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Advancing serious illness communication skills for palliative home care nurses : a critical analysis Park, Sungyou 2018

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 ADVANCING SERIOUS ILLNESS COMMUNICATION SKILLS FOR PALLIATIVE HOME CARE NURSES: A CRITICAL ANALYSIS by  Sungyou Park  BSN, National Institute for Lifelong Education (South Korea), 2009 A SPAR PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (School of Nursing) THE UNIVERSITY OF BRITISH COLUMBIA Vancouver  August 2018  ©Sungyou Park, 2018 Palliative Home Care Nursing 2 Abstract Conversations between patients and home care nurses (HCNs) regarding patients’ values, priorities and goals of care are considered an essential component of all healthcare, in particular, quality palliative care and advance care planning. The unique relationship between HCNs and patients with serious illnesses place nurses in an ideal position for facilitating and initiating serious illness conversations. These vital conversations are often considered challenging which can result in missed opportunities for improving quality of care. Many tools are available to enhance communication practice in palliative care. One  tool being implemented in BC and North America is the Serious Illness  Conversation Program. I will argue that it holds promise, but needs adaptation for nursing practice. I will use the Theory of Planned Behaviour to critically analyze how the Serious Illness Conversation Program could be integrated into nursing practice in the home care setting.    Keywords Serious Illness Conversation Guide, Serious illness conversation training / workshop, palliative care, home care nursing, goals of care conversations, advanced care planning conversations, serious illness conversations   Palliative Home Care Nursing 3 Lay Summary Home care nurses talk to patients about what is important to them. This is key to giving care that meets people’s needs. Talking to people about the end of life can be hard. Nurses can use tools and skills to get better. Some of these tools are not for nurses, but nurses can learn to use them. This paper will review the Serious Illness Conversation Program for home care nurses using the Theory of Planned Behaviour.     Palliative Home Care Nursing 4 Preface This SPAR project is an original and unpublished work by the author Sungyou Park (SP). SP identified and designed the research program with supervisor Jennifer Kryworuchko (JK) and committee member Nicole Wikjord (NW). SY performed all data collection and preliminary analysis of the research. JK and NW supported SY for the final analysis. SY, JK, NW approved the final version. Research ethics board approval was not required for this research, since the data and analysis considered only published literature.    Palliative Home Care Nursing 5 Table of Contents Abstract	....................................................................................................................................................	2	Keywords	............................................................................................................................................................................	2	Lay	Summary	..........................................................................................................................................	3	Preface	......................................................................................................................................................	4	Table	of	Figures	.....................................................................................................................................	7	Chapter	1:	Serious	Illness	Communication	and	Nursing	Practice	........................................	8	1.1	Introduction	....................................................................................................................................................................	8	1.2	Serious	Illness	Communication	..............................................................................................................................	8	1.3	The	Role	of	Home	Care	Nurses	................................................................................................................................	9	1.4	Health	Benefits	............................................................................................................................................................	10	1.5	Challenges	in	Improving	Serious	Illness	Communication	Practice	......................................................	11	1.6	Serious	Illness	Conversation	Program	(SIC	Program)	...............................................................................	12	Chapter	2.	Critical	Analysis	of	the	Serious	Illness	Conversation	Program	.....................	14	2.1	Applying	the	Theory	of	Planned	Behaviour	to	Serious	Illness	Communication	.............................	15	2.2	The	Serious	Illness	Conversation	Guide	(tool)	..............................................................................................	16	2.2.1	Set	up	the	conversation	..................................................................................................................................	17	2.2.2	Assess	illness	understanding	and	preferences	....................................................................................	19	2.2.3	Share	prognosis	.................................................................................................................................................	19	2.2.4	Explore	key	topics	............................................................................................................................................	21	2.2.5	Close	the	conversation	....................................................................................................................................	24	2.2.6	Document	the	conversation	.........................................................................................................................	25	2.2.7	Communicate	with	other	HCPs	...................................................................................................................	25	Palliative Home Care Nursing 6 2.2.8	Strengths	and	Challenges	..............................................................................................................................	25	2.3	The	Serious	Illness	Conversation	Education	(workshop)	........................................................	27	2.3.1	Introduction	and	objective	...........................................................................................................................	28	2.3.2	Reflection	..............................................................................................................................................................	28	2.3.3	Building	the	case	...............................................................................................................................................	28	2.3.4	Observing	a	demonstration	and	debriefing	...........................................................................................	29	2.3.5	Explain	the	Serious	Illness	Conversation	Guide	elements	..............................................................	30	2.3.6	Create	safety	for	role	play	.............................................................................................................................	30	2.3.7	Skill	practice/small	group	role-play	with	feedback	and	debriefing	...........................................	31	2.3.8	Large	group	debriefing,	sharing	next	steps	in	implementation,	and	evaluation	..................	31	2.3.9	Strengths	and	Challenges	..............................................................................................................................	32	2.4	Implementing	the	Serious	Illness	Conversation	Program	(systems	change)	...................	33	2.4.1	Patient	identification	.......................................................................................................................................	33	2.4.2	Reminder	system	..............................................................................................................................................	34	2.4.3	Conversation	using	the	Guide	......................................................................................................................	34	2.4.4	Document	conversation	.................................................................................................................................	34	2.4.5	Strengths	and	Challenges	..............................................................................................................................	35	Chapter	4.	Implications	for	Nursing	and	Interprofessional	Practice	...............................	37	4.1	Implications	for	Health	Policy	..............................................................................................................................	37	4.2	Implications	for	Leadership	..................................................................................................................................	38	4.3	Implications	for	Research	......................................................................................................................................	38	4.4	Conclusion	.....................................................................................................................................................................	39	References	...........................................................................................................................................	41	 Palliative Home Care Nursing 7 Table of Figures   Figure 1.1. The Theory of Planned Behaviour and the Serious Illness Conversation Program ... 16	    Palliative Home Care Nursing 8  Chapter 1: Serious Illness Communication and Nursing Practice 1.1 Introduction  Serious Illness Communication is an integral part of healthcare practice. It is even more central in palliative care, which is focused on patient’s needs and goals. Serious Illness communication skills are particularly important for home care nurses (HCN) in palliative care practice. Currently, there are many barriers to excellent communication practice in healthcare settings, particularly at the end of life.  HCN need advanced communication skills for care of patients with serious illnesses. Many tools are available to enhance communication practice in palliative care. The Serious Illness Conversation Program (SIC Program) is one of many strategies being used, and is currently being implemented across British Columbia (BC Centre for Palliative Care, 2018a). I will argue that it holds promise for nursing practice, but needs adaptation to integrate in nursing practice in the home care setting. I will use the Theory of Planned Behaviour (TPB) to critically analyze how the SIC program could be integrated into nursing practice in the home care setting (Ajzen, 1991).  1.2 Serious Illness Communication  Serious illness communication is necessary in order to continually assess and review a patients’ goals, wishes, worries, and hopes (Bernacki et al. 2014). Serious illness communication is a two-way conversation between healthcare professionals, patients, and families to listen, explore, and plan together (Bernacki et al., 2014).  Advances in healthcare and technologies have served to lengthen life, especially for those with advanced serious illnesses such as cancer, advanced congestive heart failure, advanced chronic obstructive pulmonary disease, and end-stage renal disease. As a result, the roles, Palliative Home Care Nursing 9 responsibilities, and challenges of nurses have grown, particularly in home-based palliative care. Ninety percent of the final year of life of patients with advanced serious disease is spent at home prior to their death, regardless of where death occurs (Thomas, 2006). Indeed, most seriously ill patients prefer dying at home with family by their side, rather than in a hospital (Hospice Palliative Care in Canada, 2014). Home care nurses (HCNs) are the link to resources for those patients and effective communication is critical to discover appropriate supports and resources (Stajduhar et al., 2011). These conversations are vital to ensure that the patient receives health care that is concordant with the patient’s priorities and goals (Bernacki et al., 2014). Nursing education and practice Guidelines provide some guidance in therapeutic communication, however, as a patient’s serious illness progresses, some questions or conversations may be perceived as challenging for nurses especially for novice nurses or nurses who are unfamiliar with palliative care. Gaining trust and an understanding of the wishes of patients from diverse backgrounds (i.e., ethnicities, cultures, ages, social background, mental health) is challenging and requires excellent communication skills. The purpose of this paper is to critically analyze and adapt communication training for home care nurses who provide a palliative approach to care of people with serious illness, in order to improve knowledge, attitudes, and skills to enhance confidence and comfort when engaging in the dialogues necessary for a higher enrichment of care.  1.3 The Role of Home Care Nurses  Providing palliative care at home increases patient and family satisfaction while being a more cost-effective use of medical resources (Brumley at al., 2007).  Compared to other healthcare professionals, Home Care Nurses (HCNs) have the most frequent interactions with patients.  In the case of the seriously ill patients at home, HCNs are there to assess and evaluate Palliative Home Care Nursing 10 the seriousness of the situation, to screen for care needs, and to coordinate resources (e.g., home supports, equipment rental, referral to other interdisciplinary team members) in order to provide optimal care (Stajduhar, 2011). Palliative care supports individualized care planning and a whole- person approach that embraces care of the dying and their loved ones (Offen, 2015). Providing care at home creates unique opportunities for both patients and nurses (Oudshoorn, Ward-Griffin, & McWilliam, 2007). It reduces power differentials between care-receiver and caregiver and opens up possibilities to learn about patient’s personalities, family dynamics, and untold stories (Dunne, Sullivan, & Kernohan, 2005; Oudshoorn et al., 2007; Offen, 2015). Duties and responsibilities are multidimensional and range widely from physical support (e.g., symptom management, medication management, subcutaneous medication preparations, education, wound care, procedures for relieving discomfort, and referral to appropriate interdisciplinary teams) to psychosocial support (e.g., exploring illness understanding and assessing experience, fostering hope, articulating goals of care, assessing mental status, exploring coping abilities) (Stajduhar, 2011). HCNs also function as a bridge connecting various palliative care services such as referring to a hospice, a social worker, a palliative specialist, and other resources in accordance with patients’ goals of care (Stajduhar et al., 2011).  1.4 Health Benefits Serious Illness communication is a deliberate and caring conversational approach that has many benefits such as reducing stress, anxiety, and depression in not only patients and but also their families. A randomized controlled study studied advanced care planning in elderly patients with serious illness (usual care vs usual care with facilitated advanced care) demonstrated that family members of these elderly patients in the advanced care planning group exhibited less stress, anxiety, and depression (Detering, Hancock, Reade, & Silvester, 2010). In a prospective Palliative Home Care Nursing 11 longitudinal cohort study, end-of-life conversations showed correlation in lower ventilator use, lower rates of unwanted resuscitation, less acute care treatment (e.g., intensive care unit admission), and earlier referral to a hospice program amongst patients with advanced cancer (Wright et al., 2008). In addition, in a 6.5-month follow-up after a patient’s death, families and caregivers reported less regret, easier bereavement process, and fair self-reported health (Wright et al., 2008). A prospective cohort study (Mack et al. 2012) also reported that patients who had end-of-life conversations before the last month of their lives received less aggressive care and treatments (such as chemotherapy), fewer acute care admissions and a higher number of referrals to palliative care. 1.5 Challenges in Improving Serious Illness Communication Practice Ideally, healthcare professionals (HCPs) should engage in serious illness communication early and frequently to improve quality. In reality, these conversations are often ill-timed (e.g. during a crisis), generating a gap in between what patients wanted and what really happens. A study by Heyland at el., (2013) found that among the frail elderly (i.e., those at high risk of dying in the following six months), only 20.1% of patients had discussed prognosis or treatment preferences, while 76.3% of patients had thought about the question prior to hospitalization. Another study reported 39% of end-of-life discussions happened in the last month of the life, indeed 63% of these conversations took place in hospitals (Mack et al., 2012). The challenges nurses face with SIC are a result of many factors such as social anxiety, perceived beliefs and experience around treatments, insufficient knowledge and limited experience and resources (Bramhall, 2014). Lack of training in communication skills was identified as a major challenge to fulfilling these roles and responsibilities (Banerjee et al., 2015; Wittenberg et al., 2016).  Other identified challenges were discomfort related to fears of Palliative Home Care Nursing 12 complicating sensitive situations by saying the wrong words, inadequate resources (time constraint due to workload and administrative support), communication-related factors (lack of awareness of what has been communicated between doctors and patients and families or reluctance/delaying the conversation) and perceived role ambiguity (who is to initiate the conversation) (Zhou, Stoltzfus, Houldin, Parks & Swan, 2010; Aslakson et al., 2012; Wittenberg et al., 2016). HCPs lack of confidence in communicating with patient with serious illness may cause avoidance of patient’s cues (physical or emotional) to initiate communication, undermine the previously established relationship, or contribute to missed opportunities to improve the comfort and quality of life of patient with serious illness (Griffiths, Ewing, & Rogers, 2010; Griffiths, Wilson, Ewing, Connolly & Grande, 2015). Further, this may lead to use of aggressive treatment as the default in health care is often to cure and prolong life as much as possible (Canadian Hospice Palliative Care Association, 2014). Strategies are needed to overcome difficulties, especially, improving communication skills and knowledge in order to improve engagement, consistency, and listening skills.  In order to meet these needs, there are various frameworks developed skill-based workshops for HCPs (Bernacki et al, 2014; Witten-berg Lyles, Goldsmith &Platt, 2014; Griffiths et al, 2015; Coyle et al, 2015; Lakin et al., 2016; Whitehead & Carter, 2017). One of the notable frameworks developed for HCPs is the Serious Illness Conversation Program (Bernacki et al.).   1.6 Serious Illness Conversation Program Bernacki and colleagues (2014) developed an evidence-based communication practice program, Serious Illness Conversation Program (SIC Program), taught in a two hour and a half long workshop to improve HCP's communication skills, knowledge, and confidence. SIC Program includes a conversation Guide for HCPs to initiate early discussions with patients with Palliative Home Care Nursing 13 advanced illnesses to support a systematic and intervention-like approach (Bernacki et al., 2014). The Guide proposed 7-steps to facilitate a systematic approach to help HCPs prompt appropriate questions and go through the flow of conversation to identify understanding and areas needed for further support (Ariadne Labs, 2015- 2017). It provides patient-tested language to minimize HCPs’ emotional fears (saying wrong words), lack of confidence and anxiety (Bernacki et al., 2014). Since the introduction of the program, the program has been implemented in various care settings (e.g., cancer centre, primary care, dialysis unit, critical care, surgery settings) (Ariadne Labs, 2018). In addition to the Guide, which is the main intervention to improve HCP communication practice, the SIC Program also consists of a workshop for HCPs and detailed suggestions about health systems changes required to support HCP communication practice with patients and families. The program is feasible in primary care settings (Lakin et al., 2017). Lakin and colleagues (2017) reported increased documentation, higher hospice utilization as well as high satisfaction with the training they received. The SIC Program is analyzed in detail in Chapter 2.         Palliative Home Care Nursing 14 Chapter 2. Critical Analysis of the Serious Illness Conversation Program The SIC Program by Ariadne Labs (2018) consists of three parts: tools (the Guide), education (the workshop), and systems change (documentations and HCP alert system). Here, I will argue that the SIC Program holds promise for HCN practice, but needs adaptation.  Researchers seeking to improve healthcare HCP communication have used theory from psychology to develop training programs (Parle, Maguire & Heaven, 1997; Connolly et al., 2010; Coyle et al, 2015). I looked for an appropriate behaviour modification theory to explain and predict how communication programs could lead to successful behaviour change. A structured approach that explicitly links key aspects of a communication intervention with corresponding behaviour is most likely to be successful (French et al., 2012). Theories can assist to facilitate evidence into intervention implementation (French et al., 2012). One of the theories that aligns with my purpose is the Theory of Planned Behaviour (TPB) by Ajzen (1991). I will use the TPB to critically analyze how the SIC Program could be integrated into nursing practice in the home care setting.  The TPB explains that a person’s behaviour is determined by his or her intention to act which is influenced by their attitude towards the behaviour, their subjective norms, and their perceived behavioural control (Azjen, 1991). Attitude toward behaviour is a person’s beliefs about whether a certain action is good or bad, or will have good or bad consequences (Ajzen, 1991). The subjective norms are the perceived social pressure to behave in a certain a way, for example because of culture (i.e. organizational culture) or because you hold a specific role (i.e. HCN) (Ajzen, 1991). Subjective norms exist when a person believes that a certain kind of behaviour is considered by others to be respected and supportive, or required. The norm will motivate a person to behave in that way. Perceived behavioural control is the performer’s (the Palliative Home Care Nursing 15 person engaging in the behaviour) sense of whether a certain behaviour is within the person’s own means to practice in a particular way (perhaps due to degree of complexity or possession of certain skills), which influences their actions. This reflects past experience, anticipated difficulties, or perceived challenges towards the behaviour (Ajzen, l991).  2.1 Applying the Theory of Planned Behaviour to Serious Illness Communication According to Ajzen (1991), a person will do something if (1) the individual expects the action will have a good outcome, (2) the individual believes it is something he/she is supposed to do, and (3) the individual is confident they are able to do it (see Figure 1). Behaviour, such as use of the specific strategies in the Serious Illness Communication (SIC) Program, are thought to be influenced by (1) the home care nurse’s attitudes towards SIC (belief about whether SIC will have good outcomes for the nurse, the team, the patient, or the family), (2) subjective norms that govern home care nurses’ SIC practice (belief there is a norm), and (3) the perceived behavioural control over SIC (how difficult/possible the HCN thinks the action is).    Palliative Home Care Nursing 16  Figure 1.1. The Theory of Planned Behaviour and the Serious Illness Conversation Program    In order to bring about a change of behaviour in nurses, they should be convinced of the benefits of serious illness communication, be under the impression they are expected to have such conversations (due to a new professional norm), and be trained in such a way that the prospect of engaging in such conversations is less daunting (nurses feel confident that it is something they are able to do). TPB is often utilized in studies where trying to achieve healthcare behavioural changes, such as smoking cessation or condom use. It has been found people are more likely change behaviour when they were approached from all three determinants (Ajzen, 2011). Next, I will explain how the TPB constructs are addressed in each component of the SIC Program.  2.2 The Serious Illness Conversation Guide (tool) The Serious Illness Conversation Guide is a tool for HCPs (e.g., physicians, nurses, and other interdisciplinary healthcare professionals) to use when interviewing patient with serious Palliative Home Care Nursing 17 illness and their families (Bernacki et al., 2014). The Guide proposes seven steps along with a patient tested script (i.e. actual words to use when talking to patients) in order to: 1) set up the conversation, 2) assess understanding and preferences, 3) share prognosis, 4) explore key topics, 5) close the conversation (summarize, make a recommendation, check in with patient, and affirm commitment), 6) document conversation, 7) communicate with other HCPs (Bernacki et al., 2014).  In terms of the TPB, the Guide addresses perceived behavioural control and behaviour by providing specific tools and language for SIC (see Figure 1). Perceived behavioural control refers to how much control a person can have over their behaviour in a specific circumstance, in this case, how HCN’s communicate with patients and their families (Ajzen, 1991). The SICG checklist is used to cultivate knowledge and perspective in preparing for communication with patient with serious illness, so the interviewer can feel prepared and organized. Additionally, the script and the checklist format supports a sense of control in the application of this tool into a practice. One of the core purposes of the workshop is to improve a practitioner’s behaviour by learning skills to gain confidence and comfort in implementing a new approach (Parle et al.,1997). Ajzen stressed the importance of perceived behavioural control by arguing that it is possible that perceived behavioural control alone can influence of the intention to behave leading up to actions (2002). Next, I will lay out each step of the Guide and critically analyze how it applies to HCN practice.   2.2.1 Set up the conversation  Setting up the conversation and obtaining permission from a patient is the first step of the serious illness conversation. Obtaining permission is an important part of the healthcare Palliative Home Care Nursing 18 practice as it enables patient’s choices and right to make healthcare decisions (Scott et al., 2003). As a part of shared decision process, asking permission to proceed the conversations would facilitate the patient’s involvement, if not it could undermine already established therapeutic relationships (Scott et al., 2003). Setting up the conversation and meeting the patient for the purpose of having the conversation is common way of initiating conversation in healthcare settings, especially primary care and physician practice. In the Guide, the HCP is instructed to ask “I’d like to talk about what is ahead and do some thinking in advance…is this okay?” is a gentle invitation to SIC and express a HCP’s willingness to listen and engage with patient’s voice. However, in the context of nursing, there are two different ways of initiating the conversation: for example, at specific times in delivery of care (e.g., on the day of admission into the program or post discharge from a hospital) or spontaneously, arising from conversations with patients and their families. A spontaneous conversation could emerge during the course of the provision of care, for example providing wounds care, pain assessment, or personal care. For nursing practice, it may be necessary to identify typical cues that the novice nurse could identify as opportunities for spontaneously using the Guide. Such cues might range from noticing symptom changes (i.e., an increase in pain or decrease mobility) and/or statements indicating psychological or emotional readiness to participate in SIC, for example, “I think I am dying”. These cues or ideas can open opportunities for conversation and nurses can use the chance to facilitate the SIC.    Palliative Home Care Nursing 19 2.2.2 Assess illness understanding and preferences  Assessing illness understanding and preferences for patients and their families show how much information they have received or lack. This strategy aligns with nursing roles and education emphasizing the need to check-in with patients and assess their understanding in regards to their health (Canadian Nurses Association, 2017). Nurses use three types of theoretical knowledge (biomedical, patient and personal knowledge) in their assessment and planning of nursing care (Liaschenko & Fisher, 1999), and these types of nursing knowledge are derived by the types of questions that are asked throughout the SICG. Assessing illness understanding reflects biomedical knowledge, whereas questions in later sections ask patients to further integrate this biomedical knowledge to come to a personal meaning of illness (Liaschenko & Fisher, 1999). Assessing illness understanding can take a lot of time to ensure that patients and families have not only heard facts about their disease, but have had the opportunity to integrate these facts into a sense of meaning about how this illness is part of their identity as a person, and affects their future goals and health care plan. For example, in contrast to what Bernacki et al (2014) suggest, it is unlikely that a SICG Guided conversation will be accomplished in 20 minutes. For nurses, where communication in this regard is a cornerstone of interventions aimed at promoting self-management and improving quality of life, such conversations may extend over hours, days, weeks or even months (Griffiths et al., 2010; Stajduhar et al., 2011).  2.2.3 Share prognosis The concept of prognosis is primarily associated with medical condition of advanced illnesses where physicians provide their assessment about the physical aspect of illness. Though sharing prognosis is a component of palliative conversations (Norton et al., 2013), nurses utilize this concept to examine psychosocial/spiritual needs of patients and their families during serious Palliative Home Care Nursing 20 illnesses. For example, when a patient receives news that their cancer is no longer curable, and that treatments are only intended to provide comfort. It may be important to explore the patients understanding of this change in intent for a familiar treatment like chemotherapy, and then assess the patients’ perception and understanding about their prognosis, and explore what it means to them. In the Guide, the HCP says, “I want to share with you my understanding of where things are with your illness” with three more sentences expressing uncertainty, time, and function. This step is focused on the typical scope of practice for physicians, and may not reflect nursing practice. Thus, using the language in the Guide might provoke uneasiness to nurses unless addressed clearly what ‘sharing prognosis’ means within the nursing context SIC. Still, exploring patient’s understanding of prognosis is valuable information as it might open up opportunities to link key topics. For example, typically a nurse will refer to prognostic facts delivered to patients by physicians, and then take time to explain, clarify and help patients and their families attach meaning to the prognosis for their own situation. Alternatively, nurses may use hypothetical ‘future scenarios’ to explore worst case situations that patients and families might (realistically) face, for example saying: “Sometimes we aren’t sure what the future holds, and I hope that you have many more months, but can we talk about what would be important for you if you were to have only weeks to months to live?” Further, it is important to understand that the previous healthcare experience will influence future decisions about tradeoffs. For example, a patient who was given a prognosis of 6 months previously, who lived a further 2 years, might choose more treatment since HCPs have been wrong about prognosis in the past and may be wrong again.   Palliative Home Care Nursing 21 2.2.4 Explore key topics The SICG topics include asking the patient about their goals, fears and worries, sources of strength, critical abilities, trade-offs, and family in order to enrich and inform the plan of care at the end of life (Bernacki et al., 2014).  Goals  For patients, identifying goals requires that patients reflect on the biomedical understanding of the illness, what it means for them in terms of ability to manage their illness in the context of their overall life including vocation, career, hobbies, personal responsibilities, etc. (Liaschenko & Fisher, 1999). Nurses use case knowledge and patient knowledge to pay attention to a patient’s goal to co-design/modify a plan of care as goals often change during the course of illnesses. Patients often feel reassured when they aware that they are the one who has the control and power to redesign and reshape care planning (Légaré et al., 2011). One critique is that this is not a simple step, especially since in practice a patient may be redefining goals in the context of new information, especially when the SICG is implemented in health systems at new diagnosis or change in status. When this happens, patients are not simply reiterating known goals, but integrating new information and trying to process what their new goals might be in view of emotionally devastating / psychosocial spiritually distressing news. For example, a patient who previously had a goal to live for 5 years, may need to identify goals no longer linked to survival when his disease worsens and is deemed terminal with a life expectancy of 6 months. In this case, the patient might be at a loss to identify realistic goals, and HCNs can provide a lot of guidance in helping patients define goals linked to quality of life, to personally meaningful relationships, to resolving conflicts or pursuing dreams or legacy work (Chochinov, 2002).   Palliative Home Care Nursing 22 Fears and worries For patients, fear and worries are the opposite of hopes. Often these are a reflection of past trauma or lived experience in relation to death and dying. Sometimes these are existential and spiritual crises and fear of dying (Benzein, Norberg, & Saveman, 2001). Nurses use a mindful approach to explore the meanings of fears and worries to connect with various aspect of illness such as hopes and defining meanings (person knowledge). Exploring this, and giving space for people to share their fears and worries is a primary goal of psychospiritual care at the end of life (Chochinov, 2002). In my HCN practice, I have had conversations about fears and worries that are often repeated in the ensuing weeks and months and where a primary focus of my care was to provide reassurance and counselling. Thus, the implicit assumption that patients will articulate this and then move on to the next section may not provide therapeutic value to patients and their families. Sources of strength For patients, sources of strengths are often the foundation of their coping ability (Wright & Leahey, 1999). Nurses use commendations and strength-based approaches to reinforce patient strengths (person knowledge) (Liaschenko & Fisher, 1999; Wright & Leahey, 1999). The question “tell us what your strengths are” opens opportunities to explore and review how a patient has utilized their own strengths as a way of coping previously (Slawinski, 2006). This strength-based approach can be used to recognize each person as their own expert in their unique process around serious illnesses. Although patients often identify external sources of strength, for example the family members or relationships, one key goal of supporting dying people is to help them recognize their own strengths and resilience in face of serious illness and dying (Chochinov, 2002).  Palliative Home Care Nursing 23 Critical abilities For patients, critical abilities are sources of joy or certainty which they ‘can’t imagine living without (Bernacki et al., 2014). Nurses use this personal knowledge to explore fundamental purposes of the ability and how it creates joy. Sources of certainty or joy range widely from a family’s support to a sense of independence. Patient often mention that critical abilities are deficits in self- management and activities of daily living, for example requiring assistance with toileting, feeding, mobility and so on, may seem embarrassing and a ‘last straw” for many people (Chochinov, 2002). However, nurses routinely provide personal care that compensates for loss of critical abilities during serious illness (Richards, Hilli, Pentecost, Goodwin, & Frost, 2018). Thus the focus of nurses is often to develop personal therapeutic relationships with patients and their families, such that receiving that care is perceived as undignified or embarrassing. The intimacy of the nurse patient relationship is one type of relationship in the health care setting that creates resilience for patients, and opens space for accepting care when critical abilities are lost. This is in contrast to the SICG, where one might be expected to accept these critical abilities as unquestioned fact in deciding what care to provide.    Palliative Home Care Nursing 24 Trade-offs For patients, trade-offs are in responses to treatments or past experience with invasive procedures versus their perception of quality of life (Bernacki et al., 2014). Thus, it indicates their willingness to proceed with further treatment and their related downsides in order to ‘buy more time’ (Bernacki et al., 2014). Nurses use case knowledge and patient knowledge to provide necessary information to act as a shared decision maker (Legare´ et al., 2011). Nurses’ therapeutic relationship with patients and their families is created to ensure that patients can accept care when they desire it despite the tradeoffs. For example, nurses work hard to ensure that people in critical care areas are comfortable and peaceful and retain their dignity despite the high technology environment (Canadian Association of Critical Care Nurses, 2011).  Family  For patients, families are often the sources that reflect their own life values and meaning. Nurses use person knowledge and patient knowledge to explore family’s understanding of the patient’s goals and wishes. Family dynamics can be a significant factor in exploring this topic. In some cases, family dynamics are a source of conflict and psychological suffering to a patient (Lichtenthal & Kissane, 2008). HCNs have advanced communications skills and are expected to help patients and their families navigate these challenging conversations (Canadian Nurses Association, 2017). 2.2.5 Close the conversation Closing the conversation provides a chance to summarize what a HCN has discovered and to assess the patient’s emotional status. This step also expresses the home care nursing team’s commitment and reassurance around topics and concerns that they discussed together. HCNs re-confirm the next appointment with a patient, any next steps that the patient or the HCN Palliative Home Care Nursing 25 needs to pursue, and encourages contacting the home care nursing office if there are new concerns that arise in between visits. Reflecting on another person’s communication is a fairly standard practice in nursing practice of therapeutic communication (Kourkouta & Papathanasiou, 2014).  2.2.6 Document the conversation  Currently, in my workplace, HCNs document various types of entry in one place, the electronic progress notes. Nurses are also asked to write a summarized entry on an advance care planning (ACP) document in the patient’s chart and make a short entry on the ACP documentation in greensleeves (“a green magnetized wallet for the patient’s fridge and holds a list of medications, substitute decision makers and any advance care planning documents”) (Fraser Health, 2018) in the patient’s home. Documentation is a focus on the systems change proposed to implement the Serious Illness Conversation Program (Ariadne Labs, 2018). 2.2.7 Communicate with other HCPs Verbal or written communication are the main tools used to communicate the SIC conversation and build collaborative palliative care practice with other key HCPs (e.g., other HCNs, family physicians, palliative consultation team members or other interdisciplinary team members) for an update, meeting/ joint visit or a referral to other different consultation team. 2.2.8 Strengths and Challenges Two key strengths of the Guide are the checklist format and the list of key topics. The checklist format allows revisiting of conversations to further explore or overcome barriers to conversations for various reasons, such as waiting until a patient is ready, to allow HCPs time to prepare. Another strength of the Guide is a list of key topics (e.g., goals, fears and worries, sources of strength, critical abilities, tradeoffs, and family) which are significant components to Palliative Home Care Nursing 26 learn what matters most for patient with serious illness (Heyland et al., 2006). Despite these strengths, there are some important challenges facing users.  Key challenges to HCN using the Guide in practice include how the keywords prompt reflection, and especially how the “patient tested language” situates patients in terms of temporally appreciating their situation (i.e. now or in future). Keywords such as prognosis, critical abilities, and tradeoffs are intended to prompt reflection, but need further explanation and explicit understanding from the perspective of nursing in order to implement the Guidelines in the practice setting. For example, the concept of prognosis is traditionally associated with medical doctors’ roles and responsibilities. In most cases, patient with serious illness do not expect to have a ‘timeline’ conversation with nurses or other healthcare HCPs (Heyland et al.,2009). Such keywords could provoke uneasiness to HCNs unless the underlying meanings were addressed explicitly when introducing the Guide. In context of the TPB, such uneasiness would need to be addressed in order for the Guide to bring about change in HCN practice behaviour. Without an accompanying workshop then, it might be challenging to adapt the Guide into nursing practice. Another challenge is future-oriented questions when exploring key topics. For example, "what are your most important goals if your health situation worsens"; "what are your biggest fears and worries about the future with your health"; "what gives you strength as you think about the future with your illness". These questions are valuable elements to know what is most important to seriously ill patients and their families (Heyland et al., 2006), but I feel ambiguous if those questions may diminish the significance of present due to added 'if' questions. The last issue to consider is how the “patient tested language” situates patients with respect to temporal reflection. For example, HCN often ask patients and families to reflect on their situation now, in the present, prior to prompting reflection on their future (Nordby, 2017). Palliative Home Care Nursing 27 However, for patients who are experiencing the delirium, dementia, cognitive impairment, medications, or serious illness itself, may not able to articulate to think abstractly about an imagined future. The SICG script may have been tested with largely high literacy patients and families. As a result, more research might be needed to look into how it can be used with lower health literacy or cognitively impaired people.   2.3 The Serious Illness Conversation Education (workshop) The workshop is designed to teach HCPs to use the SICG in practice. A 2.5-hour interactive classroom SIC workshop created by Bernacki et al. (2014) is to support developing competencies in using the Guide (Ariadne Labs, 2018). The purpose is to diminish the sense of difficulties and to strengthen a sense of control and positive perspective in communicating with patient with serious illness in order to increase their confidence and competence in applying the tool in actual practice (Ajzen, 1991; Ariadne Labs, 2018) (figure 1). According to the developers, the first part of the workshop is a didactic session to provide evidence (research outcomes and benefits based on advance care planning discussions) and is followed by demonstration of the SICG in use, individual practice, and debriefing. The workshop’s 10 steps are: (1) introduction and objective, (2) reflection, (3) building the case, (4) demonstration and debriefing, (5) explaining the Serious Illness Conversation Guide elements, (6) creating safety for role play, (7) skill practice/small group role-play with feedback and debriefing, (8) large group debriefing, (9) sharing next steps in implementation, (10) evaluation (Ariadne Labs, 2018). However, it is important to note that the workshop was developed first for physicians in primary care practice, and so it has not been adapted explicitly for use by other HCPs, specifically HCNs; this will be Palliative Home Care Nursing 28 explicitly explored by considering each part of the workshop and how it might be received by HCN participants.  2.3.1 Introduction and objective Similar to the first step of the SICG, this step is important in order to set the stage and to introduce goals and objectives of the workshop. This step describes the purpose of the workshop and summarizes the rationale of the systematic approach to assess patients’ values and preferences. Objectives of the training is to enhance learners’ interest and a level of participation in order to learn the skill (Ariadne Labs, 2018).  2.3.2 Reflection Reflection is a practice used by nurses all the time from hand-over to reviewing/modifying care plans and it is an essential part of caring for other people, and maintaining a registration or license to practice nursing (Oelofsen, 2012). This step provides nurses with a chance to reflect their own past communication experience with patient experiencing serious illnesses. In this step, nurses are encouraged to reflect upon their previous conversations reflecting critically and to think carefully about at what went well or what did not go well in order to cultivate collective purpose and motivation to learn better communication strategies (Oelofsen, 2012).  2.3.3 Building the case This following step provides empirical evidence and rationale for improving communication as a means to optimizing health outcomes for patients and families. These outcomes include improved perceived quality of life, less depression and anxiety, and better bereavement outcomes (Wright et al., 2008; Detering et al., 2010; Mack et al., 2012). It is also important to address benefits not only from a patient’s angle but also from the HCPs’ Palliative Home Care Nursing 29 perspectives. Nurses’ empowerment theory by Udod (2014) described sharing benefits and information increase nurse’s confidence in their own practice and enhanced willingness to practice independently. Explaining key empirical benefits and the current practice gap might reinforce appropriate attitudes toward the change. Creating special contributions to a patient’s welfare, or preventing the use of uncomfortable undesired treatments near the end of life, could contribute to boost nurses’ job satisfaction. For example, Fillion et al. (2006) delineated meaning enhancement for nurses in palliative care may assist in channeling stress into coping which is beneficial for generating job contentment.  In health care, nurses use knowledge, experience, evidence, and ethical values to develop care plans to provide whole person care (Liaschenko & Fisher, 1999). When a person approaches the end of life, a nurse’s roles and responsibilities (supporting a person’s dignity, autonomy, and the personhood) become even more significant in the support of the physical, emotional and spiritual aspects of care (Canadian Nurses Association(CNA), 2017). CNA’s Code of Ethics also seconds this notion by stating that “… nurses consider and respect the best interests of the person receiving care and any previously known wishes or advanced care planning that applies in the situation” (2017, p. 12). When nurses at the workshop recognize SIC practice as part of their standards roles and responsibility, attendees might be more motivated to learn this communication skill because individuals would perform certain behaviours when the behaviour is considered part of standard roles and responsibilities within the practicing group (Ajzen, 1991). 2.3.4 Observing a demonstration and debriefing This step is to observe the SIC between the HCP and a patient, how to implement the Guide, and debrief about the observation. The observing model is a central component and the Palliative Home Care Nursing 30 method is widely utilized in simulation-based learning (Morris, 2003). For instance, in a lab class at a nursing school, students observe an instructor’s skill (e.g., measuring blood pressure, inserting an intravenous needle, taking a medical history or cardiopulmonary resuscitation) before practicing with peers or performing a mock-up and debrief about their observations. Debriefing is used to facilitate reflection about an antecedent event (Reed, 2012) in a physically and emotionally safe place. Debriefing increases self-awareness, clarifies questions, and analyzes thoughts to search for meaning (Reed, 2012). During the debriefing, the role of a facilitator is to create a safe place for sharing thoughts and raising questions in addition to being an expert in the area and providing adequate guidance (Reed, 2012).  2.3.5 Explain the Serious Illness Conversation Guide elements  The workshop presents the Serious Illness Guide, typically as used in primary care physician practice, However, I suggest that the guide and it’s “tested language” need to be adapted for use by HCNs, and that these adaptations should be verbalized during the workshop. Refer to the earlier section 2.2 for the Guide analysis. 2.3.6 Create safety for role play  Prior to proceeding with role-playing, creating emotional safety is needed to minimize reluctance and uneasiness (Jackson and Back, 2011). Normalizing anxiety and awkwardness about impending role-playing can reduce unsupportive feelings and provide support to each other’s practice (Jackson and Back, 2011). The facilitator can use reflective stories of how they felt when practicing the new skill in front of others to remind them that this step is a part of a fundamental skill practice in which the person can receive immediate support and reassurance. Another strategy for creating a safe environment for the role play is to address clear ground rules such as confidentiality and time-outs for discussion and questions (Jackson and Back, 2011).  Palliative Home Care Nursing 31 2.3.7 Skill practice/small group role-play with feedback and debriefing  The purpose of role-playing is to enhance clinical understanding in patient care (Comer, 2005). Communication is a skill which is required over an extended period time with ample self-reflection, with the receiving of constructive criticism, and maintaining of perseverance to overcome challenges to engage and feel confident, even in difficult situations (Jackson and Back, 2011). Having a chance to practice the skill through role-playing with a facilitator is a valuable approach to exercise (Jackson and Back, 2011), especially when there are new skills to hone. Therefore, tailored role-playing scenarios are needed for this step. In addition, role-playing presents a valuable opportunity for nurses to put themselves in a patient’s position, even for a short period of time. Although nurses playing patient-role can follow a script to answer questions, it might allow different perspectives on what it feels like when asked questions about serious illness as a care receiver. Providing immediate feedback and debriefing facilitates the exercise of unfamiliar skills and can deepen the experience (Jackson and Back, 2011). For instance, in a study of undergraduate nursing school students concerning role-playing with a debriefing (Wotton, Davis, Button, & Kelton, 2010), it found students valued feedback and debriefing in the areas of skill management, enriching understanding, and rationalizing nursing actions. In fact, students identified being in favour of having more time for feedback and debriefing. Similarly, when nurses learned new techniques, they were expected to seek feedback and practice in order to perform the skill safely and effectively. This step is an extension of the skill practice strategies, in order to improve performance.  2.3.8 Large group debriefing, sharing next steps in implementation, and evaluation After completing small-group skill practice and the corresponding debriefing, the group is gathered as a large group to share thoughts and steps for implementation. This is then followed Palliative Home Care Nursing 32 by evaluation of the workshop. This last step of the workshop is to reiterate the workshop’s objectives and reassure nurses that this serious illness communication is a challenging skill. Just as nurses encourage patients to seek support and help, the facilitator may need to remind nurses to reach out for support and debriefing as much as they need. 2.3.9 Strengths and Challenges  Two key strengths of the SIC workshop are introducing role-playing and normalizing discomfort in practicing SIC skills with others. Role-playing is an important tool when practicing a new strategy or skill (Comer, 2005). By introducing the concept of role-playing, nurses may able to acknowledge that advancing communication is a skill which is an extension of assessment within the nursing scope of practice that we can practice and improve on. Another strength of the proposed workshop is normalizing awkward feeling and discomfort as such practices are hardly being monitored or evaluated by peers or nursing leaders. Addressing the uneasiness and awkwardness may promote nurse to be more open in practicing the SIC skill. Despite these strengths, there are some important challenges facing workshop participants.  Key challenges to HCN in participating the workshop include how the key topics in the Guide is being addressed during the workshop, especially key topics such as prognosis, tradeoffs, critical abilities, source of strengths, and fears and worries. These key topics are valuable areas for assessing patients’ needs and wishes. However, the unique roles of such topics are needed to be addressed from the nursing perspective. Without fully understanding the underlying implications of these topics might result in insufficient assessment (e.g., checking off a tick-box and move forward to the next question). Another challenge is the workshop recurrence. The developers of the SICG program suggested a single 2.5 hour workshop to be able to adapt the tool in the real practice. It may beneficial provide a series of 2.5 hour workshop (minimum 3 Palliative Home Care Nursing 33 workshops) over an extended period of time (e.g., one-year). The first workshop may utilize the same format suggested by the developers. The second workshop may address unique challenges in implementing by nurses and adopt real case examples in adapting the tool. The last workshop could focus on debriefing, deepening communication skills, and measuring nurses’ job satisfaction or compassion fatigue to evaluate the impact of SIC training.  2.4 Implementing the Serious Illness Conversation Program (systems change) The SICG program reinforced the significance of systems change (patient identification; reminder system; conversation using the Guide; document conversation; patient and family support) along with quality measurement and improvements (Ariadne Labs, 2018) to sustain and facilitate the SIC as standards of care, especially having a designate electronic medical record location to retrieve and update conversations of patients’ goals, values or preferences along with other key information such as medical orders for scope of treatment and the identification of the substitute medical decision maker. Four steps suggested by Bernacki et al. (2014) were briefly reviewed as this paper’s primary focus is analysis of the SICG from the perspective of nursing. 2.4.1 Patient identification  In the implementation trial by Lakin et al. (2017), they utilized the Surprise Question: “Would you be surprised if this patient died in the next 2 years?” (p. 1260) was utilized as primary screening criteria in selecting patients with whom to have serious illness conversations. However, it was also noted that this question could have missed as many as 79% of at-risk patients (Lakin et al., 2016). This highlights the need for Serious Illness Conversation implementation as part of a series of regular assessment for screening all patients with serious illness and the need for revisiting the conversation throughout the illness trajectory (Ariadne Palliative Home Care Nursing 34 Labs, 2018). For instance, SIC should be started at a time of serious illness diagnosis or after a major treatment such as chemotherapy or radiation therapy, or in the instance of a significant functional decline.  2.4.2 Reminder system The reminder system could alert appropriate timing of serious illness conversation to healthcare HCPs when the electronic health record system detects a new diagnosis, completes a series of treatments, or upon discharges a patient from an acute care facility (Ariadne Labs, 2018). Additionally, if there is newly updated documentation in the medical health record system, a reminder could also notify other HCPs or the patient’s family physician. 2.4.3 Conversation using the Guide Similar to the workshop and the Guide itself, the Guide is not used in practice by all HCPs in the same way. Specific HCPs might use the guide in different ways in a health system, since their practice with patients and families may be different. For example, social workers may meet with the same patient as part of their caseload over many years. However, nurses may be assigned to a specific patient or family for one or several shifts, or during a specific part of their serious illness trajectory (i.e. palliative care provision). HCNs may spend 2 hours per day with a patient or family at the end of life, nurses in acute care may spend 8-12 hrs with a patient and their family. Obviously, practice variation amongst HCPs offers different opportunities and challenges for communication practice. These should be considered when implementing SIC Program in health systems. Finally, health systems change must consider the interrelationship between HCP practice, how physicians and nurses and social workers, for example, can work together to improve communication practice in their care setting. 2.4.4 Document conversation Palliative Home Care Nursing 35 Documenting the conversation is an important task but is often hindered by the limitations of current electronic and paper documentation systems (Lakin et al., 2016). In order to efficiently communicate with inter/intra disciplinary teams, designated electronic medical record documentation system is needed (Ariadne Labs, 2018). Current documentation systems have restricted function in terms of communicating, updating, and sharing SIC or other information. For example, retrieval of previous serious illness conversations could be challenging as there is no specific place to record its occurrence and the outcomes of the conversation in the electronic based documentation system. A more efficient documentation system is required to embed the process in practice and provide easy access to the documentation.  2.4.5 Strengths and Challenges The key strength of the systems change is to focus the program’s sustainability and usability by actively seeking to update the documentation systems. It argues national strategies are needed to assure uniformity of quality care such as funding for education, training, adding incentives for HCPs (Lakin et al., 2017).  Challenges could remain because of inconsistent documentation systems and a pervasive culture viewing the SIC as optional and not required or essential to care. Systematic sustainability may not be feasible if this practice is only dependent upon individual HCP commitment. Bringing forth this conversation as a part of tasks to be completed will influence the intention of how to behave and healthcare professionals will begin to invest time and effort (e.g., attending workshops or requesting resource to get better) to be able to perform the task successfully. Another challenge addressed in the Lakin's et al. study (2017) is a call for incentive-like methods such as adding billing codes or financial incentives. Although it may be Palliative Home Care Nursing 36 promising for doctors adding financial incentives, however, for nurses, skill-oriented strategies (e.g., further training opportunities, systematic mentorship, and evaluation of the SIC practice) are more needed where it is fully supported by the nursing leadership and healthcare policies.    Palliative Home Care Nursing 37 Chapter 4. Implications for Nursing and Interprofessional Practice  The Serious Illness Care Program could be sustained if the program can be supported up by facilitation factors such as time to practice, professional commitment, and organizational support (Rycroft-Malone et al., 2002). Indeed, any significant practice improvement requires the support of leaders in the profession and in the organization (Sherman & Pross, 2010). Implications for policy, leadership, and research are briefly discussed to consider a way forward for advancing serious illness communication as a part of an early palliative approach. 4.1 Implications for Health Policy  An early integration into the palliative approach to care reduces health care cost while improving the quality of care and the experience of patients and families (Canadian Hospice Palliative Care Association, 2014). Serious illness communication is a practical way to deliver a palliative approach to care in non-threatening way at an early disease trajectory (Bernacki et al., 2014). Empirical evidence supports the benefits of early conversations, such as those begun in advance care planning (Zimmermann et al., 2014). Additionally, our population is aging and the need for palliative care will only increase (Thomas, 2006). Investment in palliative care education and system support for nursing and interprofessional practice could be relatively small in comparison to the costs of avoiding these conversations and providing care that people don’t want at the end of life. It is reasonable to support and develop a nationwide policy for a policy which brings cost-efficiencies, positive patients outcomes, and opportunities to support nurses’ professional skill development and satisfaction. In regards to policy of documentation systems, facilitating and incorporating the conversation into palliative care requires a consistent approach (Roeland, 2017), perhaps even more importantly, supporting an organizational culture with policies that recognize SIC as an integral part of all healthcare professional’s responsibility.  Palliative Home Care Nursing 38 4.2 Implications for Leadership To advocate for quality initiatives and policy changes to support point of care healthcare HCPs, leadership is an indispensable component (Rycroft-Malone et al., 2002). Nursing leaders’ positive attitudes and continued commitment is needed to advocate that it is within the nursing scope of practice to engage in expert communication with patient with serious illness (Sherman & Pross, 2010; Phillips & Agar, 2016). Leaders need to support regular workshops to promote expertise in communication practice, provide suitable clinical supports, and facilitate system changes which focus on the update of documentation systems and provide resources supporting the early integration of palliative care (Phillips & Agar, 2016). Facilitating professional commitment to communication practice might be considered by nurses as challenging and stressful. Continuous practical support from nursing leaders and debriefings/case reviews could provide practical suggestions to relieve some emotional tension (Sherman & Pross, 2010; Reed, 2012). Nursing leadership could play a significant part to facilitate organizational support and appropriate policies to support the nursing practice (Sherman & Pross, 2010). For example, one of the commonly identified barriers in communication practice is inadequate resources, such as time (Lakin et al., 2016). It may be feasible to ensure that home care nurses have sufficient protected time to conduct serious illness assessment and communication. 4.3 Implications for Research  Many studies examined barriers and enablers in promoting conversations with patient with serious illness from healthcare HCP perspectives, but only few studies asked patients what their perception are in relation to serious illness communication (Heyland et al., 2006). Interestingly, to my knowledge, there are no studies that examine healthcare HCPs’ outcomes such as job satisfaction or meaning-making of their work in relation to engaging and supporting Palliative Home Care Nursing 39 SIC. I would argue that since communication is an essential part of high quality nursing practice, these meaningful conversations could enrich a nurse’s work experience and provide chances to enhance meaning and therefore promote job satisfaction, reduction of professional burnout or compassion fatigue. Therefore, the SICG program deserves future study of nursing implementation to affirm its efficacy and prove feasibility for nurses, and to examine impact on patients’ health outcomes. Another research implication is to expand serious illness communication education to a wider population, including to the public and include people who may or may not have serious illnesses (see Compassionate Communities work for an example, BC Centre for Palliative Care, 2018b). Such education could generate open and safe opportunities to ask about their beliefs or worries, and share communication skills on how to provide education to help with discussion with families and loved ones and reduce fear of talking about end-of-life plans or concerns. If patients voice their plan to discuss SIC with their respective HCPs, HCPs might be more willing to make an effort to improve their communication skills; such strategies might create “pull” for a behaviour, versus the “push” for behaviour triggered by the Guide or the Workshop. There are many opportunities to broaden our understanding of expertise in serious illness communication.  4.4 Conclusion  An evidence-based tool, education, and appropriate implementation plan are key factors of the process of implementation for changes (Rycroft-Malone et al., 2002). Learning how to use the SIC Guide tool, and practicing to improve serious illness communication skills in a setting where nurses feel comfortable, may allow HCNs to feel safe, explore their own struggles and worries, and ultimately help them to develop an expert communication practice. In addition to regularly offered training, the use of mentorship, case studies, and formal/informal debriefing Palliative Home Care Nursing 40 could also contribute to skill development and enhancement (Marie Block, L., Claffey, C., Korow, M. K., & McCaffrey, R., 2005; Popil, 2011; Reed, 2012). I believe the multicomponent training program with systems changes could facilitate positive outcomes and support the training program’s adaptability and sustainability in healthcare, including nursing practice. In addition, a continuous evaluation strategy for quality measurement and improvements in palliative care could allow us to identify incremental improvements to the program.  The Serious Illness Conversation Program is an integral program to improve communication practice and nurses satisfaction in their professional role (Nordby, 2017). Preparing patients and their families for the end-of-life requires that nurses and other health care HCPs create a sense of connection between the caregiver and the care receiver; communication is the route to this therapeutic relationship. The tool, the workshop, and systems changes are a promising way of promoting in implementing and advancing the SIC skills into practice through the support of policy, research, and leadership to improve quality of care.             Palliative Home Care Nursing 41 References  Ajzen, I. (1991). The theory of planned behaviour. Organizational Behaviour and Human Decision Processes, 50(2), 179-211. 10.1016/0749-5978(91)90020-T Ajzen, I. (2002). Perceived behavioural control, Self-Efficacy, locus of control, and the theory of planned behaviour. Journal of Applied Social Psychology, 32(4), 665-683. 10.1111/j.1559-1816. 2002.tb00236.x Ajzen, I. (2011). The Theory of Planned Behaviour: Reactions and reflections. Psychology & Health, 26(9), 1113-1127. 10.1080/08870446.2011.613995 Aslakson, R. A., Wyskiel, R., Thornton, I., Copley, C., Shaffer, D., Zyra, M., . . . Pronovost, P. J. (2012). Nurse-perceived barriers to effective communication regarding prognosis and optimal end-of-life care for surgical ICU patients: A qualitative exploration. Journal of Palliative Medicine, 15(8), 91-915. doi:10.1089/jpm.2011.0481 Ariadne Labs, 2015-2017. Serious Illness Conversation Guide. Retrieved from https://www.ariadnelabs.org/wp-content/uploads/sites/2/2018/04/Serious-Illness-Conversation-Guide.2017-04-18CC2pg.pdf Ariadne Labs (2018). Serious illness care. Retrieved from https://www.ariadnelabs.org/areas-of-work/serious-illness-care/research/ Banerjee, S., Manna, R., Coyle, N., Shen, M., Pehrson, C., Zaider, T., . . . Bylund, C. (2015). Oncology nurses' communication challenges with patients and families: A qualitative study.Nurse Education in Practice, 16(1), 193-201. doi:10.1016/ j.nepr.2015.07.007 BC Centre for Palliative Care. (2018a). Serious Illness Conversations. Retrieved from,  https://www.bc-cpc.ca/cpc/serious-illness-conversations/  Palliative Home Care Nursing 42 BC Centre for Palliative Care. (2018b). Compassionate Communities. Retrieved from,  https://www.bc-cpc.ca/cpc/compassionate-communities/   Benzein, E., Norberg, A., & Saveman, B. (2001). The meaning of the lived experience of hope in patients with cancer in palliative home care. Palliative Medicine, 15(2), 117-126. doi:10.1191/026921601675617254 Bernacki, R. E., Block, S. D., & American College of Physicians High Value Care Task Force. (2014). Communication about serious illness care goals: A review and synthesis of best practices. JAMA Internal Medicine, 174(12), 1994-2003. doi:10.1001/jamainternmed.2014.5271 Bramhall, E. (2014). Effective communication skills in nursing practice. Nursing Standard (Royal College of Nursing (Great Britain): 1987), 29(14), 53. Brumley, R., Enguidanos, S., Jamison, P., Seitz, R., Morgenstern, N., Saito, S., . . . Gonzalez, J. (2007). Increased satisfaction with care and lower costs: Results of a randomized trial of In-Home palliative care. Journal of the American Geriatrics Society, 55(7), 993-1000. doi:10.1111/j.1532-5415.2007.01234.x Canadian Association of Critical Care Nurses (2011), Position Statement, Providing End of Life Care in the Intensive Care Unit. Retrieved from  https://www.caccn.ca/pdfs/CACCN%20End%20of%20Life%20Care%20Jan%2019%202011.pdf Canadian Hospice Palliative Care Association (2014), Fact Sheet : Hospice Palliative Care in Canada, Retrieved from, http://www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf Palliative Home Care Nursing 43 Canadian Nurses Association (2017). Code of ethics for registered nurses. Retrieved from https://www.cna-aiic.ca/-/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secure-interactive.pdf?la=en&hash=09C348308C44912AF216656BFA31E33519756387 Chochinov, H. M. (2002). Dignity-conserving care: A new model for palliative care. (perspectives on care at the close of life). JAMA, the Journal of the American Medical Association, 287(17), 2253. Comer, S. K. (2005). Patient care simulations: Role playing to enhance clinical understanding. Nursing Education Perspectives, 26(6), 357. Connolly, M., Perryman, J., McKenna, Y., Orford, J., Thomson, L., Shuttleworth, J., & Cocksedge, S. (2009;2010;). SAGE & THYME™: A model for training health and social care professionals in patient-focused support. Patient Education and Counselling, 79(1), 87-93. 10.1016/j.pec.2009.06.004 Coyle, N., Manna, R., Shen, M., Banerjee, S., Penn, S., Pehrson, C., . . . Bylund, C. (2015). Discussing death, dying, and end-of-life goals of care: A communication skills training module for oncology nurses. Clinical Journal of Oncology Nursing, 19(6), 697-702. doi:10.1188/15.CJON.697-702 Detering, K. M., Hancock, A. D., Reade, M. C., & Silvester, W. (2010). The impact of advance care planning on end of life care in elderly patients: Randomized controlled trial. Bmj, 340(7751), 847-847. doi:10.1136/bmj.c1345 Dunne, K., Sullivan, K., & Kernohan, G. (2005). Palliative care for patients with cancer: District nurses’ experiences. Journal of Advanced Nursing, 50(4), 372-380. doi:10.1111/j.1365-2648.2005.03402.x Palliative Home Care Nursing 44 Fillion,L., Dupuis, R., Tremblay, I., De Grace, G., & Breitbart, W. (2006). Enhancing meaning in palliative care practice: A meaning-centered intervention to promote job satisfaction. Palliative and Supportive Care, 4(4), 333-344. doi:10.1017/S1478951506060445 French, S., Green, S., O'Connor, D., McKenzie, J., Francis, J., Michie, S., . . . Grimshaw, J. (2012). Developing theory-informed behaviour change interventions to implement evidence into practice: A systematic approach using the theoretical domains framework. Implementation Science, 7(1), 38-38. doi:10.1186/1748-5908-7-38 Griffiths, J., Ewing, G., & Rogers, M. (2010). "moving swiftly on." psychological support provided by district nurses to patients with palliative care needs. Cancer Nursing, 33(5), 390-397. doi:10.1097/NCC.0b013e3181d55f9b Griffiths, J., Wilson, C., Ewing, G., Connolly, M., & Grande, G. (2015). Improving communication with palliative care cancer patients at home - A pilot study of SAGE & THYME communication skills model. European Journal of Oncology Nursing, 19(5), 465-472. doi:10.1016/j.ejon.2015.02.005 Frasr Health. (2018). Advance care planning. Retrieved from https://www.fraserhealth.ca/health-info/health-topics/advance-care-planning/ Heyland, D. K., Dodek, P., Rocker, G., Groll, D., Gafni, A., Pichora, D., . . . Canadian Researchers End-of-Life Network(CARENET). (2006). What matters most in end-of-life care: Perceptions of seriously ill patients and their family members. Canadian Medical Association Journal, 174(5), 627-U1. doi:10.1503/cmaj.050626 Heyland, D. K., Allan, D. E., Rocker, G., Dodek, P., Pichora, D., Gafni, A., & Canadian Researchers at the End-of-Life Network (CARENET). (2009). Discussing prognosis with Palliative Home Care Nursing 45 patients and their families near the end of life: Impact on satisfaction with end-of-life care.Open Medicine : A Peer-Reviewed, Independent, Open-Access Journal, 3(2), e101. Heyland, D. K., Barwich, D., Pichora, D., Dodek, P., Lamontagne, F., You, J. J., . . . ACCEPT (Advance Care Planning Evaluation in Elderly Patients) Study Team. (2013). Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Internal Medicine, 173(9), 778-787. doi:10.1001/jamainternmed.2013.180 Jackson, V. A., & Back, A. L. (2011). Teaching Communication Skills Using Role-Play: An Experience-Based Guide for Educators. Journal of Palliative Medicine, 14(6), 775–780. http://doi.org/10.1089/jpm.2010.0493 Kourkouta, L., & Papathanasiou, I. V. (2014). Communication in nursing practice. Materia Socio-Medica, 26(1), 65. doi:10.5455/msm.2014.26.65-67 Lakin, J., Block, S., Billings, J., Koritsanszky, L., Cunningham, R., Wichmann, L., . . . Bernacki, R. (2016). Improving communication about serious illness in primary care. Jama Internal Medicine, 176(9), 1380-1387. doi:10.1001/jamainternmed.2016.3212 Lakin, J., Koritsanszky, L., Cunningham, R., Maloney, F., Neal, B., Paladino, J., . . . Bernacki, R. (2017). A systematic intervention to improve serious illness communication in primary care. Health Affairs, 36(7), 1258-1264. doi:10.1377/hlthaff.2017.0219 Légaré, F., Stacey, D., Pouliot, S., Gauvin, F., Desroches, S., Kryworuchko, J., . . . Graham, I. D. (2011). Interprofessionalism and shared decision-making in primary care: A stepwise approach towards a new model. Journal of Interprofessional Care, 25(1), 18-25. doi:10.3109/13561820.2010.490502 Liaschenko, J., & Fisher, A. (1999). Theorizing the knowledge that nurses use in the conduct of their work. Scholarly Inquiry for Nursing Practice, 13(1), 29. Palliative Home Care Nursing 46 Lichtenthal, W. G., & Kissane, D. W. (2008). The management of family conflict in palliative care. Progress in Palliative Care, 16(1), 39-45. doi:10.1179/096992608X296914 Mack, J. W., Cronin, A., Keating, N. L., Taback, N., Huskamp, H. A., Malin, J. L., . . . Weeks, J. C. (2012). Associations between end-of-life discussion characteristics and care received near death: A prospective cohort study. Journal of Clinical Oncology, 30(35), 4387-4395. 10.1200/JCO.2012.43.6055 Marie Block, L., Claffey, C., Korow, M. K., & McCaffrey, R. (2005). The value of mentorship within nursing organizations. Nursing Forum, 40(4), 134-140. doi:10.1111/j.1744-6198.2005.00026.x Morris, C. (2003). Teaching and learning through active observation. Retrieved from https://faculty.londondeanery.ac.uk/e-learning/feedback/files/T-L_through_active_observation.pdf Nordby, H. (2017). Concept communication and interpretation of illness: A holistic model of understanding in nursing practice. Holistic Nursing Practice, 31(3), 158-166. 10.1097/HNP.0000000000000204 Norton, S. A., Metzger, M., DeLuca, J., Alexander, S. C., Quill, T. E., & Gramling, R. (2013). Palliative care communication: Linking patients' prognoses, values, and goals of care.Research in Nursing & Health, 36(6), 582-590. doi:10.1002/nur.21563 Oelofsen, N. (2012). Using reflective practice in frontline nursing. England: Emap Limited Offen, J. (2015). The role of UK district nurses in providing care for adult patients with a terminal diagnosis: A meta-ethnography. International Journal of Palliative Nursing, 21(3), 134-141. doi:10.12968/ijpn.2015.21.3.134 Palliative Home Care Nursing 47 Oudshoorn, A., Ward-Griffin, C., & McWilliam, C. (2007). Client–nurse relationships in home-based palliative care: A critical analysis of power relations. Journal of Clinical Nursing, 16(8), 1435-1443. doi:10.1111/j.1365-2702.2006.01720.x Parle, M., Maguire, P., & Heaven, C. (1997). The development of a training model to improve health professionals' skills, self-efficacy and outcome expectancies when communicating with cancer patients. Social Science & Medicine, 44(2), 231-240. 10.1016/S0277-9536(96)00148-7 Phillips, J. L., & Agar, M. R. (2016). Exemplary nursing leadership is central to improving care of the dying. Journal of Nursing Management, 24(1), 1-3. doi:10.1111/jonm.12353 Popil, I. (2011). Promotion of critical thinking by using case studies as teaching method. Nurse Education Today, 31(2), 204-207. doi:10.1016/j.nedt.2010.06.002 Reed, S. J. (2012). Debriefing experience scale: Development of a tool to evaluate the student learning experience in debriefing. Clinical Simulation in Nursing, 8(6), e211-e217. doi:10.1016/j.ecns.2011.11.002 Roeland, E. (2017). Tailoring palliative care to the changing needs of people facing cancer. Journal of Clinical Oncology, 35(8), 813-U179. 10.1200/JCO.2016.71.2174 Rycroft-Malone, J., Kitson, A., Harvey, G., McCormack, B., Seers, K., Titchen, A., & Estabrooks, C. (2002). Ingredients for change: Revisiting a conceptual framework. Quality & Safety in Health Care, 11(2), 174-180. doi:10.1136/qhc.11.2.174 Richards, D. A., Hilli, A., Pentecost, C., Goodwin, V. A., & Frost, J. (2018). Fundamental nursing care: A systematic review of the evidence on the effect of nursing care interventions for nutrition, elimination, mobility and hygiene. Journal of Clinical Nursing, 27(11-12), 2179-2188. doi:10.1111/jocn.14150 Palliative Home Care Nursing 48 Scott, P., Vlimki, M., Leino-Kilpi, H., Dassen, T., Gasull, M., Lemonidou, C., & Arndt, M. (2003). Autonomy, privacy and informed consent 1: Concepts and definitions. British Journal of Nursing, 12(1), 43-47. doi:10.12968/bjon.2003.12.1.10999 Sherman, R., & Pross, E. (2010). Growing future nurse leaders to build and sustain healthy work environments at the unit level. Online Journal of Issues in Nursing, 15(1), 1F. Slawinski, T. (2006). A strengths-based approach to crisis response. Journal of Workplace Behavioural Health, 21(2), 79-88. doi:10.1300/J490v21n02_06 Stajduhar, K. I. (2011). Chronic illness, palliative care, and the problematic nature of dying.The Canadian Journal of Nursing Research = Revue Canadienne De Recherche En Sciences Infirmières, 43(3), 7 Tomas K. (2006), 16 Community palliative care, retrieved from https://www.goldstandardsframework.org.uk/cd-content/uploads/files/Library%2C%20Tools%20%26%20resources/ABC%20Palliative%20Care.pdf Udod, S. (2014). Seeking connectivity in nurses' work environments: Advancing nurse empowerment theory. Canadian Journal of Nursing Research, 46(3), 1. Weiss, T., & Berger, R. (2010). The posttraumatic growth model: Sociocultural considerations. (pp. 1-14). Hoboken, NJ, USA: John Wiley & Sons, Inc. doi:10.1002/9781118270028.ch1 Whitehead, P., & Carter, K. (2017). A model for meaningful conversation in serious illness and the patient preferences about serious illness instrument. Journal of Hospice & Palliative Nursing, 19(1), 49-53. doi:10.1097/NJH.0000000000000307 Palliative Home Care Nursing 49 Wittenberg-Lyles, E., Goldsmith, J., & Platt, C. S. (2014). Palliative care communication. Seminars in Oncology Nursing, 30(4), 280-286. doi:10.1016/j.soncn.2014.08.010 Wittenberg, E., Ferrell, B., Goldsmith, J., Buller, H., & Neiman, T. (2016). Nurse Communication About Goals of Care. Journal of the Advanced Practitioner in Oncology, 7(2), 146–154. Wotton, K., Davis, J., Button, D., & Kelton, M. (2010). Third-year undergraduate nursing students' perceptions of high-fidelity simulation. Journal of Nursing Education, 49(11), 632-639. doi:10.3928/01484834-20100831-01 Wright, L. M., & Leahey, M. (1999). Maximizing time, minimizing suffering: The 15-minute (or less) family interview. Journal of Family Nursing, 5(3), 259-274. doi:10.1177/107484079900500302 Wright, A. A., Zhang, B., Ray, A., Mack, J. W., Trice, E., Balboni, T., . . . Prigerson, H. G. (2008). Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. Jama, 300(14), 1665-1673. 10.1001/jama.300.14.1665 Zhou, G., Stoltzfus, J. C., Houldin, A. D., Parks, S. M., & Swan, B. A. (2010). Knowledge, attitudes, and practice behaviours of oncology advanced practice nurses regarding advanced care planning for patients with cancer. Oncology Nursing Forum, 37(6), E400-E410. doi:10.1188/10. ONF.E400-E410 Zimmermann, C., Dr, Swami, N., BSc, Krzyzanowska, M., MD, Hannon, B., MBChB, Leighl, N., MD, Oza, A., Prof, . . . Lo, C., PhD. (2014). Early palliative care for patients with advanced cancer: A cluster-randomized controlled trial. Lancet, the, 383(9930), 1721-1730. doi:10.1016/S0140-6736(13)62416-2 

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