Improving Knowledge, Comfort, and Confidence of Nurses Providing End-of-Life Care in the Hospital Setting Through Use of the CARES Tools

Alison Stacy, DNP, RN, AGACNP-BC; Kathy Magdic, DNP, ACNP-BC, FAANP; Margaret Rosenzweig, PhD, FNP-C, AOCNP, FAAN; Bonnie Freeman, DNP, RN, ANP-BC, ACHPN; Denise Verosky, MSN, RN, CNS


Journal of Hospice and Palliative Nursing. 2019;21(3):200-206. 

In This Article



This project utilized a pre- and post-quasi-experimental design with a pre-educational and posteducational intervention. Presurveys and postsurveys evaluated self-reported changes in knowledge and comfort related to EOL care before and after use of the CARES tool. In addition, one-on-one interviews were conducted to obtain qualitative data from nurses regarding family's perceptions of Final Journey. The CARES tool and Final Journey are collectively termed "the CARES tools" for the purpose of this article. All study procedures were conducted under institutional review board approval after expedited review in the setting of minimal harm risk.

Sample and Setting

Convenience sampling of registered nurses was used on a 16-bed medical progressive care unit at a western Pennsylvania hospital. This 16-bed unit was chosen based upon the frequency of caring for patients at EOL.


Using the components of the CARES tool, the preintervention and postintervention survey questions were developed by the principal coordinator. Additional questions were included to assess the overall knowledge and comfort related to EOL care and confidence in communicating with families about the dying process. An educational PowerPoint presentation was developed by the principal coordinator to inform nurses of project details and to introduce the CARES tools. Interview questions were developed to capture feedback nurses received from families regarding Final Journey, as well as the nurses' own perspectives regarding the usefulness of the tool. All materials were approved by all authors before use.

Nursing staff completed a preintervention survey (Table 1) to assess self-reported knowledge and comfort related to EOL care, knowledge of family needs, knowledge and comfort related to common symptom management needs of the dying, and confidence in communicating about the dying process with families of dying patients. Nurses self-rated their knowledge and comfort of these components using a Likert scale. A 4-digit numerical code was required for the purpose of comparing preintervention and postintervention surveys while maintaining anonymity.

After completing the preintervention survey, nurses independently reviewed the educational PowerPoint. Following review, nurses completed a 5-question posttest, which required a 100% pass rate to ensure understanding of project requirements before implementation. The 100% pass rate was achieved through remediation as necessary.

Once preintervention surveys and education were complete, copies of the CARES tools were made available on the unit. Nurses were asked to independently use the CARES tool when providing EOL care. A copy of Final Journey was provided to all family members of "comfort measures only" (CMO) patients by the admitting nurse upon arrival to the unit. Before the end of that nurse's shift, he or she revisited the tool with families, offering to clarify any questions or concerns. Nurse discretion was used when offering the tool. For example, if a family member appeared severely emotionally distressed or not accepting of the anticipated death, the tool was not provided. After implementation, nurses completed the postintervention survey (Table 1) and were interviewed by the principal coordinator to obtain qualitative data regarding the feedback they received from families about Final Journey.