REVIEW ARTICLE
12020
Interventions concerning competence building in community
palliative care services a literature review
Mette Raunkiaer MSc, PhD (Researcher) and Helle Timm MSc, PhD (Chief)
Danish Knowlegde Center for Palliative Care, Copenhagen, Denmark
Scand J Caring Sci; 2013; 27; 804819
Interventions concerning competence building in
community palliative care services a literature
review
Background: Studies establish that many incurably ill
people would prefer to die at home, whether their
final home is their own home or a nursing home.
Experience shows that the professionals in palliative
care at the basis level need to increase their compe-
tences. The purpose of this literature review is to
examine experiences with interventions regarding the
development of competencies within community pallia-
tive care services in other words, at the individual
work places.
Method: The study has been carried out as a literature
review of international databases (PubMed/Medline, CHI-
NAL, PsycInfo) with selected key words.
Background
About 55 000 people die in Denmark every year and
about 25% die at nursing homes and 20% in own homes
(1, 2). Studies show that many incurably ill people would
prefer to stay at home and to die at home, regardless of
whether their final home is their own home or a nursing
home (NH) (35). It is therefore essential that the
community palliative basis care is able to meet these
needs. Contemporary with that experience shows that
the palliative care at the basis level needs to be improved.
Specifically, studies from NHs show that the staffs have
difficulties understanding the death process, that there
are problems with interdisciplinary cooperation and com-
municating confidentially regarding the death process.
Training is also lacking regarding symptom management
(68). When working in homes, healthcare professionals
also have a need for expanded competencies (9). For
Correspondence to:
Mette Raunkir, Danish Knowlegde Center for Palliative Care,
Strandboulevarden 47 B, 1.floor, DK-2100 Copenhagen .
E-mail: mr@pavi.dk
804 Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
doi: 10.1111/scs.
Results: The review of the literature identified 15 publica-
tions which dealt with interventions regarding education
and competence building. The publications represent indi-
vidual studies, only two of which were controlled. All
conclude that competence building has a positive effect
according to the professionals. It is unknown whether or
how patients and relatives feel a positive effect from the
interventions just as it is unknown how the development
of competencies has actually led to a more developed
practice. The effect of local competence building in pallia-
tive care in the primary sector is lacking. Methods are
needed to further examinations of how a competency has
actually led to a more developed practice.
Keywords: palliation, competencies development, pri-
mary health care, workplace education, literature review.
Submitted 22 September 2011, Accepted 7 November 2012
example, the homecare nurse is often a key healthcare
professional organising and providing nursing care
through the cooperation with the physician, hospitals,
etc. However, studies show that they need more educa-
tion in palliative care (4, 10, 11).
Other key professionals in the palliative process in com-
munities are the general practitioners (GPs), but until
recently, end-of-life care has been neglected in physician
training (12). In Nordic countries specifically, palliative
medicine has not been recognised as a specialty (13), which
is why there is a great need for physicians and GPs with
expanded palliative qualifications. The Associations for Pal-
liative Medicine in the five Nordic countries have developed
a common Nordic course at the specialised palliative level
(13). This course is, however, not able to fill the need for
education in palliation for physicians in general or for GPs.
Purpose and limitations
The purpose of this literature review is to examine
experiences with interventions regarding the develop-
ment of competencies within community palliative care
services in other words, at the individual work places,
2013 The Authors
 Competence building in palliative care services 805

possibly in cooperation with educational institutions or Table 1 Literature searches covering 01.01.2000 31.10.2010
specialised palliative institutions, etc.
Local training, competence development and organisa- Databases Search results
tional changes often follow each other. For example,
Pubmed/Medline Searches were carried out with MESH
when a nursing home implements guidelines such as Liv- controlled keywords:
erpool Care Pathways (LCP) (14) and/or The Gold Stan- (PALLIATIVE CARE AND TERMINAL CARE) AND
dards Framework (GSF) (15), it often implies education/ MODELS, EDUCATIONAL;
training regarding these guidelines1. One element of The (PC AND TC) AND CURRICULUM AND CLINICAL
GSF system deals specifically with competence building. COMPETENCE NOR (PROGRAM DEVELOPMENT
This review is limited to dealing with local or regional NOT PROGRAM EVALUATION
competence building which is not a side effect of organi- NOT MODELS, EDUCATIONAL));
sational changes such as the implementation of guidelines (PC AND TC) AND CURRICULUM AND
PROGRAM DEVELOPMENT;
or competence building understood as basic education
(PC OR TC) AND CLINICAL COMPETENCE AND
(e.g. nurse, physician) or continued education for special-
CURRICULUM NOT OE NOT PD NOT
ists. Another literature review on interventions regarding
MODELS, EDU;
cooperation and guidelines for community palliative ser- (PC OR TC) AND CURRICULUM NOT MODELS,
vices care describes studies on LCP and GSF (16). EDU NOT PD NOT PE NOT CLINICAL
COMPETENCE;
(PC OR TC) AND CURRICULUM AND
Method
PROGRAM EVALUATION NOT MODELS,
This study is inspired by Polit and Becks (17) methods of EDU NOT PROGRAM DEVELOPMENT;
how to conduct a literature study and based on biblio- (PC OR TC) AND CURRICULUM AND
graphic databases (Pubmed, CINAHL and PsycInfo) and PROGRAMME DEVELOPMENT NOT
MODELS, EDU;
with selected keywords (17: 172187). The keywords are
(PC OR TC) AND MODELS, EDU NOT
described in the section Searching and the studies
(PC AND TC) AND MODELS, EDU;
included. There exist different attitudes whether reviewers
(PC AND TC) AND CURRICULUM AND
should limit sample to published studies, include grey litera- PROGRAM EVALUATION NOT PROGRAM
ture or restrict sample to reports in peer-reviewed journals/ DEVELOPMENT
publications (17: 515519). In this literature study, we do This resulted in 423 hits, of these 273 were
not include grey literature because of access to the publica- selected for review of their abstracts or titles if
tions, but we do include not peer-reviewed publications, no abstract existed,which resulted in 48 articles
otherwise this study would represent very few publications. for review.
CINAHL A free text search was carried out using
the keywords:
Inclusion and exclusion criteria for the literature search (PC OR TC) AND Education AND Curriculum
This resulted in 181 hits, of these 36 were
Inclusion criteria were as follows:
selected for review of their abstracts or titles if
1 Competence building in palliation within the primary
no abstract existed,which resulted in 13 articles
sector. for review.
2 Reviews and individual studies. PsycInfo A free text search was carried out using
3 Literature from 01.01.2000 to 31.10.2010. the keywords:
4 Norwegian, Swedish, Danish and English language (PC OR TC) AND Education AND Curriculum
literature. This resulted in 135 hits, of which 21 were
Exclusion criteria included studies that target: selected for review of their abstracts or titles if
1 Non-western material. no abstract existed,which resulted in 8 articles
for review

Searching and the studies included

Searches were carried out in international databases (Pub-
Med/Medline, CHINAL, PsycInfo) between 01.06.2010
and 31.10.2010. The search history appears in Table 1.
1
GSF stands for The Gold Standards Framework and is a guide-
line developed for palliative care in communities. LCP stands
for The Liverpool Care Pathway and is a guideline developed
for the last part of the palliative process.
2013 The Authors
Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
A total of 69 articles were found, and 54 were
excluded on the basis of the inclusion and exclusion cri-
teria above or for other reasons such as:
1 Doubles (total three studies all represented in the
category National and international general educa-
tion programmes on palliation).
2 Discussing and describing (e.g. personal cases, per-
sonal commentary or experiences).
806 M. Raunkiaer, H. Timm
3 Education and competence building at an elementary
level (e.g. nursing school, medical training, social
work training).
4 Education at the university level (e.g. master degree
and specialist medical degrees).
5 National and international general education pro-
grammes on palliation.
6 Education and competence building exclusively at
the specialist level (e.g. Macmillan nurses training).
7 Other such as: book chapters.
As a result, this literature review includes information
from a total of 15 studies.
Method of analysis
All studies were reviewed with respect to the following
perspectives:
1 Country of origin
2 Study type
3 Target groups
4 Professional actors
5 The intervention
a Purpose
b Methods
c The development initiative/the intervention
d Conclusion/evaluation
Results
During the literature review, we identified 15 articles (as
we interpreted our inclusion criterias) which dealt with
interventions regarding education and competence build-
ing within the following general themes:
1 Competence building in home care (seven studies).
2 Competence building in nursing homes (six studies).
3 Special methods connected to education and compe-
tence building in the primary sector (two studies).
Country of origin
Seven studies deal with competence building/education
in the USA, four in Canada, three in the UK, one in
Sweden.
Study type
Fifteen articles deal with individual studies including two
controlled studies.
Target groups
Three studies focused on competence building in relation
to specific categories of illness for example, heart dis-
ease, dementia and cancer, respectively. One article, from
Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
the USA, deals with poverty/social inequality and
palliation.
Professional actors
Nine articles focus on competence building for interdisci-
plinary groups (e.g. nursing home staff, home nurses,
GPs) two of which focus explicitly on GPs; five articles
concern different key people (e.g. palliative care link
nurses, train-the-trainer, clinical nurse specialists, case
managers); and one article concerns family caregivers.
Fourteen studies focus on competence building/education
for professionals, where two focus explicitly on general
practitioners and 12 focus primarily on nursing and care
personnel. One study also focuses on users.
The intervention
Twelve studies are based on both qualitative and quanti-
tative methods where the quantitative elements are pre-
dominantly connected to aspects of evaluation and the
qualitative elements are predominantly connected to
aspects of competence building/education. Three studies
are based exclusively on qualitative methods.
Special methods in connection with education and competence
building in the primary sector (two studies)
The two studies had much more focus on methods than
on the target groups (Table 2). Both studies (18, 19)
were based on the notion of a lack of interdisciplinary
cooperation, and one focused on patients with heart fail-
ure. The study (18) regarding heart patients used work-
shops as a method to develop competencies. The
evaluation showed a trend towards improvement of par-
ticipants assessment of their preparedness to manage a
variety of clinical problems and to communicate with
other members of the healthcare team (physicians). The
other study (19) described case reviews as a method of
developing competencies. The case reviews were run by
a facilitator and district nurses. GPs, hospital professionals
and other agencies involved with the case were invited
to attend by the case presenter. The evaluation showed
that this method promoted shared learning and was use-
ful to bridge the theory-practice gap. Both studies build
on methods which involved several professional groups
and require a large degree of participation.
Education and competence building in home care (seven
studies)
Seven studies concerned competence building in home-
care settings (See Table 3). Two studies were based on
the educational needs of case managers. One American
study (20) concerned with that fact that poor patients
and families did not have equal access to essential
2013 The Authors
 Competence building in palliative care services 807

Table 2 Special methods in connection with education and competence building in the primary sector

Author Methods of developing Education and

and the intervention (a) competence-building
place The aim and the evaluation (b) initiatives Conclusion/evaluation

Zapka To design, implement (a) An interdisciplinary planning
et al. and evaluate an group from the disciplines:
(18) interdisciplinary medicine, nursing, social
USA workshop aimed at work, hospital chaplain and
improving attitudes public health. Recommendations
and skills related to included the educational setting,
communication with target groups and promotion
patient/family, health methods. Workshop faculty
team communication, consisted of a geriatrician,
and documentation, palliative care nurse, behavioural
assessment of physical scientist/health service researcher
and emotional symptoms. and hospice social worker.
(b) The evaluation used a pre- and
post-test nonexperimental design.
Bellamy To describe the experience (a) Case reviews are a recognised
et al. of the way, a hospice learning strategy.
(19) team and their community (b) An informal review as a discussion
UK colleagues are taking a among participants; an audit of the
different approach to joint case review after 12 months
the case-review process. by the use of an anonymous
questionnaire with open and closed
questions. 54 questionnaires were
sent out. 30 returned
response rate of 56%. 73%
(n = 22) of the respondents were
hospice staff, and
27% (n = 8) were community staff.
A 4-hour workshop
curriculum with several
themes guided the
methods and content of
the interdisciplinary
workshop: needed skills
reflected in clinical
practice guidelines;
modelling of behaviours
and words to improve
clinician skill development;
introduction to prognosis
and supportive care as an
integral part of clinical care
to heart failure patients;
use of different didactic
and interactive teaching
methods. 59 participants
attended the workshops
mostly nurses and
social workers.
Case reviews once a month.
The facilitators role was to
employ strategies in the
group which
facilitate learning.
The presentation of the cases
alternates between the
community team and the
hospice team. Community
nurses, GPs, hospital
professionals and other
agencies involved with the
case were invited.
There were guidelines
for presentation.
The workshop improved
participants self-reported
preparedness to
communicate with
patients/ families about
prognosis and supportive
needs; and assessment of
their preparedness to
manage clinical problems
and communicate with
other members
of the healthcare
team (physicians).
Case reviews promote
shared learning,
collaborative practice
and increased knowledge
in relation to professional
roles and open dialogue.
The model was useful to
bridge the theory-practice
gap. The affect in relation
to impact on patient care
was difficult to define
from the results.

palliative care services. The intervention consisted,
among other things, of the employment of an experi-
enced palliative care nurse and a social worker to serve
as consultants to the case management staff; a curricu-
lum for case managers; and the development of a refer-
ence manual for case managers. The evaluation showed
that the initiatives had significant influence on the pallia-
tive care knowledge and attitudes of the case managers.
The education initiatives in a Canadian study (21) con-
sisted of modules with contents such as principles and
practice of palliative care, communication, grief and
bereavement, ethics. The evaluation showed a significant
increase in knowledge pretest and post-test.
Two studies (22, 23) had explicit focus on interdisci-
plinary education programmes based on a lack of
2013 The Authors
Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
professional knowledge of palliative care in rural commu-
nities. In both studies, the initiatives were developed as
one interdisciplinary programme and one programme
especially for physicians. The evaluations showed an
increased number of patients referred to hospice care but
did not increase enrolment for people with a noncancer
diagnosis (22); a greater capacity to deliver palliative care
but also a lack of resources for homecare visits (23). One
Swedish study (24) had homecare staff as its target group
and was based on problems connected to a lack of pallia-
tive competencies and frustration within staff groups.
The interventions were based on small-group work and
concepts from, for example, problem-based learning. The
evaluation showed an increase in attitudes towards end-
of-life care and the mental well-being of the staff. A

Table 3 Education and competence building for home care
Author
and place The aim
Head et al. (20) To integrate palliative care
USA principles and practice into
the day-to-day operations
of a Medicaid managed
care provider.
Howell et al. (21) To describe the results of
Canada (Ontario) learning needs assessment,
the subsequent development,
implementation and
evaluation of a course.
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Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
Methods of developing
the intervention (a)
and the evaluation (b)
(a) The project involved
a managed care
organisation providing
Medicaid services to
patients in urban and
rural settings.
(b) Training results, impact
on participating patients,
acceptance/evaluation of
the overall programme
by case managers, and
benefit analysis for the
managed care provider.
(a) A programme was
developed as part of the
mandate of the Hospice
Palliative Care Network
Project (HPCNet).
(b) An overall programme
evaluation to obtain
feedback from
participants on the
curriculum and skill
of presenters in
facilitating learning
inclusive of a qualitative
component; and a
pretest and post-test.
Development
initiatives/interventions
Five activities were accomplished:
(i) employment of a palliative care
nurse and social worker to serve as
expert role models and consultants;
(ii) development of a palliative care
training curriculum for case managers
(iii) provision and evaluation of the
training; (iv) identification of
appropriate patients, provision of
palliative care case management
(PCCM) (v) development of a resource /
reference manual for case managers.
Seven 3-hours modules: for example,
case management in a specialised
population; principles and practice of
palliative care; communication; ethical
and legislative issues; resource
allocation: case study presentations.
Group size 2530.
808
Conclusion/evaluation
Expert staff was hired and modelled
M. Raunkiaer, H. Timm
effective PCCM. This and the
training programme had
significant influence on the
palliative care knowledge and
attitudes of existing case
managers. Patient scenarios
demonstrated desirable outcomes
in healthcare utilisation, and
timely, appropriate hospice
referrals were realised.
90% of the participants correctly
answered the questions on
pretest, 92% post-test, at
3 months 93%. The percentage
of correct responses to the
questionnaire was statistically
significant between post-test and
the 3-month follow-up period,
and pretest and the 3-month
follow-up period.
 Table 3 (Continued)

Methods of developing
Author the intervention (a) Development

2013 The Authors

and place The aim and the evaluation (b) initiatives/interventions Conclusion/evaluation

Kaufman & To increase the awareness
Forman (22) and availability of hospice
USA care.
Kelly et al. (23) To provide an evaluation of
the interdisciplinary
(a): Two programmes were
developed: an
educational programme
for nurses (N) related
healthcare professionals
(RHCP); a physician
training programme.
(b): Chi-squared tests were
used to compare pre-
and post-intervention
values for enrolment
proportions, cancer
rates, nursing home
referral rates, enrolment
time categories.
(a) Based on the Ontario Ministry
of Health Palliative Care
Programme for N/RHCP: a conference
that, for example, discussed the
benefits of the hospice approach;
eligibility criteria; the role of hospice.
27 (14%) of N/RHCP participated.
Programme for physicians: a grand
rounds presentation with the hospice
medical director five physicians
(25%) participated.
Two educational initiatives were
developed: (i) the palliative
The intervention significantly
increased the number of patients
referred for hospice care. It did
not affected the length of stay or
increase enrolment for people
with a non-cancer diagnosis.
The goals were met. The
communities reported a greater

Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science

Canada (Ontario) education programme at
Lakehead University.
Initiatives for Ontario, 1993.
(b) A survey of 353 providers
who participated in the
education programme was
completed after 8 years of
providing education.
A anonymous questionnaire
comprising 26 questions was
developed. Of 296
questionnaires, 125 were
completed and returned
response rate 42%. The
majority of respondents were
nurses followed by physicians
and counsellors.
interdisciplinary education initiative; (ii)
palliative care education for family
physicians. Goals: to improve the
knowledge and skills of practitioners;
to contribute to the development of
palliative care programmes in agencies
and district communities; to prepare
palliative care trainers; to educate
co- workers in the workplace.
capacity to deliver palliative care.
Respondents identified a lack of
resources, especially for homecare
visits, as an obstacle to improving
care.
Competence building in palliative care services
809

Table 3 (Continued)
Methods of developing
Author the intervention (a)
and place The aim and the evaluation (b)
Thulesius et al. (24) To evaluate a 1-year learner- (a) An intervention and a control
Sweden centred educational project district in rural areas
in end-of-life care for participated staffed with
homecare staff in a rural nurses, physiotherapists,
district of Sweden. assistant nurses and care
assistants. All staff with
patient contacts in homecare
service or nursing homes were
invited to participate in the
education project in the
intervention district.
(b) A 20-item questionnaire
was designed to measure
attitudes towards different
aspects of end-of-life care.
The Hospital Anxiety and
Depression (HAD) scale
was used to measure
mental well-being.
Husban & Kenned (25) To explore the role of the (a) The description of the CNSs
UK community palliative care education role was based
specialist CNS as educator. on the literature study.
(b) Hermeneutic phenomenology,
using semi-structured
interviews. 11 (of 15) CNS
volunteered, and eight
participants (two from
each team) were randomly
selected for interview.
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Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
Development
initiatives/interventions
The education focused on learner-
centred approaches, mixing small-
group work, lectures, seminars and
discussions with the objective of
producing local guidelines for end-of-
life care. Used concepts from
problem-based, portfolio-based,
experiential learning, The Plan-Do-
Check-Act model for total quality
management. Themes: for example,
symptom management, the last days,
ethics, different ethnic groups. A total
of 200 of 276 (72%) people
participated.
Three themes were indentified: conflict
of expectations, credibility as a
teacher; making the education role
work. A team approach may address
the conflict of expectations between
the role specifications and practice
reality.
810
Conclusion/evaluation
The study showed a comprehensive
educational programme to
M. Raunkiaer, H. Timm
improve attitudes towards end-of-
life care and the mental well-
being of the homecare staff. The
evaluation showed an increased
agreement in 18 of 20 attitude
statements in the education
group. 2 of 20 items showed a
decreased agreement in the
control group. The total HAD
score decreased from 8.3 pretest
to 5.3 post-test in the education
group and was 6.8 for both years
in the control group.
CNS who delivered formal education
needed the knowledge and skills
to do so. Informal education
delivery was considered integral to
the CNSs role.
 2013 The Authors
Table 3 (Continued)

Methods of developing
Author the intervention (a) Development
and place The aim and the evaluation (b) initiatives/interventions Conclusion/evaluation

Pickett et al. (26) To describe a home-based (a) The programme was
USA educational programme developed based on
developed for family a literature review.
caregivers of cancer A multidisciplinary
patients who receive panel from hospices,
hospice and home care. home care, hospitals
and ambulatory cancer
settings prepared
the modules.
(b) 237 educational module
The programme was designed for one-
to-one instruction at home with
videotape and 14 individual
information modules (e.g. identifying
family roles and shifts in
responsibilities; cancer, stress, family
emotions; symptoms; physical and
spiritual care).
According to the nurses, the
programme reacted positively to
the content, format and clarity of
the learning modules; the topics
were well-suited. Some
professionals remarked on: the
timeliness of the modules, heavy
caseloads, lack of time.

Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science

kits were distributed
to professionals affiliated
with 24-hour home care
and hospice agencies in
the greater Philadelphia area.
Telephone survey.
Competence building in palliative care services
811
812 M. Raunkiaer, H. Timm
study from UK (25) focused on the educational role of
the community palliative care clinical nurse specialist
(CNS) and showed that CNSs need knowledge and skills
to deliver education in palliation.
In our sample (material), only one American study
(26) was based on the problem that family caregivers are
insufficiently prepared to care for patients with advanced
cancer. The intervention was designed for one-to-one
instruction at home by nurses who evaluated the pro-
gramme positively with respect to the content, format
and clarity of the learning modules, but pointed out the
lack of time for preparation of the modules.
The studies on home care generally focused on compe-
tence building for various groups: case managers, inter-
disciplinary groups, CNS and relatives. Education was
structured around themes such as symptom and pain
management, communication, ethics, etc. and uses vari-
ous pedagogical methods. Evaluations predominantly
indicated that individuals had experienced a positive,
professional effect with regard to the educational
interventions.
Education and competence building in nursing homes (six
studies)
Six studies concerned education and competence building
in nursing homes (Table 4). Three studies (from Canada
and the USA) had nursing home staff as their target
groups (2729) and two studies had a kind of palliative
educational key person at nursing homes as the target
group (30, 31).The interventions in all studies originated
from problems with a lack of knowledge and access to
palliative care. Different programmes were developed
that encompassed themes such as: pain and symptom
management, communication, grief and bereavement.
Evaluations of the studies showed, for example, an
increase in effectiveness in teaching palliative care, hos-
pice enrolment, pain management, documentation, net-
working and opportunity to share care, and confidence
in talking to GPs.
In our material, only one study (32) concerned a lack
of knowledge connected to a particular diagnosis:
advanced dementia. Two educational programmes were
developed one for nursing staff and one for physicians
and included a booklet to inform family members, nurses
and GPs. The evaluation from family members showed
no significant difference in satisfaction pre- and post-
intervention.
The studies showed two different ways of working: One
in which entire personnel groups were the target group
and another where key people were trained. In both target
groups, as with home care, professional themes, which
provided the content for educational interventions and
various pedagogical methods, were used. The interven-
tions were assessed positively.
Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
Discussion
Design and methodology of the studies
Two of these 15 studies had an intervention group and a
control group. In healthcare science, validity is connected
to controlled and preferably randomised studies. How-
ever, when the point of departure is competence building
in a local context, it can be complicated and meaningless
to carry out controlled studies. To generalise results from
one context with particular economic, organisational,
professional, cultural and possibly relational and individ-
ual conditions to another is difficult.
Fourteen of 15 studies had based their assessments on
professional experiences, in other words, the assessments
of patients and relatives are grossly underrepresented.
Only one of the publications had based their assessments
on experiences from patients and relatives. This is prob-
lematic because there may not necessarily be accordance
with the professional and users assessments. Addition-
ally, subjective assessments do not necessarily reflect an
actual development or change of practice.
One study (32) focused on a particular diagnosis group
(dementia), and it was the relatives (the users) who eval-
uated the intervention. It is interesting to note that their
evaluation did not show a significant difference before
and after the educational intervention.
Principle findings
Our literature review has reviled that competence build-
ing is primarily organised in two ways: (i) for entire per-
sonnel/professional groups or (ii) specific key people.
Earlier studies (4, 33) regarding the education of entire
personnel groups and training of key people indicate that
concrete and personal support from leadership and col-
leagues is essential. It is also essential that an organisa-
tion has structures in place that can sustain and update
competencies. Similarly, with the training of key people
(e.g. train-the-trainer); it can be difficult to pass on the
competence lift to other personnel groups. The studies
included here generally do not address these types of
questions. The studies were evaluated by measuring the
level of knowledge before and after an intervention or
whether the professionals felt that they had benefited
from the experience. Only one of the studies (32)
included the users (relatives) assessment of whether the
intervention had had an effect and that evaluation
showed no statistically significant difference. Experience
from other studies (3436) indicates that interventions
do not necessarily change practice or have a positive
effect on users even though professionals themselves
experience improvements in clinical practice.
In this literature review, competence building for
whole personnel groups was often divided into two
2013 The Authors
 Table 4 Education and competence building for nursing homes (NH)

Methods of developing Education and

Author and the intervention (a) competence-building
place The aim and the evaluation (b) initiatives Conclusion/evaluation

2013 The Authors

Kortes-Miller To describe an approach to
et al. (27) developing and delivering a
Canada research-based palliative care
education curriculum in rural long-
term care (LTC) homes.
(a) Comprehensive needs assessment. The
target groups were as follows: Registered
Nurses (RNs) and practical nurses (RPNs),
healthcare aids (HCAs), recreational
therapists or employed assistants. A cross-
sectional survey design collection was
designed to elicit demographics, learning
needs and preferred educational formats.
The survey was sent to 294 healthcare
providers in three rural LTC facilities in
three communities in north-western
Ontario. The return rate was 43.5%. The
results were used as a guideline in the
development of The Palliative Care in
Long-Term Care curriculum along with
different palliative care education curricula
(b): Unclearly described, but the
programme was evaluated by participants
and facilitators.
The curriculum: A 15-hour The educational events were useful
interdisciplinary palliative care for the participants clinical
education programme, consisting practice and met their learning
of six 2-hour sessions offered needs. They liked attending the
over several weeks or 2 days (e.g. educational sessions within their
weekends). The curriculum was own community, and the time
based on an interdisciplinary frame was well received. The
approach with small-group interdisciplinary small-group
interactive learning. The learning learning format was beneficial to
objectives were, for example: their learning.
dying in Canada; pain and
symptom assessment and
management; working with
families. All sessions were offered
on site, in the evening hours over
a span of several weeks. The
participants varied form 5 to 19.
Almost all participants completed
the programme in full.

Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science

Braun & Zir (28) To describe the development and
USA (Hawaii) testing of an 8-hour curriculum
for paraprofessional staff in NHs
that features active-learning
strategies.
(a) 16 focus groups identified barriers to
providing good end-of-life care, which
gave rise to eight 1-hour stand-alone
modules and palliative care guidelines in
five domains: 10 NHs participated. 100 of
144 individuals completed the course
(b) A pre- and postcourse survey. Data
analysis: paired sample tests and chi-
squared tests.
The 8 modules consisted of: 1) a The participants achieved high
good death; 2) pain; 3) scores on post-test and found the
distressing symptoms at the end curriculum useful and liked the
of life; 4) life-prolonging opportunities to share and talk.
treatment; 5) advance directives;
6) cultural beliefs in death and
dying; 7) communication; 8) after
death care. Developed guidelines:
1) Patient/ families preferences for
care; 2) pain and symptom
management 3) relief of emotional,
spiritual and personal suffering;
4) accurate and realistic information
regarding course of illness and
prognosis; 5) the needs throughout
Competence building in palliative care services

illness, death and after death.

813
 814

Table 4 (Continued)

Methods of developing Education and

Author and the intervention (a) competence-building
M. Raunkiaer, H. Timm

place The aim and the evaluation (b) initiatives Conclusion/evaluation

Hanson et al. (29) To test whether a quality
USA improvement (QI) intervention at
NHs increases hospice, pain
management and advance care
planning (ACP).
(a): An already developed quality
improvement intervention was used
(b): 9 NHs in North Carolina were
involved. 7 NHs were intervention sites, 2
NHs were randomly chosen to be control
sites. The intervention used the plan-do-
study-act design for quality improvement
interventions. The primary study design
was a prepost-comparison of quality
indicators in intervention NHs with pre
post-comparison in control sites to test
for temporal trends. Included 3 month
recruitment and planning phase and a 9
month intervention phase. A structured
chart abstraction instrument was
developed and used on residents at
baseline, 3 months and 6 months after
the start of the intervention; and gave
quality indicators of the NHs. Care plan
notes, advance directives, etc. were
reviewed to document the use of ACP.
The quantitative data were entered into
SPSS 10.1.
Team members form the NHs The intervention NHs experienced a
interdisciplinary Palliative Care significant increase in hospice
Leadership Team participated in a enrolment after the intervention:
one-day conference covering from 35 residents at baseline to
hospice enrolment/services, pain 59 residents at the end of the
management, ACP, communication intervention period. Completed
and quality improvement pain assessments among all
techniques. The NHs received residents increased. Documented
monthly on-site education and ACP discussions were rare at
technical assistance in QI methods. baseline.
Six in-service educational sessions
were available to all clinical staff.
Hospice providers delivered on-site
education sessions. Palliative Care
Leadership Teams participated in
monthly strategy meetings with
investigators and local hospice
providers to design and implement
stepwise organisational changes
for example, procedures and
documentation tools to improve
pain assessment.

2013 The Authors

Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
 Table 4 (Continued)
2013 The Authors
Author and
place The aim
Heals (30) To explore the development and
UK implementation by a hospice
education department of a
palliative care link nurse
programme in care homes with
nursing (CHN) as a means of
providing aspects of the required
training.
Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
Ersek et al. (31) To describe the development and
USA evaluation of the Palliative Care
Educational Resource Team (PERT)
train-the-trainer programme.
Methods of developing
the intervention (a)
and the evaluation (b)
(a): A letter, which outlined the project and
a questionnaire, was sent to all managers
of CHNs (43) in the local area. The
questionnaire requested information
relating to any education in palliative/
terminal care undertaken in CHN, the
need for palliative care training and
admission of residents to hospital. The
response rate was 60%. Invitations were
issued to the 30 responding homes. The
purpose of the launch was to define the
function and role of link nurses
(b): The programme was evaluated after
12 months. A questionnaire was sent to
each link nurse, associate link nurse and
the manager, exploring their personal
management of dying people. 29
questionnaires were sent out, and 16
were returned (response rate of 55%).
(a): The train-the-trainer curriculum and
teaching materials were adapted from the
original PERT programme. 87 participated
in the workshops (73 worked at NHs or
other long-term care settings, and 12
were employed by hospice agencies)
(b): The evaluation used 3 tools:
evaluation of course materials; in-service
tracking form; teaching effectiveness self-
evaluation.
Education and
competence-building
initiatives
Two nurses from each CHN were
identified as the link nurse and the
associate link nurse. Three study
days (now 4) a year were held at
the hospice for the link and
associate link nurses. In between
the study days, three (have since
increased) newsletters were
produced. A resource file was
provided for each home which
contains relevant information such
as handouts from study days.
The curriculum consisted of 16
modules (e.g. Philosophy of end-of-
life care; pain and symptom
assessment and management;
communication, etc.) and 2-full
days of presentations. Workshop
attendees received a syllabus
containing hard copies and a CD of
all curriculum material.
Conclusion/evaluation
The following was important:
contact and liaison with the
hospice, the value of specialist
nurses working in the community,
support received from the hospices
24 hr. advice line, and better
networking. The study days
increased: knowledge, skills and
confidence in talking with GPs,
relatives and residents; better
documentation and care planning;
and identified a lack of knowledge
and reluctance to change practice
among some Registered Nurses
and healthcare assistants.
The PERT curriculum is a valuable
tool for staff educators and
provides: current information that
was relevant to NH practice, was
easy to use, and increased
effectiveness in teaching palliative
care.
Competence building in palliative care services
815
 816

Table 4 (Continued)
M. Raunkiaer, H. Timm

Methods of developing Education and

Author and the intervention (a) competence-building
place The aim and the evaluation (b) initiatives Conclusion/evaluation

Arcand et al. (32) To assess the impact, in terms of
Canada family satisfaction with end-of-life
care of a NH pilot educational
programme for nursing staff and
physicians on comfort care and
advanced dementia.
(a): Unclear
(b): Pre- and post-studies were conducted
to compare levels of satisfaction pre- and
post-intervention. The study was carried
out at a 387-bed NH. The population was
relatives of residents who died in the
context of advanced dementia. The
bereaved family member was interviewed
after death. Nursing home version
instrument was used for evaluation (a
phone interview). The number of deaths
was 71 in the preintervention group and
56 in the postintervention group. The
number of persons that could be reached
by phone in the pre- and post-
intervention was 45/61 and 35/52. The
participation rate was 60% for both
groups (27/45 and 21/35).
A pilot educational programme on
comfort care and advanced
dementia for nursing staff and
physicians at NHs was developed.
The educational session for nursing
staff was 45 minutes and for
physicians 60 minutes. Topics:
relevance of palliative care in
advanced dementia, importance of
patient-focused and family-centred
approach, and medical guidelines.
A booklet to family members,
nurses and physicians was
produced.
Although scale scores were generally
higher in the postintervention
group, most notably in the
domain of communication, no
statistically significant differences
were found between the two
groups. Only 4 of 21 family
members in the postintervention
group received the booklet.

2013 The Authors

Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
 Competence building in palliative care services 817

groups: nurses and caregivers, and physicians each of Strengths and weaknesses of this literature review
which receives different training. This segregation of the
This literature review covers only 15 studies. It could be
professionals can due to different educational needs, but
that competence building in connection with local work-
does not spontaneously advance shared learning and
places is a marginal area, which is hardly the case. The
shared care. A study (10) indicates that shared care is
explanation is more likely that, as mentioned, there is no
sought after and can contribute to the advancement of
tradition for and perhaps no resources or methodologi-
palliative care and that professionals request this type of
cal grounds for documenting and communicating local
training environment.
development initiatives in healthcare science journals. It
Nursing personnel and care personnel were the pri-
is a great challenge to develop relevant and valid evalua-
mary target groups for training initiatives rather than
tion methods. At the same time, this indicates that
GPs. This could be because the nursing personnel is the
maybe a greater part of education and competence devel-
largest group, and there is a greater need for education
opment in the primary sector takes place through forma-
among nursing and care groups rather than among phy-
lised basic training, continuing education at universities
sician. Other explanations could be that perhaps GPs do
and/or in greater regional and national educational pro-
not prioritise competence building in palliation or they
grammes. Some of those include, in the USA: The End-
prioritise and participate to a higher degree in more for-
of-Life Nursing Education Consortium (ELNEC) (37, 38)
mal, university-based educational programmes such as
Curriculum for, The Education for Physicians on End-of-
palliative specialist education. Yet another explanation
life Care (EPEC) Curriculum, Transdisciplinary Palliative
might be connected to the professional differences in
Care Education (ACE) (39); and in Scandinavia: The Nor-
employment conditions. GPs are privately employed and
dic Specialist Course in Palliative Medicine (14). Also, It
have their own practices, whereas the largest part of
is possible that an expanded searches of several more
nursing and care personnel are publicly employed. These
databases and with different key words like dying, end
different types of employment result in different possibili-
of life, cancer and hospice might have produces more
ties for continuing education.
articles.
The content of the training is primarily structured as
either (i) a process or (ii) focus on professional themes.
In training sessions where the focus was on the pallia- Conclusion
tive process, several different professional groups were
This literature review shows few and sparse studies that
often included. This indicates a greater possibility for
describe local competence building regarding palliation in
the integration of an interdisciplinary dimension and
the primary sector. It seems characteristic that they deal
shared care. In addition, the review implies that many
with individual studies, only two of which were con-
different methods are used: small groups, classroom
trolled. All of the studies concluded that competence
training, video, etc. A previous study (4) shows that
building had a positive effect according to the profession-
the choice of training material is connected to educa-
als. It is unknown whether or how patients and relatives
tional content and target groups. For example, a
felt a positive effect from the interventions just as it is
method such as professional guidance requires special
unknown how the development of competencies had
professional qualifications. Almost none of the studies
actually led to a more developed practice. The effect of
critically addressed the connection between the target
local competence building in palliative care in the pri-
groups and the chosen training methods or their
mary sector is lacking. Methods are needed to further
strengths and weaknesses.
examinations of how a competency has actually led to a
Three of 15 studies described conditions regarding
more developed practice.
competence building in the UK. We have assumed that
due to the long palliative care tradition in UK, more
often the studies used experiences from the English hos- Contributors
pice movement. This could be an indication that part of
Thank you to librarian Marianne Espenhain Nielsen for
the training is connected to formal basic training and
helping at the literature search process.
continuing education, or that it is an integrated part of
the use and dissemination of guidelines such as The Gold
Standards Framework (GSF). Another explanation could
Funding
be that local interventions are not generally documented
and communicated to such a large extent at an academic Thank you to the Danish foundation TrygFonden for
level. financial support.

2013 The Authors

Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
818 M. Raunkiaer, H. Timm
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Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science
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