Development of a Heart Failure Palliative Care Educational Program for Nurses: A Multi-Method Approach

Abstract

Background:

Comprehensive palliative care for patients with heart failure can be developed by educating cardiac nurses. The current study aimed to design a heart failure palliative care educational program for nurses.

Materials and Methods:

This study was carried out using the multi-method approach based on two out of four steps of Uys educational program development at Dr. Chamran Hospital, Isfahan, in 2020–2021. In step 1, educational needs were collected through literature review, interviews with 15 patients and 10 nurses, examination of patients’ documents and medical records, and observation. Then, in step 2, the importance and necessity of teaching the proposed topics and the teaching and evaluation method of the items were assessed through two rounds of delphi technique (15 expert panel members). Eventually, the educational program was finalized.

Results:

In step 1, the educational needs of nurses were identified in 6 general fields and 26 general learning topics. In step 2, educational needs [specialized knowledge (55% necessity and 55% importance) and social support (33% necessity and 33% importance)], teaching methods (role-playing, experiential learning, and journal club), and evaluation method (the information analysis method) were removed due to a lack of consensus (11%). Finally, the main parts of the program, including the program mission and vision, general learning topics, general goals, objectives, teaching strategies, and evaluation strategies, were compiled.

Conclusions:

This program provides nurses with up-to-date information on various aspects of the physical, psychological, social, spiritual, and educational needs of heart failure patients and ensures the provision of better services to them.

Introduction

Heart failure is a chronic, progressive, and debilitating disease affecting about 37.7 million of the population worldwide.[1] This advanced heart problem is among the leading causes of death and burden in several countries, especially those with low and middle income, such as Iran.[2] Patients with heart failure experience various physical and emotional symptoms such as severe dyspnea, fatigue, cough, muscle weakness, sleeping difficulties, and low mood.[3] Studies show that these patients have unmet psychological, social, and spiritual symptoms and needs,[4] as over 50% of those suffering from chronic heart failure are readmitted to the hospital within six months after hospitalization.[5] Multiple symptoms and frequent hospitalizations necessitate considering palliative care in this group of patients.[6] Palliative care prevents and relieves suffering through the early identification, evaluation, and treatment of pain and other physical, psychological, and spiritual problems, consequently improving the quality of life of patients and their families in the face of issues related to life-threatening diseases.[7] Given the controllability of symptoms, high and increasing prevalence, and poor disease prognosis in this group of patients, palliative care services are a very suitable alternative.[8] Palliative care seems to be quite beneficial considering the complex nature of care for patients with heart failure, the need for personalized interventions, patient-centered care planning, and the necessity of communication about the limited treatment options. More than 30% of patients with heart failure can receive assistance through palliative care services.[9] Although palliative care has numerous benefits, such as a reduction in frequent hospitalizations,[10] the incidence of symptoms,[11] and healthcare costs,[12] along with an increase in the quality of life,[13] it has not been considered seriously in patients with heart failure so far.[9,14] A general survey of heart failure specialists showed that 67% of respondents had not referred any patients to palliative care in the past 6 months.[15] In another study, only 7% of patients with heart failure participated in palliative care programs.[16]

Palliative care is sometimes delayed until the patients reach the end of their lives[3] due to several barriers, such as complex and unpredictable disease course, sudden death, patients’ insufficient knowledge about their disease, misinterpretation of the word palliative care as end-of-life care, healthcare providers’ limited palliative knowledge and their primary focus on standard treatment options, and insufficient communication and collaboration between medical professions.[17] Nurses contribute substantially as care coordinators in collaboration with other health professionals to provide palliative care to patients; however, insufficient training and lack of required resources, experience in communication skills,[18] have led to their resistance and reduced use of palliative care.[19] A study showed that nurses and doctors did not relieve the pain of heart patients entirely because they had insufficient knowledge about palliative care and the nature of heart failure. On the other hand, patients are not sufficiently familiar with palliative care because doctors and nurses fail to introduce this type of service. Even those aware of and covered by palliative care still have other unmet physical, mental, social, and spiritual needs, exacerbated by the lack of knowledge of nurses about the needs of patients and their families.[9,18,20] The unawareness of healthcare workers, particularly nurses, prevents the provision of palliative care to patients with heart failure and also leads to the lack of knowledge of patients and inability to meet their needs during palliative care. Also, it is crucial to introduce and educate palliative care to patients, along with considering other challenges related to the provision of palliative care services to terminally ill patients. The nurses also need to acquire the necessary knowledge, attitudes, and skills, which would prepare them to play a role in palliative care for heart failure patients.

Considering the above-mentioned and the lack of similar studies to educate palliative care to nurses caring for patients with heart failure, the researchers decided to develop a program based on the current situation and the palliative care needs of the patients and nurses to familiarize nurses with palliative care for patients with heart failure and enhance their knowledge in this regard. The main objectives of the study are as follows: 1. situation analysis/needs assessment for palliative care (considering that the nurses must first know these needs to meet their patient’s palliative care needs, data collection concerning the learning needs of the nurses was conducted based on their educational needs and the needs of heart failure patients); and 2. The educational program development (determining the educational goals and topics, teaching strategies, and evaluation strategies).

Materials and Methods

The current study, conducted at Dr. Chamran Hospital, Isfahan, in 2020–2021, used a multi-method approach based on two out of four steps of Uys educational program development [Figure 1]. The study went through two steps of situation analysis/needs assessment and educational program development.[21] In the first step (Situation Analysis/Needs Assessment) a combination of literature review, interviews with 15 patients and 10 nurses who were purposively selected with maximum variation from Shahid Chamran hospital, examination of patients’ documents and medical records, and observation was used in this step to determine the palliative care needs of heart failure patients and the educational needs of the nurses. The purpose of the literature review was to obtain the knowledge available in the field of related educational programs worldwide, along with the scientific documents required to develop such an educational program. To start the review process, relevant keywords were primarily identified using Mesh, Snomed, Embase, and other related literature. Thus, the keywords listed in Table 1 and a search strategy resulting from the combination of keywords by the Boolean operators of “AND” and “OR” were used to search in PubMed, Scopus, Web of Science, SID, and MAGIRAN databases for February 13, 14, and 15, 2021. Two researchers reviewed the titles and abstracts of the remaining articles after removing duplicates according to the inclusion criteria (all studies focusing on the educational needs of the nurses and the palliative care needs of heart failure patients, written in both Persian and English languages ab initio until 2021). The third researcher reviewed articles in the case of disagreement between the two assessors. The remaining 61 articles were reviewed by all three researchers, who agreed regarding the main components and findings of final articles [Table 1].

Figure 1.

The steps for the development of a program to familiarize nurses with palliative care for patients with heart failure

Table 1.

Keywords for literature review

Palliative care	AND	Heart failure	AND	Needs Assessment	AND	Nurse
OR		OR				OR
End-of-life care		Cardiac Failure		OR		Nursing
OR		OR		Educational		Personnel
Terminal Care		Heart Decompensation		Needs		OR
OR				Assessment		Registered Nurse
Hospice Care		OR		OR		OR
		Myocardial Failure		Determination of Health Care Needs		Patient
				OR		OR
				Assessment of Healthcare Needs		Client

Also, semi-structured interviews with nurses and heart failure patients were conducted using the interview guide (30 participants were approached for interviews, out of which 3 patients and 2 nurses withdrew) [Table 2]. The inclusion criteria for nurses were working experience related to the care for heart failure patients for at least 6 months, willingness to participate in the study, and adequate information about heart failure. Inclusion criteria for heart failure patients were admission to the Cardiac Unit of Dr. Chamran Hospital, chronic systolic heart failure confirmed by echocardiography [Ejection Fraction (EF) <40)] and a cardiologist, and willingness and ability to participate in the study. Participants were purposefully included in the study, and each was met by the researcher individually to introduce the research and explain the aims and process of the study. The time and place of the interviews were set at Dr. Chamran Hospital according to the convenience of the participants. The researcher conducted the interviews after providing the necessary explanations about the audio recording of the interviews and obtaining written consent from the participants. Each interview lasted for about 30–60 minutes, after which the researcher listened carefully to and transcribed the recorded information verbatim as soon as possible. Data analysis was conducted using conventional qualitative content analysis and MAXQDA 10 software. The analysis was conducted simultaneously with the data collection, using Granheim and Lundman’s five-step approach. The text of the interviews was handwritten, typed, and reread several times immediately after collecting information through interviews. When the relevant parts of the sentences were found, data coding and organizing were conducted until connecting the meaningful categories and revealing the themes. During the analysis process, the researchers considered the entire interview text as the unit of analysis. Coding, summarizing codes, and their classification were carried out after identifying the semantic units to reveal the categories. Then the concepts and content hidden in the data were extracted based on continuous comparisons.[22] The adequacy of data collection from this step was determined considering the consensus of the research team, the information obtained until reaching a comprehensive analysis, and the estimation of the current situation and the educational needs of the program audience, including the nurses of the Cardiac Unit. Then, the documents of the patients’ medical records, particularly the nursing reports, were analyzed to find information regarding the needs of heart failure patients and the educational needs of the program learners and finally the researcher attended the Cardiac Unit during the morning shifts to complete the information by observing the questions and answers exchanged between the patients/families and the nurses, taking notes, and analyzing them by conventional content analysis.

Table 2.

Interview guide

Participants	Sample questions
Patients	Have you ever heard of palliative care? Has anyone talked to you about palliative care? Are you familiar with palliative care, and what do you expect from the palliative care team? What issues and problems do you expect the palliative care team to address? What do you think about the prognosis of your disease? Which of your needs are not met? What do you expect from the nurses?
Nurses	How much are you familiar with palliative care? Do you know when to use palliative care for heart failure patients? Do heart failure patients and their families have other needs besides routine nursing care? In what areas of care for heart failure patients do you need more knowledge and experience? What services does palliative care provide for heart failure patients?

The results obtained from the above four methods were then integrated into categories and sub-categories to form the basis for the draft preparation of the program thematic headings. In the second step (program development), the goals and learning objectives (cognitive, emotional, and behavioral) of the program to familiarize nurses with palliative care for heart failure patients were designed in the form of a questionnaire for the nurses involved in the care and treatment of heart failure patients after preparing the list of topics in the previous step. Then, expert panel members were selected using purposive and snowball sampling methods (15 experts[23]) from the faculty members of Isfahan University of Medical Sciences with at least 10 years of work experience in the field of designing educational programs and palliative care for heart disease patients to get opinions and consensus (four cardiologists, six nursing specialist in the field of palliative care and program development with Ph.D degree, five cardiac nurse educator). The first round of the opinion poll was sent to the panel of experts after making phone calls to obtain their permission and introduce the design, goals, and research methodology. The questionnaire, supposed to be answered in two weeks, aimed to seek expert opinions on the importance and necessity of teaching the proposed topics. A reminder was sent after two weeks, and a phone call was made in the case of receiving no response. The expert in question would be eventually excluded from the study if the attempts to contact failed. The researchers reviewed and summarized all the expert opinions during several sessions after receiving the answers of the first opinion poll round on the necessity and importance of palliative care needs. The consensus of >80% was the criterion of agreement among experts in this study. Then, the designed educational program was sent to the experts in the second round of opinion poll to ask their opinions on the teaching and evaluation method of the items agreed upon in the previous phase.

Descriptive statistics (frequency and percentage) was used to analyze data collected in the two rounds. Eventually, the educational program was finalized at the end of this phase. The method of Lincoln and Guba was used to determine the trustworthiness of the qualitative data obtained from the study.[24] The selection of participants with different experiences, sufficient data collection, and multiple interviews aimed to ensure the data credibility. On the other hand, all participants received questions in similar fields to guarantee the dependability of the data. Concerning transferability, the researcher made deep and rich descriptions of the context, participants, study platform, barriers and limitations, and the conditions for using the findings in other social contexts. Confirmability was achieved by the detailed and comprehensive recording of all research steps, particularly data analysis, to provide other researchers interested in this field with an opportunity to conveniently continue the work. The obtained data were edited using specialized panels, based on which the final results were derived.

Ethical considerations

This study was extracted from a research project approved by the ethics committee of Isfahan University of Medical Sciences (IR.MUI.NUREMA.REC.1401.024). The participants were assured about the voluntary and confidential nature of the study. Researchers confirm that all methods were carried out following relevant guidelines and regulations, and all experimental protocols were approved by the ethics committee of Isfahan University of Medical Sciences. Written informed consent was obtained from all subjects and/or their legal guardian(s).

Result

According to the steps presented in the methodology, the research findings are as follows:

The first step: Situation analysis/needs assessment

Literature review

In general, this step included the situation analysis and needs assessment of heart failure patients, along with the educational needs of nurses. Overall, 400 articles were found by the extensive library and electronic search. Of these, 98 were duplicates, and 159 were unrelated, lacked content related to palliative care for heart failure patients, or did not concentrate on educational needs. Thus, 61 completely related articles were selected and studied.

Interviews

A total number of 25 qualitative interviews were conducted, including 10 cardiac nurses (2 head nurses, 7 nurses, and 1 nursing instructor of the Cardiac Unit of Shahid Chamran Hospital) and 15 heart failure patients.

One of the patients referred to raising awareness about the disease as one of the basic needs, stating that “When I had shortness of breath, I went to the hospital’s emergency room, where the doctor ordered an echocardiogram and emphasized the need for an echo. When I asked what my problem was, the doctor assured me not to worry. However, I heard them talking about my heart failure. For a long time, I didn’t really know what my illness was and how it would be treated” (Patient 1).

The patients also wished to access the required information about symptom management. One of them stated that “One of the problems that most cardiac patients face is their limitations in sexual activity; thus, it would be helpful to illustrate the problem and provide information on its management” (Patient 12).

Concerning palliative care for patients, one of the nurses stated that “How can we implement palliative care for the patients when we do not know what it is and what measures it includes? They have to primarily educate nurses in this field and expect them to implement it for patients” (Nurse 5).

Nurses also referred to the patients’ needs for information about the prevention of disease progression and follow-up care. As stated by one of the nurses, “Patients constantly ask, for example, what to do to keep their blood pressure low. They are worried about renal failure. They need to know the time of their next visit, and frequent questions are raised by the patients or their families in this regard” (Nurse 10).

Patients’ medical records

In total, 25 medical records were reviewed to complete the information at this stage. Pain, dyspnea, fatigue, exercise intolerance, difficulty sleeping, impaired urinary and bowel elimination, anorexia, and organ edema were among the common problems of these patients.

Observations

According to the researcher’s observations at this step, the patients raised frequent questions about their nutritional patterns, physical activity improvement, pain relief, and dyspnea management. However, the nurses only told them to wait for the doctor to come and could not guide the patients properly.

The educational needs of nurses were identified in 6 general fields and 26 general learning topics at the end of this step. These fields included an introduction to palliative care, palliative care needs of patients based on heart failure stage, specialized information about heart failure, the job description of nurses in the team, patient transfer to palliative care, and unmet wishes and needs of heart failure patients [Table 3].

Table 3.

Needs identified in the first step

Category	Sub-category
Introduction to palliative care	Definition of palliative care
	Goals of palliative care
	The importance of the prompt introduction of palliative care to patients
	Types of palliative care in heart failure
	Dimensions of palliative care (physical, including management and evaluation of symptoms, psychological, spiritual, etc.)
Palliative care needs of patients based on heart failure stage	Stage 1: Management of chronic disease
	Stage 2: Palliative and supportive care
	Stages 3,4: End-of-life care
Specialized information about heart failure	Common problems and symptoms of heart failure
	Prognosis
	Treatment
	Medications and side effects
	Diet
Job description of nurses in the team	Competence and skills required to implement palliative care
	Nursing responsibilities
	Specialized knowledge
Patient transfer to palliative care	The onset of the palliative care
	Influential factors for the transfer of heart failure patients to palliative care
	Indication evaluation of palliative care in patients
Unmet wishes and needs of heart failure patients	Physical (pain relief, performing activities without fatigue - attention to sexual issues)
	Psychological
	Social
	Spiritual
	Information (answering their questions - talking about the Prognosis of the disease)
	Communication between the palliative care team and the patient and their family
	Preferences (home death, home care)

The second step: Program development

The purpose and learning objectives of the program were formulated using the data on palliative needs extracted in the first step. The general goal of the program was initially determined as “the development of a program to familiarize nurses with palliative care for heart failure patients,” and the specific goals were also highlighted in three areas of cognitive, emotional, and behavioral. Then, the data obtained from the needs assessment were used to organize the program for the nurses’ familiarization with palliative care for heart failure patients. A questionnaire containing a list of topics was sent to 15 experts, 6 of whom were removed from the panel of experts because of failure to respond within the stipulated time. The table designed in the first round represented the importance and necessity of the needs, from which 2 needs, including specialized knowledge (55% necessity and 55% importance) and social support (33% necessity and 33% importance) were removed due to a lack of consensus [Table 4]. Then the teaching and evaluation methods were resent to the experts in the second round of opinion poll, and the items agreed upon were identified. The teaching methods of role-playing, experiential learning, and journal club were eliminated, with 11% consensus in all three. Also, the information analysis method, which belonged to the evaluation methods, was removed due to a lack of consensus (11%), leading to the development of the program in three main parts [Table 5], including the program’s mission and vision, general learning topics, general goals, special goals, and teaching and evaluation methods.

Table 4.

Frequency of the palliative care needs importance and necessity

Category	Sub-category	Importance n (%)	Necessity n (%)
Introduction to palliative care	Definition of palliative care	9 (100)	8 (88)
	Goals of palliative care	9 (100)	9 (100)
	The importance of the prompt introduction of palliative care to patients	9 (100)	9 (100)
	Types of palliative care in heart failure	9 (100)	8 (88)
	Dimensions of palliative care (physical, including management and evaluation of symptoms, psychological, spiritual, etc.)	9 (100)	8 (88)
Palliative care needs of patients based on heart failure stage	Stage 1: Management of chronic disease	9 (100)	9 (100)
	Stage 2: Palliative and supportive care	9 (100)	9 (100)
	Stages 3,4: End-of-life care	9 (100)	9 (100)
Specialized information about heart failure	Common problems and symptoms of heart failure	9 (100)	8 (88)
	Prognosis	9 (100)	9 (100)
	Treatment	9 (100)	9 (100)
	Medications and side effects	9 (100)	9 (100)
	Diet	9 (100)	9 (100)
Job description of nurses in the team	Competence and skills required to implement palliative care	9 (100)	9 (100)
	Specialized knowledge	5 (55)	5 (55)
	Nursing responsibilities	9 (100)	9 (100)
Patient transfer to palliative care	The onset of the palliative care	9 (100)	9 (100)
	Influential factors for the transfer of heart failure patients to palliative care	9 (100)	9 (100)
	Indication evaluation of palliative care in patients	9 (100)	9 (100)
Unmet wishes and needs of heart failure patients	Physical (pain relief, performing activities without fatigue - attention to sexual issues)	9 (100)	9 (100)
	Psychological	9 (100)	9 (100)
	Social	3 (33)	3 (33)
	Spiritual	9 (100)	8 (88)
	Information (answering their questions - talking about the Prognosis of the disease)	9 (100)	9 (100)
	Communication between the palliative care team and the patient and their family	9 (100)	9 (100)
	Preferences (home death, home care)	9 (100)	9 (100)

Table 5.

The program to familiarize nurses with palliative care for patients with heart failure

The program mission and vision This program aims to familiarize nurses with palliative care for patients with heart failure
Field category	General learning topics sub-category	goals	Learning objectives	Teaching strategies	Evaluation strategies
Introduction to palliative care	Definition of palliative care	An introduction to the basic concepts, principles, and foundations of palliative and supportive care	Defining palliative care (cognitive)	Lecturing	Short-answer open-ended written tests
	Goals of palliative care	Knowledge of palliative care goals (cognitive)
	The importance of the prompt introduction of palliative care to patients		Explaining the importance of the prompt introduction of palliative care to patients (cognitive)
	Types of palliative care in heart failure		Mentioning types of palliative care (cognitive)
	Dimensions of palliative care (physical, including management and evaluation of symptoms, psychological, spiritual, etc.)		Dimensions of palliative care (physical, including management and evaluation of symptoms, psychological, spiritual, etc.) (cognitive)
Palliative care needs of patients based on heart failure stage	Stage 1: Management of chronic disease	Familiarity with palliative care needs of patients based on heart failure stage	Managing the chronic disease in stage 1 (psychomotor)	Lecturing Discussion	Short-answer open-ended written tests Practical exams
	Stage 2: Palliative and supportive care		Providing palliative and supportive care in stage 2 (psychomotor)
	Stages 3,4: End-of-life care		Performing end-of-life care services in stages 3,4 (psychomotor)
Specialized information about heart failure	Common problems and symptoms of heart failure	Familiarity with specialized information about heart failure	Illustrating the common problems and symptoms of heart failure (cognitive)	Lecturing Case study	Short-answer open-ended written tests
	Prognosis		Knowing the prognosis of the disease (cognitive)		Practical exams
	Treatment		Performing pharmacological and non-pharmacological treatments (psychomotor)
	Medications and side effects		Knowledge of medications and their side effects (cognitive)
	Diet		Knowledge of the diet for heart failure (cognitive)
Job description of nurses in the team	Competence and skills required to implement palliative care	Familiarity with the job description of nurses in the team	Acquiring basic knowledge, competence, and skills required to implement palliative care (psychomotor)	Lecturing Review of articles	Short-answer open-ended written tests
	Nursing responsibilities		Knowledge of nursing responsibilities in providing palliative care (cognitive)
Patient transfer to palliative care	The onset of the palliative care	Familiarity with the patient transfer to palliative care	Knowledge of the onset of palliative care (cognitive)	Lecturing Discussion Internship	Discussion on the concepts Conducting research
	Influential factors for the transfer of heart failure patients to palliative care		Knowledge of the influential factors for the transfer of heart failure patients to palliative care (cognitive)
	Indication evaluation of palliative care in patients		Evaluating palliative care indications in patients
Unmet wishes and needs of heart failure patients	Physical (pain relief, performing activities without fatigue - attention to sexual issues)	Familiarity with unmet wishes and needs of heart failure patients	Examining and managing pain, fatigue, and other physical symptoms in patients with heart failure using standard guidelines (psychomotor/cognitive) Answering the patients’ questions about sexual issues (psychomotor/cognitive)	Discussion Internship	practical test (establishing communication with the simulated patient) Conducting research
	Psychological		Examining and managing the psychological symptoms of patients with heart failure using standard guidelines (psychomotor/cognitive)
	Spiritual		Performing spiritual care in patients with heart failure using standard guidelines (psychomotor/cognitive).
	Information (answering their questions - talking about the Prognosis of the disease)		Providing disease information such as the prognosis of the disease and answering to other patient and family questions (psychomotor/cognitive)
	Communication between the palliative care team and the patient and their family		Establishing proper communication with the patient and family (psychomotor)
	Preferences (home death, home care)		Providing end-of-life care at the patient’s bedside based on his/her preferences (psychomotor/cognitive)

Discussion

The current study aimed to develop a heart failure palliative care educational program for nurses. The situation analysis and needs assessment in the first step helped to identify the palliative care needs of heart failure patients, along with the educational needs of cardiac nurses in the field of palliative care in six main areas. During the second step, the educational goals and topics, as well as teaching and evaluation strategies, were determined and underwent expert judgment together with the results of the first step through two opinion poll rounds. Topics agreed upon by experts in terms of importance and necessity were as follows:

The introduction of palliative care is one of the topics whose inclusion in educational programs has been frequently emphasized in similar studies to empower healthcare providers.[25] According to the strategy of the World Health Organization, it is imperative to educate healthcare workers in this field.[7] Similar studies have mentioned limited knowledge, lack of trained palliative care nurses,[26,27] and the inability of nurses to manage and evaluate symptoms as barriers to the implementation of palliative care by nurses.[28] According to one study, nurses did not have enough knowledge about the nature, philosophy, and principles of palliative care, making it necessary to provide them with educational courses about the basic principles of palliative care and comprehensive symptom management.[29] Therefore, developing a program for nurses seems necessary to introduce goals, types, and components of palliative care.

Palliative care needs of patients based on heart failure stage were determined as another field considered in the program. As mentioned in different studies, cardiac patients should not be excluded from specialized palliative care services. These patients have a significant burden of symptoms in each stage of the disease, which necessitates palliative care.[30] The health system staff should also consider providing care according to the values, expectations, and preferences of these patients at the end of life.[31] Therefore, it seems necessary to familiarize nurses with the management of this chronic disease and the provision of supportive and end-of-life care services.

Specialized information about heart failure was another item related to the program development. Different studies show that patients often do not know about their disease conditions and prognosis, leading to depression and noncompliance with treatment. Patients listed access to information about their disease, including the disease nature, treatment, prognosis, and complications, among their most significant needs.[32] In another study, patients and nurses rated the need for pharmaceutical and nutritional information and the risk factors of the disease as the most critical learning needs, respectively.[33] Hence, it is necessary to consider the education related to the disease, including common problems and symptoms of heart failure, prognosis, treatment, medications, side effects, and diet.

The description of the nurse’s role in the team was also considered necessary. A study mentioned six dimensions for the competence of nurses to provide palliative care, including leadership, communication, cooperation, clinical, ethical-legal, psychosocial, and spiritual.[34] Another study reported that the main responsibility of nurses was to support the expectations and values of patients. Nurses also contribute as facilitators, coaches, and advocates, highlighting their need for communication skills and continuous education to provide such services effectively.[35] Therefore, it is necessary to consider the qualification and skills required for implementing palliative care, basic knowledge, and responsibilities of the nurse in the program development.

The patient transfer to palliative care was another critical issue that needed consideration in the program development. The onset time of providing this type of care is crucial. Evidence shows that the prompt and adequate integration of the palliative approach into the heart failure management plan in chronic heart failure would lead to improved quality of life, better control of symptoms,[36,37] less caregiver burden and hospital admission, improved consistency and coordination of care, and peaceful death in the patient’s desired place.[38] Various studies have mentioned several factors to determine the time for the patient transfer to palliative care, including physical and mental symptoms, the disease stage, the number of hospitalizations, etc.[39,40] Thus, it is necessary to provide nurses with the required education concerning the factors determining patient transfer to palliative care and its onset time.

Heart failure patients have countless unmet wishes and needs. According to the results of a review study, most palliative care focuses on the physical dimensions of patients and neglects other dimensions.[41] Even in some cases, physical care is not provided adequately. For example, pain is common but less recognized and, therefore, not treated in heart failure.[42] Other symptoms, such as the psychosocial and spiritual background of heart failure, are much less considered.[43] Heart failure patients experience uncertainty, distress, and adaptation to modified social and professional roles.[3] Another study mentioned the positive results of using tools such as the Integrated Palliative Care Outcome Scale (IPOS) for patients and nurses to comprehensively identify and highlight the unmet needs of patients.[44] Such an instrument can be localized and used in eastern countries such as Iran. According to the above results, it is necessary to consider the unmet demands of patients, including physical, psychological, social, spiritual, and communication needs, along with their preferences, in the development of palliative care programs. The most frequent teaching strategies agreed upon by the experts were lecturing and discussion. Other studies have also used these two methods in the educational programs of nurses with a focus on palliative care.[45,46] For example, a study used lecturing to provide palliative care education (issues related to death) for Swedish nurses at the undergraduate level.[47] Hence, the application of these teaching strategies seems appropriate based on previous research.

The evaluation strategies agreed upon by the experts were short-answer open-ended written tests and practical exams. Program evaluation guides decision-making and program modification. A similar study used open-ended written tests and interviews to evaluate the pursuit of nursing university studies.[48] Another study used written and bedside performance evaluation methods to evaluate nurses as the palliative care interfaces in the hospital.[49] In addition, nurses had to take a written test to assess a nurse practitioner training program.[50] As the results show, different methods have been combined to evaluate the programs. Although this study provides a practical guide to cover different dimensions of palliative care needs in heart failure patients, it faced some limitations, including, 6 of 15 experts were removed from the panel of experts because of failure to respond within the stipulated time and the use of context-based data and the qualitative nature of data collection and analysis, which would limit its generalization to other cultural and social environments. Therefore, it is recommended to review and complete the program through its implementation and evaluation.

Conclusion

Nurses specializing in various diseases can follow the proposed and similar programs to learn more about palliative care and related concepts, subsequently facilitating the provision, quality improvement, and consistency of palliative care services. This program provides nurses with up-to-date information on various aspects of the physical, psychological, social, spiritual, and educational needs of patients and ensures the provision of better services to patients, leading to more satisfaction, reducing mental tensions, and improving treatment compliance and quality of life for heart failure patients.

Financial support and sponsorship

Student Research Committee of Isfahan University of Medical Sciences

Conflicts of interest

Nothing to declare.