Palliative Nurses Association Research Articles

Palliative Nursing Summit: Nurses Leading Change and Transforming Primary Palliative Care: Nursing's Role in Providing Pain and Symptom Management.

Effective pain and symptom management is a crucial part of the care of those with life-threatening illnesses and their family members. Nurses in all settings have a vital role in providing this essential care. A recent summit held on May 12, 2017, "Nurses Leading Change and Transforming Palliative Care," convened by the Hospice and Palliative Nurses Association and attended by leaders of 26 nursing organizations strongly endorsed the importance of nursing's role in pain and symptom management and developed an agenda to advance these efforts. The agreed-upon goals of pain and symptom treatment include care that is effective (as defined by the patient), efficient (delivered in a timely manner), and safe (reduced risk of respiratory depression, prevention and early management of adverse effects, as well as attention to methods to prevent diversion such as safe storage and disposal). Through an iterative process, desired patient outcomes and nursing actions were outlined to support effective pain and symptom management in primary palliative care. These recommendations were categorized as education, clinical care, research, and regulatory concerns. This article reports on the outcomes of this summit related to pain and symptom management.

Palliative Nursing Summit: Nurses Leading Change and Transforming Care: The Nurse's Role in Coordination of Care and Transition Management.

The Hospice and Palliative Nurses Association Palliative Nursing Summit (Summit) "Nurses Leading Change and Transforming Care" brought nurses from numerous specialties together to discuss collaboration in advancing primary palliative nursing. Nursing leadership was highlighted, and the future of integrating primary palliative care was emphasized. Three workshop groups held discussions on key collaborative topics of communication/advance care planning, pain and symptom management, and coordination of care/transition management (CCTM). Nursing has historically led the way in CCTM, especially in acute- and long-term-care settings. The philosophy and principles of CCTM are in direct alignment with the values and guidelines for quality palliative care. Goals of CCTM include the achievement of optimal health, equal access to care, and appropriate utilization of health care resources, balanced with the patient's right to self-determination. This article presents an overview of the patient and family outcomes and nursing actions identified by the group regarding CCTM.

American Society for Pain Management Nursing and Hospice and Palliative Nurses Association Position Statement: Pain Management at the End of Life

Pain at the end of life continues to be of great concern as it may be unrecognized or untreated. Although nurses have an ethical obligation to reduce suffering, barriers remain regarding appropriate and adequate pain management at the end of life. This joint position statement from the American Society for Pain Management Nursing and Hospice and Palliative Nurses Association contains recommendations for nurses, prescribers, and institutions that would improve pain management for this vulnerable population.

Liberty and Justice for All.

: This series on palliative care is developed in collaboration with the Hospice and Palliative Nurses Association (HPNA; http://hpna.advancingexpertcare.org). The HPNA aims to guide nurses in preventing and relieving suffering and in giving the best possible care to patients and families, regardless of the stage of disease or the need for other therapies. The HPNA offers education, competence, advocacy, leadership, and research.

Update in Hospice and Palliative Care.

The objective of this update, presented at the 2017 Annual Assembly of the American Association of Palliative and Hospice Medicine (AAHPM) and the Hospice and Palliative Nurses Association (HPNA), is to identify, summarize, and critique a sampling of research from the prior year that has the potential for marked impact on hospice and palliative clinical practice. Eight reports of original research published between January 1, 2016 and December 31, 2016 were identified through a systematic PubMed search using the terms "hospice" and "palliative care," a hand search of 22 leading healthcare journals, and discussion with experts in the field. Candidate articles were ranked based on the study's methodological quality, appeal to a breadth of palliative care clinicians across different settings, and potential clinical practice impact. We summarize the eight articles with the highest ratings and give recommendations for clinical practice.

Competency Milestones

Advanced practice nurses with specialty-level skills in hospice and palliative care are urgently needed to optimize care delivery for Americans with advanced serious illness. Leaders in the healthcare and nursing communities encourage new nurses to pursue higher education pathways, to enroll in postgraduate training programs, and to pursue career-long learning. An integral part of the learning process is evaluating competence in the knowledge, skills, and attitudes defined for the discipline. However, there are currently no established methods to track achievement of clinical competence for either trainees or practicing palliative nurses. In this article, the authors present the Advanced Practice Palliative Nurse Competency Milestones, a tool to assess and document emerging competency of palliative nurses across the career trajectory from novice to specialist. It is derived from the evidence-based Hospice and Palliative Nurses Association competencies for advanced practice palliative nurses and mapped across a developmental continuum using Benner’s novice-to-expert framework. The authors describe the tool’s development and application over a 2-year period.

The Quality Improvement Environment: Results of the 2016 AAHPM/HPNA Membership Needs Assessment Survey

ContextThe American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA) convened the Measuring What Matters (MWM) initiative in 2013, which recommended 10 quality performance measures; yet, little is known about the quality improvement (QI) environment and implementation of the MWM among hospices and palliative care services. ObjectivesThe objective of this study was to describe the findings of the 2016 AAHPM/HPNA Needs Assessment survey exploring the QI environment among hospice and palliative care services. MethodsAn online survey was distributed to approximately 16,500 AAHPM and HPNA members, and other hospice and palliative care organizations were invited to respond. Summary data and individual write-in responses were collated and analyzed. Data analysis included generating descriptive statistics and analyzing individual write-in responses for additional information and themes. ResultsMore than 1000 responses were received. Most organizations had a designated QI leader and used an electronic medical record. Less than 50% of systems had fields for palliative care information. The top three MWM measures collected through an electronic medical record were pain treatment (66%), screening for physical symptoms (55%), and comprehensive assessment (54%). The most common barrier to implementing QI was time constraint. Most respondents had received no training and education in how to implement QI. ConclusionsThe 2016 AAHPM/HPNA Needs Assessment Survey provided important information about the QI systems and measurement environment within hospice and palliative care services. Survey insights can aid AAHPM/HPNA in developing resources to empower hospice and palliative care clinicians to make QIs that matter for their patients and families.

Special Article: Leadership in Palliative Nursing

In 2016, the Hospice and Palliative Nurses Association created the Nessa Coyle Leadership Fund to recognize the career achievements of Nessa Coyle, PhD, RN, as a pioneer in the field of palliative nursing and an exemplar of leadership. The first lectureship recognizing this award was presented at the annual assembly of the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association in February 2017. This article is based on that lectureship and summarizes key leadership themes identified in Dr Coyle’s career.

Advance Care Planning: The Nurse's Role.

: This series on palliative care is developed in collaboration with the Hospice and Palliative Nurses Association (HPNA; http://hpna.advancingexpertcare.org). The HPNA aims to guide nurses in preventing and relieving suffering and in giving the best possible care to patients and families, regardless of the stage of disease or the need for other therapies. The HPNA offers education, certification, advocacy, leadership, and research.

A Survey of Hospice and Palliative Nurses Association Nurse Educators’ Teaching Practices and Attitudes Toward Driving Safety in Hospice and Palliative Care Patients

In 2014, the National Hospice and Palliative Care organization estimated that 1.6 to 1.7 million Americans received hospice services, an increase of nearly 20% from the year 2010. Approximately 20% to 25% of hospice patients have the functional ability to drive. The increasing number of patients served by hospice and palliative services makes the issue of driving safety more important than ever. Because nurses practice at the frontline of care, they have an integral role in determining whether patients have the ability to drive safely. Our objective was to examine the teaching practices and attitudes of Hospice and Palliative Nurses Association (HPNA)–certified nurse educators regarding patient driving safety. An anonymous, cross-sectional email survey was sent to the 276 HPNA-certified nurse educators. One hundred twenty-six nurse educators (46%) responded. A large majority (90%) either strongly agree or agree that teaching nurses how to determine whether a patient is at risk for impaired driving is important. A minority, however, reported educating nurses on how to (1) determine whether a patient is at risk for impaired driving (18%), (2) counsel patients about impaired driving (21%), and (3) report potentially impaired drivers to the proper authorities (21%). Most nurse educators do not feel confident in their ability to teach nurses on the topic of impaired driving (38%) but are receptive to further education (87%). There is a need for further education of HPNA nurse educators in the area of patient driving safety.

“It Is Like Heart Failure. It Is Chronic … and It Will Kill You”: A Qualitative Analysis of Burnout Among Hospice and Palliative Care Clinicians

ContextAlthough prior surveys have identified rates of self-reported burnout among palliative care clinicians as high as 62%, limited data exist to elucidate the causes, ameliorators, and effects of this phenomenon. ObjectivesWe explored burnout among palliative care clinicians, specifically their experiences with burnout, their perceived sources of burnout, and potential individual, interpersonal, organizational, and policy-level solutions to address burnout. MethodsDuring the 2014 American Academy of Hospice and Palliative Medicine/Hospice and Palliative Nurses Association Annual Assembly, we conducted three focus groups to examine personal narratives of burnout, how burnout differs within hospice and palliative care, and strategies to mitigate burnout. Two investigators independently analyzed data using template analysis, an inductive/deductive qualitative analytic technique. ResultsWe interviewed 20 palliative care clinicians (14 physicians, four advanced practice providers, and two social workers). Common sources of burnout included increasing workload, tensions between nonspecialists and palliative care specialists, and regulatory issues. We heard grave concerns about the stability of the palliative care workforce and concerns about providing high-quality palliative care in light of a distressed and overburdened discipline. Participants proposed antiburnout solutions, including promoting the provision of generalist palliative care, frequent rotations on-and-off service, and organizational support for self-care. We observed variability in sources of burnout between clinician type and by practice setting, such as role monotony among full-time clinicians. ConclusionOur results reinforce and expand on the severity and potential ramifications of burnout on the palliative care workforce. Future research is needed to confirm our findings and investigate interventions to address or prevent burnout.

Productivity in Pediatric Palliative Care: Measuring and Monitoring an Elusive Metric

ContextWorkforce productivity is poorly defined in health care. Particularly in the field of pediatric palliative care (PPC), the absence of consensus metrics impedes aggregation and analysis of data to track workforce efficiency and effectiveness. Lack of uniformly measured data also compromises the development of innovative strategies to improve productivity and hinders investigation of the link between productivity and quality of care, which are interrelated but not interchangeable. ObjectivesTo review the literature regarding the definition and measurement of productivity in PPC; to identify barriers to productivity within traditional PPC models; and to recommend novel metrics to study productivity as a component of quality care in PPC. MethodsPubMed® and Cochrane Database of Systematic Reviews searches for scholarly literature were performed using key words (pediatric palliative care, palliative care, team, workforce, workflow, productivity, algorithm, quality care, quality improvement, quality metric, inpatient, hospital, consultation, model) for articles published between 2000 and 2016. Organizational searches of Center to Advance Palliative Care, National Hospice and Palliative Care Organization, National Association for Home Care & Hospice, American Academy of Hospice and Palliative Medicine, Hospice and Palliative Nurses Association, National Quality Forum, and National Consensus Project for Quality Palliative Care were also performed. Additional semistructured interviews were conducted with directors from seven prominent PPC programs across the U.S. to review standard operating procedures for PPC team workflow and productivity. ResultsLittle consensus exists in the PPC field regarding optimal ways to define, measure, and analyze provider and program productivity. Barriers to accurate monitoring of productivity include difficulties with identification, measurement, and interpretation of metrics applicable to an interdisciplinary care paradigm. In the context of inefficiencies inherent to traditional consultation models, novel productivity metrics are proposed. ConclusionsFurther research is needed to determine optimal metrics for monitoring productivity within PPC teams. Innovative approaches should be studied with the goal of improving efficiency of care without compromising value.

Concordance Between Veterans' Self-Report and Documentation of Surrogate Decision Makers: Implications for Quality Measurement

ContextThe Measuring What Matters initiative of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association identified documentation of a surrogate decision maker as one of the top 10 quality indicators in the acute hospital and hospice settings. ObjectivesTo better understand the potential implementation of this Measuring What Matters quality measure #8, Documentation of Surrogate in outpatient primary care settings by describing primary care patients' self-reported identification and documentation of a surrogate decision maker. MethodsExamination of patient responses to self-assessment questions from advance health care planning educational groups conducted in one medical center primary care clinic and seven community-based outpatient primary care clinics. We assessed the concordance between patient reports of identifying and naming a surrogate decision maker and having completed an advance directive (AD) with presence of an AD in the electronic medical record. ResultsOf veterans without a documented AD on file, more than half (66%) reported that they had talked with someone they trusted and nearly half (52%) reported that they had named someone to communicate their preferences. ConclusionsOur clinical project data suggest that many more veterans may have initiated communications with surrogate decision makers than is evident in the electronic medical record. System changes are needed to close the gap between veterans' plans for a surrogate decision maker and the documentation available to acute care health care providers.

For Advanced Cancer, What Treatment Is Next?

This article is the second in a series on palliative care developed in collaboration with the Hospice and Palliative Nurses Association (HPNA; http://hpna.advancingexpertcare.org). The HPNA aims to guide nurses in preventing and relieving suffering and in giving the best possible care to patients and families, regardless of the stage of disease or the need for other therapies. The HPNA offers education, certification, advocacy, leadership, and research.

Palliative Chemotherapy

This article is the first in a series on palliative care developed in collaboration with the Hospice and Palliative Nurses Association (HPNA; http://hpna.advancingexpertcare.org). The HPNA aims to guide nurses in preventing and relieving suffering and in giving the best possible care to patients and families, regardless of the stage of disease or the need for other therapies. The HPNA offers education, certification, advocacy, leadership, and research.

Making Your Measurement Matter: Implementing the AAHPM & HPNA Measuring What Matters Project (TH341)

Making Your Measurement Matter: Implementing the AAHPM & HPNA Measuring What Matters Project (TH341) David J. Casarett, MD MA FAAHPM, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Sally A. Norton, PhD RN FAAN, University of Rochester School of Nursing, Rochester, NY. Sydney Morss Dy, MD MSc, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, MD. Keela Herr, PhD RN AGSF FAAN, University of Iowa College of Nursing, Iowa City, IA. Joseph D. Rotella, MD MBA FAAHPM, American Academy of Hospice and Palliative Medicine, Chicago, IL. Katherine Ast, MSW LCSW, American Academy of Hospice and Palliative Medicine, Chicago, IL. Dale Lupu, PhD, American Academy of Hospice and Palliative Medicine, Chicago, IL. Marianne Matzo, PhD APRN-CNP FPCN FAAN, Hospice and Palliative Nurses Association, Pittsburgh, PA.

Palliative Care: Is It at the National Policy Table or On the Menu? (TH350)

Making Your Measurement Matter: Implementing the AAHPM & HPNA Measuring What Matters Project (TH341) David J. Casarett, MD MA FAAHPM, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Sally A. Norton, PhD RN FAAN, University of Rochester School of Nursing, Rochester, NY. Sydney Morss Dy, MD MSc, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, MD. Keela Herr, PhD RN AGSF FAAN, University of Iowa College of Nursing, Iowa City, IA. Joseph D. Rotella, MD MBA FAAHPM, American Academy of Hospice and Palliative Medicine, Chicago, IL. Katherine Ast, MSW LCSW, American Academy of Hospice and Palliative Medicine, Chicago, IL. Dale Lupu, PhD, American Academy of Hospice and Palliative Medicine, Chicago, IL. Marianne Matzo, PhD APRN-CNP FPCN FAAN, Hospice and Palliative Nurses Association, Pittsburgh, PA.

Methodological Research Priorities in Palliative Care and Hospice Quality Measurement

Quality measurement is a critical tool for improving palliative care and hospice, but significant research is needed to improve the application of quality indicators. We defined methodological priorities for advancing the science of quality measurement in this field based on discussions of the Technical Advisory Panel of the Measuring What Matters consensus project of the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association and a subsequent strategy meeting to better clarify research challenges, priorities, and quality measurement implementation strategies. In this article, we describe three key priorities: 1) defining the denominator(s) (or the population of interest) for palliative care quality indicators, 2) developing methods to measure quality from different data sources, and 3) conducting research to advance the development of patient/family-reported indicators. We then apply these concepts to the key quality domain of advance care planning and address relevance to implementation of indicators in improving care. Developing the science of quality measurement in these key areas of palliative care and hospice will facilitate improved quality measurement across all populations with serious illness and care for patients and families.

Hospice and Palliative Nurses Association 2015-2018 Research Agenda

Hospice and Palliative Nurses Association 2015-2018 Research Agenda

Spiritual Perspective, Mindfulness, and Spiritual Care Practice of Hospice and Palliative Nurses

Spiritual care is a key tenet of palliative care. A nurse's spiritual perspective has been recognized as an influencing factor in spiritual care, and results from several studies have shown an increase in spiritual perspective as a result of participation in programs designed to develop mindfulness as well as developing skills necessary for spiritual care. A descriptive correlational design was used with a convenience sample of nurses from the Hospice and Palliative Nurses Association. Data were collected online using the Spiritual Perspective Scale, Mindful Attention Awareness Scale, and the Nurse Spiritual Care Therapeutics Scale. Spiritual perspective was positively correlated with age (ρ = 0.2, P = .046), years of registered nurse experience (ρ = 0.208, P = .039) and higher in those with a religious affiliation (U = 392.5, P < .001, r = 0.54). A positive correlation was found between mindfulness and spiritual care (r = 0.212, P = .05), with mindfulness explaining 4.5% of the variance in spiritual care. No significant relationships were found between spiritual perspective and mindfulness or spiritual care. Identifying mindfulness as a factor that may influence spiritual care has implications for education, research, and practice.