Introduction
Palliative care is a sensitive part of the healthcare system since providers have to ensure the physical and psychological comfort of patients who are old or have terminal conditions. However, as the literature suggests, nurses lack knowledge on proper ways to assess patient’s needs and provide palliative care. Most individuals referred to palliative care facilities are cancer patients, despite the range of conditions that also require a referral, which results in patients being shifted between the hospitals. This gap leads to patients suffering from inadequate care and them being transferred between nursing homes and hospitals. This quality improvement project addresses this disparity by studying the nurse’s knowledge of palliative care assessment tools before and after an intervention in a long-term care facility. This paper will detail a PICOT-based project on nursing knowledge of palliative care and overview the terms, concepts, methodology, and implications for nurses.
Problem
Some researchers tried to determine if the patients who need to be referred to a palliative care facility due to their illness receive this referral and the nurses’ knowledge about palliative care assessments. For example, Harazneh et al. (2015) state that out of their sample, only 40% were able to identify patients who require palliative care. In practice, these findings mean that patients who need to be referred to a special facility and who require more attention and care when compared to others do not receive these services because the medical staff does not have the knowledge and training to identify those needs.
The demand for palliative care in the United States will continue to increase as the population ages, and more people with chronic or terminal illnesses will require the assistance of medical professionals. According to Cruz-Oliver (2017), the demographic characteristics of the population had changed drastically since the 1990s, when a significant proportion of children and infants died before reaching adulthood. Nowadays, the majority of deaths are attributed to people of old age, which is the consequence of the medicine’s development (Cruz-Oliver, 2017). However, this also means that a larger proportion of the population reaches old age, and the healthcare system has to be prepared to address this challenge by caring for older adults and addressing the end of life care. Most older adults die due to their chronic conditions and their complications, which are typically preceded by a period of disability and health deterioration (Cruz-Oliver, 2017). Despite these demographic changes, healthcare education and practice have not adapted to accommodate the needs of patients who need palliative care, and many nurses do not have the knowledge to assess the need for palliative care since they were not trained to use the appropriate tools.
Palliative care in general needs more attention and research to develop frameworks of the end of life care that help patients and their families go through this experience. Not all states are prepared to address the challenge since only three out of five continents have established palliative care frameworks (Cruz-Oliver, 2017). The United States has a system of palliative care as part of its healthcare, and many older adults choose nursing homes as they age and are no longer to take care of themselves. However, the state of knowledge that the medical professionals working in these facilities have is insufficient to address the needs of this population, and as a result, patients suffer from low quality of care and poor outcomes. Therefore, the problem that this quality improvement project address is the inadequate educational and practice preparation of nurses for working with the aging population since there is a need to implement new practices, frameworks, and assessment tools suitable for palliative care.
Purpose/ PICO Clinical Questions/Objectives
A PICO or PICOT question, according to the University of Laverne (n.d.), is a formula developed for medical researchers that helps them create sufficient research questions. By using this formula, one can structure the research process better and improve the process of collecting evidence and answering the question. Each element of the PICO abbreviation stands for a specific issue that must be included in the research: “population, intervention, control, outcome, and time” (University of Laverne, n.d., para 5). This quality improvement project also uses a PICO formula to address the issue of palliative care in long-term care facilities.
The purpose of this improvement initiative is to investigate whether the proposed intervention method will improve the nurses’ knowledge regarding palliative care and therefore help improve patient outcomes. This is a quality improvement project; hence, the issue in question affects the quality of services and patient outcomes. Cruz-Oliver (2017) notes that there are many underrecognized conditions that require patients to receive palliative care, while nurses are trained to address this issue only for older adults or cancer patients. Hence, a large proportion of the patient population is not assessed for palliative care and cannot receive the help they need.
The main objective is to find a solution to the insufficient provision of palliative care in the United States. Patients who should be referred to these facilities often spend time being shifted from one hospital to another, which affects their experience, emotional, and psychological health (Harazneh et al., 2015). This project helps improve the nurses’ understanding of palliate care tools and their application, which, if successful, can be implemented and used on a regular basis.
Definition of Terms
According to the WHO (2020), palliative care is “an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness” (para. 1). The goal is to ensure that patients and their family members have physical and emotional comfort when confronted with serious illnesses, which implies that nurses working in palliative care units have to be skilled not only in providing medical care but also have sufficient communication and empathy skills to help individuals live through this difficult experience. WHO (2020) also states that spiritual comfort is part of palliative care.
A palliative care trigger assessment tool is a method for determining if a patient should be referred to a palliative care facility. According to CAPC National Seminar (2019), a recent study shows that out of 60% of patients in an ICU who meet the criteria for palliative care, only 31% received a referral. The problem is linked to the fact that nurses did not use a trigger assessment tool to determine the patient’s actual state of health. Hence, a palliative trigger tool can help examine the patient’s cases and determine if one needs to be transferred to a palliative care institution.
The National Institute on Aging (NIA) (2017) defines long-term care facilities designed to meet an individual’s personal and health needs for both short and long-term periods. Nursing homes are an example of long-term care because older adults who have difficulty addressing their daily needs are referred to these institutions. Hence, long-term care is often linked to caring for patients who are old or who suffer from terminal illnesses, and it is vital for the personnel to be able to assess the needs of these patients since “people often need long-term care when they have a serious, ongoing health condition or disability” (NIA, 2017, para 10).
Conceptual Underpinning and Theoretical Framework of the Project
The Palliative Care Framework was designed to address the approaches and methods that medical professionals can use when working with patients who have terminal conditions. The difference between this framework and others is that palliative care requires nurses to show not only excellence in their clinical expertise but also their ability to provide emotional and spiritual support to their patients. According to Palliative Care Competence Framework Steering Group (2014), the goal of this framework is to “provide for core competencies in palliative care whilst also detailing individual competencies for each health and social care discipline” (p. 3). Moreover, the framework should be used when developing academic programs and designing curriculum for nurses since it includes some of the core aspects of palliative care that each medical professional should know.
Under this framework, when working with individuals who have life-shortening conditions, medical professionals should use a multidisciplinary approach, meaning that they have to collaborate with other teams and departments to ensure the comfort of the patient and their family members. Some of the competencies under this framework include communication, optimizing care to ensure the quality of life, collaboration, and addressing grief and bereavement (Palliative Care Competence Framework Steering Group, 2014). The last element is the most challenging part of palliative care since patients and their families often struggle when reflecting on end-of-life decisions, and medical professionals should be able to provide individuals with support, which is why using palliative care assessment tools is essential.
Methodology
This quality improvement project will be based on the Plan-Do-Study-Act model (PDSA). PDSA allows one to improve the intervention upon its implementation based on its effectiveness and continue making these improvements until the objective is reached. The study design is comparison, which means that the researcher will assess and compare the results before and after the implementation. This study’s setting is a long-term care center in Miami. Fifteen registered nurses from this facility will be recruited to participate. The instrument used to gather data is a questionnaire that will help the researcher assess the nurses’ palliative care knowledge before and after the implementation of the intervention for quality improvement. Additionally, as part of the quality improvement initiative, the Palliative Care Trigger Tool (PALLA 10) will be implemented.
Hence, data collection will be completed through the questionnaire, and the researcher will analyze the responses before and after the project’s onset. Human subject projection and ethical standards will be adhered to, and the participants will be notified of the projects’ purpose and the type of data that will be collected. Next, the details of the PDSA model applied to this project will be discussed. After planning the intervention, the “do” stage will include implementing the plan and introducing the PALLA 10 assessment tool. The “study” stage will include the researcher gathering the data from the nurses using the questionnaire. Finally, the “act” stage involves an evaluation of the quality improvement project and its results.
Results
The sample of this research project is registered nurses who work in long-term care facilities. The results should show whether the proposed intervention allows the nurses to improve the clinical outcomes of the patients and the medical professional’s knowledge of the palliative care practices. The study design implies a comparison between two data samples, and in this case, the responses of the nurses will be compared before and after the intervention. The sample will be selected randomly from all nurses who work in the facility, and the random sampling design will allow receiving data that represents the general state of palliative care knowledge in this facility.
Discussion
This quality improvement project is important because the population in the United States and globally is aging, and palliative care will become more in demand. As people age, they develop more chronic conditions, some of which may lead to death, requiring the caregivers to support and help the individual in question. The existing evidence shows that most nurses do not possess sufficient knowledge about this area of practice and that their knowledge affects patient outcomes (Harazneh et al., 2015). This insufficiency may become a serious burden for the healthcare system once more citizens require palliative care services. Hence, there is a need for initiatives targeting quality that would address the aspects of palliative care that have a direct impact on patient outcomes.
If the post-intervention assessment provides evidence that palliative care is more effective when nurses use a palliative care assessment tool or not, the study results can be used to advocate for the inclusion of this assessment tool in the curriculum for advanced practice nurses. Proper education is the key to addressing the patients’ needs, especially in palliative care, where pain management is only one element of the issues that an individual may face. Since palliative care is a basic human right in accordance with WHO’s definition (2017), healthcare education and practice must be adapted to ensure that all individuals who need palliative care receive it.
Implications for Advanced Practice Nursing
The main implication of this PICOT project is that an improved understanding of palliative care will help nurses be more attentive to the patients’ needs and their health problems, which will lead to better patient outcomes. Nurses who use the palliative trigger tool are able to identify the patient cases where intervention and a referral to a palliative care facility are necessary, unlike those who do not apply this assessment measure, which means that patient outcomes in the former case are better. Hence, this study and quality improvement project have the potential of enhancing the quality of care provided in long-term care facilities and general hospitals since the including of training that addresses this trigger tool can help nurses work with patients who have life-limiting conditions.
Advanced practice nurses should be able to plan the care of their patients, and in case of life-limiting illnesses, it is their responsibility to recognize the patient’s need to receive assistance and specialized care. According to Palliative Care Competence Framework Steering Group (2014), nurses should be involved in “assessing need, promoting and preserving choice, predicting likely problems and planning for the future in the context of a changing and deteriorating disease trajectory” (p. 18). Hence, the findings of this quality improvement project will contribute to the nursing theory and practice and will help approve the patients’ quality of life.
Conclusions
In summary, this paper outlines a quality improvement project designed using a PICOT question, which addresses the quality of palliative care in relation to the nurses’ knowledge. The implication is that palliative care will be in higher demand in the future since the population is aging, and nurses should be prepared to provide physical, emotional, and spiritual support to these individuals. Hence, this quality improvement project will examine 15 nurses who work in a long terms care facility in Miami through a comparative design. The nurses will respond to a questionnaire, then familiarize themselves with a palliative care framework and respond to the same questions afterward. The implications of this quality improvement project are the ability to improve patient outcomes and quality of care for people who require palliate care services.
Summary of the Literature
The issue of nurses’ knowledge regarding palliative care has been extensively studied by researchers due to the underlying implication that the comprehension of palliative care tools affects the quality of healthcare services and patient’s experience. Achora and Labrague (2019) state that “education and the clinical experience of nurses in palliative care influenced their knowledge and attitudes toward palliative care” (p. 29). Based on their findings, the author recommends including more information about palliative care into nursing education programs and ensuring that upon graduation, professionals have access to reinforced palliative care education and support networks.
Palliative care assessment tools are not a part of the study curriculum for most nurses. A study by Fatma and Terzioğlu (2017) shows that 52% of nurses who work in a gynecology unit have never had training specifically dedicated to palliative care. However, the authors acknowledge that these nurses often work with women who have terminal conditions, such as cancer, yet their understanding of how to care for them is limited by the ability to revive the physical pain and address their physiological needs. Moreover, over 70% of nurses who responded to the survey stated that they have never talked about death to their patients, which is an integral part of proper palliative care (Fatma & Terzioğlu, 2017). Both nurses and patients may feel uncomfortable discussing death and dying; however, in palliative care, it is essential to ensure that the patient’s best interests and wishes are considered, and having this discussion is an integral part of an assessment.
When considering the potential explanations as to why palliative care referrals are limited, the nature of this area of medicine should be considered. WHO (2020) argues that palliative care is more complex when compared to other areas of healthcare because it requires not only the assessment of physical needs but also bereavement counseling. Moreover, it is recognized as a part of the human’s basic rights, and therefore, it is essential for the medical personnel to receive sufficient training that will allow them to address the palliative care needs of their patients. Hence, in order to recognize that patients need palliative care, a nurse must be able to assess not only their physical symptoms but also their emotional and spiritual wellbeing, which is a challenging task if one does not have appropriate tools.
References
Achora, S., & Labrague, L. (2019). An integrative review on knowledge and attitudes of nurses toward palliative care. Journal of Hospice & Palliative Nursing, 21(1), 29-37.
CAPC National Seminar. (2019). Initiation of a trigger tool to facilitate early palliative medicine intervention in a community hospital ICU. Web.
Cruz-Oliver, D. (2017). Palliative care: An update, Modern Medicine, 114(2), 110-115.
Fatma, U. S. & Terzioğlu, F. (2017). Nurses’ knowledge and practice toward gynecologic oncology palliative care. Journal of Palliative Care & Medicine, 7(4), 3-6.
Harazneh, L., Ayed, A., & Fashafsheh, I. (2015). Knowledge of palliative care among bachelors nursing students. Journal of Health, Medicine and Nursing, 18, 25-32.
National Institute on Aging. (2017). What is long term care? Web.
Palliative Care Competence Framework Steering Group. (2014). Palliative Care Competence Framework. Web.
University of Laverne. (n.d.). What is a PICOT question? Web.
WHO. (2020). Palliative care. Web.