Nurses need a range of skill and competencies to provide high-quality palliative and end-of-life care in different healthcare settings
Becker, R. (2009) Palliative care 2: exploring the skills that nurses need to deliver high-quality care. Nursing Times; 105: 14, early online publication.
The second in this three-part series on palliative care outlines the skills nurses need to deliver effective care. Part 1 examined definitions of palliative care nursing, its core aims and values, and recent policies on end-of-life care. This article explores the evidence base to support the diverse range of knowledge, attitudes and skills needed to provide nursing care for people at the end of life.
Keywords: Palliative care, Skills, Evidence base
Robert Becker,MSc, RMN, DipN, FETC, Cert Ed (FE), RGN, is Macmillan senior lecturer in palliative care, Faculty of Health, Staffordshire University and Severn Hospice, Shropshire.
- Palliative nursing is a combination of evidence-based science, highly developed interpersonal skills, the therapeutic use of self and the ability to use all three in tandem.
- Ensuring nurses get support for themselves in an ongoing professional relationship with a trusted confidante is a key part of developing the reflective maturity necessary for palliative care nursing.
- The essential comfort measures delivered by nurses at the bedside close to the end of life are of vital importance and are the embodiment of quality nursing practice.
The following extract illustrates some of the challenges nurses face in palliative care.
‘”Will I ever be cured?” It is at times like this that we are faced with two simple choices. We can either ‘go’, make our excuses and change the subject, or ‘grow’, stay with the person and explore things further.
‘On this occasion, I chose to stay. He asked again if I knew whether he would be cured, but this time the intonation was different. It was as if he already knew the answer. I replied by saying to him that I knew very few details of his illness, but I would be happy to tell him what I knew if that was what he wanted. He replied very positively, both verbally and with a nod of his head’ (Becker, 1999).
Many nurses will have found themselves in situations like this and left wondering whether they acted correctly, said the right things and behaved with sufficient sensitivity. Later on they may have met with a colleague, manager or supervisor and told them what happened, searching for some affirmation that the skills used were appropriate and wondering whether they could have perhaps done things any better. The reply will depend very much on the experience and knowledge of the person concerned and may range from the indifferent – ‘Well, it sounds OK to me’ – through to a more counselling-oriented comment such as: ‘How do you feel about it now that you have had a chance to take stock?’
These comments highlight the difficulty in determining whether nurses’ competence to manage such delicate situations is sufficiently evidence-based, or simply a combination of spontaneous, intuitive responses based around life experience. We now know that good practice at the bedside in such situations is a combination of both (Schön, 1987; Benner, 1984).
A close analysis of this encounter will illicit a whole range of skills used to facilitate the conversation. It is important to examine how these skills have been described in the literature to date. Doing so provides a useful insight into the true nature of the diversity and essence of palliative nursing as it is delivered in clinical practice on a daily basis.
The evolution of competence
Learning is a complex issue and there are a number of ways to describe how nurses attain competence. However, for simplicity, an adapted version of Bloom’s (1956) taxonomy can be used, alongside a variation of Benner’s (1984) ‘novice to expert’ thesis. The work of Schön (1987) must also be considered, mainly because she recognised it was the ‘artistry’ of practice that helped to differentiate between a competent and an expert practitioner. As the anecdote introducing this article illustrates, such artistry needs to be acknowledged.
This also relates closely to Carper’s (1978) four patterns of knowing, which she suggested should be present in each nursing act: empirical knowledge; aesthetic knowledge; personal knowledge; and ethical knowledge.
Carper’s work emphasised the influence of nurses’ values, beliefs and life experience in their work and has stood the test of time. Elements of these four patterns can be seen in the current code of conduct (NMC, 2008).
The driving force towards developing competency assessment in both cancer and palliative nursing over the past decade has been the publication of a number of key documents. The RCN (2002) published its own core competency framework for nurses working in specialist palliative care. This was the first time such a venture had been attempted and was useful in helping to clarify and define the role of nurses working beyond the hospice environment.
The national core competency framework (NHS Executive, 2004) attempted to pull together a uniform framework of standards for cancer nursing across four levels of practitioner and a wide range of skills. Many competency statements in this document were directly transferable to the palliative setting.
The premise of both these documents is the notion that competencies can best be assessed through observing behaviour in practice, backed up by a plethora of both written and verbal evidence. However, higher education institutions find themselves with a proliferation of accredited courses for qualified staff at all levels that may be qualitatively excellent, but tend to concentrate on competency assessment via demonstrable critical thinking ability. Here lies the dilemma: how does nursing develop an acceptable model of competency assessment that embodies the best of both approaches?
To answer this we need to look a little further back in the literature. Only a small number of authors have attempted to define the skills and competencies used by nurses when caring for dying people (Taylor et al, 1997; Degner et al, 1991; Davies and Oberle, 1990; Heslin and Bramwell, 1989) (see Box 1).
Box 1. Core nursing skills for palliative care
Davies and Oberle (1990)
Degner et al (1991)
Heslin and Bramwell (1989)
These authors’ work has helped others to develop working tools and frameworks to guide practice (De Vlieger et al, 2004; Becker, 2000) (Box 2).
Box 2. Competency tools for practice and frameworks for education
De Vlieger et al (2004)
What is competency?
There are numerous definitions available for the term competency, although this article focuses on the RCN’s (2002) definition cited in relation to specialist palliative nursing. Competence in a given set of skills can be defined as: ‘The skills, knowledge, experience, attributes and behaviours required by an individual in order to perform the job effectively’ (RCN, 2002).
Therefore, in order to work it relies on the formulation of agreed competency statements that are then identified at different levels of practice.
At pre-registration level it is well established that clinical staff’s role is to conduct practice-based assessments of competence. The issue of grading competency to practice in pre-registration programmes is straightforward. In most instances the assessor simply needs to make a judgement, indicating yes or no against a given statement. At post-registration level assessing clinical skills is more complex and is predominantly based around self-judgement validated by educators and only occasionally by practitioners. This assessment usually takes the form of:
- Reflective essays, diaries and journals – linked to competencies;
- Portfolio development sometimes incorporating competencies;
- Critical incident analysis.
Currently no form of clinical assessment involving competencies can be said to be wholly objective. Indeed, this may never be fully achievable because of the holistic nature of care delivery and the many variables that can influence such assessment at any one time.
Competency in palliative nursing
Many of the areas in Boxes 1 and 2 contribute to a competent practitioner’s collective expertise, but it is important to consider the elements that stand out as essential to palliative nursing.
To illustrate this, I have used the framework developed from my own research (Becker, 2000) to devise a self-assessment competency tool for palliative nursing skills. While not definitive, it has nevertheless been extensively evaluated for its efficacy and goes some way to represent the core elements of nurses’ role in this area.
A highly developed range of sensitive and facilitative communication skills is to be expected in nursing, but is not unique to a palliative setting.
What makes palliative nursing skills stand out is the further ability to field and respond to sometimes profound or rhetorical questions about life and death; to know when to say nothing, because that is the most appropriate response; to use therapeutic comforting touch with confidence; to challenge colleagues who may wish to deny patients information; and, perhaps to discuss the imminent death of a relative with families. It is this combination of communication skills that makes palliative nursing what it is.
An ability to work with families, anticipating their needs, putting them in touch with services and supporting them when appropriate is also important, but not unique to palliative nursing.
The psychosocial element of care is often the part that is delegated to social workers, who may well have better knowledge of and access to the support available, but like so many members of the healthcare team, their involvement is transient.
It is nurses who will be there at the most difficult moments, helping patients plan their future care, offering strategies, giving ongoing psychological support and coordinating the other team members for patients’ benefit. It is the trust and confidence built through nurses’ ongoing relationships with patients and the therapeutic use of ‘self’ that is at the core of the psychosocial approach in palliative nursing.
Working closely with other members of the multidisciplinary team is a vital part of good practice in many areas of nursing.
The palliative care team, however, is not today confined merely to a charitable hospice environment. It can be found in both acute and community settings and in public and private care. The growth of the nursing role within these teams has been dramatic and continues to represent a much-admired model of working (Cox and James, 2004).
Physical care skills
This area is about the knowledge and skills necessary to deliver active, hands-on care in whatever setting throughout a long period of illness. It is not confined to the last few days of life, but is more focused during this time. In a palliative care context, such care embraces a range of skills, but focuses on the nature of both acute and chronic pain. Accurate and holistically oriented pain assessment using a range of tools is essential, as well as the ability to use these tools in situations where patients may not be able to respond to questions.
It is therefore about nurses’ observational skills and the intuitive ability to recognise signs with patients who consistently under-report pain (Farrer, 2007). It is about more than advising doctors of the appropriate prescription and dosage to manage pain; it is also about the advocacy role nurses have towards patients at a time of extreme vulnerability. It is these aspects that make palliative nursing skills so important to patient care.
Life closure skills
This area is concerned with nursing behaviours and skills that are crucial to patients’ and families’ dignity, as they perceive it, when life is close to an end and thereafter. Caring for the patient’s body and immediate surroundings is probably the most common area of activity in any nurse’s daily life. It is also the area that is most taken for granted in all healthcare practice. Now, preserving dignity has become central to government policy for older people (Department of Health, 2006).
The DH (2001) launched the Essence of Care to help practitioners take a much more patient-focused and structured approach. The DH (2003) set a range of benchmarks for standards in essential care and a toolkit for clinical areas to evaluate these standards. To complement these, the National Council for Palliative Care (2006) examined care priorities at the end of life.
These are important as they reinforce the importance of this area of care, which has often been referred to as ‘basic’ care. This implies that it involves unskilled tasks of low importance. Nothing could be further from the truth and the essential comfort measures that embody such care are vital to the overall well-being of patients and those at the bedside.
Such care has been described as sacred work, in which the carer enters into the patient’s intimate space and touches parts of the body that are usually private (Wolf, 1989). This is a highly privileged position that demands respect, a high degree of skill and sensitivity to individual need that is so essential when caring for dying patients.
One area that is seen as a key component in palliative care skills is the maturity to address the challenging intrapersonal issues intrinsic in caring for dying people and their families.
There is a need for nurses to recognise and attempt to understand personal reactions that occur as a natural consequence of working with dying and bereaved people, and to be able to reflect on how this affects care given in sensitive situations. Without doubt, this area is perhaps the most challenging of all competency areas and plays a significant part in the professional growth of those who choose to work in this field (Becker and Gamlin, 2004).
The dilemma for nurses is that, to be truly successful in using the palliative approach, there is a need to nurture a level of human contact and relationship that goes beyond the norm and, as such, can potentially make nurses feel emotionally vulnerable. Such reflective maturity is the domain of experience and learning, but is most certainly not confined to specialist nursing and is within reach of all nurses.
I hope this article has established that the full range of knowledge, skills and behaviours needed for nurses to demonstrate the palliative approach is much broader and deeper than at first realised.
Competency attained and used regularly in caring for dying people will carry through a nurse’s whole career, simply because people die of many causes in many environments.
To have the opportunity to be at the bedside of someone throughout the final months, weeks and moments of their life is indeed a privilege and honour for any carer. For nurses it is both the underpinning and overarching ethos of our profession.
- Part 3 of this series, to be published next week, explores using the palliative approach in practice.
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