One-week training evaluation in Hospital Palliative Care Service for Advanced Nurses: a mixed Method Study

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To our knowledge, the literature on the impact evaluation of clinical training in palliative care is scarce. This study aims to describe and evaluate a one-week training program in a Hospital Palliative Care Unit, specifically designed for nurses who have completed a post-degree university course. The nurse trainees were involved in various activities alongside the specialist team, including clinical, teaching, and research tasks. Methods The program was evaluated through a retrospective, observational, mixed-method study incorporating before-after training evaluation and consequent concurrent data triangulation. Two tools, reflective writing, and the portfolio, were used for training and research purposes. They have been analyzed qualitatively and quantitatively, respectively. Results Qualitative analysis of 107 pre-post reflexive writings on students’ expectations and desires led us to identify three general themes: ( 1 ) Palliative care between present and future, ( 2 ) Inpatient palliative care, ( 3 ) Metamorphosis of the trainee. Quantitative analysis of the 110 portfolios shows a statistically significant increase in perceived knowledge and skills regarding the meaning of modern palliative care, management of end-of-life, and advanced communication. Concurrent triangulation of data shows a consistency between qualitative and quantitative data. Conclusions Enabling trainees to work with a specialist hospital palliative care team transfers knowledge relating to the goals of early palliative care and specialist palliative care skills. This study underscores the need for further studies to confirm the structure and the elements of a palliative care internship for post-degree nurses, emphasizing the importance of ongoing research in this field. Figures Figure 1 Figure 2 Introduction Palliative care is the active, holistic care of individuals across all ages with profound health-related suffering due to severe illness, especially those near the end of life. It aims to improve the quality of life of patients, their families, and their caregivers.( 1 ) Palliative care nurses (PCNs) are among the main professionals involved in the complex interventions of palliative care (PC) for patients with cancer ( 2 ) and other life-threatening diseases.( 3 ) The PCN’s role requires advanced competencies necessary to cope with the patient’s physical, psycho-social, and spiritual needs and organizational issues.( 4 – 6 ) In 2013, the European Association for Palliative Care (EAPC) published a white paper on PC training, with the dual objective of proposing a set of internationally shared core competencies and providing a framework for program development training on PC. The ten core competencies outlined a framework that can include all professionals working in the PC field.( 7 , 8 ) Evidence shows that palliative care education in general, and palliative care nursing education specifically, are paramount to ensuring access to adequate palliative care. ( 9 , 10 ) Wide variations were found across countries concerning palliative care nursing education and nursing roles in both undergraduate and postgraduate programs. ( 11 , 12 ) In some cases, to meet the need for nurses trained in palliative care and to provide at least basic training, courses are developed, even lasting only one week, combining theory and practice. ( 13 ) In Italy, nurses frequently play a role in clinical work and provide consultations, team support, and education, and they are sometimes involved in research and policy, as suggested by a review in 2021.( 4 ) An Italian study ( 14 ) showed that sixty percent of the curricula in undergraduate courses had formal education in palliative care, heterogeneously distributed among different courses, and provided few compulsory teaching hours. The data on clinical training suggested that education was essentially theoretical, with poor integration of theory and practice. Moreover, training content is developed according to international, multi-professional guidelines, including global assessment and symptom management, communication, educational competencies, and interprofessional work.( 15 – 17 ) The evaluation of these training courses is poor, primarily based on the perception of self-efficacy without an impact assessment on acquiring new skills and impacting patient care.( 10 , 18 ) The tools used to measure trainees’ personal and professional development include portfolios ( 19 – 21 ) and reflective writing.( 22 – 24 ) The use of portfolios was found to improve students’ ability to integrate theory with clinical practice, self-confidence, greater willingness to take responsibility for their learning, and better decision-making skills compared to those who have not used this modality. Autobiography or reflective writing (RW) is also used to increase the understanding and analytical ability of students in the health sector in their post-clinical internship evaluation.( 25 ) RW is notably applied in theoretical learning in various study cycles ( 26 ), while its use in students’ practical and clinical learning (internship) is still sporadic in Italian settings. To our knowledge, despite strong support for reflective practice in healthcare education and clinical practice, the literature is scarce on studies focusing on the use and efficacy of self-reflection in before-after training evaluations of palliative care professionals.( 26 ) The present study thus aims to describe and evaluate the impact of a one-week training program in a hospital palliative care unit for nurses attending a post-degree university course in palliative care. Methods A retrospective, observational, mixed-method study with before-after training evaluation and concurrent data triangulation was performed.(26,27) With this method, we compared and contrasted findings between qualitative and quantitative data to search for similarities and incongruences, and we interpreted the findings jointly, as shown in Figure 1.(28,29) We decided to carry out a before-after evaluation of the training, focusing on the third order of learning (30) (“learning knowledge” to be understood as the degree to which participants state how to do what the training activity intended them to know how to do), and fourth order of learning (competence; that is, the degree to which participants show how to do what the training activity intended them to be able to do in an educational setting). The intervention A one-week training program (40 hours) was conducted inside the hospital Palliative Care Unit (PCU), with clinical activities (inpatient and outpatient visits) in the morning and training/research activities in the afternoon (see Table 1). time Monday Tuesday Wednesday Thursday Friday 9 a.m.-1 p.m. In the office: Student reception. Completion of portfolio and reflective writing. Presentation of the mission of the hospital palliative care unit. In clinic: Participation in the activities of the outpatient clinic, working alongside the various professionals (nurse, doctor, psychologist) in scheduled activities and consultations in other departments. 2 - 6 p.m. Participation in the team meeting (nurses, physicians, psychologists, bioethicists) with case discussions. Update on ongoing research, with possible collaborations. Self-assessment of student learning and exchange with the instructor. Insight into some clinical symptoms (dyspnea, delirium, pain, fatigue, cachexia...) provided by nurse instructor. In-depth study of some issues related to bioethics by the bioethicist. Portfolio and reflective writing compilation. Table 1. One-week training program The placement involved shadowing professionals at work, observation, participant observation, and practical work on new skills supervised by an instructor. Learning from experience and reflective learning were main methods used.(31) We also used other educational methods: coaching, team mentoring, briefing and debriefing, participation in research projects, and in-depth meetings on palliative care topics. The meeting contents were established by the literature on nursing education in PC:(32)pathogenesis, screening, and management (pharmacological and non-pharmacological) of symptoms such as dyspnea, in training activities. Each section consisted of 1 to 7 items defined according to the EAPC and Italian Society of Palliative Care (SICP) post-graduate core curriculum for nurses.(33,34) The portfolio developed allowed participants to track, record, and reflect on real-life experiences or simulated experiences before and after the training. Data were collected through a self-evaluation scale from poor to excellent for each statement. The self-evaluation was presented and administered to participants by a nurse (AC, EB, or CA) with experience evaluating training programs. Participants were asked to self-report the evaluation of knowledge, competence, and performance before the training and at the end. Writing instructions: 1. Take 5 minutes of silence to concentrate. 2. Silence your phone and choose a secluded place. 3. Write for at least 15 minutes, focusing your thoughts on the question asked. Pre-internship question “Reflectively describe your expectations, desires, particular interests, and your perceptions of this internship.” Post-internship question “Reflectively describe the salient aspects (positive or negative) of the internship you have just completed.” Table 2. Questions for reflective writing. Reflective writing was used before and after the training course to evaluate the trainees’ knowledge and skills related to palliative care before and after the internship through the perception and reflection of the student trainees themselves. Table 2 contains the instructions used by trainees before and after the training. There was no specific training for students in the use of reflective or autobiographical writing. The quantitative analysis used descriptive statistics and variation analysis (before-after) on the portfolio data. The before-after differences were analyzed descriptively (as median and IQR). Then, before and after measurements were compared using the Wilcoxon rank-sum test (considered statistically significant if the p-values were < 0.05). Data analysis was performed using R 4.0.4 The qualitative analysis adopted the thematic analysis of Braun and Clark’s framework of reflective analysis.(35,36) Study procedures and reporting followed the Consolidated Criteria for Reporting Qualitative Research (CoreQ) guidelines.(37) We analyzed all RWs pre-training and then all RWs post-training. The method required two or more researchers (CA, EB, SA, FS) to independently analyze the transcripts by repeatedly reading the text, gradually extrapolating the emerging themes, grouping them, and dividing them into content categories. Through an iterative process, during the analysis, the researchers checked from time to time to verify that the main themes and their content categories were consistent with the transcribed data and highlighted sentences that condensed and represented the meaning of the themes and categories identified. The methodological rigor of the analysis process was further guaranteed via the supervision of a third researcher (GA) external to the study. Extrapolating the categories, any changes in meaning were highlighted in relation to what the trainees expressed before and after the training intervention.(27) This specific thematic approach enabled the researchers to fully understand the trainees’ experiences during the internship. We concentrated the analysis on emerging themes but also on emotions and meanings that the trainees attributed to their statements. In doing so, we could search for any possible changes in meaning attributed to that phenomenon from before to after the training. The overall process was supervised by an external expert of qualitative methodology (GA). We then performed data triangulation(28)to compare the quantitative and qualitative results. Rigor and reflexivity The two palliative care physicians [ST, SA] and three palliative care nurses [CA, EB, FS], who conducted the qualitative analysis, were involved in mentoring and instruction. They had previous experience in conducting and analyzing palliative care training programs because providing training courses for hospital staff is part of the mission of the Palliative Care Unit. They were all aware that this could positively affect the analysis of the results, though they were deeply motivated to improve the training provided. The presence of an external supervisor [GA] and team-reflexive discussions during the entire analysis helped them avoid a personal influence on interpreting the results. They encouraged all the student trainees to use reflective writing freely as an additional opportunity for growth without fear of judgment on our part.(38) Results The study included 55 nurses who attended master’s courses in palliative care between 2016 and 2019 (about 12–15 students per year). We analyzed 107 reflective writings written by trainees before and after the training intervention (54 pre- and 53 post-traineeship) to evaluate their knowledge and skills related to palliative care through the perception and opinions of the trainees themselves. We analyzed 110 palliative care skills portfolios (55 pre- and 55 post-) and self-reported evaluations of knowledge, competence, and performance acquired during the training. Qualitative findings The analysis of the RW autobiographies before and after the training led us to identify three overarching themes [Table 3 ]: ( 1 ) Palliative care between present and future; ( 2 ) Hospital palliative care; ( 3 ) Trainee metamorphosis. These themes emerged with different meanings (defined within the sub-themes) concerning pre-training and post-training data collection. We highlighted this meaning shift in Table 3 and Fig. 2 , including themes and related sub-themes. Table 3 Meaning shift in reflective writing THEMES Sub-themes emerging before training From MEANING SHIFT To Sub-themes emerging after training Professional motivation to carry out an internship. Know a modern PC definition. Positive references from other colleagues. “An advanced personal and professional background” PALLIATIVE CARE BETWEEN PRESENT AND FUTURE “Internship as a stimulus for the future” Set the goal of transmitting what you have learned into your own context. To be stimulated to do research and to train professionally. Internship satisfaction/expectations exceeded. Achieve new knowledge and skills in PC. Desire to deal with other professionals or patients or PC contexts. Curiosity to explore specific characteristics of hospital PC. “Develop specific skills in PC” HOSPITAL PALLIATIVE CARE “Recognize a wider than expected mosaic of skills in the PCU professionals” Recognize the competence, passion, and humanity of the PCU. Recognize modern/early PC in PCU activities. Recognize the integration of clinic, training, and research. Recognize the role of the nurse within the PCU. Improve your being a nurse. Bringing new elements to your working situation. “How to improve being a nurse and the working situation” TRAINEE METAMORPHOSIS “Self-awareness and reflexivity of what you do” Recognize the knowledge and skills acquired. Make the team’s moments of constructive exchange. Internship as an opportunity for reflection on what is known, done and is. Theme 1. Palliative care between present and future As the first result of the training, the meanings shifted from what we designated as “an advanced personal and professional background” to “internship as a stimulus for the future.” We identified three sub-themes: (i) “Professional motivation to carry out an internship,” (ii) “Know a modern PC definition,” and (iii) “Positive references from other colleagues.” Before the training, the student trainees primarily have professional motivations to carry out this internship: “…I come from a situation where palliative care is almost ‘taboo’, where pain is seen as a normal consequence of the disease…” (Code 17_17.1b) 1 The trainees outlined the aspects that characterize PC according to the modern WHO definition and stated: “.... I have little knowledge about early palliative care since in my experience I mainly deal with the end of life and very often only the last week...” (Code 19_10.6b), suggesting an early and simultaneous approach to treatment “... together with so much technique, we also look at human frailty, accepting it and looking for a possible quality of life and care, contextualizing what are the possible treatments and enhancing the human resources…” (Code 16_4.4b) “…I will have the opportunity to experience how palliative care is not only care reserved for those who are at the end of life, but I will have the opportunity to understand how precious it can be for different patients in different situations.” (Code 17_1.6b) (iii) Moreover, they were stimulated to participate in training for positive references from other colleagues who defined the hospital PCU as a “special department....pioneering, as a particular situation…” (Code 19_10.6b), a center “where PC is best done ...” and “professionals of the highest level and skills…” (Code 18_1.6b). After training, the internship becomes a “stimulus for the future” because trainees describe how they have been sensitised to research, to grow professionally and to be oriented towards innovation. Three sub-themes emerged: (i) Have the goal of transferring what I have learned into one’s own context, (ii) To be stimulated to do research and to train professionally, (iii) Internship satisfaction/expectations exceeded. The trainees described the need to “…make sure to bring into my life and work what I have pleasantly learned here ...” (Code 18_1.7a); moreover, “…it still gave rise to a lot of questions and thoughts about the profession in palliative care, it fueled my passion and interest in this area ...” (Code 17_10.2a). The student trainees understood the importance of keeping together clinical, educational and research activities, underlined that “…it gave me many stimuli, including that of continuing to train and do research to make myself professionally more complete ...” (Code 16_3.13a). In particular, it was important to see “how nurses collaborate in education and research, aspects not taken for granted, especially in different departments” (code 18_5.6a). Student trainees demonstrated high satisfaction with the experience, with expectations exceeded by what they encountered. “Writing down my impressions, now that I have completed my internship, I can truly say that my expectations were not only met but exceeded” (Code 17_5.1a). Theme 2. Hospital Palliative Care Before the internship, the trainees described the expectation to “develop specific skills in PC,” in which three sub-themes were identified: (i) Achieve new knowledge and skills in PC, (ii) Desire to deal with other professionals or patients or PC contexts, (iii) Curiosity to explore specific characteristics of hospital PC. (i) In the first sub-themes, the student trainees expected to “…train me to have more awareness and clarity on the concept of palliative care and thus be able to adequately assist...” (Code 16_3.1b), but also more knowledge on specific aspects such as advance care planning. Indeed, the trainees said: “...I am confident to clarify everything concerning advance care planning, how the nurse and the team deal with the patient/family or how they manage what falls within the concept of the Calman gap or communication/relational aspects…” (Code 17_4.7b). “…to acquire the ability to guarantee dignity or ‘effective’ communication; the ability to perceive every need of the patient” (Code 16_5.4b). (ii) The second sub-theme highlighted the student trainees’ interest in exchanging with other professionals regarding communication skills and early identification of frailty patients. They expressed: “...I am interested in understanding and seeing the communication techniques and the approach of doctors with patients....” (Code 19_6.3b) “...therefore, I hope that this week of the internship will show me a situation of palliative care ingrained in the hospital, which can identify early those people who have a certain degree of frailty due to illness...” (Code 17_6.2b) (iii) The third sub-theme explained curiosity about learning the characteristics of the hospital PCU in more depth. There was interest in learning about the development of the Palliative Care Service (PCS) in settings other than home care services and hospices and compared their context that did not include a hospital PCS. The student trainees said: “...I expect to be confronted with a situation of palliative care that unfortunately does not exist in my region…” (Code 18_9.1b) “...to understand how a hospital setting works, having always worked in home care services...” (Code 19_4.2b) “…I would like to learn how to carry out palliative care other than in home or hospice care…” (Code 18_5.1b) After the training, four sub-themes were identified: (i) Competence, passion, and humanity of the PCS; (ii) Recognized modern/early palliative care in PCS activities; (iii) Recognized the integration of clinical aspects, education, and research in the PCS; (iv) Recognized nurses’ role within the PCS. After the internship, the trainees recognized a more comprehensive skill mosaic among PCS professionals than before the internship by outlining the specific aspects of hospital palliative care. They expressed their recognition towards the individual professionals of the PCS, which they had “…a high level of technical, clinical and relational competence and together a great humanity.” (Code 16_1.6a) They recognized PCS activities as an example of modern/early palliative care and the ability of PCS professionals to interact with other healthcare professionals (HPs). “I observed firsthand what they explained as ‘simultaneous care’, probably the result of a work of education, collaboration, and training with other HPs” (Code 17_1.5a) The PCU's mission was recognized as three-pronged: patient assistance through inpatient and outpatient consultations, research activities, and specialized training to improve PC core skills in HPs. “... What I found particularly interesting and exciting, and which certainly made my path here complete, was the complementarity of clinical aspects, research, and training ....” (Code 16_1.4a) “…The training in this service for professionals is seen as a fulcrum for daily activities and as an implementation of teamwork to allow an adequate pharmacological and care approach measured on the person’s characteristics...” (Code 19_9.6a) (iv) Finally, trainees recognized the specific role and competencies of the palliative care nurse. The trainees appreciated the autonomy and collaboration of palliative care nurses within the team. They expressed: “... I saw how the nurses collaborate in training and research; things are not taken for granted...” (Cod 18_5.6a) “... This teamwork starts from the moment of reception carried out by the nurse ...” (Code 19_17.4a) “... The nurse role almost acts as a ‘glue’ between the various professionals and the patient and his family ...” (Code 19_14.3a) Theme 3. Trainee Metamorphosis The trainees described a “metamorphosis” that passed from “how to improve being a nurse and the working situation” to “self-awareness and reflexivity of what you do.” Before the training, two sub-themes were highlighted: (i) “Improve your being a nurse” and (ii) “Bringing new elements to your working situation ”. (i) The student trainees expressed the desire to develop their own “essence” as professionals and a willingness to learn in various areas (personal, team, and towards patients and their families and caregivers). They described a non-specific palliative care training need, but “...I want to learn, I want to experiment, I want to improve my skills and abilities, first towards myself, then towards a multi-professional team and mainly towards the patient and caregivers” (Code 17_12.5b) “…I would like this internship to be not only a training experience but also an enriching human experience in which to learn ‘knowing’, ‘knowing how to do’ and ‘knowing how to be…’ (Code 19_4.3b) (ii) The trainees showed an expectation of helpful experiential and experimental learning to be transferred into their individual work situations: “I would like to be able to transmit this way of working to the colleagues and professionals I work with” (Code 18_1.7b) and “…I will make sure to bring into my life and work what I have pleasantly learned here” (Code 16_1.15b). After the internship, we identified three subthemes: (i) Recognize the knowledge and skills acquired; (ii) Make the team’s moments of constructive exchange; (iii) Internship as an opportunity for reflection on what is known, done, and is. The participants felt that they had acquired knowledge and skills, especially in recognizing and managing emotions, a skill they considered very complex: “… I also understood that managing your emotions is difficult. I was moved several times, and then discussing them I understood how it is right to feel certain emotions and how over time I will learn to manage them in the most appropriate way (I hope).” (Code 18_6.6a) In addition, they were able to understand and feel how teamwork and moments of confrontation during weekly meetings are indispensable for understanding their emotions and those of the patient and family within the care relationship, in order to be effective and authentic in clinical practice. “...I will take away the moments of exchange, always constructive, on our moods, doubts, uncertainties, criticisms” (Code 16_1.10a) (iii) The internship became an opportunity to reflect on themselves, on what they do and know: “This period was also a moment of exchange with respect to my knowledge and my actions …” (Code 16_4.3a). Quantitative findings At the end of the internship, the student trainees reported an increase in knowledge about all the portfolio topics. All the results are statistically significant. We report the main findings in Table 4 . Table 4 Quantitative results from portfolio analysis n Median p0.25 p0.75 p 1. KNOWLEDGE AND SKILLS TOWARDS THE PATIENTS IN THEIR CLINICAL SPECIFICITY PAIN ASSESSMENT AND TREATMENT Pain assessment 51 1.0 1.0 1.0 < 0.001 Drugs and routes of administration 51 1.0 1.0 1.0 < 0.001 Side effects 51 1.0 1.0 2.0 < 0.001 DYSPNEA ASSESSMENT AND TREATMENT Diagnosis and evaluation 54 1.0 0.0 1.0 < 0.001 Pharmacological therapy 53 1.0 1.0 1.0 < 0.001 Non-pharmacological therapy 51 1.0 1.0 2.0 < 0.001 DELIRIUM ASSESSMENT AND TREATMENT Diagnosis and evaluation 53 1.0 1.0 2.0 < 0.001 Drug and non-drug approach 53 2.0 1.0 2.0 < 0.001 NAUSEA/VOMITING ASSESSMENT AND TREATMENT Diagnosis and evaluation 53 1.0 0.0 1.0 < 0.001 Treatment 52 1.0 0.0 1.0 < 0.001 MANAGEMENT OF END-OF-LIFE SYMPTOMS 55 1.0 0.0 1.0 < 0.001 2. SKILLS TOWARDS THE PATIENTS AND THEIR FAMILY IN THE COMMUNICATION CONTEXT DIFFICULT COMMUNICATION Interventions with patients 51 1.0 1.0 2.0 < 0.001 Interventions with family members 53 1.0 1.0 2.0 < 0.001 Team discussion post-intervention 52 1.0 0.0 2.0 < 0.001 Nurse telephone follow-up 55 2.0 1.0 2.0 < 0.001 IMPRESSIONS AND BELIEFS ABOUT ETHICS AND BIOETHICS Collaboration with the bioethics team 55 1.0 0.0 2.0 < 0.001 Reflection on bioethics issues 55 1.0 1.0 2.0 < 0.001 3. KNOWLEDGE ON PALLIATIVE CARE TODAY (transversality, early approach, simultaneous care, teamwork, relationship between specialist level and non-specialist level) Discussion on the modern idea of PC 54 1.0 1.0 2.0 < 0.001 4. RESEARCH AND EDUCATION Participation in training activities 53 1.0 0.0 2.0 < 0.001 Coaching in a research project 52 1.0 0.0 2.0 < 0.001 Using experience and literature to learn about some main topics in more depth (pain, delirium, dyspnea, nausea, bowel obstruction) 48 1.0 1.0 2.0 < 0.001 It is important to underline that for some items, the range of the before-after self-evaluation is wider. These items regard specific non-clinical characteristics of the hospital PCU, the team discussions after difficult communication with patients and families, participation in training and research projects, and the meeting with the bioethicist. Triangulation findings After the comparison of qualitative and quantitative data, we found important similarities and no incongruences to interpret the findings. The participants were very active and participatory in the whole path of training and research, allowing the collection of very interesting data in both our quantitative and qualitative research. The triangulation of data led to both confirmatory and integrated or novel results. The results obtained highlighted the significant amount of knowledge and skills acquired by the participants after the training, in terms of the shift in meaning that they attributed to phenomena related to chronicity and incurability, which they encounter daily in their professional practice. The quantitative data refer to the participants’ perception of the skills acquired, while the qualitative data present insights and reflections with respect to the knowledge and skills indicated. The student trainees recognized: New knowledge and skills: The acquisition of different skills, relating to technical, relational, and ethical skills underscored the need to learn a broader mosaic of skills than expected for PCU professionals. The nurses expressed their satisfaction with the internship and stated that it had exceeded their expectation, their desires and curiosity; the student trainees appreciated the team’s moments of constructive exchange and recognized the competence, passion, and humanity of the PCU team. Communication skills: In relation to the skills useful for engaging in difficult communication with patient and family, the trainees recognized that they had increased their awareness and reflexivity, especially in contexts requiring complex skills, such as interpersonal abilities. PC today: The nurse trainees learned the most recent definition of palliative care and the role of early palliative care recognized in the PCU's vision and mission. They also recognized the role of specialist palliative care nurses. Research and education: The trainees recognized the integration of clinical, educational, and research activities specific to the hospital PCU and acknowledged that they had supported the team’s professionals in research activities. In conclusion, the interprofessional team acknowledged that the trainees had undergone a metamorphosis at the end of the placement. Discussion The present work describes an experiential one-week training for nurses in a specialized hospital PCU in Italy and its evaluation. The nurses were attending a post-degree course on palliative care. The student trainees’ growth The main result was the impact of a one-week internship on the nurse trainee, which went in three directions: it broadened the vision of modern palliative care, initiated deep reflection on themselves and their skills, and projected the nurses into the future. The internship thus provided an understanding of what is involved in working on a hospital palliative care team and the advanced skills that are needed. In particular, the students learned about the many skills required by the role of the palliative care nurse in the hospital. Advanced competencies go beyond technical skills, differ to some extent from those of a hospice or home care nurse, and form a very rich and challenging mosaic.( 4 , 42 ) Secondly, the placement elicited a personal reflection on what it meant for the trainees to be a nurse, what knowledge and skills they have already acquired, and what still needs to be learned. Finally, the internship projected the trainees into the future, helping them to understand the importance of continuing education and research in their professional development. The fact that the students felt motivated at the end of the placement period to continue working and training in palliative care is particularly positive and is reflected in a study published by Li in 2023. Constructing a competency framework for palliative care nurses in China, Li et al. included “achievement motivation” among the developmental competencies needed for personal and professional growth.( 42 ) The nursing students came from very different work settings: home care services, various hospital wards, hospices, and nursing homes. The more comprehensive analysis of the internships conducted over the three years highlights how the interaction and exchange between the students and the specialized palliative care team can exemplify interprofessional education( 43 ). Indeed, the students could observe healthcare professionals interacting and working collaboratively. This fueled self-reflection in two directions: bringing palliative care skills to their own work setting and bringing the skills acquired in their own work setting to the situations encountered during the internship. At the same time, the discussion enriched the team’s discussion of the clinical cases they encountered. Various elements enabled the trainees to achieve a high level of skills and growth, even with a short (one-week) albeit structured training: the use of different educational methods (portfolio, RW, discussion between peers, discussion with the Bioethics Unit on complex cases, and one-to-one coaching by a specialized nurse) ( 13 ), the professional mentor, and above all a multidisciplinary collaborative mentor team.( 44 , 45 ) These elements are in line with the most recent recommendations on the education of nurses on palliative and end-of-life care.( 46 , 47 ) Nursing students need to be accompanied in clinical practice, taking time for debriefing and constructive reflection on the clinical cases they encounter. This will support the students emotionally and enable them to develop a more aware approach to vulnerable phases of life, such as death and dying.( 47 ) From educational tools to research tools Reflective writing and skills portfolios are widely described in the literature, and the results of this study are in line with the impact they have on the training process described in the literature.( 24 ) In our case, reflective writing increased the student trainees’ understanding and reflective ability; it supported the development of clinical, relational, and self-knowledge competencies, and enabled them to express their emotions, moods, and inner journeys.( 24 , 48 ) Through the student trainees’ self-assessments of what they learned and through ongoing discussion with their mentor, the portfolio showed to be helpful in improving their ability to integrate theory with clinical practice, as previously found by other authors.( 48 , 49 ) Unlike other recent studies, in which a pre-post and mixed methods evaluation was carried out in PC training( 50 – 52 ), in this study the data triangulation methodology was applied, enriching the results and allowing us to identify coherence between the qualitative and quantitative results.( 53 ) Strengths and Limitations We used learning evaluation models that were not limited only to satisfaction with the experience but also the evaluation of the “know” and “know-how” skills, and the performance of the health professionals. Nevertheless, the study has some limitations. First, the internship experience described is related to a single center. However, it may have national relevance because there are few hospital palliative care units in Italy, and this type of training activity is even less widespread. Secondly, the study is retrospective but still comprises a substantial number of participants. Additionally, we did not envision a long-term re-evaluation of the impact of the training on the students’ skills. It could be interesting to understand whether the skills acquired have been useful and maintained in the nursing students’ work settings. Finally, the trainers did not carry out the evaluation of the students. There is therefore no comparison between the perceived skills and those assessed by an external trainer. Conclusions The educational role of the PC team is fundamental to the growth of the nurse trainees. Enabling trainees to work with a specialist hospital palliative care team transfers knowledge relating to the goals of early palliative care and specialist palliative care skills. The training should also be the subject of research projects that evaluate the qualitative and quantitative aspects and the effects on student trainees. However, further studies are needed to confirm the structure and the elements of a palliative care internship for post-degree nurses. Abbreviations PCN Palliative Care Nurse PC Palliative Care ECTS European Credit Transfer System EAPC European Association for Palliative Care RW Reflective writing PCU Palliative Care Unit SICP Italian Society of Palliative Care PCS Palliative Care Service HPs Healthcare Professionals Declarations Ethics approval and consent to participate This was a retrospective observational study for which data - portfolios and reflective writings - were collected during clinical practice for educational purposes, without the involvement of patients and relatives. Consequently, the internal regulations of the relevant hospital body (Scientific CME Committee of Reggio Emilia) did not require specific informed consent procedures. Under analysis, each document was coded, anonymized, and analyzed in aggregate form, ensuring the confidentiality of participants. The study was conducted following the Declaration of Helsinki and local regulatory requirements. Consent for publication Not applicable. Availability of data and materials The data supporting this study's findings are available upon request from the corresponding author, [EB]. Competing interests The authors declare that they have no competing interests. Funding This study was partially supported by Italian Ministry of Health – Ricerca Corrente Annual Program 2024. Author contributions GA, ST, CA, EB, SA conceived and developed the study protocol. EB, CA, FS, SA, ST contributed to the qualitative analysis. LB and EB contributed to the quantitative analysis. EB, SA and GA drafted the article, and all authors contributed substantially to its revision. GA and ST contributed to the supervision of the work. All the authors read and approved the final manuscript. Acknowledgements The authors wish to thank all the students who attended our PCU course and shared their experiences, reflections, professional desires, and presence. References Radbruch L, De Lima L, Knaul F, Wenk R, Ali Z, Bhatnaghar S, et al. 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Palliative care education and its effectiveness: a systematic review. Public Health maggio. 2021;194:96–108. Prandi C, Mastroianni C, D’angelo D, Marson R, Malinverni E, Guarda M. Il Core Competence italiano dell’infermiere in cure palliative (Italian Palliative nursing core competence) [Internet]. 2018. Disponibile su: https://www.sicp.it/aggiornamento/core-curriculum/2018/10/il-core-competence-italiano-dellinfermiere-in-cure-palliative/ Prandi C, Biagioli V, Fida R. L’autovalutazione delle competenze infermieristiche in cure palliative. Riv Ital Cure Palliat [Internet]. 2015;18(3). Disponibile su: http://repository.supsi.ch/id/eprint/9938 Clarke V, Braun V. Thematic analysis: a practical guide. Thematic Analysis, 2021, 1-100. [Internet]. London: Sage Publications Ltd; 2021. Disponibile su: http://digital.casalini.it/9781526417305 - Casalini id: 5282292. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;32:77–101. Tong A, Sainsbury P, Craig J. 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Baker L, Moss C, Bordelon C, Savin MK. Growing the Neonatal Nurse Practitioner Workforce Through Mentoring. A Scoping Review. J Perinat Neonatal Nurs 10 gennaio 2024;10.1097. Eddy K, Jordan Z, Stephenson M. Health professionals’ experience of teamwork education in acute hospital settings: a systematic review of qualitative literature. JBI Database Syst Rev Implement Rep aprile. 2016;14(4):96–137. Yoong SQ, Wang W, Seah ACW, Kumar N, Gan JON, Schmidt LT, et al. Nursing students’ experiences with patient death and palliative and end-of-life care: A systematic review and meta-synthesis. Nurse Educ Pract maggio. 2023;69:103625. Cunningham H, Taylor D, Desai UA, Quiah SC, Kaplan B, Fei L, et al. Looking Back to Move Forward: First-Year Medical Students’ Meta-Reflections on Their Narrative Portfolio Writings. Acad Med J Assoc Am Med Coll giugno. 2018;93(6):888–94. Lim AJS, Hong DZ, Pisupati A, Ong YT, Yeo JYH, Chong EJX, et al. Portfolio use in postgraduate medical education: a systematic scoping review. Postgrad Med J 21 luglio. 2023;99(1174):913–27. Martin T, Nolen-Vesterlund M, McCauley R. Every Dying Patient Should Experience a Peaceful Death: A Mixed-Methods Approach to Assessing the Benefits of Palliative Care Training on Nursing Practice. J Hosp Palliat Nurs JHPN Off J Hosp Palliat Nurses Assoc. 9 settembre. 2022. Ben-Arye E, Tapiro Y, Baruch R, Tal A, Shulman B, Gressel O et al. Integrative oncology for palliative care nurses: pre-post training evaluation. BMJ Support Palliat Care 23 gennaio 2023;spcare-2022-004117. van Meurs J, Wichmann AB, van Mierlo P, van Dongen R, van de Geer J, Vissers K, et al. Identifying, exploring and integrating the spiritual dimension in proactive care planning: A mixed methods evaluation of a communication training intervention for multidisciplinary palliative care teams. Palliat Med dicembre. 2022;36(10):1493–503. Hökkä M, Melender HL, Lehto JT, Kaakinen P. Palliative Nursing Competencies Required for Different Levels of Palliative Care Provision: A Qualitative Analysis of Health Care Professionals’ Perspectives. J Palliat Med settembre. 2021;24(10):1516–24. Footnotes Legend of codes : first number = year of internship; second number = participant code; third number: verbatim number; alphabetic letter: b = before training; a = after training Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Oct, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 19 Sep, 2024 Submission checks completed at journal 17 Sep, 2024 First submitted to journal 17 Sep, 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. 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1","display":"","copyAsset":false,"role":"figure","size":74634,"visible":true,"origin":"","legend":"\u003cp\u003eConcurrent triangulation framework\u003c/p\u003e","description":"","filename":"Fig.1ConcurrentTriangulationFramework.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5025695/v1/cb1a96847b0344054c342140.jpg"},{"id":88088583,"identity":"3ea80378-3b88-4346-832d-9cf8f0764fcb","added_by":"auto","created_at":"2025-08-01 09:50:46","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":481850,"visible":true,"origin":"","legend":"\u003cp\u003eThe student trainees’ growth\u003c/p\u003e","description":"","filename":"fig.2Thestudenttraineesgrowth.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5025695/v1/27b31be146f08b8253b5ecbc.jpg"},{"id":93419830,"identity":"ebdec8dd-fc16-4542-b67a-050e55f996b1","added_by":"auto","created_at":"2025-10-13 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It aims to improve the quality of life of patients, their families, and their caregivers.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003ePalliative care nurses (PCNs) are among the main professionals involved in the complex interventions of palliative care (PC) for patients with cancer (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and other life-threatening diseases.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) The PCN\u0026rsquo;s role requires advanced competencies necessary to cope with the patient\u0026rsquo;s physical, psycho-social, and spiritual needs and organizational issues.(\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) In 2013, the European Association for Palliative Care (EAPC) published a white paper on PC training, with the dual objective of proposing a set of internationally shared core competencies and providing a framework for program development training on PC. The ten core competencies outlined a framework that can include all professionals working in the PC field.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Evidence shows that palliative care education in general, and palliative care nursing education specifically, are paramount to ensuring access to adequate palliative care. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Wide variations were found across countries concerning palliative care nursing education and nursing roles in both undergraduate and postgraduate programs. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) In some cases, to meet the need for nurses trained in palliative care and to provide at least basic training, courses are developed, even lasting only one week, combining theory and practice. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) In Italy, nurses frequently play a role in clinical work and provide consultations, team support, and education, and they are sometimes involved in research and policy, as suggested by a review in 2021.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eAn Italian study (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) showed that sixty percent of the curricula in undergraduate courses had formal education in palliative care, heterogeneously distributed among different courses, and provided few compulsory teaching hours. The data on clinical training suggested that education was essentially theoretical, with poor integration of theory and practice.\u003c/p\u003e\u003cp\u003e Moreover, training content is developed according to international, multi-professional guidelines, including global assessment and symptom management, communication, educational competencies, and interprofessional work.(\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) The evaluation of these training courses is poor, primarily based on the perception of self-efficacy without an impact assessment on acquiring new skills and impacting patient care.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe tools used to measure trainees\u0026rsquo; personal and professional development include portfolios (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and reflective writing.(\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) The use of portfolios was found to improve students\u0026rsquo; ability to integrate theory with clinical practice, self-confidence, greater willingness to take responsibility for their learning, and better decision-making skills compared to those who have not used this modality. Autobiography or reflective writing (RW) is also used to increase the understanding and analytical ability of students in the health sector in their post-clinical internship evaluation.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) RW is notably applied in theoretical learning in various study cycles (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), while its use in students\u0026rsquo; practical and clinical learning (internship) is still sporadic in Italian settings.\u003c/p\u003e\u003cp\u003eTo our knowledge, despite strong support for reflective practice in healthcare education and clinical practice, the literature is scarce on studies focusing on the use and efficacy of self-reflection in before-after training evaluations of palliative care professionals.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe present study thus aims to describe and evaluate the impact of a one-week training program in a hospital palliative care unit for nurses attending a post-degree university course in palliative care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA retrospective, observational, mixed-method study with before-after training evaluation and concurrent data triangulation was performed.(26,27)\u003c/p\u003e\n\u003cp\u003eWith this method, we compared and contrasted findings between qualitative and quantitative data to search for similarities and incongruences, and we interpreted the findings jointly, as shown in Figure 1.(28,29)\u003c/p\u003e\n\u003cp\u003eWe decided to carry out a before-after evaluation of the training, focusing on the third order of learning (30) (\u0026ldquo;learning knowledge\u0026rdquo; to be understood as the degree to which participants state how to do what the training activity intended them to know how to do), and fourth order of learning (competence; that is, the degree to which participants show how to do what the training activity intended them to be able to do in an educational setting).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA one-week training program (40 hours) was conducted inside the hospital Palliative Care Unit (PCU), with clinical activities (inpatient and outpatient visits) in the morning and training/research activities in the afternoon (see Table 1).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003etime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonday\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTuesday\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWednesday\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eThursday\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFriday\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e9 a.m.-1 p.m.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIn the office: Student reception. Completion of portfolio and reflective writing. Presentation of the mission of the hospital palliative care unit.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eIn clinic: Participation in the activities of the outpatient clinic, working alongside the various professionals (nurse, doctor, psychologist) in scheduled activities and consultations in other departments.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 - 6 p.m.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eParticipation in the team meeting (nurses, physicians, psychologists, bioethicists) with case discussions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eUpdate on ongoing research, with possible collaborations.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSelf-assessment of student learning and exchange with the instructor.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eInsight into some clinical symptoms (dyspnea, delirium, pain, fatigue, cachexia...) provided by nurse instructor.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIn-depth study of some issues related to bioethics by the bioethicist.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePortfolio and reflective writing compilation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1. One-week training program\u003c/p\u003e\n\u003cp\u003eThe placement involved shadowing professionals at work, observation, participant observation, and practical work on new skills supervised by an instructor. Learning from experience and reflective learning were main methods used.(31) We also used other educational methods: coaching, team mentoring, briefing and debriefing, participation in research projects, and in-depth meetings on palliative care topics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe meeting contents were established by the literature on nursing education in PC:(32)pathogenesis, screening, and management (pharmacological and non-pharmacological) of symptoms such as dyspnea, in training activities. Each section consisted of 1 to 7 items defined according to the EAPC and Italian Society of Palliative Care (SICP) post-graduate core curriculum for nurses.(33,34) The portfolio developed allowed participants to track, record, and reflect on real-life experiences or simulated experiences before and after the training. Data were collected through a self-evaluation scale from poor to excellent for each statement. The self-evaluation was presented and administered to participants by a nurse (AC, EB, or CA) with experience evaluating training programs. Participants were asked to self-report the evaluation of knowledge, competence, and performance before the training and at the end.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWriting instructions:\u0026nbsp;\u003c/strong\u003e1. Take 5 minutes of silence to concentrate. 2. Silence your phone and choose a secluded place. 3. Write for at least 15 minutes, focusing your thoughts on the question asked.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-internship\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003equestion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;Reflectively describe your expectations, desires, particular interests, and your perceptions of this internship.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-internship\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003equestion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;Reflectively describe the salient aspects (positive or negative) of the internship you have just completed.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Questions for reflective writing.\u003c/p\u003e\n\u003cp\u003eReflective writing was used before and after the training course to evaluate the trainees\u0026rsquo; knowledge and skills related to palliative care before and after the internship through the perception and reflection of the student trainees themselves. Table 2 contains the instructions used by trainees before and after the training. There was no specific training for students in the use of reflective or autobiographical writing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe quantitative analysis used descriptive statistics and variation analysis (before-after) on the portfolio data. The before-after differences were analyzed descriptively (as median and IQR). Then, before and after measurements were compared using the Wilcoxon rank-sum test (considered statistically significant if the p-values were \u0026lt; 0.05). Data analysis was performed using R 4.0.4\u003c/p\u003e\n\u003cp\u003eThe qualitative analysis adopted the thematic analysis of Braun and Clark\u0026rsquo;s framework of reflective analysis.(35,36) Study procedures and reporting followed the Consolidated Criteria for Reporting Qualitative Research (CoreQ) guidelines.(37) We analyzed all RWs pre-training and then all RWs post-training. The method required two or more researchers (CA, EB, SA, FS) to independently analyze the transcripts by repeatedly reading the text, gradually extrapolating the emerging themes, grouping them, and dividing them into content categories. Through an iterative process, during the analysis, the researchers checked from time to time to verify that the main themes and their content categories were consistent with the transcribed data and highlighted sentences that condensed and represented the meaning of the themes and categories identified. The methodological rigor of the analysis process was further guaranteed via the supervision of a third researcher (GA) external to the study. Extrapolating the categories, any changes in meaning were highlighted in relation to what the trainees expressed before and after the training intervention.(27) This specific thematic approach enabled the researchers to fully understand the trainees\u0026rsquo; experiences during the internship. We concentrated the analysis on emerging themes but also on emotions and meanings that the trainees attributed to their statements. In doing so, we could search for any possible changes in meaning attributed to that phenomenon from before to after the training. The overall process was supervised by an external expert of qualitative methodology (GA).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe then performed data triangulation(28)to compare the quantitative and qualitative results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRigor and reflexivity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe two palliative care physicians [ST, SA] and three palliative care nurses [CA, EB, FS], who conducted the qualitative analysis, were involved in mentoring and instruction. They had previous experience in conducting and analyzing palliative care training programs because providing training courses for hospital staff is part of the mission of the Palliative Care Unit. They were all aware that this could positively affect the analysis of the results, though they were deeply motivated to improve the training provided. The presence of an external supervisor [GA] and team-reflexive discussions during the entire analysis helped them avoid a personal influence on interpreting the results. They encouraged all the student trainees to use reflective writing freely as an additional opportunity for growth without fear of judgment on our part.(38)\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 55 nurses who attended master\u0026rsquo;s courses in palliative care between 2016 and 2019 (about 12\u0026ndash;15 students per year). We analyzed 107 reflective writings written by trainees before and after the training intervention (54 pre- and 53 post-traineeship) to evaluate their knowledge and skills related to palliative care through the perception and opinions of the trainees themselves. We analyzed 110 palliative care skills portfolios (55 pre- and 55 post-) and self-reported evaluations of knowledge, competence, and performance acquired during the training.\u003c/p\u003e\u003cp\u003e\u003cb\u003eQualitative findings\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe analysis of the RW autobiographies before and after the training led us to identify three overarching themes [Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e3\u003c/span\u003e]: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Palliative care between present and future; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Hospital palliative care; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Trainee metamorphosis. These themes emerged with different meanings (defined within the sub-themes) concerning pre-training and post-training data collection. We highlighted this meaning shift in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, including themes and related sub-themes.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMeaning shift in reflective writing\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eTHEMES\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSub-themes emerging before training\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrom\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMEANING SHIFT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSub-themes emerging\u003c/p\u003e\u003cp\u003eafter training\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional motivation to carry out an internship.\u003c/p\u003e\u003cp\u003eKnow a modern PC definition.\u003c/p\u003e\u003cp\u003ePositive references from other colleagues.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;An advanced personal and professional background\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003ePALLIATIVE CARE BETWEEN PRESENT AND FUTURE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Internship as a stimulus for the future\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSet the goal of transmitting what you have learned into your own context.\u003c/p\u003e\u003cp\u003eTo be stimulated to do research and to train professionally.\u003c/p\u003e\u003cp\u003eInternship satisfaction/expectations exceeded.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAchieve new knowledge and skills in PC.\u003c/p\u003e\u003cp\u003eDesire to deal with other professionals or patients or PC contexts.\u003c/p\u003e\u003cp\u003eCuriosity to explore specific characteristics of hospital PC.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Develop specific skills in PC\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eHOSPITAL PALLIATIVE CARE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Recognize a wider than expected mosaic of skills in the PCU professionals\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRecognize the competence, passion, and humanity of the PCU.\u003c/p\u003e\u003cp\u003eRecognize modern/early PC in PCU activities.\u003c/p\u003e\u003cp\u003eRecognize the integration of clinic, training, and research.\u003c/p\u003e\u003cp\u003eRecognize the role of the nurse within the PCU.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImprove your being a nurse.\u003c/p\u003e\u003cp\u003eBringing new elements to your working situation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;How to improve being a nurse and the working situation\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eTRAINEE METAMORPHOSIS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Self-awareness and reflexivity of what you do\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRecognize the knowledge and skills acquired.\u003c/p\u003e\u003cp\u003eMake the team\u0026rsquo;s moments of constructive exchange.\u003c/p\u003e\u003cp\u003eInternship as an opportunity for reflection on what is known, done and is.\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\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1. Palliative care between present and future\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAs the first result of the training, the meanings shifted from what we designated as \u0026ldquo;an advanced personal and professional background\u0026rdquo; to \u0026ldquo;internship as a stimulus for the future.\u0026rdquo; We identified three sub-themes: (i) \u0026ldquo;Professional motivation to carry out an internship,\u0026rdquo; (ii) \u0026ldquo;Know a modern PC definition,\u0026rdquo; and (iii) \u0026ldquo;Positive references from other colleagues.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eBefore the training, the student trainees primarily have professional motivations to carry out this internship: \u003cem\u003e\u0026ldquo;\u0026hellip;I come from a situation where palliative care is almost \u0026lsquo;taboo\u0026rsquo;, where pain is seen as a normal consequence of the disease\u0026hellip;\u0026rdquo;\u003c/em\u003e (Code 17_17.1b)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe trainees outlined the aspects that characterize PC according to the modern WHO definition and stated: \u0026ldquo;.... \u003cem\u003eI have little knowledge about early palliative care since in my experience I mainly deal with the end of life and very often only the last week...\u0026rdquo;\u003c/em\u003e (Code 19_10.6b), suggesting an early and simultaneous approach to treatment \u0026ldquo;...\u003cem\u003etogether with so much technique, we also look at human frailty, accepting it and looking for a possible quality of life and care, contextualizing what are the possible treatments and enhancing the human resources\u0026hellip;\u0026rdquo;\u003c/em\u003e (Code 16_4.4b)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I will have the opportunity to experience how palliative care is not only care reserved for those who are at the end of life, but I will have the opportunity to understand how precious it can be for different patients in different situations.\u0026rdquo;\u003c/em\u003e (Code 17_1.6b)\u003c/p\u003e\u003cp\u003e(iii) Moreover, they were stimulated to participate in training for positive references from other colleagues who defined the hospital PCU as a \u003cem\u003e\u0026ldquo;special department....pioneering, as a particular situation\u0026hellip;\u0026rdquo;\u003c/em\u003e (Code 19_10.6b), a center \u003cem\u003e\u0026ldquo;where PC is best done ...\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;professionals of the highest level and skills\u0026hellip;\u0026rdquo;\u003c/em\u003e (Code 18_1.6b).\u003c/p\u003e\u003cp\u003eAfter training, the internship becomes a \u0026ldquo;stimulus for the future\u0026rdquo; because trainees describe how they have been sensitised to research, to grow professionally and to be oriented towards innovation. Three sub-themes emerged: (i) Have the goal of transferring what I have learned into one\u0026rsquo;s own context, (ii) To be stimulated to do research and to train professionally, (iii) Internship satisfaction/expectations exceeded.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe trainees described the need to \u003cem\u003e\u0026ldquo;\u0026hellip;make sure to bring into my life and work what I have pleasantly learned here ...\u0026rdquo;\u003c/em\u003e (Code 18_1.7a); moreover, \u003cem\u003e\u0026ldquo;\u0026hellip;it still gave rise to a lot of questions and thoughts about the profession in palliative care, it fueled my passion and interest in this area ...\u0026rdquo;\u003c/em\u003e (Code 17_10.2a).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe student trainees understood the importance of keeping together clinical, educational and research activities, underlined that \u003cem\u003e\u0026ldquo;\u0026hellip;it gave me many stimuli, including that of continuing to train and do research to make myself professionally more complete ...\u0026rdquo;\u003c/em\u003e (Code 16_3.13a). In particular, it was important to see \u003cem\u003e\u0026ldquo;how nurses collaborate in education and research, aspects not taken for granted, especially in different departments\u0026rdquo; (code 18_5.6a).\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eStudent trainees demonstrated high satisfaction with the experience, with expectations exceeded by what they encountered. \u003cem\u003e\u0026ldquo;Writing down my impressions, now that I have completed my internship, I can truly say that my expectations were not only met but exceeded\u0026rdquo;\u003c/em\u003e (Code 17_5.1a).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2. Hospital Palliative Care\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBefore the internship, the trainees described the expectation to \u0026ldquo;develop specific skills in PC,\u0026rdquo; in which three sub-themes were identified: (i) Achieve new knowledge and skills in PC, (ii) Desire to deal with other professionals or patients or PC contexts, (iii) Curiosity to explore specific characteristics of hospital PC.\u003c/p\u003e\u003cp\u003e(i) In the first sub-themes, the student trainees expected to \u003cem\u003e\u0026ldquo;\u0026hellip;train me to have more awareness and clarity on the concept of palliative care and thus be able to adequately assist...\u0026rdquo;\u003c/em\u003e (Code 16_3.1b), but also more knowledge on specific aspects such as advance care planning. Indeed, the trainees said: \u003cem\u003e\u0026ldquo;...I am confident to clarify everything concerning advance care planning, how the nurse and the team deal with the patient/family or how they manage what falls within the concept of the Calman gap or communication/relational aspects\u0026hellip;\u0026rdquo;\u003c/em\u003e (Code 17_4.7b).\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;to acquire the ability to guarantee dignity or \u0026lsquo;effective\u0026rsquo; communication; the ability to perceive every need of the patient\u0026rdquo;\u003c/em\u003e (Code 16_5.4b).\u003c/p\u003e\u003cp\u003e(ii) The second sub-theme highlighted the student trainees\u0026rsquo; interest in exchanging with other professionals regarding communication skills and early identification of frailty patients. They expressed:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...I am interested in understanding and seeing the communication techniques and the approach of doctors with patients....\u0026rdquo;\u003c/em\u003e (Code 19_6.3b)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...therefore, I hope that this week of the internship will show me a situation of palliative care ingrained in the hospital, which can identify early those people who have a certain degree of frailty due to illness...\u0026rdquo;\u003c/em\u003e (Code 17_6.2b)\u003c/p\u003e\u003cp\u003e(iii) The third sub-theme explained curiosity about learning the characteristics of the hospital PCU in more depth. There was interest in learning about the development of the Palliative Care Service (PCS) in settings other than home care services and hospices and compared their context that did not include a hospital PCS. The student trainees said:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...I expect to be confronted with a situation of palliative care that unfortunately does not exist in my region\u0026hellip;\u0026rdquo;\u003c/em\u003e (Code 18_9.1b)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...to understand how a hospital setting works, having always worked in home care services...\u0026rdquo;\u003c/em\u003e (Code 19_4.2b)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I would like to learn how to carry out palliative care other than in home or hospice care\u0026hellip;\u0026rdquo;\u003c/em\u003e (Code 18_5.1b)\u003c/p\u003e\u003cp\u003eAfter the training, four sub-themes were identified: (i) Competence, passion, and humanity of the PCS; (ii) Recognized modern/early palliative care in PCS activities; (iii) Recognized the integration of clinical aspects, education, and research in the PCS; (iv) Recognized nurses\u0026rsquo; role within the PCS.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAfter the internship, the trainees recognized a more comprehensive skill mosaic among PCS professionals than before the internship by outlining the specific aspects of hospital palliative care. They expressed their recognition towards the individual professionals of the PCS, which they had \u003cem\u003e\u0026ldquo;\u0026hellip;a high level of technical, clinical and relational competence and together a great humanity.\u0026rdquo;\u003c/em\u003e (Code 16_1.6a)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThey recognized PCS activities as an example of modern/early palliative care and the ability of PCS professionals to interact with other healthcare professionals (HPs). \u003cem\u003e\u0026ldquo;I observed firsthand what they explained as \u0026lsquo;simultaneous care\u0026rsquo;, probably the result of a work of education, collaboration, and training with other HPs\u0026rdquo;\u003c/em\u003e (Code 17_1.5a)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe PCU's mission was recognized as three-pronged: patient assistance through inpatient and outpatient consultations, research activities, and specialized training to improve PC core skills in HPs.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;... What I found particularly interesting and exciting, and which certainly made my path here complete, was the complementarity of clinical aspects, research, and training ....\u0026rdquo;\u003c/em\u003e (Code 16_1.4a)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;The training in this service for professionals is seen as a fulcrum for daily activities and as an implementation of teamwork to allow an adequate pharmacological and care approach measured on the person\u0026rsquo;s characteristics...\u0026rdquo;\u003c/em\u003e (Code 19_9.6a)\u003c/p\u003e\u003cp\u003e(iv) Finally, trainees recognized the specific role and competencies of the palliative care nurse. The trainees appreciated the autonomy and collaboration of palliative care nurses within the team. They expressed:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;... I saw how the nurses collaborate in training and research; things are not taken for granted...\u0026rdquo;\u003c/em\u003e (Cod 18_5.6a)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;... This teamwork starts from the moment of reception carried out by the nurse ...\u0026rdquo;\u003c/em\u003e (Code 19_17.4a)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;... The nurse role almost acts as a \u0026lsquo;glue\u0026rsquo; between the various professionals and the patient and his family ...\u0026rdquo;\u003c/em\u003e (Code 19_14.3a)\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 3. Trainee Metamorphosis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe trainees described a \u0026ldquo;metamorphosis\u0026rdquo; that passed from \u0026ldquo;how to improve being a nurse and the working situation\u0026rdquo; to \u0026ldquo;self-awareness and reflexivity of what you do.\u0026rdquo;\u003c/p\u003e\u003cp\u003eBefore the training, two sub-themes were highlighted: (i) \u0026ldquo;Improve your being a nurse\u0026rdquo; and (ii) \u0026ldquo;Bringing new elements to your working situation \u0026rdquo;.\u003c/p\u003e\u003cp\u003e(i) The student trainees expressed the desire to develop their own \u0026ldquo;essence\u0026rdquo; as professionals and a willingness to learn in various areas (personal, team, and towards patients and their families and caregivers). They described a non-specific palliative care training need, but \u003cem\u003e\u0026ldquo;...I want to learn, I want to experiment, I want to improve my skills and abilities, first towards myself, then towards a multi-professional team and mainly towards the patient and caregivers\u0026rdquo;\u003c/em\u003e (Code 17_12.5b)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I would like this internship to be not only a training experience but also an enriching human experience in which to learn \u0026lsquo;knowing\u0026rsquo;, \u0026lsquo;knowing how to do\u0026rsquo; and \u0026lsquo;knowing how to be\u0026hellip;\u0026rsquo;\u003c/em\u003e (Code 19_4.3b)\u003c/p\u003e\u003cp\u003e(ii) The trainees showed an expectation of helpful experiential and experimental learning to be transferred into their individual work situations: \u003cem\u003e\u0026ldquo;I would like to be able to transmit this way of working to the colleagues and professionals I work with\u0026rdquo;\u003c/em\u003e (Code 18_1.7b) and \u003cem\u003e\u0026ldquo;\u0026hellip;I will make sure to bring into my life and work what I have pleasantly learned here\u0026rdquo;\u003c/em\u003e (Code 16_1.15b).\u003c/p\u003e\u003cp\u003eAfter the internship, we identified three subthemes: (i) Recognize the knowledge and skills acquired; (ii) Make the team\u0026rsquo;s moments of constructive exchange; (iii) Internship as an opportunity for reflection on what is known, done, and is.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe participants felt that they had acquired knowledge and skills, especially in recognizing and managing emotions, a skill they considered very complex: \u003cem\u003e\u0026ldquo;\u0026hellip; I also understood that managing your emotions is difficult. I was moved several times, and then discussing them I understood how it is right to feel certain emotions and how over time I will learn to manage them in the most appropriate way (I hope).\u0026rdquo;\u003c/em\u003e (Code 18_6.6a)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIn addition, they were able to understand and feel how teamwork and moments of confrontation during weekly meetings are indispensable for understanding their emotions and those of the patient and family within the care relationship, in order to be effective and authentic in clinical practice.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...I will take away the moments of exchange, always constructive, on our moods, doubts, uncertainties, criticisms\u0026rdquo;\u003c/em\u003e (Code 16_1.10a)\u003c/p\u003e\u003cp\u003e(iii) The internship became an opportunity to reflect on themselves, on what they do and know: \u003cem\u003e\u0026ldquo;This period was also a moment of exchange with respect to my knowledge and my actions \u0026hellip;\u0026rdquo;\u003c/em\u003e (Code 16_4.3a).\u003c/p\u003e\u003cp\u003e\u003cb\u003eQuantitative findings\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAt the end of the internship, the student trainees reported an increase in knowledge about all the portfolio topics. All the results are statistically significant. We report the main findings in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eQuantitative results from portfolio analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eMedian\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep0.25\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ep0.75\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\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\u003e1. \u003cb\u003eKNOWLEDGE AND SKILLS TOWARDS THE PATIENTS IN\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTHEIR CLINICAL SPECIFICITY\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAIN ASSESSMENT AND TREATMENT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain assessment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrugs and routes of administration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSide effects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDYSPNEA ASSESSMENT AND TREATMENT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnosis and evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePharmacological therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-pharmacological therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDELIRIUM ASSESSMENT AND TREATMENT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnosis and evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrug and non-drug approach\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNAUSEA/VOMITING ASSESSMENT AND TREATMENT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnosis and evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMANAGEMENT OF END-OF-LIFE SYMPTOMS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. \u003cb\u003eSKILLS TOWARDS THE PATIENTS AND THEIR FAMILY IN THE COMMUNICATION CONTEXT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDIFFICULT COMMUNICATION\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterventions with patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterventions with family members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTeam discussion post-intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse telephone follow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIMPRESSIONS AND BELIEFS ABOUT ETHICS AND BIOETHICS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollaboration with the bioethics team\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReflection on bioethics issues\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. \u003cb\u003eKNOWLEDGE ON PALLIATIVE CARE TODAY\u003c/b\u003e (transversality, early approach, simultaneous care, teamwork, relationship between specialist level and non-specialist level)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiscussion on the modern idea of PC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. \u003cb\u003eRESEARCH AND EDUCATION\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipation in training activities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoaching in a research project\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUsing experience and literature to learn about some main topics in more depth (pain, delirium, dyspnea, nausea, bowel obstruction)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\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\u003eIt is important to underline that for some items, the range of the before-after self-evaluation is wider. These items regard specific non-clinical characteristics of the hospital PCU, the team discussions after difficult communication with patients and families, participation in training and research projects, and the meeting with the bioethicist.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTriangulation findings\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAfter the comparison of qualitative and quantitative data, we found important similarities and no incongruences to interpret the findings.\u003c/p\u003e\u003cp\u003eThe participants were very active and participatory in the whole path of training and research, allowing the collection of very interesting data in both our quantitative and qualitative research. The triangulation of data led to both confirmatory and integrated or novel results.\u003c/p\u003e\u003cp\u003eThe results obtained highlighted the significant amount of knowledge and skills acquired by the participants after the training, in terms of the shift in meaning that they attributed to phenomena related to chronicity and incurability, which they encounter daily in their professional practice.\u003c/p\u003e\u003cp\u003eThe quantitative data refer to the participants\u0026rsquo; perception of the skills acquired, while the qualitative data present insights and reflections with respect to the knowledge and skills indicated. The student trainees recognized:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eNew knowledge and skills: The acquisition of different skills, relating to technical, relational, and ethical skills underscored the need to learn a broader mosaic of skills than expected for PCU professionals. The nurses expressed their satisfaction with the internship and stated that it had exceeded their expectation, their desires and curiosity; the student trainees appreciated the team\u0026rsquo;s moments of constructive exchange and recognized the competence, passion, and humanity of the PCU team.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCommunication skills: In relation to the skills useful for engaging in difficult communication with patient and family, the trainees recognized that they had increased their awareness and reflexivity, especially in contexts requiring complex skills, such as interpersonal abilities.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePC today: The nurse trainees learned the most recent definition of palliative care and the role of early palliative care recognized in the PCU's vision and mission. They also recognized the role of specialist palliative care nurses.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eResearch and education: The trainees recognized the integration of clinical, educational, and research activities specific to the hospital PCU and acknowledged that they had supported the team\u0026rsquo;s professionals in research activities.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eIn conclusion, the interprofessional team acknowledged that the trainees had undergone a metamorphosis at the end of the placement.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present work describes an experiential one-week training for nurses in a specialized hospital PCU in Italy and its evaluation. The nurses were attending a post-degree course on palliative care.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe student trainees\u0026rsquo; growth\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe main result was the impact of a one-week internship on the nurse trainee, which went in three directions: it broadened the vision of modern palliative care, initiated deep reflection on themselves and their skills, and projected the nurses into the future.\u003c/p\u003e\u003cp\u003eThe internship thus provided an understanding of what is involved in working on a hospital palliative care team and the advanced skills that are needed. In particular, the students learned about the many skills required by the role of the palliative care nurse in the hospital. Advanced competencies go beyond technical skills, differ to some extent from those of a hospice or home care nurse, and form a very rich and challenging mosaic.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) Secondly, the placement elicited a personal reflection on what it meant for the trainees to be a nurse, what knowledge and skills they have already acquired, and what still needs to be learned. Finally, the internship projected the trainees into the future, helping them to understand the importance of continuing education and research in their professional development. The fact that the students felt motivated at the end of the placement period to continue working and training in palliative care is particularly positive and is reflected in a study published by Li in 2023. Constructing a competency framework for palliative care nurses in China, Li et al. included \u0026ldquo;achievement motivation\u0026rdquo; among the developmental competencies needed for personal and professional growth.(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe nursing students came from very different work settings: home care services, various hospital wards, hospices, and nursing homes. The more comprehensive analysis of the internships conducted over the three years highlights how the interaction and exchange between the students and the specialized palliative care team can exemplify interprofessional education(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIndeed, the students could observe healthcare professionals interacting and working collaboratively. This fueled self-reflection in two directions: bringing palliative care skills to their own work setting and bringing the skills acquired in their own work setting to the situations encountered during the internship. At the same time, the discussion enriched the team\u0026rsquo;s discussion of the clinical cases they encountered.\u003c/p\u003e\u003cp\u003eVarious elements enabled the trainees to achieve a high level of skills and growth, even with a short (one-week) albeit structured training: the use of different educational methods (portfolio, RW, discussion between peers, discussion with the Bioethics Unit on complex cases, and one-to-one coaching by a specialized nurse) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), the professional mentor, and above all a multidisciplinary collaborative mentor team.(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) These elements are in line with the most recent recommendations on the education of nurses on palliative and end-of-life care.(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) Nursing students need to be accompanied in clinical practice, taking time for debriefing and constructive reflection on the clinical cases they encounter. This will support the students emotionally and enable them to develop a more aware approach to vulnerable phases of life, such as death and dying.(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cem\u003eFrom educational tools to research tools\u003c/em\u003e\u003c/p\u003e\u003cp\u003eReflective writing and skills portfolios are widely described in the literature, and the results of this study are in line with the impact they have on the training process described in the literature.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) In our case, reflective writing increased the student trainees\u0026rsquo; understanding and reflective ability; it supported the development of clinical, relational, and self-knowledge competencies, and enabled them to express their emotions, moods, and inner journeys.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) Through the student trainees\u0026rsquo; self-assessments of what they learned and through ongoing discussion with their mentor, the portfolio showed to be helpful in improving their ability to integrate theory with clinical practice, as previously found by other authors.(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) Unlike other recent studies, in which a pre-post and mixed methods evaluation was carried out in PC training(\u003cspan additionalcitationids=\"CR51\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), in this study the data triangulation methodology was applied, enriching the results and allowing us to identify coherence between the qualitative and quantitative results.(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and Limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe used learning evaluation models that were not limited only to satisfaction with the experience but also the evaluation of the \u0026ldquo;know\u0026rdquo; and \u0026ldquo;know-how\u0026rdquo; skills, and the performance of the health professionals. Nevertheless, the study has some limitations. First, the internship experience described is related to a single center. However, it may have national relevance because there are few hospital palliative care units in Italy, and this type of training activity is even less widespread. Secondly, the study is retrospective but still comprises a substantial number of participants. Additionally, we did not envision a long-term re-evaluation of the impact of the training on the students\u0026rsquo; skills. It could be interesting to understand whether the skills acquired have been useful and maintained in the nursing students\u0026rsquo; work settings. Finally, the trainers did not carry out the evaluation of the students. There is therefore no comparison between the perceived skills and those assessed by an external trainer.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe educational role of the PC team is fundamental to the growth of the nurse trainees. Enabling trainees to work with a specialist hospital palliative care team transfers knowledge relating to the goals of early palliative care and specialist palliative care skills. The training should also be the subject of research projects that evaluate the qualitative and quantitative aspects and the effects on student trainees. However, further studies are needed to confirm the structure and the elements of a palliative care internship for post-degree nurses.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePalliative Care Nurse\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePalliative Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eECTS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEuropean Credit Transfer System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEAPC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEuropean Association for Palliative Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eReflective writing\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePalliative Care Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSICP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eItalian Society of Palliative Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePalliative Care Service\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHPs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealthcare Professionals\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis was a retrospective observational study for which data - portfolios and reflective writings - were collected during clinical practice for educational purposes, without the involvement of patients and relatives. Consequently, the internal regulations of the relevant hospital body (Scientific CME Committee of Reggio Emilia) did not require specific informed consent procedures. Under analysis, each document was coded, anonymized, and analyzed in aggregate form, ensuring the confidentiality of participants. The study was conducted following the Declaration of Helsinki and local regulatory requirements.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study's findings are available upon request from the corresponding author, [EB].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was partially supported by Italian Ministry of Health – Ricerca Corrente Annual Program 2024.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGA, ST, CA, EB, SA conceived and developed the study protocol. EB, CA, FS, SA, ST contributed to the qualitative analysis. LB and EB contributed to the quantitative analysis. EB, SA and GA drafted the article, and all authors contributed substantially to its revision. GA and ST contributed to the supervision of the work. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank all the students who attended our PCU course and shared their experiences, reflections, professional desires, and presence.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRadbruch L, De Lima L, Knaul F, Wenk R, Ali Z, Bhatnaghar S, et al. Redefining Palliative Care-A New Consensus-Based Definition. J Pain Symptom Manage ottobre. 2020;60(4):754\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZimmermann C, Ryan S, Hannon B, Saltman A, Rodin G, Mak E et al. Team-based outpatient early palliative care: a complex cancer intervention. BMJ Support Palliat Care. 12 agosto 2019;bmjspcare-2019-001903.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGustafsson LK, Rylander A. Experiences of surviving life-threatening illness: The meaning of recovery. Scand J Caring Sci dicembre. 2021;35(4):1160\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAutelitano C, Bertocchi E, Artioli G, Alquati S, Tanzi S. The Specialist Palliative Care Nurses\u0026rsquo; in an Italian Hospital: role, competences, and activities. Acta Bio-Medica Atenei Parm. 31 marzo. 2021;92(S2):e2021006.\u003c/span\u003e\u003c/li\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. 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Palliat Support Care. 22 dicembre. 2022;1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMartins Pereira S, Hern\u0026aacute;ndez-Marrero P, Pasman HR, Capelas ML, Larkin P, Francke AL. Nursing education on palliative care across Europe: Results and recommendations from the EAPC Taskforce on preparation for practice in palliative care nursing across the EU based on an online-survey and country reports. Palliat Med gennaio. 2021;35(1):130\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDehghani F, Barkhordari-Sharifabad M, Sedaghati-Kasbakhi M, Fallahzadeh H. Effect of palliative care training on perceived self-efficacy of the nurses. BMC Palliat Care 4 maggio. 2020;19(1):63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePaal P, Brandst\u0026ouml;tter C, B\u0026uuml;kki J, Elsner F, Ersteniuk A, Jentschke E et al. One-week multidisciplinary post-graduate palliative care training: an outcome-based program evaluation. BMC Med Educ. 18 agosto. 2020;20(1):276.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDurojaiye A, Ryan R, Doody O. Student nurse education and preparation for palliative care: A scoping review. PLoS ONE. 2023;18(7):e0286678.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGentry JH, Dahlin C. The Evaluation of a Palliative Care Advanced Practice Nursing Externship. J Hosp Palliat Nurs JHPN Off J Hosp Palliat Nurses Assoc. giugno. 2020;22(3):172\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMastroianni C, Ramon Codina M, D\u0026rsquo;Angelo D, Petitti T, Latina R, Casale G et al. Palliative Care Education in Undergraduate Nursing Curriculum in Italy. J Hosp Palliat Nurs JHPN Off J Hosp Palliat Nurses Assoc. febbraio. 2019;21(1):96\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuraya SY, Barr H. 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JBI Database Syst Rev Implement Rep aprile. 2016;14(4):96\u0026ndash;137.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoong SQ, Wang W, Seah ACW, Kumar N, Gan JON, Schmidt LT, et al. Nursing students\u0026rsquo; experiences with patient death and palliative and end-of-life care: A systematic review and meta-synthesis. Nurse Educ Pract maggio. 2023;69:103625.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCunningham H, Taylor D, Desai UA, Quiah SC, Kaplan B, Fei L, et al. Looking Back to Move Forward: First-Year Medical Students\u0026rsquo; Meta-Reflections on Their Narrative Portfolio Writings. Acad Med J Assoc Am Med Coll giugno. 2018;93(6):888\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLim AJS, Hong DZ, Pisupati A, Ong YT, Yeo JYH, Chong EJX, et al. Portfolio use in postgraduate medical education: a systematic scoping review. 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J Palliat Med settembre. 2021;24(10):1516\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eLegend of codes\u003c/span\u003e: first number\u0026thinsp;=\u0026thinsp;year of internship; second number\u0026thinsp;=\u0026thinsp;participant code; third number: verbatim number; alphabetic letter: b\u0026thinsp;=\u0026thinsp;before training; a\u0026thinsp;=\u0026thinsp;after training\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-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5025695/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5025695/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe educational role of a specialist palliative care team is crucial for the growth of nursing students attending a second-level course in palliative care. To our knowledge, the literature on the impact evaluation of clinical training in palliative care is scarce. This study aims to describe and evaluate a one-week training program in a Hospital Palliative Care Unit, specifically designed for nurses who have completed a post-degree university course. The nurse trainees were involved in various activities alongside the specialist team, including clinical, teaching, and research tasks.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe program was evaluated through a retrospective, observational, mixed-method study incorporating before-after training evaluation and consequent concurrent data triangulation. Two tools, reflective writing, and the portfolio, were used for training and research purposes. They have been analyzed qualitatively and quantitatively, respectively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eQualitative analysis of 107 pre-post reflexive writings on students\u0026rsquo; expectations and desires led us to identify three general themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Palliative care between present and future, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Inpatient palliative care, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Metamorphosis of the trainee. Quantitative analysis of the 110 portfolios shows a statistically significant increase in perceived knowledge and skills regarding the meaning of modern palliative care, management of end-of-life, and advanced communication. Concurrent triangulation of data shows a consistency between qualitative and quantitative data.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eEnabling trainees to work with a specialist hospital palliative care team transfers knowledge relating to the goals of early palliative care and specialist palliative care skills. This study underscores the need for further studies to confirm the structure and the elements of a palliative care internship for post-degree nurses, emphasizing the importance of ongoing research in this field.\u003c/p\u003e","manuscriptTitle":"One-week training evaluation in Hospital Palliative Care Service for Advanced Nurses: a mixed Method Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 09:50:41","doi":"10.21203/rs.3.rs-5025695/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-19T08:23:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-17T11:21:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-09-17T11:20:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc6a5363-6f94-451a-9156-cb94cbd8fbe6","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:04:07+00:00","versionOfRecord":{"articleIdentity":"rs-5025695","link":"https://doi.org/10.1186/s12909-025-08000-1","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-10-09 15:57:47","publishedOnDateReadable":"October 9th, 2025"},"versionCreatedAt":"2025-08-01 09:50:41","video":"","vorDoi":"10.1186/s12909-025-08000-1","vorDoiUrl":"https://doi.org/10.1186/s12909-025-08000-1","workflowStages":[]},"version":"v1","identity":"rs-5025695","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5025695","identity":"rs-5025695","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}