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The Role of the Nurse in a Palliative Care Setting.
Introduction
Nurses play a crucial role in Palliative Care Setting providing communication and patients support for diverse patients groups. Palliative care has grown rapidly during the last two decades. Stimulated by the development of life-saving and monitoring techniques requiring specialized personnel and equipment, palliative care units developed in a relatively uncontrolled fashion. Their spread was facilitated by the predominance of cost-reimbursement as a means of financing hospital care and the lack of hospital internal constraints on creating palliative care units. Many patients who are at high risk for experiencing a complication requiring prompt treatment are now admitted to palliative care for monitoring.
The rational of the literature review is to investigate and analyze the role of nurses in Palliative Care and identify possible problems and drawbacks. The main limitations of the literature review are limited scope of research and diverse hospital settings and patient base. The literature review is based on secondary data analysis (primary research articles) examined and analyzed using current nursing theories.
Body
The vast layer of literature pays a special attention to communication process and its impact on nurse-patient relations. The article Hospice Palliative Care Nursing Standards provides a details analysis of standards and principles of nursing and its application in Palliative Care. The authors underline that to communicate responsibly when a problem has to be solved means to communicate in a logical way based on nursing knowledge and on the facts presented in the situation. Responsible communication demonstrates accurate problem-solving behavior for the particular situation.
Nursing process is a systematic means for nurses to demonstrate accountability and responsibility to clients. Discussions of the nursing process offer several different formats, with the steps varying in number. This problem-solving process becomes a way of examining every client-nurse (or nurse colleague) interaction. It becomes a natural part of a day. While nurses are receiving a message, nurses are trying to determine its meaning. A nurse decides whether she will meet the senders request, and then nurses transmit an assertive and responsible message that conveys decision.
Similar to Jacquie et al (2005), Hill (2007) and Sindingm (2004) underline important and a positive role of effective nursing communication in palliative care. Caring is the basis of the nursing profession. Nursing communication may be technically responsible and assertive, but without caring nurses still may not be able to facilitate a change in behavior. It is important to examine what caring means. Caring is not an abstract concept; there are explicit ways nurses can communicate to show nurses care.
Encompassed in caring is a commitment to the preservation of common humanity and an unrelenting respect for the uniqueness and dignity of each individual nurses encounter. Nurses can have an extensive command of scientific facts and theories and be technically expert without being caring professionals. In addition, nurses can be technically and scientifically correct but still make moral errors. Although there is satisfaction in being technologically competent, that satisfaction is not as lasting as meaningful moments of connection with clients, family, and colleagues. Caring communication is holistic, taking into account the entire person and demonstrating respect for clients as people, not just as bodies requiring nursing interventions.
A study of caring, as lived by critical care nurses, demonstrated that caring involved affective, cognitive, and psychomotor aspects that led to outcomes. The process of caring began in the nurses feelings and knowledge and moved the nurse to competent actions that contributed to positive outcomes for the client, family, and nurse. Caring communication is equally important with colleagues as with clients. If caring exists between co-workers, that sense of well-being will likely be passed on to clients.
Conversely, if there is little caring between colleagues, then nurses will be unlikely to feel complete and satisfied enough to demonstrate a sense of caring with their clients. Caring involves being assertive and responsible. If nurses let others control them because nurses are nonassertive, or if they invade others rights by being aggressive, nurses cannot act in a caring way. If nurses care enough for yourself to be assertive, nurses will know how to care for others (Jacquie et al 2005).
In contrast to other writers and research studies, Seymour et al (2004) underline that the nature of client-nurse relationships in palliative care is described so that a nurse can explain the difference from social, collegial, and kinship relationships. The responsibilities of nurses in client-nurse relationships have also been outlined so that nurses will be able to articulate roles and interventions at each stage of the helping relationship. Nurses are invited to discover the extent to which nurses foster a helping relationship in interactions with clients. A set of pre-established rules and expectations directs the course of client-nurse interactions.
There may be some overlap in these interactions with those involving friends and family, but one factor in particular differentiates helping relationships from social relationships. A helping relationship is established for the benefit of the client, whereas kinship and friendship relationships are designed to meet mutual needs. In particular, the client-nurse relationship is established to help the client achieve and maintain optimal health.
All research studies under analysis underline that a successful helping relationship between nurse and client represents a different order of interaction than that which occurs in a friendship. This is not because of any superiority in the nurse but because of the mutual trust and the responsibilities for assisting others that characterize true professional relationships. Client-nurse relationships are entered for the benefit of the client, but such a relationship is more effective if it is mutually satisfying.
Clients are satisfied when their health care needs have been met and they sense that they have been cared for. Nurses feel a sense of accomplishment when their interventions have had a positive influence on their clients health status and when their conduct has been competent and caring. Client-nurse relationships may be a mutual learning experience, but in general the goals of therapeutic relationships are directed toward the growth of clients.
Sindingm (2004) states that in palliative care clients and nurses alike come to the relationship with unique cognitive, affective, and psychomotor abilities that they use in their joint endeavor of enhancing the clients well-being. Nurses are responsible for encouraging this interchange of ideas, values, and skills. In an effective helping relationship there is a definite and guaranteed interchange between clients and nurses in all three dimensions.
Clients and nurses both know something about health and illness in general, and about the individual clients health concerns in particular. Clients have definite notions about what has made them ill and what might improve their health; in turn, nurses have their own views, based on their knowledge and beliefs about what will help their clients. To prevent them from operating in isolation or at cross-purposes, clients and nurses must exchange essential information.
Only some research studies (Werner et a l2004; Sindingm 2004) describe and analyze the current state of palliative care and its future development trends. Recent changes in health care financing are influencing hospitals incentives for supplying palliative care. Prospective payment based on diagnostic-related groups currently includes no differential for care. Yet, the cost of care in an palliative care unit may well exceed the payment levels for medical technology that most commonly occur in palliative care. Since patients receiving palliative care will produce financial losses for the hospital, the current payment system is likely to influence the supply of palliative care beds.
Palliative care has flourished under a system in which the costs were more nearly reimbursable; in fact, cross-subsidization often resulted in payments that exceeded costsfor example, ancillary services. As funding continues to move in the direction of prospective payment, rather than cost reimbursement, hospital officials may decide that limiting the quantity of palliative care beds is preferable to attracting large numbers of critically ill patients and incurring financial loss. While the thought of limiting the growth of palliative care raises immediate concerns about equity and restriction of liberty, the failure to limit palliative care in the face of scarce health care resources also produces ethical dilemmas.
The fact that palliative care has been made widely available with little regard to age or health status suggests that our society has opted for extending life whenever possible. To the degree that this has restricted our ability to fund other types of programs, nurses may have reduced the possibility of maximizing the length and quality of life for all, while extending it for a few who become critically ill. Thus, the issue may really involve allocation for either preventive medicine or life-prolonging care.
From one perspective, prevention may be a more effective means of raising the general level of health and quality of life. But it could lead to the neglect of needy persons who could directly benefit from the resources of palliative care. Resolving this issue requires weighing the goal of maximum costefficiency against the costly needs of a relatively small number of individuals.
Following Jacquie et al (2005) in palliative care, validation invites the collaboration that is essential for successful client change. The trust developed from working together is likely to increase the accuracy and validity of the database, enriching the foundation for the rest of the nursing process. The trust growing out of mutuality provides the clients with an anchor, giving them the support they need to risk changing health behaviors. Collaboration ensures the benefits of two heads working on a health problem; this is essential because nursing cannot exist in a vacuum. Nurses cannot strive for excellence without including the full participation of clients.
In contrast to other studies, Werner et al (2004) give a detailed account if roles and duties played by nurses in palliative care settings. They underline that the outcome of the nurse-client interaction depends on the nurses ability to engage the client in decision making and share the control and power in the relationship. Nurses build their communication skills by studying and practicing techniques, trial-and-error, observing role-models, experience, and gaining comfort with the use of their own intuition. Face work and politeness theory point to the need to consider the client and nurses sense of self-esteem, autonomy, and solidarity in conversation (Spiers, 1998).
Researchers speak of saving face or helping the other save face and mean the preservation of dignity so each party continues to be willing to invest in the interaction without experiencing threat. In the complex nature of problem- solving with the client to promote health, many factors can present barriers. Each party wants to maintain a sense of personal competency and control. An attack on these or on the persons poise or sense of belonging or being liked are called face threats Sindingm (2004
Seymour et al (2004) desribes and analysis the case of morphine use in cancer pain:and the duties and responsibilities of nursing staff. The research study examines the following questions: What kind of care should be available, and where and to whom should it be provided? How should society control the supply and use of palliative care? The widespread growth of palliative care, coupled with the heightened concern about health care costs, has focused attention on these and other related questions.
The fact that these questions are being asked reflects a recognition of the competition between palliative care and other developing health care technologies for societal resources and other valued goods and services. Thus, the supply of palliative care is not unlimited. When such a valued resource is constrained, questions of how it should be distributed inevitably arise. Moreover, recent changes in the financing and delivery of health care are changing the historical influences on the development and provision of palliative care (Sindingm 2004).
This article reviews the growth and current distribution of palliative care resources, as well as the possible causes and consequences of these patterns. Issues related to the allocation of societal resources to palliative care versus other health and welfare programs (that is, macroallocation) and the allocation of existing palliative care resources among patients (that is, microallocation) will also be discussed. All authors agree that communication can either facilitate the development of a therapeutic relationship or create barriers.In general, there are two parts to face-to-face communication: the verbal expression of the senders thoughts and feelings, and the nonverbal expression.
In contrast to other research studies, Sindingm (2004) identifies that powerful nonverbal messages can stand alone: a suspicious glance, for example, or a warm smile or eyes widened with fear. The preceding data suggest that the available technology and the related costs of palliative care are growing rapidly, and constitute a noteworthy portion of health care expenditures. Further, these expenditures may not always result in sufficient benefits.
In order to understand the implications of this trend, one must be able to predict the future status of the population most at risk for receiving palliative care. In the long run, however, primary prevention of these killer diseases is expected to improve. Prevention will also lead to lowered mortality from killer diseases and higher prevalence rates for the chronic non-killer diseaseswhich will probably require more chronic, rather than critical, care. Thus, in the more distant future, chronic care needs are apt to compete more directly for critical care resources.
Summary
In sum, the literature review allows to say that palliative care is now considered routine following many complicated surgeries, and it is quickly becoming the norm for treating acute exacerbations of chronic and terminal conditions. Since palliative care beds have been increasingly available in many facilities, the criteria for admission have been lowered. Thus, the growing number of beds has influenced clinical decision making toward the use of palliative care whenever it may be helpful. Concern about this growing use has led us to research on the types of patients receiving palliative care and the degree to which they are benefitting.
Knaus et al. found that there were two types of patients who did not seem to derive much benefit from treatment in an palliative care unit. Since the elderly constitute a large percentage of those treated in palliative care, questions have been raised about their utilization patterns and clinical decisions made regarding their care. Although elderly patients do not stay in palliative care longer than younger patients, they do require more interventions and have a lower survival rate.
Given the chronically ill nature and high mortality of the nursing home population, one would expect nursing home transfers to account for a higher percentage of admissions, if most of the seriously ill or dying patients in this group were admitted. It is likely that hospital and nursing home clinicians make decisions to not treat all patients aggressively. The flaw in this approach is that most studies use a hospital stay as the unit of analysis, rather than a patients total consumption of health care in a given period.
Because patients in palliative care typically have more costly stays, people tend to assume that they are the most costly group of patients in the health care system. Yet, studies that focus on the patient over time as the unit of analysis have found that the patients cost less per year than chronic patients who are repeatedly admitted for routine care.
References
Jacquie, P., Darlene, G., Marie-Josie, P. (2005). Hospice Palliative Care Nursing Standards: How do these apply to our practice?. Alberta RN. 43, 02.
Hill RR (2007). Clinical pharmacy services in a home-based palliative care program . Am J Health Syst Pharm 64 (8): 806.
Seymour, J. E; D. Clark, M. Winslow (2004). Morphine use in cancer pain: from last resort to gold standard. Poster presentation at the Third research Forum of the European Association of Palliative Care . Palliative Medicine 18 (4): 378.
Sindingm Ch. (2004). 4Informal Care-Two-Tiered Care? the Work of Family Members and Friends in Hospitals and Cancer Centres. Journal of Sociology & Social Welfare, 31 (1), 54.
Werner, P. Carmel, S., Ziedenberg, H. (2004). Nurses and Social Workers Attitudes and Beliefs about and Involvement in Life-Sustaining Treatment Decisions. Health and Social Work 29 (32), 43.
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