How do these apply to our practice?

Hospice Palliative Care Nursing Standards: How do these apply to our practice?

Peden, Jacquie

The following is one of three articles submitted by the members of the Pallium Project Communication Initiative.

Hospice palliative care is one specialty area that has recently created nursing standards of practice. Hospice palliative care is aimed at relief of suffering and improving the quality of life for persons who are living with, or dying from, advanced illness or are bereaved (Ferris et al., 2002). Provincial and territorial regulatory bodies develop nursing practice standards, which are based on the values of the nursing profession across Canada, to guide and direct nursing practice. Specialty practice groups, in conjunction with the Canadian Nurses Association (CNA), promote nursing standards to serve as a basis for nursing certification within that specialty area.

Why are Hospice Palliative Care Nursing Standards (HPCNS) important?

According to the CNA (1996): “Standards are necessary to demonstrate to the public, government and other stakeholders that a profession is dedicated to maintaining public trust and upholding the criteria of its professional practice.” Standards are a measure of performance that reflect the values of the nursing profession and enable nurses to promote safe, competent and ethical practice (CNA, 1996). HPCNS serve as a guide for nursing practice and clearly identify the role of the hospice palliative care nurse (Canadian Hospice Palliative Care Association [CHPCA] Nursing Standards Committee, 2002).

The purpose of HPCNS is to:

* define the standard of care that can be expected

* establish requisite knowledge for nursing persons and families with advanced illness

* support on-going development of hospice palliative care nursing

* promote hospice palliative care nursing as a specialty

* serve as foundation for the development of certification in hospice palliative care (CHPCA Nursing Standards Committee, 2002)

The HPCNS are reflective of the Canadian Palliative Care Association’s 2001 Proposed Norms of Practice for hospice palliative care (CHPCA Nursing Standards Committee, 2002). The framework used for these standards is based on the six dimensions of the Supportive Care Model (Davies & Oberle, 1990): valuing, connecting, empowering, doing for, finding meaning, and preserving integrity.

The Standards

I. The hospice palliative care nurse believes in the intrinsic worth of others, the value of life and that death is a natural process.

II. The hospice palliative care nurse establishes a therapeutic connection (relationship) with the person and their family through making, sustaining and closing the relationship.

III. The hospice palliative care nurse provides care in a manner that is empowering for the person and family.

IV. The hospice palliative care nurse provides care based on best practice and/or evidence-based practice in the following areas: pain and symptom management, coordination of care and advocacy.

V. The hospice palliative care nurse assists the person and family to find meaning in their life and their experience of illness.

VI. The hospice palliative care nurse preserves the integrity of self person and family.

Although these standards are specific to hospice palliative care nursing, there are components of the standards that are fundamental to nursing practice and can guide nurses who provide end of life care. For example, the nurse advocates for persons and families, listens actively as an integral part of communication, establishes a plan of care in collaboration with the person and family, advocates for appropriate pain and symptom management, assists the person and family to maintain a sense of control and provides comprehensive, compassionate and coordinated care (CHPCA Nursing Standards Committee, 2002).

However, these standards also demonstrate how hospice palliative care nursing is a specialty that requires specialized knowledge and skills. Findings from a study conducted in Manitoba by Grantham (2004) demonstrated that, overall, hospice palliative care nurses felt prepared to use these standards. However, practice challenges were identified in all six standards.

Practice Challenges Expressed by Hospice Palliative Care Nurses

STANDARD I-Valuing

A majority (70%) of nurses felt prepared to advocate for all persons at end of life. However, 50% did not feel prepared to assist the person in finding meaning in life and achieve the best quality of life as defined by the person.

STANDARD II-Connecting

All nurses (100%) felt prepared to connect with persons and families by establishing therapeutic relationships but 50% of nurses felt unprepared to conduct a cultural and spiritual assessment.

STANDARD III-Empowering

65% felt unprepared to address sensitive and emotionally charged issues.

STANDARD IV-Doing

55% were concerned with end-of-life policy and 50% of nurses were concerned about dealing with special populations.

STANDARD V-Finding meaning

65% raised education concerns about the balance between hope and suffering.

STANDARD VI-Preserving Integrity

Half of all nurses (50%) were concerned about participating in research activities appropriate to practice.

The lack of time to spend at the bedside and to establish a therapeutic relationship was also mentioned as a practice challenge.

Application of Nursing Standards

Nursing standards not only guide nursing practice but also can be applied in the following ways:

* by developing new models of nursing-care delivery

* through staff orientation and continuing-education programs

* when evaluating performance evaluation

* with career planning and professional development

* by determining appropriate referrals for nursing consultation within a specialty area

* by ensuring quality of nursing care

* through increasing public awareness about the nursing roles of a specialty area

* by creating an environment for excellence in nursing practice

(Canadian Oncology Nursing Education Committee, 2002).

Nursing standards are designed as a benchmark to measure the nurse’s performance but are also used as the foundation for the development of nursing competencies and guidelines for practice. Therefore, nursing standards are a useful tool for nurses in determining what knowledge and skills are required to provide quality care.

Resources

Canadian Hospice Palliative Care Association Nursing Standards

www.chpca.net/interest_groups/ nurses/Hospice_Palliative_Care_ Nursing_Scandards_of_Practice.pdf

A Model to Guide Hospice Palliative Care

www.chpca.net/publications/ norms_of_practice.htm

Canadian Hospice Palliative Care

www.chpca.net

References

Canadian Hospice Palliative Care Association Nursing Standards Committee, (2002).

Hospice palliative care nursing standards of practice. Ottawa, ON: Canadian Hospice Palliative Care Association.

Canadian Nurses Association (1996).

Standards.

Retrieved September 7, 2004 from http://www.cna-nurses.ca/_frames/ welcome/frameindex.html

Canadian Oncology Nursing Education Committee (2002).

Toolkit for understanding and applying standards of care, roles on oncology nursing, role competencies. Vancouver, BC: Canadian Association of Nurses in Oncology. Retrieved September 7, 2004 from http://www.cos.ca/cano/web/ en/dissemination_toolkit_eng.pdf

Davies, B.& Oberle K. (1990).

Dimensions of the supportive role of the nurse in palliative care, Oncology Nursing Forum, 17(1), 87-94.

Ferris, F.D., Balfour, H.M., Bowen, K., Farley, J., Hardwick, M., Lamontagne, C., Lundy, M., Syme, A. & West, P.J. (2002).

A model to guide hospice palliative care: Based on national principles and norms of practice. Ottawa, ON: Canadian Hospice Palliative Care Association.

Grantham, D. (2004).

Preparedness of Manitoba Palliative Care Nurses to Practice Using Canadian Hospice Palliative Care Nursing Standards. Manitoba, (Unpublished).

BY JACQUIE PEDEN, RN, MN

DARLENE GRANTHAM, RN, MN, CHPCN

MARIE-JOSÉE PAQUIN, RN, MSC

About the Authors

Marie Josée Paquin. RN. MSc

Marie-Josée Paquin currently serves as provincial coordinator for the Alberta Hospice Palliative Network (AHPN), a provincial network hosted by the Alberta Cancer Board to facilitate leadership and service development of hospice palliative care (HPC) within Alberta’s Regional Health Authorities. AHPN is based in the Tom Baker Center in Calgary.

Jacauie Peden, RN, MN

Jacquie Peden is an advanced practice nurse in independent practice with a specialized practice in HPC. She has facilitated development of integrated programs and is an extensive contributor to HPC education programs, including contributions as a co-author of A Caregiver’s Guide, 99 Common Questions (and More) about Palliative Nursing, and the Alberta Palliative Care Resource. Peden was contributor to the HPC nursing standards development which helped inform the CNA specialty certification in HPC nursing.

Darlene Grantham, RN, MN, CHPCN(c)

Darlene Grantham is a clinical nurse specialist with the regional palliative care sub-program, Winnipeg Regional Health Authority. Grantham currently serves as chair of the Nurses Interest Group of the Canadian Hospice Palliative Care Association.

For more information contact:

Sharman Hnatiuk

Communications Assistant

The Pallium Project-Phase II

PHONE: 780.434.5364

FAX: 780.428.3187

E-MAIL: shnatiuk@pallium.ca

www.pallium.ca

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