Advancing Palliative Care through Advanced Nursing Practice: A Rapid Review

Objectives

This article aims to achieve the following objectives:

• To outline the background of ANP in PC, its interest, and training needs

• To put forward recommendations for its establishment in the Moroccan healthcare system.

Study design

The present study was conducted to identify and summarise the current knowledge on APNs and their role in PC at an international level by studying the impact of this role on outcomes and the training needed to acquire the necessary skills.

This review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, Edition 2020.^[12]

Inclusion and exclusion criteria

The inclusion criteria were: (1) studies published between 2012 and 2022; (2) studies written in English; (3) studies published in the field of nursing.

The exclusion criteria were conference abstracts, pathways, letters, textbooks, and studies that do not mention the contribution of the APN ANP in the field of PC.

Literature search and strategy

Relevant studies were searched using online scientific databases available through IMIST/CNRST, including Scopus, Web of Science, and ScienceDirect, published between 2012 and 2022. The full process, illustrated in Figure 1 (flow diagram), was conducted from 10 to 27 July 2023.

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Figure 1:

Preferred reporting items for systematic reviews and meta-analyses flow diagram. ’N’ to designate the number before sorting, and ‘n’ designates the number after sorting. APN: Advance practice nurse, PC: Palliative care.

Export to PPT

The keywords used during the search were: ‘Advanced nursing practice’ and ‘palliative care,’ attached by the logical Boolean connector ‘AND.’

The flow diagram Figure 1 shows the sorting process. The recording through database searching was n = 161 (Scopus = 10; Web of Science = 34; ScienceDirect = 117). Seventy-four studies were found to be potentially relevant following the screening. Sixty-two studies did not meet the inclusion criteria, and 12 articles were identified from the title and the abstract screening. Finally, eight relevant studies were included in this review after a second reading to refine eligibility after mobilising the AGREE II tool.^[13]

Data extraction

The following three biases were assessed to eliminate the risk of data gathering, namely selection bias (to avoid a random selection of studies, this review defined inclusion and exclusion criteria), detection bias (to ensure that the study is exhaustive and that all the relevant studies were identified, this review attempted to obtain information from the various databases available) and interpretation bias (to guarantee an objective interpretation, reading committee with five members were involved in the evaluation and synthesis of the studies).

Moreover, at the final step of the selection process, the quality analysis was assessed using the AGREE II tool developed by Brouwers et al., updated in 2016,^[13] for greater accuracy and neutrality and to ensure the final selection. This grid contains 23 items, grouped into six areas, which were evaluated for each study selected, scope and purpose, stakeholder involvement, the rigour of development, clarity of presentation, applicability, and editorial independence. All items are assessed using a Likert scale from 1 (Strongly disagree) to 7 (Strongly agree).

Article selection

As shown in the flow diagram, eight articles were selected from 161 articles. The characteristics of the selected studies with the details: Title, author(s), year publication, aim, material and methods, and relevant notes are summarised in Table 1.

The studies selected were published in English between 2015 and 2020 and addressed the objective of the study.

After reviewing the selected publications, the results were summarised in the following areas:

Definition

Role and contribution of the APN in PC

The care provided by APNs has been proven to be effective, safe, and of high quality.^[22-25] The demand for APNs has recognised an increase in their clinical expertise, leadership, and effectiveness as leaders of change on the health side and as a part of nurses’ careers.^[18,26]

APNs are necessary care providers in interdisciplinary teams working in PC departments.^[17,18,25] One of the areas in which the APN’s contribution is sought is oncology.^[19] APNs play an important role in all phases of the cancer treatment process, they contribute to the PC.^[19,15]

PC experts claim that APNs play an effective role in the care of patients with life-limiting illnesses.^[6,25,27] Due to their knowledge of pharmacology psychology and their in-depth clinical skills,^[15] APNs can meet the needs of patients and their families by promoting a positive death.^[15,28] Besides, a study conducted by Schenker et al., in 2015 revealed that the PC provided by APNs was feasible and acceptable to the patients.^[29,30]

Alotaïbi and Al Anizi cited that Bakitas et al., in 2019, have determined the roles of APNs in PC, namely communication and counselling with patients and their families, pain and accompanying symptoms management, advanced care offer, quality of life development and improving patient’s end-of-life experiences.^[19,31] It was mentioned by McCorkle et al. that APNs facilitate the management of patients with advanced cancers by helping them to understand their disease and by offering PC integrated into complete cancer treatment to potentially prolong their life expectancy.^[30]

Moreover, it was also highlighted that APNs have the necessary skills for anxiety relief and managing patients’ symptoms, which reduces the number of visits ^[19], and have leadership skills that allow them to work as administrators, specialists, clinical consultants, and researchers.^[15,32]

To this end, APNs, in particular NPs, will increasingly take on active and efficient roles in primary and specialist PCs.^[17] Then, APNs have skills that encompass the responsibilities of several workforces^[15,33], and they can provide training in best PC practice by collaborating with other care contributors.^[15,17]

PC-based training for APNs

In all fields, APNs must have at least a Master’s degree.^[15,17-20] According to Health Education England, by 2020, APNs should be trained to master’s level, providing them with the knowledge and skills to take on expanded and defined roles.^[19]

Whereas it was concluded that training should be specialised in a particular field, such as geriatrics PCs.^[15] The American Society of Clinical Oncology recommended that healthcare programmes should include PCs.^[30] However, if nurses are already practising as APNs, they can obtain a post-master’s certificate in PC offered by institutes or universities.^[15,34]

Actually, nurses need to be trained to take on more complex care responsibilities.^[18] To achieve this, university programme managers need to consolidate the basic nursing training programmes and recruit highly qualified teachers.^[18] These programmes must be based on well-defined competencies for the role and the diploma.^[18,35] A master’s programme based on the 3Ps (Physiology, Pathophysiology, and Pharmacology) was mentioned by Parker and Hill in 2017.^[18] This programme focuses on the acquisition of the following skills: Planning, critical thinking, informatics, leadership, evidence-based practice, and evaluation.^[18]

Furthermore, nurses can enrol in postgraduate training in a specialised field and complete a minimum of 500 h to obtain a license to practice in the US.^[16,35] The same point was raised by George, who added that the training should be carried out in the year preceding the recruitment exam.^[15]

As for Israel, it required 350 hours of didactic training and 400 hours of clinical training. The academic programme requires one year’s training at a state-recognised nursing school and 400 hours of internship in clinical practice supervised by a physician.^[16]

Limits and recommendations

The studies have identified a lack of clarity in the APN profession. Collett et al. noted that there is a need for a clear definition of the roles accorded to APNs and the authority of their practice since there are healthcare staff who are unaware of the qualifications of APNs and how to generate integration flows in the work departments.^[16] In addition, Alotaibi and Al Anizi reported that this lack concerns the differences between hospital services and even the variations in context in each country.^[11,19]

Furthermore, studies have mentioned the obstacles of the regulations governing the profession. Pawlow et al. highlighted that although the authorities have made efforts to improve legislation, restrictive regulations hinder the implementation of the scope of practice of APNs.^[25] It concerns the power to prescribe and bill for homecare services and the independence linked to supervision by physicians.^[25] However, Parker and Hill have determined that the legitimacy of this profile requires the acceptance of all those concerned,^[18] and Collett et al. have proposed a consolidation of knowledge,^[16,36] which can be increased by creating organisations that advocate the introduction of APNs and the increased use of this profile.^[11,16,37] Indeed, the determination of a national definition is needed and must refer to internationally accepted definitions, mentioned in coherent documents that encompass all the data concerning the scope of practice of APNs.^[18]

Limitations and strengths of the study

This study has some limitations that should be mentioned. In particular, the absence of studies dealing with ANP in the Moroccan context. In addition, the concepts of ‘APN’ and ‘PC’ are emerging in the national context.

However, this study is the first of its kind in Morocco, combining these two concepts to attract the attention of decision-makers, given that this profession is a solution to the shortage of nursing staff in this speciality.

Recommendations and implications

We recommend that the study be generalised by modifying the filters used in the first instance (year of publication, search field, the field of practice of the APN) to identify the contribution of APNs as a solution to the shortage of medical staff, which represents a major public health challenge.

As for the implications, the study approves that the implementation of the APN in the national health system is possible given the maintenance of training through the universitarisation of nursing care in the master’s degree, recognised internationally as a necessary degree for the training of APNs.

In addition, one of the departments recognising a shortage of staff and requiring a multidisciplinary team to manage patients is the PC department. The APN combines the skills of several professionals, making it the most appropriate solution for this shortage. It has been proven that the APN offers a polyvalent and high-quality range of care, given the technical and non-technical skills it possesses. This will be reflected in the quality-cost ratio.