The Core Competencies of Nurses Providing Home-based Palliative Care to Patients with Incurable Diseases: A Scoping Review

Document Type : Review article

Authors

1 Medical Education Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran;

2 Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran;

3 Social Determinants of Health Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran;

4 Artificial Intelligence in Medical Sciences Research Center, Smart University of Medical Sciences, Tehran, Iran;

5 French Institute of Research and High Education (IFRES-INT), Paris, France

Abstract

Background: To effectively deliver palliative care within community settings, nurses must possess adequate competencies. Regarding the few review studies in this field, the present study aimed to explore the necessary qualifications required for nurses providing home-based palliative care to patients with incurable diseases.
Methods: This scoping review was performed during 2024 based on the Cochrane methodology using the methodological framework of Arksey and O’Malley in six steps. A comprehensive literature review was conducted on databases of Web of Science, Scopus, PubMed/Medline, EBSCO, as well as Cochran library. Articles published in English between 1990 and 2024 were screened, and the textual narrative synthesis was used for data analysis.
Results: The extracted data were organized into three main competencies including knowledge (knowledge of the philosophy of palliative care,  familiarity with incurable diseases, and awareness of the structure of the healthcare system), attitude (interprofessional and intersectoral cooperation, cultural competence, and adherence to ethical principles), and skills (physical care, psychological care, spiritual care, social support, medication administration, care of dying patients, and communication skills).
Conclusion: Community health nurses must possess sufficient knowledge, appropriate attitudes, and essential clinical competencies to deliver effective community‑based palliative care for patients with life‑limiting illnesses. The necessary competencies to provide home-based palliative care should be integrated into the nursing education program.

Highlights

Saeideh Ghaffarifar (Google Scholar) (PubMed)

Heshmatolah Heydari (Google Scholar) (PubMed)

Keywords

INTRODUCTION

Community health nurses are considered worldwide as one of the most important strategies employed by the World Health Organization (WHO) to achieve universal health coverage (UHC). 1 Palliative care provision is regarded as one of the services that nurses can provide to clients at the community level. The WHO introduced supportive-palliative care to promote the quality of life of patients suffering from incurable diseases and their families. Palliative care starts at the point of disease diagnosis and continues the disease trajectory, in which the care provider helps the patient and his/her family more readily make peace with the condition. Rather than aiming to hasten or delay death, this approach views life and death as interconnected aspects of the life process. This care approach aids patients to live meaningfully until the moment of demise and supports the patient’s family during the disease course, at the time of death, so that they can accept the reality and mourn more peacefully. 2

According to a WHO report, palliative care and community-based care share common principles such as continuity of care, social accountability, respecting the patient’s values, and paying attention to the patient and his/her family. During the 2016 world health convention, it was suggested that health systems should integrate home-based palliative care into primary health care (PHC) programs for achieving the sustainable development goals and UHC. 3 Palliative care programs have currently no place in the structure of the health system in many countries. One of the main barriers to providing palliative care in PHC programs is the inability of professional health care providers to deliver such services. 4 Nurses are among the main professional health care providers engaged in providing hospital-based palliative care services to terminally ill patients. Given the importance of providing high-quality nursing care to patients, the concept of clinical competency has turned into a fundamental issue in nursing educational and clinical centers. 5 Therefore, it is important to evaluate clinical competency to identify performance dimensions requiring improvement, determine the nurses’ educational needs, and finally, ensure the provision of quality care. The results of a study showed that home-based and hospice palliative care in European countries is mostly provided by non-specialists lacking the necessary qualifications to provide palliative care. 6 The nurses were not adequately qualified to provide palliative care. 7 There is a gap between the care needs of terminally ill patients and the qualifications of nurses to provide palliative care at the community level, which requires attention. Various models have been designed to provide community-based palliative care for terminally ill patients, where nurses must be qualified to provide quality care. 8 , 9 According to studies, nurses are not adequately prepared to provide community-based palliative care, 7 , 10 and most of the time, their curricula are not based on the needs of patients. 11 , 12 Sufficient education has been identified as a critical factor in integrating palliative care into the healthcare system. 6

The findings of the studies show that one of the challenges nurses face in providing community-based palliative care is the mismatch between their abilities and patients’ needs. 13 , 14 To provide appropriate palliative care to patients, we need to tailor the nurses’ qualifications to the needs of patients, in which case essential qualifications must be identified. There is a need to define competencies across different levels so that health professionals are empowered. 11

Various studies have determined the qualifications required for nurses in inpatient and hospital wards. 15 , 16 Some studies have focused on determining the competency of nurses at the community level, but each of them has had limitations, 17 , 18 some have focused on determining competency in narrow dimensions, 19 - 21 and others have assessed the competencies required of nurses from the perspective of limited stakeholders such as physicians and nurses. 18 , 22 Therefore, it seems necessary to conduct a broad review study to determine the desired competencies from the perspective of various stakeholders and in all physical, psychological, spiritual, and social dimensions.

A comprehensive review of the existing literature can provide valuable insights into the essential qualification’s nurses must possess in the field of community-based palliative care. By pinpointing these competency requirements, conditions are created for developing educational programs and empowering nurses to provide community-based palliative care. Given that no comprehensive review study was found in this regard, this study aimed to explore the necessary qualifications required for nurses to provide home-based palliative care to patients with incurable diseases.

MATERIALS AND METHODS

This scoping review was conducted during November 2024 using the Cochrane methodology and the Arksey & O’Malley framework, suggesting the following six steps: developing research question, finding relevant studies, selecting the study, charting the data , collecting, summarizing, reporting the findings, and consulting. 23

In this study, the following research questions were posed:

“What are the home-based care needs of patients with incurable disease?”

“What type of care is required at each stage of disease progression for patients with incurable disease?”

“What actions should nurses take to deliver effective palliative care at home for patients with incurable diseases?”

“What competencies are required for nurses to provide home-based palliative care to patients with incurable disease at each stage of disease?”

The inclusion criteria for the retrieved articles were research articles with any type of methodology (qualitative, quantitative, and review studies), addressing the necessary qualifications of home-based caregivers regarding management, education, care, and supportive services, and being published in English. The exclusion criterion was the lack of access to the full text after attempting to contact the authors.

To identify relevant studies, we conducted a comprehensive literature search in the Web of Science, Scopus, Medline (through PubMed), EBSCO databases, as well as Cochran library using appropriate keywords in English. First, appropriate Medical Sub-Heading (MeSH) terms were searched to identify related keywords. Then, search operators, tags, and parentheses were utilized to combine these keywords and conduct a comprehensive search in the databases (Table 1). The search was restricted to studies published from the beginning of 1990 to the end of Nov 2024. No restrictions were applied regarding the geographical location or type of study. The language of the articles was restricted to English. In addition, the reference list of the retrieved articles was manually reviewed to find further relevant studies. To retrieve Gray Literature (theses, abstracts of conference articles, unpublished research projects, etc.), we performed a manual search using the Google search engine. Furthermore, the relevant articles published in renowned journals within the last two years were manually searched. The renowned journals were selected based on their scope in the field of nursing education or palliative care, Scopus site score, and agreement among the research team. These journals included Nursing Education Today, Journal of Nursing Education, Nursing Education Perspectives, Nurse Education in Practice, Nurse Educator, Journal of Continuing Education in Nursing, BMC Palliative Care, BMJ Supportive & Palliative Care, Journal of Palliative Care, Journal of Palliative Medicine, and Supportive Care in Cancer. Renowned people in the field of community-based palliative care were identified by searching during the study.

Keywords Competencies; Community Health Nursing; Home Health Care; palliative Care
PubMed (Palliative[tiab] OR supportive[tiab] OR incurable[tiab] OR “End of life”[tiab] OR “End stage” [tiab] OR “Late stage”[tiab] OR “terminal care”[tiab]) AND (“Home Care” [tiab] OR (home AND care[tiab]) OR “Domiciliary Care”[tiab] OR “Home visit”[tiab] OR “home health care” [tiab] AND (nurse [tiab] OR nursing [tiab] OR nurses [tiab])) AND 1990/01/01:2024/10/01[dp].
Scopus (TITLE-ABS-KEY (palliative OR supportive OR incurable OR “End of life” OR “End stage” OR “Late stage” OR “terminal care”) AND TITLE-ABS-KEY (“Home Care” OR (home AND care) OR “Domiciliary Care” OR “Home visit” OR “home health care”) AND TITLE (nurse OR nursing OR nurses )).
Web of Sciences ((TS= (palliative) OR TS= (supportive) OR TS= (incurable) OR TS= (“End of life”) OR TS= (“End stage”) OR TS= (“Late stage”) OR TS= (“terminal care”)) AND (TS= ( “Home Care”) OR TS= ( home AND care ) OR TS= (“Domiciliary Care”) OR TS= (“Home visit”) OR TS= (“home health care”)) AND (TS= ( nurse) OR TS= ( nursing) OR TS= (nurses ))).
EBSCO ((Competencies) And (“Community Health Nursing” OR “Home Health Care” OR “palliative Care”)).
Cochrane Competencies):ti,ab,kw AND (Community Health Nursing):ti,ab,kw AND (Home Health Care):ti,ab,kw AND (palliative Care):ti,ab,kw
Table 1.Keywords and syntax used in searching data in different databases

The selection and screening of articles were initially conducted by two of the authors based on their titles, abstracts, and keywords, followed by full text reviewing. If the title of the retrieved article was consistent with the objectives of this review, its abstract was studied. The full text of the eligible studies was reviewed. Finally, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used to report the findings of the retrieved studies 24 (Figure 1).

Figure 1. PRISMA flowchart for selection of articles

After the retrieval and selection of studies, the textual narrative synthesis was conducted for analysis. 25 Data were extracted and categorized through consensus among the research team members. It is noteworthy that all stages of the literature search, screening, and study selection were independently conducted by the first and third authors. Any disagreements between these two researchers were resolved through discussions. If the disagreement persisted, the second author was consulted to make the final decision.

Ethical considerations were observed in all stages of the study including data extraction, management, and publication. The study approval was obtained from the ethics committee of Smart University of Medical Sciences (ethical code: IR.VUMS.REC.1401.058).

RESULTS

In this scoping review, a total of 13,667 records were initially identified. After removing 105 duplicates, 13,562 records remained. Following screening the titles and abstracts, 13,495 articles were excluded. Then, 31 articles were eliminated after full-text review due to the inconsistency with the inclusion criteria. Finally, 36 articles were considered eligible and relevant to the objectives based on the assessment of their titles, abstracts, and full texts (Figure 1). In the present study, 36 articles (14 qualitative studies, 18 , 20 , 22 , 26 - 36 6 descriptive studies, 7 , 11 , 14 , 17 , 37 , 38 7 review studies, 16 , 19 , 21 , 39 - 42 4 mixed-methods studies, 9 , 13 , 43 , 44 one action research, 45 one pilot study, 46 one methodologic study, 47 one national study, 48 and one health system research 8 ) were reviewed. The retrieved publications were categorized based on the author’s name, year of publication, title, country, study design, objectives, and findings of the study (Table 2). After retrieving articles and following prespecified instructions, two researchers independently extracted the codes from the selected studies based on the objectives of this review.

No. Author, year Country Study design Goals of study Findings
1 Momen N. & et al, 2013 17 British Descriptive Study Examining the education and knowledge of general practitioners and community health nurses in palliative care Most nurses reported that they had received training in all five areas while nursing in the hospital, but had received significantly less training in working in the community, particularly in relation to syringe handling and bereavement care.
2 Teruya N. & et al, 2019 18 Japan Qualitative study Exploring the perception of visiting nurses of critical measures to ensure the rights of patients who wish to die at home. Nursing assessment, supporting the comfortable daily life of the patient and his family, supporting the patient’s views on continuing care at home until death, supporting the patient’s preparation for death, and coordination with other health professionals and related facilities for a comfortable environment for the patient
3 Bergdahl E. & et al, 2007 32 Sweden Qualitative study Exploring the abilities needed to create a caring relationship in home palliative care from an aesthetic perspective. See the unique person - distance attention, feeling empathy, understanding, adaptability openness in the relationship trust, self-confidence support, relaxation, giving information and take in the meeting, Personal and Professional knowledge, skill intuition creativity
4 Namasivayam P. & et al, 2014 31 Malaysia Qualitative study Explaining Malaysian nurses’ perspective on caring for families with patients at the end of life. The main problem identified by nurses was the different expectations of families in patient care. Participants used the core process of engaging with families to resolve these differences and implemented strategies such as preparing families for palliative care, modifying care, and staying engaged to promote greater consistency and quality of care. Dissonance was identified as a negative consequence of participants who were unable to resolve families’ expectations
5 Bergdahl E. & et al, 2011 45 Sweden Action Research Improving the ability of nurses to provide palliative care to patients. Improving knowledge, appropriate understanding and willingness to provide appropriate patient care
6 Sousa J. & et al, 2015 33 Brazil Explanatory study with Delfi Approach Identifying the nurses’ competencies for palliative care in home care. Necessary competencies were knowledge, practice, confidence, understand their own limitations, interdisciplinary work, problem solving, continuity of the care, autonomy, dignity, public education, communication, understanding the position in relation to life and death, loss and grief.
7 Wallerstedt B. & et al, 2007 34 Sweden Qualitative study Explaining the experiences’ nurses in caring for critically ill and dying patients outside special palliative care settings. Responsibility, cooperation, experience and knowledge, and emotions.
8 Martins S. & et al, 2021 11 European countries Descriptive Study Determining the standard for palliative care education for undergraduate and postgraduate nurses across Europe. Standards including: consultation, clinical care, research, team support, education, policy and decision-making.
9 Slatten K. & et al, 2014 47 Norway Methodological Study Using psychometric tools of the main competencies of palliative care nurses This instrument consists of 26 items that assess nurses’ competencies in providing palliative care across five dimensions: Life closure skills, Systematic use of Edmonton Symptom Assessment System, Teamwork skills, Knowledge in symptom management, and Interpersonal skills.
10 Hojjat-Assaric S. & et al, 2021 8 Iran Health system research Designing an integrated model of community-based palliative care into the primary health care for terminally ill cancer patients in Iran Provide the palliative care model for cancer patients into the primary health care from diagnosis to death.
11 Gafer, N. & et al, 2024 9 EMRO countries Mixed-method research Designing a model for integrating palliative care into Eastern Mediterranean health systems with a primary care approach The model including policymaking, access to medicine, education, community integration, service delivery, and research.
12 Walshe C. & et al, 2010 39 International Review study Determining the role of district nurses in providing palliative care Providing primary care at home, palliative and end-of-life care.
13 Suikkala, A. & et al, 2021 22 Finland Qualitative design Describing the views of physicians and registered nurses regarding future competence needs within palliative care. Palliative care competence at all levels in health and social welfare services, individual palliative care competence, a person-centered approach to competence, and the systematic development of competence in palliative care.
14 Dunne K. & et al, 2005 29 Norway Qualitative study Exploring the experiences of district nurses about palliative care for patients with cancer. Providing palliative care and end of life care
15 Birtwistle J. & et al, 2002 37 England Descriptive Study Determining the role of district nurses in supportive of bereavement. Provide services for bereavement care
16 Runciman P. & et al, 2014 28 Scotland Qualitative Study Exploring the district nurse’s experience about connection with a patient with multiple sclerosis. Education in each visit, the primary focus is on prevention, the second focus is on restoring health, and the third focus is on disease control.
17 Glover T. & et al, 2019 27 United State of America Qualitative study Exploring the competency consistent of reflections’ nurses and students with patients. Individual values and diversity, compassionate communication, fostering quality of life, and self-insight and emotion
18 Law J. & et al, 2011 26 Ireland Qualitative study Explaining the role and activities of nurses, who care for children with complex needs in a community setting. Transfer from acute conditions to home, community, school and perform routine activities as much as possible for children with disabilities.
19 Joren C. & et al, 2021 48 Netherland National Survey Exploring the palliative care provided by nurses in home care and hospitals. The palliative care including: physical care, psychological care, social care, spiritual care
20 Hagelin CL. & et al, 2022 43 Sweden Mixed-method research Examining the amount, content and educational methods used for palliative care in the nursing programs at Swedish universities The content including: philosophy of palliative care - common symptoms in palliative care or end-of-life care - behavioral theories - cancer - crisis responses - communication - supplementary care - clinical care of common symptoms - death and dying, thanatology - dementia - ethics - euthanasia - existential issues - grief - laws - pulmonary diseases - neurological diseases - theories of nursing care - drug treatments - philosophy - team work - professional roles - transcultural care
21 Becque YN. & et al, 2019 42 International Systematic review Evaluating the nursing interventions to support family caregivers in end-of-life care at home. Interventions including: Psychoeducation, assessment of needs, support for caregivers and peers
22 Brant JM. & et al, 2019 13 29 countries Mixed method A global survey of the roles, satisfaction and barriers of home health care nurses for provision of palliative care. Nurses in developing countries perform more tasks compared to nurses in high-income countries. Important barriers to providing home care including: lack of personnel, lack of funding and policy, poor access to end-of-life services or hospice, and reduced community awareness of the services provided.
23 Hökkä M. & et al, 2020 16 International Systematic integrative review with thematic synthesis Evaluating the required nursing competencies in palliative care. The competencies including: leadership, communication, collaboration, clinical, psychosocial and spiritual care.
24 Brownhill S. & et al, 2013 35 Australia Qualitative Study Explaining and design of a decision-making model for bereavement care in community health nurses. The decision making was influenced by the level of kindness received from the community health nurse, the workload of the community health nurse, the scope of competence, experience, skills and characteristics of the nurse, the environmental conditions of bereavement, the quality and visit requests – The visits should be done every 2-6 weeks
25 Devlin M. & et al, 2010 44 France Mixed Method Explaining the experiences of home care workers about palliative care. Giving medication - taking care of catheters - doing housework - feeding the client - preparing food - taking care of the affected areas - talking and listening to the client and the family
26 Erichsen E. & et al, 2010 30 Sweden Qualitative study Explaining nurses’ understanding of honesty in palliative care. The meaning of honesty, the reason for honesty and finally the moral conflict in the face of honesty
27 Ferrell BR. & et al, 1998 46 United State of America Pilot study Developing end-of-life care education at home The care education including: pain management - symptom management - communication with patients and family - death management
28 Karlsson M, & et al, 2010 20 Sweden Qualitative content analysis Community health nurses’ experiences of ethical dilemmas in palliative care. Frustration and concern related to ethical dilemmas in palliative care - having the knowledge and skills to manage ethical dilemmas.
29 Kelly K. & et al, 2011 36 United State of America Qualitative study Developing palliative care nursing education in California The education including: principles of palliative care - pain assessment and management - management of disease symptoms - compliance with ethical principles - cultural and spiritual considerations - communication - bereavement management - ensuring the quality of end-of-life care - preparation and care of staff, patient and family at the time of death
30 Mastroianni C. & et al, 2019 38 Italy Descriptive study Evaluating of palliative care education in the undergraduate nursing curriculum in Italy. Issues related to the end stage and death, pain, grief and supportive care of patients and families.
31 McDonnell MM & et al, 2009 14 Ireland Descriptive study Identifying the palliative care training needs of general nurses. Understanding the dying process, managing pain and symptoms, improve communication skills, nutritional assessment issues, practical skills, proper use and management of all types of syringes, and the role of complementary therapies
32 Reed FM & et al, 2015 21 International Review article Evaluating the required competency of neighborhood nurses to selection of rural clients to live and die at home. The competencies including: nursing communication, interaction, and supportive.
33 Almulla H. & et al, 2024 7 Saudi Arabia Descriptive correlational study Assessing palliative care practices and knowledge of home care nurses. Findings showed that nurses lacked adequate knowledge and skills in providing home-based palliative care.
34 Wu Y-H. & et al, 2023 41 International Qualitative meta-synthesis Identifying the needs of nurses providing home-based palliative care. The needs including: nature of community-based palliative nursing, teamwork, relationship with patient and family, and resources.
35 Gray JA. & et al. 2024 19 International A thematic analysis approach Exploring the cultural challenges in providing palliative care from the perspective of nurses in nursing facilities. Cultural needs of residents, cultural needs of family members, problems related to accommodating residents, and organizational responses.
36 Fuglsang CMB. & et al. 2023 40 International Scoping Review Determining the roles of nurses in supporting the caregivers of ill patients at home. Facilitate sharing of the care burden among several members of the family. Care must be performed according to the principles of family nursing.
Table 2.Characteristics of the studies included in this scoping review

Synthesis of the findings from the included studies indicated that the core competencies of nurses providing home-based palliative care to patients with incurable diseases categories in various aspects including knowledge (knowledge of the philosophy of palliative care, familiarity with incurable diseases, and awareness of the structure of the healthcare system), attitude (interprofessional and intersectoral cooperation, cultural competence, and adherence to ethical principles), and skills (physical care, psychological care, spiritual care, social support, medication administration, care of dying patients, and communication skills).

1. Knowledge

The data showed that one of the competencies relevant to community health nurses is knowledge related to incurable disease and the context in which care is provided. With good knowledge about the disease, the community health nurse can understand the reason for providing palliative care and how to provide care in the desired context. Knowledge was divided into knowledge of the philosophy of palliative care, familiarity with incurable diseases, and the awareness of the structure of the health system.

1.a. Knowledge of the Philosophy of Palliative Care

One of the important competencies for community health nurses is understanding the philosophy of palliative care. Community health nurses should be familiar with the reasons of providing health services to patients with end-of-life illnesses at the community level. 30 , 32 , 41 , 43

1.b. Familiarity with Incurable Diseases

The data showed that nurses must be familiar with the pathology of the disease to provide palliative care to patients with incurable diseases, and understand the patient’s needs, prognosis, complications and necessary care for each disease. 37 , 43

1.c. Awareness of the Structure of the Healthcare System

To provide health services to patients with incurable diseases, community health nurses must be familiar with the structure of the health system, health service providers, laws and guidelines, and the way to access health services at the community level. 8 , 9

2. Attitude

One of the competencies required for community health nurses to care for patients with incurable diseases is to have a positive attitude towards the philosophy of providing palliative care at the community level and the requirements related to caring for these patients in their own community. In this competency, three aspects were replaced, including interprofessional and intersectoral cooperation, cultural competence, and adherence to ethical principles.

2.a. Interprofessional and Intersectoral Cooperation

Interprofessional and interdepartmental collaboration in providing health services is an inevitable reality, and to improve the health of the community, it is essential that health team staff and various institutions have positive perspectives toward inter-disciplinary and inter-sectoral coordination. In most cases, the community health nurse plays a coordinating role and should have a positive insight to establish communication between different health professions. 16 , 18 , 33 , 34 , 40 , 41 , 47

2.b. Cultural Competence

The data showed that one of the competencies required by community health nurses is cultural competence. To provide health services in any society, services must be provided to the people in accordance with the values, beliefs, and convictions of that society. The beliefs and traditions of patients and families regarding life and death, corpse management, funeral ceremonies, and mourning vary among different ethnic groups, and the community health nurse must be able to handle these situations in different societies. To convince the patient and her family and establish good communication, the nurse must be familiar with the family culture and the context in which the patient lives. The community health nurse should accompany patients and their families through illness and death, without any comparison or prejudice regarding the community values and beliefs. 16 , 19 , 32 , 33 , 36

2.c. Adherence to Ethical Principles

One of the qualifications of community health nurses to care for patients with incurable diseases is to have a positive attitude towards observing ethical principles while caring for patients with incurable diseases. 16 , 20 , 33 , 36 , 43

3. Skills

Patients with incurable diseases have many problems in various aspects of health. The community health nurse must be able to provide comprehensive care to relieve the suffering of patients. The skills were categorized in various domains including physical care, psychological care, spiritual care, social support, medication administration, care of dying patients, and communication skills.

3.a. Physical Care

One of the most important problems for patients at the end of life is the physical symptoms that the disease causes in the individual. The nurse must be able to control these symptoms. The community health nurses must be able to care for respiratory, skin and cardiovascular patients, and relieve pain and other physical problems of incurable patients. Symptoms such as pain, nausea and vomiting, constipation, restlessness, fatigue, and dry mouth are among the most important symptoms of patients with incurable diseases. Some of these symptoms may be related to the complications of the disease itself and some to the use of medications. 7 , 11 , 14 , 16 , 17 , 21 , 33 , 36 , 38 , 43 , 44 , 46 - 48

3.b. Psychological Care

People with terminal illnesses, as well as their families, experience various psychological problems. The community health nurse must be able to diagnose the patients’ psychological problems and take appropriate measures to manage them. 11 , 16 , 21 , 33 , 35 - 37 , 42 , 43 , 47 , 48

3.c. Spiritual Care

One of the needs of patients with incurable diseases is spirituality. Community health nurses should consider spiritual care as a basic need for patients and take the necessary steps to fulfill it. 11 , 16 , 21 , 33 , 36 , 37 , 43 , 48

3.d. Social Support

Community health nurses must be competent in providing care in the social domain. The nurse should be able to support families by talking to the patient about changing roles and responsibilities in the family, relationships with family and friends, and financial concerns. 11 , 16 , 21 , 33 , 35 - 37 , 42 , 43 , 48

3.e. Medication Administration

One of the main competencies of nurses to provide palliative care is understanding medications and managing their use. One of the most important medications used to control pain in patients with incurable diseases is various types of narcotics, which can be used orally or by injection, depending on the type of disease and condition. The nurse must be fully familiar with the types of these medications, how to use them, side effects, and the care required for each of them. 9 , 33 , 36 , 44 , 46

3.f. Care of Dying Patients

The data in this study show that one of the important capabilities of community health nurses is caring for dying patients and managing the phenomenon of death. Providing care for the deceased and training in palliative care are among the elements that community health nurses must possess. 8 , 14 , 18 , 33 - 38 , 43 , 46

3.g. Communication Skills

One of the main competencies of nurses to provide palliative care is to treat patients and their families with reasonable and respectful behavior, verbal communication, appropriate skills in delivering bad news, and sensitivity and empathy in social interaction. 8 , 11 , 14 , 21 , 33 , 35 , 38 , 41 , 43 , 44 , 46

DISCUSSION

In this study, the literature review showed that community health nurses should be equipped with a variety of general and specialized qualifications to effectively provide community-based palliative care. In this study, essential competencies for nurses providing palliative care at the community level were identified in three areas; knowledge, attitude, and skills, each of which with different dimensions. Consistent with the findings of this study, findings from a systematic review considered the nature of palliative nursing, teamwork, communication with the patient and family, and resources as needs for community-based palliative nursing. 41 Also, the findings of another systematic study in the Netherlands considered assessing the needs of family caregivers and providing them with psychological support as interventions for palliative care nurses. 42 In addition, in another review study, the competencies required for community health nurses were identified in six dimensions including leadership, communication, collaboration, clinical care, psychosocial and spiritual care, ethics, and patient rights. 16 The relative advantage of the present study over previous review studies is that it identified more comprehensive competencies for community health nurses.

Findings of this study indicated that one of the essential qualifications required for community health nurses is familiarity with the philosophy of palliative care. The nurse must be familiar with the nature of the disease to be able to provide care based on the type of disease, prognosis, complications, and selected treatments to the patient and family, and provide them with the necessary training, as the study data showed. 41 Nursing schools, as the only institutions responsible for training nurses, should be completely aware of the mission, goals, and skills pertaining to community health care provision to patients with end-stage disease.

The findings of this study showed community health nurses should be well-informed about the structure of the health system and the process of receiving health services at its different referral levels. Familiarity of the community health nurse with the structures and capacities of the health system can lead to the use of all available capacities to help improve the quality of life of patients in physical, psychological, spiritual, and social dimensions. 8 , 9

The findings of the present study showed that the community health nurse should believe that palliative care could have many benefits for the patient, family, and health system. They should also have a positive attitude towards teamwork and empathy with clients, so that they can provide care in accordance with the culture of the community while adhering to ethical principles. The results of another study showed that community health nurses should have the capability of welding his/her diverse specialties tailored to the patient’s needs to improve the quality of life of the patient and his/her family. 11

According to the findings of the present study, community health nurses should demonstrate advanced competencies in empathy, understanding, and adaptability. Some of the factors that can unfavorably affect the establishment of empathy include excessive patient loads, insufficient time dedicated to individual patients, focus on treatment, and lack of education on how to express empathy. 45 In this study, cultural competency is considered as a crucial attribute for community health nurses, enabling them to deliver contextually appropriate health services aligned with the sociocultural norms in any society. Different ethnic and population groups have distinct beliefs and traditions about life and death, death circumstances, corpse management, and funeral and mourning ceremonies. 34 Therefore, a community health nurse should be able to bear and manage these situations.

Also, in this study it was shown that community health nurses must have ethical competence to provide palliative care to terminally ill patients. Consistent with these findings, the results of another study showed that nurses experience ethical dilemmas while caring for patients and must have the necessary skills to manage these situations. 20

According to the finding of this study, the skill competencies of community health nurses can encompass three key areas including providing technical care (e.g., catheter or stoma care, wound care, and medication administration), physical care (e.g., personal hygiene assistance, nutritional support, and mobility facilitation), and complementary care (e.g., massage, thermal therapy, etc.). Given that patients may experience respiratory, digestive, cardiovascular, renal, and skin complications, a community health nurse must be able to manage each of these issues. 44 The findings of this study identified pharmaceutical management as an essential requirement for community health nurses providing palliative care. Core medication-related competencies of nurses providing palliative care included the capability of delivering pharmaceutical therapy, pharmaceutical therapy assessment, and the forecast of medication requirements. 44

Moreover, it was shown that community health nurses should necessarily have the competency of providing quality psychological care. Patients with incurable diseases suffer from various psychological problems, such as anxiety and depression, and the community health nurses must be able to manage the patients’ psychological state by utilizing the capacities available in the care team. 49

The results also revealed that community health nurses must be able to provide spiritual care to patients with incurable disease. One of the basic needs of patients is the need for spirituality, which the community health nurse must meet in collaboration with other team members. 16

Another finding of this study indicated that community health nurses should be skilled in providing social support to terminally ill patients and their families, including practical and emotional dimensions. When a patient is diagnosed with a terminal illness, their role in the family changes. A community health nurse can help the family resolve some of these problems. 22

It was also revealed that caring for dying patients was another important qualification of community health nurses providing care to terminally-ill patients. Nurses caring for dying patients should manifest the sense of responsibility, cooperation, adequate expertise, as well as knowledge, and manage emotions, time, and resources, and physical care to the corpse along with relatives. 34

One of the strengths of the present study was the use of a broad search strategy to find relevant studies although several limitations should be acknowledged. The restriction to English-language publications may have excluded potentially valuable studies published in other languages. Therefore, it is recommended that further studies should be conducted in this field with other languages.

CONCLUSION

The findings of this study revealed that community health nurses need to acquire knowledge, attitudes, and skills at various levels based on their patients’ care needs to provide home-based care to terminally ill individuals. These nurses should be capable of fulfilling the needs of the patient and his/her family from the time of diagnosis till death and afterwards. The community health nurses should acquire additional essential qualifications such as familiarity with the nature and essence of community-based palliative care, the philosophy and mission of home-based care services, continuous care, sensitivity to patients’ beliefs and values when providing comprehensive and specialized care services, pain management, pharmaceutical knowledge, and provision of physical, psychological, social and spiritual care. It is suggested that the necessary competencies for providing home-based palliative care should be considered in reviewing nursing education curricula.

Acknowledgement

The present study was a part of the results of a post graduate thesis of the corresponding author (HH) in the Smart University of Medical Sciences.

Authors’ Contribution

Conceptualization and study design were done by SGh, MB, and HH. Data collection was carried out by SGh and HH. SGh, MB, and HH performed data management, analysis, and interpretation. SGh and HH prepared the initial manuscript draft, and critical revisions for important intellectual content were conducted by MB. All authors read and approved the final version of the manuscript and take responsibility for the integrity and accuracy of the data analysis. The corresponding author attests that all listed authors meet the authorship criteria.

Funding Source

This research has not received specific financial support from any funding organization.

Conflict of Interest

None declared.

Declaration on the use of AI

This study did not use Artificial Intelligence (AI)-Assisted Technology in data gathering, analysis, or article preparation.

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