Palliative and end-of-life educational interventions for staff working in long-term care facilities: An integrative review of the literature

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2020 The Authors. International Journal of Older People Nursing published by John Wiley & Sons Ltd 1Institute of Nursing and Health Research and School of Nursing, Ulster University, Newtownabbey, UK 2Institute of Nursing and Health Research and School of Nursing, Ulster University, Londonderry, UK 3International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK


| INTRODUC TI ON
Palliative and end-of-life (EOL) care for older populations has globally impacted policy and practice (World Health Organization Regional Office for Europe, 2011). With the increase in the average life expectancy and number of individuals dying at an older age due to complex conditions, the need for palliative and EOL care outside acute care settings has been rising. This has been increasingly evidenced due to the COVID-19 pandemic that has taken lives of a large proportion of older population who reside in community and residential facilities (Lancet, 2020;Kunz & Minder, 2020). Although the individual's home has traditionally been the most preferred place of death (Agar et al., 2008;Fukui, Yoshiuchi, Fujita, Sawai, & Watanabe, 2011), an increasing number of older individuals are dying in long-term care facilities (LTCFs) (Broad et al., 2013). Accordingly, LTCFs, which have also been referred to as nursing homes, care homes, residential care homes and skilled nursing facilities according to their system and policies, are residentialtype establishments that provide 24-h, 7-days-a-week care for older individuals (Froggatt et al., 2017;Sanford et al., 2015).
LTCF residents, who usually have multiple comorbidities and dementia, often progress from frailty to EOL within such facilities (Froggatt & Reitinger, 2011). Direct care providers in LTCFs include both qualified and unqualified individuals with a wide variety of educational and training backgrounds who often do not have palliative and EOL care education (Anstey, Powell, Coles, Hale, & Gould, 2016;Karacsony, Chang, Johnson, Good, & Edenborough, 2015).
Though international literature has supported the view that demand for palliative and EOL care in LTCFs is increasing, the education required to meet such a demand has been lagging (Evenblij et al., 2019;ten Koppel, Onwuteaka-Philipsen, van der Steen, et al., 2019;ten Koppel, Onwuteaka-Philipsen, Van den Block, et al., 2019;Smets et al., 2018). Limited resources and staffing continue to restrict staff education and training opportunities (Evenblij et al., 2019;Froggatt, 2005). Consequently, educational programmes on palliative and EOL care need to consider such LTCF characteristics (Froggatt, 2001).
Owing to societal needs, the number of studies on palliative and EOL care education in LTCFs has been gradually increasing since the early 2000 s. This has been guided by various international initiatives from the UK, such as the Gold Standard Framework for Care Homes (GSFCH) (The Gold Standard Framework, 2018) and Six Steps to Success (The End of Life Partnership, 2017). Moreover, the End-of-Life Nursing Education Consortium Geriatric curriculum (ELNEC-G) from Implications for practice: Palliative and EOL care educational intervention for LTCF staff need to include more consideration of context, organisational culture and the user involvement throughout the process of education and research to enhance the quality of care in this complex setting.

K E Y W O R D S
education, health personnel, integrative review, long-term care, palliative care, residential facilities What does this research add to existing knowledge in gerontology?
• While need to improve palliative care in long-term care settings is recognised globally, most initiatives are ad hoc bespoke programmes that fail to recognise clinical setting characteristics or measurable outcomes.
• This review highlights the need for robust educational interventions that considers the impact on residents, families and staff.
• Educational interventions were mostly evaluated using staff's self-reported increase in knowledge, skills and confidence, with little follow-up to ensure its incorporation into clinical practice or effect on patient outcomes.
What are the implications of this new knowledge for nursing care with older people?
• Educational interventions for LTCFs need to address the characteristics of LTCFs such as high staff turnover and limited resources.
• Our findings offer useful insights on the development of palliative care educational programmes that highlight the need for standardised programmes based on measurable outcomes with some flexibility on addressing individual facility's contextual and educational needs.
• It is important to consider the mode of delivery of educational intervention; continuous staff support and follow-up are required to sustain its educational effect into practice.

How could the findings be used to influence policy or practice or research or education?
• This review highlights the need for more high-quality studies that are guided by implementation and andragogical frameworks and consider the characteristics of long-term care settings.
• Our findings highlight the care staff's concerns towards having conversations regarding palliative and EOL care with residents and their family.
• Educational intervention also needs to contribute to develop a culture of palliative and EOL care in LTCF. the USA (American Association of Colleges of Nursing, 2019) has been used to provide education aimed at improving palliative and EOL care for those engaged in geriatric care, although its target group includes nurses in general and not specific to LTCF settings. Such initiatives have been widely recognised and used both nationally and internationally.
While various approaches for improving palliative and EOL in LTCFs have been attempted, considerable variety and differences in educational interventions have been noted. Evidence has also suggested that the types of LTCFs and levels of palliative and EOL care development vary greatly among different systems and countries (Froggatt et al., 2017;ten Koppel, Onwuteaka-Philipsen, van der Steen, et al., 2019;ten Koppel, Onwuteaka-Philipsen, Van den Block, et al., 2019).
A systematic review by Hall, Kolliakou, Petkova, Froggatt, and Higginson (2011) on the effectiveness of interventions aimed at improving palliative care in LTCFs concluded the need for more robust trials in the area. Another systematic review by Anstey et al. (2016) regarding EOL education and training for nursing home staff reported that studies on EOL or palliative care education programmes in LTCFs had insufficient quality and programme credibility. As such, robust and synthesised evidence that would help determine the most appropriate educational approaches for improving palliative and EOL care from the perspective of care providers and recipients in LTCF settings has been lacking.
Acknowledging the limitations of the existing literature, the present review aimed to synthesise the current literature on palliative and EOL care educational interventions for staff working in LTCFs and identify barriers to and facilitators of intervention implementation.
This review is part of a larger study concerning the translation and adaptation of a palliative care educational intervention developed in Europe into the Japanese LTCF setting. Therefore, studies published in both English and Japanese had been included for a wider understanding of international and Japanese evidence on this topic.

| ME THODS
An integrative review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher, Liberati, Tetzlaff, & Altman, 2009). This type of review, which is the broadest among the research review methods, does not limit the inclusion of a study based on design.
Instead, qualitative, quantitative, experimental and mixed-method studies may all be included to obtain a better understanding of the phenomenon under investigation (Booth, Sutton, & Papaioannou, 2016). This review framework as well as the five stages suggested by Whittemore and Knafl (2005) (i.e. 'problem identification stage', 'literature search stage', 'data evaluation', 'data analysis' and 'presentation') were used to guide the review process and enhance this review's rigour (Department of Health, 2008).
The problem identification stage was based on a preliminary literature search (Whittemore & Knafl, 2005). At the literature search stage, the first author performed a computerised search for peer-re- Nursing. MeSH terms and text words for LTCFs, palliative care, education and health personnel were combined. The search terms used are presented in Appendix S1, while inclusion and exclusion criteria are detailed in Table 1.
Study abstracts, titles and full texts, if necessary, were screened by the lead author (KI) against the inclusion/exclusion criteria and checked by the second reviewer (FH). Any discrepancies unresolved  1. Not mentioning elements (by name or description) of palliative and end-of-life care and educational intervention in the article's title, abstract or text 2. Studies conducted in institutions, such as hospitals, clinics, hospices or home care settings (patient's own home) 3. Educational intervention was for residents and/or family/carers 4. Education targets were external staff visiting the facilities to provide care 5. Low-quality papers with methodological flaws and/or insufficient information 6. Studies using a design with no available appraisal tools, such as audits, service evaluations and action research TA B L E 1 Inclusion and exclusion criteria by a discussion between the reviewers were adjudicated by a third reviewer (SM). Full-text versions of the studies that matched the selection criteria were retrieved and subsequently analysed.
During the data evaluation stage, two researchers independently evaluated the papers using Joanna Briggs Institute Critical Appraisal Tools for qualitative and quantitative studies (Aromataris & Munn, 2017) and the Mixed-Methods Appraisal Tool (2018) for mixed-methods studies, multi-methods studies, audit and action research (Hong et al., 2018).
Categories extracted included the type of educational intervention, education focus, target staff, evaluation method and barriers to and facilitators of educational intervention implementation. A data extraction table was developed to extract data from the included studies. All data extraction procedures were conducted by the first reviewer, after which a second reviewer checked 25% of the data extracted to confirm their accuracy.

| RE SULTS
Our literature search identified 3528 papers, among which 2629 papers were screened for their titles and abstracts based on inclusion and exclusion criteria after eliminating duplicates. Full texts of 149 papers were then obtained for full-text screening, after which 52 titles were retrieved and assessed on their quality ( Figure 1). The subsequent sections provide details of the synthesis of the included papers, educational interventions, outcome evaluations and barriers to and facilitators of educational intervention implementation. An overview of included papers is shown in Appendix S2; the item-level scores of critical appraisals are presented in Appendix S3.

| Outcome evaluations
While three studies assessed the impact of their interventions for

TA B L E 2 (Continued)
Consortium Knowledge Assessment Test (Lange, Shea, Grossman, Wallace, & Ferrell, 2009) and Palliative Care Quiz for Nursing (Ross, McDonald, & McGuinness, 1996)  secondary traumatic stress (Figley, 2013) and empowerment (Spreitzer, 1995) et al., 2018) and the Quality of Dying in Long-Term Care (Hall, Longhurst, & Higginson, 2009). The quality of EOL care from the perspective of the residents' families was assessed using the After Death Bereaved Family Member Interview (Arcand et al., 2009;Livingston et al., 2013) (Elwyn et al., 2005) to evaluate residents' and families' degree of involvement in conversations (Ampe et al., 2017); the After Death Analysis audit tool for GSF to record details of the five most recent deaths (Badger et al., 2009); and the interRAI (interRAI, 2019) for resident characteristics and care needs and estimate resource use (Mayrhofer et al., 2016). Audit data such as the number of emergency hospital admission cases (Di Giulio et al., 2019; Kunte et al., 2017), place of resident's death (Hockley et al., 2010;Kinley et al., 2017;Mayrhofer et al., 2016) Kuhn & Jeannine, 2012;Kunte et al., 2017;Mayrhofer et al., 2016) were also used to evaluate practice change due to their interventions.

| Barriers to and facilitators of educational intervention implementation
Although majority of the studies reported positive intervention outcomes, many experienced barriers to the implementation and continuation of educational interventions. The most frequently reported barrier was time constraints between education/training and work (Aasmul et al., 2018;Ampe et al., 2017;Hall, Goddard, et al., 2011;Kunte et al., 2017;Waldron et al., 2008;Wickson-Griffiths et al., 2015). The high turnover of staff and administrative personnel also contributed to the loss of learning and difficulty of ensuring continuity of education (Kuhn & Jeannine, 2012;Kunte et al., 2017;O'Brien et al., 2016). Our results showed that the overall culture on palliative and EOL care in the LTC setting affected staff members' motivation for engaging with education. Closed communication cultures within LTCFs or avoiding conversations around palliative and EOL care hindered the development of cultures that improve palliative and EOL care (Hall, Goddard, et al., 2011;Kinley et al., 2014;Nakanishi et al., 2015). Furthermore, the unwillingness or reluctance by staff to engage with the programme and lack of confidence in talking with residents regarding death and dying hindered their involvement in palliative and EOL care-related activities (Aasmul et al., 2018;Ampe et al., 2017;Hall, Goddard, et al., 2011;Sussman et al., 2018).
The included studies suggest that the lack of clarity concerning roles and responsibilities during palliative and EOL care activities impacted education within the facilities (Ampe et al., 2017;Mayrhofer et al., 2016;Sussman et al., 2018). Another barrier included relationship issues, such as lack of trust or understanding between LTCFs and external organisations, including GPs and out-of-hours services (Badger et al., 2012). Similar findings were noted among different professionals within a facility (Cronfalk et al., 2015;Farrington, 2014;Nakanishi et al., 2015). This created difficulties in establishing appropriate communications and inter-professional collaboration, both of which are necessary for the continuity and delivery of palliative and EOL care within and across organisations.
An organisation's recognition and value of palliative and EOL care quality had been found to impact how much they devoted their re-

| DISCUSS ION
The importance of palliative and EOL care education for LTCFs has been increasingly recognised, given the rise in the number individuals dying in this environment. The recent COVID-19 pandemic and global high death rates in LTCFs posed the importance of preparation and ability of staff to integrate palliative and EOL care for their residents and family (Gilissen, Pivodic, Unroe, & van den Block, 2020;Payne et al., 2020). The number of studies attempting to gather evidence on this matter has been increasing over the past two decades. Interestingly, the findings of the present review show that a gradual change has been occurring in the quality of palliative and EOL care education and their study methodologies.
However, although most of the research had been undertaken in countries advocating palliative and EOL care as a matter of policy, a gap in actual practice exists. In addition, many educational programmes have lacked details of whether such programmes were based on evidence-based practices or national standards. With regard to study quality, most of the studies adopted a pre-and post-intervention comparison design without controls, with only four randomised controlled trials (RCTs) being included herein, suggesting the lack of RCTs in this area. This may be attributed to the challenges of conducting such studies in this particular care setting given the characteristics of LTCFs, such as high staff turnover rates, limited resources for education and variations in facility types and resident characteristics (Hall et al., 2009;Murfield, Cooke, Moyle, Shum, & Harrison, 2011;Shepherd, Nuttall, Hood, & Butler, 2015 (Centeno et al., 2007;Clark et al., 2020;Froggatt et al., 2017) and that diverse educational backgrounds and practice experience of staff members, this study highlighted that preparing and providing standardised programmes that meet unique educational goals and needs has remained a challenge. Also, the included studies were conducted in countries where palliative care is at an advance stage of integration (Clark et al., 2020) and there is less evidence from countries with less integration. Therefore, it is important to question whether such standardisation is required and whether it is more helpful to consider 'core' competencies along with specific competencies for different roles and responsibilities, rather than a one-size-fits-all approach.
In their cluster RCT,  revealed no significant changes in primary outcomes given the complexity of their intervention with multiple components implemented over a year, which made it difficult to explain which component was effective.
Also, over-standardisation of the intervention meant that specific needs of each intervention site were not met. A systematic review by Low et al. (2015) on interventions aimed at altering staff behaviour and resident outcomes in nursing homes concluded that no 'magic bullet' exists for improving staff behaviour and resident outcomes.
These studies illustrated the difficulty of setting outcomes during complex interventions, such as educational programmes. Therefore, educational interventions for LTCFs cannot focus solely on the topic of palliative care. Instead, theories of learning, organisational characteristics and the context within which the intervention has to be delivered also need to be integrated into the design while also considering the implementation process.
The multifaceted needs of LTCFs have an impact on the imple- Some strengths and limitations of the current review need to be highlighted. Accordingly, one key strength has been the inclusion of both English and Japanese papers, which may have provided a wider global context compared to previous review papers on a similar topic. However, papers in other languages and grey literature may need to be explored to further enhance our understanding.

| CON CLUS ION
This integrative review has synthesised the literature on current palliative and EOL care educational interventions for staff working in LTCFs and identify barriers to and facilitators of intervention implementation. Although the importance of and need for palliative and EOL care education among staff working in LTCFs has long been recognised, suboptimal study quality and variation in education have been reported. To address such issues, this review reveals the recent increase in the number of trials that employ more updated educational approaches, includes more resident and family involvement in the design of the educational interventions and considers the specific characteristics of LTCFs.

IMPLIC ATIONS FOR PR AC TICE
• It is important to develop measures that ensure consistency in terms of educational interventions that help to address widespread variability and quality considerations in the LTCF setting.
• Staff education needs to include a focus not just on supporting skills and knowledge base but also strategies to address contextual considerations within this setting.
• Whilst there are challenges, the involvement of LTCF residents and their family in curriculum development and implementation in this setting is required in order to deliver effective person-centred palliative and end of life care.

ACK N OWLED G EM ENTS
The first author received funding from Ulster University Vice-Chancellor's Research Scholarship. English proof-read and editing were supported by the Enago.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.