Professional Growth During and After Completing a Postgraduate Education in Palliative Care – A Qualitative Study

Review of Literature

Elsner et al. (2016) underlined the need for active rather than passive learning methods in palliative care education. They advocated research exploring the most suitable approaches and methodologies for teaching palliative care. A review by Skedsmo, Nes, et al. (2023b) concluded that simulation-based learning in postgraduate nursing educations in palliative care seems to facilitate experiences of personal growth. In a qualitative study of postgraduate palliative care nursing students’ experiences with simulation-based learning, the students expressed the need to be challenged in order to experience professional growth and mastery (Skedsmo, Bingen, et al., 2023a).

Marciniak et al. (2023) assessed and compared the outcomes of postgraduate education and training in palliative care. Assessment forms to evaluate nurses’ and physicians’ learning were provided by the course instructors immediately after the courses. However, the need for evaluation to take place after returning to clinical work in order to assess the clinical relevance of the course and explore the transition from education to clinical work was highlighted (Marciniak et al., 2023). Returning to clinical work and adjusting to a new role may be challenging. Relster et al. (2023) found that after completing their master’s degrees, students experience difficulties when returning to clinical work, regardless of their connections to practice during their education and whether they returned to a previously known or unknown setting. At the undergraduate level, students also experience challenges, and Duchscher (2009) found that the transition from student to newly graduated nurse could be perceived as a shock. The transition from theoretical knowledge in education to the practical application of nursing has been characterised as a gap (Greenway et al., 2019).

A systematic review, synthesising evidence of the implications of postgraduate nursing qualifications on patient and nurse outcomes, found that postgraduate studies could improve knowledge, skills and higher-order thinking, as well as personal views of benefits, such as the perceived enhancement of knowledge and skills. However, out of the 20 studies included, only two involved participants with postgraduate education in palliative care (Abu-Qamar et al., 2020).

Objective

On the basis of recent literature searches, little is known about newly graduated palliative care nurses' experiences and perspectives of completing a postgraduate education in palliative care after returning to clinical work. According to previous research, returning to clinical work and adjusting to a new role after graduation can be challenging. Consequently, the aim of this study was to explore how newly graduated palliative care nurses experienced and perceived the relevance and impact of their education on professional growth and clinical work during and after completing the postgraduate education.

Design

This study employed a qualitative approach with an exploratory and descriptive design (Hunter et al., 2019) using individual interviews. This design was deemed appropriate because of the lack of previous research on the topic and the aim of describing the experiences of completing a postgraduate education in palliative care from newly graduated palliative care nurses’ perspectives. Semi-structured individual interviews were conducted to provide an opportunity to create an atmosphere of confidentiality, trust and discretion (Polit & Beck, 2021).

Setting and Sample

The study was conducted at a university college in Norway that offers a postgraduate education in palliative care. In the spring of 2022, 61 registered nurses and two students from other professional backgrounds constituted the cohort of nearly graduated palliative care students. Of these, students who were registered nurses and had attended all mandatory learning activities (n = 61) were invited to participate. They received both written and oral information about the study and were informed that their participation involved attending individual interviews after returning to clinical work as graduated palliative care nurses. Five students agreed to participate, and they signed informed consent forms. One of the researchers (HMB), who was not involved in the course, administered the study invitations.

Learning Activities in Postgraduate Palliative Care Education

The postgraduate palliative care education is a part-time, one-year education (August–May) that awards 30 European Credit Transfer and Accumulation System credits. The education combines learning on campus with online learning, defined as blended learning (Vallée et al., 2020). To qualify for admission to the education, students must have completed a three-year (180 credits) degree in health or social sciences and possess at least one year of relevant clinical experience. During their studies, students must hold a clinical position relevant to the programme. The postgraduate palliative care education consists of three different courses (see Table 1). The curricula cover the ten core competencies in palliative care as described by the European Association of Palliative Care (EAPC) (Gamondi, Larkin, et al., 2013a; Gamondi, Payne, et al., 2013b), and the six nursing competencies described by Hökkä, Lehto, et al. (2020). There is no clinical placement during the postgraduate education.

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Table 1.

Description of the Courses, Mandatory Learning Activities, Outcomes and Exams

Course	Credits	Mandatory learning activities	Learning outcomes in the mandatory learning activities	Exams
Theoretical foundation	10	Individual written assignment	• Immersing oneself in literature on the hospice philosoph • Reflecting on how the hospice philosophy can be applied in professional practice • Learning to write academic text • Learning to conduct a literature search	Individual written home exam that can be worked on throughout the semester Further development of the written assignment (mandatory learning activity) after feedback from the educator is received
Patient-centred palliative care	15	Individual video-based communication training and reflection Short description of the learning activity: Students acted as nurses in a video-recorded role-play of a communication scenario, which was analysed afterwards.	Exploring communication in challenging situations within palliative care through role-play Reflecting on communication with patients in the palliative phase and with their relatives	Short (4 hours) individual written home exam
		Simulation-based learning Short description of the learning activity: Students acted as nurses in two different scenarios, which were reflected upon in debriefing sessions afterwards. Experienced facilitators, who were not familiar with the students, acted as patients or relatives in the scenarios.	Specified learning outcomes in each scenario Overall learning outcomes in the learning activity: • Practising assessing, evaluating and alleviating complex symptoms and distress • Practising the application of professional knowledge in patient scenarios • Training on communicating about professional issues, analysing and drawing conclusions • Practising effective communication and collaboration with patients or family members, ensuring their involvement and well-being • Sharing experiences and insights into palliative care and clinical challenges
Service provision for incurable sick and/or dying patients	5	Group project and poster presentation	• Collaborating in groups to explore improvements in service provision and/or the enhancement of service quality • Engaging in an in-depth literature review on a chosen topic and actively incorporating professional experiences • Reflecting on how relevant literature can be applied to improve the quality of palliative care services • Learning to prepare, plan and deliver poster presentations

Ethics

The study was approved by the Norwegian Agency for Shared Services in Education and Research (reference number: 115206) and the head of the department at the university college. Participation was voluntary, based on written informed consent and performed in accordance with The Personal Data Act (2018). In education research, there is a possible power imbalance in the student–educator relationship (Leentjens & Levenson, 2013). As the participants for this study were recruited before graduating from the palliative care education, the need to inform all eligible participants of their right to not participate or to withdraw from the study without giving a reason and that it should not affect their further education was emphasised. It was strongly stressed that choosing to participate or not would have no consequences for their educational progression or evaluation. The students were also assured that the course manager (KS) would remain unaware of their participation in the study.

Data Collection

Five semi-structured individual interviews were conducted with graduated palliative care nurses in October 2022. The semi-structured interview guide (supplementary file 1) included topics such as the impact of the postgraduate education on perceptions of mastery and professional self-esteem and the relevance of active learning methods to clinical work, which enabled the researchers to explore the perspectives and details most significant to graduated palliative care nurses (Polit & Beck, 2021). The semi-structured interview guide was based on previous research (Polit & Beck, 2021). The interviews were conducted and audio recorded using videoconferencing software (Zoom). HMB conducted four of the interviews, while KH conducted the last interview. The researchers who conducted the interviews are both female experienced teachers and interviewers, not involved in the course or postgraduate education. KH is a critical care nurse and professor, while HMB is a senior educational advisor. The interviews lasted from 24 to 45 minutes, with an average of 30 minutes. These were carried out five months after the last exam and six months after the last mandatory learning activity. This timeframe facilitated a situation in which the participants had time to experience the transition from being part-time students to graduated palliative care nurses and reflect upon their experiences (Duchscher, 2009).

Analysis

The study was reported according to the Consolidated Criteria for Reporting Qualitative Research (Tong et al., 2007). The interviews were transcribed verbatim by an external transcriber. The transcribed interviews were analysed using systematic text condensation (Malterud, 2012). NVivo (Alfasoft, Norway) was used to store and organise the material in the first three steps of the analysis, supported by tables in Microsoft Word. First, the interviews were read several times to gain an impression of each interview and of the whole data material. Guided by the aim of the study, six preliminary themes were identified. Through discussion, these preliminary themes were collapsed into four preliminary themes. In the second step, meaning units related to the preliminary themes were identified and sorted, marking them with codes. The preliminary themes were then developed into code groups, and meaning units were sorted into four code groups. In the third step, the meaning units within each code group were arranged into subgroups, with four code groups reduced to three code groups and eight subgroups. The meaning units within each subgroup were reduced into a condensate. Fourth, the content under each code group was summarised into an analytical text presented in three categories. The analytical text presents the most salient content and meaning. In the first step of the analytical process KS, CO and HMB (all female) all read the data from the interviews separately and then suggested themes. In the next three steps of the analytical process, KS did the first part of the procedure and presented a proposal that was discussed with CO and HMB and then revised after discussion. An illustration of the steps in the analytical process is presented in Figure 1, while an example of the analytical process is given in Table 2. All authors agreed upon the final categories. Transcripts and results were not returned to the participants for member checking.

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Figure 1.

Illustration of the steps in the analytical process

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Table 2.

Analytical Process

Impression of the whole	Identifying and sorting meaning units – from themes to codes		Condensation – from code to meaning		Synthesising
Preliminary theme	Code group	Meaning units (selected)	Subgroup	Condensate (selected part)	Category
Learning as the acquisition of measurable knowledge and skills versus learning as transformational	An inner transformative process	‘The education made me feel like I’m standing steadier on my feet when it comes to palliative care. But at the same time, I can’t put my finger on what I know more now compared to what I knew when I was just starting. But I think that there must be something’. – Nurse 2 ‘You initiate a reflection process that enables you to see yourself perhaps a little more from the outside. Hmm’ – Nurse 1	The education facilitating transformation to become a more reflective nurse	The education in general has made me feel like I’m standing steadier on my feet when it comes to palliative care. But at the same time, I can’t put my finger on what I know more now compared to what I knew when I was just starting. But I think that there must be something. Yes, I guess it’s just that I feel that I stand stronger and more secure. [The active learning activities] start a reflection process in which you see yourself from the outside.	Awareness of learning as a transformative process

Relevant Simulation-Based Learning to Boost Learning Under and After Education

Simulation-based learning was highlighted among the participants as a learning activity in the postgraduate education that had enhanced their confidence in palliative care. Its importance for boosting confidence was articulated in two distinct ways. First, by confronting challenging clinical situations through relevant simulated scenarios, the participants gained a sense of familiarity and sense of mastery towards similar clinical situations afterwards. Second, enhanced confidence was achieved by receiving constructive and affirmative feedback from their peers on their own performance. One participant had feared causing burden to patients and their families because of the participant’s own communication style but because of feedback from peers, this participant learned to become more confident in navigating the delicate balance between being honest and considerate in challenging conversations. During and after their participation in the simulation-based learning activities, the participants also had the experience of integrating theory and applying it into practical situations, thus increasing the quality of their clinical work: ‘The scenario was with a [realistic] patient we could meet at work, so the scenario was okay. It was very useful and effective. Although the situation wasn’t real, I perceived it as very realistic when I participated. I treated the actor like a patient whom I should do my best for and try to use the things we’ve learned—the knowledge—in a realistic situation. Then, you transfer it into practice in an effective way’. – Nurse 5

Most participants regarded communication as both a cornerstone of palliative care and the domain most prone to error. They suggested adding more simulation-based learning activities to enhance future students’ personal growth and confidence in palliative care, as such activities had helped refine their communication skills and increased their awareness of their capacity to use communication effectively in managing conversations with patients and their families. To support patients in making informed decisions and ensuring their right to self-determination, some participants emphasised the need to practice initiating challenging patient conversations, especially at an early stage in the patient’s disease trajectory, and to incorporate more targeted simulated scenarios that focus on communication. Conversely, others felt that they were already trained communicators because of their experiences working as professionals and, therefore, desired opportunities to practise technical skills and procedures. However, in the simulation activities that they had attended as palliative care students, they had seen a potential for their own improvement in this domain by observing and learning from peers whom they perceived as naturally adept communicators: ‘Some people are, in a way, born to communicate. They just do it automatically without thinking about it. So, it’s really nice to hear that they have actually reflected on it along the way and have consciously chosen a strategy, right? That it’s actually possible to kind of take with you those sentences, those words, that they’ve used [for your own use]’. – Nurse 3

Clinical palliative care situations that were perceived as challenging, such as conversations with children about their parents or siblings who were in a palliative state or dying, were suggested as possible starting points for additional simulated scenarios. Opportunities to practise simulated conversations with children could lower the threshold and reduce avoidance of having these conversations in real-life practice: ‘I think it’s a good idea to practise because health personnel avoid these conversations. Maybe that’s the thing that health personnel avoid the most. Relatives are okay, but children as relatives, that’s scary. Because you’re afraid to cause more burden. Then, you avoid them, and they lose the opportunity to be seen and met. And if you don’t start to have those conversations, you’ll never have experience either’. – Nurse 5

An In-Depth Understanding of Holistic Care

During their postgraduate education, the participants became more aware of the importance of conducting holistic assessments of patients, emphasising not only a patient’s physical but also psychological, social and spiritual needs. This awareness significantly altered their current clinical practices in evaluating the needs and circumstances of patients requiring palliative care. The participants emphasised making patient-centred plans for future care before a patient’s condition worsens. A participant described this as follows:‘When a patient is in the emergency or critical care units, we do all we can, it’s all in, right? It´s not always doing what’s best for the patient in a palliative state, we go a little hard and focus on cure. But it’s a lot we cannot cure. I’ve been more aware of that. That the patients have quite different needs.’ - Nurse 3

The participants also communicated their assessments of patients differently to their multidisciplinary colleagues after completing postgraduate education, with a holistic approach to the patients’ situations and a goal of communicating and reaching consensus in the best interests of the patients. After completing postgraduate education, the participants became highly aware of the need to share information and engage in conversations with relatives. They described having evolved in how they perceived, communicated with, and included the patients’ relatives in various situations. Participants provided examples of how they explore the relatives’ understanding of the situation after attending a meeting with the patient’s doctor or when observing that the patient’s condition is worsening. Furthermore, the participants described being more focused on ‘tuning in’ to where the relatives were: ‘I focus more on listening and being calm. I’ve been that nurse who always speaks. But now, I’ve learned to make it short and clear and try to listen to what the relatives have to say before I tell them my opinion. I’ve become more service oriented; I’m telling them that I’m here if they need me. And they should just call on me or get to the hallway. I’m not walking straight into a situation before I get a sense if the relatives want me to be there’. – Nurse 4.

Awareness of Learning as a Transformative Process

The participants described completion of the postgraduate education in palliative care as a comprehensive transformation process which persisted beyond the year of their education and fostered transformative shifts in their own clinical work. They experienced becoming more reflective and confident, applying critical thinking as an integrated part of their clinical work. Active learning activities containing initiated reflections were highlighted as learning activities and processes that particularly contributed to their transformation. Through such activities, participants were able to see themselves from the outside, discern their own performances objectively, and thereby gain heightened awareness of their own competencies and areas for improvement. Despite these examples, some participants found it challenging to verbalise or pinpoint specific examples of new knowledge or competencies that they had obtained: ‘The education made me feel like I’m standing steadier on my feet when it comes to palliative care. But at the same time, I can’t put my finger on what I know more now compared to what I knew when I was just starting. But I think that there must be something’. – Nurse 2

After completion of the postgraduate education participants described their current professionality as founded in knowledge and confidence because of their postgraduate education in three areas that they actively applied as palliative care nurses: 1) reasoning with colleagues, 2) observing patients and 3) assessing situations. Knowledge and confidence were regarded as an important foundation when they had to reason for what they believed was professionally right for their patients. Facilitating colleagues’ awareness of recognising patients potentially needing palliative care to enable them to make appropriate decisions and adopt an appropriate approach towards these patients’ treatments, was highlighted as important among the participants. Additionally, the participants highlighted the importance of having confidence in observing patients and assessing their situations. They also perceived themselves as being more aware of situations in which they were continuing with futile treatment towards the end of a patient’s life. This awareness made them initiate collective reflections with colleagues about the hesitancy to dare to intervene in situations in which a patient’s death was imminent. The professional confidence that the participants gained during their postgraduate education was perceived as a resource under challenging situations: ‘Because it [the postgraduate education in palliative care] probably did something to me. I’m actually more confident at work, and I don’t fear going into difficult conversations, clinical rounds or anything. I feel that I’m more confident in the situation, and the situations are not so scary anymore ....’– Nurse 1

The participants also described the postgraduate education as transformation process that enabled them to take on the roles of mentors and facilitators of reflection among their colleagues in clinical settings. The participants described how their current colleagues perceived them as professional resources in palliative care, either when these colleagues needed supervision themselves or when undergraduate nursing students in clinical placement required supervision. They reflected on the importance of their roles as palliative care resices and the need to manage these roles wisely. A challenge that participants encountered after completing the education was that their colleagues expected them to take responsibility for all patients in need of palliative care: ‘Many of my colleagues suggest that I can take over [the patient] because I have a postgraduate education in palliative care. But I find it important to teach them and guide them to be confident in the situation’. – Nurse 4