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

Disclosures

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

Conclusion

With in-hospital deaths on the rise, nurses need to be adequately prepared to care for dying patients and their families to improve the overall EOL experience. Use of the CARES tool for nurses significantly improved knowledge regarding EOL care, knowledge, and comfort in addressing symptom management needs of the dying, including comfort/pain management, airway and emotional support, and confidence in communicating about the dying process with family members of dying patients. Final Journey helped families be more informed, helped nurses answer difficult questions, and promoted and encouraged communication between health care professionals and families. Through use of the CARES tools, unnecessary suffering at EOL can be mitigated by improving the EOL knowledge of nurses and the EOL experience as perceived by family members of dying patients.

The CARES tools are available as free downloads at www.carestool.com.

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Acknowledgments
The authors thank the progressive care registered nurses at UPMC Mercy and Bonnie Freeman who were instrumental in establishing the CARES tools.

Abstract and Introduction
Theoretical Framework
Methods
Results
Discussion
Implications and Recommendations for Nursing Practice
Limitations
Conclusion
References

Table 1. Staff Preintervention and Postintervention Survey
Please rate a Please rate answers using the following key:
1. Very low (no understanding/knowledge)
2. Low (some/little understanding/knowledge)
3. Moderate (know about, but more to learn)
4. High (good understanding of)
5. Very High (know nearly everything about topic)
How would you rate your:	Very Low	Low	Moderate	High	Very High
Knowledge regarding end-of-life (EOL) care	1	2	3	4	5
Comfort providing EOL care	1	2	3	4	5
Knowledge regarding needs of the friends and family of the dying patient	1	2	3	4	5
Knowledge and comfort in addressing symptom management needs of the dying including:
• Comfort/pain management	1	2	3	4	5
• Airway	1	2	3	4	5
• Restlessness	1	2	3	4	5
• Emotional support of patient & family	1	2	3	4	5
• Self care, ie, debriefing	1	2	3	4	5
Confidence in communicating about dying process with friends and family of the dying patient	1	2	3	4	5

Table 2. Staff Descriptive Statistics (N = 9)
	n	%
Age
20–29	3	33
30–39	4	44
40–49	2	22
≥50
Years of RN experience
<1	3	33
1–3	1	11
4–6	5	55
>6
Years of palliative care experience
<1	3	33
1–3	1	11
4–6	2	22
>6	3	33
Highest level of nursing education
Diploma	2	22
Associate degree	3	33
Bachelor of science in nursing	4	44
Master's/doctorate

Table 3. Paired-Sample t test
		Paired Differences
		Mean	SD	SEM	95% Confidence Interval of the Difference		t	df	P (2 Tailed)
		Mean	SD	SEM	Lower	Upper	t	df	P (2 Tailed)
Pair 1	Pre1-post1	−0.44444	0.52705	0.17568	−0.84957	−0.03932	−2.530	8	.035
Pair 2	Pre2-post2	−0.33333	0.50000	0.16667	−0.71767	0.05100	−2.000	8	.081
Pair 3	Pre3-post3	−0.44444	0.88192	0.29397	−1.12235	0.23346	−1.512	8	.169
Pair 4	Pre4-post4	−0.88889	0.60093	0.20031	−1.35080	−0.42698	−4.438	8	.002
Pair 5	Pre5-post5	−0.88889	0.60093	0.20031	−1.35080	−0.42698	−4.438	8	.002
Pair 6	Pre6-post6	−0.44444	0.72648	0.24216	−1.00287	0.11398	−1.835	8	.104
Pair 7	Pre7-post7	−0.66667	0.70711	0.23570	−1.21020	−0.12314	−2.828	8	.022
Pair 8	Pre8-post8	−0.44444	0.72648	0.24216	−1.00287	0.11398	−1.835	8	.104
Pair 9	Pre9-post9	−0.77778	0.66667	0.22222	−1.29022	−0.26533	−3.500	8	.008

Table 4. Nursing Interview Themes
Theme 1	Reinforces EOL care information for family
	''It"s very helpful because it bridges the gap of what all the different staff members are telling them, it takes a while for information to sink in when they are so overwhelmed from grieving already.''
	''They said they felt more at ease having that additional information and that the explanations for common symptoms was particularly helpful.''
	''Families found it useful to understand what our goals of care were, and what our role wasI to keep them comfortable.''
	''It was helpful to have a hard copy of a resource when we cannot always be in the room answering questions.''
	''Honestly just reviewing the booklet as a new nurse helped me reinforce that no I"m not killing them, they ARE going to die and that"s OK.''
Theme 2	Helps nurses answer difficult questions
	''As a new nurse, it helps answer questions which are difficult to answer without having a lot of experience.''
	''…it answers questions in a way that they can understand.''
	''…the booklet articulates things that are crucial for loved ones to understand. The booklet takes away the stress of trying to find the right words to explain certain things.''
Theme 3	Promotes and encourages communication between nurses and family
	''It provides baseline expectations and helps loved ones know what to ask for.''
	''I thought it was helpful for wording of things like stopping intravenous fluids, labs, and what to expect for breathing patterns''
	''As a new nurse not familiar with CMO patients, it helped me help them know what to expect and what not to expect''

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