Survival Guide for Palliative Care RNs
Two nurse leaders offer their top tips
1. Set up routine processes and algorithms so nurses can
more easily make decisions about treating immediate patient
needs.
The most effective nurses are the best-supported nurses.
Providing proper training and developing routine processes and
algorithms empower nurses to make decisions about treatment when
appropriate. Opportunities for quick physician consultation also
provides nurses with the support they need.
At Mount Carmel Health System, nurses interact with physicians
five days a week in daily rounds. There are weekly
interdisciplinary team meetings that further strengthen this
interdisciplinary collaboration. At the meetings, the team
discusses cases in more detail, shares information, solves
problems and learns from each member. A palliative care
physician is on-call 24 hours per day, seven days per week.
At Massey Cancer Center, there are 18 evidence-based algorithms
in place which are reviewed every year and approved by the
attending physicians for palliative care patients on our unit.
Trained nurses on the unit can use the algorithms to promptly
treat dsypnea, anxiety or pain, for example, which makes them
better able to respond quickly to patient and family needs.
Patients get immediate treatment and positive outcomes without
needing to wait for the doctor. The nursing staff knows they are
giving the right treatment in a timely fashion.
To view the algorithms, visit http://www.capc.org/signup
(E-mail address registration required to access tools.)
2. Create a culture of flexibility and responsiveness to
patient needs.
Even with good processes and procedures in place, there may be
uncertainty and gray areas. For instance, understanding a
patient's goals of care can be time consuming and complex.
However, these conversations are critical to providing
appropriate care. By focusing on and setting a patient's goals
of care, it's much easier to know how to proceed. If you're
wondering whether to draw a lab on a patient or provide
antibiotics to an elderly person with aspiration pneumonia,
there is no right or wrong textbook answer. The answers should
be determined by whether these actions meet the goals of care.
Guidelines in a unit or on a service are necessary, but they
should not be viewed as hard and fast rules. Here are two cases
from Massey Cancer Center to illustrate the point:
* Massey Cancer Center doesn't usually allow overnight visits
by children, but a nine-year-old slept with his mom on the unit
two days before she died. That was the right thing to do in that
situation.
* In another case, Massey Cancer Center made an
exception to the usual rule of extubation before transfer to the
unit. The case involved a 38-year-old father from the ICU who'd
been in a motor vehicle accident. The ICU team feared that he
might die immediately from removal of the tube. By leaving it
in, he had 24 hours in a supportive environment with his wife
and daughter.
3. Think beyond hospital walls to the broader continuum of
care.
Hospitals need to think beyond their own walls when devising a
good palliative care plan for a patient. Nurses should ask,
"What is realistic in terms of caregiving, finances and outcomes
outside the hospital?" Patients and families need education on
their options. Build those outside options and agencies into the
plan of care, and communicate with receiving agencies. In order
to ensure an orderly transition from one setting to another,
patients' medical information and reports should be sent to the
appropriate outside agencies.
4. Build in a support structure of nursing staff to prevent
burnout.
An improperly structured palliative care team can lead to nurse
burnout. It is critical to have adequate staffing and an
interdisciplinary team with a high degree of collaboration to
help mitigate burnout. The support and collaboration of the
interdisciplinary team alleviates the perception by nurses who
often think and feel they are saving the world by themselves.
Prepare staff through education and training. Teach staff
communication skills and how to have difficult conversations.
Providing the appropriate tools nurses need to take care of
patients greatly impacts the ability for them to continue their
work.
Obtain administrative buy-in and support. When leaders in the
organization value what nurses are doing there is a sense of
esprit de corps among the staff. When all staff is doing the
same thing - giving the right care at the same time - it is
rewarding and people feel a sense of connection and purpose,
which improves retention and reduces burnout.
At Massey Cancer Center, an annual memorial service with family
members is a very rewarding event for everyone. They also hold
an annual staff retreat where the interdisciplinary team spends
a day off the unit, further developing relationships and team
building. The best services are those with a close-knit group of
nurses who look out for each other. Encourage nurses to use
their vacation time and make it easy for them to take it when
they need it. Help them find sources of relaxation. The chaos of
the average day can be hard, so it's important to get mental and
emotional breaks.