A conceptual model of the nurse's role as primary palliative care provider in goals of care communication.

Objective: Nurses have opportunities to engage in goals of care conversations that can promote palliative care communication. The purpose of this study was to describe nurses' experiences in goals of care communication as summarized in the literature and to present a conceptual model of communication pathways for nurses. Methods: An integrative review of the literature (2016-2022) addressing nurses' experiences in goals of care communication was conducted using PubMed, CINAHL, and PsychInfo databases. A total of 92 articles were retrieved. A total of 12 articles were included for this review after applying the inclusion and exclusion criteria. Results: Of the 12 articles, the majority were qualitative studies (n = 8). Qualitative analysis of findings from all articles revealed three dominant themes: nurses' ambiguous role responsibilities, goals of care as end-of-life communication, and the need for nurse communication training. Conclusion: This article suggests an innovative conceptual model for advancing nurse communication about goals of care to facilitate primary palliative care. Innovation: The framework characterizes two communication pathways for Advanced Practice Nurses who direct goals of care discussions and Registered Nurses who support goals of care communication. The model informs future communication training aimed at supporting primary palliative care.

Communication and Competencies Across Undergraduate BSN Programs and Curricula.

BACKGROUND: An investigation was conducted to assess for and describe health communication instruction in entry-level baccalaureate (BSN) programs. METHOD: This cross-sectional descriptive study examined entry-level baccalaureate degree nursing programs in the United States. A three-step process was used: (1) online survey of directors of BSN programs, (2) online survey of simulation directors, and (3) analysis of course titles and descriptions. RESULTS: Communication instruction remains primarily knowledge-based rather than skills-based. The findings of this study confirm there is ambiguity in defining the scope of communication instruction across curricula, as well as radical differences in the inclusion of communication in course descriptions and content. CONCLUSION: There is a need for clear definition of the scope of health communication skill development across BSN programs for communication behaviors to be measured and competency to be determined. A knowledge-building approach to communication instruction does not align with new plans for competency-based nursing education. [J Nurs Educ. 2021;60(11):618-624.].

Book Review: Wittenberg, E., Goldsmith, J. V., Ragan, S. L., & Parnell, T. A. (2020). Caring for the Family Caregiver: Palliative Care Communication and Health Literacy. Oxford University Press.

Caring for the Family Caregiver is published by Oxford University Press and introduces the novel framework of the Family Caregiver Communication Typology. The volume offers a close analysis of caregiver health literacy and patient outcomes and invites readers to consider the family system as the driver in shaping how family caregivers deal with chronic illness demands. The expertise of all authors (three health communication scholars and one nurse who is a health literacy expert) in the analysis illuminates the delicate balance between caregivers' ability to understand and communicate in the context of social determinants of health. The book shares the interwoven challenges of palliative care, family caregiving, and health literacy. Caring for the Family Caregiver establishes the urgent call to address family caregiver information and communication needs and leaves the reader empowered to make changes in their own clinical practice communication and/or develop family caregiving research that addresses cultural and social factors.

COVID 19-transformed nursing education and communication competency: Testing COMFORT educational resources.

BACKGROUND: The COVID-19 pandemic brought a disruption to nurse education for both nursing faculty and students as all non-clinical nurse education courses worldwide moved to distance or online learning. The sudden shift to online education meant the loss of traditional activities for students to learn communication skills creating a critical demand for open educational resources for students and nursing faculty. Tools to support nursing faculty development for teaching communication are nearly non-existent and pedagogical content knowledge is needed. OBJECTIVES: The purpose of this study was to test two COMFORT COVID-19 Communication Modules (PPE and Video/Phone) for undergraduate nursing students and evaluate student communication competency post-intervention. DESIGN: This pre-post study includes qualitative and quantitative data collected to evaluate student communication competency post-intervention. SETTINGS: Undergraduate Bachelor of Science in Nursing (BSN) students at four university campuses in the Pacific and MidSouth regions of the United States. PARTICIPANTS: BSN nursing students (n = 197) predominantly in the third year of study (n = 138, 70%). METHODS: Students completed online modules as part of a nursing course. Faculty provided information and a link to access online learning modules. A pre-post assessment was completed for each module. RESULTS: Significant statistical differences were found across variables of communication attitude, knowledge, and skill across both modules. CONCLUSIONS: As nursing education in the United States shifts to competency-based education which emphasizes skill development across the BSN program, it is imperative to establish communication learning objectives that are measurable and ensure communication theory and evidence-based practice is part of curriculum content.

Opportunities to improve COVID-19 provider communication resources: A systematic review.

OBJECTIVE: Communication related to COVID-19 between provider and the patient/family is impacted by isolation requirements, time limitations, and lack of family/partner access. Our goal was to determine the content of provider communication resources and peer-reviewed articles on COVID-19 communication in order to identify opportunities for developing future COVID-19 communication curricula and support tools. METHODS: A systematic review was conducted using the UpToDate clinical decision support resource database, CINAHL, PubMed, PsycInfo, and Web of Science. The grey literature review was conducted in September 2020 and articles published between January-September 2020 written in English were included. RESULTS: A total of 89 sources were included in the review, (n = 36 provider communication resources, n = 53 peer-reviewed articles). Resources were available for all providers, mainly physicians, and consisted of general approaches to COVID-19 communication with care planning as the most common topic. Only four resources met best practices for patient-centered communication. All but three articles described physician communication where a general emphasis on patient communication was the most prevalent topic. Reduced communication channels, absence of family, time, burnout, telemedicine, and reduced patient-centered care were identified as communication barriers. Communication facilitators were team communication, time, patient-centered and family communication, and available training resources. CONCLUSIONS: Overall, resources lack content that address non-physician providers, communication with family, and strategies for telehealth communication to promote family engagement. The gaps identified in this review reveal a need to develop more materials on the following topics: provider moral distress, prevention communication, empathy and compassion, and grief and bereavement. An evidence-base and theoretical grounding in communication theory is also needed. PRACTICE IMPLICATIONS: Future development of COVID-19 communication resources for providers should address members of the interdisciplinary team, communication with family, engagement strategies for culturally-sensitive telehealth interactions, and support for provider moral distress.

The nurse influencer: A concept synthesis and analysis.

AIM: The purpose of this paper is to provide a clear definition of the concept of a nurse influencer. BACKGROUND: While the nursing profession is known for caring, advocacy, and trustworthiness, the nurse influencer is an emerging concept in health care. Clarification of this concept is essential to understand the necessary characteristics and potential opportunities for the nurse influencer. METHODS: Walker and Avant's method of concept synthesis and analysis was used. RESULTS: With time, self-efficacy, and a measurable intention, a nurse can become a nurse influencer. A nurse influencer is a nurse who has a platform to affect change through demonstrating integrity, a dedication to learning, and excellent communication of ideas and information. In addition to creating change, the nurse influencer may also disseminate knowledge and generate empowerment for themselves and others. CONCLUSION: This concept analysis, the first focusing on the nurse influencer, provides an explanation of this concept and a concept map of the nurse influencer's attributes and contributions.

Patient reported symptom outcomes during medication titration for adult heart failure management.

AIMS AND OBJECTIVES: This project used the Patient Reported Outcomes Measurement Information System (PROMIS) tools to evaluate heart failure patient's experiences of dyspnea, fatigue, and physical mobility during initiation and up titration of drugs in an outpatient setting. BACKGROUND: Investigating patient reported outcome may improve adherence to GDMT. Theoretical support for this study is found in the University of California, Theory of Symptom Management. DESIGN: Exploratory, repeated measures design. METHODS: Patients (n = 21) completed three PROMIS questionnaires for dyspnea, fatigue and physical mobility when GDMT was started or up titrated, and again at a follow up appointment within 30 days (+/- 14 days) of the baseline measures. Patients were asked open- ended queries regarding the usefulness of these questionnaires in identifying and managing symptoms. Provider input was sought on usefulness of the tools in clinical practice and decision making. RESULTS: Dyspnea change scores significantly decreased (p = .001), physical mobility scores significantly increased (p = .017), and fatigue scores did not change (p = .319). Duration of HF diagnosis was associated with dyspnea change scores. Patients reported PROMIS tools were easy to use, while providers felt the tools were easy for patients to use but were too long and time intensive for usual office practice. CONCLUSIONS: Dyspnea and physical mobility improved with up titration of GDMT but fatigue did not change. RELEVANCE TO CLINICAL PRACTICE: PROMIS tools could be helpful in tracking selected symptom changes during GDMT HF medication initiation or up titration for HF management if reformulated into shorter format.

Identifying and Addressing Family Caregiver Anxiety.

Family caregivers are an increasingly diverse group of individuals who provide significant amounts of direct and indirect care for loved ones with long-term chronic illnesses. Caregiver needs are vast, particularly as these relate to the caregiver's quality of life. However, caregivers are often unlikely to address their personal and health-related concerns. Unmet needs combined with the caregiving role often lead to high levels of caregiver anxiety. Unaddressed, this anxiety is likely to result in poor health and low quality of life. Nurses, along with the health care team, are well positioned to assess, monitor, intervene, and reassess anxiety levels in caregivers using standardized screening tools across care settings. This article focuses on the family caregiver anxiety symptom in community-based settings, where health care providers have unique opportunities to detect this symptom in a familiar environment and begin immediate intervention leading to promotion of quality of life for the caregiver and subsequently the care recipient. Additional research efforts should be focused on health care provider goals of care, dyadic assessments, and monitoring of caregiver needs while caring for their loved ones aging in place.

Palliative care services in pediatric oncology.

Pediatric cancer has experienced significant improvement in overall survival rates over the past several decades. Despite this progress, however, it remains the leading cause of death from disease beyond infancy in children. Among the children and adolescents that survive their cancer diagnosis, significant symptom burden and toxicities of therapy are often experienced. The evidence presented affords great insight in to the current empirical support for pediatric palliative care involvement, current utilization of palliative care services in the care of children with cancer and their families, and barriers that have been identified to date. Positive trends toward increased, appropriate integration of palliative care services in the care of children with cancer and their families have been observed. Continued research, advocacy, and education are necessary to optimize the care of this vulnerable population of patients and their families.

Randomized clinical trial of a community navigation intervention to improve well-being in persons living with HIV and other co-morbidities.

Long-term survival of people living with HIV (PLWH) is associated with the development of co-morbid conditions and need for symptom management and other efforts to enhance quality of life. We conducted a longitudinal, randomized trial over 36 months to evaluate the effect of a community-based navigator intervention to provide early palliative care to 179 PLWH and other chronic conditions. Outcomes included quality of life, symptom management, coping ability, social support, self-management, and completion of advance directives. Data were analyzed using SAS mixed effects model repeat measurement. Our navigator program showed variable improvement over time of three outcome variables, self-blame, symptom distress, and HIV self-management. However, the program did not improve overall quality of life, social support, or completion of advance directives.

Knowledge, Beliefs, and Behaviors Related to Palliative Care Delivery Among Pediatric Oncology Health Care Providers.

The care of pediatric patients with cancer and their families is complex and rapidly evolving. Despite significant advances in outcomes, symptoms of the disease and complications of therapy continue to cause suffering that may improve with the involvement of pediatric palliative care (PPC) services. This descriptive study responds to the observation of great variability in PPC utilization within pediatric oncology. Data collected from 156 health care professionals (nurses, advanced practice professionals, and physicians) from a statewide hematology alliance evaluates the knowledge, beliefs, and perceived barriers to PPC involvement. Data analysis reveals significant variability when comparing respondents from professional roles and practice environments. Despite progress in PPC availability, care delivery remains incongruent with current recommendations. Knowledge gained from this study emphasizes the important role for all health care providers in advocating for support of PPC programs, educating the public, and committing to intentional involvement of PPC services while caring for pediatric oncology patients.

Animal Assisted Interactions to Alleviate Psychological Symptoms in Patients on Mechanical Ventilation.

Mechanical ventilation is a common life support intervention for critically ill patients that can cause stressful psychological symptoms. Animal assisted interactions have been used in variety of inpatient settings to reduce symptom burden and promote overall well-being. Due to the severity of illness associated with critical care, use of highly technological equipment, and heightened concern for infection control and patient safety, animal-assisted interaction has not been widely adopted in the intensive care unit. This case study of the therapeutic interaction between a canine and a mechanically ventilated patient provides support for the promotion of animal-assisted interactions as an innovative symptom management strategy in the intensive care unit.

Mindful Communication: Being Present.

OBJECTIVES: To review how mindfulness can be elicited in and strategically managed through communication, with a goal toward enhancing the patient/family relationship in the experience of cancer care. DATA SOURCES: Published, peer-reviewed literature, research reports, and Web-based resources. CONCLUSION: Mindful communication, an active process whereby the health care provider and patient /family unit are attentive to the timing, nature, and context of the dialogue exchange, helps direct care that is patient-centered, reflective, and relational. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses using a patient-centered approach to communication will be more equipped to use mindfulness-based strategies that can potentially shift the way cancer care is delivered.

Multimorbidity With HIV: Views of Community-Based People Living With HIV and Other Chronic Conditions.

People living with HIV (PLWH) experience an increase in chronic conditions with aging, but little is known about experiences of living with multimorbidity with HIV. Because early palliative care services may improve well-being for individuals with multimorbidity, we planned to test an intervention to provide these services to community-dwelling PLWH with other chronic conditions. To tailor our intervention to the target population, we conducted four focus groups (n = 22) that elicited health-related needs, experiences, and views regarding palliative and other health services. We identified four themes related to patients' needs and experiences: views of HIV as background to other chronic conditions, challenges managing medications and provider interactions, concerns about coping with future health needs, and persistence of HIV stigma. In addressing multimorbidity with HIV, providers and patients may benefit from enhanced attention to communication when crossing specialty areas and from additional support to decrease stressors associated with HIV stigma.

Perceptions of Statin Discontinuation among Patients with Life-Limiting Illness.

BACKGROUND: Optimal management of chronic medications for patients with life-limiting illness is uncertain. Medication deprescribing may improve outcomes in this population, but patient concerns regarding deprescribing are unclear. OBJECTIVE: The aim of this study was to quantify the perceived benefits and concerns of statin discontinuation among patients with life-limiting illness. DESIGN: Baseline data from a multicenter, pragmatic clinical trial of statin discontinuation were used. SETTING/SUBJECTS: Cognitively intact participants with a life expectancy of 1-12 months receiving statin medications for primary or secondary prevention were enrolled. MEASUREMENTS: Responses to a 9-item questionnaire addressing patient concerns about discontinuing statins were collected. We used Pearson chi-square tests to compare responses by primary life-limiting diagnosis (cancer, cardiovascular disease, other). RESULTS: Of 297 eligible participants, 58% had cancer, 8% had cardiovascular disease, and 30% other primary diagnoses. Mean (standard deviation) age was 72 (11) years. Fewer than 5% of participants expressed concern that statin deprescribing indicated physician abandonment. About one in five participants reported being told to take statins for the rest of their life (18%) or feeling that discontinuation represented prior wasted effort (18%). Many participants reported benefits of stopping statins, including spending less money on medications (63%), potentially stopping other medications (34%), and having a better quality of life (25%). More participants with cardiovascular disease as a primary diagnosis perceived that quality-of-life benefits related to statin discontinuation (52%) than participants with cancer (27%) or noncardiovascular disease diagnoses (27%) [p = 0.034]. CONCLUSION: Few participants expressed concerns about discontinuing statins; many perceived potential benefits. Cardiovascular disease patients perceived greater potential positive impact from statin discontinuation.

Upstreaming and Normalizing Advance Care Planning Conversations-A Public Health Approach.

As a society, we simply don't talk about this universal experience called dying and death; in fact, we ignore it until we have to face it. Thus, it is often in a crisis experience when we have to make decisions while we are laden with uncertainty and intense emotions. Sixty percent of people say making sure their family is not burdened by tough decisions is extremely important, yet 56% of them have not held a conversation about its context. Instead of waiting to make end-of-life decisions, let us begin to think about what matters most while we are living, what we value most, and how we translate these values into conversations about what is important. As a public health concern, if we can upstream the advance care planning discussion into usual health promotion activities, perhaps, as a society, we can begin to normalize and reshape how we make decisions about the last chapters of our lives.

Fatigue Symptom Management in People Living With Human Immunodeficiency Virus.

Fatigue is a subjective, unpleasant, potentially disabling symptom rooted in physiological, psychological, and behavioral causes. People living with HIV are a population highly affected by fatigue due to risk factors associated with HIV-infection, treatment, and psychosocial disease burden. People with HIV are living longer, and are facing the challenge of a longer disease trajectory. Palliative nurses with expertise in symptom management can play a crucial role in helping people with HIV to engage in health behaviors that prevent or mitigate fatigue. In this paper we present a definition and overview of fatigue, describe the problem of fatigue in people living with HIV, and present a case study that illustrates the role of the palliative nurse in helping a person with HIV to cope with fatigue.

Palliative Care, Hospice, and Advance Care Planning: Views of People Living with HIV and Other Chronic Conditions.

People living with HIV (PLWH) who survive to older adulthood risk developing multiple chronic medical conditions. Health policymakers recognize the role of early palliative care and advance care planning in improving health quality for at-risk populations, but misperceptions about palliative care, hospice, and advance care planning are common. Before testing a program of early palliative care for PLWH and other chronic conditions, we conducted focus groups to elicit perceptions of palliative care, hospice, and advance care planning in our target population. Overall, participants were unfamiliar with the term palliative care, confused concepts of palliative care and hospice, and/or associated hospice care with dying. Participants misunderstood advance care planning, but valued communication about health care preferences. Accepting palliative care was contingent on distinguishing it from hospice and historical memories of HIV and dying. Provision of high-quality, comprehensive care will require changing public perceptions and individuals' views in this high-risk population.