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. 

In This Article

Abstract and Introduction


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.


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]