The NP role is ideally suited for palliative care practice.

Transcription

1 The NP role is ideally suited for palliative care practice. A qualitative descriptive study Carmel Collins RN MN NP-F/AA CHPCN(C) Sandra P. Small RN PhD

2 Background Chronic diseases (CDs) are a major public health challenge globally (Canadian Society of Palliative Care Physicians [CSPCP], 2016). Of note, the prevalence of CD is higher in persons 65+ years (CHPCA, 2015). 48% of adults (45-64 years) and 74% of seniors (age 65+ years) have a least 1 CD, and 24% of seniors have 3+ CDs Cancer, heart disease, stroke, chronic respiratory disease, diabetes 45% of residents aged 45+ years in LTC homes have dementias including Alzheimer s (Wong, Gilmore, & Ramage-Morin, 2016) These diseases account for 65% of the mortality in Canada (Stats Can, 2014) Seniors the fastest growing segment of the Canadian population therefore CD will be more prevalent in the future (CHPCA, 2015).

3 Background Persons with progressive CDs need specialized care in the form of palliative care for best quality of life as such conditions become lifethreatening and deteriorate toward death (Baxter et al., 2013). < 30% of Canadians who die from progressive CDs have access to palliative care services (CHPCA, 2015). CD management provided by generalist health care providers (i.e., ongoing pain and symptom management) (Deitrick et al., 2011; Demarest, 2004; Lynch et al., 2011; Skilbeck & Seymour, 2002).

4 Background High prevalence of CD and an ageing population = great need for PC now and even more so in the future. Factors to be considered: Limited availability of PC specialists Inadequate educational preparation of health care professionals for PC practice Patient rural or remote location Insufficient fiscal resources for access to medications & medical supplies for PC patients (CSPCP, 2016) It has been suggested in the literature that NPs could help fill the gap in PC services.

5 Research Question What role do NPs who are not PC specialists and not working specifically in palliative specialty settings play in providing PC?

6 Literature Review Findings from studies of NP practice in PC revealed NP role functions included: - Managing medical conditions - Providing psychosocial support/counseling to patients and families - Coordinating individualized plan of patient care - Collaborating with other health care professionals about patient conditions - Providing pt and family education about the condition and treatment plan - Advocating on behalf of the patient. The NP role: within palliative settings (Deitrick et al., 2011; Mitchell et al., 2016; O Connor et al., 2016; Williams & Sindani, 2001) In LTC facilities (Kaasalainen et al., 2013) As telephone consultant to RNs in hospice agencies (Osborn & Townsend, 1997)

7 Literature Review Few studies found re: patient outcomes with NP practice in PC. Findings: NP role functions are conducive to positive patient outcomes. Some examples: Staff in LTC facilities thought NPs improved the availability and timeliness of PC interventions for residents & fewer resident transfers to hospital for those interventions (Kaalasainen et al., 2013) NP led coordination and provision of home PC services for terminally ill pts improved pt access to PC resources and was believed to result in fewer hospital admissions (Mitchell et al., 2016). NP coordination and ongoing provision of PC services facilitated pts transition from hospital to community setting and fewer hospital readmissions (O Connor et al., 2016).

8 Literature Review Although NPs might make a difference for palliative pts, not all NPs may be comfortable or confident in engaging in PC interventions. PC education and experience are important factors. 607 NPs, 65% thought having more EOL education and 70% thought having more work experience would enable them better to have conversations about EOL care with pts and families (Tyree et al., 2005). 48 APRNs (38 were NPs) scored their graduate nursing programs as low in PC content. Prior to a 1-week PC ed session they scored their confidence in their ability to provide PC as low but post PC education they scored their confidence as being significantly higher (Dahlin et al., 2016) 99 LTC NPs, 61% reported little or no confidence in managing the care of PC pts but after PC education intervention 83% reported being confident with PC practice (Letizia & Jones, 2012) Faculty across a large # of nursing programs acknowledged the importance of EOL content in graduate programs but rated their programs as only moderately adequate and effective with respect to such content (Paice et al., 2006a; 2006b).

9 Methods and Procedures Qualitative description as proposed by Sandelowski (2000). Purposive sampling was employed ( invitation & snowball sampling) Semi-Structured Participant Interviews using an interview guide Data were analyzed using qualitative content analysis.

10 Participants NPs not working in palliative care settings NPs volunteered to participate Data saturation at 19 participants (16 NPs from a metropolitan setting and 3 NPs from rural settings)

11 Table 1 Participant Age and Professional Experience Characteristic Range (years) Mean (years) Age RN experience NP experience

12 Table 2 Participant Practice Stream by Sex and Academic Credentials NP (N=19) NP Practice Stream Family/All Ages (n) Adult (n) Total 17 2 Women 16 2 Men 1 - RN NP 5 - BN NP 7 - MN NP 5 2

13 Results Central theme: The nurse practitioner role is ideally suited for palliative care practice. This was based on: NPs personal professional experience providing PC their NP practice; and/or NPs knowing the nature of the nurse practitioner (Bertha) by virtue of being NPs themselves. To have a nurse practitioner who could go and visit that [palliative] person and look after all the needs whatever they may be, it would be ideal really. (Rita)

14 Results 5 other themes were categorized as facilitators of or impediments to NP practice in PC. Facilitators were inherent characteristics of the NP role itself Impediments were characteristics of individual NPs that detract from the NP role being ideally suited to PC practice

15 Facilitators of NP Practice in Palliative Care Broad scope and autonomous practice Situated practice Nursing presence The Nurse Practitioner Role is Ideally Suited for Palliative Care Practice Impediments to NP Practice in Palliative Care Having limited knowledge about palliative care Lacking emotional comfort with palliative care practice Figure 1. Thematic representation of the facilitators of and the impediments to the NP role being ideally suited for palliative care practice. NP role attributes of broad scope and autonomous practice, situated practice, and nursing presence facilitate palliative care practice. Having limited knowledge about palliative care and lacking emotional comfort with palliative care practice are impediments to NP practice in palliative care.

16 Broad Scope and Autonomous Practice NPs viewed PC patients as having complex care needs for which NP role was suited to manage (i.e., capability to assess, diagnose, treat, evaluate, and follow patients as needed) NPs can address comfort measures and pain control (Emma) NPs can provide optimal care to palliative patients for best quality of life. (Kate) Consistent with findings of other studies (Deitrick et al., 2011; Kaasalainen et al., 2013; Mitchell et al., 2016; O Connor et al., 2016; Osborn and Townsend,1997).

17 Situated Practice The NPs thought that because of NPs distinctive practice (i.e., broad scope, autonomy, collaboration, and varied work settings) NPs are well situated to encounter patients who require PC. Especially in the rural areas where there is no team. You [the NP] are the team. You are the care provider. [You] put the plans in place. Follow them [palliative patients] through all the stages titrations of medications. Providing the education and the psychosocial support. (Sarah) Many patients already are palliative when they arrive (Lynn) to LTC, being placed there because of their worsening conditions or need for extensive care. Consistent with position that in LTC NPs well positioned to promote and provide optimal PC to residents and their families (Kaasalainen et al, 2013).

18 Situated Practice The NP role is very job specific depending on where you are located and what your population is. (Sarah) 6 NPs practiced in acute care non-palliative inpatient units and specialty clinics (did not have any contact with patients requiring PC) 13 NPs practiced in community primary health care clinics or an ED, (providing care to patients with chronic diseases and patients with lifethreatening conditions), or practiced in LTC facilities (providing care to geriatric patients). These 13 NPs had varied opportunity for PC practice, from minimal to frequent.

19 Table 3 Participant Practice Settings Practice Setting NP (n) Primary health care clinics 8 LTC geriatric facilities 4 Hospital ED 1 Acute care hospital inpatient non-palliative specialty 1 unit Non-palliative specialty clinics 5

20 Nursing Presence NPs believed that nursing presence with patients and their families is essential in PC and NPs have the opportunity and competencies for it and their holistic approach to care embodies it. Demonstrates caring and permits patients to reveal their needs. Nursing presence is a fundamental concept in nursing practice (Easter, 2000; Finfgeld-Connett, 2006; McMahon & Christopher, 2011) The psychosocial skills, the advanced communication, the active listening and the empathy needed for providing PC. Helping patients find a place of comfort. (Mary) It s about being there, just absolutely being there. (Lynn) A way of being in the nurse-patient relationship that enables the nurse to understand the patient s experience and need for individualized care. (Parse, 1992; Paterson & Zderad, 2007; Sitzman & Watson, 2014).

21 Nursing Presence Development of a trust relationship I m able to talk to them [patients] about it [palliative care] in a more open way because I ve already established a trust with them. (Mary) Discussing their spirituality, their faith, their family support. Have they accomplished what they needed to accomplish in this life? Do they feel that they re missing something or are they just sick of being sick and they want it over? (Sally) The concept of nursing presence was not addressed, per se, in the prior research reviewed in relation to NP practice. However, descriptions of NP role functions, such as provision of emotional support, counseling, and holistic care (Deitrick et al., 2011; Kaasalainen et al., 2013; Owens et al., 2011; Williams & Sidani, 2001) suggest that nursing presence is inherent in NP practice.

22 Having Limited Knowledge about Palliative Care The NPs thought specialty palliative knowledge is required for NP PC practice and not having it is a definite impediment to suitability for palliative practice. What you ve learned in your [NP] program is not enough (Kate) to feel knowledgeable about providing palliative care. As a new NP you really have no concept of how to truly care for someone in palliative care and you re nervous (Kate) about providing such care.

23 Having Limited Knowledge about Palliative Care All the NPs reported having had little, if any, PC content in their formal academic NP education. They had not received what is needed to feel knowledgeable in providing palliative care. Many of the NPs had not received any PC content in their undergraduate programs, either. That nursing graduates including NPs may be lacking formal palliative care content was also noted in the literature (Dahlin et al., 2016; Letizia and Jones, 2012; Paice et al., 2006a, 2006b).

24 Having Limited Knowledge about Palliative Care NPs with PC experience talked about the importance of: clinical experience with palliative patients, continuing professional education in PC, This has also been noted in other studies about NPs (Dahlin et al., 2016; Letizia & Jones, 2012; Tyree et al., 2005). mentoring by and collaborative practice with experts in the field to gaining good knowledge for PC practice. No studies found in literature. The NPs valued being able to talk to somebody from the palliative care team or the collaborating physician (Mary) for support in palliative care decision-making because palliative care patients are complicated. (Tina)

25 Having Limited Knowledge about Palliative Care Some NPs had good PC knowledge. Other NPs, although encountering palliative patients in their practice, had limited knowledge about PC, especially with respect to evidence-based clinical practice protocols and guidelines. Needing a lot more information and knowledge (Marie) about this area of nursing, especially with respect to protocols and clinical guidelines and evidence-based practice, opioid prescribing, for providing end-of-life care, and for discussing end-of-life decisionmaking. (Sally)

26 Lacking Emotional Comfort with Palliative Care Practice They believed PC requires a particular type of person: someone who is emotionally comfortable with caring for patients and their families as they face death.

27 Lacking Emotional Comfort with Palliative Care Practice NPs who were not involved in PC practice at all indicated that they were not comfortable with it as a result of the very nature of PC. PC practice is not for everybody (Paula) Because they re not comfortable (Sally) with PC some NPs might choose to practice in an area of nursing with a patient population not needing such care. Not an area of interest for them. (Paula)

28 Lacking Emotional Comfort with Palliative Care Practice NPs who were involved in providing PC in their practices varied in their level of emotional comfort with this type of practice. more regular encounters with palliative patients = greater experience in caring for palliative patients = more NP emotional comfort with PC practice Those NPs derived great satisfaction from PC practice. When you know that you can help somebody have a better experience, it makes a difference. It makes you feel good about yourself if you can help somebody and make life easier for somebody else; then you know you ve done your job. (Rita)

29 Lacking Emotional Comfort with Palliative Care Practice No studies were found in which NP emotional comfort with palliative care practice was examined specifically. Providing care for terminally ill patients was stressful and emotionally upsetting for generalist nurses in acute care hospital settings (Bloomer et al., 2013; Wallerstedt & Andershed, 2007; Wiegel et al., 2007). Few studies found in the literature about the personal attributes of nurses who choose PC practice and none regarding NPs specifically. Nurses choosing to practice palliative care have a caring nature (Cameron & Johnston, 2015; Johnston, 2002; Richardson, 2002), have an interest in and are accepting of the holistic needs of the dying patient, and have an emotional comfort with dying and death (Johnston, 2002; Thompson et al., 2006).

30 Lacking Emotional Comfort with Palliative Care Practice Nurses who work in PC are viewed as being unique in that they choose to, and are thought to be more prepared to, work with dying and death (Johnston, 2002). As indicated by the NPs in this study, then, it seems reasonable that lacking emotional comfort interferes with the NP role being ideally suited for PC practice. Having emotional comfort with dying and death is essential for nurses if they are to provide the best care for palliative patients and families (Thompson et al., 2006).

31 Study Strengths Wide variation among the NPs in terms of their practice settings and experience working with PC patients. To my knowledge and based on a review of the literature, this is the only Canadian study in which the role of non-palliative care specialist NPs in palliative practice has been examined. This study adds to the small existing body of nursing knowledge about the NP role in palliative care in terms of identifying facilitating and inhibiting factors to the role. This research was conducted with strict adherence to qualitative descriptive methodology and as such the findings may be considered to be rigorous.

32 Study Limitations A single regional health authority within one Canadian province. No NPs were practicing in remote areas of the province. A larger sample from diverse settings within Canada might have produced different results.

33 Future Research Conduct a larger study of NPs throughout Canada to determine support for the findings of this study. Examine characteristics of NPs who choose PC practice and to determine how best to encourage NPs with such characteristics to participate in PC. Research about PC content in academic NP curriculum is warranted. Given the increasing need for palliative content in NP programs, research is needed to examine faculty preparedness to teach PC and what they might need to enhance their effectiveness to teach such curricula.

34 Future Research In Canada research should be conducted to establish details about specialist NP practice in this area of nursing. More research is needed to determine the effectiveness of NPs, both non-palliative care specialist and PC specialist roles, in palliative practice for patient and health care system outcomes.

35 Conclusion The NP role is ideally suited for PC practice, but NPs who work in palliative practice need to have specialty PC knowledge and have emotional comfort with providing care for patients who have conditions that will lead to death.

36 As we expand our horizons and embrace a palliative approach to care remember PC practice is the perfect place for a nurse practitioner. (Bertha)

37 Thank-you For the opportunity to discuss my research here today. To Dr. Sandra Small for her expert guidance throughout this research endeavour.

38 References Baxter, S., Buchanan, S., Hirst, L., Mohan, L., O Brien, L., & Randall-Wood, D. (2013). A model to guide hospice palliative care: Based on national principles and norms of practice. Retrieved from Bloomer, M.J., Endacott, R., O Connor, M., & Cross, W. (2013). The dis-ease of dying: Challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study. Palliative Medicine, 27(8), doi: / pmj.sagepub.com Cameron, D. & Johnston, B. (2015). Development of a questionnaire to measure the key attributes of the community palliative care specialist nurse role. International Journal of Palliative Nursing, 21 (2), doi: /ijpn Canadian Hospice Palliative Care Association. (2015). Fact sheet: Hospice palliative care in Canada. Retrieved from Canadian Society of Palliative Care Physicians. (2016). How to improve palliative care in Canada: A call to federal, provincial, territorial, regional and local decision-makers. Retrieved from Improve-Palliative-Care-in-Canada-FINAL-Nov-2016.pdf

39 References Dahlin, C., Coyne, P.J., & Cassel, J.B. (2016). The advanced practice registered nurses palliative care externship: A model for primary health care education. Journal of Palliative Medicine, 19(7), doi: /jpm Deitrick, L. M., Rockwell, E. H., Gratz, N., Davidson, C., Lukas, L., Stevens, D.,... Sikora, B. (2011). Delivering specialized palliative care in the community: A new role for nurse practitioners. Advances in Nursing Science, 34(4), E23-E36. doi: /ANS.0b013e f Demarest, P. (2004, May 26). The role for nurse practitioners in end-of-life care. [Letter to the editor]. Journal of the American Medical Association, 291(20), doi: /jama a Easter, A. (2000). Construct analysis of four modes of being present. Journal of Holistic Nursing, 18, doi: / Finfgeld-Connett, D. (2006). Meta-synthesis of presence in nursing. Journal of Advanced Nursing, 55(6), doi: /j x

40 References Johnston, B. (2002). Perceptions of palliative nursing (Doctoral thesis, University of Glasgow, Glasgow, Scotland). Retrieved from Kaasalainen, S., Ploeg, J., McAiney, C., Schindel Martin, L., Donald, F., Martin-Misener, R.,... Sangster-Gormley, E. (2013). Role of the nurse practitioner in providing palliative care in long-term care homes. International Journal of Palliative Nursing, 19, doi: /ijpn Letizia, M., & Jones, T. (2012). An educational intervention for nurse practitioners providing palliative care in nursing homes. Journal of Hospice and Palliative Nursing, 14, Retrieved from Lynch, M., Dahlin, C., Hultman, T., & Coakley, E. E. (2011). Palliative care nursing: Defining the discipline? Journal of Hospice & Palliative Nursing, 13, doi: /NJH.0b013e b6e McMahon, M.A., & Christopher, K.A. (2011). Toward a mid-range theory of nursing presence. Nursing Forum, 46(2), doi: /j x Mitchell, G.K., Senior, H.E., Bibo, M.P., Makoni, B., Young, S.N., Rosenberg, J.P., & Yates, P. (2016). Evaluation of a pilot of nurse practitioner led, GP supported rural palliative care provision. BMC Palliative Care, 15(93). doi: /s v

41 References O Connor, M., Palfreyman, S., Le, B., & Lau, R. (2016). Establishing a nurse practitioner model to enhance continuity between palliative care settings. International Journal of Palliative Nursing, 22(12), Retrieved from Osborn, C. L., & Townsend, C. H. (1997). Analysis of telephone communication between hospice nurses and a nurse practitioner group. Home Health Care Management & Practice, 9, doi: / Owens, D., Eby, K., Burson, S., Green, M., McGoodwin, W., & Isaac, M. (2011). Primary palliative care clinic pilot project demonstrates benefits of a nurse practitioner-directed clinic providing primary and palliative care. Journal of the American Academy of Nurse Practitioners, 24, doi: /j x Paice, J. A., Ferrell, B. R., Virani, R., Grant, M., Molloy, P., & Rhome, A. (2006a). Graduate nursing education regarding end-of-life care. Nursing Outlook, 54, doi: /j.outlook Paice, J. A., Ferrell, B. R., Virani, R., Grant, M., Molloy, P., & Rhome, A. (2006b). Appraisal of the graduate end-of-life nursing education consortium training program. Journal of Palliative Medicine, 9, doi: /jpm

42 References Parse, R.R. (1992). Human Becoming: Parse s theory of nursing. Nursing Science Quarterly, 5, doi: / Paterson, J., & Zderad, L. (2007). Humanistic Nursing. Retrieved from Richardson, J. (2002). Health promotion in palliative care: The patients perception of therapeutic interaction with the palliative nurse in the primary care setting. Journal of Advanced Nursing, 40, doi: /j x/abstract Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing and Health, 23, doi: / X(200008) Sitzman, K., & Watson, J. (2014). Caring science, mindful practice: Implementing Watson s human caring theory. New York: Springer. Skilbeck, J., & Seymour, J. (2002). Meeting complex needs: An analysis of Macmillan nurses work with patients. International Journal of Palliative Nursing, 8, Retrieved from Statistics Canada. (2014). The 10 leading causes of death, Retrieved from

43 References Thompson, G., McClement, S., & Daeninck, P. (2006). Nurses perceptions of quality endof-life care on an acute medical ward. Journal of Advanced Nursing, (53), doi: /j x Tyree, T. L., Long, C. O., & Greenberg, E. A. (2005). Nurse practitioners and end-of-life care: Beliefs, practices, and perceptions. Journal of Hospice and Palliative Nursing, 7, Retrieved from Wallerstedt, B., & Andershed, B. (2007). Caring for dying patients outside special palliative care settngs: experiences from a nursing perspective. Scandinavian Journal of Caring Sciences, 21, doi: /j x/full Wiegel, C., Parker, G., Fanning, L., Reyna, K., & Brewer Gasbarra, D. (2007). Apprehension among hospital nurses providing end-of-life care. Journal of Hospice and Palliative Nursing, 9(2), doi: /01.NJH b8 Williams, D., & Sidani, S. (2001). An analysis of the nurse practitioner role in palliative care. Canadian Journal of Nursing Leadership, 14(4), doi: /cjnl Wong, S.L., Gilmour, H., & Ramage-Morin, P.L. (2016). Alzheimer s disease and other dementias in Canada. Health Reports, 27(5), Retrieved from