NURSE DIRECTED PALLIATIVE CARE DISCUSSIONS IN THE EMERGENCY DEPARTMENT

NURSE DIRECTED PALLIATIVE CARE DISCUSSIONS IN THE EMERGENCY

DEPARTMENT

Section 1: Nature of the Project

Introduction

Preparing for death is not typically a topic that most people are comfortable

talking about. In fact, death is one of the most difficult subjects to discuss (Marcus &

Mott, 2014). Although patients are provided written information about advanced

directives, there is a gap in discussing palliative and end-of-life care when patients with

serious and life-limiting illnesses. People often go to the emergency department (ED)

without previously discussing advanced care planning or goals and preferences of care

with their healthcare providers or family. Nurses are in a unique position to have these

conversations. However, nurses frequently feel reluctant to discuss palliative and end-

oflife care (EoLC) with patients and families due to lack of training (Dame & Hoebeke,

2016; Marcus & Mott, 2014; Revels, Goldberg, & Watson 2016). The Worldwide

Palliative Care Alliance (WPCA, 2011) reported that more than 29 million individuals

who die annually from serious or life-limiting illnesses could have benefited from end-

oflife conversations. Given the frequency of interactions of the nurse with the patient and

family, the nurse is in a position to promote a caring environment for the patient that

encourages engagement in conversations about fears and goals of care in any

environment, including high stress and chaotic areas such as the ED (Revels et al., 2016).

The World Health Organization’s (WHO, 2019) definition of palliative care is “an

approach to care that improves the quality of life of patients and their families facing the

problem associated with life-threatening illness, through the prevention and relief of

suffering” (para. 1). The WHO (2019) describes palliative care as the relief of pain and

symptom management to enhance quality of life for people facing serious illness at any

age and is inclusive of preparation for and discussions of EoLC. Palliative care is not

exclusively the care provided at the end of life, but is life affirming and promotes

increasing the quality of care for people living with serious and life-limiting illness

(WHO, 2019). The National Cancer Institute (NCI) recognizes that the nurses’ role

represents the core values of palliative care that extends from curative to end-of-life care,

as this care encompasses physical, emotional, social, and spiritual support for patients and

their families with the goal of pain and symptom management (“Comprehensive Cancer

Information,” n.d.; Dame & Hoebeke, 2016). NCI ascertains palliative or comfort care

should be available to all patients and at any age, for any disease process that produces

pain or suffering, and should include discussions of patient goals of care through shared

decision-making. Palliative care may include hospice care for terminal care if necessary

(“Comprehensive Cancer Information,” n.d).

As the population continues to grow older and chronic diseases are on the rise, the

need for palliative care and EoLC discussions are becoming a part of the daily

responsibilities of the ED nurse (Revels et al., 2016). According to the Emergency Nurses

Association (2013), nurses are responsible for promoting and leading the collaborative

efforts for palliative and EoLC that may result in an increase in the number of patients

that engage in earlier palliative and EoLC decision-making. Providing written

information about advanced directives could be used as a catalyst for these discussions in

the ED, but these discussions need not stop there. Although the nurses continue to have

concerns about when and how to discuss goals and preferences of care (e.g., code status,

final wishes, and treatment modalities), providing formal training, updating palliative

care protocols, and providing palliative and end-of-life resources may increase the nurse’s

ability to provide opportunities for patients to have these discussions (Anderson et al.,

2017). The results of this project include evidence-based (EB) clinical practice guidelines

(CPG) for nurses as a foundation to begin a new approach to palliative care discussions in

the ED.

Due to the historical lack of palliative care education in nursing and medical

schools, there is inconsistency with current palliative and EoLC practice and delivery

modalities (Revels et al., 2016). Although there is a current movement to include

palliative education in nursing and medical schools, there is a gap in the definition of

palliative care. More specifically, the definition lacks consistency in language,

terminology, and goals of palliative care within the healthcare community (Revels et al.,

2016). The incorporation of focused guidelines would promote consistency in language

and terminology, communication techniques, and care delivery that may result in

decreased misunderstandings about goals of care between the patient, nurse, and the

healthcare team (Marcus & Mott, 2014). Decreasing misunderstandings around goals of

care is a primary priority for nurses that may result in an increase in quality of care and

patient satisfaction by aligning treatment goals and preferences of care (Revels et al.,

2016).

This scholarly project proposed a change in clinical practice that incorporates best

practices of palliative and end-of-life nursing care by translating evidence into practice,

thereby improving quality end-of-life outcomes. Developing EB CPG provide structure

and resources for nurses to initiate goal-setting discussions and initiate care for patients

with serious and life-limiting illnesses. The change in clinical practice guides the nurses

to use EB protocol for discussing palliative care and end-of-life goals in the ED, and

include resources and examples of how to document discussions and goals of care in the

medical record.

The CPG provides a strategic approach to engaging patients to discuss goals of

care and advanced directives. The current advanced care document—the preferred

document for discussing advanced directives at the institution—is a reference for the

nurse to use as a guide in the discussion and the documentation. Clinical tools for

discussing advanced directives and goals of care have been effective in guiding and

supporting clinical decision making around treatment preferences and goals, and can aide

in identifying the path of treatment for the patient. The CPG guides staff members

(nurses) when discussing goals of care, promoting comfort and symptom management,

and advocating for the patient to be transitioned to the most appropriate level of care

based on their personal goals, thus increasing patient trust and satisfaction. This project

was intended to increase quality and safety by promoting shared decision making in the

ED among patients, families, surrogate decision makers, and physicians at the pivotal

point between curative and comfort care (see Dame & Hoebeke, 2016).

This CPG can contribute to social change by ensuring consistency in the delivery

of EB palliative nursing care through providing resources, using guidelines for palliative

and EoLC discussions in the ED, and being the foundation for the establishment of

specific palliative care language and terminology. Everyone involved will be able to

understand the terminology and share in the discussions, including the most important

people, the patients (see Marcus & Mott, 2014). Noting that palliative care patients have a

range of diseases and respond differently to treatment options, this early palliative care

approach is relevant because it promotes understanding, trusting relationships, and

establishes patients’ preferences and goals to increase quality of care, patient satisfaction,

and comfort for a peaceful, dignified death (see Dame & Hoebeke, 2016). In addition,

this change in clinical practice has the potential to increase partnerships and trust between

the health care system and the community, as the health care system becomes a trusted

source of patient- and family-centered care.

Problem Statement

Local Nursing Practice Problem

Congruent with findings from the literature, local ED nurses do not consistently

provide EB palliative care discussions, use consistent language and terminology, or

engage in palliative-care communication strategies when caring for patients facing

serious and life-limiting illnesses (Zaleski, personal communication, 9/8/2018). Many of

the ED nurses admit to not answering the standard administrative questions for the

palliative consults as accurately as possible due to time constraints and lack of focus on

palliative care (Zaleski, personal communication, September 8, 2018). Inconsistency with

messaging and communication promotes misunderstanding and mistrust between the

patient and the health care system (Marcus & Mott, 2014). Inconsistencies in palliative

care language and delivery methods may be due to a lack of EB education and absence of

knowledge, creating barriers leading to patient mistrust and misunderstandings. In

addition, lack of consistency increases the potential for patient isolation and

inconsistencies in treatment modalities and prolongs the opportunity for patient-centered

goal setting, and ultimately results in decreased patient and family satisfaction (Dame &

Hoebeke, 2016; Fernández-Sola et al., 2017; Mierendorf & Gidvani, 2014; Revels et al.,

2016).

Lack of EoLC discussions are attributed to the lack of focus on palliative care,

inadequate communication strategies, time constraints (i.e., actual time spent with

patients and the transient nature of the ED), and competing priorities of the nurse

(Emergency Nurses Association [ENA], 2019). These inconsistencies lead to barriers in

care, resulting in decreased ability of the health care system to meet quality outcomes

such as nursing communication and providing care that aligns with patient preferences

and values.

Local Relevance

This project was designed for a small inner city 70 bed hospital with 26

emergency department beds, and eight intensive care beds (Bon Secours Health System

[BSHS] Fact Sheet, 2017). Basic demographics of this community include a high

percentage of unemployed, minimally educated, medically uninsured African Americans

with a statistically lower life expectancy (64.2 years of age) in comparison to the

surrounding geographic area due to a high incidence of chronic diseases leading to

premature death (Community Health Needs Assessment [CHNA], 2016). Data from the

CHNA showed a substantial need for increased access to preventive medical services and

health literacy to improve physical health, mental health, and overall well-being for this

community. ED visits reached 24,538 in 2018; with one-third (33%, 8,179 visits) of the

visits were patients seeking care for pain or symptom management for their serious or

life-limiting illnesses. Many of the community residents use the ED as their primary

source of medical care (Zaleski, personal communication September 9, 2018).

Lack of medical insurance, mistrust in the medical community, and decreased

participation in preventive health care eludes to the high number of community residents

that rely on the ED for medical care (CHNA, 2016). These specific circumstances may

increase the tendency of residents to prolong seeking medical care and may result in

increased severity of medical issues when they present in the ED, which coincides with

the data from the CHNA as evidenced by the morbidity and mortality percentages for this

community that range from 5% for people ages 65-84 to 13.5% for people 85 and older of

the patients who died in the ED (CHNA, 2016). Based on the characteristics of this

community (e.g., decreased life expectancy, older population, high mortality rate, high

use of ED), there are a large number of people in this community who may benefit from

early interventions such as palliative care conversations when they seek care in the ED.

This institution has a focused mission to increase the resources to the community that

includes care from preventive to end-of-life care.

Significance for Nursing Practice

Historically, nursing school curricula has not supported education about palliative

and end-of-life care (Alderidge, 2016), yet nurses are expected to promote comfort and

advocate for patients. The problem is that nurses are expected to do so without formal

training and tend to develop care strategies based on previous experiences that lead to

inconsistent care delivery and irregularities in language and terminology, messaging, and

processes of palliative and EoLC (Revels et al., 2016). With the increase in the aging and

chronically ill population, nursing and medical schools have added palliative care

education to the curriculum due to the necessity of comfort care, end-of-life symptom

management, and communication skills are becoming a priority in all areas of healthcare

and especially in the care of the dying (American Nurses Association Professional Issues

Panel, 2017). Despite this new standard of education, mature and experienced nurses

continue to provide this care without the formality of receiving EB palliative care

instruction.

This PCG provides a resource for consistency in care delivery, which promotes

continuity for initiating palliative and EoLC conversations beyond providing written

information about advanced directives. These resources promote the foundation for

nurses to feel comfortable, therefore promoting a comforting environment for patients to

engage in conversations about fear, goals, and treatment preferences.

The significance of this project was to guide nursing practice for patients in need

of palliative care and support early palliative care conversations sooner in the ED

admission and treatment process. As research shows, nurses (critical care and ED nurses)

successfully support earlier palliative and EoLC discussions for patients and families in

the absence of palliative care physicians with formal training in other settings (Anderson

et al., 2017). This research suggests that the collaborative relationships among the nurse,

patient, and physician may increase the quality of care and patient satisfaction for

seriously ill patients at times when the patient and family need to have these discussions.

This EB project might increase the ability and comfort of the nurse and extend the ability

to advocate for patient needs, allowing more patients to have the opportunity to have

conversations related to palliative and EoLC, thus increasing quality of care and patient

satisfaction (Anderson et al., 2017).

Early palliative care discussions are associated with increased quality outcomes

through identification of patient-centered goals of care including effective pain and

symptom management, practical support, and end-of-life care that includes promoting a

dignified death (Anderson et al., 2017). Through this project, I intended to provide nurses

with strategies for communicating with patients to accelerate early identification of goals

of care at a time when health care may be moving quickly from curative to comfort. In

addition, by providing valuable information to patients and family, the nurse can be in an

informed position to advocate for the patients’ preferences and desires for treatment

(Revels et al., 2016).

According to the 2016 American Nurses Association (ANA) position statement,

“Nurses’ Roles and Responsibilities in Providing Care and Support at the End of Life,”

the recommendations include additional standardized practice, education, research, and

administration changes to overcome barriers to end-of-life care (ANA, 2016). Practice

changes focus on healthcare providers having a basic knowledge of palliative and EoLC,

allowing nurses to stay abreast of basic skills to provide comfort and symptom

management. Nurses should also be comfortable having discussions with and advocating

for families and patients regarding palliative goals of care and preparing for a dignified

death (ANA, 2016). Due the current lack of a standardized EB palliative care guidelines,

the recommendations for clinical changes to overcome these barriers were the foundation

for this project to ultimately provide ED nurses and staff with knowledge and resources

concerning palliation and EoLC discussions, as well as how to promote a comforting

environment conducive to addressing palliative care needs. Therefore, when the nurse

incorporates this practice as routine, it has the potential to increase the opportunity for

patients to engage in these discussions and include shared-decision making to increase

quality of care for this patient population (see Kurian, 2014).

Purpose

Meaningful Gap-in-Practice

In the local setting, about one in five of the ED patients have palliative care needs

(Zaleski, personal communication, September 8, 2018). Lack of accurate documentation,

increase in patient needs, and lack of access to palliative care staff have resulted in many

patients with unresolved pain and symptoms, mismatched patient goals and preferences,

and may have led to inappropriate admissions, unwanted referrals to hospice, and futile

admissions to the intensive care unit (ICU, Zaleski, personal communication, September

8, 2018).

The ANA (2016), the Emergency Nurses Association (ENA, 2019), and the

American Nurses Association Professional Issues Panel (2017) recognized that the use of

evidence-based palliative guidelines and EoLC nursing educational resources decreases

barriers to initiating conversations about and providing palliative care sooner in the care

trajectory from diagnosis to death for people facing serious and life-limiting illnesses,

specifically when curative treatment is no longer effective or an option. The institution

involved in this project required all patients to be offered information about advanced

directives in the form of a patient information booklet, yet did not possess CPG for nurses

to initiate the discussion. Therefore, the CPG developed in this project is associated with

a new protocol process for nurses to initiate palliative care discussions in the ED. In

addition, this CPG has the ability to decrease misunderstandings about treatment options

and goals by providing a standardized language and approach.

The local ED nurses have expressed confusion about hospice versus palliative

care (Zaleski, personal communication, September 8, 2018). These nurses reported being

reluctant to initiate conversations related to goals of care with patients because they

believed this task was out of their scope of practice (Zaleski, personal communication,

September 8, 2018). This project provided focused EB palliative care guidance, and

assisted with communication strategies that may help to overcome barriers to identifying

palliative needs and initiating discussions of patient-centered goals through the use of a

CPG. The ED nursing educator developed and delivered the educational curriculum for

the implementation and evaluation of the project.

Practice-Focused Question

The practice-focused question for this project was: What resources are available to

guide evidence-based practice for nurses to initiate discussions about palliative care needs

with patients in the emergency department?

This evidence-based approach was intended to close the gap between clinical

practice and research by empowering nurses with knowledge, skills, and resources to

meet the needs of their patient population (Black, Balneaves, Garossino, Puyat, & Qian,

2015). Consistent with the literature, EB practice has proven to improve patient care and

quality outcomes by improving efficiency through the promotion of standardized methods

for the identification of and provisions of palliative and end-of-life conversations and

care. This transformational strategy could improve the patient experience and lead to

increased quality of care and patient satisfaction through early identification of goals and

preferences and shared-decision making (Yankovsky, Gajewski, & Duton, 2016).

Addressing the Gap-in-Practice

This scholarly project was designed using the “Walden University Manual for

Clinical Practice Guideline Development” (2019) and was based on data collected from

the most recent Community Health Needs Assessment (CHNA) for the institution. The

demographics of the community showed a large proportion of older adults with chronic

and serious illnesses that lend to increased and early rates of mortality in this community.

In addition, it described the residents as lacking preventive and ongoing care for chronic

and life-limiting conditions, therefore increasing the risk for complexity of illnesses when

seeking urgent care. Because of the lack of engagement with the healthcare system, the

admission to the ED may be the only opportunity for the patient to have discussions

about their care. This project addressed the need to increase opportunities for patients to

discuss goals and preferences of care by providing evidence-based CPG to accompany

the new protocol for nurses to initiate palliative care discussions when providing written

information regarding advanced directives. In return, this intervention may increase the

number of patients that have the opportunity to have palliative and EoLC conversation in

the ED on a routine basis.

This project provided ED nurses with CPG to implement the protocol for

initiating palliative care discussions in the ED when providing printed information about

advance care planning. It also provided evidence-based information and resources to

formulate a knowledge base of palliative care for continued learning and sustained EB

nursing practice. In addition, the resources included a pocket aide to assist the nurses

when directing the discussions and documenting the encounter. This CPG is consistent

with the extending role of the nurse and provides suggestions for improving quality of

care, patient safety, and patient and family satisfaction through shared decision-making

and the formulation of a patient-centered plan of care (Hartjes, 2015; Hollyday &

Buonocore, 2015). This CPG provided the institution with resources and is expected to

create an increase in the quality of care by better patient outcomes, increased patient

satisfaction ratings, and improvement in overall quality of life reported by patients and

family members, as has been documented in the literature (ANA, 2015; Mishelmovich,

Arber, & Odelius, 2016).

Nature of the Doctoral Project

Sources of Evidence

Peer-reviewed literature, systematic reviews, and evidence-based tools relevant to

palliative and end-of-life discussions by nurses in the ED or ICU provided a foundation to

develop unit specific nurse directed palliative care guidelines for discussions. This CPG

included information and resources related to palliative care and evidence-based

protocols for early identification and intervention. Consideration of the Emergency

Nursing Scope and Standards of Practice (2011), the Emergency Nurses Association,

“Palliative and End-of-Life Care: Position Statement” (2019), and the American

Association of Colleges of Nursing, “Essentials for Doctoral Nurses” (2006), provided

standard principles as a foundation of care within the project.

The sources of evidence for this doctoral project were initially collected by

searching CINAHL and Medline for literature from the past five years, nursing standards

for clinical practice, national nursing organization position statements, and peer-reviewed

articles. These searches focused on the role of the nurse in palliative care, end-of-life

discussions, standards of emergency and palliative care, initiating goals-of-care

discussions in the ED, and advanced care planning discussions to formulate the basis for

this project. In addition, a subsequent literature review was conducted in regards to

Watson’s caring theory/caring science for palliative care in the ED, palliative care

discussions, and identifying the nurse as the caring environment. Because the literature

review was limited to the ED nurse’s role in these discussions, research based on

palliative-care communications in the ICU and the burn unit were included because

nursing in these areas is comparable to nursing in the ED. Articles that were six or more

years old were included because of their relevance and the paucity of more recent studies.

The most recent nursing guidelines were used that were available that related to the topic.

Analysis and summarization of literature using Melnyk’s hierarchy of evidence

matrix focused on effectiveness, appropriateness, and feasibility of best practices (see

Melnyk & Fineout-Overholt, 2011). The information collected provided data congruent

with the gap in evidence-based clinical practice and suggested strategies to support ED

nurses’ understanding, confidence, and comfort when partaking in conversations with

patients and family members to identify physical, emotional, and spiritual needs. A

summary of the relevant findings from the literature offered a description of the current

state of the evidence on the topic that supported the use of evidence-based guidelines,

resources, and early palliative care nursing communication in the ED.

Approach Summary

Implementation of a CPG provided current best practices for optimal patient

outcomes to increase quality of care and patient safety. An analysis and summary of

findings based on the literature review was distributed to key members of administration,

palliative care team, and the nursing education staff to provide a proposal to promote best

practices for this intervention for this setting. It was my recommendation that the

institution track documentation related to care of end-of-life patients in the ED, as well as

patient satisfaction surveys to measure the impact of the new process. Learning objectives

of the project were to increase knowledge, implement a new CPG, and promote a caring

environment. The administration of the facility may use the CPG to expand to other

nursing units at the institution to provide opportunities for all patients to discuss goals of

care and advance care planning.

Anticipated Findings

The analysis and summarization of relevant findings of current literature using

best practices and support from Watson’s theory of caring provided a theoretical

framework for this project. Regular collaboration with nursing leadership, the clinical

practice committee, the quality and safety committee, the palliative care team, and the ED

staff educator provided input for quality assurance and performance improvement suited

for the design and implementation of the project. The education department collaborated

with leadership on financial matters for implementation and evaluation of the project.

Providing new EB CPG provided resources and support for nurses to promote a

safe and caring environment for patients to discuss sensitive topics despite the chaotic

environment of the ED (e.g., increased patient acuity, time constraints, and conflicting

patient care priorities; Pagano, 2016). Suggestions from the literature provided

assumptions that the implementation of the PCG would increase the likelihood that nurses

will be able to (a) assess and identify patients who will benefit from palliative care

discussions, (b) promote a caring environment that increases trust between the nurse and

patient by using evidence-based palliative-care communication strategies, (c) develop a

person-centered plan of care using advanced directive patient information booklet, (d)

document the encounter using consistent language and terminology for clarity of patient

goals and preferences of care, and (e) refer patient for palliative care consult if warranted.

Concise Statement

Current literature included suggests training critical care nurses to use

evidencebased palliative care to promote consistency in the approach to care for patients

with serious and life-limiting illness (Aslakson, Curtis, & Nelson, 2014). This CPG

provided nurses with a standard approach and resources to advocate for patients’ needs

and preferences of care as an extension of the palliative care team in a clear and

consistent manner, as discussed in the literature (see Salmond, & Echevarria, 2017). Care

delivery consistent with patient-centered goals decreased redundancy and duplication of

treatments (see Kettner, Moroney, & Martin, 2013).

Significance

This DNP project was significant to the field of nursing because it followed the

recommendation from the Palliative and Hospice Nursing Professional Issues Panel “Call

for Action: Nurses Lead and Transform Palliative Care,” (ANA, 2017) as it provided

resources for nurses to deliver consistency when caring for seriously ill patients, patients

with life-limiting illness, or dying patients in an environment that is not conducive to

providing comfort care. Watson’s caring theory provided a theoretical framework to

promote an environment of caring and compassion that encourages trust when discussing

intimate thoughts and feelings regarding EoLC, especially in an area that focuses on

biomedical care as opposed to comfort care for patients and families (see Anderson et al.,

2017). Providing a comfortable environment and consistent communication strategies

including language and terminology encourage nurses to focus and share openly at a time

when emotions are high for patients, families, and healthcare providers addressing the

physical, emotional, and spiritual needs of patients as they approach a sensitive time and

begin to discuss feelings of concerns about life and death (Jamison & Vulaj, 2015).

Key Stakeholders

The primary key stakeholders for this project included ED nurses, patients, and

medical/palliative care providers (see Kettner et al., 2013). Educational opportunities for

nurses and other health care staff using EB best practices provided increased basic

knowledge that sponsors collaboration around a framework to promote care and comfort.

The use of CPG provided consistency across the continuum of care from diagnosis to

death by decreasing inconsistencies and barriers to care earlier in the ED. Increasing

stakeholder participation in clinical practice through the incorporation of an EB

framework and standardization of care delivery encouraged a change in awareness,

competency, and confidence that potentially could benefit all patient populations in any

setting (see Jamison & Vulaj, 2015). This approach offered a paradigm shift in the culture

of care delivery, as it promotes shared decision-making and lends to a change in the

patient’s perspective of end-of-life care, as well as encourages trust between the

community and the healthcare system.

The target population for this project was the ED registered nursing staff. These

nurses were identified as the main points of contact for patients entering the ED and

spend a large portion of time with the patients, making it easier to interject with patients

and begin early discussions around preferences and needs in an area that is fast-paced

with competing patient priorities. In addition to the nursing staff and the ED nursing

educator, other key stakeholders were the providers (e.g., ED physician, internal medicine

and ED physicians, and palliative care practitioners), as they collaborate with nursing

staff to provide care for the patients in the ED for insight to manage pain and symptoms.

It is expected that the entire nursing staff will use the CPG to ensure optimal

implementation of the new clinical practice protocol.

Patients receiving consistent messages about healthcare and participating in

shared decision-making are more likely to be satisfied with their health care and quality

of life (see Black et al., 2015). This CPG provided mutual understanding between the

nurse, patient, and physician when addressing the discussion, documentation, and

advocacy for treatment preferences (see Black et al., 2015).

Contributions

This project contributed to nursing practice in all clinical areas by providing

nurses guidelines for discussing advanced directives and palliative care, specific language

and terminology, and communication skills to address the patient’s physical, emotional,

and spiritual needs (see Bailey, Murphy, & Porock, 2011). The impact of the project has

the ability to increase the nurses’ knowledge, ability, and comfort level when discussing

goals of care, advanced directives, and caring for patients with serious and life-limiting

illnesses in the ED. The provisions in the CPG offered nurses the directives to move

seamlessly between providing curative and crisis care when caring for patients in need of

palliation and comfort care in the ED.

Potential Transferability

Patient safety and quality outcomes are associated with the skill levels of nurses

and the provisions of ongoing educational opportunities that include formal and informal

direction to promote evidence-based clinical practice and generalizability to other

environments (see Kristensen, Nymann, & Konradsen, 2016).). Prepared nurses who

incorporate EB concepts of palliative care into everyday emergency practice can increase

quality, safety, and patient satisfaction for all patients through consistency and providing

a caring environment (see Bailey et al., 2011). The CPG is a resource to open

communication and advocacy for patient preference and goals. The use of the CPG in

routine care gives rise to patient and family satisfaction, increased patient dignity, and

enhanced quality in any environment (see Bailey et al., 2011).

Positive Social Change

This project contributed to Walden University’s social change policy by

prompting nurses to pursue educational opportunities in all areas to meet the growing and

changing needs of complex patient populations (Walden University, 2017). This resulted

in supporting initiatives that promoted access to quality care, safer care, and reduction of

overall health care cost locally and globally (Institute of Medicine [IOM], 2010).

Increased engagement and collaboration at the staff level was the first step in developing

a network of local professionals and professional organizations that work together to

resolve challenges related to quality patient care, safety, and decreasing the financial

burden on the health care system (see Salmond & Echevarria, 2017). This project aligned

with social change, as it provided an avenue to increase the application of evidence-based

clinical practice to improve the access to shared decision-making and increases quality of

care earlier in the course of treatment for patients with serious and life-limiting illness.

The project provided clinical guidelines for consistency and communication to promote

care, respect, and dignity to patients, thus, promoting a paradigm shift with the way

patients and healthcare workers view quality of care at the end of life (see Walden

University, 2017).

In addition, this project supported initiatives to build understanding and trust

between the patient populations and the healthcare community to reduce inconsistencies

that created barriers to trust in the healthcare community and increased quality and safer

care consistent with the 2010 IOM (2010) report. This project aligned with the American

Association of Colleges of Nursing (AACN, 2006), “The Essentials of Doctoral

Education for Advanced Nursing Practice, Essential I: Scientific Underpinnings for

Practice,” as it promoted the use of evidence-based clinical research to enhance health

care delivery and improve patient outcomes. This project fostered the use of Watson’s

caring theory to promote a caring environment in the ED nurse when initiating sensitive

conversations with the aging and sick population.

Summary

Through this doctoral project, I provided a CPG for standardizing the nurse’s

approach to palliative and end-of-life advanced care planning for seriously ill patients

who are admitted to the ED. This CPG focused on using knowledge and understanding of

palliative and EoLC to include pertinent information, current resources, and clinical aides

to initiate palliative goals of care and advanced directive conversations, therefore

overcoming barriers to communication when the focus of patient care shifts from curative

to comfort. Building trust through consistency and increased communication using the

CPG provided the nurses with an avenue to identify the patient’s goals and preferences of

care (Revels et al., 2016).

The use of the evidence-based clinical guidelines provided the nurses with

resources to build upon the patient’s current knowledge, discuss life-limiting illness,

death, and the dying process with patients and to collaborate with physicians and other

healthcare providers to advocate for patient care and treatment based on their preferences

and values (see Dame & Hoebeke, 2016). The use of CPG allow the patient to explore

current medical and organizational processes and protocols (e.g., ICU admission,

extensive testing, and artificial ventilation) to determine their personal desires for

treatment (see Dame & Hoebeke, 2016). Using consistent concepts, strategies, language,

and terminology that the patient and family are able to understand decreased

misunderstandings among stakeholders and decreases delays in appropriate care (see

Aslakson, Curtis, & Nelson, 2014).

Providing guidance for care that is congruent with current evidence-based

literature can affect quality improvement and quality outcomes for patients by directing

an overall cultural change related to end-of-life patient care in all areas. Provisions of a

consistent theoretical framework empowered nurses to direct patient care using EB

resources, best practices, and knowledge for understanding patient disease processes,

prognoses, and treatment options (see Kettner et al., 2013).

Section 2: Background and Context

Introduction

The identified gap in current clinical practice for this DNP project was that the

nursing staff at the institution’s ED were not using evidence-based clinical protocols

when discussing care planning, such as advanced directives, with patients with serious

and life-limiting illnesses beyond providing written advanced directive patient

information. In addition, the staff in the ED had expressed concern that there was lack of

consistency and follow up with palliative and EoLC discussions. This gap was consistent

with the literature, which revealed missed opportunities to discuss goals of care because

many patients are discharged from the ED or die before a palliative care consult can be

initiated (see WPCA, 2011).

This CPG was an attempt to close this gap, providing the ED nurses with EB

guidelines that included information and resources supporting the role of the nurse in

palliative and end-of-life care discussions. Therefore, the assumption was that there

would be an increase in the patient’s understanding of diagnosis and treatment options if

the nurse was empowered to provide an opportunity for patients to engage in advance

care discussion and shared-decision making earlier. This CPG provided guidance for a

standard first line approach for nursing staff to initiate discussing palliative care options

in the ED. This project addressed the following practice question: What resources are

available to guide evidence-based practice for nurses to initiate discussions about

palliative care needs with patients in the emergency department?

Current evidence showed the importance of consistency, training, and resources

for leveraging the ability of ED nurses and other staff to promote early discussions about

palliative care (Wang, 2016). In order for the ED nurses to promote early discussions,

there must be a standard for care delivery provided by safe and competent educated

practitioners who can carry it out effectively and efficiently. Therefore, this EB project

was the development of CPG for nurse-directed palliative care discussions by the ED

nursing staff to promote competency and consistency to improve the quality of care for

patients. Watson’s caring theory was the basic theoretical foundation for the nurses to

promote an environment of comfort and compassion that is conducive to encouraging

these discussions in the ED.

Concepts, Models, and Theories

The theoretical foundation of this quality improvement project was grounded in

the caring framework of Jean Watson’s caring theory, including the Caritas process,

transpersonal caring, and the caring moment as the theoretical foundation upon which the

nurse could build a caring and comforting environment in the ED to increase the quality

of initial palliative care conversations and the discussion of patient guided treatment goals

(advance directive). Kurt Lewin’s change theory was also used as the framework for

change to occur. Barriers to change were identified during the design of the CPG. The

project was designed with the end user, the nurse, in mind to encourage stakeholder

buyin.

Caring Theory

Caring science (caring theory) is the philosophy of human caring, a theory defined

by Jean Watson, PhD, RN, AHN-BC, FAAN, as a foundation of nursing care, as a

discipline, and a profession (Foss-Durant et al., 2015). The caring theory defined the role

of the nurse as the person, health, and as the environment and is often used to assist

nurses to embrace their passion for nursing as a caring profession (Bayuo, 2018; Revels

et al., 2018). The caring theory incorporates the Caritas process, which is a significant

part of the foundation characterized by 10 themes of caring that include the following: the

formation of a humanistic-altruistic system of values, installation of faith-hope,

cultivation of sensitivity to one’s self and to others, development of a helping-trust

relationship, promotion and acceptance of the expression of positive and negative

feelings, systematically using a scientific problem-solving method for decision making,

promotion of interpersonal teaching-learning, promoting a provision for a supportive,

protective and/or corrective mental, physical, socio-cultural and spiritual environment,

assisting with the gratification of human needs, and allowing for

existentialphenomenological forces to promote spiritual and emotional healing (Watson,

2008). The theory also defines the transpersonal relationship between the nurse and the

patient, and the caring moment as a spiritual encounter. These elements are congruent

with the mission and values of the practicum site “to bring compassion to health care and

to be good help to those in need, especially those who are poor and dying” (BSHS para.

1, 2017).

Change Theory

The introduction of Kurt Lewin’s change theory implemented change through the

stages of unfreezing, moving/change, and refreezing. Cumming et al. (2016) described

Lewin’s change theory as a simplistic approach to change that identifies the challenges

and barriers (unfreeze), implementation of new behaviors (moving/changing phase) to

incorporate the change in clinical practice (re-freeze). This theory is noted to be one of

the most commonly used in nursing practice, as it was useful to implementing this change

in the delivery of patient care in the ED.

The unfreezing phase included discussions with facility administration and staff

regarding the need for the project, addressing the reluctance of nursing staff to have

endof-life conversations, and identification of the barriers and challenges to initiating

discussions about palliation (e.g., goals of care and advanced directive) with patients in

the ED. Provision of the palliative care PCG are considered as the moving/changing

phase of implementation of the new protocol as the guidelines are developed. Refreezing

occurs once the new process becomes routine.

Definitions

Advanced directive information (Five Wishes): written information provided to the

patient upon admission to the hospital about advanced care planning.

End-of-life care discussions (advanced care discussions): care that emphasizes the

importance of frank, timely, supportive care. discussion of such matters as preferences for

life-extending care, including cardiopulmonary resuscitation, mechanical ventilation,

artificial hydration and nutrition, renal dialysis, and surgery before decisions about the

use of such measures become necessary (“End-of-Life Care,” 2012).

Nursing educator: A registered nurse certified in emergency nursing and

possesses degree in nursing education or certification that focuses on incorporating

evidence-based practice into the care provided in the emergency department and other

units to maintain best practices for increasing and maintaining quality patient care.

Palliative care: a holistic approach that improves the quality of life of patients and

their families facing the problems associated with life-threatening illness, through

assessment and treatment of pain and other problems, physical, psychosocial, and

spiritual (WHO, 2019).

Project site: small inner city 70-bed hospital with 26 emergency department beds,

and eight intensive care beds in Northeast region of the United States.

Relevance to Nursing Practice

Emergency department care is grounded primarily in a bio-medical model of care

where priorities for lifesaving and curative care are prioritized above palliative and

comfort care. In this bio-medical model of care, staff are often in conflict as to the

prioritization of interventions and conversations regarding patient-centered goals of care

when comfort care is warranted. The role of the nurse has expanded over time to support

the federal law to written information about advance directive information to patients

who seek care. Providing structure through standardized CPG and EB palliative care

resources empowered nurses to initiate these first line conversations, provide appropriate

care referrals, and be a support and advocate for patients and families when initially

providing the written information. Although advance care planning can be very difficult

for patients and professionals to discuss, the use of Watson’s (2008, 2012), theoretical

framework in this CPG promotes an environment that is congruent to communicating on

a compassionate and caring level as nurses converse with patients.

As the population grows older and the number of patients with serious and

lifelimiting illnesses increases and there continues to be a disproportional need for follow

up with palliative care providers, the CPG provides nurses with resources to initiate these

palliative care discussions and promote goal setting early in the admission and treatment

process so that palliative care providers can focus on palliation (see Salmond &

Echevarria, 2017). The preliminary research reviewed for this CPG project identified

increasing numbers of patients who died without palliative care discussions (see WPCA,

2011). This review helped identify the need for advancement in the way that this

institution is able to support patients to promote earlier conversations. Standard resources

and guidelines to support the frontline ED nurses provided consistency and were

considered a first step to afford patients an early opportunity to engage in conversations

so their wishes and treatment choices are known (Gloss, 2017; Wang, 2016).

Current palliative care practice in this specific ED were limited to a screening

assessment that included information about disease state and chronic co-morbidities,

current advance directives, previous palliative care consultations, previous hospice

admissions, and readmission within the last 30 days. These questions focus on the

administrative strategies to identify potential patients with palliative care needs but lack

the necessary information to formulate patient-centered care that address the immediate

suffrage. The steady influx into this ED of patients with immediate palliative care needs

and follow up take hours or days to address, missing the opportunity for a discussion

about palliative care needs or EoLC and therefore patients may be discharged without

their palliative care needs being addressed, (Zaleski, personal communication, September

8, 2018). The CPG make available a framework to provide an opportunity for initial

discussion and documentation to support a foundation for the follow-up comprehensive

assessment by the physician or palliative care team if necessary.

Gloss (2017) recognized that poor ED design, lack of consistent communication,

lack of formal education, high nurse to patient ratio, the need for structured clinical

guidelines, and inconsistencies in EB protocols increased barriers to having palliative and

EoLC discussions with patients in the ED setting. Thus, given the time that the nurse

spends with the patient and family, using the CPG, provides a resource for the nurse to

identify and discuss palliative care goals with patients early in the admission process (see

Dame & Hoebeke, 2016; Revels, et al., 2016). In this position and with the CPG, the

nurse may be able to provide opportunities to initiate discussions given the proper

training and resources to do so (see Revels et al., 2018). Congruent with the literature, the

potential outcome of this project is reasonable to assume the number of patients that have

palliative care discussions in the ED will increase by providing nurses with the resources

to initiate the conversation.

Local Background

Demographics of this local community included a high percentage of

unemployment and uninsured African Americans, with a statistically lower life

expectancy in comparison to surrounding geographic areas (CHNA, 2016). Death rates

among this population range 5% for people ages 65-84 to 13.5% for people 85 and older.

Discussed in the previous section, serious and life-limiting illnesses (mental health

disorders, cancer, heart disease, renal failure, and HIV/AIDs) rank among the top reasons

for ED visits documented for this population (CHNA, 2016). Death rates for this

community were consistent with the national death rates, which climbed to 2,712,630

(844.0 deaths per 100,000 population) nationally in 2017, terminal cancer and heart

disease were among the highest reason for mortality (CDC, 2017). Based on the above

data (e.g., decreased life expectancy, older population, high mortality rate, high use of

ED), there is a large number of people in this community that may benefit from palliative

care discussions when admitted to the ED.

Lack of resources may be a key factor in the inability of nurses to initiate end-

oflife goal planning in this environment. Research has documented that the ED bio-

medical focus is not conducive to such discussions, therefore, the environment (e.g., fast

paced, bio-medical focus, noise, fast turn over, and competing priorities) causes barriers

to communication, decreases understanding, and promotes the growth of confusion and

mistrust between patients and the healthcare team (Alderidge et al., 2016; Gloss, 2017).

The ED staff identified a gap between the number of patients that would benefit

from palliative care conversations and those that actually receive discussions about goals

of care and advance directives while in the ED. The ED nursing educator indicated that

there was also a lack in the follow up for patients referred for palliative care consults in

the ED and lack of continuity of care for patients between the acute environment and in

the outpatient care settings (Zaleski, personal communication, September 8, 2018).

The CPG addressed the current process for initiating conversations about advance

directives as it is not consistent with promotion of patient-centered care, shared-decision

making, or building trust with the patients within this community due to lack of health

care literacy, lack of trust, and lack of follow up (Zaleski, personal communication,

September 8, 2018). According to the ED nursing educator, lack of palliative-care staff

availability during off shifts and the amount of patients that meet the criteria for palliative

care consults, result in one-third (33%) of patients receiving alternate referrals such as

hospice referral or admissions to the hospital. Additional patients are being discharged to

home and some do not receive appropriate palliative-care follow up at all (Zaleski,

personal communication, September 8, 2018). This project addressed the lack of standard

guidelines that will empower the nursing staff to provide an opportunity for patients to

discuss how they wish to live and to die in an area that has historically not provided such

care or discussions.

Acting as a patient advocate in a specialty area such as the ED, the nurse can

alleviate additional challenges by understanding palliative care concepts and addressing

the patient’s preferences and values for care. Demonstrating understanding of the policies

and protocols, while continuing to provide clinical and emotional support to the patient

and family can be challenging in any area. This Doctor of Nursing Practice (DNP) project

developed an EB CPG to decrease the barriers and challenges for nurses to address such

issues beyond providing written material to patients for review of advance directives in

the ED.

Role of the DNP Student

I see my role in this project as providing available EB resources to empower

nurses to advocate for patients who otherwise may not have opportunities for discussions

about the way they want to live their lives, what treatment modalities they prefer, and

how they want to die. Johnson (2013) thought that mistrust in the health care system

increased barriers due to a lack of understanding and knowledge, cultural beliefs, and

treatments that are misaligned with the patient’s spiritual and religious practices thus,

causing a conflict with treatment modalities. Conflicting beliefs may be one of the

reasons that patients in this community mistrust the health care providers (e.g., traditional

treatment vs cultural practices and prayer) and do not routinely engage in preventative

and palliative care. This project has the ability to initiate a ripple effect by promoting

early share-decision making that may decrease mistrust for the patient, family, and

potentially causing a ripple effect by positively discussing the experience within the

community.

Although this responsibility is expanding and has become the role of the bedside

nurse, in my nursing career I have felt ill prepared to initiate palliative care discussions or

initiate advance care planning due to lack of training and resources. Although there is a

strive to include palliative-care instruction in medical and nursing schools, I believe there

is still the gap in the educational foundation for the mature doctors and nurses that have

historically provided this type of care based on past experiences. As a clinical instructor

for registered nursing students, I understand there is still a gap in the way the palliative

care curriculum was provided in schools that continues to affect the continuity of

palliative care globally. Being aware of the lack of consistency makes me a proponent of

continuous education for nurses that include end-of-life care training that includes the

discussion of advance directives. In addition, my greater goal is to promote sustainability

for palliative care by first providing structure and consistency to promote trustworthiness

between the community and the health care system. It is my opinion, patients who lack

opportunities to discuss their personal preferences on a level that they can understand and

feel comfortable are at higher risk for confusion, distrusting health care in general, and

creating a forum for lack of follow up.

In addition, my observation has been that bedside nurses provide comfort care to

dying patients and the family all the time and promote palliative care and advance care

decision-making, but lack consistency in their approach. Advance care discussions are not

a once and done conversation; they are fluid and demand consistency, time, and follow-

up to help patients to understand and identify their wants and needs. Providing nurses

with EB CPG increases the ability of the nurse to consistently initiate these conversations,

advocate for patient needs, and collaborate care among all disciplines using consistency

in language and approach. Starting these conversations in the ED allows patients to

become active participants in directing their treatment and identifying personal treatment

goals.

This CPG was the focus of my practicum experience for Walden University and

was developed in collaboration with an adult ED education specialist and validated by the

institutions leadership and palliative care team through the routine change policy process.

The literature review analysis was completed and provided insight for a consistent

approach to advance care planning and language for nurses to initiate these discussions.

The final written assessment of the implementation of this EB project was the final

component of the DNP program.

Summary

Preparing ED nurses to take on the role and responsibility of initiating goals of

care discussions for patients with palliative care needs promoted a vector for shared

decision making and consistency in the approach for advocacy and discussions of

palliative and end-of-life care. This approach encourages new and mature ED nurses and

ED staff to be life-long learners, to initiate research to improve patient care, and pursue

the most current best practices that guide safety and quality patient outcomes and

decrease barriers that lead to patient mistrust and misunderstandings. The next section

focuses on the analysis of evidence that supported this EB project.

Section 3: Collection and Analysis of Evidence

Introduction

Care at the end of life is often fragmented and often increases within the last six

months of life, as Medicare beneficiaries experience a higher level of care transitions;

9.5% of the care transitions are individuals presenting to the ED with end-of-life care

needs (Wang et al., 2017). The ED nurses at this local hospital have expressed concerns

about the increased number of terminal patients visiting the ED who do not have their

personal needs or goals of care discussed in a timely manner (Zaleski, personal

communication, September 8, 2018). Inconsistencies are exaggerated in the care by the

transient nature of the ED patient, lack of access to palliative care practitioners, and

limited time to discuss palliative goals of care and end-of life choices (Revels et al.,

2016). Nurses confirmed this idea by sharing that they feel reluctant to initiate the

conversations due to lack of formal training, lack of standard guidelines, and time

limitations (Zaleski, personal communication, September 8, 2018).

Through consistency of EB CPG, the nurses were provided resources for

promotion of patient and family comfort, trust building, and to foster compassion, thus

opening the door to discuss such topics as end-of-life care (Dame & Hoebeke, 2016;

Fernández-Sola et al., 2017; Mierendorf & Gidvani, 2014; Revels et al., 2016).

Operational Definitions

Alternate care pathways: care provided outside of the hospital setting such as

inpatient or home-based hospice, home health care, or palliative care in the community

setting.

Educational survey: survey questionnaires developed and used for the purpose of

evaluating the perceived effect of the education on the nurses’ understanding of training.

Questions may include the perceived preparation of the nurses to deliver palliative care

discussions in the ED, the characteristics of transition to practice activities and their

perceived difficulty in delivering the new protocol, and the overall perception of

usefulness of the training, and content delivery of the faculty and program characteristics.

Palliative care consultation: medical evaluation and treatment delivered by

palliative care experts that assist ED clinicians in managing the complexity of pain and

symptoms beyond the traditional methods in the ED.

Palliative care experts: organizational professional staff that specializes in

managing complex pain, symptoms, comorbidities, patient/family communication, and

other issues pertaining to serious and life-limiting illnesses.

Palliative care protocol: a specific written nursing procedure specific to this

organization that describes the nurse’s actions required to ensure consistency and quality

of palliative care.

Pocket card (aide): a clinical tool to promote quality, safe care for nurses beginning a

new protocol. It contains essential knowledge, skills, and strategies necessary for basic

patient care and documentation for the use of adequately communicating patients’ needs

to other members of the interdisciplinary team.

Resource booklet: a collection of information that pertains to palliative care for

nurses containing education, journal articles, pocket cards, etcetera to promote knowledge

to provide quality and safe care.

Practice-Focused Question

Upon initial environmental assessment, the ED nurses expressed inconsistencies

with care delivery methods of comfort care and discussions surrounding goals of care that

increased their reluctance to engage in conversations about advance directives and goals

of care with patients. The nurses stated that access to the palliative care team was limited,

leaving patients with their needs either not met or inconsistently met, therefore promoting

confusion and encouraging lack of trust in the healthcare community. This project was

developed and delivered to answer the following project practice-focused question: What

resources are available to guide evidence-based practice for nurses to initiate discussions

about palliative care needs with patients in the emergency department?

In order to meet the concerns of the ED nurses (e.g., lack of comfort and

consistency when communicating or initiating palliative care, an increasing aging

population, and the projected life-span of this community), there was a consistent need

for prepared and committed palliative care trained nurses to deliver the first-line

discussions about palliative goals of care that included discussions about advance

directives and treatment options. The ultimate goal of developing the CPG was to give the

ED nurses the resources necessary to have increased confidence and perceived

competence to promote a caring and comfortable environment in this very high stress,

high acuity unit to build trust and initiate conversations with patients about their palliative

care needs in a consistent and compassionate way.

Sources of Evidence

In response to the expressed need from the staff in the adult emergency

department for training and resources to promote palliative care discussions, a literature

search was conducted to collect evidence for best practices for ED nurses to initiate

conversations about advance directives and goals of care as the first-line approach for

palliative care in the ED. This EB palliative-care guideline for clinical practice was

designed in collaboration with the ED educator and the palliative care staff.

Preimplementation included an EB CPG for palliative-care nursing and initial advanced

care planning discussions for nurses. In addition, grounding the CPG and associated care

in Watson’s caring science theoretical framework created a foundation for the nurses to

promote an environment that is conducive for patients with palliative care concerns. The

ED educator the ED physician, and the palliative care team reviewed the draft CPG and

the resources for accuracy, consistency, and content validity. Addressing the ED nurses’

needs for additional education, updated guidelines, and resources was vital to this project.

The nursing education department, the ED nurses, and the hospital leadership expressed

interest and support of the implementation and success of the project. Relevant outcome

data results collected and analyzed by the institutional committees will support the

change in clinical practice to improve quality of care for patients in need of palliative care

in other nursing areas.

Using thematic analysis, common themes found in the initial review of research

included the need for early palliative care discussions, consistency of approach for endof-

life discussions, palliative care education of nursing staff, and standard guidelines for

initiation of palliative care conversations in the ED. This type of intervention can increase

the amount of patients who have conversations related to palliative care, early EoLC

planning, and understanding and completion of advance directives. It may also surpass

the delivery in the ED and become a standard of care in other areas, including the

advancement of palliative care and early palliative care discussions in the community

setting. This CPG project provided valuable resources for nurses to initiate discussions

with patients when providing them with written information about advance directives. It

also empowers nurses to pursue nursing professional development and employs nurses to

become proficient as the first line professional to approach the subject of end-of-life care

at the bedside.

Published Outcomes and Research

An exhaustive literature search was conducted using the Cumulative Index for

Nursing and Allied Health Literature (CINAHL) and Medline through the Walden

University Library online. Articles were limited to peer-reviewed and evidence-based

research related to clinical practice, role of the nurse, and other standards of care within

the past five years related to the practice problem. The literature searches for relevant EB

practice using the following terms was performed: palliative care in the ED, palliative

care education for nurses, palliative care education, end-of-life care and palliative

education, and palliative care discussions by nurses, the role of nurses in end-of-life

discussions, and advance care planning. This review collected data until the trending of

topics were exhausted for new information of current research and best practices. The

incorporation of several articles used were six or more years old because of their

relevance and the paucity of more recent studies. The sources included that are related to

professional guidelines were the most current information available and had not been

updated since the sources used, which included the Emergency Nursing Scope and

Standards of Practice (2011), and the American Association of Colleges of Nursing,

Essentials for Doctoral Nurses (2006) as a foundation of current standards of care.

The initial literature search revealed an abundance of research on palliative and

end-of life care discussions, but little on providing the discussions by nursing staff in the

ED. Therefore, information was included in analysis of research to discuss initial

conversations that are provided in the ICU and burn unit for patients requiring palliative

conversation. The selection process included palliative care discussions, delivery of

palliative care in the ED, and relevance to the role of the nurse. In addition, best practices

for preparing staff to have standardization, competency, clarity, and consistency to

promote sustainability in the acute clinical setting were also included in the search.

Additional searches included Watson’s caring theory and additional information defining

Lewin’s change theory to describe change in clinical practice.

Evidence Generated for the Doctoral Project

The nursing educator stated that the quality data from the hospital site suggested

that one in five ED patients were identified as having palliative care needs (Zaleski,

personal communication, September 8, 2018). The lack of consistency (e.g., language

surrounding palliative care, inconsistent documentation, increased patient needs, and lack

of access of palliative care staff) left many patients with unresolved pain and unmanaged

symptoms as well as mismatched patient goals and preferences and lack of follow up (see

Revels, et al., 2016). This gap in care was compounded by the increase amount of patients

that do not have palliative care discussions, unwanted referrals to hospice, and futile

admissions to the ICU (Zaleski, personal communication, September 8,2018).

Recommendation for post implementation evaluation of the project will be completed by

the hospital quality department as they collect data related to satisfaction scores from

hospital satisfaction surveys. To promote initial palliative care discussions with patients

in the ED, this CPG project was designed to improve knowledge and provide a standard

set of instructions for nursing staff to effectively engage in conversation about palliative

care including advance directive discussions. This design of the CPG was to improve

quality for patients through providing consistency in the process.

Following the recommendation from the Palliative and Hospice Nursing

Professional Issues Panel: “Call for Action: Nurses Lead and Transform Palliative Care”

(2011), nurses are called to provide quality palliative care to patients and families

regardless of the setting. In an attempt to improve quality at this practicum location, an

CPG was developed to include having discussions about advance directives and goals of

care as a first line intervention in addition to providing written information about advance

directives. In preparation for these discussions, the CPG was developed for nurses using

evidence-based resources and best practices to promote consistency in the approach to

setting palliative care goals and assisting patients to identify and meet their individual

treatment preferences.

Because the nurse is the first person to assess and interview the patient and family,

the nurse is able to provide a professional and caring environment to promote trust and

opening the avenue to approach palliative care discussions (Revels, et al., 2016). Practice

guidelines related to palliative care nursing, palliative care conversations, and

documentation of the palliative discussions and interventions were incorporated to

prepare and promote consistency (Revels, et al., 2016).

In order to evaluate the validity of the created clinical guideline, the draft

document was reviewed, revised, and approved by an expert panel using the appraisal of

guidelines for research and evaluation (AGREE II) tool. As it is noted to be the gold

standard for those desiring to develop CPG. The AGREE II tool appraises the draft

document for validity of content (AGREE II Instrument, 2013). The AGREE II tool was

also used to organize and analyze the evidence found in the literature and allowed for the

collaboration with the project team to review key findings for appropriateness for use in

this local setting and for evaluating validity and reliability of the drafted nursing

guidelines as outlined in the “Walden University Manual for Clinical Practice Guideline

Development” (2019). Copyright permission allows reproduction of the tool for

appraising clinical guidelines (Brouwers et al., 2016).

The AGREE II Tool

The AGREE II tool identified 23 items organized into 6 quality domains as a

framework to guide the development and the appraisal of CPG. Once the draft document

was reviewed for congruence with the literature and checked for inconsistencies with

quality practices, it was forwarded to the expert panelists to review.

The AGREE II checklist was provided to the expert panelist as an appropriate

method for assessing the quality for CPG (Zaccagnini & White, 2011). The expert panel

consisted of the palliative care physician, the palliative care nurse practitioner, the ED

nursing educator, and the ED medical director. The panel members have extensive

experience working with and treating patients with serious and life-limiting illnesses with

palliative care needs in the emergency care environment. Prior to the review, the panelists

were asked to declared whether they have any competing interests to the development of

the guidelines. Being they were all employees of the institution and the guidelines were

supported by leadership, the panel was able to proceed with the evaluation to respond to

the requests of nurses to meet the needs of this patient population. Using the tool, the

expert panelists were asked to evaluate the guideline based on the domains outlined in the

AGREE II checklist with narrative comments for discussion. Once the reviews were

completed, the panel met with the project team to discuss any comments or concerns. The

document was accepted with recommendations, to revise the document to include contact

information for the family spokesperson to be recorded in the medical record; it was

added to the documentation portion of the guidelines. All experts agreed that they would

recommended the guidelines for nurses to use in addition to the completing the existing

palliative care screening tool for palliative care consults used at the institution. All were

in favor of having the guidelines as a foundation for the nurse to use critical thinking and

creative expression to meet the objectives in the ED environment (e.g., providing a

private area, using therapeutic touch, etc.). Once revisions of the CPG were completed,

the guidelines were referred to the ED operations board for final approval. A description

of the checklist is summarized in Section 4.

Protection of Human Participants

This project was aligned with the goals and objectives of the practicum site’s

quality improvement process. The project consisted of evidence-based best practices

found in current peer-reviewed literature and standards of care. No direct contact with

patients was necessary to complete this DNP CPG development project. In congruence

with the Walden University institutional review board (IRB) an expedited review and

approval was requested to ensure that this DNP project complies with Walden University

policies and federally regulated ethical standards for research. Once the DNP project

proposal met the requirements for approval, notification of approval was provided to the

institution and the design and development of the project commenced. The institutional

leadership at the site had verbally expressed a commitment to the project and signed the

consent. Current public facing data was used for the project; no other data was collected

for this project. The site does not have an IRB therefore the project was deferred to

Walden IRB for protection of human subjects; approval number is #10-30-19-0616316.

The education, implementation, and the evaluation of the project will be conducted

through the education department of the institution. Careful consideration was taken to

protect the physical, social, ad psychological concerns of the nurses and protect the

personal health and identification and information of the patients in the ED. Nurses were

informed of the project justification as clinical research for a doctoral project as well as

the plan of study, identifiable risks, confidentiality, and participation guidelines for the

project. All information collected through this project will be used to inform quality

improvement at the institution and is protected by the Health Insurance Portability and

Accountability Act (HIPAA).

Summary

Through a review of current evidence-based practice and individual and group

discussions with the ED nurses, current barriers to palliative care discussions were

identified and there was a request for standardization of care guidelines and

supplementary resources to aid the nurses in the identification of patients for early

discussions related to palliative care in the ED. The purpose of this project was to provide

CPG to support the initial palliative care discussion encounter between the nurse and

patients that seek care for serious and life-limiting illness in the ED setting. This initial

conversation forms a basis for directing the treatment centered on patient goals and

preferences and initiation of advance directives discussions that may affect the patient

length of stay at the hospital, financial burden, and patient and family satisfaction. The

new guidelines provided consistency in the delivery and documentation to increase

confidence and competency of each ED nurse as they engage in palliative care

discussions to increase the number of patients that are provided the opportunity to discuss

advance directives and goals of care. Additional benefits could be the improvement of

staff satisfaction, educational preparedness, and staff retention rates. Section 4 focuses on

the findings and recommendations for future practice based on the implementation of this

CPG for nurse directed palliative care discussions in the ED.

Section 4: Findings and Recommendations

Introduction

The ANA (2016) defined the essential role of the nurse as discussing treatment

goals and advance care planning with patients with serious illness. Although all patients

in the local setting are provided an information booklet titled Five Wishes in accordance

with the federal Patient Self-Determination Act of 1990 (PDSA), no other information

has been routinely provided and the ED nurses have not been providing evidence-based

palliative care discussions about goals of care for patients with serious and life –limiting

illnesses. This DNP project was designed and developed in collaboration with the

emergency department education department, nursing leadership, and the institution’s

palliative care team to address this practice gap providing a standard of care integrating

high quality, family-centered compassionate care, guided by a sense of respect, empathy

and concern that addresses the unique needs of patients, families, and surrogate decision

makers. Because there are still alarming numbers of patients admitted to the ED without

advance directives, this project was designed to provide evidence-based resources for

nurses to institute a new protocol to discuss advanced directives and goals and to

empower nurses to offer opportunities for patients to engage in shared-decision making

and goal setting. Full implementation and evaluation of these CPG and protocols will be

the responsibility of the ED education staff at the institution.

Palliative care is not synonymous with end-of-life care; yet, it includes the care of

patients throughout the disease process, including life-prolonging interventions, life

maintaining practices, and hospice care (WHO, 2019). CPG were developed in

collaboration with the ED education department, nursing leadership, and the institution’s

palliative care team to initiate palliative and advance care discussions in the ED. Based

on the nursing process (i.e., assessment, diagnosis, plan, intervention, and evaluation),

these steps were taken to develop the CPG to provide consistency and standardization for

care delivery, encouraging shared-decision making, promoting quality of palliative care,

and increasing patient satisfaction. Incorporation of the caring theory provides a

framework for the nurses to promote an environment of comfort, caring, and compassion.

Findings and Implications

A comprehensive literature review was performed by searching CINAHL and

Medline through the Walden Library including peer-reviewed academic journals

produced 1403 articles for palliative care in the emergency department or emergency

room. The search was refined to include only those articles from 2014 through the current

date, and to include the role of the nurse. The articles were reduced to 62 articles that

related to the topic of nursing roles in discussing advanced directives and palliative care

and were reviewed for relevance to the topic. Information applying to palliative care

provided by physicians and actual care of the dying patient was removed from the review.

Articles pertaining to palliative care discussions in the ED and incorporating Watson’s

caring theory (science) to promote a caring environment in the ED were included.

Analysis and summarization of literature using Melnyk’s hierarchy of evidence

matrix was used to rank the evidence as it focused on current effectiveness,

appropriateness, and feasibility of best practices for nurses discussing goals of care

(Melnyk & Fineout-Overholt, 2011). The literature was used throughout the paper to

connect evidence with practice. In addition, the literature provided strategies to address

the gap in clinical practice and to support ED nurses’ understanding, confidence, and

comfort when supporting patients and family members to identify immediate goals of

care at this pivotal moment in their health trajectory. The next section includes a summary

of the relevant findings from the literature to describe the current state of the evidence

that supports the development of evidence-based CPG, resources, and early identification

of goals of care and initiation of advance directives in the ED.

One pertinent article discussed the findings of a single-blind, randomized clinical

trial at Mount Sinai Hospital in New York, where palliative care consults were initiated

for patients with advanced cancer in the ED. The data suggested that early consultation

may improve quality of life, decrease hospital length of stay and decrease ICU admission,

and may even extend life (Grudzen et al., 2016). Given this information, the purpose of

this DNP project was to provide focused EB palliative care nursing guidelines to

empower ED nurses to overcome barriers when identifying palliative needs and initiating

discussions of patient-centered goals and advance directives. In addition, the Patient

SelfDetermination Act (PDSA) was adopted into law in 1991 to increase the public’s use

of advanced directives. This federal law required all health care facilities that receive

payment from Medicare or Medicaid provide advance directive information to all adult

patients seeking care (Teoli, 2019). This CPG is the foundation for nurses to discuss

advanced directives initially in the ED along with patient preferences for treatment.

Nursing in this ED is consistent with the literature, filled with inconsistencies in

palliative care delivery, thus promoting barriers and leading to patient mistrust and

misunderstandings, as well as increased patient isolation and inconsistent treatment

modalities that decrease patient and family satisfaction (Dame & Hoebeke, 2016;

Fernández-Sola et al., 2017; Revels et al., 2016). This EB project addressed the gap in

practice for palliative care discussions to be initiated by promoting an opportunity to

discuss AD in the ED by the nursing staff instead of waiting for palliative care consults or

allowing for missed opportunity to discuss patient needs and goals. Consistent with the

position statements of the Emergency Nurses Association (2019) and the ANA (2016), the

ED nurse is obligated to address care concerns with seriously ill patients who enter the

ED for care.

Trends from the evidence suggested that nursing roles are changing to proactively

advocate for patient’s goals of care and nurses are initiating the conversations around

end-of-life and palliative care in the ICU and burn unit for patients with serious and

lifelimiting illnesses when the palliative care staff is unavailable; these situations and

environment are similar to the care provided in the ED. The literature also describes the

role of ED nurse as the first person to assess the patient and typically spends the majority

of the time with the patient; the nurse is in a unique position. Within the evidence review,

the authors consistently focused on the importance of nursing support (protocols,

guidelines, etc.), continued education regarding palliative care, and Watson’s theoretical

framework to promote a caring environment in healthcare organizations to foster patient

engagement.

The Emergency Nurses Association (2019) has found that the focus in the ED is

life-saving and urgent to the point that it can be a challenge for staff to provide palliative

or comfort care due to the chaotic environment. However, there are a number of studies

that demonstrated that lack of training and resources also contribute to barriers to

providing palliation in the ED (Bailey et al., 2011; Beckstrand et al., 2017; Wolf et al.,

2015). Wolf et al. (2015) suggested that palliative care would be more prevalent if

included in basic nursing education and opined that there is a great need for CPG for

palliative nursing to improve the consistency of patient care. In an additional study

conducted by Bailey et al. (2011), the lack of consistent knowledge and training for ED

nurses decreased the lack of focus on comfort needs of all patients. Studies were

consistent with the argument that palliative care education, including strategies for

communication should be provided to the nursing staff as continuing education.

The ANA and Hospice and Palliative Nurses Association (HPNA) presented a call

to action for nurses to lead and transform palliative care. Both the ANA (2016) and the

ENA “Position Statement on Palliative Care” (2019) recognize that nurses can play an

important role in the early identification and discussions around goals of care, resulting in

reducing futile admissions to the ICU and in the development and execution of patient

preferences for treatment goals. Additional studies suggested that early discussion around

advance directives increased shared decision making and the ability of the patient to

communicate goals of care (Grudzen et al., 2016; Schroeder & Lorenz, 2018).

Early consultation may improve quality of life, decrease hospital length of stay

and decrease ICU admission, and may even extend life. The American Nurses

Association Call for Action: “Nurses Lead and Transform Palliative Care” (2017)

recognized 3.6 million nurses that are able to engage in discussions related to palliative

and holistic care; Adams (2017) noted, however, that although critical care nurses are

currently extending their roles to include the palliative care discussions with patients and

families, they continue to feel as though they are not educationally prepared to

communicate effectively with families. As nurses are in a unique position to provide

written information about advance directives and promote an opportunity to discuss

values, religion, culture, and philosophy that are personal to the patient’s treatment

process, communication skills and resources to initiate these discussions continue to be

paramount (Revels, et al., 2016).

Advance directive and palliative care discussions can be challenging for staff

members as they are faced with providing quality care for seriously-ill patients who have

not expressed their wishes or goals of care with their provider or with their family. Staff

have suggested that the most impactful challenges for providing palliation in the ED is

education and training, ED design, lack of family support, work load, ED staff

communication and decision making, resource availability (time, space, appropriate

interdisciplinary personnel) and integrating palliative care discussions in ED (Alqahtani

& Mitchell, 2019). Literature suggested that early and efficient communication can

improve with patients and families by addressing organizational and educational barriers

through providing EB education and resources such as CPG, standardized language, and

consistent documentation to provide consistency in care (see Revels, et al., 2016).

As the nurse is the first medical professional to have contact with the patient, this

is an opportune time to set the stage to discuss goals of care and advance directives (see

Revels, et al., 2016). The use of information tools such as the Five Wishes discussion

booklet, provide information for the nurses to stay constant and use consistency in the

communication and language when discussing matters such as goals of care with patients

and with staff; this approach may increase quality and patient satisfaction (Hartjes, 2015;

Hollyday & Buonocore, 2015). Other studies suggested providing a space that is

dedicated to the palliative patient that provides privacy and a space for patients and

families to be more comfortable and not be subjected to the chaos of the ED (Bradley et

al., 2013, Basol et al., 2015, Tse et al., 2016).

In addition, applying Watson’s caring theory specifically to the establishment of a

safe, caring, and comfortable environment to discuss goals of care can greatly improve

the quality and trust in care. Watson’s theoretical framework can improve communication

though the use of core concepts of caring; transpersonal caring relationship, caring

moment, and use of the Caritas Process, whereby care is transformed into wholeness,

beauty, comfort, dignity, and peace within the meeting (Cara, 2003; Watson, 2008).

Alqahtani and Mitchell, (2019) suggested that providing an environment of comfort in the

ED can greatly increase the communication between the nurse and the patient. Watson

believed the nurse can become the comforting environment through transpersonal caring,

the caring moment, and the Caritas process (Revels, et al., 2016).

Watson (2008, 2012) defined transpersonal caring as the essential communication

between the nurse and the patient, as it is defined as the connection between the nurse and

the patient that protects and enhances human dignity by providing respect and honoring

the patient’s needs, wishes, routines, and rituals (Cara, 2003; Watson, 2008). This practice

can be achieved as the nurse practices and honors wholeness of mind-bodyspirit of the

patient as a person. Transpersonal caring can be achieved as the nurse is in harmony with

the needs of the patient; promoting the intention of doing and caring for a person and just

being there for support paying special attention to providing love and trust as she

completes nursing tasks for the patient as a person and not as an object or task to be

completed (Cara, 2003; Watson, 2008). This action is consistent with the nurse’s ability to

discuss current goals for care with patients and initiating a discussion around advance

directives as a starting point for shared-decision making and patient-centered care (see

Schroeder and Lorenz, 2018). Promoting privacy, controlling noise, providing thermal

comfort and ample lighting in conjunction with a caring attitude will increase the nurse’s

ability to provide a comforting environment to discuss what is important to the patient

and family currently and in the future as the illness progresses in the midst of the ED

chaos (see Alqahtani and Mitchell, 2019). The Caring moment thus becomes the moment

when the nurse and the patient come together in an encounter that is meaningful,

authentic, intentional, and increases the understanding and of new internal and external

discovery of self and others (Watson, 2008, 2012).

Linking Literature to Clinical Practice

Being that the ED nurse is the first person to assess the patient and typically

spends the majority of the time with the patient; the nurse is in a unique position to

promote conversations around palliative goals and discussions of advanced directives.

Using the existing screening assessment used by the institution (which includes

information about disease state and chronic co-morbidities, current advance directives,

previous palliative care consultations, previous hospice admissions, and readmission

within the last 30 days) gives the nurse an idea of patients that may benefit from

discussing goals of care and advance directives early in the ED. The nurse then has an

opportunity to provide the information booklet (in the patient’s language) and begin the

discussion with the family about diagnosis, prognosis, and treatment options. Consistent

with the literature, providing nurses with resources and training to communicate allows

the nurse to promote an environment that is conducive to discussing goals of care and

advance directives. The nurse must take the time to provide privacy; if possible the

patient should be provided a private room away from the main area to reduce

interruptions. Noise reduction, adequate lighting, and allowing the family to be involved

also reduces stress and increases comfort. As the nurse begins to provide care and

discussion with the patient the use of therapeutic touch increases comfort and promotes

the caring moment (see Watson 2012).

The nurse must take a moment before discussion to prepare by first reflecting on

her own beliefs and understanding of the situation (see Revels, et al., 2016). Involving the

family and spokesperson in discussion and using the resources provided as a foundation

for the discussion increases and adds value to the development of the goals of care. As the

nurse provides patient and family education regarding palliative care using the

information provided at a level the patient and family can understand; using Watson’s

theoretical framework promotes a caring environment to discuss it using the Caritas

Process within the current situation.

This project focused on the nurse’s role in identifying seriously-ill patients with

palliative care needs and initiating the discussion around goals of care and advanced

directives to include what is important to them when defining treatment. Goal setting and

discussion is the initial step in developing a holistic approach to care (physical,

emotional, psychosocial, and spiritual) for people that require palliative care and

increased comfort measures in their overall treatment plan. The use of Watson’s caring

theory as the framework for this project will encourage a paradigm shift in the nurse’s

perspective to include a palliative mind-set in a bio-medically focused environment to

provide an environment of comfort and caring when the need arises.

The use of Watson’s caring theory assists the nurse in promoting a caring

environment for patients by incorporating the Caritas process, along with the

development of a transpersonal caring relationship between the nurse and the patient, and

a sacred moment of being to make up the core values reflective of human caring (Watson,

2008, p. 34). The Caring theory or Caring science practices loving kindness, the act of

being an authentic presence, knowing and promoting one’s holistic connection of mind,

body and spirit, therefore being present and allowing the flow of the spirit to connect the

nurse and the patient (Watson, 2008, 2012). In essence, it promotes the nurse-patient

relationship through the nurse as the healing environment. In the CPG the nurse will

focus on the use of Watson’s Caritas process to incorporate the mission of the institution

(the mission of the local setting is to extend the compassionate ministry of Jesus by

improving the health and well-being of our communities and bring good help to those in

need, especially people who are poor, dying and underserved; BSHS, 2017) into the

framework of care provided in the ED. By using Caritas process, the nurse will be able to

incorporate loving, kindness as the environment of healing in the ED as the nurse

seamlessly will promote comfort and healing into every encounter with the patient to

initiate palliative care goal setting in this chaotic, bio-medical focused area.

Step 1: Development of clinical practice guidelines. The goal of this project

was to develop CPG that reflect current best practices to achieve optimal patient

outcomes through quality of care and patient safety. A review of literature was conducted

and the literature, summarized and analyzed findings using Melnyk’s (2011) hierarchy of

evidence matrix, and the summary of findings were distributed to the to key members of

administration, ED medical staff, palliative care staff, and nursing educator for review.

These key members collaborated in the identification of best practices appropriate

for use in this local facility. It was necessary to develop guidelines to formulate education

for nurses to maintain consistency in the approach to screening, delivery, and

documentation for goals of care and initial advance care planning. The existing screening

for palliative care consults resulted in a robust number of referrals for consults that were

not able to be completed in a timely manner. Providing the nursing staff with the

resources to initiate the discussions about this topic allowed the palliative care team to

focus on patients that are in need of pain and symptom management. This intervention

was the first step in developing an interdisciplinary approach to end-of-life care and

initiating it in the ED.

Step 2: Palliative care presentation. A draft of the CPG was developed from the

best practices identified and grounded in Watson’s theory. Once the draft guideline was

developed, the same expert project committee reviewed the document using the AGREE

II checklist and returned the document for revisions until the contents met the local

standards for implementation and the content was deemed valid.

The expert panel consisted of the palliative care physician, the palliative care

nurse practitioner, the ED nursing educator, and the ED medical director. The panel

members had extensive experience working with and treating patients with serious and

life-limiting illnesses with palliative care needs in the emergency care environment.

AGREE II checklist. The AGREE II checklist served as an outline for recording,

tracking, organizing, and analyzing the recommendations obtained from the expert panel

of stakeholders. The checklist also provided an outline for guidance for the development

of the CPG. The domains of the AGREE II model checklist were followed as below:

Domain 1: The expert panel assessed the CPG as it related to the to the targeted

population.

Domain 2: The expert panel evaluated the CPG based on knowledge of palliative

care and clinical experience and the need for guideline development.

Domain 3: Melnyk and Fineout-Overholt’s (2011) rating system was utilized to

appraise the literature used for the creation of the guideline. Using this rigorous method

of development established validity of the best practices found in the literature.

Domain 4: Presentation of the checklist addressed the format, clarity of the

guideline, and the consistency and appropriateness of the language.

Domain 5: The determination of applicability of the key criteria of the guideline

occurred before dissemination to the target population.

Domain 6: Editorial independence allowed the expert panel to offer

recommendations and guidance regarding the CPG and resolve conflicts of interests when

appropriate (Brouwers et al., 2016).

The expert panelists were allowed one week to review, appraise, and make

recommendations for revisions. Once the appraisals were completed, panelists and I met

twice within the next two weeks to discuss the document and reach a consensus for

approval to move to the next level (Method 2: Reaching consensus). The document was

accepted with recommendations to revise the document to include contact information for

the family spokesperson to be recorded in the medical record; this information was added

to the documentation portion of the guidelines. All experts agreed that they would

recommended the guidelines for nurses to use in addition to the completing the existing

palliative care screening tool for palliative care consults used at the institution. Once

revisions of the CPG were completed, the guidelines were referred to the ED operations

board for final approval. The approved guidelines were based on the updated protocols

for palliative care in the ED, information, and resources. Continual collaboration required

discussions with nursing leadership at the site throughout the development of this project.

Once CPG draft was reviewed, revised, and approved by the experts, the draft moved

forward for review and approval from the by the ED Operations Board for

implementation.

Step 3: Implementation of the clinical practice guidelines. The hospital has

indicated that an educational curriculum for the new guidelines will be developed by the

education department using current best practices and palliative care standards. The EB

resources provided by the project, including a resource booklet of educational

information for those staff members who are not able to attend the scheduled

presentations, was provided to the institution that included a list of the references from

this project, a copy of the protocol and guidelines, The Caritas process and the Five

Wishes pocket aide. All staff educational information will be developed and delivered by

the institution’s Nursing Education department.

Step 4: Evaluation of the clinical practice guidelines. The CPG plan included

my recommendations for the local site to collect data post implementation to improve

performance: consistency of documentation of screening assessment of palliative care

needs, increased discussions of goals of care and advanced directives, and increased

referral and follow-up palliative care consultations to meet the quality standards for

accreditation and certification. Data collection in the areas of patient satisfaction and the

financial impact of increasing the ED flow can be used to inform continued quality

improvement to increase patient treatment choices to alternative care pathways (hospice,

community palliative care), and decreased financial burden on the patient and the

institution from futile admissions to the hospital or intensive care units. Any data

collected from the project will be done by the education department and will follow

institutional and federal protocols. The final draft of the guidelines was distributed to the

administrative and education staff. Pre and Post survey evaluations of the educational

presentation will be completed by the education staff using existing institution evaluation

forms to measure attainment of knowledge and effectiveness of the content.

Recommendations

This CPG was based on the Emergency Nursing Scope and Standards of Practice

(2011), the Emergency Nurses Association, “Palliative and end-of-life care: Position

statement” (2019), developed in collaboration with the ED nursing educator and the

palliative care staff experts at the project site. The CPG were originally created for the

adult emergency department to provide guidance to the nurses when discussing palliative

care goals and advance directives: however, it could easily be replicated for use in other

areas of the institution with modifications to suit the unit population and nursing focus.

The administration and leadership agreed that there was a need for nurses to engage in

palliative care discussions as an extension of the palliative care team. I recommend that

since this tool was developed for this project, it should be further researched for

effectiveness within the institution and revised if needed to be consistent with the needs

of the nurses and the population.

The WPCA (2011) reported that more than 29 million individuals could have

benefited from end-of-life conversations prior to their deaths. Providing the nursing staff

with additional training, preparation, and support from leadership will allow the nursing

staff to consistently promote the initiation of these discussions and advocate for patient

goals of care and preferences of treatment early in the admission process. This process

will be used in addition the existing palliative care screening to identify patients with

palliative care needs and discuss immediate treatment preferences based on the advance

directives. Discussing early goals of care may eliminate the overwhelming amount of

palliative care consults and place the focus on patients with palliative needs beyond

discussing advance directives.

My recommendations included the incorporation of the clinical practice protocol

(see Appendix A) and the CPG (see Appendix B) into the daily nursing routine to

promote consistency and collaboration among staff members advocating for quality of

patient care. Once implementation has occurred, revisions from feedback from nursing

staff, palliative care team, and the nursing educator will be incorporated if necessary to

further streamline the process.

The components of the CPG were based on Jean Watson’s Caring theory (Caring

science), specifically the Caritas process (see Appendix D) and transpersonal caring for

providing a sacred space/environment, promoting the transpersonal experience, and

embracing the sacred moment between the nurse and the patient to discuss advance

directives and goals of care in the ED. This project optimized consistency in guiding the

nurses to initiate these discussions and address the need for evidence-based resources to

support the nursing staff in implementing the new guidelines for clinical practice (see

Appendix B). The practice-focused question: What resources are available to guide

evidence-based practice for nurses to implement nurse directed palliative care discussions

in the emergency department?

The institution established a protocol that coincides with the mission and values of

the institution to be used an internal quality check for patients receiving initial palliative

care discussions about goals of care in the ED by nurses. As the nurse is the first person

to have a conversation with the patient it is important that the nurse be aware of her own

feelings and beliefs around dying and caring for patients that are facing death. Watson

realizes that although this theory cannot be verifiable, measured, or testable, it provides

professionals to a way to connect with patients as beings and not objects and allows for

care to be a basis for the connection that occurs between the nurse and the patient (see

Watson, 2008).

The following interpretation of the guidelines using Watson’s Caritas process to

promote the nurse as the environment in the ED will provide a course of action to

integrate high-quality, family-centered compassionate care to patients, families, and

surrogate decision makers. This policy addresses nursing staff’s ability to provide support

to patients and families when discussing goals of care pertaining to their serious and

lifelimiting illness in the ED. The following interpretive guidelines are to be used by the

nurse to ensure standardization in the approach when providing discussions around

advance care planning, goals of care, and the advocacy for patients with serious and

lifelimiting illnesses that present into the ED when using the CPG (see Appendix B).

Watson identifies the nurse first as a person, with feelings, beliefs, and values of

their own that can influence how the nurse interacts and provides care to the patient.

Watson describes the encounter between the nurse and the patient as entering into a

caring moment that goes beyond the completion of tasks to provide holistic care to allow

the nurse and the patient form a deeper connection. In preparation for this interaction

between the nurse and a patient, the nurse may practice deep breathing and meditative

exercises to help relax and focus on herself as a person as well as a professional before

providing patient care. These practices help the nurse to identify their own inner feelings

of providing palliation to patients that are in need of comfort care and encourages the

practice of incorporating compassion, kindness, and love toward self and others as

proposed by the process of caritas nursing (see Watson, 2008).

Additionally, Watson realizes that the word nurse is synonymous with health.

Nursing is a caring science where the nurse connects to patients as to preserve humanity

and dignity. The nurse recognizes that health is holistic in nature and embraces spiritual

health as important as emotional and physical. Watson believes that the transpersonal

caring relationship between the nurse and the patient is the foundation for a holistic

approach to health (Watson, 2008).

Finally, as the nurse prepares the environment for the patient with palliative needs,

the nurse is empowered to promote any atmosphere into a venue of loving, caring,

kindness that helps people connect mind, body, and spirit (see Watson, 2008). Watson

approach sponsors preserving dignity and harmony and the promotion of healing

environment. Practicing nursing tasks and protocols that reduce stress on the individual,

endorse restraint reduction initiatives, and enhance fall prevention initiatives, are some

other examples of promoting the theory. Taking the time and the initiative to sit down

with patients, hold their hand, maintain eye contact, and provide reassurance are some

primary examples of practicing Watson’s theory.

Watson believes the nurse has the ability to enhance healing through the use of the

caring theory and that it encompasses the ideas of the nurse as the person, health, and the

environment. The following guidelines with interpretation reflect Watson’s approach to

ministering to patients in the ED to support the nurse as the person, health, and as the

environment. The caring theory promotes acts of loving kindness, of being an authentic

presence, knowing and promoting one’s holistic connection of mind, body and spirit,

being present and allowing for a spiritual connection between the nurse and the patient

(Watson, 2008, 2012).

The use of Watson’s caring theory and the Caritas process as a foundation to

promote the atmosphere of the ED into an environment that places comfort about cure,

the nurse prepares to allow her presence to transform the environment into a place where

caring, compassion, and spiritual connection increase trust and understanding of the

trajectory of care. In order to follow the protocol and the guideline, the nurse must first

enter into self-refection that moves the nurse into a manifestation of being and knowing

of their own beliefs, values, and self-care associated with the idea of death, preparation

for death, and the caring for the dying in order to be open to the beliefs and values of the

patient (see Watson, 2012).

As the nurse accepts the care of the patient in the ED, the initial introduction

conveys the nurses as a professional and places the nurse in a unique position to

administer care on a professional level and as the assessment becomes more

comprehensive to include cultural beliefs as a foundation to build a relationship with the

patient and the family in which trust can be built to uphold the patient’s care as a personal

expression of desires for holistic care (Beckstrand et al., 2017). As the nurse has

previously explored their inner perspective of own thoughts around caring for patients

with palliative care needs, the promotion of a healing and caring environment can be

employed through the Caritas Process to promote environment of comfort to discuss this

topic. The following description is the basis for building a caring environment using the

Caritas rocess (see Appendix D).

Some studies suggest providing a space that is dedicated to the palliative or dying

patient that provides privacy for patients and families and to be subjected to the chaos of

the ED (Bradley et al., 2013, Basol et al., 2015, Tse et al., 2016). However, some

institutions are unable to provide a private space and therefore, using the core concepts of

the Caritas process the nurse finds that the chaotic environment of the ED can become a

place where caring relationships and compassion build trust between the nurse and the

patient. Watson’s theory (2008, 2012) and Caritas process provided a foundation that was

used to promote an environment that is agreeable for the nurses to support a presence and

atmosphere to discuss goals of care in the ED. Providing the nurse with the resources to

engage with patients makes it more likely that the more patients will identify and

document their goals of care as the first step in providing palliative care in the ED. As the

nurse is able to understand and incorporate evidence based resources into the routine

engagement with the patient, it empowers the nurse to be an advocate for patient directed

shared-decision making and educate patients and families when needed. The nursing

scope of practice identifies education of patients and families related to all aspects of life

including end of life care. Watson differentiates curative factors as the “aim at curing the

patient of disease, carative factors aim at the caring process that helps the person attain

(or maintain) health or die a peaceful death” (Watson, 1985, p.7). The following

interpretation of the Caritas Process was used as a framework to base the project in the

ED (Watson, 2008).

Integrating the Caritas Process (The Nurse as the Environment)

Practicing loving‐kindness and equanimity increases the connection between

providing basic care and providing care that is founded in empathy and compassion.

Maintaining poise through basic interaction such as healing touch and active listening has

a profound effect on promoting healing in patients. Taking the time to sit down and listen

to their concerns helps to build trust and promotes the sense of the nurse as being present,

establishing an atmosphere of care.

Being authentically present and enabling, and sustaining the deep belief system

and subjective life world of self and one‐being‐cared‐for. Watson's theory believes the act

of being authentically present enables the belief that others are unique individuals. As the

nurse is authentically present, emotions and spirituality become evident and are able to be

experienced by the nurse and the patient within the environment. The encounter is about

making spiritual connections with patients and families understanding and experiencing a

deep connection. Building trusting relationships between the nurse and the patient is the

building block that allows for the discussion of fears, concerns, and goals of care.

Cultivating one's own spiritual practices and transpersonal self, going beyond

ego self. Watson describes meditation and centering as a spiritual practice that helps the

nurse to be in the present moment with the patient. She believes that deep breathing

exercises during hand washing or bed making are examples of being in the Caritas

Consciousness (ie, being present, accepting the patient as a being, and connecting with

the patient). Encouraging the nurse to practice these principles increases the ability of the

nurse to transform any environment into a caring environment.

Developing and sustaining a helping‐trusting, authentic caring relationship.

Through open and honest communication, the nurse maintains a safe, ethical, and mature

relationship where the patient is able to openly discuss issues without feeling judged or

coerced.

Being present to, and supportive of the expression of positive and negative

feelings. The nurse maintains a safe environment for the patient to express concerns and

fears. Acknowledges that the patient is uncertain about what experiences lay ahead. The

nurse encourages open discussion, sharing own experiences and allowing the patient and

family to express thoughts and understanding of events and education.

Creatively using self and all ways of knowing as part of the caring process;

engaging in artistry of caring‐healing practices. The nurse is aware of how he/or she

creates a healing environment is integrated through the use of healing touch, tone of

voice, appropriate eye contact, smiling and active listening. Through this approach, the

nurse is able to engage the patient in a caring moment that allows trust and sharing.

Engaging in genuine teaching‐learning experience that attends to wholeness and

meaning, attempting to stay within other's frame of reference. Through active listening

and engagement with the patient, the nurse enters into an experience of sharing

information for the purpose of educating the patient based on what the patient’s current

understanding is. The nurse must remain open to the worldview of the patient and take

this into consideration when educating the patient regarding decision making and goal

setting.

Creating healing environment at all levels, whereby wholeness, beauty, comfort,

dignity, and peace are potentiated. Watson’s beliefs that a healing environment is also

important is grounded in the works of Florence Nightingale (1946) as she noted the

benefits of a healing environment. Natural light, beauty of nature, quietness, sound,

soothing decorations, thermal regulation are important elements conducive to comfort in

an environment of spiritual healing. As the ED is not necessarily able to provide these

elements, it is the role of the nurse to use creative ideas to promote a caring environment

to endorse palliation in the ED.

Assisting with basic needs, with an intentional caring consciousness,

administering ‘human care essentials,’ which potentiate alignment of mind‐body‐spirit,

wholeness in all aspects of care. Views the patient as a being and not as a disease process

or a task. Supports and encourages others to reduce anxiety and respects the privacy of

the patient. The nurse is careful to involve the family in the care of the patient if the

patient permits and encourages the patient and the family to speak openly.

Opening and attending to mysterious dimensions of one's life‐death; soul care for

self and the one‐being‐cared‐for; “allowing and being open to miracles”. The nurse

encourages the patient and family to explore their feelings openly without judgement

about death, dying, and the afterlife. The nurse allows the caring moment to happen and

supports the patient and family in their hope.

The nurse will must incorporate the Caritas process into the routine of the ED to

promote the transition from curative to comfort. The nurse will identify potential

palliative care patients in need of care discussion using the existing palliative care

assessment screening tool and will follow up with the initiation of the palliative care

discussion to define goals of care using the CPG (Appendix B. Wang (2016), suggested

that early palliative care intervention such as identification of goals of care and initiation

of advance directives early may directly impact patient quality of life and the utilization

of healthcare such as futile admissions and treatments.

Strengths and Limitations of the Project

One important strength of the local setting included the recent focus on

evidencebased nursing practice. This facility had already begun providing evidence based

resources for nurses to increase the quality of care and patient satisfaction at the inception

of care. The protocol and the guidelines as well as the interpretive guidelines for the

NDPCD will provide a framework for nurses to provide patients with the opportunity to

have palliative care discussions and identify what their preferences for treatment that

provides them with the dignity to choose the way they want to live and to die. Another

strength of the environment was that medical and nursing schools are beginning to

integrate palliative care in their curricula, although this education continues to be

inconsistent across programs and there is little standardization in the definitions and the

languages that are used throughout the healthcare system; this can also be con. This leads

to confusion and mistrust. My recommendation is to standardize the education and

language for palliative and end-of-life care. Although this project addressed only one

aspect of palliative care at one local setting, there is much more work to do in this space

to provide quality of care and patient satisfaction for patients with serious and lifelimiting

illnesses and those who are imminently dying. Recommendations for future projects will

address issues that recognize palliative care discussions as part of the initial assessment

for patients entering the ED. Further recommendations may include palliative care

discussions to bridge the gap between curative and hospice care earlier in the disease

trajectory.

Limitations of the project is that staff have been practicing palliative care in the

ED based on life experience and may be reluctant to change their mindset. According to

the nursing educator, the staff in the ED feel having goals-of-care discussions is out of

their scope of practice, noting they have a palliative care department for this approach,

and the ED is not a place for patients in need of comfort care. Another limitation was

getting the staff together for educational activities.

My plan is to disseminate this work is to provide the draft CPG and a resource

booklet that contains palliative care discussion resources and current evidence-based

articles to support the nursing staff in implementing the change in clinical practice

throughout the institution. The new protocol and guidelines should be discussed in the

unit-based meetings, placed on the hospital intranet, and posted in all staff-access-only

rooms, if approved by leadership. Other clinical personnel such as the medical staff and

the community nurse would benefit from this information as well. My ultimate

recommendation would be to advance the protocol to all nursing staff internal and

ancillary to the hospital. I would also recommend that the institution use follow up chart

audits to collect data for Quality Assurance Performance Improvement (QAPI) to provide

insight in to the number of patients that are provided the opportunity for palliative

discussions and those that are provided a palliative care consult prior to discharge.

Summary

It is expected that upon implementation, the institution will experience an increase

in palliative care discussions. A positive result will provide a ripple effect in the use of the

protocol and nursing guidelines within to include the participation of ancillary

departments and community outreach programs promoting shared-decision making and

advance directive development. In the next section, I focus on dissemination and analysis

of self at the completion of the program.

Section 5: Dissemination Plan

Dissemination

I selected the emergency department as my study setting because this area has

been overlooked as an area appropriate for advance directives discussions and palliative

care planning (ENA, 2019). The gap in the literature clearly showed that there is a robust

number of seriously-ill patients who could benefit from early identification of goals of

care and completion of advance directives. The practice guideline for this project was

developed and will be used by the nursing staff at an inner-city emergency department to

meet the needs of the patients of the community.

My initial plans for disseminating this project included providing the nursing

education department with the draft CPG and the resources to educate the nursing staff. I

also provided a resource booklet with references and articles that will promote

understanding of the need for the CPG and the use of Watson’s caring theory for the

nursing staff to have onsite. There is the possibility the institution will expand the project

to other areas in the hospital. Beyond the initial presentation and implementation of the

CPG, I would recommend that the institution incorporate this project into the new hire

orientation and as an annual competency for the ED nursing staff. I believe that this

project closed the gap to improve the early completion of advance directives by seriously-

ill patents and for all patients. My plan is to submit a manuscript for publication to a peer-

reviewed journal for emergency nurses and possibly close the gap between ED nursing

and palliative care. Another possibility is to submit an abstract to the Emergency Nurses

Association (ENA) annual conference to be able to reach a much larger audience.

Analysis of Self

As a scholar, I believe I have identified a specific need in the continuum of care

from curative to end-of-life. I was able to investigate the gap in the care and provide

evidence-based remediation in this area of professional nursing practice. I was able to

identify a theoretical framework along with evidence that supported the creation and

implementation of a new protocol and CPG that will improve quality of care for patients

with palliative care needs. Research of this area was inspirational and frustrating at times

due to the lack of research in this specific area. This project has fostered my interest in

palliative care delivery, the need for early discussions regarding preferences and goals of

care, and the need for consistent education for all health care workers in this area. I

believe this project nurtured my personal growth as an educator, a patient advocate, a

leader, and a mentor.

As a project manager, I found that time management and communication with the

institution and my mentor increased my ability to meet goals on a timely manner.

However, there were many challenges as this project is only a small part of a much bigger

need for improvement in palliative, end-of-life, and advance care planning. I have grown

in personal and professional insight, I have developed more confidence in my ability as a

scholar and a project manager. I have been able to identify a holistic approach to

providing better outcomes for patients through providing better resources for nurses.

Developing and implementing this project honed my skills in the establishment of

EBP, application of a theoretical model to ground nursing practice, and leadership in

organizational change. Moreover, I was able to help the staff nurses to realize their own

ability to identify gaps in clinical practice and use EBP to increase quality outcomes.

Summary

The implementation of a practice guideline for the nursing staff to conduct initial

discussions around goal planning and advance directive completion will improve patient

satisfaction and improve patient outcomes. Future research and potential projects should

include the development and implementation of comfort protocols for patients that come

to the ED and initiating palliative care in the community and community outreach.

To conclude, the purpose of this DNP CPG development project was to provide

ED nurses with evidence-based resources to initiate the palliative care discussion around

goals of care and advance directives for patients with serious and life-limiting illnesses.

The anticipated outcomes for this project (EB protocol, clinical guidelines, and

interpretive guidelines) will be an increased perceived preparedness that will be evaluated

by the nursing educator using the standard evaluation tool for used by the institution.

Providing resources to prepare nurses to successfully implement the protocol, will

improve care delivery and patient outcomes. As an added benefit, perhaps the trust

between the community and the health care system will improve. In the future, the CPG

may be extended to other areas of the institution and in community outreach; if decided

by executive leadership.