Empowering Nurses to Provide Palliative Care for COPD Patients in a Pulmonary Department: Participatory Action Research

Empowering Nurses to Provide Palliative Care for COPD Patients in a Pulmonary Department: Participatory Action Research | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Empowering Nurses to Provide Palliative Care for COPD Patients in a Pulmonary Department: Participatory Action Research narjes heshmati far, mahnaz amini, Hamid reza Zendeh talab, Zahra Sadat Manzari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5731484/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Apr, 2025 Read the published version in BMC Palliative Care → Version 1 posted 4 You are reading this latest preprint version Abstract Background Chronic obstructive pulmonary disease (COPD) affects the quality of life of patients and their caregivers. Although palliative care can improve quality of life, COPD patients and their caregivers have limited access to palliative care services. This study was conducted to empower nurses to provide palliative care to COPD patients in the pulmonary department. Methods This participatory action research was conducted in four steps: observation, reflection, planning, and action. The data were collected via PCKT, FATCOD-B, and PCPS questionnaires about palliative care, interviews, focus groups, and observation. Qualitative content analysis and paired t-tests were used for data analysis. Results Three major themes emerged: professional incompetence in palliative care, basic shortages in palliative care, and a lack of professional support. Three changes were made, including enhancing palliative care knowledge, establishing a palliative care team, and increasing career motivation. There were significant increases in PCKT, FATCOD-B, and PCPS scores before and after PAR (p = 0.000). Conclusion Given the importance of providing palliative care, necessary measures and actions, including developing interprofessional collaboration and training as well as motivating staff, should be taken by health managers. participatory action research COPD nurse palliative care Figures Figure 1 INTRODUCTION Nurses play an important role in meeting the needs of patients and providing quality services ( 1 ). Despite significant advances in medical technology and treatments, health systems worldwide face various challenges. One main concern is the prevalence of chronic and incurable diseases, particularly COPD ( 2 ). The prevalence of COPD is increasing due to smoking, urbanization, tanning, and industrial pollution ( 3 ). The World Health Organization (WHO) predicts that COPD will be the third leading cause of death worldwide by 2030 ( 4 ). These patients experience many problems, such as shortness of breath, cough, pain, insomnia, fatigue, anxiety, and depression ( 5 ). As COPD progresses, patients typically experience respiratory infections, severe weight loss, and a decline in overall functional ability ( 6 ). Patients may be unable to care for themselves without assistance and support, and this dependence on others is distressing for patients and family caregivers ( 7 ). Comprehensive care of COPD patients can improve the quality of life of patients and their caregivers ( 8 ). According to the WHO, palliative care (PC) is an interdisciplinary approach aimed at managing symptoms and improving the quality of life of incurable patients ( 9 ). The main focus of PC is to improve the quality of life from diagnosis to the end of the patient's life through symptom management with physical, psychological, social, and spiritual support by multi-professional teams ( 10 ). Providing a PC creates optimal conditions that contribute to the patient's peaceful and comfortable death ( 11 ). Studies have shown that early provision of PC improves symptoms, increases patient and caregiver satisfaction, and reduces hospitalization and treatment costs ( 12 – 14 ). Despite the importance and benefits of PC, this care is not provided properly to COPD patients and has been identified as a major challenge in the health system ( 15 ). The National Consensus Project for Quality PC considers the presence of trained staff as one of the basic principles of PC ( 16 ). Considering that nurses address all aspects of human existence, the role of PC nurses in assessing and meeting the needs of patients is important ( 12 ). Few studies have investigated the empowerment of nurses in PC. Taleghani et al. (2018) reported that empowering nurses to provide PC to cancer patients through new and standardized training courses increases nurses' knowledge and improves PC quality ( 15 ). Iran lacks a comprehensive care model for incurable patients and does not have adequate facilities, trained staff, or organizational structures for these services ( 13 , 17 ). Since in Iran, sufficient measures have not been taken to empower nurses to provide PC and the number of COPD patients who need PC is increasing, it is necessary to design and implement studies to empower nurses. This study was conducted to empower nurses in providing PC to COPD patients in the pulmonary department. METHODS Design of the study The present study was carried out through participatory action research (PAR). In PAR, groups of individuals experiencing problems collaborate to bring about changes in their environments by identifying issues, generating new knowledge, and implementing solutions together ( 12 ). In this study, the cycle model proposed by O'Leary was used. Each cycle has four stages: a) observation and data collection, b) reflection, c) planning, and d) action. O’Leary’s model emphasizes that “cycles converge toward better situation understanding and improved action implementation and are based on evaluative practice that alters between action and critical reflection” ( 13 ) (Fig. 1 ). The study was inspired by nursing performance and observation of the lack of PC provision for patients with COPD. Study settings and participants This study was conducted in the pulmonary ward at Imam Reza Hospital, Mashhad, Iran. The pulmonary department has 22 active beds. COPD patients have the highest hospitalization rate, with an average of 15 patients per month. Four pulmonologists, one head nurse, eighteen nurses, one matron, three supervisors, two nursing faculty members, and one PhD student participated in this study. Additionally, the Palliative Care Team (PCT), consisting of a social worker, psychologist, nutritionist, and clinical chaplain, was added during the PAR process. The study was carried out from September 2022 to October 2024. Data analysis Qualitative data analysis was performed via the conventional content analysis approach according to the steps of Graneheim & Lundman ( 14 ) and MAXQD software (v.20). The recorded interviews were fully transcribed and reviewed several times. The codes, categories, and themes were extracted from the text of the participants' experiences. Quantitative data analysis was performed via descriptive statistics and paired sample t tests with SPSS (v.18). Rigor Trustworthiness was ensured via Lincoln and Guba’s evaluative criteria ( 20 ). In this PAR, various strategies were used, including data collection from multiple sources, maximum diversity in sampling, prolonged engagement, continuous reflection, conducting research in two cycles, expert confirmation of data analysis, and providing thorough descriptions of the data. First cycle Observation & Data Collection Both qualitative and quantitative methods were used for data collection. Qualitative data Observation, field notes, semi-structured interviews, and focus groups were used to collect data. Interviews were conducted with head nurses and staff members at the beginning and end of the study. The interviews were conducted in a room in the pulmonary ward. Each interview lasted between 45 and 60 minutes. Data saturation was achieved after 10 interviews, with two additional interviews conducted to confirm that no new themes emerged, totaling 12 interviews. The first author, the study coordinator, observed the nurses' behavior while providing patient care during three shifts in the pulmonary ward. Field notes focused on clinical performance and the use of PC services in daily practice. The interviews began with questions such as “Please explain your experience from a day of working with COPD patients”. What do you know about PC? How can you improve your ability to provide PC to patients with COPD? Quantitative data : Data were gathered using three questionnaires: knowledge, attitude, and practice towards palliative care. The Palliative Care Knowledge Test (PCKT) consists of 20 true/false questions. With scores ranging from 0 to 20, higher scores indicate higher knowledge. The test covers various domains of philosophy (2 questions), pain ( 6 ), dyspnea ( 4 ), psychiatric issues ( 4 ), and gastrointestinal issues ( 4 )( 15 ). The Cronbach’s α coefficient of this questionnaire in the current study was 0.85. Fromm el's Attitude toward Care of the Dying-form B scale (FATCOD-B) ( 16 ) is a 30-item tool answered on a five-point Likert scale. Scores range from 30–150. Higher scores indicate a positive attitude toward death and care for dying patients. The scale has been translated into multiple languages and has shown reliability. For the English( 17 ), Spanish ( 18 ), and Turkish ( 19 )FATCOD-B samples, Cronbach's α values ranged from 0.76 to 0.93 for the total scale. In our study, the Cronbach’s α was 0.89. The Palliative Care Self-Reported Practices Scale (PCPS) ( 20 ). consists of 18 items on a 5-point Likert scale, with total scores ranging from 18 to 90. Higher scores indicate better performance. The scale consists of six subscales: care provided during the dying phase, patient- and family-centered care, pain, delirium, respiratory distress, and communication. The Cronbach’s α was 0.79 in the pretest and 0.87 in the posttest. Data collection was conducted between September 2022 and May 2023. Reflection After both the quantitative and qualitative data were analyzed, the findings were shared with the participants. Once the participants confirmed the findings, they discussed the importance and priority of solving each problem. The reflection stage of the O'Leary model is crucial because it allows individuals and groups to critically evaluate their experiences. This process helps to identify strengths and weaknesses before the planning stage ( 13 ). Planning and action During focus groups, participants were asked to suggest strategies based on the identified problems and the literature review. These suggestions were evaluated via five criteria: feasibility, cost, time, human resources, and management support. Eventually, the participants agreed on three plans and developed an action plan. Consensus was defined as 80% agreement or higher. The participants in the focus groups included the matron, head nurse, supervisors, pulmonologists, and clinical nurses. The focus groups lasted between 90 and 120 minutes and were managed by the PhD student and two research team members. The action plans were implemented over 8 months from September 2023 to April 2024. Second cycle The second cycle began in May 2024 and ended in September 2024. Qualitative and quantitative data were collected and analyzed during this time. Sessions were held with participants to review the action plan and discuss any related challenges. On the basis of these reflections, necessary changes and corrections were made to the program. Results Observation & Data Collection Qualitative data Three problems were identified through the analysis of observations, interviews, and focus groups (Table 1 ). Table 1 Categories and subcategories derived from qualitative data analysis Categories Subcategories Professional incompetence in palliative care lack of knowledge Low self-confidence Insufficient skill Basic shortages for providing palliative care Lack of nurses Inadequate facilities and equipment Lack of clinical practice guideline Inappropriate organizational culture Lack of professional support Ignoring nurses Inadequate organizational support Poor interdisciplinary communication non-patient-oriented tasks Professional incompetence in palliative care lack of knowledge, low self-confidence, and inadequate skills, were the problems identified in this category. “How can I do PC when I do not know anything about it? PC is a new program that I do not think my colleagues know about either...” (p8). “I have been working in this hospital for several years. There has never been a PC workshop or class, and naturally, I do not know PC...” (p5). Basic shortages for providing palliative care lack of nurses, inadequate facilities and equipment, a lack of clinical practice guidelines, and an inappropriate organizational culture, were some of the basic shortages. “All patients require special attention and want to talk about their pain and suffering, but we often do not have the time to listen to them...” (p1). “Whenever I try to offer compassionate care to my patients, I hesitate due to the fear of being ridiculed by my colleagues…” (p18). Lack of professional support Ignoring nurses, inadequate organizational support, poor interdisciplinary communication, and nonpatient-oriented tasks were some of the problems mentioned by the nurses. “Patient care is often fragmented, everyone works independently and may not be aware of other treatments or recommendations; from the moment a patient enters the hospital, they are faced with various referrals, specialists, and protocols, which can be costly and exhausting for the patient...” (p2). The quantitative data Before the participatory action research, the knowledge score was (10.6 ± 1.4), the attitudes score was (99.6 ± 7.9), and the palliative care practice score was (68.5 ± 3.4). Reflection In the reflection, all the participants agreed on the importance of PC education. “In my opinion, PC education should be a priority. If the content is taught correctly and implemented in practice, many problems will be solved … ” (p 21). The lack of nurses was a problem that most participants emphasized. “A nurse performs many tasks during each shift. If we want to provide quality care for the patient, there should be basic planning for addressing the shortage of nurses...” (p 27). Nurses emphasized that feelings of discouragement and disappointment affect their performance. “I am not encouraged when I do my duty properly, but if I make a small mistake, I am reprimanded and punished. Therefore, I have concluded that I should not do more than my duty…” (p6). Planning and action Three action plans were developed and implemented (Table 2 ). Table 2 Action plan for empowering nurses in providing palliative care plan Act Enhancing palliative care knowledge palliative care educational workshop Intradepartmental educational conferences Journal Club Presentation Using e-learning platforms Learning through self-study Access to palliative care resources in the department education in all shifts Establishing a palliative care team Coordination with department head Identifying team members Preparing the team to provide palliative care Increasing career motivation Considering palliative care performance in the evaluation form Changing the evaluation period Selecting the best nurse based on the evaluation score Encouraging the nurse with the highest score Palliative care nursing professional development All nurses participated in an 18-hour PC workshop. The workshop addressed topics such as the importance of caring for incurable patients, effective communication, the goals and principles of PC, the status of PC in Iran, symptom management, and end-of-life care. Some nurses volunteered to present conferences and journal clubs about PC in the ward. The timetable of the educational programs was displayed at the nursing station. A virtual channel was created to share educational files. Books in the PC field were also prepared for the ward. Establishing a palliative care team The PCT was formed to provide comprehensive care to patients and their families with the support of hospital management and in coordination with the department head. The PCT was obliged to collaborate with ward staff from admission to discharge and to play an active role in providing PC to the patient's caregivers during death and bereavement. Meetings were held with the PCT, and necessary training was provided. Increasing nurses' career motivation Based on the participants' suggestions, a score for PC performance was considered in the specific index section of the evaluation form, and the evaluation period was conducted at 3-month intervals instead of annually. Additionally, with the participants' cooperation, a needs assessment and referral form to the PCT were prepared, and nurses were scored based on symptom management and collaboration with the PCT. Every three months, the nurse with the highest score was given an acknowledgment and a small gift from the head nurse. Second cycle The results of the reflections were mostly positive, and nurses reported that the changes had increased their ability to provide PC. “I used to be hesitant to discuss end-of-life issues, but now I feel like I can talk to patients about it. I recently cared for an 80-year-old woman with advanced COPD. She expressed her desire to spend her last moments with her children and grandchildren... this conversation was satisfying for both of us...” (p18). “Teamwork has improved communication and increased respect among colleagues, but these programs should not be short-term... I think this is the beginning of PC and these actions should continue…” (p16). After PAR, significant changes in PCKT, FATCOD-B, and PCPS scores were noted. The total score changed significantly from pre-intervention to post-intervention (p = 0.000) (Table 3 ). Table 3 The mean score of knowledge, attitude, and performance of nurses Scale (Number of items) Pretest Mean ± SD Posttest Mean ± SD p Total PCKT Scale 10.6 ± 1.4 17.8 ± 1.8 0.000* FATCOD-B Scale 99.6 ± 7.9 101.9 ± 8.9 0.000* Total PCPS Scale 68.5 ± 3.4 82.1 ± 6.7 0.000* * Significant at the 0.05 level DISCUSSION Nurses play an important role in managing symptoms and improving the quality of life of incurable patients ( 20 ). Nurses must continually improve their professional competence to provide safe and high-quality care ( 21 ). The current study showed that simple measures can improve PC. Using PAR as an approach with the dual purpose of practical problem-solving and empowering participants enables them to actively participate in the research process and benefit from its results ( 25 ). Nurses encounter many challenges in clinical settings, and AR offers a way to address these challenges. In this PAR, we tried to reach a common understanding and consensus about empowering nurses in PC through collaboration and partnership. Constructive collaboration and interaction between participants and faculty and the integration of evidence-based research into patient care can help solve complex clinical problems. The results of the qualitative and quantitative study revealed that nurses lack sufficient knowledge and practice regarding PC. Price et al. (2019) emphasized that one of the major challenges in providing PC is the insufficient knowledge and skills of health professionals, which has significantly limited access to PC services ( 22 ). The solution proposed by the participants was a combination of educational interventions on PC. Training through workshops, presenting journal clubs in the form of intradepartmental conferences, and sending educational files helped increase the participants' knowledge of PC. In Weiner et al.'s study (2015), implementing a multifaceted approach, such as experiential learning, educational interventions, creating learning opportunities, and constant training, increased the effectiveness of PC ( 23 ). Nurses should use best practices to update their knowledge, and online learning is a good option for training ( 24 ). Nurses have stated that they lack motivation to provide high-quality care, causing them to focus on administering medication and writing nursing reports. This research suggests that small actions, such as being recognized as a "selected nurse", can help nurses feel more appreciated and valued in their work. Health managers and politicians should create conditions that can promote motivation and responsibility among nurses. In a study by Baljoon et al. (2018), organizational factors such as nurses' empowerment, salary and financial benefits, contingent rewards, promotions, supportive relationships (coworkers), supervision, work engagement, communication, and the nature of work were identified to impact nurses' motivation ( 25 ). The participants reported barriers that prevented them from providing PC. Some of these barriers are complex issues and are beyond the scope of this research. One of the identified barriers is the shortage of nurses, which contributes to increased workloads for nurses, job dissatisfaction, professional errors, staff turnover, and potentially, patient harm ( 26 , 27 ). In this study, PCT was effective in managing patient needs and addressing challenges related to nursing shortages. An interprofessional team is crucial for providing comprehensive and ethical care to palliative patients ( 28 ). The success of a healthcare team depends on a supportive work environment fostered by effective communication, strong leadership, and mutual respect ( 29 ). Sarta et al. (2022) identified a conflict between physicians and nurses and inadequate teamwork as the main issues. Strengthening relationships and teamwork can improve PC services ( 30 ). Bennardiet et al.'s (2021) research demonstrated that effective interprofessional relationships are critical to the PC process and are considered key facilitators ( 31 ). Therefore, considering the complex conditions and high symptom burden in COPD patients, PCT is necessary in the management of disease symptoms. LIMITATIONS As with most qualitative research, the study was conducted in one pulmonary department in Iran, and therefore, the findings may not be directly generalizable to other departments. Therefore, it is suggested that future studies explore the empowerment of nurses to provide palliative care in other departments with larger sample sizes. CONCLUSION After PAR, there was a significant increase in PCKT, FATCOD-B and PCPS scores compared to before. This study revealed that accurate planning, PC training, and strengthened interdisciplinary collaboration can improve the competencies and skills of teams involved in PC. Additionally, attention to nurses' intrinsic and extrinsic motivations can create a culture of care that recognizes PC as an integral component of COPD patient care. Therefore, managers and policymakers should allocate sufficient time and financing to empowering healthcare teams. Declarations Conflict of interest The authors declare no conflicts of interest. Ethical considerations This study was part of N.H.'s PhD project, approved by the Research Ethics Committee of Mashhad University (IR.MUMS.REC.1402.007). Participants were informed about the study's aims and methods, and informed consent was obtained, and identities were protected by removing identifiers. Funding This study was supported by Mashhad University of Medical Sciences. Author Contribution Z.M. conducted the study, contributed to data analysis and interpretation, and revised the draft. H.Z. contributed to data collection and writing the first draft. M.A. contributed to the translation and revising of the draft. N.H. contributed to data collection, drafting of the work, and critical revision of important intellectual content. All authors approved the final version of the manuscript and agreed on all aspects of the work. Acknowledgement The authors of this study would like to express their appreciation and gratitude to all of the individuals who took part in this study. 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Team approaches in palliative care: a review of the literature. Int J Palliat Nurs. 2019;25(9):444–51. Saretta M, Doñate-Martínez A, Alhambra-Borrás T. Barriers and facilitators for an effective palliative care communication with older people: A systematic review. Patient Educ Couns. 2022;105(8):2671–82. Bennardi M, Diviani N, Stüssi G, Saletti P, Gamondi C, Cinesi I, et al. A qualitative exploration of interactional and organizational determinants of collaboration in cancer palliative care settings: Family members’, health care professionals’ and key informants’ perspectives. PLoS ONE. 2021;16(10):e0256965. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Apr, 2025 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 08 Jan, 2025 Editor assigned by journal 06 Jan, 2025 Submission checks completed at journal 06 Jan, 2025 First submitted to journal 29 Dec, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5731484","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":398322932,"identity":"255fdfb5-efde-42ae-a94e-ffecf0155971","order_by":0,"name":"narjes heshmati far","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIie2SsUrEQBCGBwKbZmTbPfbwXmFDcKMQzKsIB2uzthJQMFVsxF7uKWysDw4uTWwlIYWHRXwDSaHiRDirRMXKYr9iphg+5h8YAIfjH6IAWN/Rz6gKJZB/zbxvFYW4pLafxtNJ9ksFPpW0NLFa/hAs8i/bp+r8dYr+fbup8xWGD+XebQeHM/B3NkPKwVUZhXZNwfA4Cm5I0Y3VDcI8yDxfDQarLJOWKUzAMDnZKnTIEXhs+JbH51bad9rCWybf+mALq+sOLsaVCrQ8yUkRhglRGlTS6gphNa6UlpTrkJSWlDRG0ZjTBlUR5GNKUVCwl90Eeb9FiYQv5nd1l57NOF8PKmNsv8LhcDgcf+IDfv5RMzlLvSkAAAAASUVORK5CYII=","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"narjes","middleName":"heshmati","lastName":"far","suffix":""},{"id":398322933,"identity":"9614f995-6975-4172-b8fe-18d5659d969a","order_by":1,"name":"mahnaz amini","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"mahnaz","middleName":"","lastName":"amini","suffix":""},{"id":398322934,"identity":"1a66ca5f-f0a3-4f36-b345-2a9995e27cdb","order_by":2,"name":"Hamid reza Zendeh talab","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hamid","middleName":"reza Zendeh","lastName":"talab","suffix":""},{"id":398322935,"identity":"7bec649c-fbb5-40c2-96e5-7c5da0ebedf8","order_by":3,"name":"Zahra Sadat Manzari","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zahra","middleName":"Sadat","lastName":"Manzari","suffix":""}],"badges":[],"createdAt":"2024-12-29 20:23:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5731484/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5731484/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-025-01743-0","type":"published","date":"2025-04-21T15:56:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73269274,"identity":"5647d1b4-353c-4e09-baa0-281b9441b6b1","added_by":"auto","created_at":"2025-01-08 10:42:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":119158,"visible":true,"origin":"","legend":"\u003cp\u003eO’Leary Cycles Action Research\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5731484/v1/31787d2eefca617d03a93eb4.png"},{"id":81569475,"identity":"c4a49097-93fe-41a3-8d8a-fb3f397c9bfa","added_by":"auto","created_at":"2025-04-28 15:59:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":829950,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5731484/v1/4c1c0775-623a-452e-ad7f-f1afeb793d17.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Empowering Nurses to Provide Palliative Care for COPD Patients in a Pulmonary Department: Participatory Action Research","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eNurses play an important role in meeting the needs of patients and providing quality services (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Despite significant advances in medical technology and treatments, health systems worldwide face various challenges. One main concern is the prevalence of chronic and incurable diseases, particularly COPD (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The prevalence of COPD is increasing due to smoking, urbanization, tanning, and industrial pollution (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The World Health Organization (WHO) predicts that COPD will be the third leading cause of death worldwide by 2030 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). These patients experience many problems, such as shortness of breath, cough, pain, insomnia, fatigue, anxiety, and depression (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). As COPD progresses, patients typically experience respiratory infections, severe weight loss, and a decline in overall functional ability (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Patients may be unable to care for themselves without assistance and support, and this dependence on others is distressing for patients and family caregivers (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Comprehensive care of COPD patients can improve the quality of life of patients and their caregivers (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to the WHO, palliative care (PC) is an interdisciplinary approach aimed at managing symptoms and improving the quality of life of incurable patients (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The main focus of PC is to improve the quality of life from diagnosis to the end of the patient's life through symptom management with physical, psychological, social, and spiritual support by multi-professional teams (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Providing a PC creates optimal conditions that contribute to the patient's peaceful and comfortable death (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudies have shown that early provision of PC improves symptoms, increases patient and caregiver satisfaction, and reduces hospitalization and treatment costs (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Despite the importance and benefits of PC, this care is not provided properly to COPD patients and has been identified as a major challenge in the health system (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The National Consensus Project for Quality PC considers the presence of trained staff as one of the basic principles of PC (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Considering that nurses address all aspects of human existence, the role of PC nurses in assessing and meeting the needs of patients is important (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFew studies have investigated the empowerment of nurses in PC. Taleghani et al. (2018) reported that empowering nurses to provide PC to cancer patients through new and standardized training courses increases nurses' knowledge and improves PC quality (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Iran lacks a comprehensive care model for incurable patients and does not have adequate facilities, trained staff, or organizational structures for these services (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Since in Iran, sufficient measures have not been taken to empower nurses to provide PC and the number of COPD patients who need PC is increasing, it is necessary to design and implement studies to empower nurses. This study was conducted to empower nurses in providing PC to COPD patients in the pulmonary department.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign of the study\u003c/h2\u003e \u003cp\u003e The present study was carried out through participatory action research (PAR). In PAR, groups of individuals experiencing problems collaborate to bring about changes in their environments by identifying issues, generating new knowledge, and implementing solutions together (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In this study, the cycle model proposed by O'Leary was used. Each cycle has four stages: a) observation and data collection, b) reflection, c) planning, and d) action. O\u0026rsquo;Leary\u0026rsquo;s model emphasizes that \u0026ldquo;cycles converge toward better situation understanding and improved action implementation and are based on evaluative practice that alters between action and critical reflection\u0026rdquo; (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The study was inspired by nursing performance and observation of the lack of PC provision for patients with COPD.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy settings and participants\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in the pulmonary ward at Imam Reza Hospital, Mashhad, Iran. The pulmonary department has 22 active beds. COPD patients have the highest hospitalization rate, with an average of 15 patients per month. Four pulmonologists, one head nurse, eighteen nurses, one matron, three supervisors, two nursing faculty members, and one PhD student participated in this study. Additionally, the Palliative Care Team (PCT), consisting of a social worker, psychologist, nutritionist, and clinical chaplain, was added during the PAR process. The study was carried out from September 2022 to October 2024.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eQualitative data analysis was performed via the conventional content analysis approach according to the steps of Graneheim \u0026amp; Lundman (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and MAXQD software (v.20). The recorded interviews were fully transcribed and reviewed several times. The codes, categories, and themes were extracted from the text of the participants' experiences. Quantitative data analysis was performed via descriptive statistics and paired sample t tests with SPSS (v.18).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRigor\u003c/h3\u003e\n\u003cp\u003eTrustworthiness was ensured via Lincoln and Guba\u0026rsquo;s evaluative criteria (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In this PAR, various strategies were used, including data collection from multiple sources, maximum diversity in sampling, prolonged engagement, continuous reflection, conducting research in two cycles, expert confirmation of data analysis, and providing thorough descriptions of the data.\u003c/p\u003e\n\u003ch3\u003eFirst cycle\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eObservation \u0026amp; Data Collection\u003c/strong\u003e \u003cp\u003eBoth qualitative and quantitative methods were used for data collection.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eQualitative data\u003c/strong\u003e \u003cp\u003eObservation, field notes, semi-structured interviews, and focus groups were used to collect data. Interviews were conducted with head nurses and staff members at the beginning and end of the study. The interviews were conducted in a room in the pulmonary ward. Each interview lasted between 45 and 60 minutes. Data saturation was achieved after 10 interviews, with two additional interviews conducted to confirm that no new themes emerged, totaling 12 interviews. The first author, the study coordinator, observed the nurses' behavior while providing patient care during three shifts in the pulmonary ward. Field notes focused on clinical performance and the use of PC services in daily practice. The interviews began with questions such as \u0026ldquo;Please explain your experience from a day of working with COPD patients\u0026rdquo;. What do you know about PC? How can you improve your ability to provide PC to patients with COPD?\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eQuantitative data\u003c/b\u003e: Data were gathered using three questionnaires: knowledge, attitude, and practice towards palliative care.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe Palliative Care Knowledge Test (PCKT) consists of 20 true/false questions. With scores ranging from 0 to 20, higher scores indicate higher knowledge. The test covers various domains of philosophy (2 questions), pain (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), dyspnea (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), psychiatric issues (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and gastrointestinal issues (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The Cronbach\u0026rsquo;s α coefficient of this questionnaire in the current study was 0.85.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFromm el's Attitude toward Care of the Dying-form B scale (FATCOD-B) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) is a 30-item tool answered on a five-point Likert scale. Scores range from 30\u0026ndash;150. Higher scores indicate a positive attitude toward death and care for dying patients. The scale has been translated into multiple languages and has shown reliability. For the English(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), Spanish (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), and Turkish (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)FATCOD-B samples, Cronbach's α values ranged from 0.76 to 0.93 for the total scale. In our study, the Cronbach\u0026rsquo;s α was 0.89.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe Palliative Care Self-Reported Practices Scale (PCPS) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). consists of 18 items on a 5-point Likert scale, with total scores ranging from 18 to 90. Higher scores indicate better performance. The scale consists of six subscales: care provided during the dying phase, patient- and family-centered care, pain, delirium, respiratory distress, and communication. The Cronbach\u0026rsquo;s α was 0.79 in the pretest and 0.87 in the posttest. Data collection was conducted between September 2022 and May 2023.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReflection\u003c/h2\u003e \u003cp\u003eAfter both the quantitative and qualitative data were analyzed, the findings were shared with the participants. Once the participants confirmed the findings, they discussed the importance and priority of solving each problem. The reflection stage of the O'Leary model is crucial because it allows individuals and groups to critically evaluate their experiences. This process helps to identify strengths and weaknesses before the planning stage (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePlanning and action\u003c/h3\u003e\n\u003cp\u003eDuring focus groups, participants were asked to suggest strategies based on the identified problems and the literature review. These suggestions were evaluated via five criteria: feasibility, cost, time, human resources, and management support. Eventually, the participants agreed on three plans and developed an action plan. Consensus was defined as 80% agreement or higher. The participants in the focus groups included the matron, head nurse, supervisors, pulmonologists, and clinical nurses. The focus groups lasted between 90 and 120 minutes and were managed by the PhD student and two research team members. The action plans were implemented over 8 months from September 2023 to April 2024.\u003c/p\u003e\n\u003ch3\u003eSecond cycle\u003c/h3\u003e\n\u003cp\u003eThe second cycle began in May 2024 and ended in September 2024. Qualitative and quantitative data were collected and analyzed during this time. Sessions were held with participants to review the action plan and discuss any related challenges. On the basis of these reflections, necessary changes and corrections were made to the program.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eObservation \u0026amp; Data Collection\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eQualitative data\u003c/strong\u003e \u003cp\u003eThree problems were identified through the analysis of observations, interviews, and focus groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategories and subcategories derived from qualitative data analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubcategories\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eProfessional incompetence in palliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003elack\u0026nbsp;of\u0026nbsp;knowledge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eLow self-confidence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eInsufficient skill\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eBasic shortages for providing palliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eLack of nurses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eInadequate facilities and equipment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eLack of clinical practice guideline\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eInappropriate organizational culture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eLack of professional support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIgnoring nurses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eInadequate organizational support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePoor interdisciplinary communication\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003enon-patient-oriented\u0026nbsp;tasks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eProfessional incompetence in palliative care\u003c/strong\u003e \u003cp\u003elack of knowledge, low self-confidence, and inadequate skills, were the problems identified in this category.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;How can I do PC when I do not know anything about it? PC is a new program that I do not think my colleagues know about either...\u0026rdquo; (p8). \u0026ldquo;I have been working in this hospital for several years. There has never been a PC workshop or class, and naturally, I do not know PC...\u0026rdquo; (p5).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eBasic shortages for providing palliative care\u003c/strong\u003e \u003cp\u003e lack of nurses, inadequate facilities and equipment, a lack of clinical practice guidelines, and an inappropriate organizational culture, were some of the basic shortages. \u003cem\u003e\u0026ldquo;All patients require special attention and want to talk about their pain and suffering, but we often do not have the time to listen to them...\u0026rdquo; (p1). \u0026ldquo;Whenever I try to offer compassionate care to my patients, I hesitate due to the fear of being ridiculed by my colleagues\u0026hellip;\u0026rdquo; (p18).\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLack of professional support\u003c/strong\u003e \u003cp\u003eIgnoring nurses, inadequate organizational support, poor interdisciplinary communication, and nonpatient-oriented tasks were some of the problems mentioned by the nurses. \u003cem\u003e\u0026ldquo;Patient care is often fragmented, everyone works independently and may not be aware of other treatments or recommendations; from the moment a patient enters the hospital, they are faced with various referrals, specialists, and protocols, which can be costly and exhausting for the patient...\u0026rdquo; (p2).\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eThe quantitative data\u003c/strong\u003e \u003cp\u003e Before the participatory action research, the knowledge score was (10.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4), the attitudes score was (99.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9), and the palliative care practice score was (68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eReflection\u003c/h2\u003e \u003cp\u003eIn the reflection, all the participants agreed on the importance of PC education. \u003cem\u003e\u0026ldquo;In my opinion, PC education should be a priority. If the content is taught correctly and implemented in practice, many problems will be solved\u003c/em\u003e\u0026hellip;\u003cem\u003e\u0026rdquo; (p 21).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe lack of nurses was a problem that most participants emphasized. \u003cem\u003e\u0026ldquo;A nurse performs many tasks during each shift. If we want to provide quality care for the patient, there should be basic planning for addressing the shortage of nurses...\u0026rdquo; (p 27).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eNurses emphasized that feelings of discouragement and disappointment affect their performance. \u003cem\u003e\u0026ldquo;I am not encouraged when I do my duty properly, but if I make a small mistake, I am reprimanded and punished. Therefore, I have concluded that I should not do more than my duty\u0026hellip;\u0026rdquo; (p6).\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePlanning and action\u003c/h2\u003e \u003cp\u003eThree action plans were developed and implemented (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAction plan for empowering nurses in providing palliative care\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eplan\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAct\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eEnhancing palliative care knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epalliative care educational workshop\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntradepartmental educational conferences\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJournal Club Presentation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUsing e-learning platforms\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLearning through self-study\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccess to palliative care resources in the department\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eeducation in all shifts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEstablishing a palliative care team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoordination with department head\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdentifying team members\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreparing the team to provide palliative care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eIncreasing career motivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsidering palliative care performance in the evaluation form\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChanging the evaluation period\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelecting the best nurse based on the evaluation score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEncouraging the nurse with the highest score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePalliative care nursing professional development\u003c/strong\u003e \u003cp\u003eAll nurses participated in an 18-hour PC workshop. The workshop addressed topics such as the importance of caring for incurable patients, effective communication, the goals and principles of PC, the status of PC in Iran, symptom management, and end-of-life care. Some nurses volunteered to present conferences and journal clubs about PC in the ward. The timetable of the educational programs was displayed at the nursing station. A virtual channel was created to share educational files. Books in the PC field were also prepared for the ward.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEstablishing a palliative care team\u003c/strong\u003e \u003cp\u003eThe PCT was formed to provide comprehensive care to patients and their families with the support of hospital management and in coordination with the department head. The PCT was obliged to collaborate with ward staff from admission to discharge and to play an active role in providing PC to the patient's caregivers during death and bereavement. Meetings were held with the PCT, and necessary training was provided.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIncreasing nurses' career motivation\u003c/strong\u003e \u003cp\u003e Based on the participants' suggestions, a score for PC performance was considered in the specific index section of the evaluation form, and the evaluation period was conducted at 3-month intervals instead of annually. Additionally, with the participants' cooperation, a needs assessment and referral form to the PCT were prepared, and nurses were scored based on symptom management and collaboration with the PCT. Every three months, the nurse with the highest score was given an acknowledgment and a small gift from the head nurse.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSecond cycle\u003c/h2\u003e \u003cp\u003eThe results of the reflections were mostly positive, and nurses reported that the changes had increased their ability to provide PC. \u003cem\u003e\u0026ldquo;I used to be hesitant to discuss end-of-life issues, but now I feel like I can talk to patients about it. I recently cared for an 80-year-old woman with advanced COPD. She expressed her desire to spend her last moments with her children and grandchildren... this conversation was satisfying for both of us...\u0026rdquo; (p18). \u0026ldquo;Teamwork has improved communication and increased respect among colleagues, but these programs should not be short-term... I think this is the beginning of PC and these actions should continue\u0026hellip;\u0026rdquo; (p16).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAfter PAR, significant changes in PCKT, FATCOD-B, and PCPS scores were noted. The total score changed significantly from pre-intervention to post-intervention (p\u0026thinsp;=\u0026thinsp;0.000) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe mean score of knowledge, attitude, and performance of nurses\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScale (Number of items)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PCKT Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD-B Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PCPS Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Significant at the 0.05 level\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eNurses play an important role in managing symptoms and improving the quality of life of incurable patients (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Nurses must continually improve their professional competence to provide safe and high-quality care (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The current study showed that simple measures can improve PC. Using PAR as an approach with the dual purpose of practical problem-solving and empowering participants enables them to actively participate in the research process and benefit from its results (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNurses encounter many challenges in clinical settings, and AR offers a way to address these challenges. In this PAR, we tried to reach a common understanding and consensus about empowering nurses in PC through collaboration and partnership. Constructive collaboration and interaction between participants and faculty and the integration of evidence-based research into patient care can help solve complex clinical problems. The results of the qualitative and quantitative study revealed that nurses lack sufficient knowledge and practice regarding PC. Price et al. (2019) emphasized that one of the major challenges in providing PC is the insufficient knowledge and skills of health professionals, which has significantly limited access to PC services (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The solution proposed by the participants was a combination of educational interventions on PC. Training through workshops, presenting journal clubs in the form of intradepartmental conferences, and sending educational files helped increase the participants' knowledge of PC. In Weiner et al.'s study (2015), implementing a multifaceted approach, such as experiential learning, educational interventions, creating learning opportunities, and constant training, increased the effectiveness of PC (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Nurses should use best practices to update their knowledge, and online learning is a good option for training (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNurses have stated that they lack motivation to provide high-quality care, causing them to focus on administering medication and writing nursing reports. This research suggests that small actions, such as being recognized as a \"selected nurse\", can help nurses feel more appreciated and valued in their work. Health managers and politicians should create conditions that can promote motivation and responsibility among nurses. In a study by Baljoon et al. (2018), organizational factors such as nurses' empowerment, salary and financial benefits, contingent rewards, promotions, supportive relationships (coworkers), supervision, work engagement, communication, and the nature of work were identified to impact nurses' motivation (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe participants reported barriers that prevented them from providing PC. Some of these barriers are complex issues and are beyond the scope of this research. One of the identified barriers is the shortage of nurses, which contributes to increased workloads for nurses, job dissatisfaction, professional errors, staff turnover, and potentially, patient harm (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In this study, PCT was effective in managing patient needs and addressing challenges related to nursing shortages. An interprofessional team is crucial for providing comprehensive and ethical care to palliative patients (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The success of a healthcare team depends on a supportive work environment fostered by effective communication, strong leadership, and mutual respect (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Sarta et al. (2022) identified a conflict between physicians and nurses and inadequate teamwork as the main issues. Strengthening relationships and teamwork can improve PC services (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Bennardiet et al.'s (2021) research demonstrated that effective interprofessional relationships are critical to the PC process and are considered key facilitators (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Therefore, considering the complex conditions and high symptom burden in COPD patients, PCT is necessary in the management of disease symptoms.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eAs with most qualitative research, the study was conducted in one pulmonary department in Iran, and therefore, the findings may not be directly generalizable to other departments. Therefore, it is suggested that future studies explore the empowerment of nurses to provide palliative care in other departments with larger sample sizes.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAfter PAR, there was a significant increase in PCKT, FATCOD-B and PCPS scores compared to before. This study revealed that accurate planning, PC training, and strengthened interdisciplinary collaboration can improve the competencies and skills of teams involved in PC. Additionally, attention to nurses' intrinsic and extrinsic motivations can create a culture of care that recognizes PC as an integral component of COPD patient care. Therefore, managers and policymakers should allocate sufficient time and financing to empowering healthcare teams.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e This study was part of N.H.'s PhD project, approved by the Research Ethics Committee of Mashhad University (IR.MUMS.REC.1402.007). Participants were informed about the study's aims and methods, and informed consent was obtained, and identities were protected by removing identifiers.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by Mashhad University of Medical Sciences.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZ.M. conducted the study, contributed to data analysis and interpretation, and revised the draft. H.Z. contributed to data collection and writing the first draft. M.A. contributed to the translation and revising of the draft. N.H. contributed to data collection, drafting of the work, and critical revision of important intellectual content. All authors approved the final version of the manuscript and agreed on all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors of this study would like to express their appreciation and gratitude to all of the individuals who took part in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe dataset generated and analyzed in this study is not publicly available to protect the privacy of the participants. However, it can be obtained from the corresponding author upon a reasonable access request.The authors of this study would like to express their appreciation and gratitude to all of the individuals who took part in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eH\u0026ouml;kk\u0026auml; M, Martins Pereira S, P\u0026ouml;lkki T, Kyng\u0026auml;s H, Hern\u0026aacute;ndez-Marrero P. Nursing competencies across different levels of palliative care provision: A systematic integrative review with thematic synthesis. Palliat Med. 2020;34(7):851\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBolton LE, Seymour J, Gardiner C. Existential suffering in the day to day lives of those living with palliative care needs arising from chronic obstructive pulmonary disease (COPD): A systematic integrative literature review. 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PLoS ONE. 2021;16(10):e0256965.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"participatory action research, COPD, nurse, palliative care","lastPublishedDoi":"10.21203/rs.3.rs-5731484/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5731484/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChronic obstructive pulmonary disease (COPD) affects the quality of life of patients and their caregivers. Although palliative care can improve quality of life, COPD patients and their caregivers have limited access to palliative care services. This study was conducted to empower nurses to provide palliative care to COPD patients in the pulmonary department.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis participatory action research was conducted in four steps: observation, reflection, planning, and action. The data were collected via PCKT, FATCOD-B, and PCPS questionnaires about palliative care, interviews, focus groups, and observation. Qualitative content analysis and paired t-tests were used for data analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree major themes emerged: professional incompetence in palliative care, basic shortages in palliative care, and a lack of professional support. Three changes were made, including enhancing palliative care knowledge, establishing a palliative care team, and increasing career motivation. There were significant increases in PCKT, FATCOD-B, and PCPS scores before and after PAR (p\u0026thinsp;=\u0026thinsp;0.000).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eGiven the importance of providing palliative care, necessary measures and actions, including developing interprofessional collaboration and training as well as motivating staff, should be taken by health managers.\u003c/p\u003e","manuscriptTitle":"Empowering Nurses to Provide Palliative Care for COPD Patients in a Pulmonary Department: Participatory Action Research","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-08 10:42:38","doi":"10.21203/rs.3.rs-5731484/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-08T07:59:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-06T13:38:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-06T13:37:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2024-12-29T20:08:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ca95fa4d-0d36-4c2e-8b2e-55971170c0d4","owner":[],"postedDate":"January 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-28T15:58:36+00:00","versionOfRecord":{"articleIdentity":"rs-5731484","link":"https://doi.org/10.1186/s12904-025-01743-0","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2025-04-21 15:56:50","publishedOnDateReadable":"April 21st, 2025"},"versionCreatedAt":"2025-01-08 10:42:38","video":"","vorDoi":"10.1186/s12904-025-01743-0","vorDoiUrl":"https://doi.org/10.1186/s12904-025-01743-0","workflowStages":[]},"version":"v1","identity":"rs-5731484","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5731484","identity":"rs-5731484","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}