Systematic review
Do staff educational programmes affect end-of-life care in nursing homes?
Systematic review
|Updated
The aim of this report is to summarize the evidence of the effects of staff educational programmes in end-of-life care in nursing homes.
Key message
Objective
The aim of this report is to summarize the evidence of the effects of staff educational programmes in end-of-life care in nursing homes. The report is part of a project, initiated by the Directorate of Health, and aimed at providing better evidence for end-of-life care in nursing homes.
Methods
In this systematic review we have searched for, critically appraised, and summarised research from studies on the effectiveness of different staff educational programmes aimed at improving end-of-life care in nursing homes.
Results
After extensive and systematic searching, and based on explicit criteria for trustworthiness, we included five studies (six articles), all from USA, carried out in the period 1983 to 2005. All included studies aimed at improving staff’s knowledge, attitudes and skills.
The results were inconsistent. Three of the four studies that evaluated effects on staff’s knowledge found that those who were trained had more knowledge compared to those not trained. Two studies also looked at staff’s practice, and one of these tested effects of nursing home staff training in care for the dying on the quality of life of terminally ill patients. Both studies demonstrated a favourable impact on patients when staff in nursing homes are trained to work with dying patients. For example dying patients in trained homes had greater satisfaction with care and were less depressed than patients in control homes. Moreover, intervention nursing homes increased hospice enrolments, pain assessment and non-pharmacological treatments for patients in pain, compared to nursing homes where staff had not attended the educational programme.
Conclusion
Considering the large number of patients dying in nursing homes, more research that is properly designed to evaluate the effects of educational programmes in end-of-life care, is needed.
Summary
Background
In 2007, about two fifth of all deaths in Norway took place in nursing homes. Due to expected demographic changes the number and proportion of elderly dying in nursing homes will increase. Knowledge on end-of-life care in Norwegian nursing homes is very limited. Studies from other countries have documented lack of quality of such care in nursing homes, and several studies have called attention to inadequately trained staff. The present report focuses on the effects of staff educational programmes in end-of-life care: Do staff educational programmes affect knowledge, skills and attitudes of nursing home staff, and are such programmes beneficial to patients’ health?
The report is part of a larger project, initiated by the Directorate of Health, aimed at increasing evidence of end-of-life care in Norwegian nursing homes.
Methods
This is a systematic review, i.e. we have searched for, critically appraised, and summarised research from primary studies on the effect of staff educational programmes aimed at increasing quality in end-of-life care in nursing homes. To identify relevant literature we carried out a comprehensive literature search in eight databases. The first search was carried out in December 2007, and an updated search in December 2008. Potentially relevant articles (judged by title and abstract) were assessed by two reviewers independently, according to the inclusion criteria. The included studies were critically appraised for methodological quality according to approved check lists.
Results
We have made a qualitative summary of the results from five studies, described in six articles, focusing on effects of different staff educational programmes in nursing homes. All studies aimed at testing the effect of educational programmes in end-of-life care for nursing home personnel. Some studies focused on how educational programmes affected staff attitude, knowledge and skills, while others tested the effect on health gains for patients. All included studies were carried out in USA, in the period 1983 to 2005. We did not find any previous systematic review on the effect of staff educational programmes in end of-life care in nursing homes. There are however, a larger number of primary studies, but a vast majority used weak research designs, making it impossible to conclude on effectiveness of the programmes.
Three of five included studies had a randomised, controlled design. Generally, methodological quality of the included studies was low, according to predefined criteria.
All included studies described educational programmes aimed at affecting the nursing homes staff; their attitudes to death and dying and their knowledge and skills in end-of-life care. Some studies had a specific focus on pain assessment and management of pain, while others aimed at studying effects on knowledge and skills in caring for the dying in a more extensive way. Only two studies looked at effects on daily practice. One of these judged the quality of life of terminally ill patients and their satisfaction with care, while the other measured proportion of residents receiving palliative service, pain assessment and pain treatment, and documented advanced care planning discussions.
The results were inconsistent. Three of four studies that looked at effects on staff’s knowledge found that those who were trained had a higher level of knowledge compared to those not trained. However, in one of these studies the effects were very modest. The two studies evaluating how educational programmes affected staff’s behaviour or practice, both found a favourable impact when staff is trained to work with dying patients. Intervention nursing homes typically increased hospice enrolments, pain assessment, and documented advanced care planning discussions. And among patients in pain, non-pharmacological treatments increased significantly compared to nursing homes where the staff had not attended the educational programme. The study looking at dying patients and their experience of quality of life and satisfaction with care, found that patients in intervention homes were less depressed and more satisfied with care compared to patients in control sites.
Conclusion
In summary, these studies offer a mixed picture, but nevertheless demonstrate promising findings in that educational programmes in end-of-life care do matter. Most included studies had low methodological quality, educational programmes of short duration and short follow up, demonstrating need for caution in interpretation of findings. There was also a high degree of heterogeneity both in interventions and in outcomes. There is a huge need for more standardized educational programmes based on the staff’s educational needs, and studies properly designed to conclude on effects on knowledge, skills, attitudes and health gains for patients.