Applied Nursing Research 40 (2018) 26–33

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Original article

Canadian hospital nurses' roles in communication and decision-making T

about goals of care: An interpretive description of critical incidents
⁎
Patricia H. Strachan, PhD RNa, , Jennifer Kryworuchko, PhD CNCC(C) RNb, Elysée Nouvet, PhDc,
James Downar, MHSc MDCMd, John J. You, MSc MDe,f
a
McMaster University, School of Nursing, HSC 3N28H, 1280 Main St. W., Hamilton, ON L8S 4K1, Canada
b
University of British Columbia, Nursing, Centre for Health Services and Policy Research & BC Centre for Palliative Care, T275 - 2211 Wesbrook Mall, Vancouver, BC V6T
2B5, Canada
c
Western University, School of Health Studies, HSB 222, London, ON N6A 5B9, Canada
d
Palliative Care and Critical Care, University Health Network (Toronto), 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
e
Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada
f
Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Nurses in acute medical units are uniquely positioned to support goals of care communication.
Communication Further understanding of nurse and physician perceptions about hospital nurses' actual and possible roles was
Decision making required to improve goals of care communication.
Goals of care Objective: To critically examine nurse and physician perceptions of the nurse's role in communication with
Hospitals
seriously ill patients and their families.
Teaching
Design: We focus on the qualitative component of a mixed method study. We employed an interpretive de-
Nurse-patient relations
Nurse's role scriptive approach informed by Flanagan's critical incident technique.
Physician-nurse relations Settings: Participants were recruited from the acute medical units at three tertiary care hospitals in three
Canadian provinces.
Participants: Thirty participants provided interviews (10 from each site): 12 nurses, 9 staff physicians and 9
medical resident physicians.
Methods: Participants' described “critical incidents” they considered as “excellent” or “poor” or “usual” practice.
Interviews, were audiotaped and transcribed. Team-based analysis used constant comparison and triangulation
to identify healthcare team members' roles in goals of care communication.
Results: We identified two major themes from 120 critical incidents: 1) the ambiguous nature of the nurse's role
in formal, physician-led, decision-making communication, and 2) embedded in care serious illness communica-
tion. Physicians understood nurses' supportive role in relation to their own communication practices that cul-
minated in decisions about care; nurses' reported their roles were determined by unit routines, physician
practices and preferences, and their self-confidence in supporting decision-making. Nurses described their un-
ique role in facilitating informal and spontaneous communication with patients and families that was critical
background work to physician-led goals of care communication.
Conclusions: Nurses and physicians had different understandings, practices and beliefs about goals of care
communication The value of nurses embedded in care work is key to supporting the interprofessional team's work
during formal goals of care communication.

What is already known about this topic?
• The Registered Nurse's scope of practice includes initiating and
engaging in goals of care discussions and supporting decision-
making processes with seriously ill patients and their families.
• Hospital Nurses act as information brokers, advocates and
supporters for patients and families in the end-of-life decision-
making process.
• Multiple issues create conditions that impede nurses' engagement in
end-of-life communication; these include nurses' lack of confidence,
implicit understandings of existing hierarchical structures in health
care teams, and social historical constructions of nurse-physician

⁎
Corresponding author.
E-mail addresses: strachan@mcmaster.ca (P.H. Strachan), Jennifer.Kryworuchko@ubc.ca (J. Kryworuchko), james.downar@uhn.ca (J. Downar), jyou@mcmaster.ca (J.J. You).

https://doi.org/10.1016/j.apnr.2017.12.014
Received 31 July 2017; Received in revised form 25 November 2017; Accepted 14 December 2017
0897-1897/ © 2017 Elsevier Inc. All rights reserved.
P.H. Strachan et al.
relationships.
What does this study add?
• Nurses' goal of care communication is embedded in care and thus
occurs informally with patients and families on acute medical units.
Such communication is often unrecognized, since it is embedded in-
the-moment work that arises spontaneously during care and occurs
asynchronously and outside of the most often researched, physician-
led, formal, and planned decision-making processes (i.e., patient
consultations and family conferences). We unpack these hidden
practices as a way of foregrounding nurses' important roles in
communication with seriously ill patients and their families.
• Hospital nurses' hesitancy to claim their role in goals of care com-
munication and decision-making with seriously ill patients is dy-
namically influenced by uncertainties about their own relational
skills, what is perceived as physician preference for nurses' partici-
pation, and normalized routines on the medical teaching unit that
can position nurses as outsiders to these conversations.
• Physicians' practice experiences, assumptions and understandings
about the value of nurses' roles in goals of care discussions influ-
enced their intentional inclusion of nurses in these discussions.
Understanding these contextual dynamics is essential to inform ef-
forts that support nurses' active involvement and to optimize their
participation to their full scope of practice in both informal and
formal goals of care communication.
1. Introduction
Seriously ill patients at high risk of decline and death and their
families have identified effective communication and shared decision
making as crucial to their end-of-life care (Virdun, Luckett, Davidson, &
Phillips, 2015). By listening carefully to hospitalized patients and their
families, healthcare professionals can illuminate what might be im-
portant to accomplish with care, which is also referred to as “goals of
care”, and then consider the range of treatment decisions that are
salient for an individual. Goals of care communication refer to the
process of discussion that ideally informs and occurs prior to shared
decision-making processes about end-of-life care options (Sinuff et al.,
2015). Shared decision-making is an approach to decision-making
where the healthcare team listens to and actively engages seriously ill
patients and their families throughout the process from identifying
opportunities where choice exists to implementing care and assessing
how it meets their needs (Kryworuchko, Stacey, Peterson, Heyland, &
Graham, 2012). Serious illness communication refers to communication
between health care professionals and patients and/or their families,
within the context of a serious and life-threatening illness. It may in-
clude advance care planning, goals of care discussions and shared de-
cision-making regarding end-of-life care options (Bernacki, Block, and
for the American College of Physicians High Value Task Force, 2014).
As essential caregivers at the point of care, nurses in acute care
settings are uniquely positioned to support communication with ser-
iously ill patients and their families (Adams, Bailey Jr, Anderson, &
Docherty, 2011). Internationally, professional nursing standards and
position statements highlight the crucial role for nurses in serious ill-
ness discussions identifying patient-centered goals of care and salient
health decisions (American Nurses Association Professional Issues
Panel, 2017; Canadian Nurses Association, 2014; College of Nurses of
Ontario, 2009), yet nurses continue to experience challenges enacting
their role amidst the complexities of the acute care setting. A review
and synthesis of best practices in communicating about goals of care
and decision-making in serious illness has drawn attention to the need
for the development of communication expertise amongst all clinicians
on interprofessional teams working with seriously ill patients (Bernacki,
Block for the American College of Physicians High Value Task Force,
2014). Importantly, developing nursing communication expertise
27
Applied Nursing Research 40 (2018) 26–33
within interprofessional teams must attend to power differentials that
affect relational practice and to the contextual nature of nursing prac-
tice in acute care settings with patients at the end-of-life (Hartrick
Doane, Stadjuhar, Causton, Bidgood, & Cox, 2012).
Within a broad research program, we undertook a mixed methods
study (DECIsion-making about goals of care for hospitalized meDical
patiEnts:[DECIDE]) to understand factors important to optimal goals of
care discussions and decision-making with seriously ill hospitalized
patients on acute medical units in Canada, from the perspective of
physicians and nurses involved in those discussions (You et al., 2015).
Results from the multi-center (quantitative) survey component of this
study involving 13 medical units in teaching hospitals across Canada
(512 nurses, 484 residents, 260 staff physicians) indicated that a staff
physician was the preferred clinician in any final decision about goals
of care and the use of life-sustaining technology. Nurses viewed it as
acceptable that nurses initiate goals of care discussions, exchange re-
lated information with patients and families, act as a decision coach and
make a final decision with patients and/or their families. Medical re-
sidents and staff physicians generally concurred with this view, how-
ever they for nurses to make a final decision with patients and families
(You et al., 2015).
Qualitative data about practice experiences were collected along-
side this survey data via interviews conducted with 30 physicians and
nurses at three hospitals in three Canadian provinces. A culture of death
avoidance pervaded across study contexts, and goals of care discussions
and decisions about the use of life-sustaining technology were delayed
until days or hours prior to death (Nouvet, Strachan, Kryworuchko,
Downar, & You, 2016). Overall findings from these interviews identi-
fied a number of factors that contributed to goals of care discussions
and decision-making going well, or less well, in the eyes of physicians
and nurses (Kryworuchko, Strachan, Nouvet, Downar, & You, 2016). A
major theme amongst these was how physicians and nurses conducted
professional work within teams. Communication was led most often by a
physician, with nurses working in the background behind the scenes
(Kryworuchko et al., 2016: 7). In this paper we will present a more in-
depth analysis of nurse's goals of care communication work within the
acute medical context.
1.1. Aim
The aim of this paper is to critically examine nurse and physician
perceptions of the nurse's role in goals of care discussions and decision-
making with patients experiencing serious illness and their families.
2. Methods
2.1. Methodological orientation and theory
The qualitative methodology for the DECIDE mixed methods study
employed an interpretive descriptive approach (Thorne, 2008) using
Flanagan's critical incident technique (Flanagan, 1954). Our methods
were previously reported in detail (Kryworuchko et al., 2016) and are
summarized here.
2.2. Participants and setting
Participants were recruited from three selected hospital sites
(Alberta, Ontario, Quebec) of the 13 hospitals involved in the quanti-
tative study component. This was done to offer a diversity of geography
(three provinces) and language (English and French) from the Canadian
perspective. The units from which participants were recruited were
acute medical units in a tertiary care teaching hospital. Medical re-
sident physicians routinely rotated through these units. Units had
35–45 beds with nurse patient ratios of 1:4–1:8 depending on the
medical complexity of non-surgical patients. Patients had complex,
potentially life-threatening conditions and or organ failure including
P.H. Strachan et al.
cardiac, respiratory, renal, cerebrovascular and endocrine conditions.
Inclusion criteria were: nurse or physician (staff or resident) working on
one of these units. Participants were recruited by either indicating their
willingness to participate at the completion of the DECIDE quantitative
survey via a detachable form (23/30) or by snowball sampling (7/30).
A purposive sample was selected for interview based on specific criteria
to achieve both balanced and diverse representation (i.e., profession,
gender, clinical experience, study site). Private one-on-one interviews
occurred in a location of the participant's choosing such as a hospital
meeting room or the participant's or investigator's office.
2.3. Data collection
Following receipt of informed consent, demographic information
was taken from each participant. We used Flanagan's Critical Incident
Technique to elicit and probe all participants' narratives about their
perceptions of various professional roles in goals of care discussions and
decisions about the use of life-sustaining technology (Flanagan, 1954;
Norman, Redfern, Tomalin, & Oliver, 1992). This technique facilitates
collection of rich accounts and explanations of specific examples, called
critical incidents (CI), from those who have lived them regarding the
phenomena of interest, in this case, specific examples of goals of care
communication between nurses and patients with serious illness. In
these interviews, participants were guided to provide detailed accounts
of specific recent patient interactions (occurring in the last 6 months to
facilitate recall) that the participant considered to be “excellent” and
“poor” examples of goals of care communication. This also allowed the
interviewer to attend to and probe participants' examples, elicit as-
sumptions and to understand why the participant would describe a goal
of care “incident” or discussion as going well or poorly. Working from
the two extreme examples they provided, the interviewer then probed
to understand what participants viewed as “usual” goals of care dis-
cussions and the nurse's role in them. In this way dimensions of the
nurse's role in goals of care communication were explored, uncovering
aspects of CI's that may have been unappreciated by participants. This
For example, while exploring a CI, the interviewer asked, “in your ex-
perience, how does what happened in the situation you described fit
with what usually happens in goals of care discussions?” This line of
questioning enabled us to uncover and explore patterns of actual
practice related to participants' roles that may have been in contrast to
what they perceived as ideal practice. From the first interview, we
noticed patterns in the ways participants' positioned themselves in the
telling of the CIs. We then expanded questions concerning their own
and other health team members' roles and involvement in discussions
about goals of care.
Following validation of the interview guide and interviewer
training, the interviews were conducted one-on-one with the same
trained bilingual interviewer (EN) in English or French, depending on
the participants' preference. These were digitally recorded and tran-
scribed; transcriptions were reviewed for accuracy. Field notes were
made immediately following the interviews. All data and field notes
were uploaded into NVivo 9.0 (QSR International, Boston: MA).
2.4. Data analysis
To explore participant perceptions about the nurse's role, this ana-
lysis was guided by three sensitizing questions: What were the nursing
activities described? What was perceived as influencing the nurse in
relation to the activity? What assumptions, beliefs and attitudes were
expressed about the nursing role in goals of care discussions and deci-
sion-making with patients who were seriously ill and their families?
The data analysis progressed inductively during data collection
using a constant comparison approach and informed by interpretive
description (Schluter, Seaton, & Chaboyer, 2008; Thorne, 2008). The
development of the code book has been previously described in detail
(Kryworuchko et al., 2016). Coding decisions made by two members of
28
Applied Nursing Research 40 (2018) 26–33
the coding team EN/JK or EN/PS independently were then critically
reviewed asynchronously via email, and synchronously during face-to-
face and/or teleconference team meetings. We triangulated nurse and
physician accounts of nurses' involvement in serious illness conversa-
tions where goals of care discussions and/or decisions occurred or not.
We used theoretical and maximum variation sampling to develop
conceptual clarity. We based decisions about saturation on re-
commendations for the critical incident technique (Flanagan, 1954;
Schluter et al., 2008). In 30 interviews, we elicited 120 CIs. Participants
described 2–9 CIs per interview (mean = 4 CIs/interview). We sear-
ched for negative cases, challenged interpretations, and undertook a
series of intensive face-to-face, email and teleconference data analysis
meetings and iterative writing to arrive at a consensus about the results.
This analysis is based on a subset of the data analysis that was labelled
as nursing roles.
2.5. Research team and reflexivity
The analysis team was comprised of researchers with an interest in
promoting excellence in communication and decision-making in serious
illness. The interviewer (EN) was part of the analysis team. Analytic
rigor was achieved by theoretical and discipline-related triangulation
using nurse (PS, JK), physician (JY, JD), and medical anthropologist
(EN) perspectives. EN and JK read and analyzed the French data;
identified key passages were translated into English by one analyst and
then checked by the other for inclusion in English publications. We
routinely challenged the evolving analysis, our individual disciplinary
lenses and commitments. Final analysis of the nursing role was
achieved by consensus.
3. Results
Thirty participants were interviewed (10 per site) from the three
Canadian hospital study sites (Alberta, Ontario, Quebec). This included
12 nurses and 18 physicians (9 staff physicians and 9 medical re-
sidents); interviews lasted from 27 to 91 min (mean 47 min).
Participant details are reported in Table 1.
Participants' accounts drew attention to both nurse and physician
involvement in formal physician-led goals of care communication and
decision-making with patients and families experiencing serious illness.
Patients described in the critical incidents were hospitalized adults who
were considered seriously ill and for whom a discussion about goals of
care and the use of life-sustaining technology was deemed relevant (by
patients, their families or health care professionals who attended the
acute medical ward). Their diagnoses included a wide range of com-
plex, (often chronic) life-limiting illnesses including cardiac, endocrine,
cerebrovascular, respiratory, renal and multi-organ failure and septi-
cemia. There was neither clarity nor consensus amongst participants
and across sites about the appropriate and possible role of the nurse in
these conversations. Two major themes were identified: 1) the ambig-
uous nature of the nurse's role in formal, physician-led decision-making
Table 1
Participant demographics.
Characteristics Nurses Staff physicians Residents
(n = 12) (n = 9) (n = 9)
Male 1 3 4
Clinical experience
< 5 years 4 2 9
5–10 years 3 0 0
10 + years 5 7 0
Practice region
Alberta 3 3 4
Ontario 4 3 3
Quebec 5 3 2
P.H. Strachan et al. Applied Nursing Research 40 (2018) 26–33

communication, and 2) embedded-in-care serious illness communica- patient's care team and supported their inclusion in formal commu-
tion. We defined formal communication as intentional and occurring nication. However the organization of nursing work on a unit presented
during scheduled and/or physician-led patient consultations and family a barrier to this being standard practice as this physician described:
meetings where treatment decisions were made. These occurred in
I invite them in. Yeah, I invite them but often they're busy. They're just
contrast to the embedded-in-care conversation contexts that were more
too busy. And sometimes the goals of care discussion can take an hour if
informal in nature.
there's a lot of… like we will often book family conferences to address it
because it can't just be fly-by, you know. ‘Okay, we've got three minutes
3.1. The ambiguous nature of the nurse's role in formal physician-led
to talk here. Make a decision.’ And again our patients tend to be really
decision-making communication
complex and maybe we're in that gray zone and that's why (it takes a
long time). So if we're feeling that the goals of care are inappropriate in
Physician-led communication involving nurses tended to occur in
terms of the patient's expectations then we'll try to work with the family
one of two ways: nurses were either invited by physicians into a con-
so we'll book a family conference. I always invite the nurses to come but
versation or a nurse happened to be there when such a conversation
it's hard because they can't really take an hour off their time. But
occurred.
sometimes they'll come. Usually I'll just let the nurse know on my way in
The benefit of nurse involvement was described by a nurse who was
‘Hey, I'm going to talk to the patient about goals of care. Do you want to
invited by the physician to be part of a conversation:
come?’ Or I'll say ‘I'm going to phone the family. I'll let you know what
It was great because I knew what all had been said and could follow they said.’
through with her (the patient) and reinforce it and reassure her of what (Staff Physician, P18)
he (physician) had said. I thought it went really well that one. He ex-
Also impacting nurses' involvement were physician assumptions
plained everything to her and then just deferred a few questions to me
about the nature of nurses' work: these assumptions arose in part by a
and then she would ask some questions or I would interject.
physician's previous experience:
(Nurse, P10)
I don't usually seek them out to bring them to those kind of discussions
However, this nurse (like others) perceived that her role in these
and I don't know if they would have time or interest. Like I've never had a
conversations was unclear and thus was inconsistently enacted. She
nurse ask me that they want to come to a goals of care discussion.
reflected on her usual practice which was to surreptitiously learn about
(Staff Physician, P21)
formal (physician-led) communication.
Nurses acknowledged that to be involved in an interprofessional
I will usually stand behind the curtain, and not go on the other side of the
goals of care discussion, they often needed to actively seek out oppor-
curtain and be present with the conversation that's happening (between a
tunities. One nurse articulated her ambiguity in being involved and her
patient and physician). I'll just listen. I won't be a contributor in that
deference to perceived physician preferences:
conversation. I don't know why I do that.
(Nurse, P10) (I am) not usually (involved) unless I kind of make it a point, unless I go
ask a doctor and kind of happen to be there. But not necessarily. There
It became clear that inconsistencies in nursing practice were influ-
isn't necessarily an intent or effort on the physicians to actually include
enced by inconsistencies in physicians' preferences for nurses' partici-
us.
pation in, and particularly leadership in, such communication.
(Nurse, P17)
There are physicians who will grant that role to nurses, and others who
Paradoxically, nurses were also concerned that if they relied on a
will assume that role. And that's why we never know what our role is.
physician to initiate formal communication, it could also mean that
(Nurse, P30)
necessary goals of care discussions and decision-making did not occur,
One staff physician argued that nurses were not trained to lead goals which would ultimately have repercussions for the health of seriously
of care discussions and decision making about serious illness: ill patients and their families, and nursing care and morale.
Overall, both physicians and nurses offered the perspective that
With ordinary nurses, that is to say with the training that is ordinary to
nurses were not necessarily important actors in formal decision-making
nurses at this hospital, and at (X Hospital), it is the same thing; I wouldn't
processes, and yet members of both groups could find value in such
want them to be in charge of those discussions.
involvement when it occurred. When they were excluded from formal
(Staff Physician, P11)
communication, nurses developed ways to support other routes to
Yet having a nurse included as part of the conversation was pre- provision of patient- and family-centered care. In addition to covert
ferred by other physicians including a medical resident who acknowl- listening to patient/physician conversations, they searched through the
edged that a nurse's support and knowledge of the patient and family patient's chart for a record of related conversations, initiated discus-
promoted more fulsome physician-led goals of care discussions and sions with a (medical) resident or social worker in the hallway, and/or
decision-making in serious illness. asked patients and families what they had discussed with physicians.
I find that it helps with the nurse's presence there just because it's hard for
3.2. Embedded-in-care serious illness communication
me sometimes as the resident especially with the shift system with the
night float to come on. I'm not on the ward so I haven't followed, I don't
Nurses played a key role in advocating that patient wishes and
have a rapport with the family if they've been in hospital for quite some
preferences remained at the center of serious illness communication,
time. But the nurse is there day after day usually. So it's nice to have the
especially in goals of care discussions and decision-making. Distinct
nurse there just to be part of that conversation so they know the dis-
from physician-led formal communication, nurses engaged in sponta-
cussion that's had and can answer any of the patient's questions when I
neous and asynchronous communication that was embedded in the
leave.
nursing care of seriously ill patients and their families.
(Resident Physician, P25)
Nurses described their communication with seriously patients and
Notably this resident recognized the critical need for nurses to be families as most often occurring outside of physician-patient commu-
available for informed follow-up conversations with patients and their nication episodes and outside of the time when a final decision was
families after a physician had left the unit. made about the use of life-sustaining technology. One nurse described
When probed, most physicians said they valued nurses as part of the her perspective about how opportunities to explore goals of care with

29
P.H. Strachan et al. Applied Nursing Research 40 (2018) 26–33

patients and their families arose in her practice:
We're the ones that have to do a lot of the interventions like starting IVs
that are impossible, and people having to be poked numerous times …and
we're the ones doing the dressing changes that are really painful and
we're really witnessing the suffering. …We spend a lot more time. I might
spend a week with a person, eight hours a day for four or five times in a
week and so I think that amount of time and that kind of exposure and
relationship sort of leads to more conversations sometimes.
(Nurse, P17)
All nurses agreed that goals of care discussions and support of de-
cision-making processes was within the nursing scope of practice, al-
though they expressed variation in their ability and confidence to lead
the team in these formal conversations. One nurse explained that al-
though it was a recommended practice, she recognized that opportu-
nities were likely missed for goals of care conversations:
In our (Nursing) orientation, we also bring that up that it doesn't have to
be a physician that has this conversation. You can start that role.
Whether they apply it or not- I think it probably all depends on the
comfort and the experience of the nurse. Some of our senior nurses ab-
solutely, they're comfortable with having that conversation and I think
some of our newer nurses they're not that comfortable with having that
conversation. And it just could be a personality thing too. They just might
not feel comfortable talking about that with someone yet.”
(Nurse, P22)
Nurses described ways in which they informally supported decision-
making about life-sustaining treatments. Below, the nurse describes
how she ensured patients were aware of alternatives and advocated for
the patient's perspectives during decision-making.
My focus often in practice is with older people. I talk about more their
wishes and sort of make it known more is this something you want to do?
You know that you can always say no, because I find that lots of people
don't really know that that's an option. They're offered a treatment but
they're never really offered doing nothing versus something and I don't
know if people are fully prepared for some of the suffering that they
endure from the treatment itself and what the extent of the outcome of
the treatment would be. So that's what I notice a lot that plans are offered
but not a lot of plans or risks or benefits discussed about doing nothing
versus something.
(Nurse, P10)
Nurses said they were often called upon by patients or their families
to clarify and make sense of information that was conveyed by a phy-
sician. They often reframed and clarified information to acknowledge
and assuage family distress regarding illness and the possible implica-
tions of decisions. A common scenario was described:
It's usually always been the physician that has that conversation and then
(nurses) just to reinforce the conversation afterwards, because the family
a lot of times is quite overwhelmed and then has a lot of follow-up
questions afterwards. I think just reassuring them that just because they
say they made the patient ‘do not resuscitate’ doesn't mean that they're
not still going to be taking care of the patient or we aren't going to be still
taking care of the patient or that they've given up.
(Nurse, P16)
Nurses also consistently reported simplifying and contextualizing
complex medical information to help patients and families to under-
stand alternatives to life-sustaining treatment.
They had had the discussion that he would not want to be on machines,
okay? But then I explained that life sustaining measures go beyond just
intubation, chest compressions, that there are other aspects. So when I
explained this all to them that in fact giving fluids was life sustaining and
that there is an option besides, any time something happens, to call an
ambulance. They were actually extremely enthused about the concept of
maintaining a palliative amount of care, right? So what they said was
‘Well we didn't really know that that was an option to us. We just want
Dad to be comfortable.
(Nurse, P29)
Nursing surveillance during patient care positioned them to notice
and alert the healthcare team, essentially “raising the red flag” to the
need for communication. Specifically, in response to cues about a de-
cline in the patient's condition, and recognizing that communication
and decision-making could be urgently needed in advance of crisis,
nurses prompted other team members to the need for goals of care
discussions and decision-making conversations that they anticipated
would be imminently required to inform their interventions. A common
scenario was described:
They're not as responsive to us anymore, their appetite has decreased and
they're not swallowing well. They're just sleeping more and more. And I
often ask (the physician) ‘What's the plan for this patient?
(Nurse, P10)
Even with this advocacy from nurses, it was not uncommon for
discussions about life-sustaining interventions to be delayed until
physicians agreed that death might not be avoided in the short term.
I had a patient who was very ill and she was still full resuscitation code
and I started to see that she was really deteriorating and struggling with
the treatment and not in a lot of comfort… I actually talked to the
(medical) residents quite a few times saying ‘I really don't think she's
coming out of this. Is it time to talk about her level (of care)?’ and they
said ‘No, I think we can fix this.
(Nurse, P1)
Nurses also contributed to understanding the implementation and
outcomes that might arise from the decisions faced by patients and their
families. For example, they allayed fears that patients and families had
about death and dying, explaining what the process could be like and
the kind of care that could be anticipated.
It's usually a nurse that's with the family and with the patient and I think
it helps the family member to talk to someone who has actually seen what
is going to happen, like the actual what does death look like, what will
happen, what kind of care will you be giving because it's not the physician
that will be giving that care.
(Nurse, P16)
Thus, demystifying the death experience for worried families and
providing reassurance, emerged as key components of the goals of care
decision-making process that extended beyond decisions made about
end-of-life issues and the use of life-sustaining technology.
4. Discussion
In this study, nurses' roles in communication with seriously ill pa-
tients and their families occurred asynchronously from formal, physi-
cian-led, goals of care discussions and decision-making. While nurses
appreciated they were optimally positioned to have a legitimate and
recognized place in formal goals of care discussions, there was some
hesitancy on their part to claim that practice space. This was in part due
to their own and physician uncertainties about practice boundaries,
inexperience, and the practice culture and routines of the acute medical
units. Nurses were likely to respond to openings for conversations
created by seriously ill patients and their families during therapeutic
communication in care, thus nurse's communication was informal and
embedded-in-care. Our conceptualization and exploration of nurses'
roles as complementing the formal physician-led communication, or as
an informal embedded-in-care intervention, offers an opportunity to
more fully appreciate and develop the potential for nursing contribu-
tions to serious illness conversations.
In this study, the role of the nurse in goals of care discussions and

30
P.H. Strachan et al.
decision making in medical settings was revealed as a paradox. On the
one hand, nurses' roles in these conversations were largely invisible,
unknown and unwitnessed by their medical colleagues. Yet clearly their
behind the scenes work prior to and/or following physician discussions
was important to help patients and families make sense of health in-
formation and contribute to decision-making. Our analysis explicates
this paradox and serves as a rallying call for nurses and health care
teams within the hospital setting to recognize, support and optimize
nurses' involvement in goals of care and decision-making communica-
tion. Nurses' involvement in both formal and informal communication
with seriously ill patients and their families is clearly within the scope
of Canadian nursing practice, and the importance of their role was
clearly described by both nurses and physicians in our study. Nurses'
essential roles as information brokers, advocates and supporters for
patients and families during serious illness and at the end-of-life have
been previously identified (Adams et al., 2011) and were clearly ar-
ticulated by nurses in this study. Our findings reinforce others who have
identified the nurse as the most visible and accessible health team
member for the patient and family as they move through the hospita-
lization experience at the end-of-life, and that nurses sometimes per-
ceive this advocacy as filling gaps in physician-patient/family com-
munication and thus not claim it as nursing expertise (Adams et al.,
2011; Dillworth et al., 2015; Ke, Huang, O'Connor, & Lee, 2015;
Thacker, 2008). Strategic nursing communication aimed at improving
outpatients' ability to discuss prognosis and end-of-life care has shown
some improvement in patient's self-efficacy in their subsequent in-
formation-seeking from physicians (Walczak et al., 2017). For hospital
nurses' communication expertise to be valued, fostered and expected as
part of nursing practice, it is possible that a context-responsive com-
munication guide could assist nurses to lead formal and ‘embedded in
care’ goals of care and decision-making conversations in acute settings.
Similar work has been done to promote a nursing role in other
healthcare settings. For example, adaptation of the Serious Illness
Conversation Guide for acute inpatient settings clarified hospital nurses'
roles during a pilot study in long term acute care for medically complex
patients (Lamas et al., 2017). In another example, a structured goals of
care communication guide has been developed for nurses and social
workers in the outpatient setting (Bekelman et al., 2017). Conversa-
tional practices, such as “fishing” questions and “framing the difficult
question as universal” strategies, could support informal discussion
work about end-of-life issues by giving language and action to em-
bedded in care nursing communication (Parry, Land, & Seymour,
2014).
Hospital nurses' roles in goals of care discussions and decision-
making may not be fully understood by medical colleagues since most
nursing practice is unwitnessed by them. Such an impoverished un-
derstanding of nurses' actual and possible contributions to inter-pro-
fessional practice and misunderstandings about the nature and scope of
nursing practice would seem to contribute to further limitations of
nurses' roles unless they claim their own practice space. In this study,
nurses' participation in goals of care discussions was commonly im-
promptu, arising during the course of care, when they were alone with
the patient or family and rarely in the presence of a physician. Thorne,
Roberts, and Sawatsky (2016) have described that serious illness con-
versations often arise when patients test the openness of health provi-
ders to their questions and that understandings of illness often arises
over the course of many small spontaneous interactions with nurses.
This was reflected in our study when nurses' recounted their commu-
nication as background work to a single event in which a physician-led
goals of care discussion occurred.
It will be important for nurses and other team members to know
when nurses' scope of practice includes facilitating goals of care dis-
cussions and supporting decision-making. This is necessary in order to
ensure that future improvement efforts, possibly based on the status
quo, do not unnecessarily limit the contribution of nurses. The acute
medical unit culture often places constraints upon nurses' engagement
31
Applied Nursing Research 40 (2018) 26–33
in goals of care conversations and may “limit what can be said, and in
many cases have stripped the capacity of nursing to engage in these key
conversations” (Thorne et al., 2016; 98). Importantly, seriously ill
hospitalized patients and their family members (You et al., 2014) and
nurses (Dillworth et al., 2015) have identified significant gaps in ful-
some goals of care discussions and end-of-life communication and de-
cision-making. We contend that the focus on dyadic physician-patient/
family discussion and decision-making has over-shadowed the roles
nurses can and should take as advocates, in helping patients and fa-
milies prepare for and engage in serious illness conversations with
physicians, in interpreting information after the physician has left the
room and acting as an advocate for patients and a conduit for in-
formation. That these activities take place is relevant to healthcare
teams and to the hospital systems who aim to change the commu-
nication and goals of care decision-making culture through develop-
ment of communication training, best practices and institutional po-
licies. Nurses' roles in these formal and informal embedded-in-care
serious illness conversations should be developed and supported as a
practice expectation within the unpredictable and spontaneous condi-
tions of everyday practice and not in isolation of those realities.
In the context of serious illness communication, nurses in this study
described their crucial role in listening about concerns, responding to
patients' and families' questions, offering and clarifying information, as
embedded in their conversation practices. Delineating goals of care
discussions as separate from treatment decisions is important to the
discourse about how the scope of practice of nurses is useful, particu-
larly to prepare patients and families for decision making, and to help
cue the team to salient decision-making moments. For example, nurses
can explore patient and family goals for care in informal communica-
tion, and cue the team to the patient's readiness to consider specific
options as part of formal physician led decision-making processes.
Serious illness conversations aim to clarify what is most important to
people who are patients, what goals that they might have for their
healthcare, and what types of treatments would be consistent with their
values and goals. Research in serious illness communication points to
important misconceptions about serious illness communication: first,
that the conversation involves telling people about tough choices (i.e.,
when prognosis limits options) (Bernacki et al., 2014; Connors Jr et al.,
1995; Mack et al., 2012; Rao, Anderson, Inui, & Frankel, 2007), and
second, that the goal of the conversation is to arrive at some kind of
epiphany about a decision (Kryworuchko et al., 2016; Nouvet et al.,
2016). In reality, the serious illness conversation is a listening con-
versation, where the clinician aims to learn more about the patient's
goals, and this is a first step in a (decision-making and relational)
process where the healthcare team should have a series of conversations
before ever arriving at a decision (Bernacki et al., 2014; Bernacki et al.,
2015). Our study offers insight into how nurses can become more in-
tentionally involved in serious illness conversations. Hospital nurses are
essential team members in these (listening) conversations that arise in
the course of everyday healthcare practice in the medical ward setting.
Nurses should take opportunities to support patient and family under-
standings of serious illness, to elicit their strengths and fears about
living with serious illness, and to uncover what goals are important to
them, and what options that they would like to consider with the
healthcare team in more formal decision-making meetings.
To improve care, the informal and embedded communication that
nurses described as routine in their practice must also considered in
relation to information physicians share with patients and their fa-
milies. There is an urgent need to develop viable system processes that
promote interaction of nurses, patients, their families and the care team
so that everyone is “on the same page” in relation to these critical
discussions and decisions. Patients and families have previously iden-
tified prognosis, their preferences for care, their values, questions and
fears or concerns as most important to include in goals of care discus-
sions (You et al., 2014). We argue that the informal, spontaneous
conversations between nurses, patients and their families that emerge
P.H. Strachan et al.
during the course of care are critical to an informed decision-making
process about goals of care. Thus, it is imperative to promote devel-
opment of nursing expertise so nurses have the self-efficacy to engage in
these informal conversations and share their perspectives with the
team. Nurses' reliance on physician invitations or optimal unit condi-
tions to participate in formal goals of care discussion is problematic and
does not optimize their possible contribution to end-of-life decisions.
Promotion of nurses' essential roles in serious illness conversations
should be a focus in undergraduate education, post-graduate training
and integrated as an expectation in clinical system processes (Ferrell,
Malloy, Mazanec, & Virani, 2016). Consistent with their role in facil-
itating a patient and family-centered approach to holistic health, nurses
have long been credited for their work recognizing and reinforcing
family strengths to help patients live alongside serious illness (Wright &
Leahey, 2013). Incorporation of a strengths-based approach could fa-
cilitate nursing educational initiatives that support patient and family
engagement in goals of care communication and decision-making.
While hospital systems can and should promote inter-professional
environments in which nurses can work to their full capacity, nurses
then need to embrace, prepare for and learn from those opportunities.
Organizational initiatives to support greater patient satisfaction with
goals of care decisions need to recognize and include the embedded-in-
care contributions such as those that nurses have described in relation
to advance care planning (Ke et al., 2015). It may well be that the
discordance that has been previously found between hospitalized pa-
tient's wishes and their medical orders for aggressive, life-preserving
treatment (Dillworth et al., 2015; Heyland et al., 2013) could be miti-
gated by recognizing and incorporating nurses' roles more intentionally
into goals of care discussions and processes and that precede end-of-life
decisions. We echo calls for increased empirical evidence to evaluate
effective communication practices for nurses involved with goals of
care discussions (Adams et al., 2011; Bekelman et al., 2017). Ad-
ditionally, we stress the need to understand the nurse's role and any
intervention to support it within the complex, dynamic and relational
care environment.
As navigators and interpreters of medical information and the pa-
tient's illness experience, nurses should advocate for and be in-
tentionally included into hospital initiatives aimed at improving the
quality of goals of care discussions and decision-making. Recognition of
the value of these nursing activities by nurse leaders and their inter-
professional colleagues is necessary to drive change in entrenched
medical unit routines in hospitals that make synchronous inter-profes-
sional collaboration difficult. There is a need to question and rethink
the normative practices on medical units (Hartrick Doane et al., 2012)
that make asynchronous communication between medical and nursing
staff the norm and not the exception, and that routinely leave patients
and their families out of these conversations until they are maximally
stressed. Despite calls for a trained facilitator and clinical tools to
promote goals of care discussions (Bekelman et al., 2017; Bernacki
et al., 2014), a recent review has shown communication interventions
such as this are likely to be unsustainable if the contextual demands of
the dynamic and complex clinical environment are not addressed
(Lund, Richardson, & May, 2015). This has significant implications for
the development of pre and post licensing educational initiatives for
nurses.
5. Strengths and limitations
5.1. Limitations
The data from which this analysis was drawn was from three acute
medical units in three hospitals Canadian provinces. It is possible that
the experiences and practices may be different there than in other acute
medical units, and other healthcare providers may have distinct roles in
goals of care communication that are not captured in our results. It is
also possible that participants' perceptions and recounts of their
32
Applied Nursing Research 40 (2018) 26–33
experiences have left out information that could more fully describe
events. We have provided demographic data and a description of the
clinical setting, as well as representative quotes to help the reader de-
cide whether our findings resonate with their experiences.
5.2. Strengths
There are several notable strengths to this study. Participants
(nurses and physicians) were drawn from three Canadian provinces;
interviews were conducted in the participant's' native language (either
French or English) by one fluently bilingual interviewer/analyst. The
multi-disciplinary analysis team offered triangulation from three dis-
tinct disciplinary perspectives (nursing, medicine, medical anthro-
pology) that resulted in a rich analysis. The use of critical incident
technique allowed the exploration of nursing roles arising in complex
situations on acute medical units and outside of intensive care units
where much previous research is situated.
6. Conclusions
Nurses and physicians had different understandings, practices and
beliefs about goals of care communication at the end-of-life. To opti-
mize the impact of goals of care communication in acute medical set-
tings, the value of nurses embedded in care work must be understood as
key to supporting the broader healthcare team's work during formal
goals of care and decision-making communication. Implementing im-
provements for nurses' practice in acute medical unit settings will re-
quire attention to teamwork, system processes, and to supporting
nurses' skills and confidence in communication with seriously ill pa-
tients and their families. It is essential that nurses' essential roles in both
formal and embedded-in-care communication be recognized, supported
and encouraged as necessary, legitimate components of robust and
coordinated goals of care discussions and decision-making on acute
medical units. For this to happen, nurses and physicians on these units
must be prepared for and supported in learning about and enacting
timely and patient-centered serious illness communication within a
dynamic interprofessional team and in consideration of acute medical
practice contexts. Leaders in nursing education and health systems
should promote organizational conditions to optimize nurses' roles in
goals of care communication. Future research is required to evaluate
the effect of nurses' goals of care communication practices within acute
medical settings.
Conflict of interest
None declared.
Funding
This study was funded by The Canadian Institutes of Health
Research grant number MOP-119516. At the time of the study, Dr. You
was supported by a Research Early Career Award from Hamilton Health
Sciences. Dr. Nouvet was supported by a Fellowship in Ethics from the
Canadian Institutes of Health Research.
Ethical approval
The study was approved by the Research Ethics Board at each
hospital site.
University of Calgary Ethics Board E-24741, Hamilton Integrated
Research Ethics Board 11631, Comte dethique de la recherché
Universite de Sherbrooke 12-113.
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