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ICU Bedside Nurses’ Involvement in Palliative

Care Communication: A Multicenter Survey

Article in Journal of pain and symptom management · November 2015

DOI: 10.1016/j.jpainsymman.2015.11.003

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Vol. - No. - - 2015 Journal of Pain and Symptom Management 1

Brief Report

ICU Bedside Nurses’ Involvement in Palliative Care Communication:

A Multicenter Survey
Wendy G. Anderson, MD, MS, Kathleen Puntillo, RN, PhD, FAAN, FCCM,
Deborah Boyle, RN, MSN, FAAN, AOCNS, Susan Barbour, RN, MS, WOCN, ACHPN,
Kathleen Turner, RN, CHPN, CCRN-CMC, Jenica Cimino, BA, Eric Moore, RN, MBA, NEA-BC,
Janice Noort, RN, NP, MS, ACHPN, John MacMillan, MD, Diana Pearson, RN, MSN, CCRN,
Michelle Grywalski, RN, BSN, CCRN, Solomon Liao, MD, Bruce Ferrell, MD,
Jeannette Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN, Edith O’Neil-Page, RN, MSN, AOCNS,
Julia Cain, RN, MSN, ANP, Heather Herman, RN, MS, ANP, William Mitchell, MD, and
Steven Pantilat, MD, FAAHPM, SFHM
Division of Hospital Medicine and Palliative Care Program (W.G.A., J.Ci., S.P.), University of California, San Francisco; Department of
Physiological Nursing (K.P.), University of California San Francisco School of Nursing, San Francisco; University of California, Irvine
Health (D.B., M.G., S.L.), Orange; University of California, San Francisco Medical Center (S.B., K.T.), San Francisco; University of
California, Davis Medical Center (E.M., J.N., J.Ma., D.P.), Sacramento; University of California, Los Angeles Medical Center (B.F., J.Me.,
E.O.-P.), Los Angeles; and University of California, San Diego Medical Center (J.Ca., H.H., W.M.), San Diego, California, USA

Abstract
Context. Successful and sustained integration of palliative care into the intensive care unit (ICU) requires the active
engagement of bedside nurses.
Objectives. To describe the perspectives of ICU bedside nurses on their involvement in palliative care communication.
Methods. A survey was designed, based on prior work, to assess nurses’ perspectives on palliative care communication,
including the importance and frequency of their involvement, confidence, and barriers. The 46-item survey was distributed via
e-mail in 2013 to bedside nurses working in ICUs across the five academic medical centers of the University of California, U.S.
Results. The survey was sent to 1791 nurses; 598 (33%) responded. Most participants (88%) reported that their
engagement in discussions of prognosis, goals of care, and palliative care was very important to the quality of patient care.
A minority reported often discussing palliative care consultations with physicians (31%) or families (33%); 45% reported
rarely or never participating in family meeting discussions. Participating nurses most frequently cited the following barriers to
their involvement in palliative care communication: need for more training (66%), physicians not asking their perspective
(60%), and the emotional toll of discussions (43%).
Conclusion. ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key
element of overall quality of patient care. Based on the barriers participants identified regarding their engagement,
interventions are needed to ensure that nurses have the education, opportunities, and support to actively participate in these
discussions. J Pain Symptom Manage 2015;-:-e-. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by
Elsevier Inc. All rights reserved.

Key Words
Critical care nursing, family, palliative care, interdisciplinary communication

Address correspondence to: Wendy G. Anderson, MD, MS, Avenue, Box 0131, San Francisco, CA 94143-0131, USA.
Division of Hospital Medicine and Palliative Care Program, E-mail: Wendy.Anderson@ucsf.edu
University of California, San Francisco, 533 Parnassus Accepted for publication: November 9, 2015.

Ó 2015 American Academy of Hospice and Palliative Medicine. 0885-3924/$ - see front matter
Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpainsymman.2015.11.003
2 Anderson et al.
Introduction
One in five Americans die either in an intensive care
unit (ICU) or shortly after an ICU admission, and the
use of critical care services at the end of life is
increasing.1,2 Efforts to integrate palliative care in
the ICU are a national priority, yet patients and
families in ICUs often have unmet palliative care
needs.3e5 Emotional support of family members
and communication about prognosis and goals
of care are widely acknowledged areas needing
improvement.6e15 As a result of their training and
role in patient care, ICU bedside nurses have espe-
cially intense and enduring interactions with patients
and families.16e18 Nurses enact roles of confidante,
educator, advocate, cultural liaison, and translator, at
times attempting to mitigate conflict between the
patient and family, between the family and physicians,
and between clinicians in the ICU.13,19 Hence, from
the perspectives of patients, families, and physicians,
active engagement of bedside nurses is an essential
component of the teamwork necessary to provide
high-quality palliative care in the ICU.12,20,21
Prior work indicates that although bedside nurses
value their roles in communication and decision
making in the ICU,18,22 they are often not involved
in discussions of prognosis, goals of care, and pallia-
tive care.12,20,21,23,24 To tailor a system-wide initiative
to integrate palliative care into the ICU by training
and supporting bedside nurses,25 we conducted a
multicenter survey to assess nurses’ perspectives on
palliative care communication, including attitudes of
bedside nurses about their role in palliative care
communication, frequency of nurses’ participation
in key discussions, level of confidence in performing
palliative nursing communication tasks, and barriers
nurses perceived to their involvement in palliative
care discussions.
Methods
We conducted an anonymous survey of ICU nurses
working at large tertiary care hospitals (range
400e620 beds) within the five academic medical
centers of the University of California. Surveys were
completed in July through November 2013. Each
medical center contained one to two hospitals and
had between five and eight ICUs, for a total of 26
ICUs, including Burn, Cardiovascular, Medical,
Neurological, Surgical, and Trauma units. Nurses
working in all these ICUs were invited to complete
the survey.
The survey was developed by the authors, including
bedside critical care nurses, palliative care and critical
care advanced practice nurses and nurse educators, a
nurse researcher in palliative and critical care, and
Vol. - No. - - 2015
palliative care physicians. These authors together
devised the survey domains. When possible, we used
or adapted survey items from previous work. The
scope of practice of beside nurses in palliative care
communication, including types of palliative care dis-
cussions and tasks, was based on prior work.12,21,26,27
Items assessing confidence were derived from surveys
used in prior critical care nursing education efforts
focused on palliative care.26,27 Barrier items were
informed by the published literature,13,28e30 our own
clinical experiences and discussions with bedside
nurses, and a survey of 52 critical care nurses conduct-
ed at one of the sites (Puntillo, unpublished data). We
established content validity by piloting the survey with
10 critical care bedside nurses at one of the centers;
these nurses confirmed that the survey was appro-
priate based on their work experience and recommen-
ded only small changes in wording of some of the
items to clarify meaning. The final survey included
40 items that used Likert-type scales and six items
assessing participant characteristics (Appendix, avail-
able at jpsmjournal.com).
The institutional review boards at the five centers
(University of California Davis, Irvine, Los Angeles,
San Diego, and San Francisco) determined that as
quality improvement the project did not require
review. Data were collected and managed using
Research Electronic Data Capture (REDCap)31 elec-
tronic data collection tools hosted at the University
of California, San Francisco. Eligible nurses received
an e-mail invitation that included a link to the online
survey; each nurse received a unique link and could
respond only once. Nurses who did not respond
were sent two reminders.
Statistical Analysis
We used Stata 12 (StataCorp LP, College Station,
TX) for analysis. We compared confidence items by
participants’ primary shift (day vs. night) and the
ICU type that was their primary work site. For these
comparisons, we dichotomized confidence into ‘‘very
confident’’ versus ‘‘not confident,’’ ‘‘somewhat confi-
dent,’’ and ‘‘confident.’’ We also compared barrier
items, dichotomized as ‘‘strongly agree’’ and ‘‘agree’’
versus ‘‘strongly disagree’’ ‘‘disagree,’’ and ‘‘neutral,’’
by ICU type. Chi-squared tests were used for compari-
sons; we considered P-values less than 0.05 to be
statistically significant.
Results
The survey was sent to 1791 ICU nurses, of whom
598 (33%) responded. Participating nurses had
worked in the ICU for a mean of 10 (range 0.3e40)
years and represented a variety of ICU types as well
Vol. - No. - - 2015 ICU Nurse Palliative Communication 3

Table 1 practices to prevent burnout and compassion fatigue.

Characteristics of Participating ICU Nurses
Characteristica
Years in nursing, mean (SD)
Years worked as a critical care beside nurse,
mean (SD)
Primary work site, n (%)
Burn ICU
Cardiovascular ICU
Medical ICU
Medical-Surgical ICU
Neurological/Neurosurgical ICU
Surgical/Trauma ICU
Primary work shift, n (%)
Days
Nights
ICU ¼ intensive care unit.
a
Total responses for these items ranged between 574 and 590.
as day and night shift work schedules (Table 1).
Almost all participants (95%) reported that discus-
sions between families and clinicians about prognosis
and goals of care were very important to the quality of
care for seriously ill ICU patients. The vast majority
(88%) also felt that bedside nurses discussing prog-
nosis and goals of care with families and physicians
were very important to a patient’s quality of care.
The frequency of nurse involvement in different
types of palliative care discussions varied widely
(Table 2). Many reported ‘‘often’’ engaging in discus-
sions of goals of care with physicians (75%) and
families (70%). Yet few nurses reported that they
‘‘often’’ attended family meetings (24%), ‘‘often’’
participated in family meetings (19%) or ‘‘often’’
engaged in discussions about palliative care services
with physicians (32%) or families (13%).
Participating nurses’ confidence in engaging in
various elements of palliative care communication
also was varied (Table 3). Few participants (10%)
were ‘‘very confident’’ in their ability to ensure that
patients and families receive palliative care when
needed. Additionally, few participants (11%) were
‘‘very confident’’ in their ability to use self-care
Other palliative care tasks in which few nurses felt
‘‘very confident’’ included being an active, contrib-
13 (10) uting participant in a family meeting (17%), commu-
10 (8) nicating the value of palliative care to physicians
(14%), and describing palliative care to a patient’s
36 (6) family (13%). The highest degree of confidence was
92 (16) in communicating a family’s needs to physicians,
106 (18) with 34% reporting that they were ‘‘very confident’’
119 (21)
92 (16) in this domain. One-fifth of the nurses also reported
129 (22) a higher degree of confidence in identifying a family’s
needs for information about a patient’s illness and
336 (57)
252 (43) treatments, with 22% reporting that they were ‘‘very
confident’’ in this area.
The most frequently cited barrier to participating
nurses’ involvement in discussions with families and
clinicians about patient prognosis, goals of care, and
palliative care was the need for more training, with
66% of participants agreeing or strongly agreeing
that this was a barrier (Table 4). Other frequently
endorsed barriers included physicians not asking for
nurses’ perspectives (60%), concern about the
emotional toll of discussions (42%), and a lack of
clarity about bedside nurses’ roles in palliative care
communication (42%). Few participants agreed or
strongly agreed that lack of time was a barrier to their
involvement in bedside discussions (10%) or atten-
dance in family meetings (19%). Only 4% of partici-
pants agreed or strongly agreed that lack of support
from the nurse manager was a barrier. Additional
barriers identified in free response items included a
less clear role in communication for nurses who
commonly worked night shifts, lack of opportunities
for nurses to give input to physicians, cultural differ-
ences between clinicians and families, and challenges
integrating palliative care across different types of ICU
settings.
Participants’ confidence in engaging in key
elements of palliative care communication varied by
the shift and type of ICU in which they primarily
worked; Table 5 summarizes responses stratified by
these variables for items with statistically significant

Table 2
Frequency of Participating Nurses’ Involvement in Palliative Care Discussions
Frequency of Involvement, na (%)

Type of Palliative Care Discussion Never Rarely Sometimes Often

Goals of care with patients’ physicians 4 (1) 19 (3) 124 (21) 450 (75)
Goals of care with patients’ families 1 (<1) 23 (4) 154 (26) 418 (70)
Prognosis with patients’ physicians 5 (1) 41 (7) 179 (30) 371 (62)
Prognosis with patients’ families 19 (3) 97 (16) 282 (47) 199 (33)
Palliative care consultations with physicians 24 (4) 120 (20) 263 (44) 188 (32)
Attend family meetings 68 (11) 173 (29) 214 (36) 143 (24)
Participate in family meetings 78 (13) 188 (32) 213 (36) 115 (19)
Palliative care consultations with families 51 (9) 205 (34) 260 (44) 80 (13)
a
Total responses for these items ranged between 594 and 598.
4 Anderson et al. Vol. - No. - - 2015

Table 3
Participating Nurses’ Confidence in Performing Palliative Care Tasks
Level of Confidence, na (%)

Not Somewhat Very

Task Confident Confident Confident Confident

Ensure that patients and families receive palliative care when needed 74 (13) 236 (41) 217 (37) 56 (10)
Use self-care practices to prevent burnout and compassion fatigue 59 (10) 220 (38) 232 (41) 64 (11)
Describe palliative care and how it can be useful to a patient’s family 48 (8) 196 (34) 265 (45) 76 (13)
Communicate the value of palliative care consultation to a physician 56 (10) 204 (35) 248 (42) 81 (14)
Elicit a physician’s understanding of a patient’s goals of care 22 (4) 182 (31) 294 (50) 87 (15)
Define palliative care 30 (5) 194 (33) 274 (47) 90 (15)
Elicit a physician’s perspectives on a patient’s prognosis 22 (4) 116 (28) 302 (51) 98 (17)
Be an active, contributing participant in a family meeting 59 (10) 174 (30) 253 (43) 99 (17)
Assess a family’s understanding of a patient’s prognosis 6 (1) 163 (28) 318 (54) 104 (18)
Assess a family’s understanding of a patient’s goals of care 7 (1) 136 (23) 327 (56) 117 (20)
Arrange a meeting between a patient’s family and clinicians 41 (7) 160 (28) 262 (45) 118 (20)
Identify and respond to family members’ emotional distress 17 (3) 160 (27) 294 (50) 119 (20)
Identify a family’s needs for information about a patient’s illness and 3 (1) 117 (20) 337 (57) 132 (22)
treatments
Communicate the need for a family meeting to a physician 9 (2) 76 (13) 308 (53) 191 (33)
Convey a family’s communication needs to a physician 5 (1) 65 (11) 316 (54) 202 (34)
a
Total responses for these items varied between 575 and 591.

differences by shift or type. Compared to nurses who Discussion

primarily worked day shifts, fewer nurses who primar-
ily worked night shifts reported being very confident
in tasks related to family meetings, including commu-
nicating the need for a family meeting to a physician,
arranging a family meeting, and being an active
contributing participant in family meeting. Addition-
ally, we found that confidence to elicit a physician’s
understanding of a patient’s goals of care and confi-
dence to use self-care practices to prevent burnout
and compassion fatigue varied by ICU type, as did
identifying as barriers physicians not supporting
nurses’ involvement in palliative care discussions and
physicians having negative reactions to palliative care
(Table 5).
To identify ICU bedside nurses’ needs for training
and support in palliative care communication, we
conducted a multicenter survey to assess nurses’ per-
spectives, including the importance and frequency of
their involvement in discussions with families and
physicians about prognosis, goals of care and palliative
care; their confidence in these discussions; and identi-
fied barriers to their involvement. The survey was
completed by 598 nurses from several different types
of ICUs at five academic medical centers. Most partic-
ipants reported that their engagement in discussions
of prognosis, goals of care, and palliative care was
very important to the quality of patient care. Yet few

Table 4
Barriers to Participating Nurses’ Involvement in Palliative Care Discussions
Level of Agreement, na (%)

Strongly Strongly
Barrier Disagree Disagree Neutral Agree Agree

I need more training in how to discuss prognosis, goals of care, and 20 (3) 85 (14) 97 (16) 283 (48) 110 (18)
palliative care
Physicians do not ask for my perspectives on prognosis, goals of care, and 19 (3) 103 (17) 116 (20) 230 (39) 124 (21)
palliative care
Engaging in these discussions is emotionally draining 35 (6) 152 (26) 152 (36) 209 (35) 44 (7)
I am unsure of my role in discussing prognosis, goals of care, and palliative 74 (12) 169 (28) 106 (18) 195 (33) 52 (9)
care
I am not sure how to bring up prognosis and goals of care with families 49 (8) 190 (32) 120 (20) 179 (30) 53 (9)
I do not feel that physicians support my involvement in these discussions 31 (5) 165 (28) 150 (25) 172 (29) 72 (12)
Physicians have negative reactions to palliative care 37 (6) 149 (26) 174 (30) 158 (27) 61 (11)
It is hard to get coverage for my patients so I can attend family meetings 66 (11) 176 (30) 152 (26) 145 (25) 53 (9)
Families have negative reactions to palliative care 34 (6) 184 (31) 226 (38) 128 (22) 17 (3)
I am not invited to family meetings 109 (19) 192 (33) 120 (20) 127 (22) 40 (7)
I do not have time to attend family meetings 103 (17) 242 (41) 137 (23) 95 (16) 17 (3)
I do not know when or where family meetings are occurring 142 (24) 249 (42) 108 (18) 75 (13) 17 (3)
I do not have time for bedside discussions of prognosis and goals of care 132 (22) 294 (49) 110 (19) 51 (9) 7 (1)
My managers do not support my involvement in these discussions 204 (35) 261 (44) 101 (17) 18 (3) 7 (1)
a
Total responses for these items ranged between 579 and 596.
Vol. - No. - - 2015 ICU Nurse Palliative Communication 5

Table 5 management, and communication about prognosis

Key Responses Stratified by Primary Work Shift and Sitea and goals of care.32e38 A number of models have be
Survey Item n (%) P-Value used for incorporating palliative care into the ICU,
Communicate the need for a family meeting to a including proactive consultation by palliative care or
physician, % very confident ethics teams, training ICU staff, support interventions
Day shift, n ¼ 331 (%) 123 (37) 0.009 for family members, communication protocols, guide-
Night shift, n ¼ 246 (%) 66 (27)
Arrange a meeting between a patient’s family and lines and practice recommendations, and multifac-
clinicians, % very confident eted interventions that include one or more of the
Day shift, n ¼ 329 (%) 85 (26) <0.001 aforementioned models.4,39e41 Lessons from previous
Night shift, n ¼ 246 (%) 32 (13)
Be an active, contributing participant in a family ICU quality improvement work, including integrating
meeting, % very confident palliative care into the ICU, show that the success
Day shift, n ¼ 334 (%) 67 (20) 0.02 and widespread dissemination of palliative care
Night shift, n ¼ 244 (%) 31 (13)
Elicit a physician’s understanding of a patient’s within the ICU depends on the active involvement of
goals of care, % very confident bedside nurses.20,42
Burn ICU, n ¼ 32 (%) 0 (0) 0.005 Scholarly work has provided increased clarity on
Cardiovascular ICU, n ¼ 91 (%) 12 (13)
Medical ICU, n ¼ 104 (%) 24 (23) specific roles that nurses can play in discussions of
Medical-Surgical ICU, n ¼ 117 (%) 23 (20) prognosis, goals of care, and palliative care as a result
Neurological/Neurosurgical ICU, n ¼ 91 (%) 9 (10) of their training and physical proximity to pa-
Surgical/Trauma ICU, n ¼ 123 (%) 14 (11)
Use self-care practices to prevent burnout and compassion tients.12,16,17,21,26,27,43 These roles include coordi-
fatigue, % very confident nating communication between family and
Burn ICU, n ¼ 32 (%) 1 (3) 0.001 clinicians, identifying information gaps and needs of
Cardiovascular ICU, n ¼ 88 (%) 10 (11)
Medical ICU, n ¼ 101 (%) 22 (22) the family, providing emotional support, and reinforc-
Medical-Surgical ICU, n ¼ 115 (%) 14 (12) ing and clarifying information about prognosis and
Neurological/Neurosurgical ICU, n ¼ 92 (%) 7 (8) treatments. Because of the nurses’ proximity and con-
Surgical/Trauma ICU, n ¼ 120 (%) 5 (4)
I do not feel that physicians support my involvement stancy at the bedside, they are also key conveyors of
in these discussions, % agree or strongly agree important family dynamics that influence decision
Burn ICU, n ¼ 34 (%) 16 (47) 0.001 making such as individual and group identities, family
Cardiovascular ICU, n ¼ 91 (%) 45 (49)
Medical ICU, n ¼ 104 (%) 23 (22) relationships, moral convictions, values, cultural
Medical-Surgical ICU, n ¼ 117 (%) 50 (43) beliefs, and spiritual context.44
Neurological/Neurosurgical ICU, n ¼ 91 (%) 37 (41) Our findings reinforce previous work indicating
Surgical/Trauma ICU, n ¼ 123 (%) 57 (46)
Physicians have negative reactions to palliative that nursing engagement is a key component of
care, % agree or strongly agree high-quality palliative care in the ICU that is often
Burn ICU, n ¼ 33 (%) 18 (55) <0.001 not achieved in practice.12,20,21,23,43 Our partici-
Cardiovascular ICU, n ¼ 90 (%) 44 (49)
Medical ICU, n ¼ 104 (%) 20 (19) pants also identified barriers similar to those identi-
Medical-Surgical ICU, n ¼ 115 (%) 46 (40) fied in previous research: lack of clarity about their
Neurological/Neurosurgical ICU, n ¼ 91 (%) 30 (33) roles in communication about prognosis and goals
Surgical/Trauma ICU, n ¼ 119 (%) 52 (44)
of care and palliative care, lack of physician aware-
ICU ¼ intensive care unit.
a
Items shown are those that significantly varied by shift or ICU type. We ness about what nurses can contribute, and the
compared dichotomized responses to confidence items by the primary shift emotional toll of involvement in discussions.23
that participants worked (day vs. night), and the ICU type that was their pri-
mary work site. We also compared dichotomized responses to barrier items by Furthermore, our finding that physician-related bar-
ICU type. P-values shown are from chi-squared tests. riers, including physicians not supporting nurses’
involvement in palliative care discussions and physi-
cians having negative reactions to palliative care,
were often involved in key palliative care discussions, varied by unit type supports previous studies finding
such as those that occurred during family meetings. that palliative care is handled differently in
Less than one-third frequently addressed the need different types of ICUs.45e48
for palliative care consultations with physicians and The barriers cited lend insight into two key areas for
families. The most prominently cited barriers to nurse intervention. First, there is a clear need for profes-
participants’ involvement were insufficient education sional education in nursing and medicine about
of nurses, physicians not asking for nursing involve- nurses’ scope of practice in palliative care communica-
ment, and the emotional toll of involvement in tion.49 Second, the nurses’ emotional labor associated
discussions. with communication during these key times within the
Research is increasingly demonstrating the value illness trajectory points to the need to develop inter-
that palliative care integration into ICUs has for ventions to support and sustain clinicians’ well-
patients and families, including support, symptom being.50e55 Palliative care communication in the ICU
6 Anderson et al.
is a particular area of need for clinician support
because of the combination of highly emotive practice
within a highly intensive work environment.56 The
variance of barriers by ICU type suggests that unique
solutions are needed for integrating palliative care
into different unit cultures.
Based on the results of this survey, there are several
key areas for future research and interventions to in-
crease nursing involvement in palliative communica-
tion in the ICU. Although significant work has
already been done to clarify and demonstrate the
key role that nurses can play in this communica-
tion,12,20,21,23,43,57 education of nurses and physicians
alike is needed to increase awareness of the scope of
nursing practice in palliative care communication. Ed-
ucation is also needed for nurses to increase their con-
fidence in engaging in discussions of prognosis, goals
of care, and palliative care with patients and physi-
cians. There is a clear need for interventions to sup-
port the self-care of nurses so that they can be
sustained in this difficult work. Systems-level interven-
tions are needed to ensure that nurses have the oppor-
tunity to engage in palliative care discussions; our data
indicate that key areas for increased nursing involve-
ment are in family meetings and discussions with fam-
ilies and physicians about specialist palliative care
consultations. In particular, interventions could focus
on improving interdisciplinary communication with
families during evenings and nights. Although families
may be even more present in ICUs during these hours,
our participants who primarily worked a night shift re-
ported decreased confidence to engage in interdisci-
plinary discussions with families.
Our report has the following limitations. First,
nurses who did not respond to the survey may have
had different views. However, we had a large sample
size with broad representation from five medical cen-
ters, including multiple ICU types and day and night
shifts, suggesting a representative sample. Second,
we only assessed nurses’ perceptions, as opposed to
their actual engagement and skill. However, as our
goal was to gather information to refine an educa-
tional intervention for ICU nurses, their self-
perceptions are key. Third, psychometric testing of
our survey instrument was limited to assessment of
content validity. Finally, this work was conducted in
large, tertiary care hospitals within academic centers
in California, U.S.; nurses in other settings may have
different experiences and perspectives.
In conclusion, we found that ICU bedside nurses
perceive that they have important roles in palliative
care communication. We also found that interventions
are needed to enhance nurses’ involvement and confi-
dence in this communication and to support their self-
care. This work points to a novel and important way
Vol. - No. - - 2015
that palliative care specialty teams can improve the
care of seriously ill patients: through training and sup-
porting bedside nurses.58 With such training, ICU
nurses can be more frequently and actively involved
in essential palliative communication to the benefit
of patients, families, and other clinicians.
Disclosures and Acknowledgments
This work was supported by the Center for Health
Quality and Innovation Quality Enterprise Risk Man-
agement (CHQIQERM) program, a joint venture of
the University of California Center for Health Quality
and Innovation and the Office of Risk Services. The
authors declare no conflicts of interest. The authors
are indebted to the CHQIQERM program and the
leadership of all five University of California medical
centers for their support.
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Vol. - No. - - 2015 ICU Nurse Palliative Communication 8.e1

Appendix
Survey Instrument

I. First, how important do you feel the following are to the quality of care for seriously ill ICU patients?
Very
Not Important Somewhat Important Important Important

1. Families and clinicians engaging in discussions

about patient prognosis and goals of care
2. Bedside nurses engaging in discussions with
families and physicians about patient prognosis
and goals of care

II. How often do you as a bedside nurse do the following?

Never Rarely Sometimes Often

3. Discuss prognosis with patients’ families

4. Discuss goals of care with patients’ families
5. Discuss prognosis with patients’ physicians
6. Discuss goals of care with patients’ physicians
7. Attend family meetings
8. Participate in family meetings
9. Discuss palliative care consults with families
10. Discuss palliative care consults with physicians

III. Please rate your level of agreement with the following potential barriers to your involvement in discussions with
families and clinicians about patient prognosis, goals of care, and palliative care:
Strongly Disagree Disagree Neutral Agree Strongly Agree

11. I am unsure of my role in discussing prognosis,

goals of care, and palliative care
12. I need more training in how to discuss prognosis,
goals of care, and palliative care
13. I am not sure how to bring up prognosis and goals
of care with families
14. I do not feel that physicians support my
involvement in these discussions
15. Physicians do not ask for my perspectives on
prognosis, goals of care, and palliative care
16. I do not have time for bedside discussions of
prognosis and goals of care
17. I do not have time to attend family meetings
18. It is hard to get coverage for my patients so I can
attend family meetings
19. My managers do not support my involvement
in these discussions
20. I do not know when or where family
meetings are occurring
21. I am not invited to family meetings
22. Engaging in these discussions is emotionally draining
23. Families have negative reactions to palliative care
24. Physicians have negative reactions to palliative care

25. Please list any other factors that you feel limit your involvement in discussions about prognosis, goals of
care, and palliative care: ______________________________
8.e2 Anderson et al. Vol. - No. - - 2015

IV. Please rate your level of confidence to perform each of the following tasks:
Not Confident Somewhat Confident Confident Very Confident

26. Assess a family’s understanding of a patient’s

prognosis
27. Assess a family’s understanding of a patient’s goals
of care
28. Identify a family’s needs for information about a
patient’s illness and treatments
29. Identify and respond to family members’ emotional
distress
30. Elicit a physician’s perspectives on a patient’s
prognosis
31. Elicit a physician’s understanding of a patient’s
goals of care
32. Convey a family’s communication needs to a
physician
33. Communicate the need for a family meeting to a
physician
34. Arrange a meeting between a patient’s family and
clinicians
35. Be an active, contributing participant in a family
meeting
36. Define palliative care
37. Communicate the value of palliative care
consultation to a physician
38. Describe palliative care and how it can be useful to a
patient’s family
39. Ensure that patients and families receive palliative
care when needed
40. Use self-care practices to prevent burnout and
compassion fatigue

V. Finally, please tell us a little about yourself:

41. How many years have you worked as a nurse? ____
42. How many years have you worked as an ICU bedside nurse?____
43. Please select the medical center where you work (study medical centers were listed):
44. Please select the unit in which you primarily work (all ICUs at the study medical centers were listed):
45. Please select the shift you primarily work:
, Days
, Nights
46. Please share any other thoughts or comments:___________________