Nurse Education Today (2006) 26, 501–510

Nurse
Education
Today
intl.elsevierhealth.com/journals/nedt

The palliative care education needs of

nursing home staff
Evelyn Whittaker a,1, W. George Kernohan b,2
, Felicity Hasson b,*
,
Valerie Howard c,3, Dorry McLaughlin d,4

a
Northern Ireland Hospice, 71A Saintfield Road, Belfast, BT8 7HN, United Kingdom
b
University of Ulster, Institute of Nursing Research, School of Nursing, Shore Road,
Newtownabbey BT37 0QB, United Kingdom
c
Northern Ireland Hospice, 74 Somerton Road, Belfast BT15 3LH, United Kingdom
d
Northern Ireland Children’s Hospice, Horizon House, 18, 0’ Neill Road, Newtownabbey BT36 6WB,
United Kingdom

Accepted 13 January 2006

KEYWORDS Summary
Nursing home; Background: Palliative care is delivered in a number of settings, including nursing
Palliative care; homes, where staff often have limited training in palliative care.
Hospice Aim: We explored the level of palliative care knowledge among qualified staff deliv-
ering end-of-life care in nursing home settings, to inform the development of an
appropriate education and training programme.
Design: An audit of the educational needs assessment was performed using an anony-
mous postal questionnaire sent to 528 qualified nursing staff within 48 nursing homes.
Findings: In total, 227 questionnaires were returned giving a response rate of 43%.
Results indicated that less than half the sample had obtained formal training in the
area of pain assessment and management and less than a quarter had obtained training
in non-malignant conditions. Registered nurses in this study reported a lack of aware-
ness of palliative care principles or national guidelines.
Conclusion: Qualified nursing home staff agree that palliative care is a valuable
model for care in their setting. There are clear opportunities for improvement in nurs-
ing home care, based on education and training in palliative care. Results also support

* Corresponding author. Tel.: +44 028 90 366895; fax: +44 028 90 368202.
E-mail addresses: evelyn.whittaker@nihospicecare.com (E. Whittaker), wg.kernohan@ulster.ac.uk (W. George Kernohan), f.hasson@
ulster.ac.uk (F. Hasson), valerie.howard@nihospicecare.com (V. Howard), dorry.mclaughlin@nihospicecare.com (D. McLaughlin).
1
Tel.: +44 028 90 78 1836; fax: +44 028 90 79 6499.
2
Tel.: +44 028 90 366532; fax: +44 028 90 368202.
3
Tel.: +44 028 90 781836.
4
Tel.: +44 028 90 777635.


0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2006.01.004
502
the need for enhanced liaison between nursing homes and specialist palliative care
services.
c 2006 Elsevier Ltd. All rights reserved.
Introduction
Increasing numbers of people now spend the last
months or years of their life in a nursing home
with chronic and progressive conditions, as well
as suffering from multiple pathologies associated
with older age. It is widely accepted that pallia-
tive care should be part of the care extended to
patients who have a chronic progressive disease
and for whom a cure is not possible (National
Council for Hospice and Specialist Palliative Care
Services, 1998; Addington-Hall and Altmann,
2000; Department of Health, 2000) regardless of
care setting (National Institute for Clinical Excel-
lence, 2004).
Recent regional policy (DHSSPS, 2000) has rec-
ommended that all staff providing care in the inde-
pendent sector should have access to education in
palliative care and standards should be developed
to assure quality care. However, research indicates
that nursing home residents have limited access to
palliative and hospice care (Zerzan et al., 2000;
Strumpf, 2004). Although research reveals that
nursing home staff regard palliative care as an
important part of their role (Wronska and Gozdek,
1994; Copp, 1994), evidence suggests, that they
may be educationally unprepared to provide a high
level of end-of-life care (Shemmings, 1996; Ersek
et al., 1999; Raudonis et al., 2002). Indeed, con-
cern has been expressed over the quality of care
provided by homes’ own care staff (Avis et al.,
1999; Katz and Peace, 2003).
While several UK-based projects have addressed
palliative care education in nursing homes (Sidell
et al., 1997; Avis et al., 1999; Welton, 1999; Frogg-
att, 2000); none have been developed in Northern
Ireland. Since nursing homes are an increasingly
important context for end of life care, it is reason-
able to anticipate growing demand for palliative
care in this setting. It is therefore essential to de-
fine nursing staff’s educational needs for palliative
care. This paper presents the findings of the first
stage of a audit which explores the level of pallia-
tive care knowledge among qualified staff deliver-
ing end-of-life care in nursing home settings in
one UK region, to inform the development of an
appropriate educational and training programme,
to meet identified needs.
E. Whittaker et al.
Literature
In the UK ‘‘nursing homes’’ offer nursing and social
care to older people and ‘‘residential care homes’’
offer mainly social care. Within both types of
home, the General Practitioner (GP) and the Dis-
trict Nurse (DN) have traditionally provided most
end-of-life care. Today, some hospice services
have been incorporated into nursing home care to
provide palliative care for selected residents. How-
ever, specialist palliative care staff only become
involved in certain circumstances (Froggatt and
Hoult, 2002) and have been found to be largely
reactive, addressing immediate clinical needs,
rather than providing comprehensive palliative
care for all those with an incurable disease (Frogg-
att et al., 2002; Froggatt and Hoult, 2002; Good-
man et al., 2003). Therefore nursing home staff
need to have impeccable general palliative care
skills in order to meet the palliative care needs of
a large proportion of residents.
Nonetheless, research has found that nursing
homes do not always provide adequate end-of-life
care (Casarett et al., 2001). Pain and symptom
management in nursing homes has been described
as inadequate (Stein and Ferrell, 1992; Institute
of Medicine, 1997; Bernabei et al., 1998; Won
et al., 1999) with training required in syringe driver
usage (Froggatt, 2000). In addition, the persistence
of attitudes, such as fear of addiction, has been re-
corded as a serious problem adversely affecting
pain management and end-of-life care (Ferrell
et al., 1992; Gibbs, 1995). Zerzan et al. (2000) re-
ported that dying residents experience high rates
of untreated pain, additionally residents and their
family members are isolated from social and spiri-
tual support.
Training needs
Nursing home staffing and training needs may be
similar to those identified in care of the elderly hos-
pitals (Bennett, 1986), but concerns have been ex-
pressed over the level of training and skilled
nursing care in homes (Nazarko, 1994, 1996, 1999;
Sone, 1997; Department of Health, 1999). Raudonis
et al. (2002) claimed that one of the most critical
The palliative care education needs of nursing home staff
challenges is the lack of education in palliative care
among qualified staff, arguing that nurses can only
practice what they know; their basic nursing educa-
tional programmes being the foundation for their
knowledge. Yet, recent studies have documented
deficiencies in end-of-life training in most nursing
schools (Ferrell et al., 1999; Lloyd-Williams and
Field, 2002). Mallory (2003) argues that this lack
of education has been reflected in the level and
quality of end-of-life care provided to patients. In-
deed, UK research suggests that the educational
needs of nursing home staff may be greater than
those of clinicians in other settings for example,
Gibbs (1995) found that nurses working in nursing
homes were unlikely to have had continuing educa-
tion on pain management and palliative care, when
compared with nurses in hospital-based care of the
elderly wards. One reason for this is that few care
homes have an established budget for training. Katz
et al. (1999) noted that nursing home staff under-
standing of palliative care was over simplified and
often limited to personal experience, viewing palli-
ative care as technical and inappropriate for resi-
dents dying in the nursing home setting.
Palliative care in nursing homes
A number of US studies have explored nursing home
staff experiences and needs in providing care of
the dying in long term facilities (Ersek et al.,
1999; Bradley et al., 2001; Raudonis et al., 2002;
Stillman et al., 2005), all of which reported defi-
ciencies in nurses’ training and substantial gaps in
knowledge of palliative care. Similar findings have
been reported in the UK, Froggatt (2005) expressed
concerns regarding inadequate resources especially
staffing levels and knowledge and claimed that
these factors may inhibit the ability of nursing
homes to introduce new palliative care practices.
In addition, a number of studies have reported spe-
cialist palliative care providers’ concerns about the
absence of a palliative care approach and a lack of
resources required to meet the palliative care
needs of residents in homes (Avis et al., 1999;
Hirst, 2004). Froggatt and Hoult (2002) employed
a postal survey of 730 clinical nurse specialists’
perceptions of their educational and care deficits
in nursing home settings. Respondents identified
several aspects of palliative care practice that
could be addressed in educational programmes,
such as: syringe driver use, pain and symptom con-
trol, communication skills, bereavement skills and
strategies for working with dying patients.
Previous UK studies, based on a small number of
homes, found that staff felt unqualified to meet
503
the supportive care needs of residents at the end-
of-life (Hanvey, 1989; Counsel and Care, 1995;
Shemmings, 1996). Such findings are confirmed by
Katz et al. (2001), who investigated the care of dy-
ing residents in residential, nursing and dual-regis-
tered homes in England using a multi-method
approach. They found the degree of understanding
regarding palliative care varied among homes and
staff and identified a lack of training in communi-
cation skills and in particular little access to train-
ing in bereavement care for staff.
Other studies suggest that lack of knowledge
about providing specialised palliative care also
contributes to family dissatisfaction and possible
conflicts with staff (Hanson et al., 1997). It is
therefore not surprising that the education and
training of staff in palliative care within care
homes has been identified as one of the most
important means of improving the quality of care
for the dying (Komaromy et al., 2000; Froggatt
and Hoult, 2002; Nolan et al., 2003).
Education of nursing staff has been shown to in-
crease knowledge, skills and improve patient out-
comes (Ferrell et al., 1993; Grant et al., 1995;
Kenny, 2001; Strumpf, 2004). However, for pro-
grammes to be effective they must be based on
an assessment of the learning needs of the partici-
pants, to ensure that new knowledge and skills are
built upon the learners’ experiences and existing
knowledge and skills (Ersek et al., 1999). This pa-
per describes the learning needs of qualified nurses
in nursing homes with regards to palliative care, to
inform the development of appropriate education
and training.
Method
An audit was undertaken between June and July
2004. Ninety-one private nursing homes, located
within one health board area in Northern Ireland
were invited to take part in the audit. In total,
managers of 48 homes agreed to participate. Alto-
gether the 48 nursing homes at the time of data
collection employed approximately 528 qualified
staff. The majority of the homes were group
homes, providing care to a mixture of residents,
including physical disablement, elderly mentally
ill, learning disabilities and terminal care. Most
of the residents in the homes were over 65 years
of age. The number of beds in each home ranged
from 20–70, the majority having more than 35
beds. All managers expressed a commitment to
provide a high level of palliative care to their
residents.
504
Data collection
The audit was conducted using an anonymous post-
al questionnaire sent to all qualified staff in the
participating nursing homes. Nursing home quali-
fied staff numbers were obtained from the nursing
manager of each participating nursing home. Postal
questionnaires were deemed most suitable as they
allowed respondents to remain anonymous and
were also considered to be reliable in that all
respondents were asked the same standardised
questions (Parahoo, 1997). It also enabled the col-
lection of views of qualified nurses across a wide
geographical area.
Instrument
Key informants in palliative care and pre-existing
manuals on palliative care (including, Partnerships
in Caring document (DHSSPS, 2000) were used to
develop the questionnaire. It contained a mixture
of open and closed questions pertaining to educa-
tional needs and format of training programme
required. The questionnaire had three sections:
demographics (including age, level of education,
professional data); involvement in palliative care;
and educational needs (including format and
barriers to attending continuing educational pro-
grammes). Respondents were asked to identify if
they had obtained formal training in 16 educational
areas (see Table 3). Open questions probed staff’s
views and knowledge on palliative care, total pain
concept, syringe drivers and educational pro-
grammes. A section for respondents to add further
comments was provided.
One limitation of this approach is the low re-
sponse rate it can generate (Burns and Grove,
1995). Therefore, the questionnaires were taken
to nursing home managers who distributed them
to qualified staff. Many of the nursing homes
chose to distribute surveys at meetings that were
attended by all nursing staff. A letter was at-
tached to the questionnaire detailing the purpose,
voluntary participation, and return date. Re-
sponses were anonymous, and refusal to partici-
pate was granted. Completed questionnaires
were left in the manager’s office or collected by
one of the investigators (EW).
Data analysis
The quantitative data from the questionnaire were
subject to descriptive analysis on all closed vari-
ables using SPSS (VS 11). As would be expected
from a method using open-ended questions, addi-
E. Whittaker et al.
tional themes emerged from the participants’ re-
sponses (Pope and Mays, 1995). Qualitative data
were subjected to content analysis (Weber,
1990). Qualitative material was read and sentences
with identical or similar meaning were clustered
together and summarised, concentrating upon
shared perceptions. Themes were developed from
this analysis and these form the basis of the find-
ings from this study. The results of this analysis
are employed to provide illustrative quotes in the
results section.
Ethical issues
As this is an audit, research governance does not
apply. However other ethical issues were consid-
ered. Operational permission to proceed was
sought from all participating nursing homes. Each
participant was furnished with a written explana-
tion of the audit in the cover letter. All participants
were fully informed of the purpose of the research
and were able to withdraw without prejudice at
any time before or during the study. Having the
staff return their questionnaire anonymously en-
sured confidentiality. Consent was implied by
receipt of completed questionnaires.
Results
Of the 528 qualified nursing staff invited to partic-
ipate, 227 (43%) completed the questionnaire.
Demographics
Respondents ranged between the ages of twenty-
two to over sixty years with the majority of respon-
dents (68%, n = 155) identifying themselves as staff
nurses; however, 13% identified other titles that in-
cluded adaptation nurse and nursing sister. See Ta-
ble 1 for respondents’ demographics.
Education and palliative care training
The majority of participants were prepared to RGN
level of education (see Table 2). Other educational
qualifications recorded included for example, Oph-
thalmic Nursing Diploma and Ophthalmic eye
Theatre Course, Diploma in Health Education, Di-
ploma in Midwifery and BSc. (Hons) in Psychology.
Respondents were asked to record if they had
received training in a number of palliative care is-
sues (see Table 3). Findings revealed that, less than
half the sample had obtained formal training in the
The palliative care education needs of nursing home staff 505

Table 1 Respondents demographics showing a Table 3 Formal training had been undertaken by
reasonable spread of age, experience and seniority many respondents
Demographics Frequency Percentage Educational areas Frequency Percentage
Respondents age Pain assessment 81 36
22–30 32 14 Pain management 94 41
31–40 68 30 Assessment of other 82 36
41–50 63 28 symptoms
51–60 60 26 Nausea and vomiting 90 40
Missing 4 2 Other gastro-intestinal 86 38
symptoms, e.g., bowel
Position
obstruction/dysphagia
Matron/nurse manager 22 10
Constipation 106 47
Staff nurse 155 68
Oral problems 93 41
Enrolled nurse 19 8
Shortness of breath 98 43
Other 29 13
Restlessness 86 38
Missing 2 1
Fatigue/cachexia 67 29
Years of experience as qualified nurse Communication issues 87 38
Less than 1 yr 7 3 Care in the last days 87 38
1–5 yr 23 10 of life
6–10 yr 39 17 Nutrition and hydration 88 39
11–15 yr 34 15 issues at the end of life
16–20 yr 32 14 Non-malignant conditions 52 23
21 plus 86 38 Multidisciplinary 83 37
Adaptation 1 0.4 team working
Missing 5 2 Bereavement support 64 28

Years of experience working in nursing home

setting
Less than 1 yr 32 14 Pain control and resources
1–5 yr 88 39
6–10 yr 30 13
11–15 yr 59 26 While some (36%, n = 82) respondents felt compe-
16–20 yr 15 7 tent to assess a patient’s need for a syringe driver,
21 plus 2 1 most (60%, n = 135) did not feel competent in man-
Missing 1 0.4 aging drivers. Ten respondents refrained from
answering this question. In addition, over half of
respondents (51% n = 115) recorded that they did
area of pain assessment/management and less than not feel competent to care for a patient with a syr-
a quarter had obtained training in non-malignant inge driver in situ using recognised guidelines.
conditions. When asked if respondents were aware of what
When questioned, only 16 participants (7%) sta- combinations of drugs are compatible in a syringe
ted that they were completing or had completed driver, 25% (n = 56) stated that they were; 66%
a course of study in palliative care, while 22% (n = 151) were unsure; 9% (n = 20) did not answer.
(n = 50) stated that they had attended a study day Qualified staff were asked to identify the three
in relation to palliative care during the last two most common types of medication, which could
years. The majority indicated that they had at- be used within a syringe driver. Although the
tended this training session within their own time. majority of participants were able to specify
appropriate drugs, the most popular medication
Table 2 Educational qualifications specified was Diamorphine followed by Cyclizine
and Hyoscine. Some participants were unsure as
Educational qualifications Frequency Percentage
to the appropriate medication to use. For example,
RGN 190 83 some respondents reported the use of anti-Parkin-
SEN 27 12 son’s drugs or Cyclimorph, which can be given as a
RMN 17 7
sub-cutaneous injection, but are not recommended
RMHN 6 3
Nursing Diploma 39 17
for use in a syringe driver. However, 55% (n = 125)
Nursing Degree 20 9 of the sample stated that they did not have access
Other 35 15 to a syringe driver within their nursing home
and many qualitative comments revealed that
506
few registered nurses had undertaken syringe dri-
ver training. Consequently these devices were
rarely used and residents had to be referred to a
District Nurse or Specialist Palliative Care Service.
Free comments regarding syringe-driver illustrate
this:
‘‘Would be provided by palliative care team or Dis-
trict Nurses, none in the home’’ Res. 113
‘‘I know that this can be obtained through the GP
and District Nurse or Macmillan Nurses but we do
not have assess to one in the nursing home’’ Res.
77
Many respondents, recorded deficits in knowl-
edge and skills required to effectively use this
equipment.
Family care: bereavement support
Most respondents felt that they were adequately
prepared to speak to relatives about any planned
future management of their loved one; many
recognised that it was much easier to talk to a
resident or his/her family if they had built up a
relationship with them. Nevertheless, for some
nurses, this was recognised as being emotionally
draining and the cause of stress.
Some respondents believed that their wealth of
practical experience and attending additional
training sessions on bereavement counselling had
put them in a better position with regards to know-
ing how to respond and handle such situations. Two
staff said:
‘‘During the last 12 years I have gained more confi-
dence in discussing issues relating to death and
dying with relatives’’. Res. 18
‘‘I did a brief bereavement course about 6 years
ago and also my vast experience with dying has
helped me greatly’’. Res. 146
Others, who worked night-duty, felt inade-
quately informed about the residents and had no
relationship with the resident’s family.
When asked about information available within
the homes for bereaved relatives, 20% (n = 46) of
respondents indicated that information was given
orally to relatives along with emotional support at
the time of death. The majority of respondents
were not aware of whether or not written informa-
tion was available for this group within their homes.
Some staff had been involved in the care of a
resident for a number of years and developed an
attachment. Staff strategies to deal with grief in-
cluded attendance at funerals and gaining sup-
port from colleagues and management figures.
E. Whittaker et al.
Respondents acknowledged the lack of availabil-
ity to formal counselling linked to the nursing
home for residents and staff members. Although
some indicated that counselling could be gained
from pastoral services if required, it was
acknowledged that a system of support or an
established link nurse system for qualified staff
would be beneficial. When asked about this, com-
ments included:
‘‘None – nothing formal although all staff endeav-
our to offer each other support’’ Res. 52
‘‘Many benefit from staff training in bereavement
counselling with access to outside counselling ser-
vices’’ Res. 1
‘‘ . . . if a member of staff could develop counselling
role within the home or referral system to outside
agency’’ Res. 29
Some respondents pointed out the need for
unqualified staff to receive training in this area as
they were seen as developing close relationships
with residents and therefore would benefit from
some form of bereavement support.
Awareness of palliative care concepts
Many nursing homes were supported by a range of
other health care professionals in the delivery of
palliative care such as the GP, DN, Hospice teams
and Macmillan nurses. Although the majority of
respondents were aware of the role of the GP, DN
and Hospice Specialist Nurse, within their nursing
home, 39% (n = 86) stated that they were not aware
of written information available within the home
regarding referral to specialist services.
When asked if they were aware of the Liverpool
Care of the Dying Pathway, which is being imple-
mented nationally within the UK, 76% of respon-
dents (n = 155) stated that they were not aware.
When respondents were questioned about what
they understood by the term palliative care re-
sponses revealed that 59% (n = 119) were not famil-
iar with the principles of palliative care. Many
respondents mentioned that palliative care in-
volved ‘‘the care of a resident at the end of life’’,
‘‘providing care, not necessarily cure’’ and focused
on the management of symptoms and pain control.
However, fewer respondents recorded that it also
involved holistic supportive care including the care
of the resident’s family circle.
Qualitative comments indicated that many
respondents believed residents would require palli-
ative care nursing at the end-of-life, when they
were deteriorating, at the stage when pain control
is required. As stated:
The palliative care education needs of nursing home staff
‘‘A resident would have palliative care needs when
they are no longer able to care for their own needs,
when analgesia needs to be increased and moni-
tored’’ Res. 37
‘‘When a resident is terminally ill and in serious
pain needing pain control measures’’ Res. 107
Other respondents felt palliative care nursing
was required at the stage of diagnosis. As
commented:
‘‘From the beginning of illness to the end-of-
life’’ Res. 28
‘‘From diagnosis initially, but especially when
symptoms become noticeable’’ Res. 153
‘‘From the time of admission’’ Res. 221
When questioned about their knowledge of the
‘‘total pain concept’’, many respondents recorded
that they were not familiar with this terminology,
while others believed it was in relation to pain
management and pain relief. Respondents were
then asked what conditions or situations would
they consider to be palliative care emergencies.
Qualitative findings revealed that the majority felt
that such a situation would only arise when a
resident was experiencing pain or breathing
difficulties.
Palliative care education programme:
facilitators and barriers
The majority of respondents were in favour of fur-
ther education on palliative care with many iden-
tifying their lack of knowledge, skills and formal
training in this area as being a barrier to deliver-
ing high quality care to residents. Respondents
identified a number of specific training areas
including assessment and management of pain,
and management of the psychological impact of
death on other residents, residents’ families and
nursing home staff. Some respondents also re-
quested training in relation to legal and ethical is-
sues. One commented:
‘‘Update on legal, ethical issues, e.g., living wills,
withdrawing, withholding treatment, assessing pal-
liative care services, talking to and observing palli-
ative care specialists’’ Res. 1
Most respondents requested that training was
delivered in-house, with guest lecturers from palli-
ative care services, and attendance at information
days at Hospice sites, also suggested. The primary
factors influencing attendance at a palliative care
training programme were potential loss of pay,
time and remote location of the training.
507
Discussion
As the population ages, it is becoming increas-
ingly common for older people to die in nursing
homes. It is accepted that palliative care should
be provided regardless of care setting (National
Institute for Clinical Excellence, 2004) and that
nursing home staff are increasingly being required
to meet the needs of palliative care residents. In
fact, it is estimated that 20% of deaths occur in
these settings and many residents would benefit
from palliation of symptoms at the end of life
(Addington-Hall, 2000; Hirst, 2004; NCPC, 2005).
However this audit surveyed 48 nursing homes
to determine qualified staff’ educational needs,
barriers to meeting those needs and their pre-
ferred educational format and found inadequate
knowledge and lack of awareness regarding the
principles of palliative care, which may prevent
optimal care.
Findings revealed that most respondents had
not obtained any formal training in for example,
non-malignant conditions, bereavement support,
dealing with fatigue or cachexia. Such findings
confirm previous evidence (Mallory, 2003) that
historically nurses have not been prepared to care
for dying patients and that nurse education lacks
an effective and efficient approach to educating
nurses about end of life care. Nevertheless, find-
ings do indicate that respondents have a wealth
of experience working within the nursing home
setting and have a keen interest in continuing
education. Previous studies have identified similar
educational needs among nurses who want to in-
crease their competence in providing physical,
psychological and spiritual care to dying patients
(Ersek et al., 1999).
Staff were not always familiar with the palliative
care approach or the equipment required to meet
residents care needs, for example, most were not
aware of the principles of palliative care or the Liv-
erpool Care of the Dying Pathway (Ellershaw and
Wilkinson, 2003). Many were also unfamiliar with
the term ‘‘total pain’’ concept. Substantial gaps
in nurse training and deficiencies in nursing knowl-
edge of palliative care have also been reported
elsewhere (Ersek et al., 1999; Bradley et al.,
2001; Raudonis et al., 2002).
In this study, respondents reported lack of com-
petence to: assess a patient’s need for a syringe
driver, care for a patient with a syringe driver
in situ using recognised guidelines and some could
not identify the appropriate medication to use with
such equipment. Several authors have also identi-
fied a lack of nursing knowledge and skills regarding
508
pain and symptom management as a factor in pre-
venting optimal care (Ferrell et al., 1992; Gibbs,
1995). Like Froggatt (2000), the issue of syringe dri-
ver usage was reported as being problematic, how-
ever, respondents’ lack of competency must be
linked to the scarcity of such equipment within
the nursing home environment and lack of formal
training in this subject area.
With regards to bereavement support most
respondents identified a gap in service provision
with regards to formal support structures for resi-
dents and staff members, to deal with the death
of another resident. Only 30% of respondents in this
study had obtained formal training in bereavement
support; many noting that supporting residents’
families was stressful, as was dealing with their
own emotions. This area needs to be addressed if
residents, relatives and nursing home staff in these
settings are to have their bereavement needs met.
Such findings are reflective of Katz et al. (2001) re-
search, which reported a lack of training in com-
munication skills and little access to training in
bereavement care in nursing homes.
Findings suggest the need for the development
of an educational programme for qualified staff,
focusing on enhancing palliative care in nursing
homes. The findings of this audit will be used to de-
velop an palliative care educational programme for
registered nurses working in nursing home settings.
Limitations
The present study was subject to a number of lim-
itations for example, from the 91 private nursing
homes’ invited to take part in the research; it is
unclear why only 48 homes agreed to participate.
In addition the low response rate to the study
postal questionnaire means that the results re-
ported must be treated with some caution. There
was no systematic way of encouraging all staff to
complete the survey therefore findings may be a
result of biased sampling since the most experi-
enced and confident of staff may have chosen to
respond. In addition, it is unclear whether staff
knowledge and confidence in their abilities is
based on actual expertise, as no research was
undertaken to observe staff in clinical practice.
The use of questionnaires to study this topic is
also problematic as it they only provide a brief in-
sight into the problem being investigated and
therefore further research should consider the
use of other qualitative methods to identify gaps
in training and practice. Furthermore this is a
small scale study conducted in one area of the
E. Whittaker et al.
UK, which may limit the generalisability of its
findings and therefore further research is required
to explore national trends.
Conclusion
Palliative care is focused on quality of life issues
for people with advanced progressive disease by
means of pain relief and symptom control using a
holistic approach. Such care is provided in a range
of care settings such as hospice facilities, hospi-
tals, and in nursing homes. As more people end
their lives in nursing homes, this are of care has
increasing relevance. The caring behaviours of
nursing home staff are critical elements in the
experience of nursing home residents with pallia-
tive care needs. This audit has shown deficiencies
in knowledge and skills in palliative care amongst
registered nurses. There is an opportunity for
improvement in nursing home care and it is recom-
mended that a palliative care educational-training
programme be considered.
Acknowledgements
The authors thank the nursing home for their par-
ticipation in this study and the Big Lottery fund
for funding this project.
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