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Palliative and End-of-Life Care Education Needs of Nurses Across Inpatient Care

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Article  in  The Journal of Continuing Education in Nursing · July 2017

DOI: 10.3928/00220124-20170616-10

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Deborah M Price

University of Michigan

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Linda Strodtman

University of Michigan

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Heather M Smith

Milwaukee VA Medical Center and Medical College of Wisconsin, Milwwaukee, WI

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Jennifer Zybert

Children's Hospital Los Angeles

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329The Journal of Continuing Education in Nursing · Vol 48, No 7, 2017

Palliative and End-of-Life Care Education Needs of Nurses Across Inpatient Care Settings Deborah M. Price, DNP, RN; Linda Strodtman, PhD, RN; Marcos Montagnini, MD, FACP; Heather M. Smith, PhD; Jillian Miller, BSN, RN; Jennifer Zybert, BSNc; Justin Oldfield, MD; Tyler Policht, MD; and Bidisha Ghosh, MS

The provision of high-quality care for people who are nearing the end of life (EOL) is the professional re- sponsibility of health care staff. Palliative care is an ap- proach that improves the quality of life of patients and their families who are facing life-threatening illness from onset of diagnosis through the EOL (World Health Or- ganization, 2015). Approximately 28% of deaths occur in the hospital setting (Centers for Disease Control and

Prevention [CDC], 2016); therefore, it is important for hospital nurses to be competent in basic palliative and EOL care, including communication skills, interprofes- sional collaboration, and symptom management (Insti- tute of Medicine, 2014). Nursing professionals may not always be adequately prepared to deliver quality pal- liative and EOL care to patients and families, and com- monly recognized barriers include nurses’ lack of experi- ence, education, or involvement in the patient’s plan of care (Espinosa, Young, & Walsh, 2008; Harris, Gaudet, & O’Reardon, 2014; Sato et al., 2014; White & Coyne, 2011).

Professional organizations such as the American As- sociation of Critical-Care Nurses and American Nurses Association have published clinical practice guidelines and protocols to guide nursing knowledge and skills re- lated to EOL care. The American Association of Col- leges of Nursing (2008) has identified core competencies related to palliative care for undergraduate nursing curri- cula in the Essentials of Baccalaureate Education for Pro-

Background: Educating nurses about palliative and end-of-life (EOL) care is a high priority in health care set- tings. The purpose of this study was to assess nurses’ per- ceived competency regarding the provision of palliative and EOL care to hospitalized patients.

Method: This study surveyed nurses from 25 pediat- ric and adult acute and intensive care units (ICU; N = 583) Quantitative data analysis was descriptive and cor- relational. Qualitative data analysis identified themes of participant concerns.

Results: Data analysis revealed that perceived com- petency in palliative and EOL care is significantly higher in the ICU nurses (p , .0001). Mean scores were signifi- cantly higher when nurses had more than 10 years of ex- perience (p , .0001). Open-ended responses indicated concerns regarding improved communication behaviors, decision making, and facilitation of continuity of care.

Conclusion: The results provide guidance for develop- ment of palliative and EOL care nursing education pro- grams tailored to address specific unit needs according to staff characteristics, patient population focus of care, and acuity level of care. J Contin Educ Nurs. 2017;48(7):329-336.

abstract

Dr. Price is Clinical Assistant Professor, Dr. Strodtman is Assis- tant Professor Emerita, Ms. Miller is Research Assistant, Ms. Zybert is Honors Student, Ms. Ghosh is Statistician Intermediate, University of Michican School of Nursing, and Dr. Montagnini is Professor of Medi- cine, School of Medicine, University of Michigan, and Veterans Affairs Ann Arbor Healthcare System; Dr. Oldfield is Co-Chief Resident, and Dr. Policht is Resident, Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan; and Dr. Smith is Lead Psychologist and Associate Professor, Clement J. Zablocki Veterans Af- fairs Medical Center and Medical College of Wisconsin, Milwaukee, Wisconsin.

The authors have disclosed no potential conflicts of interest, finan- cial or otherwise.

Address correspondence to Deborah M. Price, DNP, RN, Clinical Assistant Professor, University of Michigan School of Nursing, 426 N. Ingalls Street, Ann Arbor, MI 48109; e-mail: [email protected].

Received: January 7, 2017; Accepted: March 20, 2017 doi:10.3928/00220124-20170616-10

330 Copyright © SLACK Incorporated

fessional Nursing Practice. Nationally, programs such as the End-of-Life Nursing Education Consortium and the Center to Advance Palliative Care have done much to promote education and training of nursing professionals in palliative and EOL care. The American Association of Critical-Care Nurses (2016) has included palliative and EOL care components in their Essentials of Criti- cal Care Orientation modules, which are used by more than 1,100 hospitals across the United States and Cana- da. These programs require extensive training to com- prehensively address the core domains of palliative and EOL care. For judicious use of resources and time, it is recommended that education be targeted to those nurs- ing populations who have the highest frequency of car- ing for patients and families needing palliative or EOL care. In addition, palliative and EOL care educational needs of nurses may vary according to patient popu- lation and acuity level or lived experience of the nurs- ing staff (Montagnini, Smith, & Balistrieri, 2012). Unit leadership may more efficiently choose to address staff education by focusing on aspects of palliative and EOL care related to unique staffing needs or pertinent aspects of care relevant to their specific patient population. This study sought to determine and compare the baseline pal- liative and EOL care educational needs of nurses work- ing in adult and pediatric intensive care unit (ICU) and acute care settings.

BACKGROUND A variety of studies have examined perceived compe-

tence of nursing professionals in palliative and EOL care in various acute and critical care settings. Nurses who work in acute care units represent a large and important subset of nurses who provide palliative and EOL care (Broglio & Bookbinder, 2014; Gagnon & Duggleby, 2013; Moir, Roberts, Martz, Perry, & Tivis, 2015; White & Coyne, 2011; White, Roczen, Coyne, & Wiencek, 2014). Key factors that appear to positively influence palliative and EOL care given to patients in acute care units include having a greater amount of professional ex- perience and years of practice, having positive collabora- tion and communication experiences with medical col- leagues, and having educational resources related to care of the dying patient (Broglio & Bookbinder, 2014; Ga- gnon & Duggleby, 2013). Educational gaps of acute care nurses include knowledge of symptom management and communication strategies that facilitate EOL discussions related to goals of care, and transitions from curative to comfort care (Moir et al., 2015; White & Coyne, 2011).

ICUs are known to have aggressive treatment modali- ties that focus primarily on curative efforts for patients, although emphasis can also include palliative compo-

nents and then a shift to EOL care when warranted (At- tia, Abd-Elzaziz, & Kandeel, 2012; Harris et al., 2014). The ICU nurse plays a key role in the integration of palliative care in the comprehensive treatment of criti- cally ill patients, regardless of prognosis (Puntillo, 2011). Barriers to the provision of quality palliative and EOL care by ICU nurses include environmental factors and the nurses’ knowledge, skills, and comfort level in caring for the dying patient and family members (Attia et al., 2016; Harris et al., 2014). In addition, the ICU nurses’ communication and involvement with the medical team in discussions of prognosis, goals of care, and palliative care has been shown to be directly related to the quality of EOL care provided to the patient and family mem- bers (Anderson et al., 2016; Attia et al., 2012; Milic et al., 2015; Rajamani et al., 2015). Montagnini et al. (2012) similarly identified that ICU staff perceived deficiencies in the provision of EOL care in the areas of communi- cation, decision making, and continuity of care. Their study highlighted the importance of teamwork and con- flict resolution in optimizing quality EOL care in the ICU (Montagnini et al., 2012).

Pediatric palliative and EOL care, although similar to adult palliative and EOL care, has distinctively different elements, including the tragic nature of a child’s death, uncertain prognostication, changing developmental sta- tus, and implications of the death of a child on the family system (Meier & Beresford, 2007). This creates particu- lar demands and educational needs for nurses who work with the pediatric patient population. Pelant, McCaf- frey, and Beckel (2012) identified the most pertinent pal- liative care education needs of inpatient pediatric nurses to be assistance with family coping, pain management, communicating with the family, and having difficult conversations. Stayer and Lockhart (2016) studied the experience of pediatric ICU nurses caring for children with life-threatening illness that may result in death and found that nurses perceived support for the patient and family as critically important, but that it led to emotion- al impact that markedly affected nurses and triggered a grief response. Challenges to EOL care in the pediatric patient were seen with symptom management, unclear communication, and remaining respectful of parental wishes when personally not in agreement (Morrison & Meier, 2011; Stayer & Lockhart 2016).

The purpose of this study was to complete a compre- hensive, baseline assessment using a validated assessment tool across adult and pediatric intensive and acute care settings to determine nursing educational needs related to palliative and EOL care. The specific aims of this study were to assess nurses’ self-perceived competence of knowledge, attitudes, and behaviors regarding the

331The Journal of Continuing Education in Nursing · Vol 48, No 7, 2017

provision of palliative and EOL care in the hospitalized patient and identify deficits in delivery of quality EOL care.

METHOD This descriptive study surveyed the knowledge, at-

titudes, and behaviors of inpatient nurses around seven palliative and EOL care domains. These domains in- cluded decision making, communication, continuity of care, emotional support for patients and families, symptom management, spiritual support for patients and families, and emotional support for staff (Clark et al., 2003; Figure). Institutional review board exempt approval was obtained. Nursing leadership from 25 pediatric and adult inpatient units in a large university setting agreed to invite their nursing staff to participate in the study.

Instrument The Scale of End-of-Life Care in the ICU (EOL-

ICU), developed by Montagnini et al. (2012), is com- posed of 28 quantitative questions that assess self- perceived confidence in providing EOL care in the ICU setting. Given the aim of assessing self-perceived compe- tence in providing EOL care among nurses across inpa- tient settings, the original instrument was modified for the current study to broaden the language beyond the ICU setting. For example, item 16 was revised from “It is important for physicians, nurses, and other ICU team members to collaborate in end-of-life decision making” to “It is important for physicians, nurses, and other team members to collaborate in end-of-life decision making.” This was the first time that this tool was used in the pedi- atric setting, and no additional modifications were nec- essary to accommodate pediatric care providers.

The revised instrument, known as the End-of-Life Care Questionnaire (EOLC-Q), includes all of the items of the original instrument: 12 items that assess knowledge, 5 items that assess attitudes, and 11 items that assess behaviors in providing palliative and EOL care. The items are grouped into subscales that examine perceived competency in seven domains of palliative and EOL care as identified by the Robert Woods John- son Foundation Critical End-of-Life Peer Workgroup (Clarke, 2003). The EOLC-Q questions are scored on a 5-point Likert scale as follows: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree, and not applicable. Items checked as not applicable were coded as zero. In addition, demographic items assessed included gender, unit worked, acuity level of unit, age, education, years of experience in current role, frequency of contact with patients with life-limiting ill-

ness, and frequency per month of EOL conversations. Four open-ended questions asked respondents to brief- ly reflect on a memorable palliative or EOL experience (positive or negative).

The questionnaire was converted in this study to an electronic survey using Qualtrics® software and dis- tributed to all nurses on participating units. The survey could be taken on a computer, smartphone, or iPad®, and it took approximately 8 minutes to complete. Respon- dents received reminder e-mails every 2 weeks over the course of 12 weeks. Participants were assured that re- sponses would be anonymous and were offered the op- portunity to be placed in a raffle to receive one of several $25 Amazon gift certificates for completing the survey.

Statistical Analysis Data were cleaned and then analyzed using SAS® ver-

sion 9.4 software. Means were calculated for each EOL domain subscale to identify areas of greatest perceived competency and deficiency. The potential differences be- tween the pediatric and adult units in acute and intensive care settings for the EOL care domain subscales were cal- culated using a one-way ANOVA. Correlations were cal- culated to examine the relationship between demographic variables and mean scores of the EOL domain subscales.

Open-ended responses were analyzed and grouped to add meaning to the quantitative data. The qualitative analysis for theme identification and grouping was con- ducted by three nurse and two physician researchers using a theme-generating process and then comparison-focused discussion for obtaining interrater agreement on themes and subthemes. The analysis was considered to be com- plete when there was redundancy and saturation of theme identification.

With the exception of the subscale measuring emotional support for staff, internal consistency of the original scale

Figure. Domains of palliative care. Adapted from Clarke (2003). Note. EOL = end-of-life.

332 Copyright © SLACK Incorporated

was high in the adult ICU setting (Montagnini et al., 2012). Similarly, Cronbach’s alpha indicated adequate to high in- ternal consistency reliability for the EOLC-Q in all adult and pediatric settings in the current study (alpha range = .68 to .93 for the total sample), with the exception of the emo- tional support for staff subscale (alpha = .17). Reliability for spiritual support could not be determined due to only one item addressing this domain in the questionnaire.

RESULTS Five-hundred eighty-three RNs completed the sur-

vey, comprising 182 nurses from adult acute care units, 227 nurses from adult ICU units, 85 nurses from acute

care pediatrics, and 89 nurses from the pediatric ICUs, averaging a 27% (range = 6% to 40%) unit response rate. Ninety-one percent of the nurses who participated in the study were women and 9% were men. Seventy- five percent of the nurses had a baccalaureate degree in nursing, with an average age of 38 years and an overall average of 8 years in current practice. Fifty-one percent of the pediatric ICU nurses had been in their current practice longer than 10 years, compared with 36% of the adult ICU nurses, 28% of the adult acute care nurses, and 38% of the pediatric acute care nurses. Frequency of contact with patients with life-limiting illnesses was significantly higher by nurses working in the adult ICU

TABLE 1

NURSE DEMOGRAPHICS BY SETTING

Nurse Demographics (%)

Variable Adult ICU (N = 182)

Adult Acute Care (N = 227)

Pediatric ICU (N = 89)

Pediatric Acute Care (N = 85)

Age (years)

20 to 30 30 40 32 37

31 to 40 35 24 18 27

41 to 50 21 22 20 12

.50 14 14 30 24

Gender

Female 83 94 95 94

Male 17 6 5 6

Highest degree obtained

Associate 16 20 17 14

Bachelor 74 75 77 76

Master’s or higher 10 5 6 10

Years in current practice

,5 38 48 33 43

6 to 10 25 23 17 19

.10 37 29 50 38

Frequency of contact with patients and families with potential life-limiting illness

Infrequent (monthly) 18 36 38 47

Frequent (weekly) 82 64 62 53

Average number of conversations with patients and families about palliative care per month

0 20 29 41 42

1 to 2 49 55 55 55

3 to 4 21 12 2 2

>5 10 4 2 0

Note. ICU = intensive care unit.

333The Journal of Continuing Education in Nursing · Vol 48, No 7, 2017

(p , .0001), compared with nurses in adult acute care units, but not for pediatric ICU and acute care nurses. Similarly, a significant difference was observed in the number of EOL conversations the adult ICU nurses had with patients and family members per month, compared with the adult acute care nurses (p , .0001), but not for pediatric ICU and acute care nurses. Demographic vari- ables according to acuity of units and populations are summarized in Table 1.

Overall, mean self-perceived competencies in the EOL care domains were significantly higher in the adult ICU nurses than adult or pediatric acute care nurses. Pe- diatric ICU nurses also had significantly higher means overall, compared with pediatric acute care nurses (p , .0001). Also, adult acute care nurses had significantly higher means than pediatric acute care nurses. ICU nurses (either adult or pediatric) had significantly higher means than either pediatric or adult acute care nurses for attitudes toward EOL care and symptom manage- ment. Adult ICU nurses had significantly higher sub- scale means than acute care nurses (adult or pediatric) for knowledge and decision making. Also, pediatric ICU nurses and adult acute care nurses both had significantly higher means than pediatric acute care nurses for knowl- edge and decision making. Spiritual care was significant- ly higher for the adult ICU nurses (p , .05), compared with pediatric acute care nurses. Adult and pediatric ICU nurses had significantly higher means than their acute care counterparts for emotional support for fami- lies and patients. The mean scores for emotional support

for staff in the pediatric acute care and ICU units were significantly higher than adult acute and ICU nurses. Mean subscale data are summarized in Table 2.

A significant difference was found in total mean scores by the number of years in current practice (p , .0001). Respondents who had more than 10 years of experience perceived themselves to be more competent in provid- ing EOL care, compared with those who had less than 10 years of experience. In addition, there was a signifi- cant difference in mean scores for knowledge, decision making, emotional support for family, and spiritual sup- port for those nurses with more than 10 years of experi- ence in their current practice (p , .0001). Nurses who had 6 or more years of experience had significantly high- er mean scores in symptom management. No significant difference was observed in behaviors, communication, continuity of care, or emotional support for staff among respondents.

Open-ended responses from nurses in all settings in- dicated concerns regarding the need for improved com- munication behaviors between the physician and the pa- tient and his or her family regarding realistic prognoses and code status. In addition, nurses felt that care pro- vided was sometimes futile or caused undue suffering. Nurses also believed that sometimes the patient’s or fam- ily’s wishes were not honored or decision making was not supported with clear and timely information. Nurses expressed that concerns for continuity of care were often related to the moral distress they experienced in caring for patients at the EOL and a desire to not take the same

TABLE 2

SELF-PERCEIVED COMPETENCY IN END-OF-LIFE CARE ACCORDING TO SETTING

Variable Adult ICU (N = 199),

Mean Score (SD) Adult Acute Care

(N = 223), Mean Score (SD) Pediatric ICU (N = 91),

Mean Score (SD) Pediatric Acute Care (N = 86), Mean Score (SD)

Knowledge 4.03 (0.8)* 3.74 (0.8) 3.9 (0.7)* 3.38 (0.8)

Attitudes 4.01 (0.6)* 3.68 (0.7) 4.0 (0.5)* 3.53 (0.6)

Behavior 3.25 (0.8) 3.28 (0.7) 3.09 (0.7) 3.21 (0.7)

Decision making 3.63 (0.9)* 3.40 (0.8) 3.3 (0.8)* 2.96 (0.8)

Communication 3.41 (0.8) 3.42 (0.8) 3.32 (0.8) 3.45 (0.7)

Continuity of care 3.34 (1.0) 3.42 (0.8) 3.31 (0.9) 3.36 (0.9)

Patient and family support

3.94 (0.9)* 3.77 (0.9) 3.85 (0.8)* 3.41 (1.0)

Symptom management 4.19 (0.8)* 3.77 (0.8) 4.05 (0.7)* 3.41 (0.8)

Staff support 3.41 (0.8) 3.46 (0.8) 3.66 (0.7) 3.73 (0.6)*

Total 3.72 (0.6)* 3.55 (0.6) 3.61 (0.5) 3.35 (0.6)

Note. ICU = intensive care unit. *p , .0001.

334 Copyright © SLACK Incorporated

assignment for more than 3 consecutive days. Nurses in all settings identified that the palliative care special- ists are not consulted soon enough to help with patient decision making, symptom management, and communi- cation. The nurses also identified that a peaceful, quiet environment is imperative at the end of life.

Provider and patient and family educational needs were apparent throughout the open-ended responses. The need to empower patients, patient education about disease and treatment options, understanding of code status, and understanding of what it means to transition from curative to comfort care was highlighted. Nurs- ing staff identified the desire to obtain more education in palliative and EOL care, particularly on how to have goals of care discussions with patients and families, cul- tural preferences, and how to handle moral distress when personal values conflicted with family values.

DISCUSSION This study expands on perceived palliative and EOL

care competencies in knowledge, attitudes, and behav- iors of nurses who work with adult or pediatric patient populations in intensive or acute care settings. The re- sults indicate that ICU nurses generally perceive them- selves to be more confident than acute care nurses in knowledge and comfort level in caring for EOL patients, particularly related to patient and family support, deci- sion making, and symptom management. At this insti- tution, all nurses receive a 45-minute overview about the provision of palliative care at their central nursing orientation upon employment. The ICU nurses receive further palliative and EOL care education in their criti- cal care orientation program, which uses the Essentials of Critical Care Orientation modules by the AACN. In addition, the increased frequency of contact with criti-

cally ill patients at the end of life whose families decide to deescalate or withdraw care provides enhanced op- portunities for learning and experience. Areas of lower perceived competence of ICU nurses pertained to be- haviors associated with decision making in withdrawal of care, decision making related to goals of care and code status, and communication and collaboration with phy- sicians. ICU nurses indicated that continuity of care was of concern, and that the need for additional staff support was related to this.

Acute care nurses perceived that they were relatively competent with patient and family support, as well as symptom management. They perceived that more assis- tance is needed in developing behaviors to help patients and their families with decision making and improving interdisciplinary and patient and family communication. Earlier palliative care consultation was also indicated to enhance patient EOL care. In addition, support for staff coping with personal distress that came from caring for patients at the end of life was viewed as important in the adult settings. In contrast, pediatric acute care nurses perceived adequate support, which may be indicative of a supportive pediatric palliative care team and collegial or management support (Stayer & Lockhart, 2016). In all settings, nurses appreciated the involvement of the pal- liative care team when they were consulted, citing that goals of care were more often shared, EOL symptom management improved, and interdisciplinary collabo- ration occurred. Perceived educational needs of nurses in both ICU and acute care settings are summarized in Table 3.

The results of this study were disseminated through- out the institution to unit-based leadership committees in all practice settings. Nurses concurred with the study results and ascertained educational needs through dis-

TABLE 3

NURSE PERCEPTIONS OF GREATEST PALLIATIVE CARE EDUCATIONAL NEEDS

Educational Need Adult and Pediatric ICU Adult and Pediatric Acute Care

Communication With physicians and other disciplines related to withdrawal of care, code status

Advocate for patient and family with interdis- ciplinary team related to goals of care, earlier palliative care consultation

Decision making High acuity with focus on technological treatment/interventions

Trajectory of illness and transitions of care

Symptom management Withdrawal of care End-of-life comfort care

Family and patient support Code status discussions; grieving process Code status discussions; grieving process

Staff support Personal distress experienced in critical care situ- ations

Increased time and resources to meet patient and family end-of-life needs

Note. ICU = intensive care unit.

335The Journal of Continuing Education in Nursing · Vol 48, No 7, 2017

cussion and identification of patient exemplars. In addi- tion, nursing leadership identified key areas for program development specific to their unit’s palliative and EOL education needs. Discussion on ways to promote inter- disciplinary collaboration and involve the palliative care team earlier is ongoing, including implementation of an institution-wide, criteria-driven checklist for initiation of a palliative conversation or consultation. Many units have incorporated specific unit palliative care education needs into their annual staff retreats, particularly related to EOL care and ways to enhance interdisciplinary col- laboration and communication. The pediatric palliative care team provides 4-hour interdisciplinary workshops that focus on EOL care, patient and family communi- cation strategies, interdisciplinary role clarification, and provider resilience approaches. It is hoped these work- shops will expand into adult settings.

Harris et al. (2014) used nurses who had received End-of-Life Nursing Education Consortium training as unit liaisons, and it is hoped that future planning of educational programs at this institution will result in comprehensive EOL training for unit-based palliative care champions. These nurses also will have educational materials made available to them and become expert re- source nurses to their unit nursing colleagues. Key strat- egies that address palliative care learning needs are iden- tified in Table 4.

STUDY LIMITATIONS Generalization of this study is limited to nursing

professionals who work in large, academic, inpatient settings. Response rates varied among nursing units, and those who responded to the survey may have been more likely to be interested in palliative and EOL care. In addition, the survey instrument did not measure ac-

tual competency in palliative and EOL care but, rather, perceived competency.

IMPLICATIONS FOR NURSING PRACTICE The results of this study are specific to the authors’

institution but were congruent with what has been re- ported in the literature. A baseline needs assessment should be completed to identify unique needs for each institution and unit prior to implementing a palliative care education program. This study demonstrated that nursing educational needs regarding the domains of palliative and EOL care may be different according to patient population and acuity setting and related to de- mographic variables of staff, including years in current practice. Nurses who work in adult and pediatric ICUs may provide EOL care more frequently in relation to symptom management, decision making pertaining to life-saving technologies, and physician communication issues. Acute care adult and pediatric nurses may focus more on assisting the patient with transitions in care, fa- cilitating patient and family wishes, and promoting con- tinuity of care between inpatient and outpatient settings. All nursing units should have resources available to pro- mote basic competencies in providing quality palliative and EOL care and opportunities to receive staff support as needed. As one nurse stated, “I am thankful that end of life is being addressed and not whispered about be- hind closed curtains.”

REFERENCES American Association of Colleges of Nursing. (2008). The essentials of

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American Association of Critical-Care Nurses. (2016). Essentials of Criti- cal Care Orientation (ECCO) 3.0. Retrieved from https://www.aacn. org/education/online-courses/essentials-of-critical-care-orientation

TABLE 4

STRATEGIES TO ADDRESS STAFF PALLIATIVE CARE NEEDS

Strategy Key Component

Baseline needs assessment Leadership support

Use validated tool with easy access (e.g., online)

Communication Interdisciplinary end-of-life workshop for skill development and role clarification

Education Train-the-trainer program for unit-based champions (e.g., End-of-Life Nursing Education Consor- tium)

Ongoing support for unit-based champions (e.g., forums, education updates via e-mail)

Available palliative care resources for all staff (e.g., online or printed guides)

Staff support Interdisciplinary comfort rounds (e.g., monthly)

Designated staff space in the unit for debriefing and contemplation resilience workshops

Reassessment Use validated tool to assess effectiveness of implemented interventions

336 Copyright © SLACK Incorporated

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