efficacy has been included, as it provides information about the confidence of the participant to implement what has been learned in clinical practice, and has been used for the evaluation of training programs in pharmacology⁶ as well as in palliative care.⁷

Participants rated all items on a four-point Likert scale with the descriptors correct/ rather correct/ barely correct/ incorrect (stimmt/ stimmt eher/ stimmt kaum/ stimmt nicht) and documented demographic variables such as age, gender, profession, weekly working hours, and work experience. The BPW has been shown to have good sensitivity to change in both the knowledge and self-efficacy parts before and after palliative care training and no ceiling effects. Reliability is acceptable with Cronbach alpha 0.71 for the knowledge part and 0.86 for the self-efficacy part of the test. The time for completion was less than 10 minutes in the validation study.⁵ We developed the BPW with an extensive content validation for nursing home settings and the construction of numerous items for the psychosocial domain.

Statistical procedures

The item scores were analyzed descriptively, calculating the percentage of right answers. Right answers were defined by the response correct or rather correct (items 3, 8, 14, 16, 18, 24–26 ) or barely correct and incorrect for items 1, 2, 4–7, 9–13, 15, 17, and 19–23, which had been constructed with reversed polarization. Nonparametric Mann-Whitney U tests were used to test each item for differences between the ratings of the present sample and the expert group of the validation study. Two mean scores (knowledge and self-efficacy) were calculated, converting the ratings on the Likert scale to numerical values (correct four points, rather correct three, barely correct two, and incorrect one), with reversed scoring for those items with reversed polarization. T-tests for independent samples were calculated to show differences compared with the expert group. Multivariate analyses of variance (MANOVAs) with LSD-Post-Hoc-Tests and Pearson's correlation analysis were used to explore relationships between the mean scores and demographic variables. The significance level was set to p<0.05 for all tests, except for the comparison of the item scores of this sample and the expert group, where we used Bonferroni adjusted statistical thresholds to account for alpha inflation due to multiple testing. For the knowledge test, significance levels were adjusted to p<0.002 and for the self-efficacy test, to p<0.003.

Results

The majority (84.6%) of the participants was female. Professional groups were assistant nurses for the elderly (N=40), nurses for the elderly (N=36), general nurses (N=18), and others (N=14, a very heterogeneous group) (and N=21 missing answers). In Germany, both nurses for the elderly (Altenpfleger) and general nurses (Krankenpfleger) have a professional training of three years. The education of general nurses is regulated by federal law (Krankenpflegegesetz), and the education of nurses for the elderly is regulated by the federal states (Bundesländer). It is now possible to study nursing as an academic subject, graduating with a bachelor of science degree. Nurses on a management level have an academic background (none of the participants of this study). Assistant nurses of the elderly have completed one year of professional training, as regulated by state law. Mean age was 45.1 (range: 20–64 years, SD=11.2). The mean work experience in nursing care was 13 years with a range from 1 to 37 years (SD=8.7). Weekly workload ranged from 6 to 70 hours with a mean of 33.7 (SD=9.8). Previous experience with palliative care was at 16.4%. Care workers had experienced a median of 15.0 (range: 0–600, SD=71.9) patient deaths in their clinical work.

Results of the knowledge test are shown in Table 1. On average, 52.8% answers were true, compared to 77.91% for the experts in the validation study. Compared to the experts, 12 items scored significantly lower (Mann-Whitney U test, alpha adjusted for multiple testing). Results of the self-efficacy part of the test are shown in Table 2. Specific self-efficacy reached a mean of M=78.5% of correct answers (correct or rather correct), compared to 94.1% in the expert group. All items scored significantly lower compared to the expert group (see Table 2). The self-efficacy mean score did not correlate significantly with the knowledge mean score (p=0.75). Not enough data were available to calculate MANOVAs with sex as a fixed factor. Nurses with experience in palliative care had significantly lower self-efficacy mean scores (p=0.007), but no significance concerning knowledge was found. Correlations with age demonstrated lower self-efficacy mean scores for older nurses (r=–0.22, p<0.02) and for nurses with longer work experience (r=–0.31, p<0.001).

Table 1.

Palliative Care Knowledge

	Correct answers (%)
Knowledge	Sample (n=130)	Expert group (n=23)	Mann-Whitney U test Bonferroni adjusted p=0.002
1. Long-term opioid treatments induce psychological addiction.^*	77.7	45.8 (c)	0.004
2. A death without fear is always an important goal of palliative care.^*	5.7	23.3 (c)	0.001
3. In the attending of patients, all team members are equal.	30.6	(n)
4. Palliative care should never be combined with curative treatments.^*	51.7	75	0.002
5. When opioids are taken on a regular basis, nonsteroidal antiinflammatory drugs should not be used.^*	65.8	100	<0.001
6. Subcutaneous infusions are required for alleviating dry mouth in dying patients.^*	75.4	95.7	<0.001
7. Management with an opioid patch is adequate for residents in the final phase of life suffering from pain.^*	33.3	75	0.36
8. Adjuvant therapies (for example physiotherapy) are important for pain management.	57.7	85.7	<0.001
9. For family members it is always important to stay at the bed of the dying person until death occurs.^*	35.0	54.2	0.56
10. Constipation must be accepted as an accompanying symptom, because pain reduction is more important.^*	41.9	66.7	0.14
11. Palliative care calls for constant emotional closeness.^*	30.4	54.2	0.77
12. With old age, people have learned from many experiences of loss to cope independently with grief.^*	75.0	87.5	<0.001
13. The philosophy of palliative care means that no life prolonging interventions are performed.^*	46.2	50	0.81
14. The pain threshold is lowered by anxiety or fatigue.	26.2	70.8	0.96
15. Residents with life threatening illness should always be told the truth to allow them to prepare for death.^*	44.7	54.2	0.29
16 Team members must not be certain in belief to provide spiritual care for a dying person.	75.4	95.8	<0.001
17. The patient provided palliative care must accept death.^*	50.4	69.6	<0.001
18. Communication skill can be learned.	76.2	100	<0.001
19. Corridor neighbors should not be informed about the death of a resident to avoid unrest.^*	75.8	81.8	<0.001
20. Medical aspects of treatment always have priority in palliative care.^*	72.1	95.8	<0.001
21. Visible rituals and farewell ceremonies should be avoided when a resident has died to prevent unrest.^*	87.3	100	<0.001
22. The provision of antidepressants in pain treatment is not reasonable.^*	73.9	90.9	<0.001
23. Coanalgesics are not required with opioid treatment.^*	77.6	95.8	<0.001
24. The final phase describes the last three days of life.	34.6	73.9	0.52
25. The caregiver's own feelings (for example disgust) can be shown in the care of residents.	16.2	73.9	0.02
26. Physiological needs (for example sexuality) are still important while facing death.	35.4	100	<0.001

Data of the expert group has been collected in the validation study of the BPW.⁴

Items marked with a ^* should be answered with “no.”

(c), changed item; (n), new item.

Table 2.

Specific Self-Efficacy

	% correct answers
Items—specific self-efficacy I think that I am capable of…	Sample n=130	Expert group n=23	Mann-Whitney U test Bonferroni adjusted p=0.003
1. Collecting objective data that describe the pain level of the patient	73.3	87	<0.001
2. Counseling a patient about how nausea can be alleviated	77.7	87.5	<0.001
3. Informing a patient and the family about palliative care in the institution	68.5	100	<0.001
4. Convincing a family doctor about the need for palliative care support	73.8	95.8	<0.001
5. Detection and discussion of actual problems in the SEP	87.7	100	<0.001
6. Organizing contact to a hospice service	73.8	100	<0.001
7. Talking to an anxious patient and the relatives so that they feel safe	93.1	100	<0.001
8. Identifying the complex needs of a dying resident and reacting appropriately	85.4	100	<0.001
9. Offering suitable concepts of relaxation to a patient with pain	67.7	87.5	<0.001
10. Talking to a patient who expresses a wish for hastening death	80.0	95.8	<0.001
11. Performing adequate mouth care for dying residents	87.7	91.7	<0.001
12. Teaching the patient about possible side effects of prescribed medications	63.8	87.5	<0.001
13. Identifying specific psychological problems of residents	76.9	91.7	<0.001
14. Integrating the cultural aspects of death and dying in my care of terminally ill patients	77.7	91.7	<0.001
15. Empathizing with different life situations, family constellations, and associated needs of patients and reacting appropriately	84.6	95.8	<0.001

SEP, social environment of the patient.

Discussion

Knowledge score

The nursing home professionals' knowledge was low, with only 52.8% correct answers. Equivalent results of low knowledge in palliative care nurses were reported by other authors,⁸ with a score of 62% correct answers in the Palliative Care Knowledge Test (PCQN) testing 164 licensed nurses in 24 homes for the elderly in Texas.

Research indicated that a lack of palliative care knowledge in other facilities across all professional groups is a basic problem. It was pointed out that a lack of knowledge and deficits of skills are among the most common barriers to high-quality palliative care.⁹ According to recent international reports, inadequate training in palliative care appears to be a general problem for all professional groups, including informal caregivers,¹⁰ medical students,¹¹ internal care residents,^12,13 home care nurses,¹⁴ and cancer nurses.⁹ Previous experience in palliative care correlated with better knowledge in the BPW. This is in line with the results of other studies,^6,12 which showed improved knowledge after palliative care training.

Self-efficacy score

In contrast to knowledge, which correlated positively with work experience, a negative correlation of specific self-efficacy with age and working experience was observed. This was contrary to our expectation, but could be related to a lack of awareness of the need for and the problems with performing palliative care in inexperienced care workers in the early stages of their career. Research showed that older care workers in palliative care have higher quality expectations, perhaps because they not only focus on aspects of basic care but on more complex psychosocial demands such as establishing a supportive relationship with the patient.¹⁵ Experiencing problems with the care of dying patients may lead to disillusionment, and even first exposure to palliative care may deepen the feeling of inadequacy, as awareness of the patients' suffering increases, but knowledge, skills, and means to alleviate this suffering are not available yet. Organizational structures may impede implementation of newly gained palliative care skills in clinical practice after training, and this may lead to further disillusionment and to a drop of self-efficacy. In another study,¹⁶ a strong ceiling effect for their self-efficacy instrument for palliative care (SEP) was found, which means that caregivers rated their self-efficacy as continuously high, which could also be related to an underestimation of the complexity of palliative care operations. Ceiling effects were stronger for nurses with lower education levels. Lack of awareness seems more probable with lower education levels. Performance of psychosocial support can probably be evaluated as “easy” by inexperienced care workers, as our results showed. That study¹⁶ did not report a correlation with age, probably caused by the general ceiling effect.

Conclusion

Contrary to our expectations, self-efficacy was lower in older and more experienced care workers, probably because of an underestimation of the specific demands of palliative care by younger or inexperienced care workers. This subgroup may have to be motivated to get involved in education and training, because they may not be aware of their knowledge deficits.

Palliative care knowledge and self-efficacy in nursing home care professionals were low, suggesting the urgent need for training and indicating psychosocial skills as an area that has to receive specific consideration in the curriculum.

Increased knowledge in palliative care after training could be shown.^5,7,9,17 Knowledge of palliative care is certainly a prerequisite for good performance in the care of the dying, but correlations to patient-reported outcome measures should be explored in the future.

Footnotes

Acknowledgments

We would like to thank all participants; the administrations of the nursing homes and the Servicestelle Hospizarbeit for the excellent cooperation; Veronika Schönhofer-Nellesssen and Beatrix Hillermann, directors of the training program; and Mr. Spicher for access to the nursing homes. The study is part of a project financed by the Ministerium für Gesundheit, Emanzipation, Pflege und Alter in cooperation with ALPHA-Rheinland.

Author Disclosure Statement

No competing financial interests exist.

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