ABSTRACT

This study was conducted to examine the postgraduate theses on palliative care in nursing in Türkiye and to reveal the nursing practices used. The population of the retrospective descriptive study consisted of theses in the field of nursing registered in the National Thesis Center of the Council of Higher Education, while the sample consisted of 55 theses between 2010 and 2022 that met the inclusion criteria among the theses in the field of nursing as a result of the screening made within the scope of PRISMA rules. It was seen that the first thesis on palliative care in nursing was published in 2010. Of the theses obtained, 13 were doctoral (23.6%) and 42 were master’s theses (76.4%), 60% were published between 2019 and 2022, 92.8% were conducted with quantitative research methods, 76.5% of these theses used at least one of the descriptive designs and 15.7% were randomized controlled experimental studies. Additionally, it was determined that 36.4% of the theses were sampled by healthcare personnel working in palliative care clinics, and 72.7% did not use a sampling method. Among the interventions implemented by nurses; the most common ones were palliative care training, simulation training/practice, and theory-model based nursing care practice. However, neonatal palliative education, psychoeducation, application of the case management model and face-to-face fan practice were rarely included. In recent years, complementary practices such as ear acupuncture, aromatherapy massage and relaxation exercise, as well as red-white light application, were observed. It should be emphasized that thesis studies in palliative care and nursing have increased in recent years, but mostly at the master’s level and descriptive type, the number of doctoral level studies is insufficient, and the need for randomized controlled intervention studies to provide evidence for palliative care nursing should be emphasized.

Introduction

World Health Organization (WHO) defined palliative care as follows; “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual” (1). Palliative care aims to eliminate or alleviate the symptoms of the patients, starting with the diagnosis of life-threatening problems. Considering the biophysiological, psychological, socio-cultural and economic factors affecting the lives of patients and their families, it supports improving the quality of life in the last stages of life (2, 3).

In palliative care, the nurse performs not only the role of caregiver/care provider but also the roles of educator, manager and coordinator. In this respect, palliative care nurses have also important roles and responsibilities such as cooperation with other disciplines in their practices regarding symptom control and their responses to the disease (4). Palliative care nurses have important roles for determining the needs of individuals/families; explaining the concerns of individuals about their lives; giving care for values and preferences and the planning of advanced care (5, 6). Palliative care nurses have also necessity for following developments in their fields and performing the role of investigator in research. In recent years, it is stated that the importance of palliative care nursing has increased with the increase in palliative services and the development of practices in the field of palliative care (7-9).

Graduate education in nursing contributes to the delivery of quality nursing care ensuring that up-to-date information is followed and transferred to practices after graduation, the selection of appropriate scientific methods in solving problems related to nursing practice, the development of new hypotheses and the use of evidence-based data obtained as a result of research (10, 11). Postgraduate thesis studies have an important role in the formation of scientific and professional knowledge, the dissemination of science and the professional development of nursing (12). Providing the evidence-based care contributes to the strengthening of the scientific foundations of the field and improves nurses’ ability to produce solutions to different problems and to think critically and systematically and gives the ability to use qualified maintenance methods (13). The use of scientific research data in care not only allows to increase the quality of care in nursing, but also is important in terms of professional development and allows the creation of health policies (14). Accordingly, graduate education and studies ensure the formation of professional members who produce/develop knowledge in their field (15). It is stated that the professional power of nursing can be increased by synthesizing evidence-based nursing practices and professional knowledge (11). According to the John Hopkins Evidence-Based Nursing Practice model, experimental/randomized controlled studies are considered first-level studies in terms of evidence (16, 17). In this context, it is important to examine studies with a high level of evidence.

It is known that scientific and academic studies on the subject are increasing day by day with the increase in chronic diseases and the increasing importance given to palliative care in Türkiye. Graduate thesis studies are studies in which theoretical knowledge and the results of this knowledge are transferred into practice. As a matter of fact, the analysis of scientific theses is important in providing a perspective on the fieldand revealing the general appearance of the examined area (18). From this point of view this study is aimed to guide palliative care nurses and researchers.

It is aimed to examine the graduate thesis studies on palliative care in the field of nursing in our country and to reveal the applied nursing practices with this study. Accordingly, answers to the following research questions were sought in the study:

- What is the distribution of graduate theses in nursing related to palliative care according to their types?

- What is the distribution of graduate theses in nursing related to palliative care according to their years?

- Which research types are preferred in graduate theses in nursing related to palliative care?

- What are the sample groups and sampling methods used in graduate theses in nursing related to palliative care?

- What are the sampling characteristics in graduate theses in nursing related to palliative care?

- What are the nursing practices in graduate theses in nursing related to palliative care?

Methods

This retrospective descriptive study was conducted by using the database of the National Thesis Center of the Council of Higher Education in the field of nursing between 2010 and 2022 (19). During the screening through the Thesis Center, Turkish language, master’s and doctoral theses and dissertations covering the field of nursing were screened using the keywords “palliative care”, “nursing”, “postgraduate”, and “Türkiye”. Between August 1 and August 13, 2022, all theses that met the screening criteria were included in the study. The process of selecting the theses meeting the inclusion criteria was methodologically arranged according to the PRISMA flowchart (Figure 1).

Inclusion criteria for the study;

- Access to the full text,

- Theses to be accessible,

- To be done by department(s) of the nursing,

- Between the years of 2010 to 2022.

The limitations of the study, were that only the theses registered to the National Thesis Center database system were selected, theses published in full text were included and the low number of theses in the field of nursing.

Ethical aspect of the study, since theses that were accessible to the National Thesis Center database were included in the sampling and it did not involve experimental procedures on humans or animals ethics committee approval was not required.

Data gathering, seventy four theses were found which met the inclusion criteria, were registered in the database for the field of nursing on palliative care. Reviewing the theses 55 theses were included in the study, which met the inclusion criteria. Of the theses to be included in the study as a result of reviewing, 42 were graduate theses and 13 were doctoral theses.

Data analysis, the quality of the study was evaluated using the Critical Appraisal Skill Program. The program includes a checklist that systematically evaluates the results of the study. The questions in the checlist are replied as “Yes” and “No” (https://casp-uk.net/casptools-checklists/). SPSS for Windows Version 20.00 (SPSS Inc., Chicago, IL., USA) packaged software was used in the statistical analysis of the data obtained at the end of the study. The data were evaluated by frequency analysis. The form was developed by the researchers in line with the research questions and the data were evaluated accordingly. Theses included in the study in the content of the form are summarized according to author-advisor, thesis year, the purpose of the study, the type of study, the intervention applied, the sampling method, the group and number of sampling, the evaluation instruments used and the results of the studies in chronological order (Table 6).

Findings

In this retrospective descriptive study, 55 theses registered to the National Thesis Center, were included between January 2010 and August 2022, 13 (23.6%) of which were doctoral theses and 42 (76.4%) of which were graduate theses (Table 1). According to the detailed analysis based on years, although the first graduate thesis study on palliative care in the field of nursing in our country belonged to 2010. It was determined that 60% (n=33) of the studies were conducted in 2019 and later (Table 2).

It was determined that 92.8% (n=51) of the thesis studies evaluated were conducted in quantitative design type; the majority (37.3%) (n=19) of the quantitative design types were descriptive and consisted of graduate theses; 8 of the experimental and quasi-experimental studies conducted were doctoral dissertations (Table 3).

It was determined that the thesis studies evaluated consisted of different sampling groups; 36.4% (n=20) of the sampling was conducted with healthcare personnel working in the palliative care unit (Table 4); 72.7% (n=40) of them were carried out without using any method; however, the simplest random sampling method was used among those which were used the method (Table 4). It was determined that the most of the doctoral thesis studies were on patients (n=7) who benefitted from palliative care services; the graduate thesis studies were mostly carried out on the healthcare personnel (n=19) working in the palliative care unit.

It was observed that most of the experimental/quasi-experimental researches (73.3%) which were evaluated were made as doctoral thesis; when nursing practices were examined in theses palliative care education (n=3, 20.0%), simulation (n=2, 13.3%) were mostly discussed, and Watson’s Nursing Approach Based on the Human Care Model (n=2, 13.3%) was discussed (Table 5).

Discussion

It was determined that the majority of 55 graduate theses types (76.4%) were conducted as graduate thesis, the number of doctoral dissertations was low and the first thesis was made in 2010 in the context of this study, which was conducted to evaluate the graduate theses related to palliative care in the field of nursing in Türkiye and to determine the nursing practices used in the theses. It was determined that more than half (60%) of the theses were carried out in 2019 and afterwards. It was found that the majority of thesis consisted of graduate theses in accordance with our study in many systematic review studies in which the theses on different subjects in the field of nursing are discussed (20, 21). It is believed that it is resulted from the low number of students in doctoral programs in our country and the low number of nurses working in this specialty.

Palliative care, which was first defined by WHO in 1986, includes a philosophy of care that has developed from various aspects until today. It is based on holistic and humanistic care. It is known that the emergence of palliative care nursing in the world dates back to the 1990s, when the concept of palliative care emerged. In Türkiye, the concept of palliative care didn’t come to the fore until 2000s (1, 22). The reason why the first thesis on palliative care in nursing was made in 2010 in our country and the most important reasons for the increase in number over the years was thought to be a result of the increase in the number of clinics providing palliative care services. Especially in the last two decades; development of palliative care nursing has emphasized the concept of palliative care more in national and international studies.

When the research methods used in the theses included in the study were evaluated, it was determined that most of them (92.8%) had a quantitative research design and it was determined that theses were mostly of descriptive type (37.3%), and all of the descriptive theses were graduate thesis. In a study evaluating the trends in nursing research in Türkiye, it was determined that the experimental and quasi-experimental studies among the dissertations were very few (23.5%) and more than half of these studies (66.7%) were doctoral theses, and that graduate theses were mostly conducted in the descriptive type of quantitative research designs (20). In a study conducted in Brazil, it was found that almost half (45.6%) of doctoral dissertations in nursing were conducted descriptively (23). On the other hand, in Sweden, it was determined that doctoral dissertations in the field of nursing mostly had experimental and quasi-experimental designs (24). While in a study evaluating graduate theses in the field of nursing, 39.5% of dissertations were done by non-invasive method, in another study evaluating doctoral dissertation studies, almost half of theses (42%) were conducted in experimental or quasi-experimental type, which was found to be consistent with the results of our study (21, 25). While it is determined that graduate theses are more often quantitative in nature and mostly included studies aimed at determining the situation or in relational style, it is seen that the number of studies with experimental design in doctoral dissertations is increasing. In many studies in the literature, it is seen that graduate theses in the field of nursing are mostly designed in descriptive type and this situation stems from the effort to increase the knowledge in the disciplines in which the graduate studies are conducted due to their nature (13, 20, 26). In addition, it is thought that the reason why descriptive studies are preferred in graduate theses is likely to be related to the short duration of the research. The reasons why randomized controlled studies are preferred in doctoral dissertation are as follows; to contribute to the literature of the research subjects, the necessity of being unique and not studied before, the usability of evidence-based studies in finding answers to social problems, and willing to practice and to develop new methods/models. The fact that experimental designs are at the doctoral level in graduate programs is an expected situation due to the purpose/target and program qualifications of graduate programs. The fact that doctoral dissertations are mostly experimental shows that evidence-based knowledge and nursing practices have become widespread. This finding is stated as an indication that the purposes of graduate doctoral programs conducted in Türkiye have been achieved (20).

In our study, it was determined that the theses conducted in qualitative design and quantitative + qualitative (mixed) design were less frequent and both types were frequently used in the design of doctoral dissertations. It is stated that the mixed method contributes to a better understanding of the research problem than using a single method, which focuses on the use of quantitative methods that support qualitative data or qualitative data that supports quantitative data (27). Qualitative research methods try to reveal people's feelings, thoughts, behaviors and perspectives in a holistic way (28). The use of qualitative studies in the field of nursing is important in supporting quantitative data with experience (29).

While the sampling group of the majority (36.4%) of the graduate theses evaluated within the scope of the study was composed of healthcare personnel working in the palliative care unit, it was determined that doctoral dissertations were mostly conducted on patients benefiting from palliative care services. Researches including palliative patient groupsare fewer in number in our country. In our country, the inability of academic nurses to work in the clinic as clinicians at the same time and concerns about the fact that nurses’ inability to study with vulnerable populations leads to more descriptive studies (30). It is difficult to conduct research as palliative care patients are a vulnerable group. In addition to the difficulty of obtaining voluntary informed consent from this vulnerable group to participate in the study, possible data loss due to reasons such as wanting to withdraw from the study in the continuation of the study or death are stated as the barriers that affect the studies in this field on patients (8, 9).

Nursing practices discussed in the theses within the scope of this study are detected that the most commonly palliative care training, simulation training/practice, and Watson’s Nursing Care Approach Based on Watson’s Nursing Approach Based on the Human Care Model are achieved. Palliative care training has been included in basic, secondary and higher education programs in the last 20 years around the world (31). In addition to the absence of structured training programs in Türkiye, in recent years, the regarding subject has been mentioned in programs such as panels, congresses and symposiums (32). In 2022 for the first time in our country the 1st International Congress on Palliative Care in Nursing was hosted by Malatya İnönü University. Among the theses covered in this study, it was observed that palliative care training reduced the symptom burden and repeated hospitalizations given to patients with chronic heart failure (33). It has been determined that palliative care training given to individuals who care for patients and newborn nurses increases the level of knowledge (34, 35). As a result of the findings of the theses dealing with the subject of palliative care training, it has been determined that palliative care training will be appropriate for patients who need palliative care and for nurses who care for them and the content of palliative care education will be developed with current literature.

Palliative care for nursing students with interprofessional simulation training and different simulation applications have been shown to increase the knowledge, awareness, satisfaction, confidence and skills of the teacher by providing an effective and safe learning environment, and it can be useful to better understand the importance of teamwork (36, 37).

Considering the models or theories used in theses for palliative care patients in our country, in two doctoral theses Watson’s Human Care Model is used. In these theses, it is determined that nursing care provided in line with the model, it has a positive effect on the care outcomes of the patients and reduces the despair level of the relatives of the patients (38, 39). In addition, it was determined that the satisfaction level of patients with nursing care increased (38). In this study, which evaluates the theses related to palliative care, finding that there is limited use of models/theories is supported by many reviews in which nursing theses are evaluated (40, 41). However, theories/models offer the opportunity to provide holistic and quality care (42). Therefore, it is important for the development of scientific knowledge that the conceptual framework of doctoral dissertation studies is based on theory/model or that researches based on theory/model are predominantly involved (11). In the process of doctoral education within the scope of the Turkish Higher Education Qualifications Framework, it focuses on the development of students’ doctoral theses “to be able to evaluate and use new information in the field with a systematic approach and gain the knowledge and skills to produce scientific solutions to problem” (http://tyyc.yok.gov.tr, accessed date: 21.01.2023). In this context, it is important to support the use of theory/model in palliative care nursing.

Although various models were used in the delivery of nursing care, when the theses covered in this study were evaluated; it was determined that the case management model was used in cancer patients receiving palliative care. It has been determined that this model provides better symptom control, improves quality of life and increases the satisfaction levels of patients and their families, and it is stated that it can be used in palliative care patients (43).

In other theses on palliative care in Türkiye, it was seen that face-fan application, red-white light application, listening to Turkish music accompanied by a tambourine, auricular acupressure application, aromatherapy massage, psychoeducation and relaxation exercise were used. It was determined that face-fan application increased the quality of life of patients for palliative care patients receiving lung cancer treatment in a doctoral thesis conducted to evaluate its effect in the management of dyspnea (44). As a matter of fact, it is emphasized that face-fan application on various patient groups reduces the level of dyspnea, improves exercise performance, increases the duration of exercise, has no side effects and can increase the quality of life of the patient because it is easy to apply (45, 46). Another nursing practice in the dissertations discussed is red-white light application. At the end of the application, it was concluded that the application of bright white light reduced the fatigue levels of cancer patients receiving palliative care and had positive results on sleep (46). Many studies on the application of bright white light also showed parallelism with this doctoral thesis on palliative care patients, in which the fatigue level of the patients decreased and their sleep quality improved (48, 49).

In another nursing practice, it was determined that Turkish music played with the tambourine reduced pain and anxiety for cancer patients hospitalized in the palliative care service, increased comfort and functional capacity, and were effective in controlling vital signs (50). In the reviewed literature, similar to this study, the benefits of music therapy such as reducing pain levels of individuals, feeling more comfortable, lowering heart rate, reducing anxiety are emphasized (51-53).

Among the theses within the scope of this study, in a doctoral thesis, it was determined that application of auricular acupressure was beneficial in the management of constipation in palliative care patients and increased the quality of life (54). It is possible to encounter similar studies in the current literature (55, 56). In this respect, it is thought that auricular acupressure may be also appropriate for palliative care patients.

Another nursing practice is aromatherapy massage. With the help of this application a decrease in pain intensity and an increase in plasma beta-endorphin levels were found in cancer patients (57). In studies evaluating aromatherapy massage, it is emphasized that it has a positive effect on reducing the pain of patients and reduces the level of anxiety, stress and depression (58).

In addition to the applications in experimental studies in the theses evaluated, quasi-experimental psycho education was shown to increase caregivers’ quality of life and their ability to cope with stress (59). In the literature, it is seen that psychosocial and spiritual support and symptom control trainings such as psychoeducation are effective on the health status, quality of life and ability to cope with stress of caregivers in different patient groups (60). In another quasi-experimental type thesis; it was concluded that applying relaxation exercises to caregivers reduced the burden of caregiving, burnout and anxiety levels (61). However, no similar study was found specific to the relaxation exercise intervention applied to caregivers of patients receiving palliative care.

Results and Recommendations

As a result of the information obtained from this study; it has been determined that the number of theses conducted in the field of palliative care has increased since 2019. It was determined that the theses discussed were mostly descriptive in nature with a quantitative design type to determine the current situation, and experimental and quasi-experimental studies were mostly doctoral theses. When nursing practices were reviewed, it was seen that palliative care education, training/application for simulation, and Watson’s Nursing Approach Based on Watson’s Nursing Approach Based on the Human Care Model were mostly discussed. It was determined that nursing practices, which were handled according to the results of all graduate thesis included in this study, positively affected the parameters and variables reviewed in the samples of patients, patient relatives and nursing students. It was observed that theories/models were used limitedly in the theses reviewed, and studies based on theory/models were frequently preferred at the doctoral level.

Accordingly, it is recommended to increase the number of experimental randomized controlled studies with high evidence value, with follow-up appropriate to the graduate education period, in which a cause-effect relationship between variables can be established in studies in the field of palliative care nursing in Türkiye. At the same time, it is important for the development of nursing science to plan the researches that are planned to be conducted on palliative care based on nursing theories. Increasing research funds for graduate students in order to conduct high-evidence research on palliative care nursing will provide encouragement and support for students to do research.

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Analysis of the Graduate Theses Related to Palliative Care in Türkiye in Terms of Study Method and Nursing Practices