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Hospice and Palliative Care Nursing KnowledgeShannon Grabe Ferris State University AbstractThis article will discuss hospice, palliative and end of life care. It will define palliative and hospice care and provide polices of Medicare hospice benefit. Two different theories will be discussed on nursing theory and one non nursing theory and how they relate to hospice and palliative care. Nurses need to be educated on end of life care for patients and their families and knowledge about hospice and palliative care will help nurses provide the best patient centered care. There will also be three QSEN competencies and three American Nursing Association standards will be related to hospice and palliative care. There are educational and experience interventions that can be done to help improve nursing knowledge on these topics. Hospice and Palliative Care Nursing KnowledgeDeath is a scary and difficult process for not only the patient and their loved ones, but also the nurses who care for them. Nurses are compassionate and caring individuals and important to patient care. A nurse’s goal is to help the patient get well but at times this goal is unrealistic. Most nurses eventually are faced with caring for a patient who is terminally ill. Caring for a patient during end of life involves caring for a patient in a different way. The death of a patient is often difficult and nurses must build their knowledge base in regards to death and dying.In order for a nurses to properly educate their patients, and their caregivers, they themselves must be educated. Educating others is part of the nursing role. Patients rely on nurses to educate them on issues related to their wellbeing. Nurses are more knowledgeable in areas like psychiatric care and philosophy then they are to palliative care (Prem, Karannan, Kumar, Karthikbau, Syed, Sisodia & Jaykumar, 2012). Nurses need more education on the process of dying and how to care for patients during this process. More than two and a half million people die each year and most of them do so in a hospital setting (Chiplasky, n.d.). If nurses are ignorant as to how end of life care is given it is the patients who often suffer. This is a very traumatic time in a patient’s life as they need to be armed with the right information and resources to ensure they have good, supportive care. Nurses are responsible for continuing their education throughout their career. Ultimately it is the nurses’ responsibility to educate themselves on hospice and palliative care for the well-being of their patients and their families.Palliative care which is provided by hospice is an important aspect of end of life care. Hospice is a coordinated program of interdisciplinary care including the medical director, nurses, certified nurse’s aides, volunteers, bereavement counselors, social workers, and spiritual care leaders. The services are provided primarily in the home to terminally ill patients and their families. Palliative care is comprehensive care for patients with a disease that is not responsive to a cure, the care also extends to the families. If patients are unaware of their options related to hospice and palliative care they miss out on care that will provide comfort and support to not only the patients, but their families, during the dying process.Theory BaseNursing TheoryThe nursing theory that is relevant to this issue is Katherine Kolcabas’ comfort theory. Kolcabas theory develops comfort as a holistic positive outcome of nursing care. Nurses need to be highly aware of their patients comfort at end of life (Vendinndki & Kolcaba, 1997).??There may be many comfort issues that these patients face, from pain and anxiety to spiritual and emotional needs that must be met. Nurses need to have a good understanding of end of life in order to ensure the patients are comfortable and cared for in this last stage of their lives.?Kolcaba defined comfort as “the immediate state of being strengthened through having the human needs for relief, ease, and transcendence addressed in four contexts of experience” (Vendlinndki & Kolcaba, 1997, p. 272).??The three types of comforts that Kolcaba use are: relief, the state of a patient who has a specific need such as pain; ease, the state of calm or content; and transcendence, the state in which one rises above ones problems or pain. The “contexts of experiences” Kolcaba talks about are physical, psycho-spiritual, sociocultural, and environmental. The comfort theory address comfort on many levels and is a great tool to assess and address comfort in patients at end of life (Carper, 1978).????????????Comfort is an important concern to patients and their families at end of life. When patients have a terminal illness they often fear they will experience pain during the dying process. Using Katherine Kolcabas’ comfort theory and comfort tool will help ensure all patients have a comfortable death.??Knowing that their loved one is comfortable also, gives the patients loved ones peace of mind and gives them a sense of peace knowing that comfort has been established (Vendlinnski & Kolcaba, 1997). Non Nursing Theory The change theory developed by Kurt Lewin, known as the father of social psychology, is a good theory to relate to the change in knowledge base for nurses dealing with end of life care. The change theory has three steps including the unfreezing stage, which is the need for change, moving, where the change is initiated after careful process and planning, and refreezing, when the change becomes operational (Taylor, Lillis, LeMone, & Lynn, 2011).??The care of patients’ shifts when they reach this stage in life and nurses must be able to recognize the need for change.????????????There is a need for change in nursing care when patients move to hospice and palliative care. The process and the way nurses care for these patients has to change. First, the nurse needs to recognize the need for the change (unfreezing), then they need to plan, research, and educate themselves on the best way to care for these patients (moving). Finally, they can implement the new care approach for these patients (refreezing). Being able to adapt and change is a big part of nursing care. Not every patient is the same and nurses have to be able to change the care to best fit the patient’s needs.Assessment of the Healthcare EnvironmentPolicies ????????????There are many different policies regarding qualifying for the hospice benefit and palliative care. As stated earlier, palliative care is for individuals whose disease is not responsive to a cure, and hospice provides care to terminally ill patients with a prognosis of six months or less (Smeltzer, Bare, Hinkle, & Cheever, 2010). If a patient has not expired after six months but continues to have rapid decline the patient will most likely be re-certificated every two months and this continues until the patient expires or no longer is eligible. There are numerous hospices nationwide and they will have different guidelines to qualify patients based on their disease process which are provided by Medicare.????????????The hospice benefit is 100% covered under Medicare which means there is no cost to the patient. Medicare does have some qualification that must be met first in order to qualify for the benefit. According to the Us Department of Health and Human Services (2013) the patient must meet all of the following criteria to receive the Medicare hospice benefit, patients must be eligible for Medicare part A, the primary care physician and the hospice medical director both certify that?the patient is terminally ill and have six months or less to live if the disease runs its normal course and patients must sign a statement that they will chose hospice over other medical treatment for their illness “Medicare will still pay for covered benefits for any health problems” ( US Department of Health and Human Services, 2013, Medicare Hospice Benefits section) related to patients terminal illness. An example of this is patients’ curative form radiation or chemo treatments while on hospice. If patients seek palliative radiation or chemo treatments for pain control or to help them walk better while they are passing, hospice may pay for these services because they are related to the patients’ terminal illness. Patients must also chose and receive care form an approved hospice program. The hospice benefit provides many different service to the patient and their families. The hospice nurse, social worker or spiritual care provider, and medical director are on call seven days a week, 24 hours a day for patients to help support the patients and their families. The patients, their families, and the hospice team will work together to set up a plan of care that meets the individual needs of the terminally ill patients (US Department of Health and Human Services, 2013).????????????Unfortunately, information available on policies for end of life education to nurses in the hospital setting is lacking. There are nearly two and half million people who die each year and most of them do so in a hospital (Chiplaskey, n.d.). So the likelihood of a nurse working in the hospital setting and caring for a dying patient is very high. The assumption of a nurse already having a basic knowledge of end of life care and options for the patients with terminal illness is inaccurate. According to an article by Prem et al. (2012) “Overall level of knowledge about palliative care was poor, and nurses had a greater knowledge about psychiatric and philosophy…” (p.125).Safety Issues????????????Patient safety is the number one concern of nurses in any setting and if nurses do not have the knowledge about caring for a certain type of patient whatever it may be it is the nurses’ responsibility to educate themselves to ensure the patients get the best care. Nurses tend to avoid the topic of death and dying because they see the death of a patient as a failure. The lack of knowledge on the nurse’s part will reduce the successful delivery of palliative care (Prem et al., 2012). The patients will receive inadequate care because nurses do not have the knowledge to provide comfort to the dying patient.????????????When patients receives a terminal diagnosis they are emotionally distraught and may not be able to process everything right away. Nurses need to have the education about hospice and palliative care to be able to educate the patients on the choices they have at end of life. Patients may receive unnecessary or even unwanted care if they do not know and understand all of their options.??There are many myths surrounding hospice care and patients may need education about hospice to make an informed decision. One myth is that hospice is a place that people go to die, but, in fact, hospice is a philosophy of care that can be provided anywhere a patient calls home (heartland). A gallop poll showed that 90% of people state that they want to die in the comfort of their own home, but only 20-25 % actually do (Wallace, Grossman, Campbell, Robert, Lange, & Shea, 2009).Inference/Complications/ConsequencesKnowledgeLogical interpretation of the research data shows that nurses need more education on end of life care. The outcome of the patients and this point in their life and the care that they receive is dependent on the nurse’s education and knowledge of this topic. Nurses play a significant role in the care of dying patients, critically ill as well as terminally ill, patients have little to no knowledge on palliative care and is an obstacle to providing good palliative care to patients (David, & Banerjee, 2010). There are many different aspect of palliative care and the medical perspective at end of life changes form curative to comfort care. With 87% of nurses stating that at some point in their career they have cared for a dying patient nurses need to have a knowledge on the way care shifts at end of life (Chiplaskey, n.d.). The focus for patients at end of life is comfort care and establishing the relief of pain and anxiety in the dying patient. Palliative care programs reduce pain levels, provide comfort and peace of mind. Palliative care program have shown to also control fatigue, breathlessness, nausea, depression and other symptoms causing distress in terminally ill patients. If hospital nurses had adequate knowledge in palliative care they can help ensure patients comfort at end of life when they are in the hospital setting.Hospice vs HospitalHospice and palliative care nurses focus their care on the terminally ill and dying patients. They have extensive amounts of experience in developing care plans for patients and their families that will be patient centered and provide comfort to the patients as well as providing bereavement and support to the families after the patient has passed. Hospice will build a support system around the patients and their families and provide a comfortable, peaceful death (Heartland Hospice, n.d). “Healing is not just the curing of a disease; it also involves holistically addressing the physical, psychological, emotional, and spiritual wellness of a patient.” (Verret, & Rohloff, 2013, p54). Hospitals focus their care on sustaining life and do not have a large knowledge base to care for the dying patient. “Hospitals are in the business of healing and there is a point where curative care is no longer realistic.” (Verret, & Rohloff, 2013, p 54). Hospitals do however, offer access to life support systems and life sustaining interventions. Some patients with a terminal illness just are not ready to face the idea of giving up hope and want to extend their lives and the hospitals are well equipped to help those patients. Medical BenefitsAccording to the article by Verret and Rohloff (2013) there are significant medical benefits to palliative care. “ Patients receiving palliative care have shown physical improvement as patient symptoms are addressed early , leading to longer survival as well as higher quality of life” (Verret, & Rohloff, 2013, p 53). Pain management is a significant part of palliative care and patients with terminal illness have pain levels that are difficult to treat. The lack of knowledge on nurses’ part to treat pain in terminally ill patients can lead to unsatisfied patients and decrease the outcomes of patients. According to the article by Prem et al. (2012) less than 35 % of nurses had correct responses to the knowledge subscale. One study in a Massachusetts hospital followed 151 cancer patients and 50 % of the patients received palliative care along with standard treatment and the other 50 % received standard treatment alone. Although the patients that were receiving the palliative care received less aggressive end of life care than the other half of the patients, the patients that were on palliative care lived 2.7 months longer than the other group (Verret, & Rohloff, 2013). The palliative care reduced their pain and anxiety levels and increased their comfort which lead to enhanced physical outcomes. Quality and Safety ImprovementInterventionsEducation is the biggest intervention to help increase the knowledge base of nurses about end of life care, palliative care and hospice. One education tool is for hospitals to have a policy that all staff members are required to attend an educational seminar on end of life care of patients and get a basic knowledge of what palliative and hospice care is, who may qualify, and what the benefits are to the patients. If the nurses in the hospitals have this basic knowledge base they will be able to better educate their patients. Having nurse lead bereavement program will help support staff education (Hansen, Goodell, Dehaven, & Smith, 2009). The article “Effectiveness of palliative care booklet in enhancing nursing knowledge” by David and Banerjee (2010) showed that after the nurses received the educational booklet on palliative care their post test scores increased by nine percent. The educational booklet talked about the general concepts of palliative care, the care components such as physical, social, emotional, and spiritual and the role of nurses in palliative care. Before the use of this educational tool 89 % of the nurses in this study stated that they did not have any education on palliative care in their core nursing education. The use of educational tools such as this booklet will help nurses gain an understanding of palliative care (David, & Banerjee, 2010). Nursing school is an important part of nurses education. Nursing students should learn about palliative care and symptom management so holistic care can be provided to patients (Wallace et al., 2009). Studies have shown that only two percent of nursing textbooks have information on end of life care. There need to be more education in nursing school about end of life care. There are many textbooks that focus on end of life care that should be used to help educate nursing students. The American Association of Critical Care Nurses is also calling for the student to be competent in end of life care for accredited undergraduate programs (Wallace et al., 2009). Experience with end of life care is also needed in nursing students. The clinical experiences gained by students will follow them throughout their career. If students get experience with a dying patient in the clinical setting it will help educate and prepare them for caring for dying patients as registered nurses. One study showed that 28% of nursing students stated that they had never cared for a dying patient (Chiplaskey, n.d.). The more experience that nursing students and nurses get with palliative and end of life care the more will help them gain knowledge and provide better patient care. QSENQuality and Safety Education on Nurses ( QSEN) competencies are quality and safety competencies designed for nursing to proposed targets for knowledge, skills and attitudes for patient- centered care, teamwork and collaboration, evidence based practice, quality improvement, safety and informatics. There are three QSEN competencies that relate to the importance of knowledge on hospice and palliative care (QSEN, 2005). The first QSEN competency that is relevant to this issue is patient-centered care. The patients are always the nurses’ main focus and nurses need to be knowledgeable on hospice and palliative care to ensure that patients get the most holistic care at end of life. The nurses need to be knowledgeable about patients, families and communities values and their physical and emotional support. Nurses need the skills on how to communicate the patients’ values and provide patient-centered care, sensitivity and respect. Nurses should be respectful and encourage the patients to express their values (QSEN, 2005). Team work and collaboration is a large part of hospice and palliative care. Nurses work with an interdisplinary team to collaborate the best care plan for the patients. They must have the knowledge to describe their strengths, limitations and values as a functioning team members and be able to recognize the contribution of the other team member to help the patients achieve their goals. They must have the skills to initiate a plan for self-development as a team member, and acknowledge your potential to contribute to the team and value other team members’ contributions (QSEN, 2005). The last QSEN competence is quality improvement of the policies on education of hospice and palliative care. There needs to be more education to help the nurses have a better understanding so they can educate their patients. Nurses need to have the knowledge to describe strategies for learning about care in the setting where they engage in clinical practice. Nurses need to have the skills to seek information about outcomes for the populations they are serving and have an appreciation for continuing quality improvement (QSEN, 2005).American Nursing AssociationThe American Nursing Association (ANA) is an organization that represents the interests of the nation’s registered nurses. The ANA “advances the nursing profession by fostering high standards of nursing practice” (American Nursing Association, 2010, p. xii). The ANA has developed 16 standards. There are three standards that relate to the knowledge deficit in nurses in regard to palliative and hospice care. The three standards are education, communication, and collaboration. Education is the main focus of this paper and it is critical it is to the care of patients with a terminal illness or that are at the end of their life. Nurses need to have a commitment to continuing their education and to lifelong learning. Nurses need to participate in education and learning experiences and share their finding to help educate other nurses (ANA, 2010)Communication is an essential skill for nurses. They need to be able to effectively communicate with their patients, fellow team members, and the families and caregivers. Nurses need to be able to communicate the educational information that the patients need regarding their options at end of life. Nurses need to continually assess their communication skills to ensure that they are effectively communicating and make improvements when necessary (ANA, 2010).Collaboration with other members of the patient’s health care team is important to nursing care. Hospice and palliative care has a large interdisciplinary team that works together to support the patients and their families. Nurses are an important part of this team and need to work effectively with the team to achieve the best outcome for the patients. The nurses adhere to the ANA code of conduct and standard when working with other team members to create a trusting and cooperative work environment that engages in the team building process (ANA, 2010). ConclusionCaring for patients at the end of their lives is difficult for nurses. Nurses want to help heal people not watch they gradually decline. The hospice and palliative care philosophies help nurses care and comfort patients and their families at a difficult time. It is reassuring for nurses to know that they did everything they could to make patients’ last days comfortable and peaceful. Having the knowledge and understanding to care for patients with a terminal illness who are facing the dying process will help both the patients and the nurses. Patients and their families rely on care and compassion of nurses during difficult times in their lives. Based on how important palliative care is and how in the coming years the need for it will only increase, because of the baby boomer population. It seems only reasonable that there is more palliative care education in nursing schools and hospitals to ensure that patients at end of life get the best quality care. “You may not always remember who you laughed with but, you will never forget who you cried with” (Heartland Hospice, n.d.). ReferencesAmerican Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Washington, DC: . Chiplaskey, L.M. (n.d.). End of life care: Are nurses educationally prepared? RN Journal, 313. David, A., & Banerjee, S. (2010). Effectiveness of “palliative care booklet” in enhancing nurses knowledge. Indian Journal of Palliative Care, 16(3), 164-167.Hansen, L., Goodell, T.T., Dehaven, J., & Smith, M. (2009). Nurses perceptions of end of life care after multiple interventions for improvement. Nursing Education in Critical Care, 18(3), 263-271. Heartland Hospice. (n.d.) Hospice Myths (PowerPoint Slides). Prem, V., Karannan, H., Kumar, S.P., Karthikbabu, S., Syed, N., Sisodia, V., & Jaykumar, S. (2012). Study of nurses knowledge about palliative care: A quantitative cross sectional survey. Indian Journal of Palliative Care, 18(2), 122-127. Qsen, (2005). Competencies, Retrieved from , S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Medical surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Taylor, C.R., Lillis, S. C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. U.S. Department of Health & Human Services. (2013). Medicare hospice benefit. Centers for Medicare and Medicaid Services. Baltimore, MA. Retrieved from: Vendlinnski,S., & Kolcaba,K.Y. (1997). Comfort care: a framework for hospice nursing. The American Journal of Hospice & Palliative Care, 14(6), 271-276. Verret, D., & Rohloff, R.M. (2013). The value of palliative care. Healthcare financial Management, 67(3), 50 -54. Wallace, M., Grossman, S., Campbell, S., Robert, T., Lange, J., & Shea, J. (2009). Integration of end of life care content in undergraduate nursing curriculum: Student knowledge and perception. Journal of Professional Nursing, 25(1), 50-56. ................
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