PALLIATIVE CARE PROFESSIONAL DEVELOPMENT A MULTICENTER PROGRAM FOR CRITICAL CARE NURSES: 1.0 Hour

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1 PALLIATIVE CARE PROFESSIONAL DEVELOPMENT FOR CRITICAL CARE NURSES: A MULTICENTER PROGRAM By Wendy G. Anderson, MD, MS, Kathleen Puntillo, RN, PhD, Jenica Cimino, BA, Janice Noort, RN, NP, MS, ACHPN, Diana Pearson, RN, MSN, CCRN-K, Deborah Boyle, RN, MSN, AOCNS, Michelle Grywalski, RN, BSN, Jeannette Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN, Edith O Neil-Page, RN, MSN, AOCNS, Julia Cain, RN, MSN, ANP, Heather Herman, RN, MS, ANP, Susan Barbour, RN, WOCN, ACHPN, Kathleen Turner, RN, CHPN, CCRN-CMC, Eric Moore, RN, MBA, NEA-BC, Solomon Liao, MD, Bruce Ferrell, MD, William Mitchell, MD, Kyle Edmonds, MD, Nathan Fairman, MD, MPH, Denah Joseph, MFT, John MacMillan, MD, Michelle M. Milic, MD, Monica Miller, RN, MS, CCRN, Laura Nakagawa, LCWS, David L. O Riordan, PhD, Christopher Pietras, MD, Kathryn Thornberry, MSW, LCSW, and Steven Z. Pantilat, MD C E 1.0 Hour This article has been designated for CE contact hour(s). See more CE information at the end of this article. This article is followed by an AJCC Patient Care Page on page 372. Background Integrating palliative care into intensive care units (ICUs) requires involvement of bedside nurses, who report inadequate education in palliative care. Objective To implement and evaluate a palliative care professional development program for ICU bedside nurses. Methods From May 2013 to January 2015, palliative care advanced practice nurses and nurse educators in 5 academic medical centers completed a 3-day train-the-trainer program followed by 2 years of mentoring to implement the initiative. The program consisted of 8-hour communication workshops for bedside nurses and structured rounds in ICUs, where nurse leaders coached bedside nurses in identifying and addressing palliative care needs. Primary outcomes were nurses ratings of their palliative care communication skills in surveys, and nurses identification of palliative care needs during coaching rounds. Results Each center held at least 6 workshops, training 428 bedside nurses. Nurses rated their skill level higher after the workshop for 15 tasks (eg, responding to family distress, ensuring families understand information in family meetings, all P <.01 vs preworkshop). Coaching rounds in each ICU took a mean of 3 hours per month. For 82% of 1110 patients discussed in rounds, bedside nurses identified palliative care needs and created plans to address them. Conclusions Communication skills training workshops increased nurses ratings of their palliative care communication skills. Coaching rounds supported nurses in identifying and addressing palliative care needs. (American Journal of Critical Care. 2017; 26: ) AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5

2 Palliative care is a specialty and focus of care that aims to improve quality of care for patients who have serious and complex illnesses and their families. 1-3 Patients in intensive care units (ICUs) and their families have palliative care needs, including emotional support, management of pain and symptoms, and clinician-family communication to ensure that patients receive treatments that are consistent with their goals In the ICU, palliative care is provided along with life-sustaining therapies and may be delivered by the ICU team (primary palliative care), a palliative care consult service (specialty palliative care), or both. 2,3,14 A number of barriers to integrating palliative care into the ICU have been identified, including inadequate training of clinicians and misperceptions About the Authors Wendy G. Anderson is an associate professor, Jenica Cimino is a clinical research coordinator, David L. O Riordan is a senior research specialist, and Steven Z. Pantilat is a professor in the Division of Hospital Medicine and Palliative Care Program, University of California, San Francisco, California. Anderson is an associate professor and Kathleen Puntillo is a professor emerita in the Department of Physiological Nursing, University of California San Francisco School of Nursing, San Francisco, California. Janice Noort is a palliative care nurse practitioner, Diana Pearson is a critical care nurse educator, Eric Moore is a palliative care and medical surgical nurse manager, Nathan Fairman is a psychiatry and palliative care physician, John MacMillan is a physician and palliative care medical director, Monica Miller is a critical care nurse, and Laura Nakagawa is a social worker at University of California, Davis Medical Center, Sacramento, California. Deborah Boyle is an oncology clinical nurse specialist, Michelle Grywalski is a critical care nurse educator, and Solomon Liao is a palliative care physician and service director at University of California, Irvine Health, Orange, California. Jeannette Meyer and Edith O Neil-Page are palliative care clinical nurse specialists and Christopher Pietras is director of palliative care at University of California, Los Angeles Medical Center, Los Angeles, California. Pietras is an assistant professor in the Division of General Internal Medicine, Hospitalist Section/Palliative Care, University of California, Los Angeles, California. Bruce Ferrell is a palliative care physician and medical director at Vitas Hospice, Encino, California. Julia Cain and Heather Herman are palliative care nurse practitioners, William Mitchell is a palliative care physician and service director, Kyle Edmonds is a a palliative care physician, and Kathryn Thornberry is a palliative care social worker at University of California, San Diego Health, San Diego, California. Susan Barbour is a palliative care clinical nurse specialist, Kathleen Turner is a critical care bedside nurse, and Denah Joseph is a chaplain and palliative care service associate director at University of California, San Francisco Medical Center, San Francisco, California. Michelle M. Milic is an associate professor in the Division of Pulmonary, Critical Care, and Sleep Medicine, MedStar Georgetown University Hospital, Washington, DC. Corresponding author: Wendy G. Anderson, MD, MS, University of California, San Francisco, 533 Parnassus Avenue, Box 0131, San Francisco, CA ( wendy.anderson@ucsf.edu). that such treatment is the same as hospice, comfortfocused care, or end-of-life care. 3 Families, physicians, and nurses identify involvement of bedside nurses as a key factor in the quality of ICU palliative care Nurses training and constancy at the bedside position them to identify palliative care needs, coordinate communication among families and an array of clinicians, and support and educate families. 15,16,19,21 Despite the success of palliative nursing education programs, 22,23 we found at our centers and in the literature that ICU nurses perceived a number of barriers to their involvement in palliative care, including lack of clarity about their role and inadequate communication training. 17,18,24 To address these deficits, we developed, implemented, and evaluated a system-wide initiative called Integrating Multidisciplinary Palliative Care into the ICU (IMPACT-ICU), based on pilot work at one of our centers. 25 IMPACT-ICU aims to train and support bedside nurses to lead primary palliative care by identifying patients palliative care needs and integrating the perspectives of their colleagues from other disciplines into a plan that addresses those needs. Methods The project was conducted between May 2013 and January 2015 at the 5 medical centers of an academic health system. Each of these centers contains 1 to 2 hospitals, 400 to 785 beds, and 5 to 8 ICUs. We targeted 2 ICUs at each center, including cardiac, medical, medical-surgical, neurologic, and surgicaltrauma units. Investigators at the coordinating site, including bedside and advanced practice nurses, a nurse researcher, palliative and critical care physicians, and a chaplain led the initiative. Leadership teams at each site included 2 nurse leaders, who were palliative care advanced practice nurses or nurse educators with experience in nursing education and palliative care communication; a palliative care physician; and the director of the palliative care consultation service. A grant from our health system funded the program design, nurse leader training, and program evaluation, with the goal of the initiative continuing without additional funding through the nurse leaders roles as educators. In consultation with the institutional review AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5

3 Table 1 Intervention planning worksheet: factors influencing bedside nurses involvement in palliative care Target behavior Target audience Other key individuals Daily palliative care assessments and plans to address patient/family needs ICU bedside nurses ICU physicians, family members of patients, advanced practice nurses, palliative care teams Predisposing: stages of precontemplation and contemplation KNOW What is palliative care? What are the key domains in a palliative care assessment? How to assess patient symptoms, family support, communication about prognosis, and goals of care BELIEVE/VALUE Responsibility: It is my job to assess palliative care needs and work with the ICU team to address them Possible positive impact: It is rewarding to connect with families and physicians about what really matters Possible negative impact: Physicians get upset if I voice concerns Efficacy: I can identify needs and bring together a plan to address them Others expect me to play this role: hospital/unit leadership, physicians Social norm: Senior and charge nurses, peers play this role INTENTION To assess patient symptoms on a daily basis and report to ICU team To start discussions with families about prognosis and goals of care To initiate discussions with physicians about prognosis and goals of care To attend family meetings and actively participate in discussions Abbreviation: ICU, intensive care unit. Enabling: stages of preparation and action BE ABLE TO (skills) Assess patients symptoms Assess family understanding of prognosis and goals of care Collaborate with physicians to develop a plan to address palliative care needs Address family information and emotional needs in family meeting Describe palliative care and the benefits of a consultation to a physician and a family member Cope with stresses of ICU work ACCESS TO Effective, learner-centered communication skills training to practice palliative care communication Physicians present in unit and willing to have discussions Support at the bedside from advanced practice nurses to navigate difficult situations and barriers Palliative care consultations for complicated patients BARRIERS REMOVED Even if physician not agreeable to palliative care consultation, unit resource nurses and advance practice nurses can be called to navigate difficult situations and barriers Coverage from colleagues to facilitate discussions with family members and attending family meetings Reinforcing: stages of maintenance of behavior REMINDED Nurse contributes palliative care assessment to team as part of daily rounds Advanced practice nurses round on unit regularly to remind nurses to perform assessments POSITIVE REINFORCEMENT Positive connection with families and physicians Feel you are making a difference to patients and families Feel care you are providing is what patients really want, and know patients/family understand prognosis Have the opportunity to voice concerns to family and physician Praise from physicians, managers, advance practice nurses, palliative care teams, peers NEGATIVE REINFORCEMENT Physicians disregard/do not respond to nurses concerns SOCIAL SUPPORT Support from peers in unit Support from palliative care team members ICU-palliative care committee meetings Managers boards at the 5 centers, we determined that, as quality improvement, the project did not require review. To design the structure, methods, and content of our intervention, we used a planning worksheet that integrates aspects of 5 common behavior theories: health belief model, theory of planned behavior, social cognitive theory, an ecological perspective, and transtheoretical model. 26 We organized factors found in previous work to influence bedside nurses involvement in palliative care 17,18,21,25,27-29 on the basis of whether they predisposed, enabled, or reinforced bedside nurses to perform daily palliative care assessments and develop plans to address identified needs (Table 1). An overview of the initiative follows. The project guide is available from the authors. Train-the-Trainer Program for Nurse Leaders To guide the nurse leaders at each site, the coordinating site developed a 2-year train-the-trainer program. 30 This program began with an in-person 3-day training session, the length and content of which were informed by prior experience of the coordinating center in training faculty to facilitate use of role playing in communication skills training In the 3-day session, the leaders learned skills training theories and processes, 21,25,31-33 observed a communication workshop for bedside nurses conducted by the coordinating center faculty, and practiced role-play facilitation under the direction of the coordinating center faculty. After returning to their centers, the nurse leaders assembled local leadership teams at AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5

4 Nurse leaders at 5 centers conducted palliative care communication workshops for ICU bedside nurses. their site, which included bedside and advance practice nurses, managers, educators, social workers, chaplains, and physicians who assisted them in implementing the initiative. Coordinating site investigators conducted 2-day visits at each site to provide feedback on the first communication workshop conducted by the nurse leaders and their teams. Monthly phone calls and yearly in-person meetings facilitated mentoring from coordinating site investigators and peer mentoring among sites. Communication Skills Training Workshop for Bedside Nurses Nurse leaders worked with ICU managers to schedule workshops and invite nurses to participate. Bedside nurses did not pay to attend; they received continuing education credit and could use education leave. The workshop goal was to teach bedside nurses communication skills for building therapeutic relationships with families, eliciting family goals and needs, and working effectively with physicians to promote awareness among the family and care team of the patient s status and the family s needs and goals. The content, length, and methods of the communication skills training workshops for bedside nurses are described elsewhere 25 and followed best training strategies: 8 hours in length, using a small-group format and a learner-centered approach, brief didactics about palliative care and the nurse s role in prognosis and goals of care communication, and facilitated role-playing. 21,25,31-33 In role-plays, nurse leaders guided bedside nurse participants as they played the part of nurses, families, and physicians to practice skills in discussing prognosis and goals of care in one-on-one discussions and family meetings. A reflection session was focused on skills for coping with the stress of working in the ICU. Specialty Palliative Nursing Coaching Rounds To train bedside nurses in the process of identifying palliative care needs and mobilizing the ICU interdisciplinary team to address these needs, we created a coaching program in which the nurse leaders rounded regularly in target ICUs. Rounds focused on nurses caring for seriously ill patients, defined as patients with serious illness before ICU admission, severe acute illnesses and traumas, multiple organ system failure, or other conditions leading to a high risk for death or long-term functional impairment. The rounding process was pilot tested between May 2013 and October 2013, revised on the basis of feedback from all sites, and implemented in a final form between November 2013 and December We developed a record to guide the rounding process and track nurse and patient data (Appendix 1 available online only at First, the nurse leaders guided the bedside nurse through the process of identifying the patient s uncontrolled signs and symptoms, 12 the family s support needs, 4,34 and communication to date about prognosis and goals of care. The rounds discussion included the bedside nurse s assessment of the family s and physicians perspectives, and identifying whether a multidisciplinary family meeting had occurred. 34 Nurse leaders provided support and education to the bedside nurse, based on challenges the bedside nurse identified. Finally, the nurse leader coached the bedside nurse to develop a plan to address the identified needs. This plan could involve care provided by the ICU clinicians (primary palliative care), a consultation from a palliative care advanced practice nurse, and/or a consultation from the full palliative care team (specialty palliative care). 2,14 Leaders aimed to conduct rounds at least twice per month in each unit, for at least 4 hours per unit per month. Program Evaluation Our evaluation plan (Appendix 2 available online only) included inputs, activities, and outcomes, following the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation evaluation framework. 35,36 Quantitative data sources included 3 elements: First was a survey that bedside nurses (n = 428) completed at the beginning and end of the workshop, rating their skill level in 15 palliative care communication tasks on Likerttype scales. The survey was based on instruments developed for our needs assessment 18 and ICU nurse communication trainings. 21,25 Next was a survey designed by the authors that nurse leaders (n = 8) completed before and after the 3-day train-thetrainer session and at the end of the 2-year training, rating on Likert-type scales their skill level in key elements of small-group facilitation and role-playing for communication skills training. 33 Last, records were kept of the coaching rounds in the ICUs (1110 patients, Appendix 1), including information from patients medical records about hospital length of stay, whether palliative care was consulted, and discharge disposition. Qualitative data sources included notes taken during the 3-day nurse leader training, in-person meetings (day-long, yearly), site visits (2 days per AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5

5 site), and conference calls (1-hour, monthly), and exit surveys completed by project leaders at each site (open-response about impact to date and plans for sustaining and expanding the program). Analysis Levels of skill were dichotomized as poor, fair, or good versus very good or excellent. We used McNemar tests to compare the number of bedside nurses who reported a very good or excellent level of skill versus a good, fair, or poor level for each survey item before and after the communication workshop. From rounding records, we reported types of support and education provided by the nurse leaders, frequency of needs identified by bedside nurses, and frequency of bedside nurse involvement in palliative care communication; r 2 statistics were used to assess changes over time. Data were collected and managed using Research Electronic Data Capture (REDCap) electronic data collection tools hosted at the coordinating site. 37 We used SPSS version 22 for Mac (IBM Corp) for statistical analyses. The principal investigator of the project conducted a thematic analysis of qualitative data to identify key themes in the domains of barriers, facilitators, and impacts of the program. 38 Rigor was established through detailed evaluation planning and data collection, continuous iterative analysis during the evaluation period, triangulation of themes across different data sources, reflexive dialogue with team members, and verification of themes by the site leadership teams Results Train-the-Trainer Program for Nurse Leaders Between May 2013 and January 2015, the coordinating site trained 2 nurse leaders from each of the other 4 sites. Although statistical comparisons were not conducted because of the small sample size, the percentage of nurse leaders who reported a very good or excellent level of skill to conduct small-group communication skills training sessions for bedside nurses was higher after the 3-day in-person training and at the end of the 2-year program than at the beginning of the program for all skills assessed (Appendix 3 available online only). Communication Skills Training Workshops for Bedside Nurses in the Intensive Care Unit Between June 2013 and January 2015, nurse leaders and their teams conducted at least six 8-hour workshops at each center, with a total of 35 workshops for 428 ICU nurses. The percentage of nurses reporting a very good or excellent level of skill was Elicit a family s understanding of a patient s prognosis. Elicit a family s understanding of a patient s goals of care. Identify a family s need for information about a patient s illness and treatments. Identify and respond to a family member s expressions of emotional distress. Elicit a physician s perspectives on a patient s prognosis. Elicit a physician s understanding of a patient s goals of care. Convey a family s communication needs to a physician. Communicate the need for a family meeting to a physician. Provide families with emotional support during family meetings. Ensure that a family s needs for information are addressed during a family meeting. Ensure that a family member understands information that is presented during a family meeting. Define palliative care. Communicate the value of a palliative care consultation to a physician. Describe palliative care and how it can be useful to a patient s family member. Use self-care practices to prevent burnout and compassion fatigue. 24% 19% 25% 20% 20% 28% 24% 36% 31% 32% 31% 31% 31% 45% 47% 56% 55% Before workshop (n = 428) After workshop (n = 428) 65% 64% 61% 62% 65% 67% 63% 65% 66% Figure 1 Intensive care unit (ICU) bedside nurses evaluations of the communication workshop. Participating bedside nurses rated their skill to engage in 15 palliative care communication tasks before and after the workshop. Response options were: excellent, very good, good, fair, and poor ; the chart shows the percentage of nurses rating their skill as excellent or very good. For all skills shown, the percentage of participants reporting an excellent or very good level of skill was higher after than before the workshop (P <.01). significantly higher in surveys completed after the workshop for all 15 palliative care communication tasks assessed (all P <.01 compared with surveys completed before the workshop; Figure 1). Specialty Palliative Nursing Coaching Rounds Between May 2013 and December 2014, nurse leaders rounded in each of the 10 target ICUs a mean 71% 71% 70% 69% % of ICU bedside nurses who reported excellent or very good level of skill AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5

6 Percentage of patients Percentage of patients Percentage of patients Uncontrolled patient symptoms identified by bedside nurse N = R 2 = 0.53, P = Months into project period (May 2013-December 2014) Family distress identified by bedside nurse N = 1110 R 2 = 0.67, P = Months into project period (May 2013-December 2014) Concerns about family-clinician communication about prognosis and goals of care identified by bedside nurse N = R 2 = 0.79, P = Months into project period (May 2013-December 2014) Figure 2 Bedside nurses identification of palliative care needs for patients discussed during coaching rounds throughout the project period. The identification of needs was tracked via records completed by nurse leaders during rounds. Blue lines indicate the percentage of patients at each time point; red lines indicate line of best fit for trend during the project period. of 1.6 times per month (range, 0-4), for a mean of 3 hours per unit per month (range, 0-9). Records tracking the patient discussed and support provided to the nurse were completed for 1110 patients. Review of these patients medical records revealed that they were seriously ill: median hospital length of stay was 20 days (range, days), 36% died during the hospital stay, and 20% were discharged to a skilled nursing facility. Despite the seriousness of their illnesses, only 36% of patients upon whom rounds had been focused had a palliative care service consultation documented during their hospital stay. During coaching rounds, bedside nurses identified palliative care needs for 82% of patients. Uncontrolled symptoms were identified as a need in 53%, including pain (26% of patients), shortness of breath (14% of patients), anxiety (13% of patients), and confusion (10% of patients). Family distress was identified in 50% of patients families. Bedside nurses expressed concern about the quality of family-clinician communication about prognosis and goals of care in 52% of patients. Throughout the project, bedside nurses identification of family distress and concerns about family-clinician communication about prognosis and goals of care during coaching rounds increased, but no significant trend was apparent in identification of uncontrolled symptoms (Figure 2). In addition, bedside nurses increasingly reported that they had discussed the patient s prognosis and goals of care with the patient s physician, although frequency of discussions with families did not increase (Figure 3). The plan developed by the bedside nurse and nurse leader to address the identified needs most frequently entailed the ICU interdisciplinary team providing primary palliative care (49% of patients). For 19% of patients, the bedside nurse and nurse leader planned for a palliative care advanced practice nurse to assess the patient. For 32% of patients, the bedside nurse advocated to the ICU physician team for a consultation by the entire palliative care team. During rounds, nurse leaders provided education and support to the bedside nurse on a range of topics, including information about palliative care; advising on communication strategies and skills for having discussions with families, physicians, or in family meetings; pain and symptom assessment and management; supporting the nurse; and resources (Appendix 4 available online only). Implementation Facilitators, Barriers, and Additional Program Impacts Table 2 lists the main barriers we encountered while implementing the program and how we AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5

7 100 Bedside nurse had discussed patient s prognosis and goals of care with the family N = 1110 R 2 = 0.08, P = Bedside nurse had discussed patient s prognosis and goals of care with the physician N = 1110 R 2 = 0.76, P =.01 Percentage of patients Percentage of patients Months into project period (May 2013-December 2014) Months into project period (May 2013-December 2014) Figure 3 Bedside nurses involvement in communication about prognosis and goals of care with families and physicians during the project period. Their involvement was tracked via records completed by nurse leaders during rounds. Blue lines indicate the percentage of patients at each time point; red lines indicate line of best fit for trend during the project period. Table 2 Barriers to program implementation and how each was addressed Barrier Concerns that bedside nurses involvement in communication about prognosis and goals of care would be at odds with physicians, leading to conflict and confusion Concern that our program was advocating palliative care team consults for all patients, and that palliative care indicated that a patient was at the end of their life Varying unit cultures around involvement of nurses and other nonphysician clinicians in communication about prognosis and goals of care Methods of addressing Improving collaboration with physicians and decreasing mixed messages to families was a key program focus in the communication workshop and rounding. Nurses roles were delineated: to elicit needs and provide family support independently, and to clarify and reinforce understanding of prognostic information provided by physicians. In describing the program to center and unit leaders and physicians, we emphasized this collaborative focus. Teaching nurses to define palliative care and describe it to families and physicians using patient-centered language was a key program focus. 1 The main program focus was on supporting nurses to provide generalist or primary palliative care, 2 with engagement of specialty palliative care services for the most complicated patients. A key component of information we provided about the program the definition of palliative care, including that it is for all seriously ill patients and their families, focuses on quality of life, and can be provided concurrently with life-prolonging therapies. We also emphasized the role of all clinicians in providing palliative care. Extensive stakeholder discussions to address concerns about nurses role and get buy-in before beginning project. Selecting units where managers and medical directors as well as beside nurses supported the program. Ongoing monitoring of program implementation in each unit, and willingness to switch units when needed. In one originally chosen target unit, key physicians were not accepting of nurses involvement in prognosis and communicating goals of care. We switched units, and the program was implemented in the new unit. addressed them. Discussions among the site teams and hospital and unit leaders, nurses, and physicians about the definition of palliative care, the difference between primary and specialty palliative care, and the role of nurses in palliative care communication were sufficient to overcome barriers and implement the program in 9 of the initially chosen 10 target ICUs. In 1 ICU, resistance to nurses involvement in palliative care communication remained so strong that we thought we could not sufficiently implement the project; we changed to another target unit at that hospital, in which we did implement the program. An additional factor that facilitated implementation of our program was engagement of stakeholders from multiple levels and disciplines, including medical center and unit leaders and other clinicians who were involved in the care of patients on the target units. In our qualitative analysis, we found a number of positive effects related to the initiative (Table 3). AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5

8 Table 3 Influence of the IMPACT-ICU program at the initiative medical centers: themes with exemplar quotations from project records and exit interviews with initiative leaders from each site Theme Increased scope of practice and efficacy of bedside nurses to advocate for patients and families and ensure that they receive care that is consistent with their goals Involvement of nurses improves quality of interdisciplinary prognosis and goals of care communication, including focus on family perspective Increased access of bedside nurses to specialty palliative care and stronger working relationship between bedside nurses and palliative care nurses and consult teams Expansion of palliative care service into the ICU, and synergy between the IMPACT-ICU program and other efforts to integrate palliative care into the ICU and hospital Appreciation and demand for communication workshop among bedside nurses Exemplar quotations As a result of the training received through the IMPACT-ICU program, a nurse in one of our ICUs facilitated a family meeting that allowed a patient to make a decision to go home instead of continuing therapy in the ICU. The patient did not know his true prognosis. The nurse coached the patient and family to ask about prognosis in the family meeting. Hearing this information allowed the patient to say he wanted no more treatment for his cancer, and wanted to be home with his family. Three days later he passed away surrounded by his family. If not for the nurse, this patient may have been intubated and not been able to make his wishes known. The family called after the patient passed away and thanked the nurses. Nurse educator and site leader At our palliative care committee, a physician reported how the ICU nurse had been instrumental in their family meeting and helped to assure that the family s needs for communication were met. The physician also commented on how the nurse really brought the family s perspective to the table and enhanced the quality of the meeting. Nurse educator and site leader IMPACT-ICU has led to a consistent line of communication between our palliative care clinical nurse specialists and ICU nurses, empowering bedside nurses and giving access to specialty palliative care nursing recommendations and education even when the palliative care consult team is not involved. Palliative care physician and site leader The palliative care team is very appreciative of the staff nurse s participation in family meetings. Palliative care clinical nurse specialist and site leader As a member of the palliative care team, I feel that there are many more nurses who are knowledgeable and enthusiastic about collaborating with our service, and know how to make that happen more often than before. Palliative care team member and initiative leader The most significant contribution of the IMPACT-ICU project was the much-needed expansion of palliative care into the ICU setting. Critical care is an area that our palliative care service has very much wanted to further penetrate; this project enabled us to help meet this goal. Palliative care nurse practitioner and site leader The nurses who participated have resoundingly appreciated the communication workshop. It was so successful that nurses from the other ICUs were upset that they couldn t participate. Hence we have planned 2 upcoming sessions for the other ICU nurses and 2 for medical, surgical, oncology nurses. Palliative care clinical nurse specialist and site leader Abbreviations: ICU, intensive care unit; IMPACT-ICU, Integrating Multidisciplinary Palliative Care Into the ICU. These advantages included improved quality of interdisciplinary communication, increased access of bedside nurses to specialty palliative care, and synergy with other efforts to integrate palliative care in the ICU. Leaders at all sites reported continuing initiative activities after the end of the project period, including expansion to additional ICUs and acute care units, and interprofessional trainings including physicians, therapists, and social workers. Discussion We developed and disseminated across 5 medical centers a professional development program for bedside nurses to promote their ability to lead primary palliative care by identifying patients palliative care needs and integrating the perspectives of their colleagues from other disciplines into a plan to address those needs. Our program, IMPACT-ICU, was designed to address identified barriers to integration of palliative care into the ICU and to increase bedside nurses engagement in palliative care. 3,17,18,21,25-29 A combination of learner-centered communication training workshops and bedside coaching rounds led by advanced practice palliative care nurses and nurse educators helped bedside nurses to feel more skilled to engage in palliative care communication, as well as to be more involved in identifying and addressing palliative care needs. The initiative was focused on nurses, to address the gap between their actual and potential involvement in palliative care communication ,21,24 Our findings indicate that IMPACT-ICU prepared nurses AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5

9 to positively contribute to communications among patients families and the interprofessional team. Training bedside nurses is necessary but not sufficient for full integration of palliative care into the ICU. Programs like IMPACT-ICU could complement training developed for other ICU clinicians Some of our sites have expanded the IMPACT-ICU program to include participants from other disciplines. We hope that training of ICU clinicians, in conjunction with integration of palliative care processes into routine practice, 44 will influence aspects of palliative care that did not improve with our program, such as identification of uncontrolled symptoms. Our work is significant, considering the growing focus on ICU palliative care, 3-10,45-47 for which a number of models exist. 3,4,8,46,47 Prior work emphasizes the importance of care provision by clinicians with expertise in palliative care, 47 yet palliative care consultation services cannot see all seriously ill ICU patients. 48 For example, only 36% of patients discussed on our rounds received a palliative care service consultation. We provided bedside nurses with the core skills that palliative care consultants use to navigate discussions of prognosis and goals of care and coached them as they incorporated these skills in practice. Engaging palliative care specialists to train and coach frontline clinicians is a promising model for extending the reach of palliative care consultation services. 49 Although we did not achieve our target rounding frequency or time, our findings indicate that contact between specialty palliative care teams and ICU nurses strengthened relationships and enhanced collaboration. Consistent with previous work, 5 the main challenges we encountered in implementation related to the definition of palliative care and the concepts of primary and specialty palliative care. 1,2,14 Challenges to palliative care integration, as well as nurses experiences, often vary by ICU type. 17,18,50-55 In our initiative, the culture around nursing involvement and palliative care led to our substituting 1 ICU for another. Certainly, our experience underscores the importance of developing a shared vision of palliative care and the role of nurses and of seeking input and support from key unit stakeholders before and throughout implementation. 7 Our project had the following limitations. First, primary outcomes were nurses self-reported skills and identification of palliative care needs; we did not evaluate patient or family outcomes. Second, our only objective measure of nurse leaders teaching was the reported skill level of the bedside nurses they taught. Third, we focused on nurses; significant patient and family outcome improvements require training, support, and coordination of all members of the ICU interdisciplinary team. Finally, we implemented this initiative with the support of a grant in large, tertiary care academic centers, with nursing education and palliative care consultation services; different models will be required for dissemination to other settings. Conclusions The IMPACT-ICU program enabled nurse leaders to implement communication skills training workshops and coaching rounds for ICU bedside nurses. Workshops and rounds, in turn, increased bedside nurses self-ratings of their expertise and involvement in palliative care communication and identification of patients palliative care needs. Such changes, in coordination with training and support of other disciplines, could be expected to improve patient care; future research should examine this potential. ACKNOWLEDGMENTS This project would not have been possible without the support of the leadership of all 5 University of California medical centers, the dedication and caring of the bedside nurses who participated in this program, and the support and guidance of the University of California Center for Health Quality and Innovation Quality Enterprise Risk Management (CHQIQERM) program. FINANCIAL DISCLOSURES This work was supported by the CHQIQERM program, a joint venture of the University of California Center for Health Quality and Innovation and the Office of Risk Services. SEE ALSO For more about palliative care, visit the Critical Care Nurse website, and read the article by Perrin and Kazanowski, Overcoming Barriers to Palliative Care Consultation (October 2015). REFERENCES 1. Center to Advance Palliative Care. Get palliative care: what is palliative care? Accessed May 29, Quill TE, Abernethy AP. Generalist plus specialist palliative care: creating a more sustainable model. N Engl J Med. 2013; 368(13): Aslakson RA, Curtis JR, Nelson JE. The changing role of palliative care in the ICU. Crit Care Med. 2014;42(11): Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force Crit Care Med. 2007;35(2): Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ, Pronovost PJ. Evidence-based palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med. 2014;17(2): Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2): Nelson JE, Bassett R, Boss RD, et al. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU). Crit Care Med. 2010; 38(9): AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5

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Effect of a qualityimprovement intervention on end-of-life care in the intensive care unit: a randomized trial. Am J Respir Crit Care Med. 2011;183(3): Hua MS, Li G, Blinderman CD, Wunsch H. Estimates of the need for palliative care consultation across United States intensive care units using a trigger-based model. Am J Respir Crit Care Med. 2014;189(4): Braus N, Campbell TC, Kwekkeboom KL, et al. Prospective study of a proactive palliative care rounding intervention in a medical ICU. Intensive Care Med. 2016;42(1): Aslakson RA, Wyskiel R, Shaeffer D, et al. Surgical intensive care unit clinician estimates of the adequacy of communication regarding patient prognosis. Crit Care. 2010; 14(6): R Baggs JG, Norton SA, Schmitt MH, Dombeck MT, Sellers CR, Quinn JR. Intensive care unit cultures and end-of-life decision making. J Crit Care. 2007;22(2): Baggs JG, Schmitt MH, Prendergast TJ, et al. Who is attending? End-of-life decision making in the intensive care unit. 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11 54. Mosenthal AC, Weissman DE, Curtis JR, et al. Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med. 2012; 40(4): Creutzfeldt CJ, Wunsch H, Curtis JR, Hua M. Prevalence and outcomes of patients meeting palliative care consultation triggers in neurological intensive care units. Neurocrit Care. 2015; 23(1): To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA Phone, (800) or (949) (ext 532); fax, (949) ; , reprints@aacn.org. C E 1.0 Hour Category C Notice to CE enrollees: This article has been designated for CE contact hour(s). The evaluation demonstrates your knowledge of the following objectives: 1. Define the role of bedside nurses in the provision of palliative care that includes primary and specialty models of care. 2. Describe barriers and facilitators to palliative care integration in the intensive care unit and nurses involvement in palliative care. 3. Evaluate how advanced practice nurses, nurse educators, and palliative care specialists can support bedside nurses in providing primary palliative care. To complete the evaluation for CE contact hour(s) for this article #A , visit and click the CE Articles button. No CE evaluation fee for AACN members. This expires on September 1, The American Association of Critical-Care Nurses is an accredited provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Registered Nursing of California (#01036) and Louisiana (#LSBN12).

12 Content IMPACT-ICU INTEGRATING MULTIDISCIPLINARY PALLIATIVE CARE INTO THE ICU Patient-Nurse Rounding Record Site: Unit: Bed: Bedside RN: Date: / / Completed by: Patient Information Place patient sticker below Patient Name: MRN: Age: Sex: Primary Service: Critical Care Hospital Medicine Family Medicine Pediatric Critical Care Transplant Head and Neck Surgery Neurosurgery Neurology Neuro Critical Care Trauma Surgery General Surgery Orthopedic Surgery Surgical Oncology Urology Vascular Surgery Hospital Admission Date: / / ICU Admission Date: / / Is palliative care already consulting on patient? No Yes - CNS only Yes - full team Cardiology General Internal Medicine Geriatrics Medical Oncology Other: STEP 1: Identify Patients to Screen for Palliative Care Needs Does your patient have a serious illness? Pre-existing the ICU admission, e.g. cancer, advanced organ disease, dementia Prompting the hospital admission, e.g. intracranial hemorrhage, severe trauma Developed during the hospital stay, e.g., multiple organ system failure High risk for death or long-term functional impairment, e.g. s/p cardiac arrest, chronic critical illness Please check one to indicate the disease category for patient s primary serious illness: Cancer Pulmonary Cardiovascular Renal Gastrointestinal Hepatic Neurologic/stroke/neurodegenerative Infectious/immunological/HIV Complex chronic conditions/failure to thrive Multiple organ system failure Trauma Other STEP 2: Screen for and Develop Plan to Address Palliative Care Needs Bedside Nurse s Primary Palliative Care Assessment: 1. Does your patient have any uncontrolled symptoms? Check all that apply Pain Short of breath Restless Confused Appendix 1 Patient-nurse rounding record. Anxious Scared Tired Sad Hungry Thirsty 2. Is the patient s family emotionally distressed or struggling to cope? Yes No / family not present Nauseated Constipated Other: 3. Do you have concerns about the quality of family-clinician communication about prognosis and goals of care? Yes No Plan for addressing identified needs: Please check at least one if bedside nurse identified a need above Primary palliative care plan developed with bedside nurse to meet patient and family need(s) Palliative care CNS consult recommended (or already involved) Full team palliative care consult recommended (or already involved) Continued Abbreviations: CNS, clinical nurse specialist; ICU, intensive care unit; IMPACT-ICU, Integrating Multidisciplinary Palliative Care Into the ICU; MD, physician; RN, registered nurse; s/p, status post.