Nurses play a key role in planning the care for patients as they are at the bedside with the patient and are knowledgeable about a patient’s history and management. However, at times, nurses are often uncomfortable having crucial conversations with patients, thus providing training is essential to enhance communication and improving self-efficacy. These crucial conversations may involve advance care planning (ACP), discussions between patients, families and healthcare providers focusing on goals of care and options prior to the late states of illness and diminishing cognitive capacity. Advance care planning includes discussions about serious illnesses, poor prognosis of diseases, answering difficult questions around advance directives, treatment choices, and care. Because providers give prognoses to patients, the current focus of ACP training has been on providers such as physicians and advanced practice registered nurses. However, these conversations happen multiple time with many members of an interdisciplinary healthcare team, including the bedside nurse. Nurses spend a considerable amount of time with patients and families at the bedside and often know the most about them.
The purpose of this study is to examine the nurse’s role in communicating with families in hospice and palliative care. It is hypothesized that nurses play a role in advance care planning with the communication they perform with patients under care. Our long-term goal is show that nurses play a role in advance care planning; currently it is a function that is emphasized as a provider role. With nurses being involved in advance care planning, the need for education and training for nurses is necessary to build skills, competence and self-efficacy. This will ensure that nurses are comfortable initiating and continuing conversations with patients and families, thus bringing patients to the right level of care at the right time and mitigate crisis situations where last minute choices were not discussed with patients and families about decisions with their health in a serious illness. The aim of the survey is to measure nurses’ comfort in communicating with palliative and hospice patients about their care needs.
Methods: This descriptive cross-sectional study used a nationwide online survey that was conducted through the United States Hospice and Palliative Nurses Association (HPNA) membership between May 2018-June 2018. The survey measured nurses’ comfort in communicating with palliative and hospice patients about their care needs. We modified the Nurses’ Activities in Communicating with Families Questionnaire with permission from Curtis, J.R. & Engelberg, R.A. at the University of Washington School of Medicine End-of-Life Care Research Program. Items were reviewed with the department chair and the department statistician for relevance and significance to the study. Upon IRB approval, the online survey was administered electronically using Qualtrics. After the initial email on April 29, 2018, one additional email reminder was sent seven days later. The survey was also posted on the HPNA website. Respondents were asked to rate the perceived competency comfort in palliative and hospice care with 18 items using a 5-point Likert scale. Once the survey was closed, the data was exported from Qualtrics to SPSS version 25. Total scores ranged from 0 to 90 with higher scores indicating higher levels of comfort in palliative and hospice care or higher competency. Survey data were analyzed using SPSS. Descriptive statistics were used to summarize the survey responses. Analysis of variance was used to compare summary scores and demographics. Spearman correlation coefficients were computed for more specific measures such as years of experience.
Results: One hundred fifty-one nurses from the United States participated in this survey. Most nurses were female (94.7%) and were Caucasian (90.4%). Other characteristics included: 61% had their Master’s or Bachelor’s in Nursing; 13.8% were ages 35-44 years, 29.6% ages 45-54 years, 43.4% were 55-64 years; 30.9% lived in the Northeast; and 66% worked in homecare or acute care. As years of experience increased, mean scores increased between 3 months to 5 years but then plateaued thereafter (3mths-1yr=72.0, 1-5yr=79.1, 6-10yr=83.0, 11-15yr=83.3, 16-20yr=80.4, 20+ years=82.1; p-value-0.014) Also, scores did not reach the maximum level of 90. Nurses in the group of 11-15 years of experience reached the highest mean score of 83.3.
Conclusions and Implications: Comfort by nurses in caring for patients in palliative and hospice care requires at least five years of experience. Even after five years, opportunity exists to increase comfort levels. To provide nurses with adequate experience in hospice and palliative care, and advance care planning, education and training should be integrated at the undergraduate level and incorporated into orientation at the clinical level. In addition, hospice and palliative education can be built into clinical competencies to allow nurses to practice their skills and build comfort levels in caring for patients.