Dorothy J. Wholihan

Abstract

BACKGROUND: Advanced practice registered nurses (APRNs) are essential to care for the growing number of individuals with advanced illness given the shortage of palliative care clinicians. PROBLEM: Graduate education for specialty practice palliative APRNs lacks consistency in structure, content, and standardization of specialty palliative APRN education. APPROACH: A workgroup of expert palliative APRNs and graduate faculty conducted focused discussions and a literature review to develop consensus recommendations based on national palliative APRN competencies and aligned with the 8 core concepts of the AACN Essentials. OUTCOME: Recommendations include: (a) definition of core concepts; (b) associated skills; (c) andragogical approaches; (d) evaluation methods; and (e) references for curricular development. CONCLUSION: The Recommendations for Specialty Palliative APRN Education is a first step toward the standardization of quality advanced practice specialty palliative nursing education. These recommendations provide the foundation for a comprehensive curriculum for palliative APRNs.

Abstract

Introduction: Caring for families experiencing perinatal loss is a fundamental component of midwifery practice, but little attention is paid to perinatal palliative care in midwifery curricula. Lack of educational preparation and self-care resources negatively impacts midwifery students and health care teams caring for families experiencing stillbirth. Process: A private, urban university conducted a curricular quality improvement project to integrate perinatal palliative care into the midwifery curriculum using a high-fidelity, branching simulation pedagogy. Simulation objectives were developed from curricular gap analyses and the Core Competencies for Basic Midwifery Practice. Development of the Unexpected Perinatal Loss Simulation was guided by the International Nursing Association for Clinical Simulation and Learning Outcomes and Objectives and Design Standards. The Unexpected Perinatal Loss Simulation was revised based on qualitative data from student focus groups and expert content validation. Outcomes: Qualitative data yielded 4 key domains: presimulation, simulation skills, prior experience/personal reflections, and recommendations. Simulation procedures and scenario content were revised, after which 8 expert clinicians in the fields of midwifery, palliative care, and psychiatry validated the scenario content using the Lynn method. Two items did not meet the content validity index (CVI) threshold of 0.78, necessitating review by stakeholders; however, the overall scenario CVI threshold was met (0.82). Discussion: Through this project, faculty integrated perinatal palliative care into the midwifery program using a novel approach of high-fidelity, branching simulation, structured debriefing, and an introductory self-care skills workshop. Potential clinical impact includes skillful perinatal palliative care with effective communication skills to mitigate how families experience and remember a traumatic loss and facilitate the grieving process. Students voiced insights into how they would process loss and seek support to mitigate their own grief as future midwives.

Abstract

Preoperative frailty is strongly associated with risks of postoperative delirium. However, gaps exist in targeted recommendations for clinical decision making related to surgical interventions in frail older patients. A case study is presented involving a frail 74-year-old referred to the palliative care team for assistance with clinical decision making and in weighing risks and benefits of a surgical intervention. A literature review on the quantification of postoperative delirium risk and how this information might inform medical decision making in frail surgical patients did not identify clear clinical guidelines. In the absence of practice guidelines, the Patient Priorities Care model is proposed as a framework to help providers working with patients and caregivers facing complex medical decisions to better align interventions with patient values.