Introduction
Cancer persists as a prominent contributor to morbidity and mortality on a global scale, accounting for approximately 19.3 million novel cases and close to 10 million fatalities in 2020, as reported by Ferlay et al. [1]. In the context of China, cancer continues to exert a considerable burden on public health, manifesting in over 4.5 million new diagnoses and resulting in approximately 3 million deaths annually [2]. Pain is a common symptom among patients with cancer, with studies reporting that 30–70% of these patients experience moderate to severe pain at some point during their illness [3]. Managing this pain is a fundamental aspect of palliative care, particularly for oncology nurses, whose role is critical in alleviating patient suffering.
Despite these statistics, there remains a gap in the integration of palliative care into oncology nursing in China. Traditionally, the Chinese healthcare system has prioritized curative treatment, often leading to a neglect of palliative care services. Consequently, many Chinese oncology nurses have limited access to formal palliative care training and lack standardized frameworks to guide their practice [4]. This is particularly concerning given the increasing demand for palliative care services driven by rising cancer rates in China. Palliative care is an essential component of cancer treatment, aiming to improve the quality of life of patients with life-threatening illnesses [5]. In oncology, palliative care focuses on relieving symptoms, particularly pain, which is one of the most common and distressing issues faced by patients. Oncology nurses play a crucial role in this aspect of care, and require both strong theoretical knowledge and practical skills to effectively manage pain and other symptoms in terminally ill patients [6].
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This study aims to explore how core competence in palliative care influences practice ability through self-reported pain assessment as a mediator. Specifically, we aimed to develop a model where self-reported pain assessment mediates the relationship between core competence (independent variable) and practice ability (dependent variable). The rationale behind this model is that pain assessment plays a crucial role in converting theoretical knowledge into practical skills. This approach will clarify how palliative care competence translates into effective practice, especially with regard to pain management for cancer patients with cancer in China.
Background
Core competence in palliative care refers to the set of essential knowledge, skills, and attitudes that oncology nurses must possess to provide high-quality care to patients with advanced illnesses [7]. These competencies include patient and family-centered communication, cultural and ethical values, and effective care delivery. Pain assessment is a fundamental component of palliative care, relying heavily on patients’ own descriptions of their pain experiences, including intensity, duration, and characteristics [8]. Nurses’ ability to conduct thorough and accurate pain assessments is often contingent on their core competence in palliative care, as it requires an understanding of pain mechanisms, patient communication, and the cultural nuances of expressing pain, particularly in Chinese patients [9]. Practice ability in palliative care refers to the actual application of palliative care knowledge in clinical settings [10]. This includes a nurse’s effectiveness in managing pain, addressing psychological distress, and providing holistic care to patients and their families.
The relationship between these concepts is both complex and cyclical, with self-reported pain assessment playing a pivotal role in translating palliative care competence into clinical practice. Some studies have attempted to explain the relationship among the three concepts. Core competence in palliative care provides nurses with the essential knowledge and skills for performing effective pain management [11]. However, the quality of their clinical practice is contingent on their ability to accurately assess pain using self-reported measures [12]. Strong competence in palliative care enhances nurses’ accuracy in pain assessment, which in turn improves the application of their skills in practice [13]. Therefore, self-reported pain assessment serves as a critical link between competence and practice ability, ensuring that theoretical knowledge is effectively translated into clinical actions.
Kirkpatrick’s Model of Training Evaluation is widely used in the healthcare sector to assess the effectiveness of training programs [14]. The model has four levels, which also can be applied to explain the relationship among core competence, self-reported pain assessment, and practice ability. In Kirkpatrick’s Model of Training Evaluation, “reaction” refers to participants’ response to the training, including their satisfaction and engagement. “Learning” denotes the increase in knowledge or skills resulting from the training. “Behavior” involves the application of these learned skills in the workplace, while “Results” focus on the ultimate impact of these behavioral changes on outcomes such as patient care and organizational performance [15].
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Core competence in palliative care represents the learning outcome of training, where nurses enhance their knowledge and skills in pain and symptom management, communication, and patient care, aligning with the “learning” level of Kirkpatrick’s model. Self-reported pain assessment reflects the behavioral change resulting from this training, as nurses apply their knowledge by assessing patients’ pain through self-reported measures, corresponding to the “behavior” level of Kirkpatrick’s model. The final outcome, improved practice ability in palliative care, aligns with the “results” level, where the quality of patient care is enhanced through the nurses’ improved practice. Kirkpatrick’s model suggests that behavior change, exemplified by self-reported pain assessment, is crucial for translating learning into positive outcomes, linking core competencies to real-world clinical practice.
The international research on palliative care, particularly in oncology nursing, has advanced significantly, focusing on the development of palliative care competencies, pain assessment methods, and the practical application of these skills in clinical settings. In high-income countries where palliative care services are well-established, core competence in palliative care has been extensively studied. Competency frameworks have been developed to guide the education and training of healthcare professionals, emphasizing key areas such as pain and symptom management, communication skills, ethical decision-making, and interdisciplinary teamwork [7, 16]. Research indicates that nurses with strong palliative care competencies are more likely to provide high-quality care, manage patient symptoms effectively, and address the emotional and psychological needs of patients and their families [17]. For instance, Bainbridge et al. demonstrated that comprehensive palliative care training programs significantly enhance nurses’ competencies and improve patient outcomes in oncology settings [18].
Pain assessment is central to palliative care, with international research highlighting the importance of accurate pain assessment for effectively managing cancer-related pain. Research in Western countries has addressed challenges in self-reported pain assessment, including cultural differences, communication barriers, and cognitive impairments [19]. Effective pain assessment requires not only validated tools but also the ability of nurses to interpret and act on patient-reported information, emphasizing the need for integrated pain assessment training within palliative care education [20]. The practical application of palliative care skills is another key focus of international research. Studies have evaluated the effectiveness of various educational interventions in enhancing nurses’ practice abilities. For example, a systematic review by Asegid et al. found that simulation-based training significantly improves nurses’ confidence and ability to manage palliative care scenarios, including pain management, end-of-life care, and communication with patients and families [21].
In China, research on palliative care, particularly within oncology nursing, is still in its developmental stages compared to Western countries. However, there is growing recognition of the importance of palliative care in the Chinese healthcare system, driven by the increasing burden of cancer and the need to improve the quality of life of patients with advanced illnesses. Chinese research has begun to explore the concept of core competence in palliative care, particularly in the context of nursing education and practice. Studies have identified significant gaps in the palliative care knowledge and skills of Chinese oncology nurses, which are often attributed to the limited integration of palliative care into nursing curricula and lack of standardized training programs [22]. Recently, efforts have been made to develop and implement palliative care training programs for nurses in China. For instance, a study by Cheng et al. highlighted the effectiveness of a structured palliative care education program for improving the competencies of Chinese oncology nurses [23]. The study found that nurses who participated in the program demonstrated significant improvements in their knowledge, attitudes, and skills related to palliative care, particularly in pain management and communication.
Pain assessment practices in China have historically been influenced by cultural beliefs and attitudes toward pain and suffering. Research has shown that Chinese patients may be less likely to report pain or may underreport the severity of their pain due to cultural norms that emphasize stoicism and avoidance of burdening others [24]. This presents unique challenges for oncology nurses in accurately assessing and managing pain in Chinese patients. Studies have begun to address these challenges by exploring the use of culturally appropriate pain assessment tools and training programs for Chinese nurses. For example, a study by Li et al. found that a pain-education nursing training program significantly improved the accuracy of pain assessment conducted by Chinese oncology nurses [25]. The study also emphasized the importance of cultural competence in pain assessment, highlighting the need for nurses to understand and respect the cultural factors that influence patients’ pain experiences.
The practical application of palliative care skills in China has received increasing attention in recent years. Research has identified several barriers to the effective practice of palliative care in Chinese oncology settings, including a lack of access to palliative care resources, limited interdisciplinary collaboration, and absence of standardized care protocols [26, 27]. However, there have been positive developments as well. For instance, studies have shown that targeted training programs can significantly improve the practice ability of Chinese oncology nurses. A study by Tang et al. demonstrated that nurses who received specialized training in palliative care were more confident and effective in managing complex patients, including those with severe pain and those receiving end-of-life care [28].
Studies on palliative care, both internationally and in China, have highlighted the importance of enhancing oncology nurses’ competencies in this field. While international studies offer insights into effective pain assessment and palliative care practices, Chinese research is beginning to address the cultural and systemic challenges unique to China. This study will contribute to clinical practice by clarifying how palliative care competence influences clinical practice, particularly in pain management. By identifying self-reported pain assessment as a mediator, it underscores the need to improve nurses’ assessment skills to ensure effective application of their knowledge in patient care. The findings could guide the development of targeted training programs and standardized assessment tools, improving pain management and palliative care practice among Chinese oncology nurses. Ultimately, this could lead to better integration of palliative care into routine oncology care, thus enhancing patient outcomes and reducing suffering among cancer patients.
Methods
Design
This multicenter, cross-sectional study was conducted using survey data collected from oncology nurses in Hubei Province, China. It was designed to test the following study hypotheses, which were generated based on previous research findings and the theoretical model [15] that guided this study.
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H1
Palliative care core competence is positively associated with self-reported pain assessment ability.
H2
Palliative care core competence is positively associated with palliative care practice ability.
H3
Self-reported pain assessment ability is positively associated with palliative care practice ability.
H4
Self-reported pain assessment ability exhibits a mediating effect between palliative care core competence and palliative care practice ability.
By testing the above mentioned hypotheses, the present study aimed to enhance our understanding of how oncology nurses’ palliative care core competence influences their palliative care practice ability through the mediating effect of self-reported pain assessment ability.
This multicenter, cross-sectional study employed a stratified random integral sampling technique to select participants. The investigation was carried out within the Oncology departments of 26 tertiary hospitals situated across Hubei Province, China, spanning from June to August 2023. The study’s scope encompassed 13 prefecture-level administrative divisions within the province. To designate the study sites, a randomized selection process facilitated by a digital lottery system was utilized, resulting in the selection of two tertiary hospitals within each prefecture-level administrative division.
The nurses included in the study adhered to the following inclusion criteria: (1) they were actively employed within the oncology unit; (2) they possessed experience in providing care to terminally ill patients within the oncology setting; (3) they had accumulated at least six months of work experience in their current unit; (4) they held a valid Nurse Practice Qualification Certificate issued by the People’s Republic of China; and (5) they provided consent and voluntarily participated in the research project. Nurses who were enrolled in departmental studies during the investigation period were excluded. Furthermore, nurses who were absent from duty during the investigation period due to reasons such as maternity leave, sick leave, or overseas study were also excluded from the study.
The sample size was determined using the single population mean formula: [n = Z2*δ2/ε2] [29], where Z represents the z-score corresponding to a 95% confidence level (Z = 1.96), δ (δ denotes the standard deviation (δ = 13.60)) as reported by An et al., and ε (ε signifies the maximum acceptable error (ε = 0.8)) [13]. A 5% non-response rate was factored into the calculation, resulting in a final sample size of 1165. Given that 1198 questionnaires were included in the data analysis, the sample size was deemed adequate to ensure the robustness and reliability of the statistical analysis conducted.
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Measures
Social demographic characteristics
The participants’ sociodemographic characteristics were gathered utilizing a self-administered questionnaire specifically designed for this study. This questionnaire encompassed 12 variables, namely age, gender, years of professional experience, marital status, education, and professional title.
Palliative care self-report practice scale
The palliative care practice ability of the oncology nurses was evaluated using the Palliative Care Self-Report Practice Scale (PCPS), originally devised by Nakazawa and colleagues in 2010 [10]. The original scale encompasses six subscales with a total of 18 items: pain management (3 items), dyspnea management (3 items), delirium management (3 items), care during the dying phase (3 items), communication (3 items), and patient and family-centered care (3 items). The Cronbach’s α coefficients for the various dimensions of the original scale range from 0.80 to 0.91, and the test-retest reliability coefficients lie between 0.64 and 0.74 [10].
The Chinese version of the PCPS was introduced by Fu and colleagues in 2021 [30]. This adaptation comprises 17 items organized into three dimensions: physical symptom care (8 items), psycho-emotional care (6 items), and communication (3 items). The scale employs a Likert 5-point scoring system, where 1 represents “never” and 5 signifies “always,” resulting in a total possible score range of 17 to 85. Higher scores indicate a superior level of palliative nursing practice ability among the nurses. The Chinese version of the PCPS has demonstrated robust reliability and validity, with an overall Cronbach’s α coefficient of 0.909 and individual dimension coefficients of 0.926, 0.920, and 0.884, respectively.
End-of-life professional caregiver survey
The palliative care core competence of oncology nurses was evaluated using the End-of-life Professional Caregiver Survey (EPCS), an instrument originally developed by Lazenby and colleagues at the Yale School of Nursing [7]. This scale serves as a tool to assess self-perceived palliative care core competence and identify educational needs among nurses specializing in palliative care. The original EPCS encompasses 28 items organized into three subscales: patient and family-centered communication (12 items), cultural and ethical values (8 items), and effective care delivery (8 items). Lazenby et al. reported Cronbach’s alpha coefficients for the overall scale and each subscale as 0.96, 0.95, 0.89, and 0.87, respectively [7].
The Chinese version of the EPCS was introduced by Zou at Wuhan University, and its psychometric properties were assessed among Chinese palliative nurses in 2021 [31]. This adapted version comprises 21 items categorized into three dimensions: patient and family-centered communication (PFCC, 5 items), cultural and ethical values (CEV, 11 items), and effective care delivery (ECD, 5 items). Utilizing a 5-point Likert scoring system, where 0 signifies “strongly disagree” and 4 represents “strongly agree,” the total possible score ranges from 0 to 84. Higher scores indicate a stronger self-perceived core competence in palliative care and fewer perceived educational needs. The Chinese version of the EPCS demonstrated excellent reliability and validity, with an overall Cronbach’s α coefficient of 0.964 and subscale coefficients of 0.887, 0.956, and 0.964, respectively.
Self-perceived pain assessment knowledge and confidence scale
The pain assessment ability of oncology nurses was evaluated using the Self-Perceived Pain Assessment Knowledge and Confidence Scale (Self-PAC), an instrument initially developed by Phillips and colleagues at the University of Technology, Sydney [8]. This scale is specifically designed to assess palliative nurses’ proficiency in pain assessment and their adherence to clinical practice guidelines for managing cancer pain. The Self-PAC consists of 17 items divided into three dimensions: pain assessment knowledge (six items), pain assessment tool knowledge (four items), and pain assessment confidence (seven items). Phillips et al. reported Cronbach’s alpha coefficients for each dimension as 0.944, 0.846, and 0.912, respectively [8].
In 2023, professor Lv introduced the Chinese version of the Self-PAC and evaluated its psychometric properties among Chinese palliative health professionals [32]. This adapted version retains the same 17 items and three dimensions as the original scale. It utilizes a 10-point visual analogue scale, ranging from 0 (no knowledge/not confident) to 10 (extensive knowledge/extremely confident), to calculate scores. Higher scores indicate a greater level of knowledge and proficiency in pain assessment. The Chinese version of the Self-PAC demonstrated strong reliability and validity, with an overall Cronbach’s α coefficient of 0.935 and subscale coefficients of 0.940, 0.834, and 0.969, respectively. Additionally, the test-retest reliability after three weeks was found to be 0.930, further confirming its stability and consistency over time [32].
Data collection
This study utilized the Wenjuanxing platform as the medium for data collection. Head nurses from various selected departments participated in a standardized online research training session organized by our research group. Following the training, they were responsible for disseminating the research questionnaire link and detailed instructions to the nurses within their departments, inviting them to participate during their regular working hours. The online survey format enabled nurses to access and complete the questionnaire at their own convenience, from any location with internet connectivity. The questionnaire was meticulously designed with clear and concise instructions, and accompanied by an informed consent form that elaborated on the study’s objectives and significance. The Wenjuanxing platform incorporated features to prevent multiple submissions, thereby enhancing the accuracy of the collected data. The research team rigorously reviewed the responses for completeness and consistency, excluding any incomplete or inconsistent submissions from the analysis. The questionnaire was distributed via email, and the survey was conducted over a specified period. The study enrolled 1,261 palliative care nurses from 26 tertiary hospitals situated across 13 cities in Hubei Province. After thorough screening, 1,198 questionnaires were deemed eligible for analysis, resulting in an effective response rate of 95.00%.
Statistical analysis
Data was analyzed using SPSS 26.0 and AMOS 26.0 statistical software. All statistical tests were two-sided, with the significance level set at P < 0.05. Descriptive statistics for demographic and other variables included means and standard deviation (SD) for continuous variables, and numbers (N) and percentages (%) for categorical variables. T-tests and one-way ANOVA were employed to compare differences in the PCPS scores between categorical groups. Pearson’s correlation analysis was utilized to examine the relationship among PCPS, EPCS, and Self-PAC scores.
The study used structural equation modeling (SEM) to examine the mediation effect of pain assessment ability on the pathway from palliative care core competence to palliative care practice ability. Path analysis was conducted using AMOS 26.0 software. Bootstrap was employed to test the mediating effect, with the significance level set at 0.05. Model fit was assessed using the following indices: χ2/df, root mean square error of approximation (RMSEA), incremental fit index (IFI), comparative fit index (CFI), normed fit index (NFI), and goodness of fit index (GFI). Adequate model fit was indicated by χ2/df < 3, RMSEA < 0.08, IFI > 0.90, CFI > 0.90, and GFI > 0.90 [33].
Ethics statement
Study participation was entirely voluntary, and all data were gathered anonymously to ensure participant privacy. Given the online survey format, participants were notified that clicking on either the “yes” or “no” box on the initial page of the survey to indicate their consent constituted their informed consent for participation. Furthermore, participants were advised of their right to withdraw from the survey at any time without penalty, and assured that their responses would be kept strictly confidential and would not be disclosed to any third parties. Prior to the commencement of the study, ethics approval was obtained from Shiyan Taihe Hospital (Affiliated Hospital of Hubei University of Medicine) with approval number #2021KS021.
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Results
Sample characteristics
The age range of the study participants spanned from 21 to 50 years, with a mean age of 34.63 ± 9.22 years. Approximately 58.83% of the participants had experienced bereavement, while 57.43% had relatives who had suffered from cancer. Additional demographic characteristics of the study sample are presented in Table 1.
Table 1
Demographics information of nurses(n = 1198)
Variables | n (%) | PCPS(Mean ± SD) | F/t | P | |
|---|---|---|---|---|---|
Age(Years) | ≤ 25 | 100 (8.4) | 68.14 ± 12.11 | 1.0081) | 0.389 |
26∽35 | 694(57.9) | 66.87 ± 13.14 | |||
36∽45 | 257(21.5) | 68.38 ± 12.27 | |||
≥ 46 | 147(12.3) | 67.42 ± 12.28 | |||
Gender | Male | 21(1.8) | 54.73 ± 15.56 | 3.2502) | 0.001 |
Female | 1177(98.3) | 68.59 ± 19.43 | |||
Marital status | Unmarried | 265(22.1) | 66.39 ± 13.10 | 0.1031) | 0.902 |
Married | 903(75.4) | 67.47 ± 12.28 | |||
Divorced or widowed | 30(2.5) | 65.30 ± 16.39 | |||
Education background | College degree or under | 98(8.2) | 63.14 ± 11.34 | 26.3651) | <0.001 |
Bachelor’s degree | 1072(89.5) | 69.23 ± 12.75 | |||
Master’s degree or above | 28(2.3) | 73.26 ± 5.61 | |||
Professional title | Senior nurse or under | 550(45.9) | 68.45 ± 13.24 | 7.9361) | <0.001 |
Supervisor nurse | 564(47.1) | 67.54 ± 12.63 | |||
Associate professor nurse or above | 84(7.0) | 73.46 ± 8.79 | |||
Working years (Years) | 1∽3 | 143(11.9) | 69.14 ± 11.73 | 1.6451) | 0.177 |
4∽5 | 211(17.6) | 66.74 ± 11.42 | |||
6∽10 | 384(32.1) | 66.63 ± 13.33 | |||
≥ 11 | 460(38.4) | 67.73 ± 13.15 | |||
Number of deaths cared for in the past year | 0∽10 | 942(78.6) | 67.25 ± 13.10 | 2.2201) | 0.084 |
11∽30 | 179(14.9) | 68.65 ± 12.57 | |||
31∽50 | 36(3.0) | 68.78 ± 7.93 | |||
≥ 51 | 41(3.4) | 63.22 ± 7.68 | |||
Participate in palliative care training | No | 384(32.1) | 64.41 ± 13.19 | 5.5842) | <0.001 |
Yes | 814(68.0) | 68.77 ± 12.33 | |||
Degree of interest in palliative care | Not interested | 62(5.2) | 63.23 ± 10.72 | 31.7591) | <0.001 |
General | 601(50.2) | 64.98 ± 13.66 | |||
Extremely interested | 535(44.7) | 70.53 ± 11.16 | |||
Self-assessment of palliative care competency | Not competent | 68(5.7) | 57.50 ± 12.69 | 80.7181) | <0.001 |
General | 593(49.5) | 64.36 ± 12.10 | |||
Competent | 537(44.8) | 71.94 ± 11.79 | |||
PCPS, EPCS, and Self-PAC scores
The total scores of the PCPS, EPCS, and Self-PAC among oncology nurses were (67.17 ± 12.57), (76.67 ± 19.59), and (125.68 ± 31.16), respectively, as depicted in Table 2.
Table 2
The total scores and dimension scores of the PCPS, EPCS and Self-PAC (Mean ± SD, n = 1198)
Scales and dimensions | Number of items | Equal score of item (Mean ± SD) | Total score (Mean ± SD) |
|---|---|---|---|
Total score of PCPS [17–85] | 17 | 3.96 ± 0.75 | 67.17 ± 12.57 |
physical symptom care [8–40] | 8 | 4.06 ± 0.76 | 32.50 ± 6.10 |
psycho-psychological care [6–30] | 6 | 3.88 ± 0.82 | 23.35 ± 4.97 |
Communication [3–15] | 3 | 3.86 ± 0.83 | 11.58 ± 2.48 |
Total score of EPCS [0–84] | 21 | 3.65 ± 0.93 | 76.67 ± 19.59 |
PFCC [0–20] | 5 | 3.77 ± 0.95 | 18.86 ± 4.77 |
CEV [0–44] | 11 | 3.53 ± 0.99 | 38.88 ± 10.90 |
ECD [0–20] | 5 | 3.79 ± 0.95 | 18.93 ± 4.77 |
Total score of Self-PAC [0-170] | 17 | 7.40 ± 1.83 | 125.68 ± 31.16 |
pain assessment knowledge [0–60] | 6 | 7.28 ± 1.83 | 43.69 ± 10.99 |
pain assessment tool knowledge [0–40] | 4 | 7.36 ± 1.94 | 29.35 ± 7.16 |
pain assessment confidence [0–70] | 7 | 7.52 ± 1.94 | 52.65 ± 13.59 |
Correlations among the PCPS, EPCS, and Self-PAC scores
Pearson correlation analysis revealed significant positive correlations among the PCPS, EPCS, and Self-PAC scores of the oncology nurses (P < 0.01). Detailed data are presented in Table 3.
Table 3
Correlations between PCPS, EPCS and Self-PAC (r)
Variables | PCPS | EPCS | Self-PAC |
|---|---|---|---|
PCPS | 1 | 0.77** | 0.56** |
EPCS | 0.77** | 1 | 0.48** |
Self-PAC | 0.56** | 0.48** | 1 |
Analyses of the mediation effect
A mediation model was constructed with oncology nursing core competence as the independent variable, pain assessment ability as the mediating variable, and palliative care practice ability as the dependent variable. The results indicated that χ2/df was 2.475 and RMSEA was 0.076. Additionally, the fit indices GFI, CFI, NFI, and IFI were 0.950, 0.979, 0.971, and 0.979, respectively, suggesting good model fit and acceptability. In the mediation effect model, core competence exhibited a direct positive impact on practice ability (β = 0.709, P < 0.001). Core competence also positively influenced pain assessment ability (β = 0.498, P < 0.001), and pain assessment ability positively affected practice ability (β = 0.209, P < 0.001). Bootstrap analysis was conducted with the original data (n = 1198) randomly selected 5000 times. The results revealed that pain assessment ability played a partial mediating role between palliative care core competence and practice ability (ES = 0.125, 95% CI: 0.090–0.168), accounting for 12.8% of the total effect value. The mediating effect model is depicted in Fig. 1.
Fig. 1
Mediating effect model of Self-PAC between EPCS and PCPS. PCPS: Palliative Care Self-Report Practice Scale; EPCS: End-of-life Professional Caregiver Survey; Self-PAC: Self-Perceived Pain Assessment Knowledge and Confidence Scale; PFCC: patient and family centered communication; CEV: cultural and ethical values; ECD: effective care delivery
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Discussion
This study examined the current status and identified the mediating effect of pain assessment ability on the relationship between nurses’ core competence and their ability to practice palliative care. The mean score on the Palliative Care Practice Scale (PCPS) was 67.17 ± 12.57, which was relatively high and comparable to scores reported in studies conducted by Sato et al. in Japan [34] and An et al. in China [13]. However, participants reported suboptimal performance in the communication dimension of palliative nursing practice ability, consistent with findings from previous research. Studies focusing on communication in palliative care have highlighted numerous challenges and complexities in interactions between palliative care professionals and patients [35, 36]. Therefore, communication represents a prevalent issue among palliative nurses and poses a significant barrier to improving palliative care practice. Communication is a pivotal clinical therapeutic tool in palliative care. However, the present study found that palliative care nurses reported inadequate communication abilities. Several factors may have contributed to this observation. Firstly, clinical nurses in China often face heavy workloads and imbalanced patient-to-nurse ratios, leaving insufficient time for effective patient communication. Additionally, the slow development of palliative care in China has led to inadequate training systems, with managers failing to provide sufficient opportunities for nurses to develop palliative care communication skills [27]. Furthermore, cultural factors, such as traditional Chinese taboos surrounding death discussions, limited awareness of death, and mistrust towards nurses among patients and families, may further hinder effective communication with palliative care nurses [37]. Notably, the study found a significant disparity in PCPS scores between palliative care nurses who had received palliative care training and those who had not. This emphasizes the potential effectiveness of enhancing individual practice abilities in addressing issues related to palliative care practice. Therefore, it is imperative to implement relevant training and educational programs for palliative care nurses, focusing on communication skills, in order to enhance their palliative care practice abilities [38].
The interplay between nurses’ core competencies and their proficiency in palliative care practice holds paramount significance. Empirical studies have underscored that robust core competencies, encompassing the aptitude to assess patient needs, administer pain management, offer psychological support, and foster collaboration within multidisciplinary teams, markedly augment the efficacy of nursing interventions in the realm of palliative care [39]. Nurses who demonstrate excellence in these competencies are more adept at devising individualized care plans, addressing intricate clinical scenarios, and navigating ethical dilemmas, ultimately contributing to enhanced patient outcomes and an elevated quality of life. Consequently, bolstering these core competencies is indispensable for the progression of palliative care practice. Within the spectrum of core competencies, nurses’ capacity for pain assessment in palliative care stands as a pivotal indicator of their practice proficiency. Proficient pain assessment skills empower nurses to precisely discern patients’ pain intensity, devise tailored nursing interventions, effectively mitigate pain, and thereby elevate patients’ quality of life [40]. This capability not only mirrors nurses’ professional proficiency but also exhibits a direct correlation with the overall effectiveness of palliative care delivery. Hence, refining nurses’ pain assessment abilities constitutes an efficacious strategy for elevating the standard of palliative care practice.
Based on the results of the mediation effect analysis, it was evident that palliative pain assessment ability served as a mediating variable in the relationship between palliative nurses’ core competence and their nursing practice ability. Strengthening the palliative pain assessment ability among palliative nurses is crucial for effectively translating core competence into enhanced clinical nursing practice performance [41]. Comprehensive pain evaluation and management of terminally ill patients are crucial in palliative care [42]. According to the findings of the present study, pain assessment knowledge of palliative care nurses was a significant area for improvement in palliative nursing practice, possibly due to the absence of a structured pain assessment and management system and insufficient education and training in pain assessment of terminal patients.
Indeed, an efficient pain assessment and management framework holds immense potential in guiding palliative care nurses to deliver optimal pain relief to patients, as evidenced by Lundin and Godskesen [43]. However, despite China’s considerable research endeavors in addressing physical symptoms within the realm of palliative care, the proficiency of healthcare professionals in managing pain remains at a moderate level [37]. Notably, Chinese palliative care nurses primarily rely on standardized pain assessment tools, which lack specificity for end-of-life patients, as pointed out by Yang et al. [44]. In contrast, the United States, Britain, and Hong Kong have developed relatively sophisticated practice guidelines for pain management in palliative care, as documented by Chapman et al. [45] and Chan et al. [46]. To enhance the quality of palliative care in China, it is advisable to establish locally relevant and culturally appropriate practice guidelines for pain management in palliative care by drawing insights from these international guidelines and integrating them with the unique cultural backdrop of China. Such an approach would facilitate the provision of high-standard palliative care tailored to the needs of patients.
To foster the sustained and healthy progression of palliative care throughout China, the National Health Commission of the People’s Republic of China has initiated a series of pilot projects in batches since 2017. To date, three rounds of national pilot initiatives for palliative care have encompassed 185 cities (districts) across the nation, with the scope of these pilot projects progressively expanding from the city (district) level to the provincial (city) level, aiming for comprehensive implementation [47]. These pilot endeavors serve as the cornerstone for the subsequent phased expansion of palliative care coverage. In this regard, pertinent authorities have issued the “Basic Standards and Management Regulations for Palliative Care Centers,” outlining precise requirements for the establishment and governance of palliative care centers [48]. Despite the introduction of a suite of national-level policies and measures for palliative care, their effective implementation poses a significant challenge at present. The findings of this study underscore the necessity for rigorous scrutiny of the gender composition, educational attainment, and dedication to palliative care among nursing staff within pilot institutions. Consequently, there is a pressing need to bolster the training of nursing personnel in core palliative care competencies and curriculum design. This involves augmenting their communication proficiency and pain assessment skills specifically for cancer patients, alongside enhancing their resilience to stress and expertise in resolving emotional distress. Furthermore, personnel allocation must be thoughtfully considered, with workloads judiciously arranged to guarantee the efficient practice of palliative care and the robust development of China’s palliative care industry.
Limitations
The current study is subject to several limitations that warrant acknowledgment. Firstly, the data collection was confined to oncology departments within tertiary hospitals, potentially restricting the generalizability of the findings to alternative settings, such as nursing homes and community-based care environments. This limitation underscores the need for caution in extrapolating the results to a broader context. Secondly, the study’s scope was exclusively focused on oncology nurses, excluding other vital stakeholders such as physicians and other medical personnel involved in palliative care. Consequently, the findings may not comprehensively reflect the overall landscape of palliative care practice in mainland China, limiting the study’s holistic perspective. Thirdly, the reliance on subjective self-reports from palliative care nurses may have introduced an element of bias, potentially leading to an overestimation of the reported levels of palliative care practice ability. This dependency on self-reported data highlights the importance of exploring objective measures and multi-source data collection methods in future research endeavors.
Conclusion
In conclusion, this study emphasizes the pivotal role of pain assessment ability and core competence in shaping palliative care practices among Chinese oncology nurses. The findings demonstrate the necessity of implementing effective palliative training programs tailored to the specific needs of palliative care nurses, including comprehensive training in pain assessment, communication skills, and spiritual care. Additionally, governmental authorities need to make concerted efforts to address workforce shortages by recruiting more palliative care nurses, thereby alleviating the burden on the existing staff. Moreover, managerial initiatives should prioritize the enhancement of referral criteria for palliative care procedures and refinement of training and assessment systems for palliative care nurses.
Acknowledgements
We would like to thanks all the oncology nurses who participated the survey. We also would thank for the experts who gave some advice and suggestion to the study.
Declarations
Competing interests
The authors declare no competing interests.
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