Palliative care nursing mainly revolves around enhancing the quality of life of seriously ill patients and their families during life-sustaining treatment and at the end of life. Whether or not they have been trained in palliative care, critical care nurses frequently have patients who are in need of such care. How prepared do they feel?
DailyNurse: What are some examples of palliative care nursing practices a critical care nurse might perform?
Alexander Wolf: Critical care nurses are regularly tasked with assessing and managing the distressing physical, psychological, and spiritual symptoms of critical illness. Those of us who are palliative care specialists can benefit from critical care nurses’ insight into patient/family dynamics, psychosocial situation, and cultural background.
In addition, these nurses frequently have a difficult job of bearing witness to suffering, providing a therapeutic presence in difficult circumstances, and employing two-way communication skills to help determine the treatment goals of the patient and family. These nurses must also be adept in ethical and legal aspects of care, for instance. They also need to be able to help interpret patients’ advance directives and to advocate for the wishes that patients have outlined, when appropriate.
Critical care nurses are also instrumental in providing expert, compassionate end-of-life care in the intensive care unit, which may involve the careful withdrawal of life-sustaining treatments such as dialysis and mechanical ventilation. This often requires thoughtful preparation and culturally sensitive communication with patients and family members, and skilled symptom management throughout the dying process.
DN: What is the phenomenon of “moral distress” that affects many palliative care providers?
AW: Nurses and other providers frequently report episodes of moral distress, in which an individual identifies the morally correct action to take, but feels unable to take it due to some type of constraint. Helplessness or frustration are just a few of the many emotions that an individual might feel as a result — others might include outrage or guilt, among others.
“Critical care nurses tend to experience frequent and intense moral distress in situations pertaining to the end of life, such as providing treatment perceived as inappropriate or futile, prolongation of life or death and lying to or withholding information from patients or family members.”
Alexander Wolf, Palliative Care and Moral Distress, Critical Care Nurse, Vol. 39.5, October 2019
Previous studies have also indicated that these feelings don’t seem to entirely go away either. “Moral residue” often remains, and repeated episodes of moral distress often remind an individual of the previous episodes, causing their distress to intensify. As a result, an individual may try to protect themselves by avoiding or withdrawing emotionally from ethically challenging situations, or by quitting their job.
DN: Is palliative care training appropriate only for certain providers?
AW: Palliative care has evolved so much in recent years — it is no longer solely a subspecialty — now it is an important skill set for all healthcare providers, including nurses and physicians.
In addition, there is a continued shortage of specialists relative to the number of patients with palliative care needs. This really underscores the importance of nurses and other healthcare providers to be proficient to provide basic palliative care. In 2014, the National Academies of Medicine recommended taking measures to improve the palliative care knowledge base of all clinicians.
Numerous medical professional societies recommend timely access to palliative care, including for patients in the intensive care unit, but the lack of provider training remains a significant barrier. Our study indicates that many critical care nurses have not had much palliative care education, so we still have to work hard to better prepare nurses to meet patients’ care needs.
DN: Ideally, what changes would you like to see result from your study?
AW: There are many changes we would love to see, but here are a select few.
Bedside nurses — particularly those who have had palliative care education — need to be empowered as leaders for integrating palliative care in their practice environment. They would be in an ideal position to educate their peers and interprofessional team members. We need to better recognize nursing excellence. Physician and nurse leaders need to collaborate to ensure that bedside nurses have a voice when they feel their patients’ needs are not being met.
The critical care nurses in our study seemed to highly value palliative care, but few felt highly competent, and even fewer reported having any recent education in palliative care. Many nursing programs have done a great job in recent years to include palliative care in school curricula and in student clinical experiences, but it cannot just be “squeezed in”. There is clearly still a lot we need to do to integrate palliative care as a key competency area for nurses across specialties, particularly in critical care.
“Nearly half of respondents [in this study] rated themselves as not competent or somewhat competent in knowledge of advance directives, living wills, and do-not-resuscitate order policies. Previous studies have illuminated knowledge gaps among acute and critical care nurses in this domain…. Given the legal and ethical implications, this knowledge gap should be a key focus of palliative care education initiatives…”
Wolf, Palliative Care and Moral Distress, Critical Care Nurse, Vol. 39.5, October 2019
Additionally, the nurses in our study placed a high value on interprofessional collaboration. In continuing education for nurses it would be wise to be inclusive of other healthcare professionals. This could help foster increased recognition of patients’ palliative care needs by all team members.
For more information on Critical Care Nurse and the AACN, visit http://ccn.aacnjournals.org/.
Thanks are extended to Alexander Wolf, DNP, RN, APRN, Nurse Practitioner, Palliative Care, at TriHealth
While some nurses have an ardent passion to become
researchers, Elizabeth Johnston Taylor, PhD, RN, FAAN, a nurse researcher at
Loma Linda University Health in Southern California, admits that she kind of fell
into it. But that doesn’t mean she doesn’t love her job. In fact, it’s quite the
“I find great joy in doing research,” she says.
According to Taylor, nurse researchers will begin a
research project by looking for an answer to a problem. For example, she says, “How
can we improve the quality of life or decrease depression among people with
disease X? or “How can the health care system better provide care for those
with condition S?” S/he will identify something that needs further study. She
says that once they decide what question needs to be answered, they design a
study using scientific methods that will best answer it—whether they are
quantitative or qualitative, use a small sample or big data, are biological in
nature or psychological, etc.
“Each phenomenon you want to study obviously is going to
require its own unique approach,” explains Taylor.
Oftentimes, nurse researchers will get others to help them with data collection, and then may work with a statistician or a team to analyze the data that is collected. Once they’ve found information that may or may not completely answer the question, it’s important to write about the results to disseminate the findings. “What good is it if you don’t share it with the world and allow the world to benefit from it?” she points out.
Taylor’s program of research—which is a researcher’s area of expertise or what s/he often studies—explores patients’ spiritual responses to illness and how nurses can support or nurture spiritual well-being. “From attending some conferences and just having conversations with chaplains, I got anecdotal evidence that some chaplains believe nurses are inappropriately providing spiritual care and/or doing things with patients that they think are within their purview, but a chaplain doesn’t think it is,” explains Taylor. “I’m doing an exploratory study where I’m asking chaplains to tell me more about these kinds of phenomena.”
For nurses thinking about getting into research, Taylor says that they need to realize that this isn’t a part-time job or something you take on with only minimal interest. They will need to earn a PhD and then obtain funding to pursue a program of research. “It really takes a lot of effort,” says Taylor. “Most academics who have a successful program of research probably work anywhere from 40 to 60 hours plus a week. So it really requires a great deal of commitment as well as a great deal of curiosity and passion.”
A circumcision clinic led by nurse practitioners (NPs) had a 5-year complication rate of 4.1% as compared with 3.4% for circumcisions performed by physicians. Neither the overall rate nor any of the rates for specific types of complications differed significantly between NPs and MDs, reported Jonathan A. Gerber, MD, of Texas Children’s Hospital (TCH) in Houston, at the American Urological Association annual meeting.
The second study showed a 3-year complication rate of about 5% for circumcisions performed by a specially trained physician assistant (PA). That compared with complication rates of 4%-5% in published reviews of physician-performed circumcisions. The PA-performed circumcisions also generated substantial revenue for the urology practice, said Kaity Colon-Sanchez, PA-C, of Nemours Children’s Hospital in Orlando.
About 70%-80% of newborn male infants undergo circumcision, making it the most common urologic procedure. An ongoing shortage of pediatric urologists has created a significant imbalance between the need for circumcision and the resources to provide the service. To address the problem, TCH established an APP-led newborn circumcision clinic, said Gerber.
One previous study documented results of a service wherein NPs performed minor urologic procedures, but the procedures all occurred in an operating room. The TCH service is provided in an outpatient setting.
Pediatric urologists trained APPs to perform Gomco clamp circumcisions. The training consisted of observing 10 newborn circumcisions, assisting in 10 procedures, and then performing 10 circumcisions under direct supervision of a pediatric urologist. Thereafter, a pediatric urologist was on call for all APP-performed circumcisions. APPs were limited to performing circumcisions for infants <30 days old and weighing <10 lbs.
Investigators retrospectively reviewed records for circumcisions performed over a 5-year period, which allowed for comparison of outcomes before and after implementation of the APP-led clinic.
Gerber reported data for 314 APP-performed circumcisions and 237 performed by pediatric urologists. The analysis focused primarily on complications. The study population had a mean age of 23.8 days and mean weight of 8.6 pounds. Physicians performed circumcisions on older (28.4 vs 20.3 days, P<0.0001) and heavier (8.9 vs 8.4 lb, P<0.0063) infants and used more lidocaine per procedure (0.96 vs 0.8 mL).
Overall, 21 complications occurred, with no significant differences between the APP and physician procedures:
Total: 13 (4.1%) vs 8 (3.4%)
Revision circumcision: 1 each
30-day return to emergency department (ED): 2 vs 0
Other penile surgery: 2 vs 4
Intraprocedure bleeding: 11 vs 4
The data showed no difference in outcomes for patients <30 vs ≥30 days or weight <10 vs ≥10 lbs, the traditional age and weight cutoffs for uncomplicated circumcision.
Colon-Sanchez reported her 3-year experience performing clinic-based circumcision in a pediatric urology service. She evaluated 371 infants for neonatal circumcision. They had a mean age of 7.8 weeks (range of 1 to 13 weeks) and weighed an average of 5.2 kg (11.4 lbs) and had a weight range of 3.2-7.5 kg. Subsequently, 95 infants did not undergo circumcision, 91 because of an abnormal genital exam. Colon-Sanchez performed 272 circumcisions with the Plastibell device and four with the Gomco device.
The clinic charged $366 for families that paid for the procedures themselves, and billed $722 when procedures were covered by insurance. Colon-Sanchez noted that the 95 patients excluded from the analysis did not represent lost revenue, as the office visit was considered billable and many of the patients required additional surgery.
Records revealed a complication rate of 6.43%, consisting of retained Plastibell device in 1.80% of cases, swelling in 1.40%, adhesions in 1.10%, cosmesis issues in 0.73%, and ED visits for bleeding in 1.40%.
The results compared favorably with those from studies of circumcisions performed by physicians, said Colon-Sanchez. A study of more than 1,000 circumcisions performed by pediatricians and ob/gyns showed an acute complication rate of 3.9%, all involving bleeding. A study of 9,000 surgeries at a pediatric urology service showed that 4.7% of the procedures involved late complications of circumcisions. Additionally, 7.4% of visits to the pediatric urology outpatient clinic during a 1-year period involved concerns related to newborn circumcisions.
Matt Austin, PhD, an assistant professor in the school’s Armstrong Institute for Patient Safety and Quality, and Jordan Derk, MPH, used the latest data from Leapfrog’s semiannual hospital safety grades to estimate that there are 161,250 such deaths each year, down from the 206,000 deaths they estimated three years prior, according to their report.
Austin and Derk said they used 16 measures from Leapfrog’s 2019 data to identify deaths that could clearly be attributed to a patient safety event or closely related prevention process. The reduction is the result of two main factors, they wrote: One, hospitals have made some improvement on the performance measures included in Leapfrog’s safety grades. And, two, some of the measures “have been re-defined and rebaselined” in the past three years, they wrote.
Furthermore, these data likely represent an undercount, Austin and Derk wrote, noting that other studies have estimated anywhere from 44,000 to 440,000 deaths due to medical errors.
“The measures included in this analysis reflect a subset of all potential harms that patients may encounter in U.S. hospitals, and as such, these results likely reflect an underestimation of the avoidable deaths in U.S. hospitals,” they wrote.
“Also, we have only estimated the deaths from patient safety events and have not captured other morbidities that may be equally important,” they added.
The updated analysis was released to coincide with the latest release of Leapfrog’s controversial scores, which assessed quality data from more than 2,600 hospitals and assigned each an “A” through “F” letter grade.
Less than one-third (32%) of hospitals secured an “A” grade. More than a quarter (26%) earned a “B.” The group gave a “C” to another 36%, a “D” to 6%, and an “F” to less than 1% of hospitals.
The analysis from Austin and Derk found that the rate of avoidable deaths per 1,000 admissions was 3.24 at “A” hospitals, 4.37 at “B” hospitals, 6.08 at “C” hospitals, and 6.21 and “D” and “F” hospitals combined. That means patients admitted to a “D” or “F” hospital face nearly double the risk of those admitted to an “A” hospital, the Leapfrog group said.
In a recent Health Affairs study, Aiken and colleagues assessed safety at 535 hospitals in four large states during two time points between 2005 and 2016, and reported that the results were “disappointing.” Only 21% of the hospitals showed “sizeable improvements” in “work environment scores” while 7% saw their scores worsen, Aiken said.
Another 71% of hospitals “basically remained the same,” she said.
Aiken also reported a similar lack of improvement in patient safety measures at hospitals that showed little improvement in their work environment. In the study, about 30% of nurses graded their own hospitals “unfavorably” on measures of patient safety and infection prevention and about 31% of nurses had high scores on the Maslach Burnout Inventory.
And despite the “blame-free culture” espoused by the 1999 report, which stressed that errors are due to problems with systems not individuals, 50% of the nurses in the study by Aiken’s group reported that they believed their errors would be held against them, she said.
Aiken said the recommendation for how to fix the situation hasn’t changed since it was outlined in the 1999 report — “identify safe nurse staffing and supportive work environments as patient safety interventions.”
In another Health Affairs study, Margaret Smith, MD, of the University of Michigan Medical School in Ann Arbor, and colleagues examined the interpersonal and organizational factors that may increase the chance of “failure to rescue,” or deaths following a major surgical complication.
“We decided to take a slightly different view and look at interpersonal, organizational dynamics and their relationship with rescue,” she explained at the Tuesday panel.
Recent studies have explored targets for interventions that could improve rescue, and focused on resource-heavy solutions, such as increasing ICU staff or improving nurse-patient ratios. While important, these factors only account for a proportion of the variation seen in rescue rates among hospitals, Smith noted.
The typical course of events is an operation, followed by a seminal complication, then a domino effect of other complications, which ultimately end in a patient’s death, she added.
Smith’s group conducted 50 semi-structured interviews at five hospitals across Michigan with a range of providers (surgeons, nurses, respiratory therapists), and asked what they felt were the greatest contributors to effective rescue. The study was done from July to December 2016.
After recording and transcribing each 30-60 minute interview, Smith and colleagues identified five core elements as being part of the “successful rescue” of surgical patients:
Teamwork: working well together in moments of crisis
Action taking: responding swiftly after identifying a complication
Psychological safety: ability of all clinicians to feel comfortable expressing their concerns regardless of where they fit in the clinical hierarchy
Recognition of complications
The interviewed clinicians said they generally felt they performed well on the first three measures, but said early recognition of complications and effective communication were areas that needed improvement, Smith stated.
For example, attending surgeons said they did not think complications were spotted early enough. “When we’re talking about early recognition, people have this kind of clinical hunch [that] ‘something’s wrong’… [and] how that’s communicated is often very poor,” Smith said.
The challenge is how to communicate these “hunches” in a way that everyone understands them and ways that trigger actionable steps, she added.
In terms of communication, a senior nurse reported that when more providers cared for a single patient, it was more challenging to pass information along, or have information miscommunicated or misinterpreted.
Smith recommended that hospitals focus upstream of these potential crises by providing all clinicians, regardless of their experience, with the tools to know when a patient is deviating from a normal trajectory.
Her group also stressed the need for more effective language in communicating concerns.
“We need to ‘tool and task’ these providers with the skill-set to work on these multidisciplinary teams to communicate and identify developing complications,” she said.
Smith said her group is developing pilot programs to help clinicians recognize when patients are deviating from a traditional course.
If a patient completes a procedure without a complication, certain daily benchmarks should be expected. These benchmarks would be given to junior nurses and night staff, so that even without years of experience, they can recognize when a patient is not on track, Smith said.
“There are many issues affecting the health of our nation—opioids, measles outbreaks, low literacy rates, untreated mental illness, lack of affordable housing, and many others. Conversations with hundreds of nurses made it clear that they are willing to help people face these challenges, but they can’t do it alone,” said Paul Kuehnert, DNP, RN, FAAN, associate vice president at RWJF. “Nurses need support from their employers, other health care professionals, community organizations, and government entities to better address unmet needs.”
The nurses interviewed shared that nursing as a profession must evolve to meet the ever-growing needs of patients, as well as the shifts within the industry that hinder nurses from learning and helping to the best of their abilities. They also provided their points of view regarding how prepared nurses are after their training and education, and what resources are provided to them by their employers. Interviewees also discussed that while patient needs are expanding, there is not enough focus on them in health care settings.
“Nurses are uniquely qualified to address many of the unmet needs of people and communities, and this research shows they have a strong desire to do that,” Kuehnert shared. “Nursing is consistently ranked among the most trusted professions, and nurses have firsthand knowledge of what patients and communities need to be healthier.”