Terminally ill patients and their families face many daunting choices. That’s why nurses need to be comfortable communicating about palliative and end-of life care and guiding these individuals through the decision-making process.
Associate professor Mary Minton and assistant professor Mary Isaacson of the Department of Nursing conducted a survey of nurses working at six Avera Health facilities in eastern South Dakota. They discovered that the respondents are relatively comfortable guiding their patients through this process. However, the nurses said they learned these skills on-the-job, rather than as part of their nursing education.
Nurses are on the front lines, when it comes to having those conversations, Minton explained. “Nurses are in a position to provide a safe, nonthreatening atmosphere where patients can set goals and make decisions about their care. They spend more time with patients and are usually more involved in end-of-life care.” However, she added, “Within a health-care environment focused on finding a cure, we have to embrace the ‘letting go’ of interventions—that it’s OK to do that.”
Minton and Isaacson will use the research to help health-care professionals gain the skills necessary to be both comfortable and competent in helping patients and families make decisions about end-of-life care. The researchers hope to integrate the strategies and communication techniques the respondents described into nursing curriculum and professional workshops.
The study was conducted in collaboration with Avera Health and funded through a one-year, $15,000 grant from the Hospice and Palliative Nurses Foundation.
Evaluating nurse comfort levels
Minton and Isaacson used an assessment tool they developed called C-COPE—Comfort with Communication in Palliative and End-of-Life Care, which is also now being used by other nurse-researchers. They invited nurses at six Avera Health facilities in eastern South Dakota—four rural and two urban—to complete the online survey.
Of the 750 to 1,000 registered nurses at these facilities, 277 responded, ranking their comfort level on facets of palliative and end-of-life care communication ranging from physical symptoms to cultural and religious concerns. Overall, the respondents reported what Minton termed “a fair amount of comfort.” Individual scores ranged from 26 to 106, with a lower score associated with a higher comfort level, and an average score of 47.9.
Rural nurses, in general, were more comfortable guiding patients through palliative and end-of-life care planning than their urban counterparts. “That makes perfect sense, given the proximity in which nurses live and work in these rural areas—they are integral to that community,” said Isaacson, who worked as a nurse in a rural setting.
Techniques learned through experience
The researchers then interviewed five rural and five urban nurses who had an average of eight years experience in home health and hospice care to identify the communication strategies they use in guiding patients and their families in end-of-life decision making.
“What we found is that their techniques were constantly evolving—there was not a linear method,” Minton said. However, some key themes emerged from this qualitative portion of the study.
First, the nurses established the context by asking the patients, “What do you know about your illness—where did you start and where have you been?” Then, they listened attentively to what these patients and their families had experienced.
As these nurses educated their clients about the decisions they needed to make, they built a trusting relationship. Lastly, interwoven throughout their conversations with patients and families was honesty. Describing the situation realistically, often multiple times, was essential, Minton explained.
“The amount of dexterity these nurses have navigating these situations speaks to how at ease they are—they do not question what they do, she added. And at the end of the day, these skilled nurses’ patients and their families know that their wishes will be honored.