Background

According to the World Health Organization, “palliative care is an approach that improves the quality of life of the patients and their families facing problems associated with life-threatening illness through preventing and relieving the patient’s suffering and by identifying early identification, evaluation and treatment of pain and other physical, psychological and spiritual problems” [1].

This approach can be beneficial for different groups of patients, including patients with cancer, cardiovascular, lung diseases, acquired immunodeficiency syndrome, diabetes, kidney failure, neurological diseases and dementia [1]. In other words, palliative care can be applicable for all patients with dangerous diseases, regardless of age and type of disease, and regardless of the background [2].

The evidence shows that if the palliative care approach is implemented on time, it leads to the improvement of the quality of life, better symptom management [3–5], caregivers’ burden reduction, fewer hospitalizations, continuity and coordination of care, cost-effectiveness of care, and a good and peaceful death in the desired place of the patient [6–8]. However, providing palliative care requires training [9]. However, providing palliative care requires training [9] and increased professional training and improved information exchange are key determinants that facilitate the integration of palliative care into the health care system [10].

Therefore, based on an international consensus, the integration of palliative care education in the teaching program of nursing curricula in undergraduate and graduate courses has become mandatory [11]. Despite this broad consensus, it is still a complex issue for beginning education in palliative care at the undergraduate level [12, 13]. In Iran, palliative care is still a major challenge for the health system [14] and is not performed in an integrated way for patients [15].

Despite the importance of the topic and the recommendations of experts in this field, no coherent actions have been taken in the field of palliative care education. Also, concepts such as death, care and family have been emphasized in the nursing undergraduate curriculum [16]. Meanwhile, studies conducted in the field of palliative care show that Iranian nurses have a neutral or negative attitude towards palliative care [17] and they have relatively poor knowledge [18].

So early integration of palliative care education impacts upon students perceived preparedness for practice and positively influences their attitudes to palliative care provision [17].

Moreover, a challenge raised in this field is the lack of appropriate educational models and operational plans [19]. Even though a century has passed since the history of nursing education in Iran, the situation of nurses’ education in the field of palliative care remains unfavorable [16].

Furthermore, inadequate training of nursing students in this regard results in them being unprepared for their future roles as palliative care providers upon graduation [20]. This is despite the fact that providing students with appropriate scientific services and training can lead to a sense of self-confidence and self-belief in doing assigned tasks, which is called self-efficacy [21]. In nursing profession, self-efficacy in the educational system evaluates the success of the training; and the level of self-efficacy can be used to measure the ability of nursing students during their studies to become health workers, that is, professional nurses [22]. Also, self-efficacy is considered as an important determinant in palliative care nursing [23]. However, undergraduate nursing students are not sufficiently trained to achieve the qualifications required in palliative care [24].

The level of self-efficacy of nursing students is related to their stress level and how they overcome difficult situations; so that the low self-efficacy of the student leads to experiencing too much stress [25], avoiding behaviors in dealing with the patient in need of palliative care [26], having low self-confidence and avoiding asking for help in case the patient’s condition worsens [24].

Educational institutions are expected to use different methods of active learning in palliative care, such as watching videos focused on the process of communication between nurses and patients and families, practicing listening to the patient’s symptoms, simulating a case to learn how to correctly assess the patient, Use nursing diagnosis and interventions [27].

Therefore, focusing on the importance of palliative care education and the lack of palliative care education in Iran’s undergraduate nursing curriculum, the present study aimed to determine the effect of a combined (theoretical/practical) palliative care educational program on the self-efficacy of nursing students.

Methods

Results

The mean age of the participants was 22.78 (SD1.17) years. 13 participants (56.5%) were males and 10 participants (43.5%) were females and the majority (91.3%) were single (Table 1).

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Table 1. Demographic characteristics of the samples.

https://doi.org/10.1371/journal.pone.0302938.t001

The mean score on perceived self-efficacy after the intervention was 37.56 (SD1 9.29), which was higher than before the intervention 24.52 (SD 8.32). And a significant statistical difference was seen (P = 0.021).

The mean score on perceived self-efficacy in the field of symptom management after the intervention was 19.48 (SD 5.13) more than before the intervention 12.96 (SD 5.12). And a significant statistical difference was seen (P = 0.034).

The mean score on perceived self-efficacy in the field of psychosocial support after the intervention was 18.08 (SD 4.92) more than before the intervention 11.56 (SD 3.91)and a significant statistical difference was seen (P = 0.041) (Table 2).

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Table 2. Comparison of perceived self-efficacy before and after the intervention.

https://doi.org/10.1371/journal.pone.0302938.t002

Discussion

The purpose of this study was to investigate the effect of combined training (theoretical-practical) of palliative care on self-efficacy of nursing students. The results showed that combined training (theoretical-practical)improves the nursing students’ perceived self-efficacy score.

In this study, the combined learning method (theoretical and practical) was used in different ways, including watching movies, discussing in small groups, case-based learning, bedside learning. In fact, the purpose of using these methods was that the nursing student would be able to acquire the necessary knowledge and skills to take care of patients in need of palliative care.

Meanwhile, important concepts such as general principles of palliative care [33], assessment and management of pain and other symptoms [34] and communication [33] were included in the educational program. Moreover, since trying to keep students active and creative in the teaching-learning process and achieving self-efficacy is one of the most important things in choosing a teaching method in universities, professors should pay special attention while choosing a teaching method and they should use certain methods to improve self-efficacy [35].

Therefore, in the present study, a combination of different educational methods was used. And in the practical part of education based on Bandura’s theory, an attempt was made to provide four sources that develop self-efficacy. So that at first, by holding theory workshops, students were provided with the opportunity to acquire knowledge related to palliative care.

Previous studies also acknowledged that it is necessary to acquire knowledge and receive training in relation to communication skills and symptom management, in order to gain self-efficacy in palliative care [36].

After the theoretical training, a situation was prepared so that during the practical training, the students would be present at the patient’s bedside so that under the supervision of the supervisor, through an interview with the patient, they detected the symptoms, planned and implemented the symptoms management in order to provide an opportunity to accumulate experiences.

Billings et al. also mentioned this issue in 2013 and introduced students’ clinical experiences as an important predictor of students’ self-efficacy [36]. On the other hand, according to Carper’s theory, nursing knowledge (ways of knowing) is improved through personal, experimental, ethical and aesthetic knowledge; and, when experimental knowledge is expanded through aesthetic and personal knowledge and ethical concerns are resolved through reflection and education, a better self-efficacy will be experienced to provide palliative care [37].

Vicarious experiences gained during training courses and clinical placements help nursing students gain confidence to handle similar situations and gaining positive experiences in the field of providing palliative care can increase the self-efficacy of nursing students [24]. The presence of a supervisor in the practical training of palliative care as a model provides a "vicarious source" and as Bandura states, if people see that others can do something, then they convince themselves that they can reach it and at least some improvement in their performance is created [38].

The next source was "verbal persuasion" of the students. Bradbury-Jones et al. state that the instructor’s support in clinical settings plays an essential role in developing student empowerment; and receiving positive verbal feedback can strengthen a person’s abilities to perform a specific action [39].

In the current study, the supervisor’s effort to encourage students while providing care was a step to provide this resource. The last source was emotional state Emotional arousal can also affect a person’s expectations of personal competence [40] strategies that provide emotional support are effective in enhancing self-efficacy. Conversely, stress, anxiety and negative experiences can reduce self-efficacy.

In the present study, the students were under the psycho-emotional support of the supervisor, and the supervisor provided the opportunity to express their feelings and use appropriate methods to release negative emotions. On the whole, the designed educational intervention was able to increase the self-efficacy of nursing students generally in both areas [symptom management, psycho-social dimension]. In line with this finding, Adriansen et al. and Carey et al. also state that providing training programs over a course, allows nurses to practice what they learn and then reflect on their experiences, ponder over their professional practice, encourage them to change their attitudes and actions, evaluate themselves and determine whether they have met the needs of their patients or not [41, 42]. After completing palliative care training programs, they report increased confidence in assessment and symptom management skills, as well as feeling empowered to approach doctors about their patients’ concerns [43].

Bassah et al also -during a study aimed at explaining students’ perception of the implementation of the palliative care educational program- stated that the use of interactive learning methods such as role playing, group discussion and case study is effective in increasing their learning in palliative care education [44]. Dehghani et al also reported an increase in self-efficacy in general and in both areas [symptom management, psycho-social dimension] by implementing a training program related to palliative care for nurses [32].

This study had strengths and weaknesses. The weakness of this study was no control group in this study, due to the existence of only one group of nursing students of the seventh semester who had passed all theoretical and internship units in Meybod School of Nursing and were ready to enter the nursing internship course. Not having a control group is one of the limitations of the present study. Therefore, it is recommended to include a control group in future studies to investigate the effect of the educational intervention in order to obtain more reliable findings. Also, in this study, there was no follow-up after the intervention. therefore, re-evaluating the effect of educational intervention on self-efficacy after a certain period of time is suggested in future studies to determine the durability of the intervention’s effects.

The strong point of the study was that the research project approved in the Strategic Research Center of Medical Education affiliated to the Ministry of Health and Medical Education of Iran and currently this center emphasizes the implementation of innovative research in the educational programs of students, therefore this study with the design of the Palliative care educational program made a change in the internship program of nursing students and the students became familiar with the concept of palliative care and how to provide it to cancer patients.

Conclusion

The results showed that the implementation of an educational program can improve nursing students’ perceived self-efficacy in palliative care. because this study was in the time frame of the training course of the internship students, it was simply implemented and accepted by the students, which can be of interest to the planners and managers of the nursing education system. So by planning and holding consecutive training courses in the field of palliative care, nurses with high self-efficacy can be trained and prepared to provide service in the palliative care system.

Acknowledgments

The authors of this article would like to express their gratitude to the nursing students who participated in the research and also thank the supervisors of the oncology wards of hospitals contributing in the implementation of the research.