Digital Repository Doctoral Projects Spring 2023 Implementation of Education for Hospice Nurses at Inspiration Home Health & Hospice to Improve Knowledge, Attitudes, & Skills Alisha Richins Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Richins, A. (2023). Implementation of Education for Hospice Nurses at Inspiration Home Health & Hospice to Improve Knowledge, Attitudes, & Skills. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. DNP, MSN/Ed, RN, CNE, COI DNP, APRN, CPNP-PC, CNE March 13, 2023 March 13, 2023 IMPLEMENTATION OF EDUCATION 2 Table of Contents Abstract………………………………………………………………………………………………4 Implementation of Education for Hospice Nurses………………………………………………… 5 Background & Problem Statement………………………………………………………….7 Diversity of Population and Project Site……………………………………………………7 Significance for Practice Reflective of Role-Specific Leadership………………………….8 Literature Review……………………………………………………………………………………9 Search Methods…………………………………………………………………………….10 Synthesis of Literature……………………………………………………………………...10 Use of Palliative Guidelines……………………………………………………….10 Better Patient Care…………………………………………………………………11 Improved Job Satisfaction……………………………………………………...….13 Discussion…………………………………………………………………………………..14 Implications for Practice. …………………………………………………………………..14 Framework and Project Implications. ……………………………………………………………...15 Conceptual Framework Description. ……………………………………………………...15 PDSA Method Applied to Project. ……………………………………………………...….16 Framework Application to Project. ………………………………………………………...16 Project Plan. ……………………………………………………………………………………..….16 Project Design. ……………………………………………………………………………..17 Needs Assessment/Gap Analysis of Project Site and Population. ……………………..…..17 Cost Analysis and Sustainability of Project. ………………………………………..……17 Project Outcomes ………………………………………………………………………..18 Consent Procedures and Ethical Considerations. …………………………………………..18 Instrument(s) to Measure Intervention Effectiveness. ……………………………………..19 Project Implementation. …………………………………………………………………………..19 Project Intervention. ………………………………………………………………………..21 ELNEC Modules and learning objectives. ………………………………………………....22 Project Timeline …………………………………………………………………………....24 Barriers to Implementation ………………………………………………………………....24 Project Evaluation …………………………………………………………………………………...25 Data Maintenance/Security ………………………………………………………………....25 Data Collection and Analysis. ……………………………………………………………....25 Findings. ………………………………………………………………………………….....27 Strengths. ………………………………………………………………………...…28 Weaknesses. ……………………………………………………………………..….29 Discussion. ………………………………………………………………………………………..….29 Translation of Evidence into Practice. ……………………………………………………...29 Implications for Practice and Future Scholarship. ……………………………………….....30 Sustainability. ……………………………………………………………………....30 Dissemination. ………………………………………………………………….…..30 Conclusion. ……………………………………………………………………………….....30 References ……………………………………………………………………………………..…...32 Appendix A: Pre-Survey. ………………………………………………………………………...…..36 Appendix B: Post-Survey. …………………………………………………………………………....38 Appendix C: Project Budget. ……………………………………………………………………..…..41 Appendix D: Project Timeline …………………………………………………………………..…..42 IMPLEMENTATION OF EDUCATION 3 Abstract Utah hospice nurses care for almost one million hospice patients annually, with an anticipated growth rate of 4% per year (National Hospice and Palliative Care Organization [NHPCO] 2020). The nursing shortage in Utah ranks 11th nationally, with an all-time high nurse turnover rate detailed by the Utah Medical Education Council (UMEC) report. (Ruttinger et al., 2020). Continuing education and support increases job satisfaction and nurse retention (Mitrea et al., 2017). Purpose: The purpose of this project is to provide education for nurses working with hospice companies will allow them to retain nurses to care for the dying as the population ages and hospice utilization increases. Methods: A needs gap analysis identified a deficit in organized education for the hospice nurses leading to a risk of inability to maintain competence and skills when caring for the terminally ill. A literature review was performed and included: descriptive studies, systematic reviews, qualitative studies, quantitative studies, and guidelines this was then used as a basis for best practices for the project. Results: Five nurses participated as the pilot group. This project shows how implementing an education program using end-of-life nursing consortium modules at a Utah hospice company improved competence and knowledge in nurses caring for the terminally ill and dying. Implications for Practice: This project will provide nurses working at Inspiration Home Health and Hospice with education and training to enhance patient care and improve job satisfaction by applying skills from the National Coalition for Hospice and Palliative Care practice guidelines. Keywords: hospice, palliative care, hospice nursing, end-of-life care, nursing education IMPLEMENTATION OF EDUCATION 4 Implementation of Education for Hospice Nurses at Inspiration Home Health & Hospice to Improve Knowledge, Attitudes, and Skills Eighty percent of Americans would choose to die in their home rather than the hospital if given a choice, but only twenty-five percent of people do (Firestone & Inderweis 2008). Passing at home generally requires the services of hospice care. Hospice services employ the principles of palliative care and focus on “caring, not curing” terminal illnesses (NHPCO, 2021). Hospice services have been available for terminally ill persons through Medicare for almost forty years (NHPCO, 2021). Any illness in which a person has a limited life expectancy with a prognosis of only months to live is considered terminally ill (NCHPO, 2021). Hospice services provide patient and family-centered care that focuses on comfort and quality of life. When utilized early in a terminal illness, this care allows the patient and family to accept their condition and alleviates fear and stress for patients and families. In addition, hospice services provide an interdisciplinary care team to relieve suffering; this team includes registered nurses, certified nursing assistants, chaplains, social workers, and clinicians, who all have a role in easing distress at end-of-life. The cost of care needed at the end of life rises seven times in the hospital compared to the cost of dying at home. The cost of dying at home is roughly $5,000 in the last month of life, compared to almost $33,000 for dying in the hospital (NHPCO, 2021). As a result, the cost of hospice services to Medicare in 2019 was nearly 21 billion dollars (NHPCO, 2021). Extrapolated hospice services saved Medicare over 126 billion dollars in 2019. As the population continues to age, the cost of dying will rise, and hospice utilization will increase by 4% annually IMPLEMENTATION OF EDUCATION 5 as well (NHPCO, 2021). As of 2019, 4,840 licensed hospice companies cared for 1.61 million hospice patients in the United States (NHPCO, 2021). Medicare reports that 53% of its members who died in 2019 received hospice services, with Utah residents representing the highest utilization of hospice services in the United States (NHPCO, 2021). The primary purpose of this project is to recommend, implement and evaluate an evidence-based nursing education program for nurses working at a large hospice company in Utah to support the expected increase in hospice utilization and the need for expertly trained nurses. Background and Problem Statement As defined by the National Coalition for Hospice and Palliative care (NCHPC), palliative care clinicians (PCCs) care for persons with serious illnesses. Persons with serious health conditions and a high risk of mortality excessively strain their caregivers (NCHPC, 2018). PCCs may perform various tasks and services to care for seriously ill persons to reduce the adverse effects of illness and alleviate caregiver strain. PCCs can assess and manage pain and other distressing symptoms of serious illness. PCCs utilize person and family-centered care approaches while attending to the physical, functional, psychological, practical, and spiritual consequences of serious illness to improve quality of life. PCCs can work in various settings when caring for the seriously ill, most working in a hospice setting. The NHPCO provides national standards for hospices. Several other organizations exist to ensure quality care for the dying. As healthcare is constantly evolving to meet the demands of society, it is paramount that hospice companies use these guidelines to ensure a good foundation for care exists. Hospice companies without licensing cannot bill Medicare for services rendered, the largest payor source for these services. End-of-life care is the primary function of any IMPLEMENTATION OF EDUCATION 6 hospice, and the utilization of training and education of employees is essential to continue licensing and operational abilities. NHPCO outlines the importance of standards for license and accreditation, and embedded in the standards is a need for ongoing education for nurses. Education and opportunities for training improve the attitudes and performance of nurses in health care and decrease burnout and nurse turnover rates (Gamma et al., 2013). Diversity of Population and Project Site Twenty-seven thousand three hundred thirty registered nurses are working in Utah, with 5% of those nurses working in home health or hospice care. Inspiration Home Health & Hospice, A Step Forward Company (IHHH), cares for an average of over 300 terminally ill patients residing in the Wasatch front of Utah each month with the help of 40 registered nurses. Of the 40 registered nurse care managers (RNCM) currently employed at IHHH, 30 hold bachelor's degrees in nursing, and 10 hold associate degrees in nursing. 60% of the RNCM have worked with IHHH for more than three years. There are eight RNCMs that have been working with terminally ill patients for less than 12 months. The median age of the RNCM is 41 years. There are 37 female RNCMs and three male RNCMs. Lindsay Sanchez, Director of Nursing for Inspiration Hospice Services (personal communication, September 8, 2021), stated that hospice nurses' orientation, training, and ongoing education are imperative to meet Medicare standards and support nurses working in this setting. Lindsay notes that the nurses enjoy positive continuing education and feedback. The NCHPO and the NCHPC support the need for ongoing education for nurses working in palliative care and hospice settings and support Mrs. Sanchez's statement (NCHPO, 2021, NCHPC, 2018). Implementation of an education program using end-of-life nursing education consortium IMPLEMENTATION OF EDUCATION 7 (ELNEC) modules will benefit the educational needs of the RNCM working at IHHH and improve the care rendered to the dying and terminally ill patients they serve in Utah. Significance for Practice Reflective of Role-Specific Leadership The NCHP 2018 guidelines illustrate that care for the dying requires complex nursing skills to provide comfort and alleviate suffering. PCCs often utilize these skills in stressful situations where time is limited to prepare for the patient's death (NHPCO, 2020). PCCs expect to manage suffering at the end of life (Blinderman & Billings, 2015). Patients with terminal illnesses report fear of pain as the priority for end-of-life care (Coyne et al., 2018). As such, hospice and PCCs need to be familiar with medications and services to alleviate pain. In addition to pain management, many other distressing symptoms can occur in dying, which is not a standard part of nursing care. The symptoms of death can be discomforting not only to the patient but also to the family. Well-prepared PCCs are needed to accommodate the care required to attend to hospice patients and families and communicate gracefully. PCCs that have not cared for the dying before entering employment with hospice will need training and education to master the skills necessary to provide end-of-life care (Mitrea et al., 2017). The role of an educator is a necessary skill for nurses to utilize in practice and to meet the needs of those in their care. This project uses the author's role as an educator to improve the knowledge and skills of nurses working as PCCs at IHHH. Literature Review This literature review explores evidence-based practice standards for developing and implementing a standardized educational program for palliative and hospice care nurses. Themes arose from the literature review to validate the need for the project: IMPLEMENTATION OF EDUCATION 8 1. Use palliative care guidelines to ensure consistent, quality care for patients with serious illnesses. 2. Ongoing education to increase job satisfaction (Felder et al., 2014). 3. Increased nurse knowledge and skill lead to better patient care (Mitrea et al., 2017). Recommendations found in the guidelines outline the importance of continued education and training for clinicians practicing in palliative care. Implications from the policies state that education, training, and professional development improve patient care and symptom management of palliative care patients and care for the seriously ill. In addition to these guidelines, a literature review affirmed the need for education and ongoing support for nurses working in palliative care. Search Methods Search terms for this project include palliative care education, continuing education, hospice education, care of the dying, hospice guidelines, case study, professional development, continuing education, systematic review, hospice, clinical practice guidelines, and education needs for hospice care. The databases used were Google Scholar, PubMed, UpToDate, EBSCO, and CINAHL. Database search exclusion criteria included journal articles more than ten years old and journal articles that do not align with the field of healthcare or nursing. Synthesis of the Literature Use of palliative guidelines The National Coalition for Hospice and Palliative Care (NCHPC) published clinical practice guidelines in 2018. These practice guidelines improve access to palliative care in all settings by encouraging organizations and clinicians to integrate palliative care principles and IMPLEMENTATION OF EDUCATION 9 best practices into their routine patient assessments and care (National Coalition for Hospice and Palliative Care [NCHPC], 2018). These protocols were developed with collaboration from the National Consensus Project for quality palliative care and included the representation of 16 influential organizations in palliative care. The NCHPC guidelines have eight domains, and elements of each part include skills needed for the palliative care clinician (PCC). The eight domains presented in the guidelines with the subset of skills identified by the NCHPC are listed in table 1. These skills are considered to be “essential" for clinicians working in palliative care (NCHPC, 2018). Table 1 NCHPC Domains and Essential Skills Needed in Each Domain Domain Essential Skill/s structure and process of care -understand the value of palliative care -training for palliative assessments -aware of palliative care principles and practice physical aspects of care -identify and treat specific symptoms -assess symptom burden, functional status, and quality of life psychological and psychiatric aspects of care social aspects of care -screen and manage depression, grief, and loss -assess caregiver support, social and environmental needs -patient and family coping techniques -family dynamics spiritual, religious, and -assess for spiritual distress and needs existential aspects of care cultural aspects of care -navigate cultural influences of care care of the patient nearing the end of life ethical and legal aspects of care -knowledge of hospice eligibility criteria -ability to talk to patients and families about dying -advanced care planning -mitigate legal/ethical conflicts IMPLEMENTATION OF EDUCATION 10 All essential skills listed in table 1 are important for PCCs working in hospice and palliative care. The skills relevant to this project include (a) education, training, and professional development for all clinicians, (b) identifying and treating specific symptoms, (c) the ability to talk to patients about dying. Ahluwalia et al. included 139 systematic reviews analyzing support of the NCHPC guidelines and concluded that “a substantial body of evidence exists to support” the guidelines as they relate to quality hospice and palliative care (2018). From the extensive review, Ahluwalia determined that effort should be made to focus on improved practice and utilizing the key areas of clinical practice. Better patient care Mitrea et al. (2017) researched the effects of one such organized method for training PCC, known as the End-of-Life Nursing Consortium (ELNEC) training program, with 306 nurses working in palliative care. Utilizing focus groups to evaluate the training courses’ effect on the nurses’ knowledge and competencies found the long-term impact of enhancing nurses’ knowledge, improving competencies, and increasing the quality of care for patients. The ELNEC training is standardized for national and international use with modules competencies in palliative care. This quality review provides insight into the impact of education on hospice nurses to improve confidence and competence. After completing the ELNEC training, all participants showed enhanced knowledge, improved competence, and improved effect on quality care for patients. Mitrea et al. highlight the importance of utilizing continuing education to gain the skills and expertise needed to provide care to the dying (Mitrea et al., 2017). In the Institute of Medicines (IOM) Future of Nursing Report (Bleich, 2011), eight recommendations were presented with details to improve nursing education to gain skills and IMPLEMENTATION OF EDUCATION 11 expertise. In 2016, Altman et al. provided an overview and summary of four critical elements related to the fields of nursing from the IOM report. These four elements include nurses practicing to their full abilities, increased education, increased workforce, and increased participation in healthcare teams. The IOM recommendations and included elements promote the power of nurses to act as leaders in healthcare positions and community settings, integrating leadership and collaboration in nursing education. Increased leadership education also leads nurses to pursue more leadership roles and impact healthcare models and patient care (Bleich, 2011). Improved job satisfaction Education of nurses is essential to continue to provide quality care, especially when facing care for individuals at end-of-life. Furthermore, a descriptive study by Fielder et al. (2014) found that new graduate nurses provided with ongoing education and opportunities for leadership and certification had decreased job turnover rates and reported higher job satisfaction overall. In addition, the evidence-based practice change of new graduate nurses receiving further support and education upon initial employment is beneficial for both new graduate nurses and patients. Gamma et al. (2013) performed a descriptive correlation study with 360 nurses working in a palliative care setting to identify factors affecting nurses’ attitudes while caring for dying patients. The more education, training, and experience nurses had overall, the better prepared and capable they were when tending to terminally ill patients. This study supports the need for more robust palliative care training and education in nursing school programs. Jahner (2019) showed that turnover rate and burnout occur when nurses have less enjoyment and job satisfaction. Fielder’s study shows the impact that further education has on healthcare, not only for nurses but for improving outcomes for patients in their care. Continued IMPLEMENTATION OF EDUCATION 12 education for nurses leads to improved patient care. Havens et al. (2018) evaluated nurse burnout, job satisfaction, and work engagement in relationships with colleagues and showed that better relationships led to better outcomes. A component of the NCHPC guidelines includes interdisciplinary team (IDT) meetings held frequently to improve relationships and provide skills and training (NCHPC, 2018). Jahner’s study supports Haven's findings in drawing attention to improving the patient's care by focusing on the provider's care as a fourth aim of the Institute of Medicine's triple aim (Bleich, 2011). A meta-analysis conducted by Chua & Shorey (2021) examined the relationship between education and the attitudes of nurses’ when caring for dying patients. Nine studies were reviewed and demonstrated that educational interventions did improve nurses' attitudes about their role in caring for the dying after the educational intervention. Furthermore, the nurses showed a significant reduction in death avoidance attitudes. Chua & Shorey encouraged group-based learning and noted that incorporating the use of online modules for education was a sustainable method. This study supports other studies' findings on the effects of increased education and improved attitudes when nurses care for patients at end-of-life. Reduced turnover rates are ever more critical as the nursing shortage reaches all-time highs, and care for the dying is a nursing challenge (Ruttinger et al., 2020). In a descriptive study, Fielder et al. (2014) demonstrated that a nurse residency program consisting of opportunities for mentorship and enhanced education had a modest reduction in nurse turnover rates and significant increases in job satisfaction. Discussion The literature on hospice education standards contained various study types and methodologies. Methods included in this literature review included descriptive studies, IMPLEMENTATION OF EDUCATION 13 systematic reviews, qualitative studies, quantitative studies, and guidelines. A strength of the literature review was the inclusion of the NCHPC guidelines as a resource and reference to establish baseline results. Limitations in the literature review showed a lack of articles depicting improved patient care outcomes directly resulting from enhanced nursing education. This, however, can be dependent on this author's ability to find relevant, current studies on this topic. Implications for Practice It is evident through this literature review that clinicians caring for seriously ill persons that have support through education and ongoing training provide better patient care and have better patient outcomes. They are also better able to care for themselves and have improved job satisfaction and support in their care teams. The NCHPC guidelines show the clinical implications of training for caregivers and allows support for the patient and family throughout the dying process. This project will provide nurses working at IHHH with education and training to enhance patient care and improve job satisfaction by applying skills from the NCHPC practice guidelines. Framework and Project Application Throughout the project, employing the conceptual framework of role theory utilizes various roles of a nurse. McEwen & Wills (2019) cite that a nurse's role has a significant impact on their attitude and behavior in their job. As this project aims to improve nurse attitudes while working in hospice, role theory focuses on education for nurses to reduce role strain and ambiguity. Conceptual Framework Description IMPLEMENTATION OF EDUCATION 14 Analyzing the many roles in which nurses practice, this project will focus on the nurse role of continuous learner and the nurse role of educator. Therefore, the nurses working at Inspiration Hospice will be in the role of learner and the DNP student in the role of educator. In addition to using the role theory framework, this project uses the plan-do-study-act (PDSA) model. The PDSA method is a valuable process for evaluating change and is an acceptable model to drive healthcare improvements (Taylor et al., 2013). However, limitations to this model include the simplicity of the cycle method when used for more complicated challenges and misuse of the technique due to lack of understanding. Additionally, researchers cannot use the PDSA method alone to implement projects and require a framework or additional quality improvement methods. PDSA Method Applied to Project The planning stage for this project is identifying a need for education seen in hospice nurses. This stage aligns with the NHPCO protocols for ongoing instruction and refinement in skills and education. Planning also consists of a thorough literature review and evaluation of evidence-based practices and guidelines available and a pre-intervention survey to gather baseline attitudes, knowledge, and skills. In the do stage, the implementation of the educational intervention is conducted. Post-intervention assessments are completed in the study stage, and this is where we evaluate the outcome of the intervention. The last stage of the PDSA method is act; the success of the intervention warrants full adoption of the intervention for all nurses. Framework Application to Project The use of the PDSA method with role theory applied in this project allowed the project to have continued cycles of evaluation and intervention based on the pre and post-survey assessments. The nurse participants were able to expand their role from that of a bedside IMPLEMENTATION OF EDUCATION 15 caregiver to an adult learner and allowed growth of their role as a patient advocate. Reduction of the ambiguity of their role as hospice nurses aimed to improve their job satisfaction and reduce role strain. Project Plan This project used the End-of-Life Nursing Consortium (ELNEC) core curriculum modules for the impetus of the education intervention (Relias Academy, n.d.). The ELNEC core curriculum includes eight individualized computer-based modules; completing these in succession provides a certificate of completion. The modules in this curriculum are specific to palliative care and have an introduction to palliative care nursing, pain management; symptom management; ethical issues; cultural considerations; communication, loss, grief, and bereavement, final hours of life. Each course is taken sequentially and ranges in time for completion and continuing education credits of 1-2 hours. Project Design This project is a quality improvement initiative focusing on educational interventions. The strategies used in the project design are detailed below: • Planning phase: the problem is a lack of education among the nurses • Do phase: o Pre-survey using FATCOD and PCQN (see appendix A) o ELNEC modules assigned and course curriculum completed o post-surveys using FATCOD and PCQN (see appendix B) • Study phase: review and comparisons of pre and post-survey changes and analysis • Act phase: adjustment of modules or implementation based on results Needs Assessment/Gap Analysis of Project Site and Population IMPLEMENTATION OF EDUCATION 16 Critical stakeholders for this project include members of the hospice interdisciplinary team (IDT) at IHHH. The IDT team consists of the medical director, the director of nursing, the assistant director, and myself. Following a needs assessment, a gap was identified by myself as a deficit in organized education for the hospice nurses leading to a risk of inability to maintain competence and skills when caring for the terminally ill. Therefore, the stakeholders were delegated by the Chief Operations Officer at IHHH after I discussed the needs assessment and project proposal. Cost Analysis and Sustainability of Project The implementation cost for this project was $295 for staff training. This cost included monies for the pilot program implementation for using the ELNEC program fees and access to the palliative care modules. The executive team at IHHH allotted $300 for the pilot study implementation. The cost of the sustainability for the program at full implementation is approximately $17,000. This includes an investment of almost $450 per nurse annually and accounts for the 40 full-time nurses working at IHHH. The cost is budgeted for the intervention into the nurse's salary, allowing for time spent on monthly education, and does not require additional money. The cost of the ELNEC modules is $59/per person/year. Therefore, the actual price is $2360 yearly for the ELNEC core curriculum. (See appendix C, Budget.) Project Outcomes The long-term goal of this project is that all hospice nurses' working at Inspiration Home Health and Hospice will receive monthly education on the subject of caring for the terminally ill; totaling a minimum of 12 hours per year, which will lead to improved job satisfaction. In addition, awareness and education of the essential skills necessary to care for the terminally ill is IMPLEMENTATION OF EDUCATION 17 an expected outcome of this project. Short-term yields are similar to long-term goals and include better patient care with improved skills and knowledge. The mission statement of the project site is, "We believe that nothing is more important than delivering compassionate and loving care to our patients and families” (Inspiration Hospice, n.d.). This project aligns with the mission statement of Inspiration Home Health and Hospice, as the focus is on providing the best possible patient care. Best patient care is provided by nurses that are well prepared, well educated, and competent in the skills and abilities they have to deliver to the patient. With the completion of the educational interventions of this project, the nurses will be able to provide care with improved skills and knowledge. Consent Procedures and Ethical Considerations The Institutional Review Board (IRB) at Weber State University confirmed this project meets the requirements for a quality improvement project and does not need formal IRB approval. As this is a quality improvement project and there is no testing of human subjects, IRB approval from Inspiration Hospice Company is unnecessary. Survey results used in the project will be aggregated from anonymous submissions and kept secure. Instrument(s) to Measure Intervention Effectiveness A pre and post-survey (see Appendix A and B) were utilized to evaluate the intervention's effectiveness. The pre-survey included 20 Likert-scale-based questions derived from a combination of Frommelt's Attitudes Towards Care of the Dying (FATCOD) and The Palliative Care Quiz for Nurses (PCQN). The survey was sent to the pilot group of nurses working at Inspiration Hospice to asses attitude and knowledge before providing access to the core curriculum educational modules. A post-survey that contained the same Likert-scale-based IMPLEMENTATION OF EDUCATION 18 questions was also given after the intervention and included three additional questions about the participant's experience with the pilot project. The surveys were comprised of questions from best practice surveys, FATCOD (Frommelt, 1991), and PCQN (Ross et al., 1996), with permission from the authors to evaluate the attitudes and knowledge of nurses working in hospice and palliative care. The project used questions from each instrument to create a new survey, questions were selected for relevance to the population for the survey site, and elimination of redundancy felt to be found in the interventions when compared together. The surveys were limited in questions to provide for ease of completion by participants and allow for timely completion. Project Implementation This project was implemented at Inspiration Home Health and Hospice (IHHH), a large hospice company serving patients in Weber, Davis, Salt Lake, and Utah counties from October to December of 2022. The executive team of IHHH approved the project after a proposal was made to address the identified gap in education for hospice nurses. Five nurses were chosen for the initial implementation phase using a pilot group to allow for budget and time constraints and to evaluate success before implementation company wide. Selection criteria for the five nurses of the pilot study included: • Interest in participation • Good performance in the current job role • The ability for time management skills The project lead sent an email to the pilot group informing them of the selection for participation in the project and asking for a voluntary agreement in early October 2022. All five selected nurses agreed to participate in the pilot study, and information was sent to thank them IMPLEMENTATION OF EDUCATION 19 for their participation and provide the next steps, including pre-survey links, timeline, and expectations for the study period via company email and internal group text communication. The demographics of the pilot group are listed in table 2. Table 2 Pilot Group Demographics n % Sex Female Male 5 0 100% 0 Age <30 30-39 40-49 >50 0 2 1 2 0 40% 20% 40% 3 1 1 60% 20% 20% 3 2 0 60% 40% 0 Variables Experience <5 years 5-10 years >10 years Education level Diploma Bachelor Post-graduate Note. N=5 This project provided access to eight core curriculum modules created by the End-of-lifenursing-education-consortium (ELNEC). Each course was available to the pilot group to complete on their own timeframe with a given deadline of December 1st, 2022. The ELNEC course site descriptions stated that course modules' time for completion was an average of one to two hours for each module. The modules consisted of eight topics relevant to the care of the IMPLEMENTATION OF EDUCATION 20 dying and aligned with the NCHPC domains and essential skills needed for palliative care clinicians listed in Table 1 (NCHPC, 2018). Project Intervention Pre-surveys were sent to the pilot group to complete via Qualtrics and were accessible online and completed anonymously. The pre-survey consisted of 20 questions to assess the mindset and competency of the job role in the care of the dying and the principles of hospice (see Appendix A). The surveys utilized in the project were comprised of questions from two standard evaluation tools and were relevant to the study design. After completion of the pre-survey, the educational modules were available for access through the Relias Academy website. An invitation was sent for the group members to create a personal account and log in for use throughout the project. The eight modules were listed sequentially, and the user needed to complete the module in its entirety before moving on to the subsequent module. A variety of teaching methods were used in the ELNEC modules, including text, embedded videos, and images. Questions and checkpoints throughout the individual modules needed to be completed before moving through the course sections to ensure attention and focus. After the module, a post-education quiz was presented, and an 80% pass rate was required to complete the module successfully. Certificates of completion were made available for each module, with a cumulative course completion certificate provided after all modules were completed. A post-survey was then conducted with the same 20 questions as the pre-survey and three additional free-text questions to evaluate critical takeaways from the education and impact of the project (see Appendix B, post-survey). ELNEC modules and learning objectives IMPLEMENTATION OF EDUCATION 21 The initial module of the eight core curriculum modules was an introduction to palliative care nursing and covered topics intended to provide a brief synopsis of palliative care philosophy and principles and described the role of a palliative care team. This module also discussed aspects of assessments needed to address the psychological, spiritual, social, and physical needs of persons facing severe illness and the role of the palliative care team in providing quality care at the end of life. As pain management and alleviating suffering are core principles in hospice care, module two focused on these topics. Education was presented to address adequate pain relief at the end of life. The information included pharmacological and non-pharmacological therapies to relieve pain and the nurse's role in pain management using assessment tools and interventions. In addition to pain management, other distressing symptoms associated with the end of life are addressed in the third module. Students completing this module can identify common signs of distress at the end of life and describe interventions to prevent or diminish these symptoms. Ethical issues were addressed in module four, and the objectives for this lesson include awareness of ethical dilemmas and problems that arise during the end-of-life care. In addition, advanced directives are discussed here as ways to prevent ethical dilemmas, and the nurse's role in responding to ethical dilemmas and situations is also addressed in this module. Spirituality and culture influence patients facing the end of life, and the nurse's role in assessing spirituality is presented in module five. The part of the interdisciplinary team is discussed, and education on spiritual assessments is the main component of this module. Communication between clinical staff, patients, and family is vital at the end of life, and this is iterated in module six. Communication characteristics that patients and families expect of IMPLEMENTATION OF EDUCATION 22 healthcare professionals are identified, and essential factors in communicating bad news are also offered. Loss, grief, and bereavement concepts are delivered in module seven. Factors affecting the grief process, interventions for normal grieving, and death awareness are also covered. Selfawareness concepts are presented in this module as a way for the user to recognize how the care of the dying and grief can personally affect them, and the need for support for coping with death anxiety and loss is presented. The final module of the core curriculum is how to care for persons in the last hours of their life. This education demonstrates the physical signs of dying, recognition of the active stages, and the patient's and family's care needs during this time. In addition, the palliative care nurse's role is discussed surrounding a patient's death. In all the modules, the role of the nurse is discussed in relation to skills needed to care for the dying. This is consistent with the framework of role theory used as a basis for this project with the identification of the many roles nurses fill (McEwen, 2019). While completing the project, the pilot group are learners working to improve their role as advocates and nurses for patients in their care. Project Timeline The timeline for the project was to be no more than 12 weeks, with initial implementation occurring in October 2022 and being completed by December 2022. The project's timeline with the components of project implementation can be found in Appendix D. The intervention phase started in the Fall of 2022 with a pre-survey (Appendix A) of the pilot group. The pilot group was given nine weeks to complete the intervention once the pre-survey was completed, and this allowed for ample time to complete the eight core curriculum modules. The core curriculum IMPLEMENTATION OF EDUCATION 23 modules were accessible online through the ELNEC Relias Academy website with an estimated 60 to 90 minutes per module for completion, or ten hours necessary for course completion. Using a project timeline tool allowed interventions to be met with awareness of time restrictions while keeping the team on task for success during the implementation phase (see Appendix D, Project Timeline); however, barriers did exist. Barriers to implementation Although the five nurses agreed to the outlined timeframe and committed to completing the modules by December 1st, only two nurses achieved this goal. One nurse could not complete the modules due to time constraints of work, kids, and balance; she asked for an extension for completion and was given until January 2023. Another nurse could not log in to create her account to access the modules; multiple emails were sent between her and the project lead and have still not been resolved. Two nurses completed all eight modules and were provided access to the post-surveys but have not completed them. One nurse has not logged into the ELNEC modules or reached out to ask for help. In January 2023, emails were sent to all pilot group participants to address barriers to project completion. As a result, the original timeframe for completion was extended to February 2023, and all five pilot group nurses were able to complete the project. Project Evaluation The project outcome was met by the pilot group after completion of the educational modules. Initially five nurses were selected top participate but only four were able to complete the project requirements. There was modest improvement noted overall in the pre and post survey comparisons however free text feedback showed that participants gained knowledge and competence in their skills through the project. Data were collected and analyzed through IMPLEMENTATION OF EDUCATION 24 Qualtrics. Project data was reviewed in relation to outcomes and meaning for implementation was discussed with the project team. Data Maintenance/Security The surveys conducted through Qualtrics are secured through embedded programming available to university students. Individual links were sent directly to the participants using their secure, encrypted employer emails, thus ensuring data security. In addition, the survey responses in both the pre- and post-surveys were anonymous, and no identifiable information was provided to the project team. Data Collection and Analysis After completion of the pilot study, analysis of the participant’s responses to the pre- and post-surveys were reviewed. The data collected from the survey’s responses were analyzed using Qualtrics software and exported to word documents for further review. In addition, the free-text questions included in the post-survey were individually examined by the project manager. A table with the data was created with a sample of questions chosen to be represented from the surveys (See Table 3). Finally, the data was calculated into percentages for ease of reference in the table. Place Table 3 Here before findings. Table 3 Pre (Post) Measures of Implementation of ELNEC Education Survey Question 3. The extent of the disease determines the method of pain treatment. Strongly Disagree 50 (0) Percentage of Participants Disagree Neutral Agree 0 (50) 0 (0) 0 (0) Strongly Agree 50 (50) IMPLEMENTATION OF EDUCATION 4. Adjuvant therapies are important in managing pain. 6. During the last days of life drowsiness form electrolyte imbalances may decrease the need for sedation. 10.The accumulation of losses makes burnout inevitable for those who work in palliative care. 19. Giving nursing care to a dying person is a worthwhile learning experience. 21. My knowledge and skills have improved from taking this course. 25 25 (0) 0 (25) 0 (25) 25 (25) 50 (50) 50 (0) 0 (25) 25 (25) 0 (0) 25 (50) 0 (50) 25 (25) 50 (25) 25 (0) 0 (0) 0 (0) 0 (0) 0 (0) 50 (0) 50 (100) Strongly Disagree 0 Disagree Neutral Agree Strongly Agree 0 50 50 0 Note. N=4 (N=4). This table demonstrates participant responses in the Implementation of ELNEC Education before (and after) the educational intervention. Findings After completion of the ELNEC education modules, a 25% improvement was noted in the pilot group's response in responding to patients needs for pain with adjuvant treatments. Presurvey responses to feeling that burnout was inevitable when working in palliative care showed that 75% of the group agreed or was neutral with this, and post-survey responses demonstrated a change to 75% reporting that they strongly disagree or disagree, indicating that burnout is IMPLEMENTATION OF EDUCATION 26 preventable to those working in palliative care. Improved knowledge was demonstrated related to recognition of end-of-life symptoms and appropriate interventions as well. After completion of the education all participants felt strongly that caring for a dying person is worthwhile. The biggest overall improvement from this project was shown to be the change of the pilot group in variable responses to wanting to be present when the person they are caring for is dying to all of them desiring to be present when the person dies. This result shows a significant improvement in the participants confidence in caring for the dying. The post-survey included three additional Likert questions and two free-text questions for participants to complete (See Table 4). 75% of participants felt that their knowledge and skills improved and doing the education did not interfere with their job responsibilities. Three fourths of the participants felt that the training was relevant to their job role. Several comments in the post-surveys stated they learned more about pain management as well as non-pain medication interventions. One comment stated that one of their key takeaways was that “burnout can be prevented.” Additionally, several comments related that they had learned more about palliative care and end-of-life care (see Table 4). Free Text Responses in the Post Survey Table 4 Statement Name 3 things you enjoyed most from this course Participants response “Learning how much palliative care helps improve quality of life, learning caregiver statistics, learning about proper EOL care” “Identifying different types of grief. Review of pain IMPLEMENTATION OF EDUCATION 27 medications. Use of the adjunct therapy with pain medications.” What are 3 key take-aways “Increasing education related to pain management. Discussing symptoms with medication and non medication interventions.” “Burnout can be prevented, patients with palliative care actually live longer, managing symptoms.” Note. (N=4). This table demonstrates participant responses after the Implementation of ELNEC Education Strengths Implementation of the ELNEC modules showed an overall improvement in the pilot groups' knowledge and competency in the care of the seriously ill and dying. The responses in the free text responses were positive and showed that the intention of the project was completed. The results show that using the ELNEC modules for hospice nurses not only meets the standards set by the NCHPO but also provides participants with worthwhile education and job satisfaction. Weaknesses The main weakness of this project was the number of participants. IHHH only approved a pilot group of five nurses for the project implementation. This is 12% of the entire nursing staff at IHHH. Additionally, barriers did exist during project implementation and included the participants' difficulty in completing the intervention in a timely manner. This also resulted in the participants having to repeat the pre-survey information to have conclusive data. As a result, some of the pre-survey information may be inaccurate. IMPLEMENTATION OF EDUCATION 28 Discussion This project aimed to improve the knowledge and skills of nurses working at IHHH and subsequently improve the care given to the dying. Improved care given to the dying was accomplished by implementing the educational intervention. Furthermore, it provided awareness to the executive team regarding the importance of ongoing education and skill improvement as an essential part of the role of hospice nurses. In addition, this project demonstrates the varying roles of the nurse and the significance of utilizing these roles to enhance job satisfaction and maintain patient dignity. Translation of Evidence into Practice The evidence suggests that ongoing education and support for nurses working in hospice allows for improved outcomes and decreased burnout by developing competence in job roles. The effects of this project demonstrated meaningful results in the field of palliative and hospice care nursing by showing improved levels of knowledge throughout the project. This project also showed that an opportunity exists to prioritize education in the roles of hospice nurses without interfering with day-to-day tasks. Implications for Practice and Future Scholarship Implications for practice align with the NCHPC domains and essential skills and the IOM's recommendations of ongoing educational support to allow for advanced skills and training for nurses working in palliative and hospice care (NCHPC, 2018., Bleich, 2011). This project utilized the eight domains of the NCHPC for hospice nurses as a foundation for education and showed skills associated with the necessary outcomes. Future educational interventions and initiatives using ELNEC modules versus other education would be interesting to see if the ELNEC modules are the most effective way to achieve desired outcomes. IMPLEMENTATION OF EDUCATION 29 Sustainability The outcomes of this project were shared with IHHH executive team, and other stakeholders within the organization. Plans for implementing ELNEC modules for future education are being discussed at the time of this writing. As the ELNEC modules are available and updated frequently, sustainability using this education for the nurses at IHHH is ensured. Dissemination In addition to sharing the outcomes and evaluation details with the executive team, the DNP project led plans to submit the abstract to the Sigma Theta Tau Nu Nu Chapter Induction Meeting as a poster presentation. The final poster presentation will also be available for reference in the Weber State University DNP Nursing repository as a resource to other DNP students looking for projects on successful educational interventions. Conclusion The project's ultimate goals were to use palliative care guidelines, better patient care, and improve job satisfaction. This project used standards and domains from the NCHPC and NCHPO as a basis for an educational intervention for hospice nurses working at IHHH. This project resulted in better education and knowledge for the nurses when caring for the dying, leading to better patient care. In addition, the pilot group that was part of this project has relayed a sense of improved job satisfaction, thus indicating that education is an imperative tool to use for the success of individual nurses, organizations, and patients. 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BMJ Qual Saf 23, 290-298. https://doi.org/10.1136/bmjqs-2013-001862 Appendix A PRE-Survey Hospice Education The following survey takes approximately 10 minutes to complete. The survey questions will be about your knowledge and attitudes toward caring for the dying and terminally ill. By participating in this survey, you are giving your consent. The results of this survey are reported using aggregated data, keeping responses anonymous and confidential. Data will be used for educational or quality improvement purposes to improve outcomes. If you have any questions, please contact arichins@mail.weber.edu Question 1 2 3 4 5 6 7 Palliative care is appropriate only in situations where there is evidence of a downward trajectory or deterioration. Morphine is the standard used to compare the analgesic effect of other opioids. The extent of the disease determines the method of pain treatment. Adjuvant therapies are important in managing pain. It is crucial for family members to remain at the bedside until death occurs. During the last day of life, drowsiness associated with electrolyte imbalance may decrease the need for sedation. Drug addiction is a major problem when morphine is used Strongly Disagree Strongly Agree 1 4 2 3 5 IMPLEMENTATION OF EDUCATION 8 9 10 11 12 13 14 15 16 17 18 19 20 35 on a long-term basis for the management of pain. Individuals who are taking opioids should also follow a bowel regimen (laxative treatment). The provision of palliative care requires emotional detachment. The accumulation of losses makes burnout inevitable for those who work in palliative care. It is possible for nurses to help patients prepare for death. Dying persons should be given honest answers about their conditions. As a patient nears death, the nurse should withdraw his/her involvement with the patient. I am afraid to become friends with a dying person. I would hope the person I’m caring for dies when I am not present. When a patient asks “Nurse am I dying?,” I think it is best to change the subject to something cheerful The nurse should not be the one to talk about death with the dying person. Death is not the worst thing that can happen to a person Giving nursing care to a dying person is a worthwhile learning experience. Educating families about death and dying is not a nursing responsibility. Compiled from Palliative Care Quiz for Nurses and Frommelts Attitude Towards Care of the Dying. Permission for use given by: Frances Fotergill Bourbonnais, PhD, RN Emeritus Professor IMPLEMENTATION OF EDUCATION 36 on behalf of Dr. Ross and Katherine H Murray Frommelt, PhD, RN, PDE, CGC, FT, Professor Emeritus respectively Appendix B POST-Survey Hospice Education The following survey that takes approximately 10 minutes to complete. The survey questions will be about your knowledge and attitudes in caring for the dying and terminally ill. By participating in this survey, you are giving your consent. The results of this survey are reported using aggregated data, keeping responses anonymous and confidential. Data will be used for educational or quality improvement purposes to improve outcomes. If you have any questions, please contact arichins@mail.weber.edu Question 1 2 3 4 5 6 7 8 Palliative care is appropriate only in situations where there is evidence of a downward trajectory or deterioration. Morphine is the standard used to compare the analgesic effect of other opioids. The extent of the disease determines the method of pain treatment. Adjuvant therapies are important in managing pain. It is crucial for family members to remain at the bedside until death occurs. During the last day of life, drowsiness associated with electrolyte imbalance may decrease the need for sedation. Drug addiction is a major problem when morphine is used on a long-term basis for the management of pain. Individuals who are taking opioids should also follow a Strongly Disagree Strongly Agree 1 4 2 3 5 IMPLEMENTATION OF EDUCATION 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 bowel regimen (laxative treatment). The provision of palliative care requires emotional detachment. The accumulation of losses makes burnout inevitable for those who work in palliative care. It is possible for nurses to help patients prepare for death. Dying persons should be given honest answers about their conditions. As a patient nears death, the nurse should withdraw his/her involvement with the patient. I am afraid to become friends with a dying person. I would hope the person I’m caring for dies when I am not present. When a patient asks “Nurse am I dying?,” I think it is best to change the subject to something cheerful The nurse should not be the one to talk about death with the dying person. Death is not the worst thing that can happen to a person Giving nursing care to a dying person is a worthwhile learning experience. Educating families about death and dying is not a nursing responsibility. My knowledge & skills have improved by taking the course The course workload did not interfere with my everyday tasks at work. The training was relevant to my job role. 37 IMPLEMENTATION OF EDUCATION 24 25 38 Name three things you enjoyed most from this course. What were three key take-aways from the training? Compiled from Palliative Care Quiz for Nurses and Frommelts Attitude Towards Care of the Dying. Permission for use given by: Frances Fotergill Bourbonnais, PhD, RN Emeritus Professor on behalf of Dr. Ross and Katherine H Murray Frommelt, PhD, RN, PDE, CGC, FT, Professor Emeritus respectively Appendix C IMPLEMENTATION OF EDUCATION 39 IMPLEMENTATION OF EDUCATION Appendix D 40