When Nurses Need To Be the Patient's Voice

A workshop for nurses at UCSF Medical Center to enhance their palliative care communications skills has been in high demand for five years. Nurses learn to represent patients and their families during acutely vulnerable times.

When Kathleen Turner, RN, BSN, enrolled in nursing school, she intended on becoming a hospice nurse.

"My mother had worked for hospice for a long time, and she and I had cared for my grandmother in the last six months of her life," says Turner. "And seeing how those hospice nurses were with my family, that's what I wanted to do."

But for her final clinical rotation, Turner's instructor threw her a curveball and assigned her to, of all places, an intensive care unit.

"I was so angry," she recalls with a laugh. "And she said, 'You know, I think this is going to be a good fit for you.' I went, and I understood that there was plenty of suffering in the intensive care unit and there was a huge opportunity to bring what I liked about palliative care into critical care."

Turner, who is now a charge nurse and clinical nurse III in the medical-surgical intensive care unit at the University of California, San Francisco Medical Center, stuck with critical care nursing as a speciality but has retained her passion for palliative care. Today she is a facilitator of a UCSF Medical Center workshop to help critical care nurses improve their palliative care communication skills.

An article that Turner co-authored in the July 2015 American Journal of Critical Care, "Communicating with Patients' Families and Physicians About Prognosis and Goals of Care," details how nurses who take the workshop report increased skill and confidence regarding palliative care communication.

Learning to Speak for the Patient

The workshop was developed in 2010 at the request of USCF's bedside ICU nurses, says Kathleen Puntillo, PhD, RN, who is professor emerita in the Department of Physiological Nursing at the UCSF School of Nursing.

"We asked the nurses what their concerns were," she says. "Their biggest one was they felt like they needed more education and more preparation in improving their skills in communicating difficult conversations."

In response, UCSF Medical Center's ICU Palliative Care Committee (formerly called the End-of-Life Care Committee) created an eight-hour workshop for critical care nurses to learn and practice palliative care communication skills. During the workshop, of which Turner and Puntillo are facilitators, nurses' roles and skills in communicating a patient's prognosis and goals of care are defined.

"It's really clear that our primary duty is to that patient, especially in a situation like the ICU where the patient is so vulnerable and so rarely able to speak for themselves," says Turner. "It's not just our right or something extra for us to do, but it's our core responsibility to be that patient's voice and that family's voice during this really difficult time."

Throughout the day, participants practice communication skills through facilitated role-playing sessions. The workshop ends with time for reflection on burnout, distress, and self-care.

According to the journal article, the workshop has been successful. Prior to attending, participants are given a self-evaluation and asked to rate their confidence and skill levels with certain tasks related to communication of prognosis and care goals. They are then asked to again rate their confidence and skills immediately after the workshop and three months later.

The nurses reported an increase in confidence and skills in both follow-up surveys. For example, prior to taking the workshop, 31% of nurses said they had the confidence and skills to ensure that the informational needs of the patient's family were being addressed. Immediately after the workshop, 71% said they had the skills and confidence to meet this need. At three months out, 77% reported improvement.

Nurses Want Palliative Care Training

The workshop was originally intended to be held a few times at most, says Turner, but it's been going strong for the past five years.

"The response from the nurses at the bedside has really been amazing," she says. "Consistently, every time we've opened registration for this workshop, it fills the first day and usually within a few hours."

The workshop has been expanded to four other University of California Health hospitals through a "train-the-trainer program," says Puntillo. Overall, more than 500 nurses have completed the workshop.

As someone who has worked in hospice and had a family member whose end–of-life wishes were not clearly articulated, I hope discussions about palliative care become more commonplace, not just in the UC Health system but at healthcare facilities across the country.

"It's really something that's applicable, I think for all hospitalized patients, certainly all of the patients in the ICU," says Turner. Palliative care discussions are "really about trying to figure out what it is that our patients and families need from their experience. How we can make this experience less traumatic? How we can promote respect and dignity for our patients? How we can make sure that the care they're receiving is aligned with their goals? That's not a death and dying thing, that's a human being thing."