This study sought to describe pediatric nurses' experiences with PEOLB care, to examine natural groupings of nurses based on perceived goals and problems in providing PEOLB care, and to assess patterns of nurse collaboration with a hospital-based palliative care service from an organizational perspective. Using survey data from nurses in a freestanding children's hospital, we have shown that pediatric nurses report a range of PEOLB education, exposure to hospice programs, and experience in caring for dying children. Further, we have demonstrated that nurses perceive the goals of and obstacles to PEOLB care differently, and moreover, that nurses can be categorized into clusters based upon their views. Lastly, we have identified the significant impact of the hospital unit on nurses' involvement of the PPC team when caring for dying children and their families, more so than individual characteristics of nurses that are frequently targeted as pathways for improving the delivery of PEOLB care.
This study, although limited with regard to assessing only a single children's hospital, nevertheless highlights two significant findings regarding the organization, implementation, and delivery of PPC services in the inpatient setting. First, hospitals consist of clusters of nurses who range from enthusiastic proponents for a broad array of palliative care goals to those who have a much more restricted vision of what PPC should attempt to accomplish. Although this finding is not surprising, this study is the first to document the existence of such attitudinal groupings regarding palliative care perceptions within a hospital setting. We employed a technique (hierarchical agglomerative cluster analysis) that sorted individual nurses, on the basis of their response to all the questions regarding attitudes and beliefs about the problems PPC confronts and the goals it should pursue, into groups composed of individuals who were the most similar to other members in that group, and most dissimilar to members in other groups. This is a technique used by marketing research to identify and understand groups of people with similar preferences and values. By direct analogy, our findings regarding discrete groups of nurses, bound together by common but not universally shared attitudes, can be thought of as an initial foray into the social marketing of PPC interventions among hospital-based pediatric nurses. The practical implication of identifying these different “market segments” of nurses (such as nurses who feel that every item is an important goal, as in Goals Cluster 1 of , as compared with nurses who feel that pain control is more important than decisional support, as in Goals Cluster 5) is that hospital-wide PPC interventions need to be tailored and “sold” to each of these different groups, if the architects of the intervention hope to have the members of the group willingly (or even better, enthusiastically) adopt and support the intervention. For instance, if the planned intervention is very comprehensive, one market segment of nurses will see both the need for such a wide-ranging service and approve of its expansive set of goals, but other market segments of nurses will likely be more skeptical, believing the a more narrowly focused intervention is warranted and proper. The converse would also be true: a more circumscribed intervention (say, emphasizing improved pharmacological pain management) would have, based on our market segmentation analysis, fans and foes. Anticipating such reactions can both motivate and guide how the champions for the planned intervention design the intervention and its rollout, anticipating concerns and addressing them prospectively.
A second and likely related finding is the contextual significance of the hospital unit with respect to the PEOLB care problems that nurses perceive and how nurses work with the available palliative care resources. Our study is not the first to note associations between perceptions of PEOLB barriers and the hospital unit; Burns et al.19
found significant differences in reported barriers to PPC between intensive care unit staff and staff working on general hospital units. One possible explanation for these differences is variation in unit culture. Hospital units can be characterized as having distinct cultures that affect nurses' attitudes and actions as well as the success of care delivery redesign within an organization.20,21
Unit culture may also impact the level of acceptance a palliative care service is able to garner among nurses, particularly if nurses view the service as either encroaching on their role as the primary PEOLB care provider or perceive the service as adding to their workloads. Although this study did not examine unit-level PEOLB culture, we suspect that varying PEOLB norms at the unit level may partially explain the findings.
The results of the study also have practical implications for the design and implementation of PPC services in the inpatient setting. As stated above, the first set of findings about clusters of nursing views is similar to marketing research, helping the planners of a PPC service to understand the expectations and possible reactions of nurses whose practice may be impacted by the development of the service. Elsayem and colleagues22
describe significant differences among nurses regarding the acceptance of a newly established inpatient palliative care service at a comprehensive cancer center, differences which ultimately resulted in a substantial revision of the delivery model for PEOLB services. Administrators may find a preemptive analysis of nurses' views regarding PEOLB care useful before rolling out a new service or model of care delivery in order to anticipate the reception of such services as well as to facilitate their acceptance among staff.
Our findings also suggest that incorporation of a systems-level approach to both understanding the barriers to effective PEOLB care delivery and crafting interventions may be more fruitful than individual-level approaches alone. Common individual-level approaches include formal PEOLB education, retreats, and team-building workshops. Although these pathways may be valuable for building a clinician's repertoire of PEOLB care knowledge and skill set, they do not account for the organizational context in which PEOLB care is delivered. A systems-level approach to PEOLB care, such as identifying and addressing obstacles to the appropriate use of palliative care resources, may complement or synergize individually focused interventions.
In the end, surveys of hospital staff can serve several purposes, the first of which may be simply to create a sense of organizational legitimacy throughout the staff for subsequent palliative care endeavors. Beyond this tactical reason of conducting a survey, for our hospital this survey had very practical implications, shaping our strategy for advancing our palliative care team's mission, recognizing that different units within the hospital had different perspectives and degrees of adamancy regarding pressing patient care problems and appropriate palliative care goals, and making us more mindful during educational outreach sessions that even within units nurses differed regarding what they thought was important, allowing us to better hone our message to different groups of nurses, and hopefully to greater effect.