Palliative Care Scale Research Articles

Implementation of an educational intervention pilot for residents on acute care general internal medicine wards around the ‘comfort measures strategy’ for end of life care

Purpose This multi-component educational intervention was aimed at General Internal Medicine residents’ perceived self-efficacy in providing end of life care. This study also measured the uptake of the Comfort Measures Order Set. Methods This non-randomized study was conducted over nine 4-week rotations on one General Internal Medicine ward. The intervention consisted of: 1) a didactic module, 2) presence of the Palliative Care Consult Team at General Internal Medicine rounds and, 3) provision of end of life care educational materials. Twenty learners completed a pre/post Self-Efficacy in Palliative Care Scale. Data/Results Data revealed improved self-efficacy ratings on the overall scale, and on all three subscales of the Self-Efficacy in Palliative Care Scale. The Comfort Measures Order Set was implemented in 62% of patient deaths in the intervention group, and 51% of patient deaths in the control group, demonstrating no statistical difference between these groups. Conclusion The uptake of the order set in both the intervention and control groups demonstrated utility in providing a clinical framework for delivering end of life care and highlighted the need for on-going education and enhancement of clinicians' self-efficacy in end of life care.

Cardiologist and Hospitalist Decision-Making in Palliative Care Referral for Hospitalized Patients with Heart Failure: A Multi-Institutional Survey (GP700)

•Identify several subjective and system-level factors that are influential in hospitalist and cardiologist decision-making regarding the timing and appropriateness of palliative care referral in hospitalized advanced heart failure patients.•Recognize the low uptake of guidelines among hospitalists and cardiologists regarding palliative care delivery to heart failure patients and be able to name opportunities to improve awareness of these guidelines. Despite frequent hospitalizations, end-stage heart failure patients rarely receive palliative care during admissions. To evaluate factors influencing provider decisions about palliative care referral in hospitalized heart failure patients. We conducted a multi-institutional, randomized, vignette-based survey of cardiologists and hospitalists. Participants reported their likelihood of referring a standardized patient with an acute heart failure exacerbation with multiple prior hospital admissions and acute renal failure to palliative care (scale of 0-100%) after the initial stem and again after being cued with three randomized vignette modifiers, including (a) presence versus absence of continuity with an outpatient cardiologist; (b) presence versus absence of documented advance care planning in the medical record; and (c) the patient voicing that he is accepting of his severe illness versus wanting everything done. Adjusted generalized linear models and predictive margins were used to evaluate the impact of each randomized modifier on likelihood of palliative care referral. Response rate was 28.2% (n=188). The mean likelihood of referring the heart failure patient described in the initial vignette to palliative care was similar for cardiologists and hospitalists (59.2% versus 58.5%, P=0.56). Predictive margins from generalized linear models demonstrated (a) lack of continuity with an outpatient cardiologist; (b) documentation of advance care planning in the chart; and (c) patient acceptance of serious illness were associated with higher likelihood of palliative care referral. No interaction effect was noted based on provider specialty. The majority of hospitalists and cardiologists were unaware of palliative care guidelines for patients with heart failure (74.3% versus 70.3%, P=0.71). Factors like patient understanding of disease, provider continuity, and advance care planning documentation may be more impactful in palliative care referral for hospitalized heart failure patients than objective clinical data alone.

Cultural Adaptation, Validation, and Analysis of the Self-Efficacy in Palliative Care Scale for Use with Spanish Nurses.

The aim of the present study is to validate the Self-Efficacy in Palliative Care Scale (SEPC) in Spanish nursing professionals and students, to describe their levels of self-efficacy, and to determine the influencing factors. A validation study and a cross-sectional descriptive study were carried out, with the data analysed using contrast tests and multiple linear regression; 552 nurses and 440 nursing students participated. The Spanish version consists of 23 items and has a high degree of reliability (α = 0.944). Confirmatory factor analysis revealed one additional factor (i.e., management of psychosocial and spiritual aspects) in comparison to the original scale. Contrast tests revealed that the mean SEPC score was higher in professionals than in students (p < 0.001) and that the professionals who had higher levels of self-efficacy were older (p < 0.001), had more previous training (p < 0.001), and had more experience in end-of-life care (p = 0.001). The linear analysis results confirm a significant association between age and previous training in end-of-life care. The Spanish version of the SEPC is a reliable tool for both nursing professionals and students. The level of self-efficacy of both groups is moderate and is influenced by age, experience, and training in end-of-life care.

The developing and evaluation of an electronic tool to assess the effect of undergraduate training in palliative care: the electronic international medical education in palliative care (IMEP-e) assessment tool

BackgroundWith increased demand for palliative care (PC), the World Health Organisation (WHO) have called for PC teaching to be made routine. However, medical students report feeling unprepared in dealing with end-of-life care. Necessary benchmarking of the preparedness of clinicians to provide PC is required to identify where current training is sub-optimal and ensure future doctors are equipped to meet the needs of their patients. The aim of this study is to assess the utility of an electronic International Medical Education in Palliative Care (IMEP-e) assessment tool that examines the preparedness of clinicians to provide PC.MethodsA multi-phase pilot study.Phase 1: To transpose the Self-Efficacy Palliative Care Scale (SEPCs) and the Thanatophobia Scale (TS) to an electronic format and evaluate its utility.Phase 2: To assess the effects of PC teaching by comparing data from year three (Y3) and year five (Y5 - who have participated in PC placement) medical students.Scales: The 23 item SEPC and 7 item TS assess attitudes towards caring for dying patients.ResultsTotal questionnaires sent =360 (280 Y3, 80 Y5). Total response rate = 46.39%, n = 167 (127 Y3, 40 Y5). Completed data: n = 125 (95 Y3, 30 Y5). Analysis identified statistically significant differences (p < 0.001) between year groups across all subscales of the SEPC; communication skills (t = − 13.52), Pain and Treatment management (t = − 14.25) and multidisciplinary management (t = − 7.89). The TS shows a statistically significant increased positive attitudes (z = − 2.85 p < 0.005). From the focus group, three themes were identified from the qualitative feedback including university based teaching, hospice based teaching and utility of IMEP-e tool.ConclusionThe IMEP-e tool is a viable and comparable method for collecting data on the preparedness to practice PC. A larger scale study is needed to determine and evaluate if, and how, preparing clinicians to work in PC has been adapted in to routine training.

Self-Efficacy of internship nursing students in dealing with Palliative patients

Palliative care is one of the practice areas that is perceived difficult by nurses and nursing students. S tudents tend to avoid seeing patien t s with the deteriorating condition. This research aimed to identify the self-efficacy of internship nursing students in facing palliative patients within communication, management of the patient, and multidisciplinary teamwork components. This study was a descriptive quantitative. Samples were recruited from a population of internship nursing students at Faculty of Nursing Universitas Padjadjaran using a total sampling technique (n=159). Data were collected using Self-Efficacy Palliative Care scale (SEPC). Data were analyzed using mean scores calculated from the total scores of each respondent . The results showed that more than half of the respondents had a low level of self-efficacy. In terms of its component s , students’ self-efficacy in communication , multidisciplinary team collaboration , and patient management had a mean score of 38.24 (SD 10.35), 39.21 (SD 9.44), and 48.18 (SD 9.56) respectively . Based on the results, it is recommended to develop an active learning strategy for internship nursing students, especially in the aspects of communication, patient management, and multidisciplinary team collaboration.

Palliative Care Nursing Competence of Chinese Oncology Nurses and Its Related Factors

In China, the development of palliative care is challenging because of limited available resources and rapidly increasing demands. The nurses' competence is a significant element in providing high-quality palliative care. This cross-sectional study aimed to describe the palliative care competence among oncology nurses and to examine the relationships between it and palliative care knowledge, attitudes, and workplace learning conditions. A total of 220 nurses with more than 6 months of experience and who worked in inpatient wards were invited to participate in this study. Four questionnaires were administered to collect data-the Palliative Care Quiz for Nurses, the Attitudes Toward Palliative Care Scale, the Workplace Learning Conditions scale, and the Palliative Care Nursing Self-competence Scale. The data were analyzed using descriptive statistics and Pearson correlations. The moderate level of competence was reported by 212 participants (response rate, 96.36%). The scores were lower in the aspects of competence such as spiritual care and ethical and legal issues. Competence was positively related to workplace learning conditions and knowledge but not attitudes. The results highlighted the necessity of improving the palliative care competence among oncology nurses. The optimization of learning conditions in the hospital is recommended to be a vital force in strengthening competence.

Reliability and Validity of the Turkish Version of the FACIT-PAL Quality of Life Instrument

ContextThe accurate measurement of quality of life (QoL) among people with chronic and incurable illnesses is essential for evaluating service delivery, understanding the impact of illness and treatment effects, and testing intervention effectiveness. Palliative care interventions are relatively new in Turkey; therefore, it is important that reliable and valid QoL instruments are available to evaluate palliative care effectiveness in Turkish speakers. ObjectivesThe purpose of this study was to translate, linguistically validate, and determine the psychometric properties of the newly translated Functional Assessment of Chronic Illness Therapy–Palliative Care (FACIT-Pal) scale (FACIT-Pal-TR) for Turkish-speaking cancer patients. MethodsWe used standard multilingual translation and validation methods for the initial translation of the FACIT-Pal-TR and then assessed the psychometric properties of reliability and validity of the translated scale. We used the Karnofsky Performance Scale and Edmonton Symptom Assessment Scale to assess concurrent and construct validity. ResultsA convenience sample of 232 cancer patients participated in this study. The Cronbach's alpha coefficient of FACIT-Pal-TR was 0.932 (between 0.732 and 0.860 for subscales). There was a statistically significant relationship between test and retest scores (r = 0.877, P < 0.001). The factor loadings of FACIT-Pal-TR were between 0.205 and 0.815. FACIT-Pal-TR construct validity was acceptable with 45 items and five subscales. There were statistically significant relationships between FACIT-Pal-TR scores and Edmonton Symptom Assessment Scale (P < 0.001) and Karnofsky Performance Scale (r = 0.656; P < 0.001) scores. ConclusionsThe FACIT-Pal-TR demonstrates strong reliability and validity for evaluating palliative care–specific QoL in Turkish cancer patients.

Confidence in palliative care issues by medical students and internal medicine residents

BackgroundPalliative care (PC) is a relatively new field in Brazil, but this knowledge is of great importance in medical practice.ObjectiveTo evaluate the degree of confidence among medical students and first-year...

Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial

BackgroundAdvanced heart failure (HF) is characterized by high morbidity and mortality. Conventional therapy may not sufficiently reduce patient suffering and maximize quality of life. ObjectivesThe authors investigated whether an interdisciplinary palliative care intervention in addition to evidence-based HF care improves certain outcomes. MethodsThe authors randomized 150 patients with advanced HF between August 15, 2012, and June 25, 2015, to usual care (UC) (n = 75) or UC plus a palliative care intervention (UC + PAL) (n = 75) at a single center. Primary endpoints were 2 quality-of-life measurements, the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary and the Functional Assessment of Chronic Illness Therapy–Palliative Care scale (FACIT–Pal), assessed at 6 months. Secondary endpoints included assessments of depression and anxiety (measured via the Hospital Anxiety and Depression Scale [HADS]), spiritual well-being (measured via the FACIT–Spiritual Well-Being scale [FACIT–Sp]), hospitalizations, and mortality. ResultsPatients randomized to UC + PAL versus UC alone had clinically significant incremental improvement in KCCQ and FACIT–Pal scores from randomization to 6 months (KCCQ difference = 9.49 points, 95% confidence interval [CI]: 0.94 to 18.05, p = 0.030; FACIT–Pal difference = 11.77 points, 95% CI: 0.84 to 22.71, p = 0.035). Depression improved in UC + PAL patients (HADS-depression difference = −1.94 points; p = 0.020) versus UC-alone patients, with similar findings for anxiety (HADS-anxiety difference = −1.83 points; p = 0.048). Spiritual well-being was improved in UC + PAL versus UC-alone patients (FACIT–Sp difference = 3.98 points; p = 0.027). Randomization to UC + PAL did not affect rehospitalization or mortality. ConclusionsAn interdisciplinary palliative care intervention in advanced HF patients showed consistently greater benefits in quality of life, anxiety, depression, and spiritual well-being compared with UC alone. (Palliative Care in Heart Failure [PAL-HF]; NCT01589601)

암환자를 위한 통합적 완화 돌봄 측정도구 개발 및 평가

Purpose This study was done to develop and to evaluate an integrative palliative care scale for cancer patients. Methods The process included construction of a conceptual framework, generation of initial items, verification of content validity, selection of secondary items, preliminary study, and extraction of final items. The participants were 173 cancer patients in Daegu and Gyeongbuk. Item analysis, factor analysis, criterion related validity, and internal consistency were used to analyze the data. Results Eighteen items were selected for the final scale, and categorized into 3 factors explaining 58.3% of total variance. The factors were labeled as social/environmental palliative care (9 items), psychological palliative care (4 items), and physical palliative care (3 items), and spiritually palliative care (2 items). The scores for the scale were significantly correlated with the quality of life of cancer patients. Cronbach’s alpha coefficient for the 18 items was .88. Conclusion The above findings indicate that the integrative palliative care scale has good validity and reliability when used for cancer patients. Keywords: Patients, Palliative care 주요어: 환자, 완화 돌봄

Validación de dos herramientas para la evaluación de cambios en las actitudes de alumnos en situaciones frecuentes en cuidado paliativo

Objective: To determine the psychometric properties of two scales designed to examine attitudes regarding palliative care: Comfort Scale in Palliative Care (CSPC, Pereira et al.) and Tanatophobia Scale (TS, Merrill et al.) Method: Seventy-seven students who completed an online course on psychosocial aspects of palliative care offered by the Latin American Association of Palliative Care participated in the study. They also completed the scales before and after the course. Construct validity and reliability of the CSPC and the TS were assessed using a Principal Components Analysis, internal reliability coefficient and test-retest reliability. Further, comparative statistics between the pre-course and post-course results were obtained in order to determine changes in attitudes. Results: The Principal Components Analysis showed satisfactory fit to the data. 3 components were extracted: two for the CSPC and one for the TS, which explained 55.37% of the variance. Internal consistency coefficients were satisfactory in all cases and Cronbach´s Alphas were satisfactory for all the scales, particularly for the CSPC. Test-retest reliability in t1 and t2 was found to be non significant, indicating that measures were not related in time. Regarding pre-course/post-course comparisons, significant changes in comfort assisting patients (p = 0.004) and comfort assisting families (p = 0.001) following the course were identified, but changes in thanatophobia were non significant (p > 0.05). Conclusions: both scales are valid and reliable. Attitudes regarding the practice of palliative care and how they change, particularly regarding psychosocial issues, can be accurately measured using the examined scales.

Palliative care education in Zagreb – an assessment of the effectiveness of an undergraduate course

Palliative care in Croatia is insufficiently developed. Although the Croatian Society for Hospice and Palliative Care was formed by Professor Anica Jusic in 1989 (1) there have been limited and local developments of services – within certain cities and towns, usually as a result of local enthusiastic doctors or other professionals (2). However there has been growing awareness of the need for education of medical and nursing students and when the English Course for Medical Students was started in Zagreb in 2003 it was agreed that there would be an optional course in palliative care. Dr David Oliver was elected as Visiting Professor and has been leading the course for five years. He is a Consultant in Palliative Medicine at the Wisdom Hospice in Rochester and holds an honorary post as Reader (Associate Professor) at the University of Kent in the UK. Over the years the course has continued to develop and has included more local Croatian teachers. The course comprises sessions on the principles of palliative care, the basic principles of pain and symptom management, psychosocial care, communication, family care, and bereavement. It is held over three days and there is a short examination at the end. The aim has been to have an interactive approach, using audio-visual presentations and case discussions, as well as more didactic lectures. It is held at the end of the third year, when students have only just started to experience patient involvement. Every year the course has been evaluated and the students have been asked to complete a short questionnaire on their understanding and attitudes to end-of-life care, based on the previous Self-efficacy in Palliative Care Scale and parts of the Thanatophobia Scale (3). In 2012, all sessions were evaluated at better than 4 on a 0 to 5 point scale and the overall usefulness of the course was evaluated at 4.4 out of 5. Results from 2008- 2012 showed evidence of increasing confidence in all areas – talking about dying, discussing cancer, assessing symptoms, discussing psychological issues, and working as part of a multidisciplinary team – with improved scores (Table 1). There also seems to be a movement to feeling less uneasy when coping with dying patients but little change is observed in discussing dying and death, which again may be related to their limited patient exposure. Table 1 Results of questionnaire on attitudes and feelings These results would support the effectiveness of education in palliative care, and it would seem that, even at this early stage in their training, students can gain more confidence and change their attitudes to dying patients. Within Zagreb this has led to the development of the Centre for Palliative Medicine, Medical Ethics and Communication Skills (4) and communication skills are now to be taught within every year of the curriculum. Palliative care is an essential part of the care that is offered to patients and their families and we hope that this small contribution will encourage other medical and nursing schools to introduce similar courses. Within the English Course in Zagreb it is hoped that the education can be extended to all students within the Medical Faculty and both at this early stage and later in the curriculum, when they will have gained more confidence in the care of patients and their families.

The impact of a medical undergraduate student-selected module in palliative care

BackgroundThe need for undergraduate medical education in palliative care is widely recognised. An optional student-selected module ‘Fundamentals of Palliative Medicine’ was introduced in 2011 and offered to third-year medical students....

Patients' reports or clinicians' assessments: which are better for prognosticating?

BackgroundThe Prognosis in Palliative care Scale (PiPS) predicts survival in advanced cancer patients more accurately than a doctor's or a nurse's estimate. PiPS scores are derived using observer ratings of...

Transdermal Buprenorphine for the Treatment of Cancer Pain: Results from a Multicenter, Observational, Post-Marketing Study in Spain (RELIEF Study)

SUMMARY This study evaluated health outcomes in patients with cancer pain during treatment with transdermal buprenorphine, including quality of life, effectiveness, tolerability, and functional consequences for patients and their carers. In this 3-month, noncomparative, multicenter, observational study performed in a normal clinical practice setting in Spain, patients received transdermal buprenorphine 37, 52.5 or 70 µg/h, with patches changed every 96 h. The effect of transdermal buprenorphine on quality of life (primary study focus) was assessed using the Visual Analog Scale (VAS) component of the EuroQol 5 Dimensions™ (EQ-5D). In addition, pain (assessed using the Brief Pain Inventory - Short Form [BPI-SF] and VAS-pain), the impact of pain on patients and carers (assessed using the Beck Depression Inventory, sleep quality analysis, VAS-patient limitation, VAS-carer limitation and the Palliative Care Scale), patient's use of health resources, patient satisfaction, and tolerability, were evaluated. Of 116 patients entering the study, 42 completed the 3-month study period. Five patients withdrew due to adverse events. The two main reasons for study discontinuation were nontreatment-related death (27.1%) and lost to follow-up (18.8%). The mean age was 62.9 years and the mean baseline duration of pain was 7.78 weeks. In the month prior to starting transdermal buprenorphine, 80% of patients had received at least one nonopioid analgesic medication; 21% had received an opioid analgesic (most commonly tramadol). The most common dose of transdermal buprenorphine used was 35 µg/h. The mean improvement from baseline in the EQ-5D VAS score among 65 patients with data was 15.20 ± 24.96 (p < 0.0001). EQ-5D descriptive parameters also improved during the study (not statistically significant). Mean improvements in BPI scores for worst pain (3.76) and average pain (3.03) were significant (p < 0.0001). The other measures of pain relief also supported transdermal buprenorphine as an effective analgesic. Sleep quality improved during the study. VAS scores (100 mm scale) for patient limitation and caregiver burden due to pain improved, with a significant mean change in VAS-carer limitation score (30.34; p < 0.0001). Adverse events were reported by ten (8.6%) patients, most commonly affecting the gastrointestinal system (vomiting [4.3% of patients], nausea [2.6%] and constipation [0.9%]). The majority of patients reported satisfaction with their analgesic treatment. In this observational study in normal clinical practice, transdermal buprenorphine provided effective pain relief and was generally well tolerated by patients with cancer pain. It also improved quality of life for patients and reduced caregiver burden. Considering the high number of study discontinuations (mainly due to nontreatment-related death and lost to follow-up), the results of this study need to be evaluated with caution.

Preparing for palliative medicine; evaluation of an education programme for fourth year medical undergraduates

Prompted by directives from the GMC, ‘care of the dying’ is identified as ‘core curricula’ for undergraduate medical education. However, there are many technical and interpersonal challenges faced in learning the practice of palliative medicine. Accordingly, the design and delivery of education programmes need to be both carefully considered and evaluated. Using Bandura’s Social Cognitive Theory as a driver, appropriate methodology for evaluating a novel education programme in palliative medicine was drafted. A pre- and post-survey of an education programme and palliative care placement for fourth year medical undergraduate students from Liverpool University (n = 216) was completed using a composite questionnaire containing; i) Self-efficacy in Palliative Care Scale (SEPC) and ii) Thanatophobia Scale. Both scales have shown reliability and validity within the sample population. Additionally, a randomly selected Focus Group was conducted to provide qualitative information on the students’ experience. A total of 139 pre- and post-questionnaires (64%) were completed. Analysis identified significant improvements in perceived efficacy (SEPC Communication t = −16.41, P < 0.001; SEPC Patient Management t = −22.31, P < 0.001; SEPC Multidisciplinary Teamwork t = −15.56, P < 0.001). Significant improvements in thanatophobia were also recorded (z = −7.51, P < 0.001) although some interesting anomalies were noted. This study demonstrates that considered and appropriately structured clinical education has been shown to significantly improve students’ belief in their ability to practice palliative medicine and to improve their attitude towards care. In accordance with the study’s theoretical driver, it is reasonable to propose that the engaged active learning will have a positive effect on the future care of dying patients.

Measuring and improving palliative care in South Africa: multiprofessional clinical perspectives on development and application of appropriate outcome tools

Background: Despite innovation and expanding coverage of specialist palliative care provision in South Africa, there have been no multidimensional outcome measures to inform patient monitoring, service evaluation or quality audit. Aim: To identify South African palliative care providers' recommendations on the design, development and utilisation of multidimensional palliative care outcome measures appropriate for the epidemiology and delivery settings for advanced disease in South Africa.Methods: South African palliative care professionals participated in a review of outcome measurement and current use. Participants addressed the objectives of appraising current practice and setting priorities for the development and application of feasible, acceptable and appropriate outcome measures within the African context.Results: None of the 32 multiprofessional palliative care participants were currently using a multidimensional palliative care scale. Current practice for monitoring outcomes relied on the use of unvalidated scales, longhand note taking, and use of clinicians' recall of previous health status. Recommendations for future measures included selecting items that take account of the family burden of disease, the differences between HIV and cancer patient trajectories, and the paediatric burden of advanced disease in South Africa. Adequate resources should be allocated to staff training to familiarise them with measure use, service infrastructure to be able to utilise outcome data, and ensuring acceptability and appropriateness among patients and families in terms of language, translation and identifying mechanisms to standardise data collection.Conclusions: Recommendations have been generated from the data, addressing: (i) service enablement for applied and translational research; (ii) validation within South Africa; (iii) development of tools equally applicable to HIV and cancer but separate tools for children; (iv) inclusion of family domains; and (v) support for staff to implement tools. The design of multidimensional outcome measures using this guidance is timely to evaluate and inform current practice, and to guide future funding and service development.

Assessing undergraduate palliative care education: validity and reliability of two scales examining perceived efficacy and outcome expectancies in palliative care.

Medical students have traditionally received little education in palliative care. However, in 1999, as part of a revised medical curriculum, Year 4 undergraduates at Liverpool University participated in a 2-week programme of education in palliative care. To assess the effect of the education programme, 2 assessment scales were identified: the Self-efficacy in Palliative Care Scale (SEPC) (assessing efficacy in communication, patient management and multiprofessional teamworking) and the Thanatophobia Scale (assessing attitudes towards palliative care). The aim of this study was to examine the psychometric properties of these scales. The scales were examined by 5 palliative care doctors for content validity and appropriate wording. Following this, the SEPC and Thanatophobia Scales were completed by the undergraduates (n = 139) prior to and after completion of the education programme. Both scales were analysed independently on pre- and post-test scores. Cronbach's alphas of 0.84-0.85 and 0.92-0.95 were recorded, respectively, indicating high reliability. Varimax rotated principal components analysis of the SEPC Scale suggested 3 distinct factors, as theoretically expected, with high factor loadings of 0.45-0.89 at pre- and post-test. Principal components analysis of the Thanatophobia Scale suggested only 1 factor underlies the scale, as theoretically expected. All 7 items had high factor loadings of 0.60-0.81 at pre- and post-test. The results suggest that the SEPC and Thanatophobia Scales are valid and reliable assessment scales that may be of use when evaluating the impact of an education programme.