Nurse Comfort With Palliative and End-of-Life Communication

A Rural and Urban Comparison

Mary J. Isaacson, PhD, RN, CHPN; Mary E. Minton, PhD, RN, CNS, CHPN; Patricia DaRosa, DDS, MSc; Shana Harming, BS

Journal of Hospice and Palliative Nursing. 2019;21(1):38-45.

Abstract and Introduction

Abstract

Communication is a key component of palliative and end-of-life care. Little is known about comfort with palliative and end-of-life communication among nurses working in rural and urban settings. We assessed this comparison using the 28-item (including 2 ranked items) Comfort with Communication in Palliative and End-of-Life Care instrument. Descriptive analyses of the sample (N = 252) identified statistically significant results differences for age and experience; rural nurses were older and more experienced. Urban nurses reported less comfort than did rural nurses based on composite score analysis (P = .03) and reported less comfort than did rural nurses in talking with patients and families about "end-of-life decisions" (P < .05). Overall, years of experience were significant for more comfort with end-of-life communication. Our instrument could be used within academic settings to establish baseline awareness of comfort with palliative and end-of-life communication and in institutional settings to provide a continuing education bridge from prelicensure through licensure. Moreover, experienced nurses are integral in mentoring new graduates in initiating and sustaining difficult conversations.

Introduction

Within health care organizations, nurses are the frontline caregivers spending the most time with patients and families.^[1] A principal nursing role is sharing information that includes education related to the disease, medications, and treatment.^[2] During day-to-day interactions, trusting relationships develop among patients, families, and nurses,^[3] which provide the foundation for critical conversations, especially in those with life-limiting illness. Yet, even with this trust, nurses often center their communication on treatment and cure versus facilitating open discussions related to goals and wishes for care.^[4] Nurses report several reasons for this hesitancy in initiating palliative and end-of-life (EOL) care discussions including insufficient formal communication training,^[5] lack of time,^[6] and organizational structures within health care facilities impeding, rather than supporting, collaborative relationships between nurses and physicians.^[7]

The Institute of Medicine and The Hastings Center recommend that health care professionals must be proficient and adept in communicating with patients and families confronting choices regarding life-sustaining or EOL care.^[8,9] While preparation for communication belongs as a focal component in health care curriculum,^[8] the crucial influence of experience^[10] underscores the additional importance of mentoring and time in the development of this skill set.^[11–13] Patient- and family-centered communication is collaborative and reciprocal and emphasizes mutual influence and adaptation by all parties.^[11,14] Health care professionals must ensure that the patient and family understand the severity of the illness as this understanding of the illness may influence patient readiness for EOL discussions.^[15] Recent findings support the implementation of a nurse-facilitated communication support program to promote patient engagement in early information seeking.^[16]

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Table 1. Participant's Characteristics by Rural and Urban Areas
Variable	Total N = 252^a n (%)	Rural n = 54 n (%)	Urban n = 198 n (%)	P
Gender, female	235 (94.4)	51 (96.2)	184 (93.9)	.740^b
Missing data	3 (1.2)	1	2
Race
White	245 (98.8)	52 (98.1)	193 (99.0)	^c
American Indian	1 (0.4)	1 (1.9)	0
Asian or Pacific Islander	1 (0.4)	0	1 (0.5)
Other	1 (0.4)	0	1 (0.5)
Missing data	4 (1.6)	1	3
Level of education
Associate degree	52 (20.7)	16 (29.6)	36 (18.3)	0.00^d
Bachelor's degree	167 (66.5)	28 (51.9)	139 (70.6)
Master's degree	15 (6.0)	3 (5.6)	12 (6.1)
Other (eg, LPN)	17 (6.8)	7 (13.0)	10 (5.1)
Missing data	1 (0.4)	0	1
Work setting
Outpatient hospital	34 (13.7)	11 (20.4)	23 (11.8)	^c
Inpatient hospital	188 (75.5)	29 (53.7)	159 (81.5)
Home health	5 (2.0)	3 (5.6)	2 (1.0)
Hospice	14 (5.6)	7 (13.0)	7 (3.6)
Palliative care	3 (1.2)	3 (5.6)	0
Other (e-care, float pool)	5 (2.0)	1 (1.9)	4 (2.0)
Missing data	3 (1.2)	0	3
Religion
Protestant	108 (43.4)	28 (51.9)	80 (41.0)	.444^b
Catholic	72 (28.9)	14 (25.9)	58 (29.7)
Christian, other	62 (24.9)	10 (18.5)	52 (26.7)
Other	7 (2.8)	2 (3.7)	5 (2.6)
Missing data	3 (1.2)	0	3
Age, median (IQR), y	35 (27-49)	42 (30-54)	32 (27-45.5)	.008^e
Missing data	32 (12.7)
Tenure as RN, median (IQR), y	8 (3.5–22)	18 (6-31)	6 (3-17)	.009^e
Missing data	37 (14.7)	5	32
Length in current facility, median (IQR), y	5 (3-12)	5 (3-16)	5 (3-11)	.903^e
Missing data	57 (22.6)	5	52

Abbreviations: IQR, interquartile range; LPN, licensed practical nurse; RN, registered nurse.
^a Demographic variable sum may not equal the total sample because of participant nonreport.
^b Pearson χ² test.
^cχ² Test not performed because of 25% expected count of less than 5.
^d Fisher exact test.
^e Mann-Whitney U test.

Table 2. Differences in C-COPE Scores: Rural and Urban RNs
	n	Median	Interquartile Range	P ^a
Overall	252	46.0	38–57
Rural RN	54	42.0	34–53	.03
Urban RN	198	47.0	39–58	.03

Abbreviations: C-COPE, Comfort with Communication in Palliative and End-of-Life Care; RN, registered nurse.
^a Mann-Whitney U test.

Table 3. Itemized C-COPE: Rural and Urban RNs
C-COPE Items		Rural n = 54 %	Urban n = 198 %
Patient communication (difficult or very difficult)
Talking with patients once they have received ''difficult news''	32.1	22.2	34.8
Talking with patients about spiritual and/or religious concerns	11.9	9.3	12.6
Talking with patients about spiritual and/or religious concerns that are different than my own beliefs	21.8	18.5	22.7
Remaining silent and listening to the expression of feelings from patients	1.6	0	2.0
Talking to patients about end-of-life decisions	23.0	13.0	25.8^a
Talking with patients from cultures other than my own	22.6	16.7	24.2
Talking with patients about physical symptoms	2.0	0	2.5
Talking with patients about psychosocial symptoms	6.0	5.6	6.1
Talking with patients about suffering	19.4	13.0	21.2
Talking with patients without using medical jargon	3.6	3.7	3.5
Family communication (difficult or very difficult)
Talking with families once they have received ''difficult news''	31.7	24.1	33.8
Talking with families about spiritual and/or religious concerns	13.1	11.1	13.6
Talking with families about spiritual and/or religious concerns that are different than my beliefs	20.6	16.7	21.7
Discussing decisions to be made when a family member is the patient's proxy	18.7	20.4	18.2
Remaining silent and listening to the expression of feelings from families	2.0	3.7	1.5
Talking to families about end-of-life decisions	24.6	11.1	28.3^a
Talking with families from cultures other than my own	22.6	20.4	23.2
Talking with families about the patient's physical symptoms	2.8	0	3.5
Talking with families about the patient's psychosocial symptoms	6.7	3.7	7.6
Talking with families about suffering	19.4	18.5	19.7
Talking with families without using medical jargon	5.2	3.7	5.6
Team communication (difficult or very difficult)
Talking with physician(s) about palliative care issues	9.5	9.3	9.6
Talking with nurse colleagues about palliative care issues	2.4	0	3.0
Talking with physician(s) about end-of-life issues	9.9	7.4	10.6
Talking with nurse colleagues about end-of-life issues	2.8	1.9	3.0
Talking with chaplain(s) about palliative care and/or end-of-life issues	3.6	1.9	4.0