Purpose: The purpose of this presentation is to share the quantitative findings from a multi-method study with rural and urban nurses regarding comfort with palliative and EOL care communication. Our specific aim was to assess rural and urban nurse comfort with palliative and EOL care communication using the Comfort with Communication in Palliative and End of Life Care (C-COPE) instrument.
Methods: This multi-method study was guided by the COMFORT Communication Model (Wittenberg-Lyles, Goldsmith, Ferrell, & Ragan, 2013). The C-COPE instrument, developed by the authors, is a 28-item, 5-point, Likert style survey. The C-COPE included demographic data and allowed nurses to rate comfort with palliative and EOL communication via an online method using QuestionPro. The instrument development included content validity by 3 experts and psychometric analysis. The C-COPE was reliable and stable via test-retest, internal consistency (Cronbach’s alpha = 0.91), and intraclass correlation coefficient measurements (>0.77). Our sample comprised registered nurses representing four rural and two urban settings within one major health system. Data analysis included descriptive and inferential statistics.
Results: Descriptive analysis of the sample (N = 271) identified statistically significant results in age and tenure as a registered nurse, with rural nurses being older and having a longer tenure when compared to their counterparts. While all the participants reported overall being comfortable with most of the communication items of the C-COPE, urban nurses reported less comfort than rural nurses in four items: talking with patients once they have received “difficult news” (73.7% vs 63.1%, p=0. 05), talking with patients about spiritual and/or religious concerns (89.5% vs 81.2%, p=0.04), talking with patients about “EOL decisions” (86% vs 68.2%, p=0. 01), and talking with family about “EOL decisions” (87.7% vs 64.2%, p=0. 00).
The two ranked items on the C-COPE were specific to patient and family communication on topics of initial diagnosis, treatment options, remission, recurrence of disease, EOL care, and palliative care. Rural and urban nurses ranked similarly in identifying more discomfort in communication with patients and families for the topics of EOL care, palliative care, recurrence of disease, and initial diagnosis.
Discussion: Overall, summative scores as well as the itemized analysis of the pilot test of the C-COPE suggest a higher level of comfort among rural nurses as compared with urban nurses regarding communication in palliative and EOL care. The statistically significant differences in the specific communication topics of “difficult news,” spiritual and/or religious concerns, and EOL decision-making indicates the need to address further the possible root causes for this discrepancy. Sprinkled throughout healthcare research are protocols and guidelines which address timing, setting, and choice of words to assist professionals in the sensitive nature of communicating difficult news (Baile et.al., 2000; Malloy et.al, 2010; National Institute on Aging, 2016; Reid, 2011). Challenges remain, however, in the actual delivery. The ability and ease with which difficult news is shared with both patients and families potentially opens the door for discussing attendant EOL, spiritual, and cultural concerns. This skill is imperative regardless of setting; the discrepancy noted in our sample warrants a deeper exploration.
In contrast to the C-COPE results, findings for the five ranked topics of communication were not specific to geographic location. Of the five topics, all nurses indicated that communication with both families and patients in EOL and palliative care carried more discomfort. Furthermore, this descriptive finding holds significance given the recent American Society of Clinical Oncology guideline update regarding the early incorporation of palliative care services for patients with advanced cancer (Ferrell et al., 2016). Early initiation of services depends on the ability of nurses to be comfortable with initiating communication specific to palliative care early in the disease trajectory.
Conclusion: Recommendations emerge from our study and represent implications for nursing practice, research, and education. The C-COPE instrument should be trialed with additional nurse samples representing geographic and ethnic diversity. Further exploration is indicated regarding the key finding that rural nurses were more comfortable than urban nurses with EOL decision-making communication. Statistical differences between rural and urban nurses were found regarding the items: talking with patients regarding difficult news, spiritual and or religious concern and about EOL decisionsboth with patients and with families. However, since on average rural nurses had a longer tenure at the same facility and were older, their life and work experiences may play a role in their comfort with communication. Additionally, rural nurses may possess a stronger familiarity with their patients which allows for more ease with discussion about these difficult topics.
Practicing nurses are an integral component for care delivery and for mentoring of new graduates. The C-COPE could be used within institutional and community healthcare settings to promote palliative and EOL continuing education for all nurses and to provide a bridge from pre-licensure through licensure.