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Emergency Medicine Australasia (2015) 27, 287–294
doi: 10.1111/1742-6723.12428
ORIGINAL RESEARCH
Staff perceptions of palliative care in a public Australian, metropolitan emergency department Andrew RUSS,1 David MOUNTAIN,1,2 Ian R ROGERS,3,4 Freya SHEARER,3 Leanne MONTEROSSO,5,6,7 Gail ROSS-ADJIE5,6 and Jeremy R ROGERS6 1
School of Primary, Aboriginal and Rural Health Care, Emergency Medicine (Academic Unit), University of Western Australia, Perth, Western Australia, Australia, 2Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia, 3Emergency Department, St John of God Murdoch Hospital, Perth, Western Australia, Australia, 4School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia, 5Centre for Nursing and Midwifery Research, St John of God Murdoch Hospital, Perth, Western Australia, Australia, 6School of Nursing and Midwifery, The University of Notre Dame Australia, Fremantle, Western Australia, Australia, and 7School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
Abstract Objective: The primary aim was to investigate staff experiences and attitudes towards palliative care provision in a public metropolitan ED. Methods: Using a previously validated survey tool, data were collected from ED clinical staff using Likerttype, open-ended and dichotomous items asking about perceptions of palliative care and education needs. Comparisons were made between nursing and medical staff. Results: Medical staff and nurses’ perceptions of palliative care were similar, differing on only 10 of 37 (Likert) items. All staff reported confidence with symptom management, whereas medical staff felt more confident with decision-oriented communication and nurses were more supportive of nasogastric feeding. Staff were moderately accurate in determining the five most common causes of death. Four out of five conditions selected as appropriate for palliative care were cancer diagnoses. End-of-life communication and ethical issues were the two
most frequently requested areas for further education. Conclusions: Our study suggests that overall ED staff were confident regarding symptom management in palliative care. Cancer diagnoses were overrepresented in both the top five causes of death and conditions most appropriate for a palliative approach, suggesting that staff might underestimate the role of a palliative approach in non-cancer diagnoses. Areas suggested for further education include communication and ethical issues surrounding end-of-life care. Key words: emergency department, emergency medicine, palliative care.
Introduction Palliative care is an approach that aims to improve the quality of life (QoL) of patients and families facing lifethreatening illnesses by the assessment and management of pain, other physical problems, psychosocial issues and spiritual needs.1 Research suggests that palliative interventions are
Correspondence: Dr Andrew Russ, School of Primary, Aboriginal and Rural Health Care, Emergency Medicine (Academic Unit), University of Western Australia, 2 Verdun Street, R Block, 2nd Floor, Nedlands, Perth, WA 6009, Australia. Email: dr.andy.russ@ gmail.com Andrew Russ, PhD, BA (Hons), Research Associate; David Mountain, MBBS, FACEM, Associate Professor; Ian R Rogers, MBBS, FACEM, Professor; Freya Shearer, BSc (Hons), Academic Support Officer; Leanne Monterosso, PhD, BNurs (Hons), RN, RM, FACN, Professor; Gail Ross-Adjie, PhD, RN, MACN, Nurse Researcher; Jeremy R Rogers, BSc, Research Assistant. Accepted 17 May 2015
Key findings • ED staff express confidence regarding symptom management. • ED staff overestimate the potential role of palliative care in noncancer diagnoses. • ED staff desire education in end-of-life communication and issues.
more beneficial the earlier they start during end-of-life (EoL) care.2–4 As EDs are a common contact point for patients with life-limiting illnesses, ED staff should be able to identify the need for and provide basic palliative care.5 However, ED services focus on severe illness and trauma, and palliative care might not be a dominant mindset for ED staff.5 Indeed, ED attitudes and knowledge of palliative care represent potential barriers to identifying and initiating palliative services.5,6 Possible barriers include: failing to identify the need for palliative services,5 poorly communicating relevant information for EoL decision-making7 and lacking a clear role in providing palliative services.8 Therefore, understanding ED staff perceptions of palliative care and their perceived role is important for improving the ED’s role in palliative care. A recent Western Australian study of attitudes toward palliative care in a private, metropolitan ED reported that staff were confident with symptom management but underestimated the
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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A RUSS ET AL.
importance of non-cancer diagnoses and desired further education in EoL communication and the ethical issues surrounding EoL care.9 However, the study was performed in a single, private, metropolitan ED and might not be representative of staff working in other types of ED. The aim of the current study was to investigate staff experiences and attitudes towards palliative care in a public metropolitan ED.
Methods Study design Setting and sample Data were collected from ED staff at Sir Charles Gairdner Hospital (SCGH). The ED at SCGH saw 64 000 presentations in 2013 and is part of a 590bed, adult-only tertiary teaching hospital situated in Perth, Western Australia. The hospital provides comprehensive specialty care, with the exception of obstetrics and gynaecology, and includes a consultative palliative care service. During data collection, the ED had 75 medical staff, including 22 consultants, 23 registrars, and approximately 30 junior medical staff and interns. Nursing staff consisted of 130 registered nurses (RNs), three nurse-practitioners and 10 senior nurse managers/educators. Data collection was anonymous and voluntary. The project was approved by the SCGH human research ethics committee.
Survey content, administration and sample characteristics The survey tool mirrored that used by Shearer et al.,9 originally adapted from Eagar et al.10 Evidence for the survey’s validity was reported by Shearer et al. who showed that survey items are sensitive to differences between nurses’ and physician’s attitudes towards aspects of palliative care.9 Thus, the survey tool was appropriate, given our aim of investigating differences between ED nurses and physicians in their attitudes towards palliative care. Section A contains demographic questions including age, sex, profession and experience. In
section B, respondents provided their understanding of palliative care in a free-response item. The survey had three subscales: confidence with patient/family interactions and clinical management (12 items, 4-point Likert-type responses, 1 = need further basic instruction, 4 = confident to perform independently); views about death and dying (10 items, 5-point Likert-type responses, 1 = strongly disagree, 5 = strongly agree); and attitudes towards palliative care (15 items, 5-point Likert-type responses, 1 = strongly disagree, 5 = strongly agree). In section F, respondents indicated their desire for future education on a predetermined set of competencies (dichotomous responses). In section G, respondents guessed the top five causes of death from a list of the top 20 causes reported by the Australian Bureau of Statistics (ABS),11 and then identified five causes they thought most appropriate for palliative care. Two novel item-blocks were added at the end of the survey to explore issues around the World Health Organization’s definition of palliative care. Section H contained items asking respondents to rate how responsible they thought the ED was for identifying the need for, and provision of palliative care (10 4-point Likert items, 1 = notat-all responsible, 4 = highly responsible). Items in section I asked about perceptions (5-point Likert items, 1 = strongly disagree, 5 = strongly agree) of other problematic issues identified in the palliative care literature. Electronic and hard copy surveys were distributed. Electronic links were emailed to all ED staff, and hard copy versions were also provided to nursing staff in weekly meetings.
Data analyses Analyses were performed using SPSS version 22 (IBM Corporation, Armonk, NY, USA). Values of P < 0.05 were considered statistically significant. For comparisons of nursing and medical staff, significance tests are independent sample t-tests unless otherwise specified. Where appropriate, χ2tests were used to analyse dichotomous responses. Content analysis was performed on the free-text responses. Free-
text responses were coded into topic areas, then themes and sub-themes within topic areas to detect patterns and consistencies. Rigour of the analysis process was ensured by applying the criteria of credibility, auditability, neutrality and fittingness. An audit trail was used to document all theoretical decisions with analysis.
Results The overall response rate was 29% (n = 65), 25% nursing staff (n = 36) and 38% medical staff (n = 29). All demographic data are displayed in Table 1.
Section B: What do you understand by palliative care? Content analysis of participants’ responses (62 out of 65) to the question ‘What do you understand by palliative care’ identified two key themes: QoL and EoL care.
Section C: Patient/family interactions and clinical management (Table 2) All item means were above the scale mid-point, suggesting that staff were generally confident at communicating with patients and family and managing patient’s symptoms, with medical staff only significantly more confident than nursing staff at answering queries about medication effects.
Section D: Views about death and dying (Table 3) Generally, staff agreed with items: ‘The use of strong pain medication can cause the person to stop breathing’, ‘Hospitals are not good places to die’, ‘Families have the right to refuse a medical treatment, even if that treatment prolongs life’ and ‘Dying patients should be referred to a hospice or acute care’. Nurses disagreed less strongly than medical staff that ‘feeding tubes should be used to prevent starvation at the end of life’, although were still below the scale mid-point. Medical staff and nurses did not differ on any other item in section D and generally disagreed with the other items.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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PALLIATIVE CARE
TABLE 1.
Demographic characteristics of survey respondents By profession
Age (years) Mean (standard deviation) Sex Female, n (%) Years qualified as health professional, n (%) 5 Knowledge of palliative care, n (%) No knowledge Limited knowledge Working knowledge Extensive knowledge Highest level of palliative care training, n (%) No training On the job training Graduate diploma or higher
Total sample
Nurses (n = 36)
Medical (n = 29)
n = 65
35.6 (12.2)
†
†
30 (83.3)
11 (39.2)
41 (63.0)
1 (2.7) 11 (30.5) 24 (66.6)
4 (14.2) 8 (28.5) 16 (57.1)
5 (7.6) 19 (29.2) 40 (61.5)
1 (2.7) 11 (30.5) 24 (66.6) –
† † † †
† † † †
7 (19.4) 29 (80.5) –
8 (27.5) 21 (72.1) –
15 (23.0) 50 (76.9) –
†Missing data due to administrative error. ‘–’ indicates no responses.
TABLE 2. Comparison of staff (nursing and medical) confidence with patient/family interactions and patient management, mean (standard deviation) Statement
Total sample
Reacting to reports of pain from the patients Supporting the patient or family member when they become upset Reacting to and coping with nausea/vomiting Reacting to and coping with reports of constipation Answering queries about the effects of certain medications Reacting to and coping with terminal dyspnoea (breathlessness) Reacting to and coping with limited patient decision-making capacity Answering patients’ questions about the dying process Reacting to and coping with terminal delirium Discussing patients’ wishes for after their death Informing people of the support services available Discussing different environmental options (e.g. hospital, house, family)
3.3 3.3 3.3 3.2 3.1 2.9 2.8 2.8 2.6 2.5 2.2 2.2
(0.8) (0.8) (0.7) (0.8) (0.8) (1.0) (0.9) (1.0) (1.0) (1.1) (1.0) (0.9)
By profession Nurses 3.3 3.1 3.1 3.3 2.9 2.9 2.8 2.6 2.6 2.6 2.3 2.25
(0.7) (0.8) (0.8) (0.7) (0.8) (1.1) (0.9) (0.9) (1.0) (1.1) (1.0) (1.0)
P-value
Medical 3.3 3.4 3.4 3.2 3.4 2.9 2.9 3.0 2.7 2.3 2.1 2.24
(0.9) (0.7) (0.7) (0.8) (0.8) (1.0) (1.0) (1.1) (1.0) (1.0) (1.0) (0.9)
0.9 0.2 0.1 0.7 0.02 0.9 0.6 0.09 0.6 0.3 0.3 0.9
Items were measured on a 4-point Likert-type scale (1 = need further basic instruction, 2 = confident to perform with close supervision/coaching, 3 = confident to perform with minimal consultation, 4 = confident to perform independently).
Section E: Attitudes towards palliative care (Table 4) Medical staff disagreed more with ‘Opening discussions of end-of-life care should be deferred until there is no further effective curative treatment available’ compared with nursing staff, although most staff
generally disagreed with this item. Nursing staff agreed more that ‘Complete pain relief is a reasonable goal even when the pain is not caused by a terminal condition such as cancer’ and ‘Patients should be maintained in a pain-free state’, although staff generally agreed with these items.
Section F: Education needs (Table 5) Significantly more nurses than physicians selected ‘End-of-life communication skills: giving bad news, talking with family, discussing prognosis, discussing treatment options’, ‘Ethical issues: NFR orders, advanced care
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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TABLE 3.
A RUSS ET AL.
Comparison of staff (nursing and medical) views about death and dying, mean (standard deviation)
Statement
Total sample
Families have the right to refuse a medical treatment, even if that treatment prolongs life The use of strong pain medication can cause the person to stop breathing Hospitals are not good places to die Dying patients should be referred to a hospice or acute care The end of life is a time of great suffering Feeding tubes should be used to prevent starvation at the end of life I am not comfortable talking to families about death I am not comfortable caring for a dying patient When a patient dies I feel that something went wrong Little can be done to help someone achieve a sense of peace at the end of life
By profession
P-value
Nurses
Medical
3.8 (0.8)
3.8 (0.8)
3.6 (0.9)
0.3
3.2 3.2 3.0 2.3 2.1 1.9 1.8 1.8 1.5
3.1 3.0 3.0 2.2 2.4 1.9 1.6 1.7 1.5
3.3 3.4 3.0 2.3 1.8 2.0 2.0 1.8 1.4
0.4 0.1 0.7† 0.5 0.01 0.9† 0.12 0.6 0.5
(1.0) (0.9) (0.9) (0.8) (1.0) (0.8) (0.8) (0.8) (0.5)
(1.1) (1.0) (1.1) (0.9) (0.9) (0.9) (0.7) (0.9) (0.6)
(1.0) (0.8) (0.7) (0.6) (1.0) (0.8) (0.9) (0.7) (0.5)
Items were measured on a 5-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = unsure/mixed, 4 = agree, 5 = strongly agree). †Mann–Whitney test.
TABLE 4.
Comparison of staff (nursing and medical) attitudes towards palliative care, mean (standard deviation)
Statement
Total sample
Pain medication should be given as needed to terminally ill patients Patients should have the right to determine their own degree of medical intervention Spiritual care should include counselling the terminally ill patient Patients should be maintained in a pain-free state Patients have a right to determine their own degree of psychosocial intervention Palliative care should be the standard medical treatment for patients who are suffering from a terminal illness Addiction to oral morphine is not a serious issue, given that terminally ill patients have a short time to live Complete pain relief is a reasonable goal even when the pain is not caused by a terminal condition such as cancer The most appropriate person to make end-of-life decisions is the patient’s primary care provider I do not like talking about death and dying with patients As a rule, terminally ill patients prefer not to talk about death and dying Pain at the end of life is an inevitable part of the dying process Opening discussions of end-of-life care should be deferred until there is no further effective curative treatment available Estimation of pain by a medical officer or RN is a more valid measure of pain than patient self-reporting A patient should experience discomfort before receiving the next dose of pain medications
By profession
P-value
Nurses
Medical
4.5 (0.6) 4.2 (0.6)
4.6 (0.4) 4.3 (0.6)
4.3 (0.8) 4.1 (0.6)
0.3† 0.4
4.0 (0.8) 4.0 (0.7) 3.9 (0.7)
4.2 (0.7) 4.2 (0.6) 3.9 (0.7)
3.9 (0.9) 3.7 (0.8) 4.0 (0.6)
0.1 0.01 0.9†
3.7 (0.8)
3.6 (0.7)
3.9 (0.9)
0.3
3.6 (0.9)
3.8 (0.7)
3.3 (0.9)
0.05†
3.5 (0.8)
3.7 (0.7)
3.2 (0.9)
0.01
2.3 (0.8)
2.4 (0.8)
2.2 (0.7)
0.3
2.1 2.1 2.0 1.8
2.1 2.1 2.0 2.0
2.2 2.1 1.9 1.6
0.8 0.9 0.6† 0.02
(0.8) (0.7) (0.7) (0.7)
(0.8) (0.8) (0.8) (0.6)
(0.8) (0.7) (0.5) (0.7)
1.8 (0.6)
1.8 (0.7)
1.8 (0.6)
0.7
1.6 (0.7)
1.5 (0.8)
1.6 (0.5)
0.3†
Items were measured on a 5-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = unsure/mixed, 4 = agree, 5 = strongly agree). †Mann–Whitney test.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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PALLIATIVE CARE
TABLE 5.
Self-reported education needs (n [%] )
Topic Ethical issues: NFR orders, Advanced Care, Directives, patient’s decision making capacity End-of-life communication skills: giving bad news, talking with family, discussing prognosis, discussing treatment options Use of the Liverpool Care Pathway Dealing with delirium Dealing with breathlessness Pain assessment and management Spirituality and cultural aspects of end-of-life care Use of i.v. hydration and/or non-oral feeding in end-of-life care Dealing with insomnia problems Dealing with nausea and vomiting Dealing with appetite problems Dealing with bowel problems
Total sample
Nurses
Medical
P-value†
43 (66)
30 (83)
13 (45)
Emergency Medicine Australasia (2015) 27, 287–294
doi: 10.1111/1742-6723.12428
ORIGINAL RESEARCH
Staff perceptions of palliative care in a public Australian, metropolitan emergency department Andrew RUSS,1 David MOUNTAIN,1,2 Ian R ROGERS,3,4 Freya SHEARER,3 Leanne MONTEROSSO,5,6,7 Gail ROSS-ADJIE5,6 and Jeremy R ROGERS6 1
School of Primary, Aboriginal and Rural Health Care, Emergency Medicine (Academic Unit), University of Western Australia, Perth, Western Australia, Australia, 2Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia, 3Emergency Department, St John of God Murdoch Hospital, Perth, Western Australia, Australia, 4School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia, 5Centre for Nursing and Midwifery Research, St John of God Murdoch Hospital, Perth, Western Australia, Australia, 6School of Nursing and Midwifery, The University of Notre Dame Australia, Fremantle, Western Australia, Australia, and 7School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
Abstract Objective: The primary aim was to investigate staff experiences and attitudes towards palliative care provision in a public metropolitan ED. Methods: Using a previously validated survey tool, data were collected from ED clinical staff using Likerttype, open-ended and dichotomous items asking about perceptions of palliative care and education needs. Comparisons were made between nursing and medical staff. Results: Medical staff and nurses’ perceptions of palliative care were similar, differing on only 10 of 37 (Likert) items. All staff reported confidence with symptom management, whereas medical staff felt more confident with decision-oriented communication and nurses were more supportive of nasogastric feeding. Staff were moderately accurate in determining the five most common causes of death. Four out of five conditions selected as appropriate for palliative care were cancer diagnoses. End-of-life communication and ethical issues were the two
most frequently requested areas for further education. Conclusions: Our study suggests that overall ED staff were confident regarding symptom management in palliative care. Cancer diagnoses were overrepresented in both the top five causes of death and conditions most appropriate for a palliative approach, suggesting that staff might underestimate the role of a palliative approach in non-cancer diagnoses. Areas suggested for further education include communication and ethical issues surrounding end-of-life care. Key words: emergency department, emergency medicine, palliative care.
Introduction Palliative care is an approach that aims to improve the quality of life (QoL) of patients and families facing lifethreatening illnesses by the assessment and management of pain, other physical problems, psychosocial issues and spiritual needs.1 Research suggests that palliative interventions are
Correspondence: Dr Andrew Russ, School of Primary, Aboriginal and Rural Health Care, Emergency Medicine (Academic Unit), University of Western Australia, 2 Verdun Street, R Block, 2nd Floor, Nedlands, Perth, WA 6009, Australia. Email: dr.andy.russ@ gmail.com Andrew Russ, PhD, BA (Hons), Research Associate; David Mountain, MBBS, FACEM, Associate Professor; Ian R Rogers, MBBS, FACEM, Professor; Freya Shearer, BSc (Hons), Academic Support Officer; Leanne Monterosso, PhD, BNurs (Hons), RN, RM, FACN, Professor; Gail Ross-Adjie, PhD, RN, MACN, Nurse Researcher; Jeremy R Rogers, BSc, Research Assistant. Accepted 17 May 2015
Key findings • ED staff express confidence regarding symptom management. • ED staff overestimate the potential role of palliative care in noncancer diagnoses. • ED staff desire education in end-of-life communication and issues.
more beneficial the earlier they start during end-of-life (EoL) care.2–4 As EDs are a common contact point for patients with life-limiting illnesses, ED staff should be able to identify the need for and provide basic palliative care.5 However, ED services focus on severe illness and trauma, and palliative care might not be a dominant mindset for ED staff.5 Indeed, ED attitudes and knowledge of palliative care represent potential barriers to identifying and initiating palliative services.5,6 Possible barriers include: failing to identify the need for palliative services,5 poorly communicating relevant information for EoL decision-making7 and lacking a clear role in providing palliative services.8 Therefore, understanding ED staff perceptions of palliative care and their perceived role is important for improving the ED’s role in palliative care. A recent Western Australian study of attitudes toward palliative care in a private, metropolitan ED reported that staff were confident with symptom management but underestimated the
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
288
A RUSS ET AL.
importance of non-cancer diagnoses and desired further education in EoL communication and the ethical issues surrounding EoL care.9 However, the study was performed in a single, private, metropolitan ED and might not be representative of staff working in other types of ED. The aim of the current study was to investigate staff experiences and attitudes towards palliative care in a public metropolitan ED.
Methods Study design Setting and sample Data were collected from ED staff at Sir Charles Gairdner Hospital (SCGH). The ED at SCGH saw 64 000 presentations in 2013 and is part of a 590bed, adult-only tertiary teaching hospital situated in Perth, Western Australia. The hospital provides comprehensive specialty care, with the exception of obstetrics and gynaecology, and includes a consultative palliative care service. During data collection, the ED had 75 medical staff, including 22 consultants, 23 registrars, and approximately 30 junior medical staff and interns. Nursing staff consisted of 130 registered nurses (RNs), three nurse-practitioners and 10 senior nurse managers/educators. Data collection was anonymous and voluntary. The project was approved by the SCGH human research ethics committee.
Survey content, administration and sample characteristics The survey tool mirrored that used by Shearer et al.,9 originally adapted from Eagar et al.10 Evidence for the survey’s validity was reported by Shearer et al. who showed that survey items are sensitive to differences between nurses’ and physician’s attitudes towards aspects of palliative care.9 Thus, the survey tool was appropriate, given our aim of investigating differences between ED nurses and physicians in their attitudes towards palliative care. Section A contains demographic questions including age, sex, profession and experience. In
section B, respondents provided their understanding of palliative care in a free-response item. The survey had three subscales: confidence with patient/family interactions and clinical management (12 items, 4-point Likert-type responses, 1 = need further basic instruction, 4 = confident to perform independently); views about death and dying (10 items, 5-point Likert-type responses, 1 = strongly disagree, 5 = strongly agree); and attitudes towards palliative care (15 items, 5-point Likert-type responses, 1 = strongly disagree, 5 = strongly agree). In section F, respondents indicated their desire for future education on a predetermined set of competencies (dichotomous responses). In section G, respondents guessed the top five causes of death from a list of the top 20 causes reported by the Australian Bureau of Statistics (ABS),11 and then identified five causes they thought most appropriate for palliative care. Two novel item-blocks were added at the end of the survey to explore issues around the World Health Organization’s definition of palliative care. Section H contained items asking respondents to rate how responsible they thought the ED was for identifying the need for, and provision of palliative care (10 4-point Likert items, 1 = notat-all responsible, 4 = highly responsible). Items in section I asked about perceptions (5-point Likert items, 1 = strongly disagree, 5 = strongly agree) of other problematic issues identified in the palliative care literature. Electronic and hard copy surveys were distributed. Electronic links were emailed to all ED staff, and hard copy versions were also provided to nursing staff in weekly meetings.
Data analyses Analyses were performed using SPSS version 22 (IBM Corporation, Armonk, NY, USA). Values of P < 0.05 were considered statistically significant. For comparisons of nursing and medical staff, significance tests are independent sample t-tests unless otherwise specified. Where appropriate, χ2tests were used to analyse dichotomous responses. Content analysis was performed on the free-text responses. Free-
text responses were coded into topic areas, then themes and sub-themes within topic areas to detect patterns and consistencies. Rigour of the analysis process was ensured by applying the criteria of credibility, auditability, neutrality and fittingness. An audit trail was used to document all theoretical decisions with analysis.
Results The overall response rate was 29% (n = 65), 25% nursing staff (n = 36) and 38% medical staff (n = 29). All demographic data are displayed in Table 1.
Section B: What do you understand by palliative care? Content analysis of participants’ responses (62 out of 65) to the question ‘What do you understand by palliative care’ identified two key themes: QoL and EoL care.
Section C: Patient/family interactions and clinical management (Table 2) All item means were above the scale mid-point, suggesting that staff were generally confident at communicating with patients and family and managing patient’s symptoms, with medical staff only significantly more confident than nursing staff at answering queries about medication effects.
Section D: Views about death and dying (Table 3) Generally, staff agreed with items: ‘The use of strong pain medication can cause the person to stop breathing’, ‘Hospitals are not good places to die’, ‘Families have the right to refuse a medical treatment, even if that treatment prolongs life’ and ‘Dying patients should be referred to a hospice or acute care’. Nurses disagreed less strongly than medical staff that ‘feeding tubes should be used to prevent starvation at the end of life’, although were still below the scale mid-point. Medical staff and nurses did not differ on any other item in section D and generally disagreed with the other items.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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PALLIATIVE CARE
TABLE 1.
Demographic characteristics of survey respondents By profession
Age (years) Mean (standard deviation) Sex Female, n (%) Years qualified as health professional, n (%) 5 Knowledge of palliative care, n (%) No knowledge Limited knowledge Working knowledge Extensive knowledge Highest level of palliative care training, n (%) No training On the job training Graduate diploma or higher
Total sample
Nurses (n = 36)
Medical (n = 29)
n = 65
35.6 (12.2)
†
†
30 (83.3)
11 (39.2)
41 (63.0)
1 (2.7) 11 (30.5) 24 (66.6)
4 (14.2) 8 (28.5) 16 (57.1)
5 (7.6) 19 (29.2) 40 (61.5)
1 (2.7) 11 (30.5) 24 (66.6) –
† † † †
† † † †
7 (19.4) 29 (80.5) –
8 (27.5) 21 (72.1) –
15 (23.0) 50 (76.9) –
†Missing data due to administrative error. ‘–’ indicates no responses.
TABLE 2. Comparison of staff (nursing and medical) confidence with patient/family interactions and patient management, mean (standard deviation) Statement
Total sample
Reacting to reports of pain from the patients Supporting the patient or family member when they become upset Reacting to and coping with nausea/vomiting Reacting to and coping with reports of constipation Answering queries about the effects of certain medications Reacting to and coping with terminal dyspnoea (breathlessness) Reacting to and coping with limited patient decision-making capacity Answering patients’ questions about the dying process Reacting to and coping with terminal delirium Discussing patients’ wishes for after their death Informing people of the support services available Discussing different environmental options (e.g. hospital, house, family)
3.3 3.3 3.3 3.2 3.1 2.9 2.8 2.8 2.6 2.5 2.2 2.2
(0.8) (0.8) (0.7) (0.8) (0.8) (1.0) (0.9) (1.0) (1.0) (1.1) (1.0) (0.9)
By profession Nurses 3.3 3.1 3.1 3.3 2.9 2.9 2.8 2.6 2.6 2.6 2.3 2.25
(0.7) (0.8) (0.8) (0.7) (0.8) (1.1) (0.9) (0.9) (1.0) (1.1) (1.0) (1.0)
P-value
Medical 3.3 3.4 3.4 3.2 3.4 2.9 2.9 3.0 2.7 2.3 2.1 2.24
(0.9) (0.7) (0.7) (0.8) (0.8) (1.0) (1.0) (1.1) (1.0) (1.0) (1.0) (0.9)
0.9 0.2 0.1 0.7 0.02 0.9 0.6 0.09 0.6 0.3 0.3 0.9
Items were measured on a 4-point Likert-type scale (1 = need further basic instruction, 2 = confident to perform with close supervision/coaching, 3 = confident to perform with minimal consultation, 4 = confident to perform independently).
Section E: Attitudes towards palliative care (Table 4) Medical staff disagreed more with ‘Opening discussions of end-of-life care should be deferred until there is no further effective curative treatment available’ compared with nursing staff, although most staff
generally disagreed with this item. Nursing staff agreed more that ‘Complete pain relief is a reasonable goal even when the pain is not caused by a terminal condition such as cancer’ and ‘Patients should be maintained in a pain-free state’, although staff generally agreed with these items.
Section F: Education needs (Table 5) Significantly more nurses than physicians selected ‘End-of-life communication skills: giving bad news, talking with family, discussing prognosis, discussing treatment options’, ‘Ethical issues: NFR orders, advanced care
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
290
TABLE 3.
A RUSS ET AL.
Comparison of staff (nursing and medical) views about death and dying, mean (standard deviation)
Statement
Total sample
Families have the right to refuse a medical treatment, even if that treatment prolongs life The use of strong pain medication can cause the person to stop breathing Hospitals are not good places to die Dying patients should be referred to a hospice or acute care The end of life is a time of great suffering Feeding tubes should be used to prevent starvation at the end of life I am not comfortable talking to families about death I am not comfortable caring for a dying patient When a patient dies I feel that something went wrong Little can be done to help someone achieve a sense of peace at the end of life
By profession
P-value
Nurses
Medical
3.8 (0.8)
3.8 (0.8)
3.6 (0.9)
0.3
3.2 3.2 3.0 2.3 2.1 1.9 1.8 1.8 1.5
3.1 3.0 3.0 2.2 2.4 1.9 1.6 1.7 1.5
3.3 3.4 3.0 2.3 1.8 2.0 2.0 1.8 1.4
0.4 0.1 0.7† 0.5 0.01 0.9† 0.12 0.6 0.5
(1.0) (0.9) (0.9) (0.8) (1.0) (0.8) (0.8) (0.8) (0.5)
(1.1) (1.0) (1.1) (0.9) (0.9) (0.9) (0.7) (0.9) (0.6)
(1.0) (0.8) (0.7) (0.6) (1.0) (0.8) (0.9) (0.7) (0.5)
Items were measured on a 5-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = unsure/mixed, 4 = agree, 5 = strongly agree). †Mann–Whitney test.
TABLE 4.
Comparison of staff (nursing and medical) attitudes towards palliative care, mean (standard deviation)
Statement
Total sample
Pain medication should be given as needed to terminally ill patients Patients should have the right to determine their own degree of medical intervention Spiritual care should include counselling the terminally ill patient Patients should be maintained in a pain-free state Patients have a right to determine their own degree of psychosocial intervention Palliative care should be the standard medical treatment for patients who are suffering from a terminal illness Addiction to oral morphine is not a serious issue, given that terminally ill patients have a short time to live Complete pain relief is a reasonable goal even when the pain is not caused by a terminal condition such as cancer The most appropriate person to make end-of-life decisions is the patient’s primary care provider I do not like talking about death and dying with patients As a rule, terminally ill patients prefer not to talk about death and dying Pain at the end of life is an inevitable part of the dying process Opening discussions of end-of-life care should be deferred until there is no further effective curative treatment available Estimation of pain by a medical officer or RN is a more valid measure of pain than patient self-reporting A patient should experience discomfort before receiving the next dose of pain medications
By profession
P-value
Nurses
Medical
4.5 (0.6) 4.2 (0.6)
4.6 (0.4) 4.3 (0.6)
4.3 (0.8) 4.1 (0.6)
0.3† 0.4
4.0 (0.8) 4.0 (0.7) 3.9 (0.7)
4.2 (0.7) 4.2 (0.6) 3.9 (0.7)
3.9 (0.9) 3.7 (0.8) 4.0 (0.6)
0.1 0.01 0.9†
3.7 (0.8)
3.6 (0.7)
3.9 (0.9)
0.3
3.6 (0.9)
3.8 (0.7)
3.3 (0.9)
0.05†
3.5 (0.8)
3.7 (0.7)
3.2 (0.9)
0.01
2.3 (0.8)
2.4 (0.8)
2.2 (0.7)
0.3
2.1 2.1 2.0 1.8
2.1 2.1 2.0 2.0
2.2 2.1 1.9 1.6
0.8 0.9 0.6† 0.02
(0.8) (0.7) (0.7) (0.7)
(0.8) (0.8) (0.8) (0.6)
(0.8) (0.7) (0.5) (0.7)
1.8 (0.6)
1.8 (0.7)
1.8 (0.6)
0.7
1.6 (0.7)
1.5 (0.8)
1.6 (0.5)
0.3†
Items were measured on a 5-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = unsure/mixed, 4 = agree, 5 = strongly agree). †Mann–Whitney test.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
291
PALLIATIVE CARE
TABLE 5.
Self-reported education needs (n [%] )
Topic Ethical issues: NFR orders, Advanced Care, Directives, patient’s decision making capacity End-of-life communication skills: giving bad news, talking with family, discussing prognosis, discussing treatment options Use of the Liverpool Care Pathway Dealing with delirium Dealing with breathlessness Pain assessment and management Spirituality and cultural aspects of end-of-life care Use of i.v. hydration and/or non-oral feeding in end-of-life care Dealing with insomnia problems Dealing with nausea and vomiting Dealing with appetite problems Dealing with bowel problems
Total sample
Nurses
Medical
P-value†
43 (66)
30 (83)
13 (45)
