Background
Contemporary phenomena, such as an ageing world population, the increase in noncommunicable diseases, and the emergence of novel viruses, recently highlighted by the COVID-19 pandemic, demonstrate that there is an immense demand for palliative care (PC), which is expected to double by 2060 [
1]. In turn, the increasing complexity of health care at the end of life requires a competency framework that allows palliative care nurses to respond to the changing situations experienced by persons at the end of life. In Spain, unlike countries such as Ireland, Canada [
2] and Australia [
3], there is no regulation regarding competencies in PC.The variability of university training in nursing, as well as specific training from professional organisations and the fact that PC nursing [
4] is not a recognised specialisation in Spain are factors that hinder the professional development of nurses in PC. Health policies developed in recent years have promoted the vigorous development of PC throughout Europe, but the lack of education and training opportunities have been repeatedly identified as obstacles to such development [
5], as has the absence of an official specialisation process [
6].
The vast majority of patients who die will be cared for by healthcare professionals for whom PC and the management of death is not their primary area of expertise [
7]. The situations that nurses experience in PC are a continuous challenge for the development of their competencies in the relational, practical, and ethical dimensions. For this reason, they need knowledge, training, guidance and support to fulfil their role [
8]. At the same time, nursing encompasses a range of dimensions that cannot be easily reduced to a mechanistic list of competencies. It encompasses a wide repertoire of skills that change according to the demands of each clinical specialisation in which nursing care is performed and therefore depends on the context [
9].
The competency frameworks based on Virginia Henderson’s model, influential in Spain [
10], along with the NANDA, NIC, and NOC languages [
11], have been promoted by the General Council of Nursing in Spain since the 1990s [
12], as well as by university nursing schools. The Council itself initiated the project for the Standardisation of Nursing Practice Interventions (NIPE in the original Spanish) in the national health system, driven by the Ministry of Health and Consumer Affairs in 2002, with the goal of establishing standardised methodology and common terminology. Currently, hospital working groups comprising 33 provincial nursing colleges are involved in the project. This team of over 400 professionals ensures the necessary consensus. However, from the outset, mechanisms were established to gather the largest number of professionals and institutions into the project. This implies that new professionals, institutions, and associations are continually being incorporated. Nevertheless, the use of common methodology and terminology is uneven and has not reached full implementation [
10]. The factors involved, all of which are also associated with the development of the nursing role itself, are multifactorial.
In 2011, the Asociación Española de Enfermería en Cuidados Paliativos (AECPAL) initiated a line of research with the aim of developing a competency framework, based on the models of the International Council of Nurses [
13], the Canadian Nurse Association [
14] and the European Association of Palliative Care [
15]. In 2013, AECPAL proposed 98 competencies grouped into three areas: ethics and law, delivery and management of care, and professional development. To seek professional consensus based on the proposed competency framework, a first phase of study was carried out in which 237 Spanish expert PC nurses were asked to what extent the proposed competencies fit the purview of PC nursing, concorded with actual PC nursing practice, and were important aspects of PC nursing [
16]. The published results showed that of the 98 proposed competencies, 62 were accepted (defined as 75% of participants marking “yes” for purview and “high” or “very high” for concordance and importance). In contrast, 36 competencies were rejected (did not meet the 75% threshold for the three parameters) (Tables
1,
2,
3 and
4). All 98 proposed competencies reached the 75% threshold for importance.
Table 1
Count of competencies by area and 75% consensus reached (yes or no) for purview, concordance and importance
Ethics and law | 23 | 17 | 6 | 21 | 2 | 23 | 0 |
Delivery and management of care | 55 | 51 | 4 | 43 | 12 | 55 | 0 |
Professional development | 20 | 20 | 0 | 6 | 14 | 20 | 0 |
Total | 98 | 88 | 10 | 70 | 28 | 98 | 0 |
Table 2
Rejected competencies in ethics and law and parameters for which they failed to reach 75% consensus
Responsibility |
C 1.1 | To respect the values, lifestyles and beliefs of the person during the care process. Adapting care, accordingly, even when opposed to the nurses’ own values | X | |
C 1.2 | To give support to the family in order to respect the values and decisions of the person | X | |
C 1.5a | To participate in the development of national and regional policies as well as guidelines in relation to the rights of the person at the end of life | | X |
Ethical and legal rules |
C 1.8 | To be familiar with current regulations governing research processes and to ensure compliance, guaranteeing respect for the rights of persons who are research subjects | X | |
Ethical practice |
C 1.11 | To avoid the influence that the nurse’s own beliefs and values may have on the delivery of care | X | |
C 1.17 | To maintain the principles of intimacy, confidentiality and dignity with the body after death | X | |
C 1.18 | To protect confidentiality and professional secrecy by recognizing that the owner of the information is the patient and information will only be shared with prior consent in the cases established by law | X | |
C 1.23 | To accompany the person to clarify their values, motives and consequences and to obtain specialized help if deemed necessary, in the request for assisted suicide, refusal of treatment or euthanasia | | X |
Table 3
Rejected competencies in care delivery and management and parameters for which they failed to reach 75% consensus
Essential principals surrounding the care plan |
C2.10 | To participate in and promote debate about innovations and changes in care for people in the process of advanced illness and the end of life | | X |
Planning |
C2.22 | To define and prioritize nursing diagnoses with patient and family | | X |
C2.24 | To define collaboration problems with the other professionals involved in the care process | X | |
C2.29 | To record the activation of specific techniques, protocols and procedures used, indicating the outcome criteria | X | X |
Evaluation |
C2.34 | To assess the results of activities outlined in the care plan activities, in relation to the planned objectives | | X |
C2.36 | To use the results of assessments to deepen the individualization of the care plan | | X |
C2.37 | To evaluate the results of the delegated activities, techniques, protocols and procedures used | | X |
Therapeutic communication and interpersonal relationships |
C2.46 | To accompany the family after death by detecting specific needs in the grief process | | X |
Safe environment, comprehensive care and resource management |
C2.47 | To prevent risk through early detection, communication and recording of security problems to the corresponding authorities | X | |
C2.49 | To develop criteria that allow assigning the most appropriate and capable nurse to provide care and attention, taking into account their knowledge and/or emotional response to the complexity of the situation | | X |
C2.50 | To establish and maintain transdisciplinary and interdisciplinary relationships for decision-making that guarantee comprehensive care | | X |
C2.51 | To use quality indicators and current or potential risk management adapted to the end-of-life situation | | X |
C2.54 | To design specific care plans to support nurses at other levels of care in caring for people at the end of life | | X |
C2.55 | To establish circuits and intervention criteria between the different levels of care involved in end-of-life care | | X |
Table 4
Rejected competencies in professional development and the parameters for which they failed to reach 75% consensus
Professional commitment |
C3.3 | To know and analyze the political and/or institutional situation related to the care needs of people at the end of life | | X |
C3.4 | To implement the necessary changes at a professional, institutional and political level to improve care for people at the end of life | | X |
Quality improvement |
C3.7 | To know, develop and apply quality indicators and standards of care plans for people at the end of life | | X |
C3.8 | To participate in the evaluation processes and improvement of the quality of care for people at the end of life | | X |
C3.9 | To incorporate the criteria of effectiveness and efficiency to guarantee the best care while optimizing available resources | | X |
C3.10 | To generate resources to respond to specific care needs with quality criteria | | X |
C 3.11 | To apply and disseminate the conclusions and proposals for improvement of the analysis of the results of the quality-of-care assessment | | X |
Continuous training and teaching |
C3.12 | To lead the learning process for nurses in palliative care | | X |
C3.14 | To participate in the detection of training needs and collaborate in the development, implementation and evaluation of educational programs in palliative care for all professionals in the health field | | X |
C3.15 | To educate society about caring for people at the end of life | | X |
Research |
C3.17 | To identify research priorities and establish feasible lines of research and develop research networks at the local, national and international level | | X |
C3.18 | To consider the ethical issues of research with human beings who are vulnerable because they are at the end of life | | X |
C3.19 | To acquire leadership, collaboration and promotion skills in palliative care research projects at the local, national and international levels | | X |
C3.20 | To disseminate the results of research in palliative care | | X |
The competencies in ethics and law involve actions in which the nurse is responsible for encouraging the patient to participate in their end-of-life process (keeping in mind their personhood and privacy) and for promoting the patient’s autonomy in decision-making within a framework of citizens’ rights. Table
2 demonstrates the rejected ethics and law competencies. For most of the rejected competencies in this area, the cause attributed by participants in the current phase was that it didn’t fall under the purview of PC.
The competencies surrounding delivery and management of care mostly involve creating and carrying out the individualised care plan along with the sick person and their family, while considering the person’s clinical situation of progressive fragility. Table
3 shows the rejected competencies in care delivery and management. For most of the rejected competencies in this area, the attributed cause was the lack of concordance with nursing practice in PC.
Finally, the competencies related to professional development concern nurses’ leadership in the development of PC in applying high-quality methods to improve care, participating in continuous training and teaching, and collecting scientific data to contribute to the improvement of the care for people at the end of life. Table
4 shows the rejected professional development competencies. For all the competencies in this area that didn’t reach consensus, the attributed cause was the lack of concordance with nursing practice in PC.
In the present phase of the study, our objective was to understand why 36 of the 98 competencies were rejected (that is, why they failed to reach 75% consensus across the three parameters). The next step will be to plan reparative actions, reword some of the competencies, and/or remove some of them from the AECPAL’s proposed competencies framework to achieve a shared competency model [
17].
Discussion
We asked a sample of leaders in PC nursing why they thought 36 of 98 proposed PC nursing competencies had been rejected by PC nurses in an earlier phase of the study. Our analysis of their responses revealed four main reasons: the rejection of SNL, contextual factors, specificity (too much or too little), and the complexity of end-of-life care.
The first purported reason for rejection was the rejection of SNL. Surprisingly, the participants sometimes identified aspects of general nursing common to daily practice as reasons why the PC competencies had been rejected. This tendency could be linked to the rejection of competencies expressed using SNL. The view that SNL is not very useful or well-integrated into clinical practice, as described by the participants, may be related to seeing SNL as a conceptual imposition [
23]. This situation may be exacerbated by the chasm between the extensive use of SNL in academic settings [
21] and its relative absence in care settings. Research reveals deficits and inaccuracies in nursing records and difficulties in the use of NNN, as well as controversies about its usefulness for representing care delivery and outcomes [
24,
25]. In turn, in the study by Rios et al., nurses in primary care reported that these classifications are not very understandable, are difficult to use in care practice, and are not very useful, coinciding with our results [
26]. However, AECPAL has opted to promote the use of SNL by developing a guide for standardised care plans [
27] and incorporating a wearable infusion device into patient care [
28]. These steps favour clinical judgement and decision-making based on the homogeneity and objectification of interventions and, by standardising them, enrich care plans. SNL is also key to nursing itself, can affect how nursing evolves in multidisciplinary environments such as palliative care. The review by Conolly et al. did not find a consensus on which SNL should be used in defining competency models in palliative care [
29]. However, it is clear that SNL of some type must be used to describe specific nursing actions in order to make it possible to evaluate subsequently whether professionals’ follow them in practice, in line with the PIMAC project [
30]. This project also sought consensus among experts to define competencies and create an evaluation instrument to identify the professional’s perception of her own competency level as well as her supervisor’s perception of her competency level. Undoubtedly, as Hokka et al. point out, nursing competencies in PC, especially those that are most relevant to each level of PC delivery, should be better described to improve development, education and practice [
31].
The second reason why some competencies were rejected, according to the participants, was contextual factors that affect how nursing competencies can be carried out and determine the nursing model of care offered to patients and their families. As del Pino points out, in multidisciplinary contexts such as PC, it is especially important to use patient-centred care models that reflect nurses’ autonomous role, using SNL to improve the quality of care provided [
32].
As the participants pointed out, health policies and institutional strategic plans tend not to empower nurses or place them in leadership roles, which in turn limits nurses’ influence on health planning in Spain. Proof of this was the non-concordance with the competencies related to development, leadership, and professional commitment. Hokka et al., however, found that if expert nurses develop their competencies related to professionalism and leadership, they can bring about changes in practice [
31]. For the nursing perspective to have an impact on the quality of care, nurses must be present in management positions.
A growing number of people with advanced chronic health conditions and PC needs are dying without having their health and social needs met. This is reason enough to redefine traditional models of care with a view to focusing them on the person, rather than the disease [
33]. Most health institutions are still governed by a disease-based model of care organised around medical specialties. This orientation generates a major source of ethical and professional conflicts in nursing practice.
In Spain, according to Codorniu et al., nursing care is not considered very important and receives little consideration at the policy level. Spain’s health system does not fully take into account the resources necessary to perform nursing care well, nor does it invest in evaluating its outcomes [
34]. Economic and human resources are decisive for prioritising strategies for the development of nursing competencies. Nursing is consistently underfunded, as can be seen in the small number of nurses for each health area or specialisation, the scant investment in nursing research, and the lack of funding to promote a care model that includes SNL. Despite the findings, as institutions foster nurses’ clinical autonomy and support continuing education, nurses will undoubtedly have more opportunities to make decisions autonomously.
Nurses tend to cede leadership roles to other kinds of health professionals, an action that probably limits the quality of care that patients receive [
32]. The Nursing Now movement proposes transition models that will facilitate changes in social attitudes towards nurses and the equalisation of functions, skills, knowledge and competencies [
35]. Our results give visibility to the need to rethink how to integrate management skills by training nurses in leadership during their university studies and then helping them transition to leadership roles [
36]. As we have argued, leadership is closely linked to ethics. In this sense, including leadership competencies in the model reflects this commitment from the international nursing code of ethics: “Nurses participate in professional governing bodies and associations so that the contribution of nursing is present in the planning and redesigning of health, academic and social policies” [
37].
The third reason why competencies were purportedly rejected was problems related to the specificity of the proposed competencies; that is, some were too narrow or too broad, especially in the case of ethics. Paradoxically, the competencies that are most directly related to the principles of PC (C1.14 to help the person in a situation of advanced disease and at the end of life so that they can exercise their autonomy with their friends, family and care providers and C2.43 to create an intimate therapeutic context that stimulates communication) were considered broadly applicable to all nurses, as expressed in the nursing code of ethics [
38]. These principles are present in all areas of care but are developed in greater depth in PC.
Care is a fundamental value on which PC nursing is based. According to this principle, the patient is treated as an individual and not as a condition or a disease [
39,
40]. Several authors point out that experience, training in PC, and bioethical challenges are necessary for a nurse to develop the necessary confidence and skills to care for a person at the end of life [
41]. Our findings suggest that, considering the complex life experiences that nurses in PC experience, greater consensus should be developed on the definition and criteria for care complexity and the different degrees of intervention according to the nurse’s expertise. This proposal is in line with Currow, who outlines the need to define levels of care, referral strategies, and resource allocation appropriate to each case [
42].
At the same time, we must incorporate specialist and advanced practice nurses, given that patient care is increasingly complex [
43]. Also according to Hokka et al., having staff members with insufficient skills in PC can hinder the learning of nursing students [
44]. Therefore, expert nurses are key elements for the implementation of PC. Kennedy et al. demonstrated that PC, which emphasises a multi-professional approach, is undoubtedly an ideal environment to establish the functions of advanced practice nurses, who provide safe, effective, and person-centred care in the face of growing demands. They also argue that it is necessary to define and explain their functions, given the lack of clarity and regulatory frameworks in many countries [
45].
According to Benner, because nurses acquire competencies over time, the competencies that they bring to bear in a given situation will vary with the degree of expertise that they have achieved [
43]. Ethical competencies are required in each PC process since nurses interact regularly and meaningfully with people who are facing some of the most demanding and emotional moments of their lives [
8]. Also, where the patient is cared for determines the nurse’s level of involvement. In this sense, while ethical competencies are crucial for all nurses, they are especially important in PC, where nurses interact intensely with patients.
Finally, the fourth reason that participants attributed to the rejection of competencies was complexity—referring to the emergence of processes that interact in complex systems [
46]. Participants offered this reason for the rejection of the competency related to supporting the patient during the limitation of therapeutic effort, life support, euthanasia, and assisted suicide (C1.23) [
47]. Undoubtedly, it is the request for assisted suicide or euthanasia—and not the rejection of treatment—that arouses debate. As Busquets says, it is a situation that implies a high fragility for the person and family due to the magnitude of the help they need and, in turn, is ethically complex for health professionals, including nurses [
48].
Nurses have a code of ethics developed in 1973 and periodically updated by the International Council of Nurses (ICN) [
38]. This code serves as a guide for resolving ethical issues that may arise in the practice of the profession in a way that respects human rights, including cultural rights, the right to life, freedom of choice, and the right to dignity and respect. In conjunction with the ethical and legal principles of PC focused on providing relief and comprehensive care, this framework guides the actions of the nursing community in Spain. Having a national strategy for PC [
49] enables the promotion of the application of bioethical principles through recommendations for nursing care processes based on these principles and the current legislation in the different regions of Spain.
Even when PC professionals apply these international and national ethics strategies, the request for help to die can make PC professionals feel that they are not responding adequately to the needs of patients. This dilemma suggests a subsequent line of research to explore PC nurses’ self-efficacy and self-competence, described by Bandura as influencing the acquisition, development and achievement of competencies [
50]. Undoubtedly, competency development must respond to the needs of patients since their requests act as signals that modulate professional behaviours [
32]. Requesting help to die is not mutually exclusive with PC. In fact, Rosso et al. show that in some US states and Canada, between 81 and 92% of people who died by euthanasia had received specific PC [
51]. At the time of data collection for phase I, there was no euthanasia law in Spain. The Euthanasia Regulation (Organic Law 3/2021) came into force on June 25, 2021, making it possible for people with terminal or seriously incapacitating conditions to request to end their life [
48]. It remains to be seen how this new law will affect PC and the competencies of PC nurses. Finally, we cannot ignore that the attitude of PC nurses to death is influenced by external factors (society, culture, experiences) [
52]. Therefore, it is essential to ensure that PC nurses have the appropriate training, professional guidance, and development.
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