Promoting the Role of Ambulatory Care Nurses in Care of Patients with Serious Illness

Background/purpose: The goal of palliative care (PC) is to prevent, assess, and relieve suffering through comprehensive symptom management and continued conversations regarding goals of care and quality of life. The fourth edition of National Consensus Project Clinical Practice Guidelines for Quality Palliative Care (NCP) describe eight essential domains and provide a template for delivery of this care in the community setting. Ambulatory care nurses are cornerstones of the interdisciplinary team from which primary palliative nursing care takes shape.

At our Magnet-designated comprehensive cancer center, we seek to address the eight domains of NCP and meet the needs of patients facing the serious illness of cancer by addressing the physical, psychosocial, spiritual, and emotional aspects of the disease. Nurses in our ambulatory care areas play a vital role in providing primary PC from time of diagnosis to death and advocate for referral to PC specialists to extend the reach of the offerings.

Description: To enhance delivery of PC, we adopted the COMFORTTMSM communication curriculum to broaden oncology nurses’ competencies to engage in difficult conversations in routine practice in the ambulatory care setting. We began with focus on the NCP domains of structure and processes of care, psychosocial and psychiatric aspects of care, and social aspects of care. The ambulatory care clinical specialist partnered with PC experts to offer classes with communication skills-building sessions and a communication toolkit, which included evidence-based patient decision prompts and palliative interview guides. Class time was also dedicated to debriefing and discussion to address barriers and concerns related to integration of COMFORTTMSM techniques into nurses’ busy clinic practices. To foster engagement, the curriculum was offered as part of nursing grand rounds and included as an element of advancement on the clinical ladder. Attendees were encouraged to adopt tools learned in the COMFORTTMSM curriculum to improve PC delivery in their clinics.

Evaluation/outcomes: The COMFORTTMSM communication curriculum became the inspiration for adoption of evidence-based practice to address NCP domains. Attendees from neuro-oncology clinic expressed concern for the social domain of PC and chose to adopt a question prompt list to assist their advanced cancer population in asking questions and making decisions about their care. Patient surveys indicated increases in questions asked during consultation by 50% and ease in discussing difficult issues by 39%. The head and neck and endocrine oncology clinic nurses implemented a patient interview technique known as BATHE to address the emotional needs of patients and families and incorporate the NCP domain of psychological and psychiatric aspects of care. Use of BATHE resulted in a 4% improvement in patient satisfaction scores for nurses’ concern for questions and worries.

We have successfully enhanced the delivery of palliative care in our ambulatory care setting through introduction of the COMFORTTMSM communication curriculum and adoption of tools and practices in diverse clinic settings. Ambulatory care nurses from all clinics are now encouraged to participate in COMFORTTMSM sessions and adopt care processes to address NCP domains of quality palliative care.