Building bridges of excellence: a comprehensive competence framework for nurses in hospice and palliative care—a mixed method study

In mainland China, there is a high demand for hospice & palliative care (HPC) due to the ageing population, rising burden of chronic diseases, and poor quality of death. China’s seventh national census of 2020 reported the number of individuals aged ≥ 65 years was 190.64 million, accounting for 13.50% of the total population [1]. Over 75.8% of the Chinese older adults had ≥ 1 chronic disease, [2] and the deaths due to chronic diseases accounted for 88.5% of annual total deaths [3]. This indicates that each year, a significant number of Chinese older adults require HPC, and the need would increase further when other age groups of end-of-life patients are added. A cross-sectional study, published in The Lancet, utilized comprehensive databases such as the National Center for Pediatric Cancer Surveillance, the nationwide Hospital Quality Monitoring System, and public databases covering over 31 provinces in mainland China. This study aimed to estimate the incidence of cancer among children (aged 0–14 years) and adolescents (aged 15–19 years) in China, revealing that 121,145 cancer cases were diagnosed between 2018 and 2020 [4]. This significant figure underscores a substantial demand for pediatric HPC in China. A retrospective study reflecting on a six-year experience in the development of a pediatric palliative care service in a tertiary children's hospital in China highlighted the feasibility and positive impact of palliative care services, particularly counseling services, on children with end-of-life illnesses. However, the study emphasized the persistence of unmet pediatric palliative care needs, warranting ongoing attention [5]. Beyond the evident demand for HPC, China also needs to improve the quality of death, as it was ranked 53rd out of 81 nations and territories in the Quality of Death and Dying 2021 report [6]. These situations highlight the urgent need for comprehensive and improved HPC services in China.

However, the HPC development in China is facing various challenges, such as the traditional concept of death, insufficient financial support, and a shortage of HPC professionals, including HPC nurses. A notable number of the Chinese population is profoundly influenced by Confucianism, which places high importance on “filial piety” [7‐9]. This cultural aspect may make it challenging for individuals to decide to forgo non-essential resuscitation for their parents or other elders. Because individuals unfamiliar with the concept of HPC may equate it with passive acceptance of impending death, contrary to their deeply held beliefs [10]. Consequently, Chinese HPC professionals confront unique cultural challenges, necessitating them to undertake the responsibility of educating and disseminating the principles of HPC. Predominantly, this responsibility has been shouldered by HPC nurses.

Simultaneously, certain HPC services, such as psychological support, spiritual care, and bereavement care, remain excluded from the hospital’s billing system. As a result, HPC professionals, especially nurses, are compelled to offer these essential services on a pro bono basis to patients and caregivers. The immature HPC charging model has been a subject of ongoing discussion within the development of HPC in China, yet a definitive solution remains elusive. Unlike well-established HPC systems where multidisciplinary teams collaborate seamlessly, in China, HPC is predominantly undertaken by doctors and nurses alone, [11] placing a substantial burden on HPC nurses in terms of workload and diverse responsibilities. Consequently, the challenges highlighted in this paragraph cast a shadow on the human resource development of HPC nurses.

The government has taken actions to overcome above obstacles, such as incorporating HPC into national health planning, announcing HPC pilot cities, and issuing national HPC practice guidelines and management standards [12]. These policies and approaches have promoted the establishment of independent HPC institutions and HPC departments or HPC wards at different levels of hospitals. However, there has been an increasing disparity between the growing social needs for HPC and the availability of well-trained doctors and nurses in this field. In the current stage, the direct impact of these policies on alleviating the shortage of HPC professionals, including HPC nurse, was not significant. Establishing a robust training system for HPC, enabling general nurses to acquire essential HPC competencies, and facilitating specialized HPC nurses' continuous improvement in their capabilities could potentially address the challenges we currently face.

Domestic medical school has not established HPC undergraduate program. Chinese nurses learn HPC knowledge and skills mainly through continuous education. But the available HPC continuous education has several limitations. For example, programs designed and provided by different hospitals or associations lead to the absence of standardization on knowledge content, training strategy, and evaluation criteria. Programs were primarily one-time, leading to an unclear pathway for the self-growth and development of HPC nurses. A lack of available nurses’ HPC competence assessment tool meant nurses are unable to identify their most suitable program and study objectives. Although, national level associations, such as the Chinese Nursing Association, provided well-organized HPC continuous education programs, they can only take a limited number of participants. These issues may harm the motivation for nurses working in the HPC field. Therefore, it is crucial to develop a rigorous training and evaluation system which with no doubt requires a well-established HPC competence framework as foundation.

Scholars and some overseas associations have published HPC competence frameworks for nursing students, general nurses, and HPC specialized nurses [13‐15]. Due to the differences of socio-economic backgrounds, framework development time, culture traditions, and nurses’ characteristics, the competences listed in each formwork were differ. This fact creates the obstacles when using existing frameworks. Furthermore, previous competence frameworks were mono-structured, which may not fulfil the need of continuous development. Given the uneven global development HPC, [16] we should adopt an international perspective to design and establish a comprehensive and dynamic HPC competence framework to provide a theoretical basis for the assessment, training, and management of HPC competence for scholars from regions at different stages of development.

The objectives of the study are 1) to comprehensively integrate HPC competence profiles for nurses from published research articles and other reliable publications, 2) construct the HPC competence framework for nurses, and 3) explore the underlying structure of the constructed framework.

This study was designed in four steps using a mixed-method approach (Fig. 1). The ethical approval was obtained from the Ethics Review Committee of the Nanjing Medical University (NMU2020-277), all steps recruited participants obtained written or online informed consent.

This mixed-method study presented the process of constructing a HPC competence framework for nurses and revealed it had a two-factor structure. We observed in systematic review that although hospice care has evolved for several decades, the HPC related competence had few changes. The earliest paper [17] recruited in systematic review was published in 1995 by American scholars suggesting 8 HPC nurse competences, including connecting competence, encouraging choice, speaking truth, strengthening the family, comforting, spiritual caring, guiding letting go [17]. Excepting “speaking truth” that has become a legal requirement and has been rarely mentioned in the subsequent studies, other 7 competences suggested by [17] were continually listed in different expressions as general or HPC nurses’ competences in later research articles, especially Chinese articles (Additional file 3). For example, the connecting competence was later presented as communication competence/abilities, [36] or as multi-professional collaboration competence/ ability [15]. This fact may prevent us to estimate optimistically the development of HPC nurses’ competence in the recent two decades. Meanwhile, it further revealed the necessity of constructing a standardized HPC competence framework, that may help reduce the duplication of synthesis efforts by scholars in different nations or regions as well as provide clear competence goals for human resource training in the HPC field.

The competence profile “adaptive ability” and “psychological regulation ability” extracted from the interview were not reported in the articles recruited in the systematic review. In addition, the “psychological regulation” also retained in the Delphi survey. These results indicated that Chinese HPC nurse and experts agreed the importance this competence. From the 13 interviewees, we gathered that they were simultaneously providing care to both end-of-life patients and regular patients, irrespective of their working department. The nurses had to constantly switch the role between encouraging the patients pursuing active treatment and helping dying patients pursing inner peace. Here was a quote from one of the interviewees to show the psychological struggles.

“…… It is very different, although the communication skills are same, the direction of is different. If the patient is receiving anti-tumors treatment, we have to maintain his/her willingness and confidence on treatment. The patient may often say “I can't be treated”, and then the doctors and nurses will naturally say “you are fine, you will try and then you will be better”. But, for those receiving HPC care, you may have to help him/her thinking about what he/she has to do or to prepare when he/she is dying. The direction is different. So, this is why that many nurses in hospice, especially all the nurses who are new to hospice, will be upset and frustrated most of the time ……”

The role conflicts may increase the working pressure and the psychological burden of nurses [61]. Considering this situation may not change in a short time, the HPC competence framework constructed in this study can be a suitable foundation of Chinese HPC nurse selection and training. Additionally, our research confirmed the importance of including the views of frontline staff when constructing a competence framework.

As a result of two-round Delphi survey, among all competences, the “achievement motivation” was assessed at the lowest average importance score (4.31 ± 0.75) and the largest CV (0.17). Some experts regarded this competence belonged to a relative higher level that the HPC nurses may not really use it in daily work. Other experts and our research team decided this competence should be retained considering the future implementation of the constructed framework. McClelland published an article in 1973 discussed that one of the central pieces of evidence about competence replacing intelligence was the impact of achievement, [62] showing that achievement motivation was a very implicit but very powerful intrinsic contributor to competency. This competence framework was developed for different level of HPC nurses, including RN, APN, and nurse manager, some level may need this competence. Meanwhile, this framework may be used for assessment tool development, having domain like “achievement motivation” may help distinguish individuals competence evaluation.

The competences that were repeatedly modified in the two rounds of Delphi surveys were “interprofessional collaboration”, “spirit of contribution”, “psychological care” “spirit care”, “self-psychological regulation”, and “affinity”. The “interprofessional collaboration” was revised from “spirit of teamwork”. As having the spirit of teamwork is the foundation of interprofessional collaboration, this revision increased the requirements of nurses. Although in China the nurses may not be the actual leaders of HPC teams, in real world the nurses are the absolute core working force and the persons who know the patients and caregivers the best [63]. Therefore, the nurse should have beyond team-member-level competence. The modification of the other five competences is mainly the improvement of expression, and will not be discussed further here.

The exploratory factor analysis showed our HPC competence framework had two factors. Based on the authors’ observation of clinic work the 18 competences in the Basic Competences factor directly contributed to the nurses’ daily work while the 7 competences in the Developmental Competences factor contributed more to high requirement aspects such as, research and self-continuous development. The importance scores of factor Basic Competences were higher than that of Developmental Competences may indicated that currently the Chinese clinical nurses focused more in completing daily work with high quality. The importance score of all competences ≥ 4.71 (out of 5) indicated Chinese clinical nurses have realized both Basic Competences and the Developmental Competences were important. According to these results, when using our HPC competence framework to guide the training program design, the organizers could consider based on the qualifications of trainee selecting the competences in on factor as the main training content. Or the organizers could make the training series, from the improving the Basic Competences to more advanced Developmental Competences. The overseas HPC frameworks supported the above suggestions because three frameworks recruited in the systematic review categorized competences. The America and New Zealand HPC framework [23, 24] categorized competences to the core competences that all nurses should master and specialty competences that only nurses working in palliative specialty environment were needed. The United Kingdom HPC framework [43] gave fixed seven competency areas, but with progressive competency requirements for increasing qualification level of nurses. Although the Australia [44] and Canada framework [20] listed several competency domains and give unified requirements, these two frameworks were designed only for HPC specialized nurses. In summary, although the specific content of the frameworks in different countries was different, structuring the competences was a unified trend.

Implementation value of our HPC competence framework also proved by covering the HPC needs of Chinese patients. A previous systematic review summarized seven care needs of Chinese dying patients and their family caregivers (Fig. 3) [64]. The competences for meeting these needs are all covered by our competence framework. For example, the patients have the need of “pain and symptom control” that is matched by “Symptom management” and “Comfort care” in the current framework. Other possible match relationships are shown in Fig. 3. Therefore, it can be foreseen that the nurses trained under this HPC competence framework will be capable providing proper care of Chinese dying patients and their family caregivers. In addition, nurses working in HPC field may use the framework to do self-assessment, identify future training needs, and even guiding the career development. Hospitals or health-care facilities may use the framework as guide to develop an appraisal system assessing staff’s competence or being the basis of the human resource allocation.

From a design perspective, our study extracted competencies from international publications and synthesized the attitudes of two key stakeholders: academic and clinical experts in the HPC field, and nurses working on the HPC frontline. Therefore, we are confident in stating that this 25-competencies framework has broad applicability, and nurses trained with these competencies as a target should be competent in clinical palliative care work in most countries. Furthermore, we have grouped the 25 competencies into Basic Competences and Developmental Competences based on clinical nurses' ratings. This grouping suggests that a continuous HPC education program may consider a two-stage design. We propose including Basic Competences in HPC training for general nurses or in the initial training for novice HPC nurses. Developmental Competences may be reserved for the continuous education program targeting experienced HPC nurses seeking career development.

The strength of this study included 1) extracting competence from multi-resources including published literatures, clinical nurses’ interviews, and experts’ opinions, maximized the comprehensiveness and clinical usefulness of the extracted content; 2) exploring the underline structure of the constructed HPC competence framework that deepened the understanding of the Chinese nurses’ attitude on HPC competences, and increase the implementation potential of the framework. This study has a limitation due to the nature of Delphi survey. Although the Delphi panel members had diverse background and rich experience in HPC, they may not be adequate to represent all opinions of the HPC experts in China. Therefore, the online survey recruiting a large sample was conducted for more opinion collection. Another limitation was that clinical nurses may not have a holistic view or a clear understanding of the future HPC development in China, so the structure of the competency framework derived from the clinical nurse perspective alone may need to be modified in consultation with relevant government department officers and experts in the HPC field. Considering that clinical nurses reflected current realities of clinical palliative and hospice care, it was recommended using the known framework structure until further results are available.

By extracting and synthesizing HPC related competence profiles for nurses from publications and interview transcripts and pursuing consensus from experts, we constructed a 25 HPC competence framework for nurses. This framework may have two underline factors that one about basic competence (18 competences) contributing to direct care and self-regulation, another one about developmental competence (7 competences) contributing to advanced practice and career development. This framework has promising implementation potential that researchers may consider using it as foundation to develop competence assessment or self-evaluation tools and education programs.