Training Proposal in Palliative Care for Primary Care Nurses in a Health Area in Spain

Round 1

Reviewer 1 Report

Good understanding of the topic with very clear background/context provided.

Need for both theoretical learning and practical application acknowledged and assessment for both incorporated.  

Well articulated.

Good, 

Note - section 2.1 - header should read 'Design' not Desing.

2.4. Instruments

The aim of training is to provide nurses with the knowledge, skills, attitudes and judgment associated with their profession and field of action  

Consider changing 'field of action' to 'field of expertise'

Author Response

Dear Reviewer 1,

We appreciate the comments and have made the changes that appear in them.

Kind regards.

Reviewer 2 Report

Dear Editor,

Thank you for inviting me to read this interesting article. Training in Palliative Care in Primary Care contexts is extremely important.

The most important issue with the present manuscript is that the authors need to better organize the methods section of the manuscript, as without this change it is not possible for the reader to understand the research carried out.
The elaboration of the training program involved several phases, from bibliographical research, to the determination of training needs, to the study of departmental protocols, however the steps of each of these parts are not explicit enough.

Best regards

Minor editing of English language required.

Author Response

Dear Reviewer 2,

We appreciate your comments. We have modified the material and method section to make the design easier to understand.

Kind regards.

Reviewer 3 Report

Please see attached

Comments for author File: Comments.pdf

Author Response

Dear Reviewer 3,

We appreciate all your comments, which will undoubtedly provide a higher quality to the work and we proceed to respond to them point-by-point.

Point one: This is an important area of research, however the focus is on two major components – palliative care delivery and bereavement. Perhaps this should focus on one or the other? It feels like it is too much for one report unless the training needs to be identified were specifically related to grief and bereavement?

Response: Bereavement care is part of palliative care nursing competencies. This type of care includes care for the bereaved after the death of the patient, so this type of care should be included in any training plan on palliative care. All nurses who care for people at the end of life must include care for the family and care for the bereaved in their care plan, according to their care setting. This implies that hospital nurses will be able to care for the bereaved in the moments before and immediately after death, while primary care nurses will be able to monitor the bereaved to assess their adaptation to loss and detect risk factors for complicated grief for their corresponding approach.

Additionally, the inclusion of a bereavement care protocol as part of the training plan aims to provide the necessary knowledge to carry out this type of care in the health department to which the nurses to whom said training plan is directed to belong. Indicating that the bereaved must be cared for, without indicating how to do it, can make it difficult for said care to be carried out. The protocol specifies the time periods for visits and the assessments (early detection of complicated grief) and care to be carried out in each of them, including when the bereaved needs to be referred to another professional and referral to mental health specialists.

Point two: No abbreviations should be used in an abstract.

Response: Abbreviations have been removed.

Point three: Line 64 you use the word transversal. Unclear what is meant by this. Perhaps re-phrase/change the word to improve meaning.

Response: “The theoretical competencies of palliative care nurses are transversal for all nurses regardless of their field of practice”. The word transversal is used as a synonym for equality, in such a way that it indicates that the theoretical competencies are the same regardless of the place where care is provided. We have changed the word transversal to horizontal to favor understanding.

Point four: Here you talk more about bereavement and palliative care, however the title does not reflect this. Perhaps reword the title to reflect bereavement care as a focus.

Response: As specified in point one, palliative care includes bereavement care, which is why it is part of palliative care training and we have not considered extending the title further. Bereavement care appears in the keywords to guide the reader to the content of the paper.

Point five: Design is actually spelled incorrectly in the heading.

Response: The word Design has been modified.

Point six: This is unclear as to what you have actually undertaken. Is this more of an in-house information collecting exercise as opposed to a robust research design? It is unclear

Response: Most palliative care training plans have been designed for nurses without taking into account neither their training needs nor their care tasks based on their field of work. The first step in designing a training plan is the analysis of the situation, so it is necessary to know the existing training plans and the training needs of the nurses to whom it is going to be addressed. On the other hand, the assessment of knowledge about palliative care and how they are applied, allowed us to show that despite having the knowledge; these did not reach the patients and their families. These results indicate that non-specific general training can lead to an increase in knowledge, but it does not ensure that it is applied in the care provided.

We believe that the review of existing training plans and the assessment of both theoretical and practical training needs offers a solid design, since it contemplates a broad vision of palliative care training for primary care nurses.

Point seven: If you have undertaken a systematic review, what is the research question, did you register this with Prospero for example. The date range in the data collection section states 10 years (2018-2022) – this is not ten years.

Response: The research question was: Do standardized palliative care basic training plans, compared to specific training plans, improve the practical training of primary care nurses?

The systematic review was not registered in Prospero because it was not the aim of the study. The review was carried out as part of the design of the training plan and with the intention of obtaining a synthesis of the existing training plans in basic training in palliative care for nurses. The time period has been modified.

Point eight: There appears to be a mixture of approaches to the different components of the work, but it is overly complex in terms of trying to understand exactly what has been undertaken. Perhaps focusing on just one of these would be more useful at this time. There was a survey and a ‘test’ questionnaire and a systematic review?

Response: If the design of the training plan had only focused on a systematic review, it would not meet the training needs of the group to which it is addressed. By complementing it with the assessment of their knowledge in palliative care and how they apply that knowledge, we have been able to design a more adjusted and specific training that could influence the care that the population receives.

Point nine: Ethical approval is present, but how was the possibility of coercion managed if department coordinators were used in recruitment?

Response: The following paragraph has been included in the paper to clarify the ethical aspects: “The management of possible coercion during recruitment was solved by preventing coordinators from accessing the number of responses from the nurses under their charge, with reminders of a general scope”.

Point ten: On line 239 you discuss the questionnaire and pass rates. Was this a test they completed as part of this study or previously? It is not clear.

Response: The assessment of the theoretical and practical training needs was carried out using the INCUE questionnaire, as part of this study in the analysis of the situation. The systematic review of existing training plans and the assessment of training needs were carried out sequentially.

Point eleven: Overall: These are very important areas for research and knowledge acquisition however it appears too complex to have so many considerations in a single publication. It is difficult to read and understand exactly what you are attempting to do with so many approaches. Please consider revising this manuscript to focus on either PC training or bereavement with a singular detailed approach.

Response: With the modifications made to the manuscript, we hope to have corrected its weaknesses, as well as to facilitate the reading and understanding of the study carried out. Also, have clarified the issues raised in your comments.

Kind regards.

Round 2

Reviewer 2 Report

After careful revisions, the authors have made significant improvements to the manuscript.

Only minimal adjustments to the English language are needed.