DEVELOPMENT OF A PALLIATIVE SUPERUSER EDUCATIONAL
CURRICULUM TO IMPROVE NURSES’ COMFORT AND
KNOWLEDGE IN THE PROVISION OF END-OF-LIFE-CARE: A
HOSPITAL BASED QI PROJECT
By
Alyssa Solimene
MSN, University of Medicine and Dentistry of New Jersey, 1999
BSN, Rutgers the State University of New Jersey, 1989

Pennsylvania Western University
250 University Avenue
California, PA 15419
A DNP Research Project Submitted to Pennsylvania Western University
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
July, 2022

7/28/2022
____________
Date
____________
Date
____________
Date
7/29/22
____________
Date

______________________________________________________
Committee Chair
______________________________________________________
Committee Member
______________________________________________________
Committee Member
______________________________________________________
Dean, College of Health Sciences

TITLE OF DNP RESEARCH PROJECT
Committee Signature Page
Student’s name Alyssa Solimene
Committee Chairperson Dr. Donna Falsetti
Committee Member Dr. Tara Orgon-Stamper
Committee Member Dr. Elise Powell

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

2

DEVELOPMENT OF A PALLIATIVE SUPERUSER EDUCATIONAL CURRICULUM TO
IMPROVE NURSES’ COMFORT AND KNOWLEDGE IN THE PROVISION OF END-OFLIFE CARE: A HOSPITAL-BASED QI PROJECT.
Abstract
Patients who are receiving comfort-directed care at the end of their lives will be cared for by
nurses throughout their hospital stay. Providing bedside end-of-life care requires specialty
assessment, communication, and intervention skills. Nurses who provide bedside end-of-life care
in the acute care setting may not receive specialty palliative care training as part of their
undergraduate education. To address this an educational curriculum was designed by members of
the Palliative Care team and a Palliative Superuser training program was developed. Guided by
the Comfort ALways Matters (CALM) framework the course focused on specialized assessment
and symptom management, holistic approaches to patients and their caregivers, and
communication instruction. Course description is a four-hour workshop presented by certified
registered nurse practitioners from the inpatient palliative care team. Nurses who complete the
superuser training will act as mentors to their peers and will continue to receive educational
updates every two months. A goal of training ten percent of nurses in the acute hospital setting
was set. Individual class size is limited to 10 attendees to facilitate small group discussion.
Program availability was advertised by email and flyer to the managers of all inpatient units.
Nurses who expressed interest and volunteered to attend were chosen by their managers and
enrolled in the class. Pre- and post- testing of nurses who volunteered for the training revealed
improvement in knowledge, confidence, and comfort in providing end of life care after

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

3

completing the initial training session. Early positive results of the QI initiative suggested that
ongoing training will be valuable to the institution and the patients.
Introduction
Dying while hospitalized may be sudden and unexpected, but for some patients an inhospital death may not be unexpected. Patients who have been diagnosed with a chronic
progressive disease, which may cause recurrent episodes of exacerbation and recovery with
progression over many years, have likely experienced numerous trips to the hospital with
shortening periods of stability separating them, eventually resulting in the inability to recover.
Other patients may have been admitted to the hospital with a new and life-threatening diagnosis;
stroke, heart attack, trauma, infection, or sepsis from which there is a low survival probability, or
if survivable, will result in marked decline in level of function or quality of life, with a
diminished recovery potential. Patients with metastatic cancer who have been receiving cancerdirected treatments may find that the disease has progressed despite treatment or that the
emotional and physical cost may be too great to continue to pursue treatments, even if available.
A timely example includes people who received aggressive treatment for COVID-19 pneumonia
and have been maintained on life-support and who either continue to decline or show no signs of
recovery despite aggressive medical interventions. These patients often benefit from having a
consultation from the palliative care team to facilitate an exploration of goals of care.
The Center to Advance Palliative Care (CAPC) reports that 75% of hospitals larger than
50 beds has an inpatient PC team. PC teams are groups of specialists who become involved as
consultants most commonly to establish and clarify overall goals of care with patients and their
loved ones (CAPC, 2018). The patient and their loved ones are given information about the
diagnosis, treatment options, potential outcomes, and prognosis. The possibility of this being the

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

4

patient’s final admission is recognized. A distinction that can be explored is that life-prolonging
care is used to extend the amount of time someone stays alive, often at the expense of comfort.
Comfort-directed care aims to maximize the quality and comfort of the time remaining
(Blinderman & Billings, 2015).
Approximately 6 percent of all inpatient hospital admissions have had a consult order
placed for Palliative Care (Rogers 2019). Palliative Care consults are most commonly used to
explore and elicit what the treatment priorities are for this sickest subset of patients. The role of
the palliative care team is to establish rapport with patients and their families. A provider trained
in palliative care can provide clarity about medical or surgical diagnosis, review current
treatment options, provide prognostication, and explore and establish personal priorities to
establish the goals of care for an individual. A palliative care consultation seeks to assist patients
in acknowledging their priorities, in the face of the severity of the situation they find themselves
in. This discussion can sometimes only be held with others who know the patient well, or who
have been appointed to speak on their behalf due to the severity of illness or injury. Establishing
priorities allows for goal-setting, and treatment plans can follow.
Avoidance of suffering, not being reliant on machines, reducing burden on family,
retention of dignity and independence in decision-making are frequently cited priorities offered
by patients and their families. When comfort is established as the primary goal, treatment will be
provided to relieve suffering and promote comfort. The focus of comfort-directed care is the
relief of suffering, treating uncomfortable end of life symptoms. Ultimately the goal is to allow a
natural death while assuring maximum comfort, without attempts to hasten nor delay the
outcome (Powazki, et al., 2014).

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

5

Consultation with palliative specialists enables the care teams to provide care to patients
and families that they find most meaningful in the face of severe illness, or limited prognosis.
These patients are frequently too ill or unstable to leave the acute care environment, some will
have life-support withdrawn during their stay and have a life expectancy limited to just minutes
or hours. Others may have a longer life expectancy but have a higher symptom burden which
require management in an acute care setting. If a patient and their loved ones determine that their
goal is to have care focused on quality of time over quantity, changes are made in the medical
record to identify the patient as someone who prioritizes comfort-directed care documented as
“Comfort Measures Only”, or “CMO”. Establishing comfort as the goal of care allows for
patients to receive care solely focused on maintaining and promoting their comfort, without
treatments to prolong their lives. Families are encouraged to visit or stay with the patient who is
moved to a private room. A liberal diet for pleasure is provided, and adjustments that encourage
peaceful time to spend with family without interruption. are some of the institutional changes
that are made.
Once a decision to pursue comfort-directed care is made, the primary admitting team and
other consultants are notified and will subsequently discontinue treatments, and examinations
that are no longer beneficial given the change in goals of care. If a patient was dependent on life
support, a plan to liberate them from machines is made with comfort as the guiding principle.
The palliative care team remains involved in the ongoing care of patients who have chosen a
comfort-directed approach. In addition to the primary admitting team, the palliative consultants
will perform a chart review and medication reconciliation and then place orders for medications
and interventions to relieve uncomfortable symptoms at end of life to ensure continued relief in
the medical record.

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

6

Bedside nurses are tasked with providing care which can feel wholly different than usual
bedside nursing care. Nursing care in an acute care hospital is focused on performing and
documenting assessments, providing ordered medications and treatments, facilitating ordered
testing, and engaging with families, patients, and treatments teams. Nurses are skilled in
therapeutic communication, advanced assessment skills, and safe medication administration. The
care of patients who have elected comfort-directed care requires the same skillset but may feel
different to the nurse. The basic tenets of bedside nursing care remain unchanged. The nurse at
the bedside will continue to assess, treat, and facilitate care for patients in much the same way –
with comfort as the goal of care (Bloomer, et at., 2013).
Nurses find themselves having to switch their professional approach to a patient they
know well, or to become involved in care for a patient new to them who requires specialized
nursing care at the end of their lives. Nursing roles in providing comfort measures to patients
includes scheduled and as-needed medication administration, eliminating intrusive and
burdensome routine care practices, establishing a comfortable and quiet environment for care,
and communicating clearly to provide anticipatory guidance of the dying process to patients and
their loved ones. Ultimately the goal is to allow a natural death while assuring maximum
comfort, without attempts to hasten nor delay the outcome (Powazki, et al., 2014).
In the 450-bed quaternary referral acute care hospital located in an urban setting, the
palliative care team observed instances when patients who were admitted under CMO status and
nearing the end of their lives may not have received effective doses of medications, frequent
enough assessments, or the same level of nursing attention when compared to earlier during the
hospital stay. Informal discussions on the floors revealed a level of discomfort and worry with
providing care for patients at the end of their lives. Informal feedback from nurses who

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

7

expressed frustration with an inability to provide quality end of life care was communicated to
members on the palliative care team as well. Frequently cited reasons are inexperience, lack of
training, short-staffing, and emotional concerns. An educational offering, known as the Palliative
Superuser Workshop was developed to address this as a means of promoting nurses’ confidence,
improving knowledge, and establishing a mentorship program specifically for end-of-life care.
Managers expressed enthusiasm for this novel training approach, and provided support for the
program. The concept of the super user role is borrowed from Information Technology, “The
term super user is a widely accepted concept within the world of IT.The key quality of a super
user is to act as a change agent in the organization. They are incredibly valuable if fundamental
changes to the known way of working are going to be made. A super user is an internal expert on
a system (Mitchell, 2020)”. Characteristics of superusers in information technology are those
who are open-minded and ready for change, who are patient with others, enjoy positive social
capital with their peers, are confident early-adopters and are eager to learn (Boffa & Pawola,
2006).
The World Health Organization (2015) defines palliative care as an approach that
improves the quality of life for patients and families who are facing a life-threatening illness that
can begin at the time of initial diagnosis through the end of life, along with curative efforts, and
can facilitate the transition to comfort-based care in the face of disease progression. The Institute
of Medicine’s 2014 paper “Dying in America” identifies the basic skills required of nurses that
include communication, interprofessional collaboration, and expertise in symptom management.
The American Nurses’ Association (ANA) and the Hospice and Palliative Nurses Association
(HPNA) published a joint Call to Action in 2017 for nurses to lead and transform palliative care.
This call-to-action highlighted areas of training opportunities for practicing nurses to enhance

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

8

communication skills, identify and explore goals of care, and to become proficient and confident
in the management of end-of-life symptoms. The Superuser QI program was developed to
answer the call, to improve access for nursing education in palliative care, and to provide
organizational foundational support that promotes a culture of change that allows bedside nurses
to become palliative care champions (ANA, HPNA, 2017).
This call to action supports the development and implementation of the palliative
superuser program. This quality improvement project seeks to enhance the knowledge and skills
of bedside nurses. A dual effect of improved end of life experiences for patients and their loved
ones as well as a positive effect on the nursing culture in caring for dying patients is anticipated
when superuser trained nurses can begin to mentor their peers. Nurses are the key workers in a
system that cares for patients approaching death in the acute care setting. The nurse will be
present with the patient and their loved ones in their last hours and minutes. End-of-life clinical
competency is critical for excellence in end-of-life care. Nurses manage the symptom burden at
the bedside, which often includes more severe and frequent symptoms such as pain, anxiety, and
dyspnea, for dying patients (Martin-Rosello, et al., 2018). The responsibility for promoting
comfort and providing relief relies on the strength of the nurses’ assessment and intervention
skills (McGuire, et al., 2016). Competent assessment of patients and identification of patient
needs direct the use of ordered medications and interventions to promote relief and reduction in
symptom burden (Stacy, et al., 2019). The skillful identification and effective treatment of neardeath symptoms is the aim of competent and compassionate nursing care (Teno, et al., 2021).
Relief of suffering fosters dignity and allays anxiety for patients at the end of their lives.
When caring for patients at the end of their lives, the primary nursing competencies of
communication, advocacy, and symptom management involve skillful assessment and

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

9

responsive treatment of physical, emotional, and spiritual health. Barriers to improved nurse
engagement with palliative care includes lack of knowledge and familiarity with palliative care;
end-of-life care planning, symptom management, lack of prognostic clarity, and indeterminate
role identification (Hagan, et al., 2018). Nurses’ scope of practice includes the care of patients at
the end of their lives, yet many undergraduate training programs lack specific information about
the specialized care of dying patients. Insufficient training, inconsistent administrative support,
and staffing concerns for bedside end-of-life care frequently act as barriers to nurses providing
effective and responsive bedside palliative care (Frey, et. al., 2014).
A meta synthesis of research between 1990 and 2013 explored the effects of teamwork
education in acute care hospitals. Results included that, in addition to an organizational culture
that fosters teamwork, an increase in education improves the baseline knowledge of healthcare
providers. Education of team members should be practical and include authentic learning
opportunities with time to reflect and debrief. Interactional training including role play and
simulation adds to confidence and motivation after training, and improved knowledge increases
daily practice competence (Eddy, et al., 2016).
Adequate symptom management is essential to providing quality end of life care.
Surveying nurses’ perceptions of end-of-life medication use at end of life was undertaken and
published by Howes in 2015. Using seven focus groups of nurses (n=22), factors affecting
medication use, symptom identification, assessment, and familiarity with the medication were
explored. Results revealed that a main barrier to provision of quality symptom management at
end of life is fear surrounding the medication effects potentially hastening death, adverse
reactions, and risk of medication errors (specifically with pain pumps). Care interventions are
guided by empathetic alignment with patients’ suffering and the provision of relief through

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

10

understanding the use of medications and they are crucial to improving the experience of patients
who die in the hospital (Howes, 2015). Emotional conflicts related to the transition in goals of
care for patients from curative to palliative may also be a barrier to providing adequate and
responsive end-of-life care. It was included that primary identification of symptoms is a first step
to appropriate medication delivery in end-of-life care. The research also indicated that increased
and ongoing education, specifically via a mentorship model drives improvement in nurses’
ability to provide end of life care (Howes, 2015).
In Sweden a palliative care guide was developed as a clinical decision support tool for
nurses to improve the provision of high quality personalized palliative care. The four elements of
good palliative care identified were: 1) identification and assessment of palliative care needs, 2)
guidance in exploration of goals of care and advance care planning, 3) symptom and needsoriented care based on evidence, and 4) focus on provision of bereavement care to families. Pilot
testing of the tool conducted on 34 units for 250 patients resulted in a significant reduction in
suffering and improved quality of life (Birgisdottir et al, 2021). Results support the need for
early integration of palliative care competency training and education for nurses and healthcare
workers caring for patients at the end of their lives.
White and Meeker (2019) published a qualitative descriptive analysis of 26 semistructured interviews with acute care nurses to examine attitudes of and effects on nurses who
provide care to patients who are transitioning from curative to palliative care. Primary sources of
moral distress cited by nurses were the realization that ongoing aggressive care has become
burdensome or futile. A challenge identified included addressing uncomfortable symptoms and
suffering balanced against the concern for oversedation. Nurses also identified that caring for and
managing the needs of patients with opposing care goals as part of the same assignment is

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

11

difficult, specifically with concern for not being able to provide adequate symptom control
before death. Barriers to comfort and competence of nurses include lack of experience and lack
of involvement in end-of-life care at the bedside. Review of the interview data further
highlighted the value of mentorship and education through classroom and situational (bedside)
training. Authors concluded that skillful training results in increased confidence and compassion.
A descriptive cross-sectional analysis of 714 members of the Oncology Nursing Society
from Georgia, Virginia, Washington, and Wisconsin was published by White and Coyne (2011).
Self-report surveys were distributed, and results were used to rank end-of-life core care
competencies. Twenty five percent of the participants felt that they were not adequately prepared
to provide competent bedside care of a dying patient. Analysis of responses identified gaps in
end-of-life education. White and Coyne suggest that end-of-life educational curricula focus on
topics nurses identify as core competencies. The two most commonly cited by nurses in this
study were symptom management and communication strategies.
Rawlings and colleagues (2020) published the results of an exploratory cross-sectional
survey of nurses who took part in an asynchronous online educational offering on end-of-life
care. The study supported the hypothesis that acquisition of knowledge would change the
motivation level of participants and result in the generation of an intent to change personal
nursing practice. Seventy-one percent of the participants self-reported changes in practice after
completion of the training modules. Nurses identified the effect of professional development,
which leads to improvement in the belief in one’s own abilities, and increased feelings of selfefficacy. Increased self-efficacy scores were found to be predictive of behavior changes.
Changed bedside care behaviors were reported by 79% of nurses who completed the training
modules.

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

12

In a 2018 paper Bennet et al. examined the effects of a one-hour teaching intervention on
nursing students’ aggressiveness of care behaviors. The experiment used a pre-test, post-test
design to determine the effect of a brief end-of-life teaching intervention on student care
behaviors towards patients at the end of life. The hypothesis was that the intention to perform a
behavior is informed by beliefs and attitudes about the behavior as well as subjective and peer
norms. A total of 471 nursing students participated in the study by completing an aggressiveness
of nursing care scale prior to attending a standardized lecture that sought to inform students that
nursing care priorities for dying patients may need to be different than for other patients to
promote improved quality of life. Pre-testing revealed average scores in the moderately
aggressive to aggressive range. These scores indicate an emphasis on care aimed at curative
interventions without respect to comfort. Post-testing revealed a statistical reduction in scores to
non-aggressive and comfort-directed nursing interventions without attention to the underlying
disease (Bennett, et al., 2018).
Despite being central to the provision of bedside palliative care, few nurses receive
formal communication training. Discussing life preferences and communicating relevant
information is central to the nurses’ bedside role with patients at the end of their lives (National
Consensus Project, 2013). Coyle and colleagues (2015) devised a program and study to address
the need for effective, compassionate communication. A communication workshop was
developed and presented to 247 oncology nurses. Pre- and post-testing was used to evaluate
confidence in communicating with patients at the end of their lives. The training involved a 45minute lecture and a 90-minute group activity including experiential role-play with a
standardized patient interaction. Results revealed an improvement in the self-perceived ability to
discuss end-of-life care preferences and the process of dying, by communicating relevant

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

13

information to patients who are at the end of their life. The intervention was seen as valuable
skills training by 98 percent of nurses who attended the program. (Coyle, et al., 2015).
Wensley, et al. (2020) published their multidimensional framework that evaluates
patients’ perspectives of comfort while hospitalized. In a two-stage qualitative descriptive study,
the Comfort Always Matters (CALM) framework was developed from data found in 62 studies
exploring patients’ perceptions of comfort. Comfort is defined as multidimensional and as more
than the absence of pain. It is defined as a holistic concept that includes four layers of
interactional environment: the patient, the family, the staff, and the environment. In the acute
care setting, the nurses are the main patient-facing representative of the staff and the managers of
the environment. Most important features of comfort cited by patients include dignity, empathy,
kindness, and compassion. High-quality care includes the promotion of comfort, relief of
suffering, and the recognition of avoidable suffering as a source of harm. Comfort is a transient
and dynamic state that includes the relief of physical and emotional distress, the fostering of an
emerging sense of strength, safety, and positivity, and an acceptance of the situation. The
framework guides practice and promotes quality initiatives with a goal of improving patients’
experience of care. In the CALM framework the five categories that fall under the ‘Staff’ are 1)
symptom management, 2) holistic care and assistance, 3) engagement and commitment, 4)
information and participation, and 5) perceived and actual competence (Wensley, et al. 2020).
The CALM framework was used to construct the palliative superuser curriculum used in our
quality improvement initiative (see Appendix A).
Acknowledgement of the barriers faced by nurses in the acute care setting and
observations of the challenges in providing care to patients with disparate needs resulted in the
creation of the Quality Improvement initiative. Palliative care nursing is a specialized field

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

14

though its’ approach is applicable to many patient and disease states. Providing instruction in
practical applications of palliative care principles with the goal of increasing not only the
personal knowledge of attendees but also an overall increase in knowledge through the superuser
concept was a main objective for the quality improvement project. The palliative superuser
curriculum includes palliative care overview, exercises in empathetic patient engagement and
physical assessment, symptom management and medication administration, communication, and
bereavement support. Information presentation was augmented with case-building/case-study
interaction, communication role play, and writing exercises. The purpose of the Palliative
Superuser Quality Improvement initiative was to address the educational needs of nurses in our
hospital to improve their knowledge and comfort while providing care to patients who have
chosen to receive comfort-directed care at the end of their lives. Enrollment was voluntary and
flyers were distributed by unit managers throughout the hospital. Nurses who enrolled were
asked to complete a pre-test survey to assess baseline knowledge and comfort.
When planning the scope of the project, the role of attendees to act as mentors to their
peers in the future was established as a long-term goal of the program. Nurses who receive
training in and are competent in a specific set of tasks can guide and support peers who did not
receive the training firsthand (Andersen & Watkins, 2018). Trained nurses act as peer coaches
and mentors to their colleagues (Usher, et al., 2015). A goal of enrolling ten percent of the total
number of nurses was chosen as a reasonable target for a facility of our size, with current staffing
patterns. Mentorship is an effective form of education that facilitates the assimilation to comfortoriented care by less-experienced nurses (White & Coyne, 2011). While preceptorship focuses
on skill mastery, nurse peer mentorship contributes to the professional development of nurses by
building upon current practice and providing support to increase specialized knowledge and

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

15

enhance confidence. Learning critical skills required to become proficient in end-of-life nursing
care requires mentorship and support. Mentorship is an investment in the personal and
professional development of the mentee (Isaacson, et al., 2019).
Method
The Palliative Superuser Program extended invitations to nurse volunteers from all
nursing units and all shifts. Nurses who volunteered to enroll in superuser training attended a
four-hour workshop presented by four advanced practice palliative care specialists. Pre- and
post-testing of volunteer participants was used to assess baseline knowledge of end-of-life care
and comfort with providing care to dying persons. Pre-testing was sent to nurses by email and
results were compiled by Qualtrics software. Nurses who completed the four-hour initial training
were sent a link to the same Qualtrics survey one week after they attended the training. Certified
Registered Nurse Practitioners from the inpatient palliative care team produced and presented
curriculum content to the nurses enrolled in the initial training. Teaching methods included
didactic presentation, as well as the use of interactional case-building and case study analysis.
Writing exercises and peer role play were also used as educational strategies. Small group size
allowed for registrants to benefit from peer interactions and contributions.
The quasi-experimental design of the QI project allowed for comparison of the results of
the surveys at two points in time, once before and once after the intervention.. The null
hypothesis in the pre-test post-test design is that the intervention would have no effect on scores
(Allen, 2017). The participants of the superuser training are expected to benefit directly from the
intervention, by experiencing an increase in the knowledge and enhancement of their comfort in
the provision of bedside end of life care.

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

16

As a means of assessing the effectiveness of the superuser training a pre-test/post-test
survey was distributed to enrollees to determine baseline, pre-existing knowledge of end-of-life
nursing care knowledge and comfort, and after completion of the training to demonstrate whether
there were measurable gains from the learning intervention. Surveys were developed by
members of the palliative care team and reviewed by a departmental subject-matter expert.
Analysis of scores to determine if the educational offering improved their comfort and
knowledge in end-of-life nursing interventions was performed. A total of 10 nurses in the first
superuser workshop were sent a 10- item survey. These were scored with 5-point Likert scale (1strongly disagree, 2- disagree, 3 neutral, 4 agree, 5- strongly agree) (Appendix B). Nine (n=9)
pre-test surveys were returned. Post-testing was completed by 6 nurses (n=6) after attending the
four-hour workshop training. Free text questions were included at the end of each survey. Pretesting surveys included a free-text query to list three goals of attending the superuser workshop.
The post-test survey included free text questions to query whether the educational initiative met
their professional and personal goals, and to enable them to list what they felt to be the most and
least valuable information from the education.
Application was made to both the University IRB and the Health Network IRB and in
both cases, it was determined that the evidence-based quality improvement project did not
qualify as research and did not require Institutional Review Board approval. The goal of the QI
initiative was not to generate or contribute to generalizable knowledge and did not involve
randomized sampling. The findings of the outcomes’ surveys are intended to influence
institutional practice and identify areas where improvement is seen after training. The main goal
of the project is to improve bedside nursing care of patients dying while hospitalized.

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

17

Results
Data were analyzed using Minitab statistical software. Nine of ten pre-test surveys and
six of ten post-test surveys were returned. The single group pretest-posttest design was used to
examine the same group of nurses before and after the experimental intervention to measure the
outcome effect of the superuser training workshop on participants’ knowledge and comfort. The
paired-sample t test was used to compare pre-test and post-test mean scores. Qualitative analysis
was done for the open-ended questions by reviewing answers for categorization, and grouping
them into positive, negative, and neutral groups.
A paired-sample t-test was run to determine whether there was a statistically significant
mean difference in scores before and after the educational presentation. Nurses’ scores were
higher after the superuser workshop 4.534 (+/- 0.189) than before attending the workshop 2.887
(+/- 0.520). A statistically significant mean increase of -1.647 (95% CI, -2.066 to -1.228) with a
P-value p = 0.00 (<0.05) was observed (see Table 1). Review of post-test survey data reveals an
increase in all metrics, most significantly for three survey items: 1) knowledge of the difference
between resuscitation status, 2) comfort with recognition of patients’ suffering and
uncomfortable symptoms at the end of life, and 3) knowledge and comfort in managing patients’
symptoms at the end of life.
Review of the free text responses to a question asking nurses to list their goals of
attendance included: “being able to speak with family members”, “when is a palliative care
consult appropriate”, “how to help families with difficult decisions”, and “learning more so I can
help my peers”. One hundred percent of post-test respondents reported that the palliative
superuser workshop met their personal and professional goals. This lends support and validation
of the intervention as beneficial to the targeted nurses’ practice, and the breadth and depth of

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

18

information appears to have been a match for expectations. Post-test free text replies to the query
about what the most valuable information from the training was included: “increased comfort
with providing palliative care”, “how to talk to families and what is acceptable”, and “use of
Robinul (medication) before terminal extubation to promote comfort”. When asked what the
least valuable information was there was only one response; “none, very valuable information
was given”. All free-text responses could be categorized as positive.
Discussion
Review of the survey data and analysis of the nurses’ responses who attended the
superuser training workshop confirms the value of the intervention. The very small sample size
makes it difficult to generalize the findings but does provide support for the Palliative Superuser
QI project to continue to enroll and train registered nurses throughout the hospital. This paper
discusses the results of the first cohort of nurses who attended the palliative superuser workshop.
Plans to offer the palliative superuser workshop to future cohorts at two-month intervals, based
on the success of the first group, are underway. Training one in ten nurses in specialty end-of-life
nursing assessment and intervention will ultimately improve the comfort and knowledge of
nurses who care for patients at the end of their life. The ongoing nature of rolling enrollment and
mentorship makes the project sustainable.
The results summarized in this paper will be presented to the nurse managers at the
hospital as a means to ensure additional support for future attendees. Superusers who have
completed the specialty training will act as mentors to their peers when performing bedside care
of patients at the end of their lives. This expands the reach of the initiative and improves the
experience of patients and their nurses. Suggested next steps include having the Palliative

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

Superuser Quality Improvement training used as a model for specialty instruction to nurses
throughout the hospital system.

19

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

20

References
Allen, M. (2017). The sage encyclopedia of communication research methods
(Vols. 1-4). Thousand Oaks, CA: SAGE Publications, Inc doi: 10.4135/9781483381411
American Nurses Association and Hospice and Palliative Nurses Association. Call to
action: nurses lead and transform palliative care. 2017
https://nursingworld.ord/ThePracticeofProfessionalNursing/Palliative-Care-Call-forAction/PalliativeCare-ProfessionalIssuesPanel-CallforAction.pdf
Andersen, L. W., Holmberg, M. J., Berg, K. M., Donnino, M. W., & Granfeldt, A.
(2019). In-Hospital cardiac arrest: A review. JAMA, 321(12), 1200–1210.
https://doi.org/10.1001/jama.2019.1696
Andersen, T., & Watkins, K. (2018). The value of peer mentorship as an educational
strategy in nursing. The Journal of nursing education, 57(4), 217–224.
https://doi.org/10.3928/01484834-20180322-05
Bennett, M.P., Lovan, S.,Hager, K.,Canonica, L., & Taylor, B. (2018). A one hour
teaching intervention can improve end-of-life care. Nurse Education Today, 67(8), 93-99.
https://doi:10.1016/j.nedt.2018.05.010
Birgisdottir, D., Duarte, A., Dahlman, A., Sallerfors, B., Rasmussen, B.H., & Furst, C.J.
(2021). A novel care guide for personalised palliative care – A National Initiative for Improved
Quality of Care. BMC Palliative Care, 20(176), 1-12. https://doi.org/10.1186/s12904-02100874-4

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

21

Blinderman, C.D., & Billings, A. (2015). comfort care for patients dying in the hospital.
New England Journal of Medicine, 373(1), 2549-61. https://doi.org/10.1056/NEJMra1411746
Bloomer, M.J., Endacott, R., O’Connor, M., & Cross, W. (2013). The ‘dis-ease’ of dying:
challenges in nursing care of the dying in the acute hospital setting. A qualitative observational
study. Palliative Medicine, 27(8), 757-764. https://doi.org/10.1177/026921631377176
Boffa, D. P., & Pawola, L. M. (2006). Identification and conceptualization of nurse super
users. Journal of Healthcare Information Management: Journal of Health Information
Management, 20(4), 60–68.
Centers for Disease Control and Prevention. (2016). Deaths: Final data for 2013. U.S.
Department of Health and Human Services National Vital Statistics Report, 64(2), 1-119
Cheong, C. Y., Ha, N. H. L., Tan, L. L. C., & Low, J. A. (2020). Attitudes towards the
dying and death anxiety in acute care nurses–can a workshop make any difference? A mixedmethods evaluation. Palliative & Supportive Care, 18(2), 164-169.
Coyle, N., Manna, R., Shen, M., Banerjee, S. C., Penn, S., Pehrson, C., Krueger, C. A.,
Maloney, E. K., Zaider, T., & Bylund, C. L. (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. https://doi.org/10.1188/15.CJON.697-702
Eddy, K., Jordan, Z., & Stephenson, M. (2016). Health professionals' experience of
teamwork education in acute hospital settings: a systematic review of qualitative literature. JBI
Database of Systematic Reviews and Implementation Reports, 14(4), 96–137.
https://doi.org/10.11124/JBISRIR-2016-1843

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

22

Frey, R., Gott, M., Raphael, D., O'Callaghan, A., Robinson, J., Boyd, M., Laking, G.,
Manson, L., & Snow, B. (2014). Clinical staff perceptions of palliative care-related quality of
care, service access, education and training needs and delivery confidence in an acute hospital
setting. BMJ Supportive and Palliative Care, 4(4), 381–389. https://doi.org/10.1136/bmjspcare2012-000346
Hagan, T.L., Xu, J., Lopez, R.P., & Bressler, T. (2018). Nursing’s role in leading
palliative care: A call to action. Nursing Education Today, 61(2) 216-219.
https://doi.org/10.1016/j.nedt.2017.11.037
Hall, M., Levant, S., & DeFrances, C. (2013). Trends in inpatient hospital deaths:
National Hospital Discharge Survey, 2000-2010. NCHS Data Brief. 118. 1-8.
Hao, Y., Zhan, L., Huang, M., Cui, X., Zhou, Y., & Xu, E. (2021). Nurses' knowledge
and attitudes towards palliative care and death: a learning intervention. BMC palliative
care, 20(1), 50. https://doi.org/10.1186/s12904-021-00738-x
Hanna, N., Quach, B., Scott, M., Qureshi, D., Tanuseputro, P., & Webber, C. (2021).
Operationalizing Burdensome Transitions Among Adults at the End of Life: A Scoping
Review. Journal of pain and symptom management, 61(6), 1261–1277.e10.
https://doi.org/10.1016/j.jpainsymman.2020.10.018
Howes, J. (2015). Nurses’ Perception of medication use at the End of Life in an Acute
Care Setting. Journal of Hospice and Palliative Nursing, 17(6), 508-514.
https://doi.org/10.1097/NJH.00000000000000192
Institute of Medicine. (2014). Dying in America: Improving quality and honoring
individual preferences near the end of life. Washington, DC: National Academies Press.

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

23

Isaacson, M.J., Minton, M.E., DaRosa, P., & Harming, S. (2019). Nurse Comfort with
Palliative and End of Life Communication. Journal of Hospice and Palliative Nursing, 21(1),
38-45.
Johanson, K.M., & Kindahl, B. (2012). Moving between rooms -moving between life and
death; nurses’ experiences of caring for terminally ill patients in hospitals. Journal of Clinical
Nursing, 21(1314), 2034-2043.
Machira, G., Mageto, I., & Mwaura, J. (2021). End-of-life care education needs of
nurses: a cross-sectional study. Annals of Nursing and Practice, 7(1), 1109-1115.
https://doi.org/10.102379/9501/scimj. 1109-1115
Martin-Rosello, M. L., Sanz-Amores, M. R., & Salvador-Comino, M. R. (2018).
Instruments to evaluate complexity in end-of-life care. Current opinion in supportive and
palliative care, 12(4), 480–488. Https://doi.org/10.1097/SPC.0000000000000403
McGuire, D. B., Kaiser, K. S., Haisfield-Wolfe, M. E., & Iyamu, F. (2016). Pain
Assessment in Noncommunicative Adult Palliative Care Patients. The Nursing clinics of North
America, 51(3), 397–431. https://doi.org/10.1016/j.cnur.2016.05.009
Mitchell, S. (2020, March, 18). Aces in places: 5 characteristic of a Super User
https://sekoia.co.uk/news/aces-in-places-5-characteristics-of-a-super-user/
National Consensus Project for Quality Palliative care. Clinical practice guidelines for
quality palliative care.32013.
https://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

24

Price, D.M., Stroddtman, L., Montagnini, M, Smith, H.M., Miller, J. Zybert, J., Oldfield,
J., Ploicht, T., & Ghosh, B. (2017). Palliative and end of life care education needs of nurses
across inpatient care settings. Journal of Continuing Education in Nursing. 48(7), 329-336.
https://doi.org/10.3928/00220124-20170616-10
Powazki, R., Walsh, D., Cathern, B., Rybicki, L., Thomas, S., Morgan, G., Karius, D.,
Davis, M.P., & Shotriya, S. (2014). The care of the actively dying in an Academic medical
center: a survey of registered nurses’ professional capability and comfort. The American Journal
of Hospice and Palliative care, 31(6), 619-627. https://doi.org/10.1177/1049909113505194
Rawlings, D., Yin, H., Devery, K., & Morgan, D. (2020) End-of-life care in acute
hospitals: practice change reported by health professionals following online education.
Healthcare 8(254), 1-13. https://doi.org/10.3390/healthcare8030254
Rogers, M., Meier, D. E., Heitner, R., Aldridge, M., Hill Spragens, L., Kelley, A.,
Nemec, S. R., & Morrison, R. S. (2019). The national palliative care registry: a decade of
supporting growth and sustainability of palliative care programs. Journal of Palliative
Medicine, 22(9), 1026–1031. https://doi.org/10.1089/jpm.2019.0262
Shmerling, R.H. (2018, Oct. 31). Where people die [Harvard Health Blog]. Retrieved
from https://www.health.harvard.edu/blog
Stacy, A., Magdic, K., Rosenzweig, M., Freeman, B., & Versoky, D., (2019). Improving
knowledge, comfort, and confidence of nurses providing end of life care in the hospital setting
through use of the ‘CARES’ tools. Journal of Hospice and Palliative Nursing, 21(30), 200-206.
https://doi.org/10.1097/NNJH.00000000000000510

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

25

Teno, J. M., Bunker, J. N., Bradley, M., Bandini, J., Ritchie, C., Schlang, D., Kim, H., &
Anhang-Price, R. (2021). Bereaved family more likely to report "too little" care than "too much"
care at the end of life. Journal of Palliative Medicine, 24(6), 894–904.
https://doi.org/10.1089/jpm.2020.0498
Teno, J. M., Gozalo, P., Trivedi, A. N., Bunker, J., Lima, J., Ogarek, J., & Mor, V.
(2018). Site of Death, Place of Care, and Health Care Transitions Among US Medicare
Beneficiaries, 2000-2015. JAMA, 320(3), 264–271. https://doi.org/10.1001/jama.2018.8981
Usher, B. M., DiNella, J., Ren, D., Liang, Z., & Tuite, P. K. (2015). Development of endof-life peer nurse coaches: A hospital-based quality improvement project. Journal of Hospice
and Palliative Nursing, 17(6), 551-558. https://doi.org/10.1097/NJH.0000000000000198
Wensley, C., Botti, M., McKillop, A., & Merry, A. F. (2020). Maximizing comfort: how
do patients describe the care that matters? A two-stage qualitative descriptive study to develop a
quality improvement framework for comfort-related care in inpatient settings. BMJ Open, 10(5),
1-18. https://doi.org/10.1136/bmjopen-2019-033336
White, K.R., & Coyne, P.J., (2011). Nurses’ perceptions of educational gaps in delivering
end of life Care. Oncology Nursing Forum, 38(6), 711-717.
White, D., & Meeker, M.A., (2019). Guiding the process of dying: the personal impact on
nurses. Journal of Hospice and Palliative Nurses, 21(5),390-396.
https://doi.org/10.918314/Medscape.2019.21.5.390
World Health Organization. (2015). Palliative care fact sheet. Retrieved from
http://www.who.int/mediacentre/factsheets/fs402/en/

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

26

Appendix A

From Wensley, C., Botti, M., McKillop, A., & Merry, A. F. (2020). Maximizing comfort:
how do patients describe the care that matters? A two-stage qualitative descriptive study to
develop a quality improvement framework for comfort-related care in inpatient settings. BMJ
Open, 10(5), 1-18

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

Appendix B
Palliative Superuser Survey
Name: ________________________

Pre-test
Unit: ____

Using the following scale to indicate your response
1 strongly agree,2 agree,3 neutral,4 disagree,5 strongly disagree
1. I have a good understanding of the role of Palliative Care
2. I have a good understanding of Comfort Measures Only
3. I have a good understanding of the dying process
4. I have a good understanding of what it means to provide empathy
5. I know where I can turn for help when caring for someone at the end of their life
6. I feel comfortable caring for patients at the end of life
7. I feel knowledgeable recognizing and assessing uncomfortable symptoms at the end of life
8. I feel comfortable managing symptoms at the end of life
9. I feel comfortable communicating with dying patients and their families
10. I feel being comfortable being present with a dying patient
Please list goals you hope to attain after attending the palliative superuser workshop:

27

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

Palliative Superuser Survey
Name: ________________________

Post-test
Unit: ____

Using the following scale to indicate your response
1 strongly agree,2 agree,3 neutral,4 disagree,5 strongly disagree
1. I have a good understanding of the role of Palliative Care
2. I have a good understanding of Comfort Measures Only
3. I have a good understanding of the dying process
4. I have a good understanding of what it means to provide empathy
5. I know where I can turn for help when caring for someone at the end of their life
6. I feel comfortable caring for patients at the end of life
7. I feel knowledgeable recognizing and assessing uncomfortable symptoms at the end of life
8. I feel comfortable managing symptoms at the end of life
9. I feel comfortable communicating with dying patients and their families
10. I feel being comfortable being present with a dying patient
The least valuable information I received from the palliative superuser workshop is:
The most valuable information I received from the palliative superuser workshop is:

28

PALLIATIVE SUPERUSER EDUCATION TO IMPROVE NURSES KNOWLEDGE AND COMFORT

Table 1

Boxplot of Pre, Post
5.0

4.5

Data

4.0

3.5

3.0

2.5

2.0
Pre

Post

29