Feature Article
The Impact of the End-of-Life Nursing
Education Consortium International Training
Program on the Clinical Practice of Eastern
European Nurses Working in Specialized
Palliative Care Services
A Romanian Case Study
Nicoleta Mitrea, PhD, APRN, MSc Daniela Mosoiu, MD, PhD
Camelia Ancut a, APRN, MSc Pam Malloy, RN, MN, FPCN
Liliana Rogozea, MD, PhD
Palliative care nurses in Romania have a long history of
collaborating with the End-of-Life Nursing Education
Consortium (ELNEC) project, a national education
initiative administered by the American Association of
Colleges of Nursing (AACN) in Washington, DC, and
the City of Hope National Medical Center in Duarte,
California. Between January 2013 and October 2014,
1360 Romanian nurses participated in ELNEC palliative
care training courses; 306 of these nurses attended both
the introductory and advanced ELNEC courses. The aims
of this study were to identify the changes implemented
by the participant nurses in their clinical practice, after
attending ELNEC palliative care introductory and advanced
courses, and to compare the participant nurses palliative
care knowledge precourse versus postcourse. The data
were collected from 6 focus groups at 3 to 6 months
postcourse, in 6 different locations in Romania. Five themes
were identified, with related subthemes including new
Nicoleta Mitrea, PhD, APRN, MSc, is medical faculty, Transylvania
University and HOSPICE Casa Sperant ei, Brasov, Romania.
Daniela Mosoiu, MD, PhD, is medical faculty, Transylvania University;
and HOSPICE Casa Sperant ei, Brasov, Romania.
Camelia Ancuta, APRN, MSc, HOSPICE Casa Sperantei, Brasov, Romania.
Pam Malloy, RN, MN, FPCN, is ELNEC project director, American Asso-
ciation of Colleges of Nursing, Washington, DC.
Liliana Rogozea, MD, PhD, is medical faculty, Transylvania University,
Brasov, Romania.
Address correspondence to Daniela Mos oiu, MD, PhD, Sitei 17A, Brasov,
Romania 500074 (daniela.mosoiu@hospice.ro).
The authors have no conflicts of interest to disclose.
Copyright B 2017 by The Hospice and Palliative Nurses Association.
All rights reserved.
DOI: 10.1097/NJH.0000000000000367
424 www.jhpn.com
perspectives of care, the importance of communication
skills, the role of interprofessional teams in the healthcare
system, addressing the needs of the patient and family, and
informed decision-making by the patient and family. This
study showed that the ELNEC introductory and advanced
courses lead to changes in the participant nurses clinical
practice and aided nurses in identifying barriers in the
Romanian public healthcare system that need to be
addressed to improve palliative care.
KEY WORDS
barriers, changes, clinical practice, ELNEC, medical
education, palliative care
BACKGROUND
In December 1989, after the fall of the communist regime,
palliative care (PC) began to develop slowly and be recog-
nized in Romania. In the early 1990s, with generous inter-
national financial and technical support, charitable PC
organizations were established to answer the urgent need
to properly care for patients with incurable chronic dis-
eases. Nongovernmental organizations implemented the
necessary changes to make PC possible. They did so by
reacting to and representing and advocating for a very large
segment of the population whose needs were great, ini-
tially human immunodeficiency virusYpositive patients.
Sadly, more than 50% of Europes human immunodefi-
ciency virusYpositive children/pediatric patients were born
in Romania in 1988 to 1989.1 As a result of this reality, sev-
eral hospices in Cernavod", Bucharest, and Curtea de Argez
were established in 1992.2
It was the establishment of HOSPICE Casa Speranei
(HCS) service in Brasov, in 1992, that marked the true
Volume 19 & Number 5 & October 2017

beginning of the Romanian PC movement. The HCS was
the first charitable organization whose mission was to in-
troduce and develop PC in Romania.3 The HCS began its
PC work rendering home PC service for patients who re-
ceived a diagnosis of cancer who had been discharged
from hospitals. In time, HCS became the pioneering insti-
tution that assumed the leading role in developing PC ser-
vices in Romania, coordinating national PC educational
programs and creating and advocating for the legislative
changes necessary to support the hospice and PC move-
ment and to include this care in the national public health
strategy.4
In 2003, HCS was recognized as a center of excellence
for developing PC in the Southeastern European region,
as noted in Clark and Wrights5 study, Transitions in End
of Life Care. The HCSs work and influence were ac-
knowledged in 475 PC centers in 28 countries from Central-
Eastern Europe and Central Asia.5 From 1997 to 2015, HCS
has cared for more than 20 000 patients6 (adults who re-
ceived a diagnosis of cancer and children experiencing
life-limiting and life-threatening illnesses) and has trained
more than 19 500 healthcare professionals.7
To be an accredited PC service in Romania under con-
tract with the National House of Insurances, the PC service
must employ specialized professionals. These specialized
professionals include physicians trained and certified in PC
and nurses who have completed medical education in PC.
Since 1999, physicians must complete the approved national
PC program and attain specialized competency in PC. As of
2016, there were 501 physicians trained at the specialized
competency level in PC; an additional 60 physicians are
currently enrolled in the PC specialization program.
By year-end 2014, 72 types of specialized PC services
were registered in Romania (compared with 46 services
in 2010), delivered by 57 suppliers (19 of which were in
the public healthcare system; 26 were in nongovernmental
organizations; 12 services were for profit).8 Types of ser-
vices include self-standing PC in patient units, hospital
PC wards, PC mobile hospital teams, ambulatory ser-
vices, home PC teams, and PC day centers. There are
PC service suppliers that render more than 1 type of ser-
vice, but HCS is the only organization that renders all of
the services listed.
INTRODUCTION
National legislation in Romania requires that nurses obtain
30 credits annually in continuing medical education courses
to enhance their knowledge and skills, before they may ob-
tain their annual authorization to practice nursing.9 The
HCS is the pioneering PC organization in Romania, the pro-
moter of PC education for interdisciplinary teams, and an
advocate for developing PC services nationally and in the
Eastern European region.10 The HCS is the organization
Journal of Hospice & Palliative Nursing
Feature Article
authorized by the Romanian Order for Registered Nurses,
Midwives, and Nursing Technicians for delivering contin-
ued PC educational programs for nurses in Romania, both
for nurses in specialized PC services and other clinical spe-
cialties. Despite the delivery of PC educational programs
for 15 years, including master classes, competency programs
for physicians, seminars, symposiums, courses, and confer-
ences, nurses have experienced difficulties in implementing
new knowledge and skills into their daily clinical practice.
Recognizing these difficulties, nurses enrolled in the End-
of-Life Nursing Education Consortium (ELNEC) Interna-
tional Training Program to advance their PC practice.
This research study reports on the effect of ELNECs intro-
ductory and advanced courses on participant nurses PC
knowledge, their clinical practice, the changes that they
were able to implement, and the barriers that need to be
addressed to fully integrate PC principles into their clin-
ical practice.
In April 2011, 5 nurses from HCS, in Brasov, Romania,
participated in the ELNEC International Training Program
held in Salzburg, Austria. Based on the European recom-
mendations for developing PC nursing education,11 includ-
ing interactive delivery and specific adult learning techniques,
the 5 nurse participants translated and adapted the ELNEC
International Curriculum. The nurses adapted 2 PC course
modules, 1 introductory and 1 advanced, each consisting
of 18 teaching hours, creating continued PC medical edu-
cation for nurses for 15 credit points by the Romanian Order
for Registered Nurses, Midwives, and Nursing Technicians.
Using these modules, nurse trainers were able to train other
nurses in PC skills and principles. Between January 2013
and October 2014, 1360 Romanian nurses participated in
ELNEC PC training courses, 306 of whom attended both
the introductory and advanced courses. Currently, there
are 14 PC nurse trainers at HCS, and together with educa-
tional support staff, they organize and hold introductory
and advanced PC courses for nurses in Romania and in
the region.
Research Methodology
For this phenomenological study, quantitative (precourse
and postcourse tests) and qualitative (focus group) methods
have been combined to identify and analyze the knowledge
acquired by nurses from the introductory and advanced PC
modules and the implementation of this knowledge into the
nurses every day clinical practice in Romania.
Research Aim
The aim of this study was to identify, through quantitative
and qualitative research methods, the clinical practice
changes implemented by nurses who underwent PC intro-
ductory and advanced module training and the barriers
that need to be overcome to implement the PC training
in nurses clinical practice in Romania.
www.jhpn.com 425
 Feature Article
Research Objectives
1. Evaluate the effect of the introductory and ad-
vanced PC training modules on specialized PC par-
ticipant nurses level of knowledge in Romania;
2. Establish the domains of competency and the spe-
cific competencies implemented in the nurses clin-
ical practice after the introductory and advanced
PC module training;
3. Determine the barriers blocking the enhancement
of PC nursing in patient and family care.
Research Methods
To accomplish the first objective, evaluating the effect of
the introductory and advanced PC training modules on
nurses level of knowledge, questionnaires in the form
of precourse and postcourse tests were used. As to the
second objective (identifying competencies implemented
in clinical practice) and the third objective (identifying bar-
riers in PC enhancement), 6 focus groups were organized
with nurses from 6 different specialized PC service loca-
tions, 6 months after the nurses attended the introductory
and advanced PC courses. The focus group discussions
were audio-recorded, then transcribed verbatim, and ana-
lyzed and coded into subthemes, themes, and domains.
Results of the Quantitative Research
Between January 2013 and October 2014, HCS nurse
trainers trained 1360 nurses from different specialties, in-
FIGURE 1. Nurses average grades in precourse and postcourse tests in correlation with nurses county of residence in Romania.
426 www.jhpn.com
cluding PC specialized services using specially adapted PC
training modules based on the ELNEC International curric-
ulum. Of these 1360 nurses, 306 nurses from PC specialized
services were trained in both the PC introductory and
advanced course modules. The nurses were from 30 of the
42 counties in Romania: Arad (AR), Bac"u (BC), Bihor (BH),
Bistrita N"s"ud (BN), Brasov (BV), Br"ila (BR), Bucuresti
(B), Buz"u (BZ), Cluj (CJ), Covasna (CV), Constanta (CT),
D$mbovita (DB), Dolj (DJ), Galati (GL), Harghita (HR),
Ialomit a (IL), Iasi (IS), Maramures (MM), Mehedint i
(MH), Murez (MS), Neam (NT), Prahova (PH), S"laj (SJ),
Sibiu (SB), Satu Mare (SM), Suceava (SV), Timis (TM),
V$lcea (VL), and si Vrancea (VN). On the precourse tests,
nurses scored grades between an average of 4.05 (MH) and
7.58 (MM), with postcourse test grades ranging from an av-
erage of 6.65 (MH) and 9.68 (CV). From precourse test to
postcourse test, there was an average increase of 2.5 points
in the nurses knowledge (Figure 1.)
The grades obtained at precourse and postcourse tests
were analyzed and correlated using multiple variables, in-
cluding participant nurses ages, geographic areas of the
specialized PC service where the nurses worked, years of
nursing experience, and previous exposure to continued
medical education in the field of PC.
The age of the participant nurses seemed to affect the
level of improvement from precourse to postcourse tests.
The average grades on precourse tests were between
5.52 for the nurses older than 60 years to 6.26 for the
nurses aged 51 to 60 years. For the postcourse tests,
Volume 19 & Number 5 & October 2017

the results showed an increase in the nurses knowledge
from an average grade of 8.7 for the 21- to 30-year age group
to an average grade of 9.24 for the 51- to 60-year age group.
We conclude that increased participant age was a factor that
positively affected participants PC knowledge.
The geographic area of the specialized PC service where
the participant nurses worked was used as a variable in ex-
amining precourse and postcourse test scores. The results
showed average grades on the precourse tests of 5.56 for
nurses working in rural areas and 6.19 for nurses working
in urban areas. Postcourse average grades were 8.86 for
nurses working in urban areas and 8.91 for nurses working
in rural areas. Because neither precourse nor postcourse results
were significantly different from one another, we concluded
that this variable, the geographic area of the specialized
PC service, did not affect participants PC knowledge.
Researchers found that years of nursing experience was
a significant variable in the study. When the grades
obtained in precourse tests and postcourse tests were cor-
related with the years of professional nursing experience,
the differences in the scores spanned a large range, showing
that the increase in nurses knowledge correlated with par-
ticipants years of professional nursing experience (Table 1).
Nurses previous exposure to continuing medical edu-
cation courses in PC was used as another variable in exam-
ining the scores of participant nurses on precourse and
postcourse tests. The average grades of nurses previously
exposed to PC education was 5.96 in precourse tests and
8.88 in postcourse tests. The average grades of nurses not
previously exposed to PC education was 6.15 in precourse
tests and 8.87 in postcourse tests. Given the very small var-
iation in the results, we concluded that previous exposure to
PC education did not have an influence on the knowledge of
the nurses participating in the HCS introductory and ad-
vanced PC courses.
Regardless of the variable correlated with the results
in precourse and postcourse tests, the nurses participating
in the study showed an increased level of PC knowledge
after attending the introductory and advanced courses
taught by HCS nurse trainers. Moreover, it has been dem-
onstrated that nurses professional experience and mature
age positively influenced the increase in PC knowledge.
TABLE 1 Minimum and Maximum Grades at Precourse and Postcourse Tests in Correlation
With Participants Professional Nursing Experience, Expressed in Years
Experience as Nurses
Expressed in Years 0Y5 Y 6Y10 Y
Minimum grades at pretests 2 3.4
Maximum grades at pretests 8.3 7 7.7
Minimum grades at posttests 6.2 7.4
Maximum grades are posttests 8.71 10
Journal of Hospice & Palliative Nursing
Feature Article
Results of the Qualitative Research
Between December 2013 and October 2014, 6 focus groups
were organized in 6 different specialized PC (public system,
private, or nongovernmental) service locations: Bucurezti
(B), T$rgovizte (DB), Toplia (CJ), Ojasca (BZ), Piatra Neamt
(NT) and si Brasov (BV).
Before the start of the focus groups, a period of 6 months
had elapsed since the nurses had attended the PC introduc-
tory and advanced courses taught by HCS nurse trainers.
The focus group participants were a fairly homogenous
group in that all nurse participants had cared for patients
with cancer and other chronic progressive diseases and
all were interested in applying/incorporating the new knowl-
edge gained during the PC courses in their daily routine/
clinical practice. Before the focus group start, each partici-
pant was sent an information letter and a consent form. The
nurse participants consented to participation, data collec-
tion, confidentiality, and other conditions.
The length of each focus group session varied between
1 hour and 1 hour and 56 minutes. Two facilitators, the
main and secondary researchers, were present at each fo-
cus group. The interview guide was divided into 3 parts:
introduction, main questions, and closure, containing a
total of 13 questions. After each focus group, new themes
and subthemes were identified and added to the list of
themes and subthemes. The first 4 focus groups each gen-
erated new themes. The last 2 focus groups identified
themes previously named by the first 4 focus groups.
Two researchers independently analyzed the data collected
and then reached consensus. Finding no additional themes,
researchers ended the qualitative analysis after the sixth
focus group.
Analysis and coding of the 6 focus groups revealed that
participant specialty PC nurses had implemented 5 domains
of change in their clinical practices after the introductory and
advanced PC courses. The domains were as follows:
n new perspective of care
n communication
n the team in the healthcare system
n the patient and the family
n decision-making
See Table 2.
11Y15 Y 16Y20 Y 921 Y
3.5 3 4.2
7.5 8
7.6 6.4 7.5
10 9.75 10
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 Feature Article

TABLE 2 The Results of the Qualitative Research Structured in Domains, Themes,

and Subthemes
Domains Themes Subthemes With Examples
New perspectives of Changes in the clinical practices Symptom control (n = 7)
care (n = 63) regarding the patients physical EG: The courses helped me understand in-depth the control of
care (n = 27) different symptoms, what needs to be done when confronted
with pain, nausea, etc; what needs to be administered; in what
dosages; what secondary effects to look for.

Professional competencies on wound management (n = 13)

EG: We monitor skin tissue much more often, we move the
patient; we are more aware of the benefits.

Professional competencies on continual monitoring and evaluation

of the patient (n = 3)
BE: We evaluate the critical patients more often; we change
the route of drug administration when they can no longer swallow.

Changes in the clinical practice Nurses highly appreciate and apply the holistic evaluation (n = 10)
regarding approaching the psychological DE: We need to encourage them to open up to us, to assure
needs of patients (n = 21) them of our support and maintain hope.

Nurses as a therapeutic presence (n = 4)

AO: We need to be there with our souls, with our spirit, to
help them pass over to the other side. Holding hands is a
therapy. A sweet voice can be all that you have to offer.

Personalized care (n = 3)
OD: Everything we do is personalized for each patient and for
each family. No cases are alike.

Respect for patients wishes and decisions (n = 2)

ET: Some patients feel that the end is near, and I ask them
where do they want to die: home or in the hospital. I believe it is
important to respect this decision.

Respect for patients dignity is essential (n = 2)

DE: Here, we walk alongside patients and their families in their
suffering; we help them, and we respect their dignity till the
end, till they dont need us anymore.

Support for families through information, Better time management to allocate more time to family
education; responding to their education (n = 9)
psychological and social needs (n = 15) DE: When families are concerned about morphine, I stop and
explain in detail about the use of morphine for controlling pain
and dyspnea with the information I learned at the courses.

Professional competency on family counseling (n = 4)

ET: In PC, we care for the family, too. We rely on them, and
they count on us.

Bereavement support for the families (n = 2)

DE: Families suffer when losing a loved one. We are there to
support them. Only in PC courses were we taught this.
(continues)

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 Feature Article

TABLE 2 The Results of the Qualitative Research Structured in Domains, Themes,

and Subthemes, Continued
Domains Themes Subthemes With Examples
Communication Professional competencies in Allocating more time for patients identifying their wishes (n = 2)
(n = 32) communication (n = 18) DE: In order to know their wishes, we need to spend more
time with them communicating, encouraging them to express
themselves, their wishes.

Communication while performing nursing techniques (n = 5)

FI: We need to be patient when performing nursing
techniques. Communication during these stressful moments for
patients helps tremendously. Patients trust us when we are
explaining what we do.

Implementing active listening skills (n = 6)

SD: We must be aware of our own emotions; we must remain
objective; we are there to help them, not to impose our thoughts,
opinions, judgments. First, weve learned to listen. It was said at
the courses, listen twice as much as you speak or you have 2 ears
and only one mouth. These words have stayed with me.

Implementing the protocol on communicating bad news (n = 2)

IR: Before the course, I could just say to the patient what they
were diagnosed with or to the family that the patient has died.
Now, I dont do that anymore. I pay attention to emotions. I try
to always implement the steps in the protocol for the
communication of bad news.

Patients have the right to know their diagnosis (n = 3)

LP: Better communication skills have made me more confident
in myself, and now, I feel more confident in respecting patients
rights, in being their advocate.

Communicating bad news in the Only physicians are allowed to communicate bad news, in some
healthcare system (n = 14) places (n = 4)
Nr 8: We, as nurses, are not allowed to communicate bad news to
patients or families, even if weve learned how to do it.

Families as barriers in communicating bad news to patients (n = 3)

SC: There are patients who want to know and patients that
dont want to know. It is their right to choose. We have a major
role in educating families in understanding what is important
for patients.

The fear of patients reactions, barrier in communicating bad

news (n = 4)
CT: I would feel more comfortable delivering bad news
together with another colleague. Some reactions of patients
or families can be exaggerated. Im not sure how to handle
these situations.
(continues)

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 Feature Article

TABLE 2 The Results of the Qualitative Research Structured in Domains, Themes,

and Subthemes, Continued
Domains Themes Subthemes With Examples
The team in the Tensions between the Nurses working with physicians (n = 7)
healthcare system theoretical concept SD: In the public hospitals, nurses should bow down to physicians. They
of teamwork and reality keep their clinical judgments to themselves. We are not allowed to think.
(n = 21) Nr 11: If we speak out, it is interpreted as if we do not respect the
physicians, that we are undermining their authority. We are seen as robots.
The interdisciplinary team: the ideal care team in public hospitals (n = 8)
Nr 4: It would be just wonderful if the interdisciplinary teamwork would be
implemented in our settings, too. At the moment, this is just a dream, a vision.

Nurses do not take Educating patients and families about disease management is physicians
responsibility (n = 12) responsibility (n = 5)
EG: In this situation we ask the patient or the family to talk to the doctor.
We always let the doctor handle the discussion about the management of
the disease. It is not our responsibility; it is not in our area of competency.

Nurses team (n = 16) Mutual support (n = 4)

TM: There is a strong collaboration between nurses. We can discuss openly
and support each other. We are respected for this even by the doctors.
We have more credibility.
Nurses as patient advocates (n = 4)
PN: I speak as a nurse; patients are much closer to nurses. We must be the
bond between patients, families, and physicians.
EI: I say now all that I consider needs to be said to the physicians in order for
the patient not to suffer needlessly. I believe this is the right thing to do.

Basic nursing education, inherited traditions on hospital wards, and barriers

in acquiring and implementing new professional competencies (n = 5)
IR: For me, the basic education as a nurse is a barrier. We were taught to act
not think, not to want to learn more, not to look further, not to look for more.

Desire to participate at courses with physicians (n = 3)

IT: A huge barrier in the nurse-physician relationship is the communication
between them. We need to go to these kind of courses together.

Deficiencies in the Multiple responsibilities negatively influence the quality of care (n = 11)
healthcare system makes FI: I could do more of what Ive learned if I had more time. We work 2 nurses on
teamwork difficult 2 floors, each caring for 16 patients with complex needs. During night shifts,
(n = 24) we are 1 nurse to 20 patients.

Lack of financial motivation (n = 4)

EG: We work with joy, and we do what we like, but the salaries are extremely low.
Lack of resources, barrier in practicing more professional competencies (n = 5)
SI: We lack the material resources we need. Weve learned at the courses
what we need, what needs to be done, but we lack many things.
Superficiality of medical personnel in the public healthcare system (n = 2)
FI: In the public hospitals, we are used to treating the disease, not the patient.
Some medical professionals underestimate PC interventions (n = 2)
SC: Our colleagues say about PC unit that is the place where patients die,
the last stop before leaving earth I All my colleagues should participate in
these courses in order to deeply understand the concept and the role of PC
interventions in delivering good quality of care to patients and families.

Fear is removed because Nurses no longer fear administering morphine and other opioid drugs (n = 2)
of new knowledge SD: What helped me the most during the courses have been the sessions on
(n = 4) pain management. I do not fear opioids anymore. I know and understand
the facts. Im so relieved.

Nurses do not fear discussing benefits and risks of parenteral hydration (n = 2)

CP: Now, I have courage, because now I know the risks and benefits. Now, I
give fearless explanations to family members or to other medical professionals.
(continues)

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 Feature Article

TABLE 2 The Results of the Qualitative Research Structured in Domains, Themes,

and Subthemes, Continued
Domains Themes Subthemes With Examples
The patient and the The family and the terminal patient Fear of the final moments leads to not respecting the patients
family (n = 35) (n = 22) preferred place of death (n = 4)
ET: In our unit, most patients want to die at home. Yet, families
are afraid, particularly of not knowing how to care for their loved
ones at home.

The patient burden for the family is abandoned in the hospital (n = 3)

No. 2: In the hospital, we encounter often patients that are
abandoned by their families; families no longer willing to care for
them, awaiting their death in the hospital.

Inability to feed/hydrate patient is equal to lack of proper

care/neglect (n = 7)
No. 2: We are tied to intravenous hydration. Physicians say, let
the family see that we are doing something, that we give them
what they want us to give. If we do not administer intravenous
hydration, we are accused of misconduct.

Family relationships influence the process of care (n = 4)

AF: I now put families first; I evaluate the preexisting relationships
with the terminally ill patient. Many times, there is more work to
do with the family, not with the patient. If there are tensions in the
family, we end up caring not as we would like to for the patients.

Nurses accept the silence conspiracy (n = 4)

EG: There are patients who ask to know the diagnosis and
families insist on not telling the truth. They prevent us from telling
the patient the truth.

The patient and the decision for Not accepting the disease influences the decision for treatment (n = 2)
treatment (n = 4) No. 8: There are patients who, regardless of the support from the
family, do not accept the idea of an incurable disease. This can
lead to postponing the right treatments. Is not easy for them.

Lack of information with regard to available treatments cause the

patient to make uninformed decisions (n = 2)
Nr 9: We had patients that after surgery no one told them what
they are supposed to do next, go to the oncologist, go to
radiotherapist, etc. They will be back after 3 to 4 months in very
bad condition, when it is too late. There is a huge need for more
detailed information to be given.

The patient in relationship with Patients fear honestly expressing their concerns because of
medical professionals (n = 9) physicians unpredictable reactions (n = 2)
Nr 7: Patients are afraid to tell the doctor what they really feel.
Some doctors will tell them, it is impossible for you to feel like this!

The patient communicates easily with the nurses (n = 4)

No. 10: Often, I ask patients why they didnt say to the doctors
when doing their rounds what they told me. They answer,
because they fear what the doctor will say or think.

The patients social status, education, and profession influences

the communication process approach (n = 3)
No. 11: It matters who you are, what you do, how educated you are.
The simple person is not treated well. There is a lot of inequity.
(continues)

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TABLE 2 The Results of the Qualitative Research Structured in Domains, Themes,

and Subthemes, Continued
Domains Themes Subthemes With Examples
Decision-making (n = 16) Intravenous hydration and withdrawing artificial feeding at the end of life are physicians
decisions (n = 2)
DE: Intravenous hydration is the doctors call. We artificially hydrate patients in the morning, in
the evening. They get dyspnea or other secondary effects, but it does not matter; it is the
doctors decision.

Medical decisions are influenced by the families pressure (n = 3)

AL: We, sometimes, take the time to give such detailed information to the families about the
futility of different treatments (vitamins at the end of life, intravenous hydration interventions,
transfusions, etc). Yet, the family goes to the doctor who does what the family wants, despite
the futility. We feel so bad. What a waste of time with no benefit to anyone.

End-of-life treatment decisions differ one location to another (n = 2)

MN: In our location, when there is no more deglutition reflex, feeding is stopped, only care of
the mouth and lips is maintained; we talk with the family; we explain to them that is a burden for
the patient to continue feeding, and we all focus on ensuring patients comfort.

Contradictions in the physician-nurse Nurses are aware of the burden caused by intramuscular-
team with regard to therapeutic and intravenous-administered treatment but cannot
decisions (n = 6) influence the physicians decision (n = 3)
EG: In specialized PC services, treatment at the end of life
is subcutaneous. Unfortunately in our setting, because of
physicians deciding so, we administer the treatment
intravenously. It is important for us that weve learned
from the courses; physicians need to practice what
theyve learned, too.

Nurses recommendations are disregarded by

physicians (n = 3)
Nr 5: In our location, family physicians dont know a thing
about morphine. I had a neighbor once that suffered
tremendous pain caused by a cerebral tumor and the
recommended dose of morphine was 20 mg in 24 hours.
I advised the family to safely, step-by-step increase the dose.
When they confronted the physician, he expressed
frustration toward the family for listening to a nurse and
following her instructions.
Medical decision influenced by the physicians level of medical education (n = 3)
SD: It is so important for the physicians to be educated and well trained, too. They are
accountable for their patients, and many times, they do things because they dont know what
to do differently.
Abbreviation: PC, palliative care.

Conclusions of the Qualitative Research
The qualitative study demonstrated the positive, long-term
effect of the ELNEC International Training Program and the
educational modules translated and adapted from it. The
PC educational programs enabled nurses in specialized
PC services to enhance their knowledge, develop special-
ized levels of PC competencies, and have a greater effect
on the quality of care delivered to patients. Furthermore,
the study revealed how the failure to respect and/or pro-
mote the professional autonomy of nurses compromised
optimal PC care, the interdependence of nurses and physi-
cians in the interdisciplinary team, and the uniqueness of
nursings contribution to quality healthcare provided to pa-
tients and families.
The qualitative study also revealed the areas of health-
care delivery in need of improvement and the barriers en-
countered in implementing changes in the nurses daily
clinical practice (Figure 2).
DISCUSSION
Previous international studies have confirmed the findings
of this study, specifically physicians resistance to change
current practices in communication and interdisciplinary

432 www.jhpn.com Volume 19 & Number 5 & October 2017


FIGURE 2. Areas of improvement and barriers to the work of specialized palliative care nurses in Romania.
teamwork.12,13 With this awareness, nurses can work to ef-
fect change within their healthcare settings to create better
communication and teamwork. Because nurses become
better prepared and equipped with PC knowledge, they
can assume the role of patient advocates and other respon-
sibilities and roles. Because PC nurses confront organiza-
tional and system constraints, they will have the added
skills to increase the effect of nursing on the general quality
of care delivered to patients and families. Moreover, nurses
are the professionals who spend the most time in direct
contact with the patients.14 Society may perceive that
nurses provide strictly physical care, but the reality is that
nurses confront a more complex clinical process in caring
for patients and families.15 In todays PC, nurses are called
on to care for patients psychological, social, and spiritual
needs, in addition to their physical needs.
Journal of Hospice & Palliative Nursing
Feature Article
In our study, as in other international studies, time con-
straints were found to be a constant barrier to enhancing
the quality of nursing practice; nurses were hindered in
implementing newly learned knowledge and skills by
overburdened caseloads and the lack of time and re-
sources.12,16 From this perspective, nurses work within
complex healthcare systems with a multitude of factors
influencing their clinical practice.
CONCLUSION
The results of the phenomenological study showed through
the precourse and postcourse test evaluation process an
impressive increase in the participant nurses knowledge
after attending introductory or advanced PC courses. Con-
tinued medical education courses delivered in the form of
www.jhpn.com 433
 Feature Article
PC modules adapted from the ELNEC international training
program resulted in the implementation of positive changes
in nurses daily clinical practice. Using in-depth and detailed
references, the participant nurses took advantage of the
recommended supplemental materials in the ELNEC Inter-
national Training Program and the interactive teaching
techniques specific to the adult learning process, the study
cases, role plays, demonstrations, now lets practice ex-
ercises, small group work, and brainstorming, to master
new information and skills, which allowed for the develop-
ment of new professional competencies in PC.
Acknowledgment
The authors wish to acknowledge Mary Callaway of
Open Society Foundations and Catharine Grimes from
Bristol-Myers Squibb Foundation for their support and
contribution to PC in Romania.
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