Palliative Nursing Competencies Required for Different Levels of Palliative Care Provision: A Qualitative Analysis of Health Care Professionals' Perspectives

Data collection and sample

A purposive sample of professionals, working in different levels of palliative care across various settings, was invited to provide information in workshops about competencies relevant to different levels of palliative care. The workshops were organized in different parts of Finland. Before the recruitment began, the Ethical Committee of North Ostrobothnia's Hospital District was asked whether ethical approval would be required. The Ethical Committee stated that formal approval was not required because the study did not intervene with the professionals' integrity. Participating organizations were informed of the data collection and they agreed with it. The sample (n = 222) included representatives from a range of health care and patient organizations (Table 1).

Managers from each of the organizations were asked to propose the most appropriate representatives for the aim of the study. Individuals recommended by the managers were sent an invitation letter that included information on the purpose of the study, why the study was being conducted, and those responsible for it.

Teachers from universities of applied sciences (UASs) participating in a national EduPal project, whose aim was to develop palliative care education, organized the workshops. The workshops were organized either at the UASs or the workplaces of the workshop members. In some cases, a basic level group and a specialist level group were invited to the same workshop; in these instances, the workshops covered more than one working group (WG). In total, data were collected from 36 WGs in 21 workshops. The workshops were moderated by teachers of the UASs and, in two workshops, the research team members (H.-L.M. and J.T.L.) acted as the moderator. However, no participant–moderator relationships were formed before the start of the study. No persons other than the participants and moderators were present in the workshops.

A questionnaire was used to collect the data. The moderators started the workshops by presenting the study and the project, and by going through the instructions for the workshop activities. The participants were informed that their participation was voluntary and that the collected data would be treated anonymously. All the participants provided their informed consent. The questionnaire was developed specifically for this study. It consisted of 10 open-ended questions covering competencies relevant to the field of palliative care, along with other aspects of palliative care development. The questionnaire had been pretested on one WG before data collection. The results of the pretest indicated that no changes to the questionnaire were required; hence, the pretest data could be included in the actual research data.

The participants discussed their views and documented their answers. In most cases, the answers were documented on paper while a small portion of the WGs used computers to document their answers. The moderators did not participate in the discussions but were available for the purpose of clarifying any questions. Moreover, they observed the discussions and made field notes. More detailed description of the data sampling is presented in our previous article regarding the competencies of physicians. ²⁰ The workshops lasted from two to four hours. This article reports the findings from the data concerning the following questions: 1.

What are the required palliative care nursing competencies of every registered nurse at the basic level?

Data analysis

Data collected from the workshops were transcribed verbatim. Qualitative content analysis was used in the analysis, with only the manifest content being analyzed. The unit of analysis was set as either a word, phrase, sentence, or many sentences, that is, anything constituting a unit of meaning. In the reduction phase, meaningful expressions related to the study questions were coded. Codes were then grouped based on similarities in content. In the abstraction phase, subcategories and main categories were created and named based on their contents (Table 2). ²¹ Two researchers (M.H. and H.-L.M.) independently coded all the material. They compared the identified codes and, when differences were found, discussed the issue together to find a consensus. The first author (M.H.) created the categorization, which was then critically checked by two other research team members (H.-L.M. and J.T.L.). The researchers made the final decisions regarding the analysis together as a team. ²¹ The analysis was performed manually. The number of codes was counted so that the frequencies (f) of codes for each category could be presented. Basic level data yielded 651 codes and specialist level data yielded 465 codes. Data saturation was achieved in both cases, which meant that no further data collection was necessary. ²² In reporting the findings, citations from the original data are presented in italics.

An inductive approach, that is, categories emerging from the data, was applied in the analysis of the basic level data (Table 3). ²¹ The analysis of specialist level data applied a combination of deductive and inductive approaches (Table 4). More specifically, the analysis began in the first part with a deductive approach, followed by an inductive approach in the second part.

The first part of the specialist level data analysis applied a deductive approach. This means that the researcher operationalized a structured or unconstrained matrix of analysis based on previous knowledge, for example, a theory or model.^21,23 This approach was chosen because many WGs expressed that specialist nurses should possess the same competencies as nurses working at the basic level, along with additional competencies. Hence, the categories representing basic level competencies were used as a structured matrix for the analysis of the specialist level data. In this part of the analysis, only data corresponding to the basic level main categories of the framework were coded. Second, codes that included new information that was unique to the specialist level were included in the analysis. They were abstracted inductively into new subcategories, which belonged to the main categories that had been identified from the basic level data analysis.

The second part of the specialist level data analysis applied an inductive approach. This part of the analysis concentrated on the codes, which were so unique to the specialist level that they did not fit into the structured matrix. As such, this part of the data analysis produced new main categories and subcategories.

The frequencies (f) of the codes constituting each category were counted to show the noteworthiness of the category in relation to the entirety. These frequencies are reported in association with the reporting of the categories.

Nursing competencies required for basic level palliative care

The content analysis identified 17 main categories, including a total of 75 subcategories related to nursing competencies required for basic level palliative care (Table 3). Of these main categories “Competence in managing the most common symptoms” was the category that included the largest number of codes (f = 75). The subcategory with the most codes (f = 30) was “Assessing the patient's symptoms and defining the need for treatment.”

“Competence in supporting the patient and her/his closest ones” was another main category that included an extensive set of codes (f = 74). The subcategory that was constituted from the largest number of codes was “Identification of the need for, and implementation of, psychosocial support” (f = 20).

Nursing competencies required for specialist level palliative care

The first part of specialist level data, that is, the data corresponding to the basic level main categories and the new subcategories unique for the specialist level are given in Table 4. Of the subcategories unique for the specialist level, most codes were included in “Participation as an expert in advanced care planning and setting goals of care” (f = 4) and “Addressing existential suffering” (f = 4).

The second part of the content analysis of the specialist level data identified 10 main categories, which included a total of 37 subcategories (Table 4). The main category that included the largest number of codes was “Competence in maintaining expertise and taking care of own well-being at work” (f = 34).

Another main category with a large number of codes (f = 26) was “Advanced symptom management in nursing care of patients in palliative care.”

Nursing competencies aligned to basic level palliative care

Both similarities and differences were found when comparing the results of this study with previous competence statements and literature. For example, competence in symptom management was the most emphasized main competence category. Symptom management has also been highlighted in earlier research and statements on the competencies of nurses^17,24–28 and physicians ²⁰ and in an interprofessional competence framework. ⁹

“Competence in supporting the patient and her/his closest ones” and “Competence in encountering the patient and her/his closest ones” were also often discussed in the WGs. Supporting the patient and family is a competence that has also been mentioned in earlier nursing competence reports.^24,25,27 The main category “Competence in supporting the patient and closest ones” included the subcategory of “Maintenance of hope.” This means that nurses providing palliative care should have the competence to maintain hope among their patients and their closest ones. This area of competence has not been mentioned in earlier statements of nursing competence, although maintaining hope has been shown to be important for patients throughout all phases of cancer care. ²⁹

The professionals considered encounters with the patient as an important aspect of palliative care nursing, with this main category described as respectful encountering, seeing the patient as a person and the encounter as a unique situation. Nurses should be present to patients and their family. The aspect of encounters with patients was described as being similar to the caring encounter concept, ³⁰ yet it had not been widely mentioned earlier in conjunction with palliative nursing competencies.^24–28

Many professionals from the WGs mentioned an unhesitant, or bold, attitude when providing palliative care. This need for courage was associated with the implementation of care, encounters, being present, breaking bad news, and when bringing along one's own expertise. This finding may reflect the need to develop and refine palliative care education, as it is already stated that palliative care professionals need to improve their competencies. ³¹ Nevertheless, courage in action was identified as a nursing competency in a recent study. ¹⁰ Moreover, a study reported that developing competence through education can increase courage among nurses. ³²

Competencies aligned to specialist palliative care

The content analysis identified certain competencies that were unique and specifically related to specialist palliative care. Nurses working at the specialist level of palliative care were perceived as professionals who coordinate the care of the patient and link the care between different levels and settings of palliative care. The results described nurses involved in specialist palliative care as being quite autonomous, because of their multiple roles in palliative care, a finding that has support from earlier research. ¹⁷

Research and development of palliative care was identified as a competence area for specialized nurses, as also in earlier literature.^24–28 Earlier literature has emphasized that participating in policy making is an aspect for specialist nurses.^{18,24,26,27,33} However, we did not identify competencies related to policy making from the specialist level data. This may reflect the fact that the role of specialist nurses is still at a stage of early development in Finland and/or that there can be limited opportunities for nurses to participate in policy making.

At both levels of palliative care, there were subcategories representing a small number of reduced expressions. Still, they are, nevertheless, important because they present the diverse competencies that nurses must possess to work in palliative care.

Strengths and limitations of the study

The trustworthiness of the study was ensured by choosing a research method that was suitable for the purpose of the study, as well as pretesting the questionnaire on a sample of participants (Supplementary Data). ¹⁹ Moreover, the study sample was large and represented diverse settings and levels of care. All the university hospital catchment areas in Finland were covered. Therefore, it can be considered that the data represent the whole phenomenon of interest quite well.

The response rate could not be calculated because the WG nurses were suggested by managers at the participating organizations. The workshops were organized only once, and thus, there was no opportunity to ask the participants any further questions. An additional limitation was that the transcripts were not sent to the participants for correction and/or comments. Moreover, the results were not sent to the participants, and thus, they had no possibility to provide feedback.