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T
he increasingly complex nature of
palliative care and its application in
different settings makes the educa-
tion of health professionals a priority.
The palliative care approach has been
described by the Department of Health
(DoH) (1996) as care that should be prac-
tised by all health professionals regardless
of setting. Therefore all health practition-
ers working with those with cancer and
other life-threatening conditions, e.g.
neurological conditions, cardiac and res-
piratory failure, should be able to provide
care with a palliative approach, as out-
lined in Box 1. The European Oncology
Nursing Society (EONS) supports the
dissemination of the principles of pallia-
tive nursing as a priority for nurses at all
stages of their professional development
(EONS, 1994). In recognition of this,
Kingston University, in the UK, has
developed a module in palliative care for
undergraduate student nurses. This article
describes the evaluation of the module,
which took place between January 2000
and May 2000.
Background
There is evidence that education in pallia-
tive care is inconsistent and that there is a
need for greater emphasis on palliative
care in the education of health profession-
als (Field, 1984; Benoliel, 1988; Oliver,
1989; Jeffrey, 1994; Chippendale, 2001).
Student nurses and newly registered
nurses have been identified as feeling inad-
equately prepared for aspects of palliative
care such as talking to patients about
death and dying (Birch, 1983; Hockley,
1989; Corner and Wilson-Barnett, 1992).
In 1994, under the auspices of EONS and
funded by the European Commission’s
‘Europe against Cancer’ programme and
Cancer Relief Macmillan Fund (a UK
charity), a working party was established
to identify a core curriculum appropriate
for preregistration nursing courses in all
European Union member states.
The core curriculum consists of five
themes; a central theme covering the prin-
ciples of palliative care serves to integrate
the remaining four themes, which are con-
cerned with symptom control, facing
death, ethical and legal issues and commu-
nication (Figure 1). This framework repre-
sents the key concepts related to the
knowledge, skills and attitudes required in
palliative care. The working party recom-
mended that a minimum of 12 hours be
devoted to deal specifically with palliative
nursing. The report does not give guid-
ance in relation to the stage in the course
that these 12 hours are included or over
what period of time they should be
included. The working party worked with
the assumption that many of the issues
inherent within the themes, such as com-
munication skills, loss and grief, and
anatomy and physiology will already have
been addressed in the curriculum.
Until 1998, teaching in palliative care
within the undergraduate nursing pro-
gramme at Kingston University followed
Education
Anne Arber is Senior
Lecturer and Pathway
Leader in Cancer and
Palliative Care, Kingston
University and St George’s
Hospital Medical School,
London, UK
Student nurses’ knowledge
of palliative care:
evaluating an education module
Anne Arber
Abstract
T
here is evidence that education in palliative care in the UK is
somewhat patchy and that this important area of health care
should be given a greater emphasis in the nursing curriculum.
This article describes an evaluation of a palliative care module
taken by a group of third year student nurses. The effect of the
module was evaluated using the palliative care quiz for nursing
(PCQN), administered at the beginning and at the end of the mod-
ule. The results demonstrate that the students significantly
increased their understanding of aspects of pain and symptom
control. In particular, they became knowledgeable about adjuvant
therapies and opioid use. In contrast to previous studies, the stu-
dents rejected the ‘fear of addiction’ associated with opioid use.
Deficits in knowledge included side-effects of codeine, use of
sedation and the use of placebos. The results support the need
to develop a compulsory module in palliative care that is formally
assessed and includes a palliative care placement. This would
enable comprehensive and systematic coverage of palliative care
in the undergraduate nursing curriculum.
International Journal of Palliative Nursing, 2001, Vol 7, No 12 597
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an integrated approach whereby different
aspects of palliative care were introduced
throughout the course. This is a common
approach used in the UK and the usual
mode of delivery for death education in
the USA and Canada, as identified by
Degner and Gow (1988). They found that
students were not always offered place-
ments that gave them clinical experience
of caring for and working with people
with terminal illnesses and the bereaved.
The main drawback to this approach,
they argued, is the variability in the
amount and type of education received
by student nurses.
Since 1998 student nurses at Kingston
University have been offered an optional
module in palliative care. Approximately
one-third of students opt to take the
module; those that do not will have a
minimal knowledge of palliative care. A
modular approach to palliative nursing
has been recommended as providing a
more systematic coverage of the palliative
approach (EONS, 1994). The aim of the
palliative care approach (DoH, 1996) is to
integrate both physical and psychosocial
wellbeing by focusing on quality of life,
sensitive communication and respect for
choice and autonomy (Box 1).
Since 1999 the palliative module has
also included a 1-week hospice place-
ment. This placement enables students to
be in a supportive environment and to
observe skilled role models delivering
hospice care in a multidisciplinary team.
The students receive approximately
50 hours of teaching in addition to the
1-week hospice placement over a period
of 5 months. This is far in excess of
the 12 hours recommended by EONS.
Most importantly, the students are also
required to produce a written assignment
in relation to palliative care.
At Kingston University palliative care
education has been prioritized as an
important aspect of the undergraduate
nursing programme. Good relationships
and close collaboration with the local
hospital, hospice and community pallia-
tive colleagues ensure the success of
this module. Students report excellent
mentorship and support during their
hospice placement and this has challenged
many of their preconceptions about
hospice care.
A number of authors have pointed out
the need for rigorous evaluation of the
effectiveness of teaching and learning in
all aspects of palliative care (Copp, 1994;
Yates et al, 1997). With this in mind the
module was evaluated using Ross et al’s
(1996) palliative care quiz for nursing
(PCQN). Ross et al suggested that this
tool could provide data about the level of
knowledge possessed by participants and
highlight any misconceptions they may
have relating to palliative care.
The aim of the evaluation
The evaluation had two main objectives:
● To measure third year student nurses’
knowledge of palliative care at the
beginning and end of a module in pallia-
tive care using the PCQN
● To identify significant change in student
nurses’ knowledge of palliative care at
the end of the module.
Method
The PCQN is a 20-item test of knowledge;
answers are given as ‘true’, ‘false’ or ‘don’t
know’ (Table 1). It has been validated by a
Student nurses’ knowledge of palliative care: evaluating an education module
598 International Journal of Palliative Nursing, 2001, Vol 7, No 12
Box 1. The palliative care approach
The palliative care approach is a vital and integral part of all clinical
practice, whatever the illness or its stage, informed by a knowledge and
practice of palliative care principles and supported by specialist palliative
care. The key principles underpinning palliative care, which should be
practised by all health professionals in primary care, hospital and other
settings, comprise:
● Focus on quality of life including good symptom control
● Whole-person approach taking into account the person’s previous life
experiences and current situation
● Care that encompasses both the person with life-threatening disease
and those that matter to that person
● Respect for patient autonomy and choice
● Emphasis on open and sensitive communication, which extends to
patients, informal carers and professional colleagues
(DoH, 1996)
Figure 1. Framework for the inclusion of palliative nursing in basic
nursing courses.
Managing nursing
problems relating
to symptoms
Ethical and legal
issues
Facing
death
Communication
Integrating
theme
The principles
of palliative
care
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600 International Journal of Palliative Nursing, 2001, Vol 7, No 12
The questions on the PCQN are
grouped into three conceptual categories:
● The philosophy and principles of pal-
liative care (questions 1, 9, 12, 17)
● The management of pain and other
symptoms (questions 2–4, 6–8, 10,
13–16, 18, 20)
● Psychosocial and spiritual care of indi-
viduals and families (questions 5, 11, 19).
wide process of consultation with experts
in the field of palliative care, piloting and
in-depth testing of the items. It focuses on
the basic type of information necessary
for entry to practice. In this sense it is
considered suitable for undergraduate
nursing students. The tool is easily admin-
istered and can be quickly completed by
the participants.
Student nurses’ knowledge of palliative care: evaluating an education module
Answer known before/after module
Correct No/ No/ Yes/ Yes/
Question answer No Yes No Yes P-value
1. Palliative care is only appropriate in situations where 2 11 2 17 P=0.022
there is evidence of irreversible deterioration False (6.3%) (34.4%) (6.3%) (53.1%)
2. The analgesic effect of other opioids is measured 14 9 3 5 P=0.146
against that of morphine. True (45.2%) (29.0%) (9.7%) (16.1%)
3. The extent of the disease determines the methods 5 3 25 P=0.146
of pain management. False (15.2%) – (9.1%) (75.6%)
4. Adjuvant therapies are important in managing pain 3 9 21 P=0.004
True (9.1%) (27.3%) – (63.6%)
5. It is crucial for family members to remain at the 14127P=0.375
bedside until death occurs. False (3.0%) (12.1%) (3.0%) (81.8%)
6. During the last days of life, drowsiness associated with 22 7 3 1 P=0.344
electrolyte imbalance may decrease the need for sedation True (66.7%) (21.2%) (9.1%) (3.0%)
7. Drug addiction is a major problem when morphine is 3 11 18 P=0.001
used on a long-term basis. False (9.4%) (34.4%) – (56.3%)
8. Individuals who are taking opioids should also take 33
regular medication to prevent constipation True – – – (100%)
9. Professional carers in palliative care must remain 31227P=1.000
emotionally detached. False (9.1%) (3.0%) (6.1%) (81.8%)
10. During the terminal stages of an illness, drugs that can
cause respiratory depression are appropriate for severe 15 11 2 2 P=0.022
dyspnoea True (50.0%) (36.7%) (6.7%) (6.7%)
11. Men generally resolve their grief more quickly 1 2 30 P=0.500
than women. False (3.0%) – (6.1%) (90.9%)
12. The philosophy of palliative care is compatible with 24 3 5 – P=0.727
that of aggressive treatment. True (75.0%) (9.4%) (15.6%) –
13. The use of placebos is appropriate in the treatment 21 6 2 4 P=0.289
of some types of pain. False (63.6%) (18.2%) (6.1%) (12.1%)
14. In high doses, codeine causes more nausea and 20 3 7 2 P=0.344
vomiting than morphine. True (62.5%) (9.4%) (21.9%) (6.3%)
15. Suffering and physical pain are synonymous. 12 6 4 11 P=0.754
False (36.4%) (18.2%) (12.1%) (33.3%)
16. Pethidine is not an effective analgesic for the 7 19 3 4 P=0.001
control of chronic pain. True (21.2%) (57.6%) (9.1%) (12.1%)
17. The cumulative effect of repeated losses inevitably leads 73617P=0.508
to burnout for those who work in palliative care False (21.2%) (9.1%) (18.2%) (51.5%)
18. Manifestations of chronic pain are different from 58217P=0.109
those of acute pain. True (15.6%) (25.0%) (6.3%) (53.1%)
19. The loss of a distant or difficult relationship is easier to 42323P=1.000
resolve than the loss of one that is close or intimate False (12.5%) (6.3%) (9.4%) (71.9%)
20. The pain threshold is lowered by fatigue or anxiety 89610P=0.607
True (24.2%) (27.3%) (18.2%) (30.3%)
Table 1. Questions and results of the palliative care quiz for nursing (n=33)
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For the purpose of our study, one item
on the PCQN was changed: the drug
name demerol was changed to its British
equivalent of pethidine (question 16).
The PCQN was administered to all stu-
dents present on the first day of the mod-
ule (n = 45) in January 2000. Verbal
consent was sought and all the students
agreed to complete the quiz. Confiden-
tiality was maintained by use of student
identification numbers, rather than names.
The same questionnaire was adminis-
tered on the penultimate day of the mod-
ule in May 2000. Twelve students were
absent on this day, leaving a total sample
size of 33. If a student omitted to answer
any question on either questionnaire, this
question was eliminated from their data
and not included in the analysis.
Analysis
The change in knowledge before and after
the palliative care module was statistically
tested using McNemar’s test for change
(Ott and Mendenhall, 1994). This enables
the change in students’ level of knowledge
from the beginning to the end of the mod-
ule to be tested statistically. It tests the null
hypothesis that there was no difference in
knowledge overall, in particular that the
number of individuals who learned the
correct answer through the module (i.e.
answered the question incorrectly before,
yet correctly after the module) was equal
to the number of individuals whose
knowledge deteriorated (i.e. answered the
question correctly before, yet incorrectly
after the module). The critical significance
level was set to 0.05.
Findings
The total number of correct responses to
the PCQN before and after the module is
shown in Table 1. The overall percentages
are shown in brackets. The correct
response for each question is identified.
There is a significant increase of two
questions answered correctly following the
module (median 2.00). The lower quartile
was 0.25 and the upper quartile 4.0
(Wilcoxon signed ranks test; P = 0.001 (Ott
and Mendenhall, 1994)). Therefore, there is
a statistically significant increase in stu-
dents’ knowledge of palliative care by the
end of the module.
Philosophy of palliative care
There is a significant change in the stu-
dents’ level of knowledge on question one
related to the principles of palliative care
(Table 1). The appropriateness of pallia-
tive care was correctly identified by 11
(34.4%) students following the module as
not exclusively limited to situations where
there is irreversible deterioration (question
1). This demonstrates a tendency for
change (P = 0.022).
The students had difficulty identifying
the philosophy of palliative care as com-
patible with that of aggressive treatment
(question 12). Ross et al (1996) also iden-
tified a misconception that palliative care
is not compatible with the provision of
aggressive treatment. In the UK defini-
tions of palliative care usually refer to
active total care rather than aggressive
treatment (World Health Organization
(WHO), 1990). It is possible that the
terminology used in this question was
confusing and that this may account for
the students’ answers.
A number of students changed their
view about whether burnout was a risk for
those working in palliative care (question
17); six students who believed that
repeated losses did not inevitably lead to
burnout in palliative care at the start of the
module changed their view by the end of
the module and identified that repeated
losses did lead to burnout. This is an
important area for further research.
Psychosocial and spiritual care
Knowledge of psychosocial care includ-
ing the role of the family (question 5),
responses to loss and grief (question 19)
and gender and grief (question 11) was
good. Over 70% of students could
answer these questions correctly at the
start of the module. Proctor et al (2000)
found that their sample of 247 trained
nurses also had reasonable knowledge of
psychosocial aspects of care. The authors
suggest that this may be because practi-
tioners draw on practical and personal
knowledge and that this reflects acquisi-
tion of knowledge by experience rather
than by formal learning. This explanation
does not necessarily apply to the student
nurse group who will have had limited
practice experience. However, it may
reflect the attention given to teaching and
learning about psychosocial aspects of
care in the undergraduate nursing pro-
grammes. This is a good basis on which
to develop palliative education.
Pain and symptom control
There is a statistically significant change
in students’ level of knowledge on four
Student nurses’ knowledge of palliative care: evaluating an education module
International Journal of Palliative Nursing, 2001, Vol 7, No 12 601
‘The students had
difficulty
identifying the
philosophy of
palliative care as
compatible with
that of aggressive
treatment
(question 12).’
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questions related to pain and symptom
control. There is a significant improve-
ment in knowledge of adjuvant therapies
(question 4) with nine students (27.3%)
knowing the correct answer following the
module (P = 0.004). There is also a signifi-
cant improvement in knowledge related to
drug addiction not being a major problem
when morphine is used on a long-term
basis (question 7). Eleven students
(34.4%), who hadn’t known the correct
answer before the module took place
knew the correct answer following the
module (P = 0.001). Many studies have
found that nurses and doctors overesti-
mate the incidence of psychological
dependence related to the use of opioids.
The fear of patients becoming addicted to
these drugs acts as a barrier to pain con-
trol (Marks and Sachar, 1973; Watt-
Watson, 1985; McCaffery et al, 1990;
Hollen et al, 2000).
There is also a significant improvement
in the students’ ability to identify that
pethidine is not an effective analgesic for
chronic pain (question 16). An extra 19
students (57.6%) knew the correct
answer following the module (P = 0.001).
Hollen et al (2000) discussed how nurses
who reported more than 16 hours of pain
education were significantly more edu-
cated about opioids and Hauck (1986)
also found that education decreased con-
cerns about addiction. Hospice nurses
have been found to perform well when
managing the patient’s concern about
addiction (Sloan et al, 1999). The specific
focus of the module on the palliative care
approach, including pain and symptom
control, combined with a placement in a
hospice where students can observe
competent role models, may enable stu-
dents to discard the fear of addiction
found in other studies and improve their
knowledge of the use of opioids.
There is a tendency for improvement in
knowledge related to the appropriateness
of drugs that cause respiratory depression
for treating dyspnoea (question 10). There
was an increase of 11 students (36.7%)
who know that drugs that cause respira-
tory depression are appropriate for severe
dyspnoea (P = 0.022). Hauck (1986) also
found that education decreases concerns
about respiratory distress.
Students were already knowledgeable
about aspects of pain and symptom con-
trol when they started the module. All stu-
dents knew that when taking opioids,
regular medication is necessary to prevent
constipation (question 8). Over 75% of
students identified that the extent of the
disease determines the methods of pain
management (question 3).
Deficits in knowledge of symptom con-
trol following the module concern the
side-effects of codeine (question 14), the
need for sedation (question 6) and the use
of placebos (question 13). Of the stu-
dents, 63.6% were unable to identify, at
the beginning and end of the module, that
the use of placebos is inappropriate in
the treatment of pain. Hollen et al (2000)
found that 20% of hospice nurses and
more than 30% of the hospital nurses
believed that administration of a placebo
is a useful test for determining the
reality of pain. Pain experts acknowledge,
however, that a placebo response is to be
expected and is linked to the patient’s
expectations of a beneficial effect (Wall,
1999); therefore a placebo response is not
a useful test for determining the reality
of pain. As such, it is a concern that
63.6% of students in this study have
wrongly identified appropriate treatment
of pain and 30% of hospital nurses and
a smaller proportion of hospice nurses
have inaccurate understanding of the
placebo response.
At the end of the module the results of
the quiz were discussed with the students.
This enabled clarification of some of the
misconceptions related to placebos, seda-
tion and side-effects of specific drugs. In
the future I believe it is necessary to spend
more time facilitating learning related to
these specific needs.
Limitations
This evaluation has a small sample size so
there is difficulty generalizing these find-
ings to other groups of students. Also it is
difficult to extrapolate from the findings
to the students’ actual practice. A longitu-
dinal study would need to be undertaken
in order to identify the impact of this
module and clinical placement in practice.
Ideally, a comparative study would enable
comparison between those that attend the
module and those receiving the integrated
curriculum with or without the hospice
placement. There is also the need to
develop the PCQN further as some of the
questions may be ambiguous in the
British context.
Recommendations
The PCQN is a useful evaluative tool that
could be developed in palliative nursing in
Student nurses’ knowledge of palliative care: evaluating an education module
602 International Journal of Palliative Nursing, 2001, Vol 7, No 12
‘Pain experts
acknowledge…
that a placebo
response is to
be expected and
is linked to
the patient’s
expectations of a
beneficial effect…
therefore a
placebo response
is not a useful test
for determining
the reality of
pain.’
International Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 131.227.130.074 on December 28, 2015. For personal use only. No other uses without permission. . All rights reserved.
the UK. It provides educators and practi-
tioners with useful information on nurses’
level of knowledge before training and
practice and is a useful adjunct to other
forms of evaluation. By identifying deficits
in knowledge such as the side-effects of
analgesic drugs and the use of sedation and
placebos, these may be addressed more
specifically in the programme.
The modular approach to palliative care
education combined with a clinical place-
ment appears successful in challenging
some of the misconceptions about pallia-
tive care and opioid use. Most impor-
tantly students are assessed on their
understanding and practice of palliative
care. However, further research needs to
be undertaken into student nurses’ experi-
ence of emotional work and stress when
working with those with life-limiting and
life-threatening disease.
Conclusion
The students who completed the pallia-
tive module did increase their knowledge
regarding palliative care with respect to
aspects of symptom control and opioid
use. An earlier focus group evaluation by
the first students to take the module, as
well as informal feedback from other stu-
dents, indicates that the module provides
the nurses with an increased feeling of
confidence when working with those
with advanced disease and those who are
dying (Arber and Gallaher, 1999).
Although more investigation is needed,
there does seem to be a strong argument
for a required module in palliative care
that is assessed separately, rather than the
integrated course so popular in many
programmes. This would enable more
systematic coverage of the palliative care
approach as an established component of
undergraduate nursing courses. This is
essential to bringing the palliative care
approach into all areas of health care
involving those with chronic and life-
threatening illness.
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Student nurses’ knowledge of palliative care: evaluating an education module
International Journal of Palliative Nursing, 2001, Vol 7, No 12 603
KEY WORDS
● Palliative care approach
● Education
● Pain and symptom control
● Evaluation
● Psychosocial care
● Curriculum development
‘… there does
seem to be a
strong argument
for a required
module in
palliative care
that is assessed
separately,
rather than the
integrated course
so popular
in many
programmes.’
International Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 131.227.130.074 on December 28, 2015. For personal use only. No other uses without permission. . All rights reserved.
