Two nurse leaders offer their top tips

Jill Laird, RN, MS, RCNS, and Sharol Herr RN, BSN, MS, share the most important pieces of advice they convey to nurses attending trainings at their Palliative Care Leadership Centers. Laird is Nurse Clinician and Manager of the Thomas Palliative Care Unit at the Palliative Care Leadership Center at Massey Cancer Center of the Virginia Commonwealth University Medical Center in Richmond. Herr is the Palliative Nurse Clinician & Education Coordinator for the Palliative Care Leadership Center at Mount Carmel Health System in Columbus, Ohio.

For more information on PCLCs, visit PCLC page

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, 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, 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, click here
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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 to illustrate the point:

• Massey 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 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, 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.

Joan T. Panke, APRN, BC-PCM, brings the experience of a 21-year clinical and research nursing career to her new position of Palliative Care Coordinator at the Washington Cancer Institute (WCI) in Washington, DC (WHC). Panke is starting a palliative care program at WCI, which is part of the Washington Hospital Center's (WHC) 907-bed hospital and a member of MedStar Health.

To help fast track their program, Panke and her WCI team attended the CAPC-sponsored Palliative Care Leadership Center (Leadership Center) at Massey Cancer Center.

What is the status of your palliative care program?
We are at the very beginning, and it's going to start as a consult service. We're starting slowly with one advanced practice nurse, and that lends itself well to starting with the Cancer Institute. We have a core planning team consisting of two physicians, the director of patient and community services, a representative from the finance department, and myself.

For now, I will see all the consults and will be working with the patient's primary physician and other team members. The plan is to grow the number of palliative clinicians as well as expand the service out to the entire hospital system.

How important is having the right team in place?
The central principle of palliative care is that you can't do this alone - you need a team. The ideal would be to have a full palliative care team in place, with palliative experts from multiple disciplines. But sometimes that is not possible - particularly at the start.

Too often the healthcare team is scattered and act as solo practitioners, but palliative care helps bring everyone together. Also, the team is made up of all the patient's providers. Palliative care may be able to decrease fragmentation and improve communication.

How did your team prepare for the Leadership Center training?
In preparation for our PCLC Training at Massey, we collected information about what services were available, identified gaps in care, and completed both clinical and financial needs assessments. These exercises helped highlight where palliative care could most impact and improve care at our institution.

How did the Leadership Center training equip your team with the tools needed to advance your program?
We went to the Leadership Center at Massey because they are a cancer center within a larger hospital, which is similar to WHC. Massey serves as a model for our service. Their team helped us focus by using real examples and sharing their experience in starting their program. We came out feeling energized and very clear about what we needed to do. They gave us real confidence, we felt less overwhelmed and the two days at Massey helped us focus on realistic goals. After the training, we came away with an implementation plan.

The palliative program at Massey has a coherent team and they will continue to be a great support for us as we move forward. The follow-up calls, the mentoring, the Leadership Centers in general have been a great help. When I get in a jam, I call the folks at Massey.

With programs competing for resources, how do you advance a palliative care intervention?
Across the country we are seeing the real impact of the nursing shortage, and the impact of financial crunches on all services and hospital administration decision-making. To bring in a service that isn't necessarily a revenue generator is tough in these times. People recognize the importance, but don't have a real understanding about all the benefits a palliative care service can bring to an institution in terms of cost avoidance and increasing bed capacity, for example. You need to make sure that you are tracking and showing the impact, whether it is financial, clinical outcomes or patient/family or referral source satisfaction.

What is your advice for nursing professionals interested in starting a palliative care program?
Have a very clear plan and the tools to get there. Know that you probably are going to have to tweak the plan over time. As you develop your plan, you must get buy-in from finance and administration. As nurses, we have to learn to speak their language and understand their priorities and obligations. Bring in people that can build that team such as those from finance and administration.

Everyone wants to provide quality care, but in this economic environment, we need to make a strong business case in order to survive. That means we have to learn more and expand our understanding of systems and outcomes, which not only increases our knowledge, but also our appreciation of our own nursing field.

What has been the impact of palliative care on nursing?
When I started working in palliative care, it was because I was able to practice nursing the way I was trained to practice and the way I believed nurses should practice. We were taught that the patient should be viewed from a holistic perspective, but so often the tasks and the focus on the physical dimension does take priority today.

Palliative care helps refocus us on patient- and family-centered goals that include, but go beyond, the physical to incorporate the spiritual, emotional, and practical needs and concerns. A more holistic approach to care means we are giving higher quality care. By giving improved care that addresses more of the patient's and family's needs, ultimately we see nurses and other staff who are more satisfied with their work, and ultimately with the nursing profession.

"The Role of Nursing in Palliative Care"
Co-sponsored with HPNA
July 19, 1:30 PM EST
$45

• Carolyn Ceronsky, MS, APRN, BC, Fairview Health Services
• Patrick J. Coyne, MSN, APRN, BC, Massey Cancer Center of Virginia Commonwealth University
• Sandra Muchka, RN, MS, APNP, Medical College of Wisconsin
• Sharol Herr, RN, MA, Mt. Carmel Health System
• Judy Lentz, CEO of Hospice and Palliative Nurses Association (HPNA)

For more information on other CAPC Audio Conferences, visit www.capc.org

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