'Hopefulness' contributes to good end-of-life care

More education and experience also are benefits

Researchers at a large children's hospital found that nurses who were comfortable working with dying children and their families were also nurses who reported high levels of hopefulness.1

"The study was prompted by our desire to see why it appeared that some nurses were more comfortable with end-of-life care and, in particular, talking to the families and having difficult conversations with them," says Gina Santucci, MSN, RN, nursing coordinator, Pediatric Advanced Care Team (PACT) of the Children's Hospital of Philadelphia.

Investigators analyzed nurses' work experience, education levels, and hopefulness, and compared these to their self-assessment of competence in palliative care.

The study found that nurses with more nursing experience tended to express higher levels of comfort working with dying children and their families, and the same was true with nurses who had more years of education and higher levels of hopefulness, according to the Adult Dispositional Hope Scale.

Santucci wanted to include "hopefulness" in the study due to her own personal experiences as a nurse.

"I've worked on the floor and taken care of patients, and when I look back at my experiences, I can remember situations where I didn't feel hopeful about what I was doing," Santucci says. "Then there were other experiences that were equally difficult, but I felt everything was working well, and I felt hope had something to do with it."

The study was a web-based questionnaire, and 932 nurses at the hospital were invited to participate, via e-mail. Nurses also were reminded of the survey at staff meetings.

In all, 410 nurses completed the questionnaire, which is a 44% response rate, Santucci says, adding, "We were happy that the response rate was over 20%.

"Our most substantial finding was with education, specifically, palliative care; that was the highest," she says.

Nurses who had more hours of palliative care education were the most comfortable in providing palliative care and talking about death and dying with their patients and families, Santucci says.

The web-based survey included these kinds of questions — asking for a rating from four, which means extremely competent to zero, meaning not competent — to assess a nurse's opinion of her/his own competency in each of these areas:

  • proving nursing interventions to improve the child's quality of life;
  • managing pain;
  • managing other symptoms;
  • talking with children and families about dying;
  • emphasizing goals, not limitations;
  • understanding the role of hospice;
  • recognizing impending death;
  • understanding advance directives;
  • being sensitive to spiritual needs;
  • being sensitive to cultural values and issues;
  • understanding ethical issues surrounding end-of-life care; and
  • knowing where to find help within the hospital when faced with an ethical dilemma.

Also, nurses with the most education reported feeling more competent, she adds.

The second highest correlation was between experience and feelings of comfort and competence in dealing with dying patients.

Researchers found that nurses with more experience expressed being comfortable with talking to dying patients and their families, Santucci says.

"But once nurses had five to six years of experience, their comfort level hit a plateau," she adds. "Also, their difficulty in talking with families was higher if they were new nurses, and would gradually decrease with years of practice, reaching a plateau at about 10 years of practice."

The study found that there also was a slight increase in comfort with higher levels of hope, Santucci says.

"With increased hopefulness, there was a significant decrease in difficulty in talking to families about end-of-life challenges, and there was a slight increase in confidence," she says.

While the solution is fairly obvious with education and experience, enhancing hopefulness among nurses is more of a challenge, Santucci says.

"The question is, 'How do you engender hope and how do you change things to make nurses more hopeful?'" Santucci says. "How do you eliminate those things we do to take away hope."

There likely will be another study that looks at this issue, she adds.

"My ideas are that when people are dying at home, sometimes they get less and less visitors because people are not comfortable around death," Santucci says.

Although nurses in a children's hospital are wonderful, it's difficult sometimes for them to sit and be with a family, not saying much, but just being present, she explains.

"It's having an understanding of what the family may want, and that can only be done when you sit and listen for a long time," Santucci says. "It's hard to express, but when a child is dying, knowing what you need to do and being in tune with the child and family takes a lot of time, and it's difficult for everybody."


1. Feudtner C, et al. Hopeful thinking and level of comfort regarding providing pediatric palliative care: A survey of hospital nurses. Pediatrics. 2007;119:e186-e192.