Evaluation of the End-of-Life Nursing Education ConsortiumVJapan Faculty Development Program

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1 Evaluation of the End-of-Life Nursing Education ConsortiumVJapan Faculty Development Program Validity and Reliability of the End-of-Life Nursing Education Questionnaire Sayaka Takenouchi, MPH ƒ Mitsunori Miyashita, RN, MS, PhD ƒ Keiko Tamura, RN, MS, OCNS, PhD ƒ Yoshiyuki Kizawa, MD ƒ Shinji Kosugi, MD, PhD This article describes the development and psychometric testing of the End-of-Life Nursing Education Questionnaire to measure effectiveness of nursing faculty development programs in end-of-life care in Japan. The questionnaire was developed and validated with the data provided by a cross-sectional survey from 143 participants in the End-of-Life Nursing Education ConsortiumVJapan Faculty Development Program held in Tokyo, in July and November Face and content validation was followed by data collection. Factor analysis was performed, and internal consistency reliability was tested. The response rate was 99% for preprogram and postprogram evaluations. The outcome was the development of 20 items in five domains. Cronbach s! ranged from.84 to.97, and interclass correlation coefficients for test-retest reliability were 0.63 to The data support face, content, and construct validity of the questionnaire. There were significant changes in responses between preprogram and postprogram evaluations on nearly all domains, and this proved sufficient sensitivity of the questionnaire. The End-of-Life Nursing Education Questionnaire is a valid and reliable instrument to evaluate the effectiveness of nursing faculty development program in end-of-life care. The changes reported by participants of this study suggest that the program successfully met its objectives in facilitating significant changes in nursing faculties. KEY WORDS End-of-life care, End-of-Life Nursing Education Consortium, End-of-Life Nursing Education Questionnaire, nursing education, palliative care Japanese society is facing serious issues with increasing numbers of mortalities over births. In 2009, a total of 1.14 million people (9.1% of the population) died, 1 and it is estimated that more than 1.4 million people (11% of the population 2 ) will be in this category by Undergraduate and graduate nursing faculty and staff development educators in healthcare institutions need to realize that they have great responsibilities. They have to be prepared to teach and lead initiatives in excellence in end-of-life (EOL) care under these circumstances. The literature, however, indicates that there are inadequate knowledge levels and education of nurses in symptom management in EOL care and other palliative care skills. 3 In 2004, the Ministry of Education, Culture, Sports, Science and Technology of Japan formulated competency statements identifying abilities that all nursing students should acquire during their undergraduate education to prepare them to provide quality care to patients with life-limiting illnesses. 4 Although many nursing schools tried to change their curricula to include EOL care content in response to this statement, there was great variability among the quality and quantity of those content. 5 The immediate demand was emphasized for well-trained nursing faculties who could introduce effective curricula Sayaka Takenouchi, MPH, is Assistant Professor, Faculty of Nursing, Nursing Science for Adult Health Nursing, Department of Human Health Science, Kyoto University Graduate School of Medicine, Japan. Mitsunori Miyashita, RN, MS, PhD, is Professor, Department of Palliative Nursing, Health Science, Tohoku University, Miyagi, Japan. Keiko Tamura, RN, MS, OCNS, PhD, is Nurse Manager, Yodogawa Christian Hospital, Osaka, Japan. Yoshiyuki Kizawa, MD, is Lecturer, Institute of Clinical Medicine, Graduate School Comprehensive Human Sciences, University of Tsukuba, Japan. Shinji Kosugi, MD, PhD, is Professor, Graduate School of Public Health, Kyoto University Graduate School of Medicine, Japan. Address correspondence to Sayaka Takenouchi, MPH, 53 Kawaharacho Shogoin, Sakyo-ku, Kyoto , Japan (t-sayaka@hs.med.kyoto-u.ac.jp). DOI: /NJH.0b013e31822da9d Volume 13 & Number 6 & November/December 2011

2 incorporating EOL care teaching for nursing students to overcome the issues that exist in Japan. 3,5 On the other hand, there are various educational training structures for clinical nurses who are involved in EOL care in Japan. One is the certification system to authorize nurses with advanced skills and specialized knowledge in oncology nursing as an oncology certified nurse specialist (CNS). 6,7 The system was introduced by the Japanese Nursing Association (JNA) in 1996, and the roles of the CNS include hands-on practice, teaching, and consultation. 6 Likewise, another practical certification system for certified nurses (CN) was also introduced by the JNA 6,8 in A CN is a CNS whose proficient skills and knowledge raise the quality of nursing care in clinical practice. Currently, there are two CN certification fields especially relevant to palliative and EOL care: cancer pain management and hospice care. 8 Other than the certification systems of the CNS and CN, there are many other educational opportunities such as palliative nursing seminars held by regional nursing associations, local study groups, and in-service education at various health institutions. The literature, however, indicates that there is a wide variety of content within those independent educational programs for nurses who care for patients with terminal illnesses. 3 Accordingly, it has become a subject of discussion whether palliative care training within basic nursing education/continuing nursing education needs to be reevaluated in Japan. Growing needs were identified to develop faculty development programs so that nursing educators would be prepared to provide effective palliative/eol care education. 3,9 As a consequence, the educational program End-of-Life Nursing Education Consortium (ELNEC) was introduced in 2007 as a possible solution. 10,11 The ELNEC Core Training Program was developed by the American Association of Colleges of Nursing and the City of Hope in the United States. 10 Between 2003 and 2007, seven Japanese nurses attended the ELNEC Core Training Programs held in the United States to become ELNEC trainers and learn the skills to educate nurse educators in their own country. With funding from the Health and Labour Sciences Research Grant for Clinical Cancer Research from 2007 to 2009, the ELNEC Core curriculum was translated into Japanese by bilingual interdisciplinary team members of the ELNEC Japan project team who specialize in palliative and EOL care. It was then modified to make it relevant to the field and respectful to Japanese culture. This resulted in the ELNECVJapan Faculty Development Program. The expectation was that, with this program, nurse educators would learn the methods of interactive teaching and contribute to improving the quality of palliative nursing care and EOL care for practicing nurses, as well as nursing students, in Japan. The translated curriculum was reviewed and modified through the discussions of nationally recognized palliative care experts with extensive input from reviewers, including nurses who are ELNEC trainers. Following the modification process of the program based on pilot study results exploring the feasibility of the translated program, six national ELNECVJapan Faculty Development Programs have been held since To date, there are more than 420 nurses throughout the country who have been trained as ELNEC Japan trainers. It is estimated that those trainers have returned to their institutions and regions and have trained more than 11,000 nurses and other interdisciplinary team members since the first program in This article describes the development and psychometric testing of the End-of-Life Nursing Education Questionnaire (ELNEQ), created to measure the effectiveness of nursing faculty development programs in EOL care and evaluate the effectiveness of the ELNECVJapan Faculty Development Program. A variety of instruments, such as the Palliative Care Quiz for Nursing and the Frommelt Attitude Toward Care of the Dying Scale, have been developed to evaluate knowledge levels and attitudes towards caring for dying patients. 12,13 These instruments are helpful to explore strategies for teaching EOL care contents, but few instruments have been designed to evaluate the effectiveness of nursing faculty development programsva program that uses interactive teaching techniques not only to facilitate participants to learn the basic contents of EOL care but also to help them be prepared to teach and lead initiatives in improving palliative care such as the ELNECVJapan Faculty Development Program. There also are two separate scales, the Palliative Care Self-Reported Practices Scale and the Palliative Care Difficulties Scale, specifically available to evaluate the effectiveness of educational programs for general nurses in Japan. 14 Despite both scales being reliable and valid, their use was limited to general nurses and they were not applicable to evaluate outcomes of faculty development programs such as the ELNECVJapan Faculty Development Program. Therefore, the authors decided to develop a self-administered questionnaire to assess the participants confidence, motivation, and preparation to teach and lead initiatives in EOL care. Following is a presentation of the development and initial validation of the questionnaire. METHODS The Kyoto University Hospital Institutional Review Board approved this study. The authors informed participants that participation in the study was voluntary, and their names would be removed from all study data. All participants gave consent prior to participating in the ELNECV Japan Faculty Development Program. Journal of Hospice & Palliative Nursing 369

3 Program Description The ELNECVJapan Faculty Development Program has been offered biannually or annually since 2008 and has been delivered over 2-day sessions. The goals and objectives of the program were as follows: 1. To learn and develop abilities to teach EOL and palliative care. 2. To assess the challenges in teaching EOL and palliative nursing care and to set realistic and measurable goals. The curriculum also focuses on the following: Y Teaching key aspects of EOL care (physical, psychological, and spiritual assessment; ethical and cultural issues; bereavement care). Y Teaching communication at the EOL care through lectures, role playing, group discussions (advance care planning with patients and family members, supporting the patient and family members after breaking bad news, conducting family meetings). Y Managing challenges in palliative care education (assessing barriers to teaching, using interactive teaching methods, and influencing attitudes toward EOL care). Y Promoting clinical and educational programs in palliative nursing by assisting participants (introducing the ELNEC Japan training program for clinical nurses, showing how to plan and organize the ELNEC Japan training). Y Informal networking activities and dialogue (employing ice-breaking sessions, arranging luncheons to build relationships). The programs were led by faculty members (who were involved in translation of the ELNEC Core and specialized in palliative nursing, geriatric nursing, and nursing education), using experiential and didactic teaching methods. These programs consisted of all eight modules of the ELNEC Core curriculum, and more than 1 hour was spent on each module. Extensive literature from professional journals, as well as documents from other national projects promoting palliative care and studies involving evidence-based practice, was added to the ELNEC Core original curriculum developed in the United States. Participants and Setting The programs were advertised by posting articles on the occasional newsletter of the Japanese Society for Palliative Medicine and on the Internet sites of national nursing and professional organizations for hospices and palliative care in Japan. Applicants were required to be a registered nurse with a minimum of 5 years experience in caring for patients with a life-threatening illness on a daily basis or faculty members of a nursing school. Applicants had to present a recommendation letter and written approval from their director to support their implementation of palliative care educational services and programs in their institutions or regions. Applicants were also asked to describe their professional background, including experience in EOL care, and educational or service projects that they had given in application forms. Questionnaire Development and Administration From January 2008 through February 2010, development and validation of the ELNEQ scale took place in the sequence presented below. Item Generation Forty items of the ELNEQ were drawn up based on course objectives, reviews of literature, and input from two focus groups with four nurses in each group who attended the ELNEC Japan pilot study. Dual-moderator focus groups were conducted with these eight nurses who attended the pilot study of the ELNECVJapan Faculty Development Program in January 2008 in Kyoto, Japan, which was held 2 weeks prior to those focus groups. The use of focus groups served to ensure that the items within the questionnaire captured the essence of course objectives and experience with the ELNECVJapan Faculty Development Programs. 17 Topics posted by the moderator and used to elicit concepts to determine items were participants experiences and general impressions from the pilot study of the ELNECVJapan Faculty Development Program, changes in patient care practices or teaching practices, and their own beliefs. Of the eight nurses, all were women and employed full time. The average of participants clinical experience in nursing has a mean (SD) of 10.8 (6.8) years, and the average age of the participants has a mean (SD) of 32 (7.2) years. Participants in the focus group were then asked to discuss topics posted by a moderator based on the course objectives and expected effects of the program described earlier. All focus group discussions were transcribed verbatim by a professional transcriptionist. Identifying information was removed, and all participants were assigned code numbers. The investigator read the transcripts separately and identified repetitive phrases or concepts using a constant comparison technique. 17 Analyses of the transcripts produced key words and phrases that suggested the outcomes from the ELNECVJapan Faculty Development Program. Over the course of several meetings, five palliative care experts, four nurses, and one physician who took part in translating the ELNEC Core curriculum refined the items based on the analysis of the focus group data. This resulted in the development of the initial item pool, which contained 40 items of self-administered questions. The questionnaire had closed items using 5-point rating scales written in Japanese. Questionnaire Administration The authors administered the questionnaires at three points in time for participants in the ELNECVJapan Faculty Volume 13 & Number 6 & November/December 2011

4 Development Program in July and November 2009; (1) 3 weeks prior to (items to gather demographic background and ELNEQ), (2) immediately prior to the first session (ELNEQ), and (3) immediately after the last session (ELNEQ). Copies of questionnaires consisting of items to gather demographic background and ELNEQ were mailed to participants 3 weeks prior to the program, and they were turned in on the first day of the program. Other questionnaires were administered on-site immediately prior to the first session and following the last session of the program. To maintain confidentiality, questionnaires were marked with study identification numbers that allowed linking of each participant s questionnaires over the three periods. All the data input was done manually. The authors also administered daily evaluations that assessed participants ratings of the overall program, usefulness for teaching, the clarity of presentations by each lecturer, and quality of each module s contents. Statistical Analysis Some of the items in the initial item pool were deleted basedondataobtainedfromparticipantsoftheelnecv Japan Pilot Study, Osaka, July Participants who responded to 90% or more of the 40 items were included as participants in the analysis. Each item was analyzed by considering the percentage of missing data to enhance feasibility (cutoffs: missing more than 1% of data) and ceiling effect to enhance sensitivity (cutoffs: more than 90% of responses are 1 or 5 on a 5-point rating scale). Face validity and content validity were then monitored by eight experts in palliative care nursing and medicine. These experts were the members of an expert panel of the ELNECVJapan faculty, and there were seven experienced nurses and a physician in the panel. Construct validity of the questionnaire was assessed statistically by means of exploratory factor analysis with Promax rotation, and standard regression coefficients were taken as a minimum of 0.4. Internal consistency was also tested using Cronbach s! calculation. The values of Cronbach s! were interpreted as.71 to.80, acceptable;.81 to.90, good; and.91 to 1, excellent. 18 The test-retest reliability was explored by calculating intraclass correlation coefficients with 3-week interval administrations. The scores of intraclass correlation coefficients were interpreted conventionally as lower than 0, poor agreement; 0 to 0.20, slight agreement; 0.21 to 0.40, fair agreement; 0.41 to 0.60, moderate agreement; 0.61 to 0.80, substantial agreement; and 0.81 to 1, almost perfect agreement. 19 We measured changes using preprogram versus postprogram reports. The change was tested using nonparametric tests (Wilcoxon signed-rank test). Magnitudes of changes between preprogram and postprogram evaluations are described as mean differences, the median and range, Z statistics, P values, and effect sizes. Effect sizes, r, for each domain were calculated as the Z value divided by the square root of the number of participants in the study. 20 Effect size values of 0.2, 0.5, and 0.8 are considered small, medium, and large effects, respectively. 21 All statistical analyses were conducted using the SAS/ STAT version 9.2 statistical software (SAS Inc, Cary, North Carolina) except for the Z statistic of each domain. Z statistics were obtained using SPSS version 15.0 statistical software (SPSS Inc, Chicago, IL) to calculate effect sizes. Tests were two tailed, and statistical significance was set at less than.05. RESULTS Respondents The response rate for the mailed questionnaires (items to gather demographic background and ELNEQ) was 99% (n = 142), and the response rate for the completion of the ELNEQ prior to and following the program was 99% (n = 141). Table 1 shows participants demographic and professional characteristics. Women nurses were 99% of the participants, and more than two-thirds of them were CNSs or nurses certified by the JNA. Psychometric Results Missing values that were less than 1.5% and the ceiling effect were not confirmed. The results of factor analysis are shown in Table 2, and these results were identical to the development phase. Eight experts in palliative care TABLE 1 Demographics in Palliative Care Education of Participants in the End-of-Life Nursing Education Consortium Japan Faculty Development Programs, Tokyo, July and November 2009 (N = 143) Characteristic Gender, %women 99 Job title, % Certified nurse specialist 5.0 Certified nurse 65.0 Nurse manager 15.0 Clinical nurse educator 15.9 Faculty, school of nursing 12.9 Years in practice, mean [SD] (range) 16.0 [7.6] (3-32) Years in teaching palliative care, mean [SD] (range) 6.5 [3.3] (3-32) Journal of Hospice & Palliative Nursing 371

5 TABLE 2 Factor Analysis of the End-of-Life (EOL) Nursing Education Questionnaire (n = 143) a Domain and Item Confidence in teaching Factor Loading I am satisfied with my ability to teach EOL care j0.02 j I have sufficient ability to teach EOL care j j0.01 It is not difficult for me to teach EOL care j I have no trouble teaching EOL care j Motivation for teaching I am motivated to teach EOL care. j I want to be actively involved in teaching EOL care. j j0.02 j0.08 I want to spend more time teaching EOL care on patients final hours j I want to spend more time teaching nurses roles in EOL care. j j Preparation to provide teaching I am prepared to run group discussions in teaching EOL care. j0.06 j j I am prepared to run case studies in teaching EOL care. j I am prepared to run role-play sessions in teaching EOL care I am prepared to give effective lectures on EOL care Preparation to lead initiatives in EOL care I am prepared to contribute to improve the quality of EOL care in my home institution or region. I know how to improve the quality of EOL care in my home institution or region. I am prepared to make plans to improve the quality of EOL care in my home institution or region. I have plans to improve the quality of EOL care in my home institution or region. j0.09 j j j j j j0.14 Expected influences on participants Participants of my educational programs will improve quality of their EOL care. Participants of my educational programs will improve their ability of managing symptoms of patients with terminal illness. Participants of my educational programs will improve quality of their care for imminently dying. Participants of my educational programs will become more aware of their roles as patients advocates. j0.01 j0.05 j j j a Items in boldface indicate the factor loadings for each domain Volume 13 & Number 6 & November/December 2011

6 nursing and medicine reviewed the questionnaire for content and face validity. All experts felt that all items represented a realistic expectation of the ELNECVJapan Faculty Development Program. The initial item pool was reduced by considering the redundancy of the questionnaire and eliminating items with factor loadings that were less than 0.6. The resulting 20 items constituted the ELNEQ, which was thought to have five domains: (1) confidence in teaching, (2) motivation for teaching, (3) preparation to provide teaching, (4) preparation to lead initiatives in EOL care, and (5) expected influences on participants. Reliability Table 3 summarizes the reliability of the ELNEQ. Cronbach s! to test internal consistency ranged from.84 to.97, and intraclass correlation coefficients for test-retest reliability were 0.63 to Sensitivity Responsiveness As shown in Table 4, respondents reported improvements in confidence levels, preparation to teach and lead initiatives in EOL care, and expected influences on the participants of their educational programs when compared prior to and following the program. On a 5-point scale (1 = not at all, 5 = very much), respondents average ratings of confidence in teaching increased at the end of the program and represented a medium to large effect size. Respondents felt that they were well prepared to teach EOL care by attending this program, and ratings of this item showed large effect sizes. Participants also found themselves more prepared to assume a leadership role in providing quality EOL care in their home institutions or their regions at the end of the program. The average increase in this item also showed a large effect size. Ratings of respondents expected TABLE 3 Reliability of the End-of-Life Nursing Education Questionnaire (N = 143) Domain Cronbach s! Interclass Correlation Coefficient Confidence in teaching Motivation for teaching Preparation to provide teaching Preparation to lead initiatives in EOL care Expected influences on participants influence on the participants of their educational programs also improved, representing a medium effect size. Ratings of motivation for teaching did not show significant changes, although ratings for four other domainsv confidence in teaching, preparation to provide teaching, preparation to lead initiatives in EOL care, and expected influences on participantsvshowed moderate to significant changes. Course Evaluation Participants in the ELNECVJapan Faculty Development Program also answered both closed- and open-ended questions for course evaluation immediately after the last session. Participants rated the program highly. On a 5-point scale (1= lowest rating, 5 = highest rating), the average rating of the overall evaluation has a mean (SD) of 4.1 (0.6). The average rating of usefulness for teaching has a mean (SD) of 4.2 (0.7). The average rating of clarity of presentations has a mean (SD) of 4.3 (0.7). The average rating of content quality has a mean (SD) of 4.2 (1.1). A large number of participants also spontaneously reported their experience in the program as widely adaptable to their educational opportunities and clinical practice in providing palliative care. DISCUSSION These results demonstrated that the ELNEQ has a more than satisfactory level of internal consistency, test-retest reliability, face validity, and construct validity. There are three noteworthy strengths seen in this questionnaire. Initially, it is the first instrument that allows us to evaluate effectiveness of faculty development programs for palliative nursing care. The ELNEQ has great potential to be widely used to evaluate the effectiveness of faculty development programs such as the ELNEC train-the-trainer course offered in the United States and many other countries. Second, its items were systemically developed as indicated by participants in focus groups and with statistical substantiation. Existing measures were limited to assess changes in knowledge levels and attitudes toward patient care resulting from continuing nursing educational programs. A final, unique advantage is that the instrument contains a range of expected outcomes of a faculty development program as described in sophisticated programs such as the Program in Palliative Care Education and Practice offered at Harvard Medical School. 15,16 No other questionnaire exists to evaluate the magnitude of participants changes in confidence, motivation, and preparation to teach and lead initiatives in palliative nursing care simultaneously There are, however, some limitations in validating the ELNEQ. First, the data were collected only in the ELNECV Japan Faculty Development Programs, and caution is Journal of Hospice & Palliative Nursing 373

7 TABLE 4 Self-Reported Ratings of 143 Participants, From the End-of-Life (EOL) Nursing Education Questionnaire Completed Before and After Participating in the End-of-Life Nursing Education Consortium Japan Faculty Development Program, Tokyo, July and November 2009 a Domain Preprogram Mean (SD) Median (Range) Postprogram Mean (SD) Median (Range) Z Statistics P Value Effect Size Confidence in teaching 1.9 (0.6) 2 (1-4) 2.5 (0.8) 3 (1-5) Motivation for teaching 4.2 (0.6) 4 (3-5) 4.2 (0.6) 4 (3-5) Preparation to provide teaching Preparation to lead initiatives in EOL care Expected influences on participants 2.2 (1.0) 2 (1-5) 3.6 (0.6) 4 (2-5) (0.7) 3 (1-4) 3.5 (0.6) 4 (2-5) (0.8) 3 (1-4) 3.3 (0.6) 3 (1-5) a From the End-of-Life Nursing Education Questionnaire, participants were asked to rate various responses to the following statement: For each of the following, please indicate how much you agree on EOL nursing education. The mean ratings shown in the table were means of the responses to each item rated on a 5-point scale (1 = not at all, 2 = a little bit, 3 = somewhat, 4 = quite a bit, 5 = very much). needed in extrapolating these results to evaluate other faculty development programs. This potential bias could be minimized by testing in other faculty development programs to cross-validate the stability of its psychometric properties as well as its feasibility in different settings. Second, a follow-up study is needed to consolidate the scale and its dimensions because the data were collected in a short period immediately prior to the first session and after the last session of the program. Also, the sample size was limited to a sampling of all participants attending the ELNECVJapan Faculty Development Program at the time of the study. Third, this questionnaire was originally developed in Japanese, and further validation processes are needed when using it in other languages. Finally, although face, content, and construct validity were assessed in this study, the lack of a valid gold standard makes it impossible to test criterion validity. Despite these limitations, the results and literature support the authors presumption that the ELNEQ can contribute to evaluate the effectiveness of faculty development programs in EOL care. 15,16 This evaluation of the ELNECVJapan Faculty Development Program demonstrates positive changes in selfrated confidence in teaching, preparing to teach, and leading initiatives in EOL care. Participants evaluated theprogramhighlyandalsoreportedincreasesinthe length and frequency of their educational sessions related to palliative care after completing the program. They also reported using new teaching strategies in their teaching practice, including practical work, case studies, and role plays. These will be reported at a later time. Participants immediate changes indicate that they were well prepared and equipped with the tools and knowledge in EOL education. To date, we have 349 participants who have become ELNEC Japan trainers by completing the program throughout the country. They returned to their institutions or regions to train other nurses and members of interdisciplinary teams. We did not observe any significant change in motivation for teaching. This is considered to be due in large part to the participants representing a highly motivated group of faculty with willingness to devote efforts to conduct educational services or programs in their home institutions or regions. The large magnitude of reported changes and the positive ratings of the course evaluation suggest that the ELNECVJapan Faculty Development Program successfully met its objectives in facilitating significant change in multiple dimensions in nursing faculty development programs in palliative nursing. We evaluated this program by measuring only short-term outcomes with the ELNEQ in this study, but this is merely the first step toward evaluating the program. We are now in the process of developing an instrument to measure knowledge about EOL care for nurses who participated in the educational programs by the ELNEC Japan trainers who participated in the ELNECVJapan Faculty Development Program and also collecting data on long-term effects to determine if observed early changes are sustained over time. We are very interested in the change a program of this kind has on participants patient care practices, but it is impossible to assess this aspect of their experience. Although further Volume 13 & Number 6 & November/December 2011

8 assessment is needed to understand fully the impact of this program, based on the results and evidence from this program and other studies, 15,16,22 the authors recommend this model of faculty development program to facilitate nursing educators to build confidence in teaching and be prepared to teach and lead initiatives regarding quality palliative care. The authors believe the efforts on this project will improve palliative nursing care at the bedside and achieve a sense of peace in patients and families with terminal illness. Acknowledgments This project was made possible by grant H19_Cancer Clinical_ General_002 from the Health and Labour Sciences Research Grant for Clinical Cancer Research. 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