Critical Appraisal: Hospice Nurse Identification of Comfortable and Difficult Topics

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Table of Contents

  • Review of Literature
  • Methodology
  • Researchers' Interpretation of Findings
  • Application to Professional Practice
  • References

The presented critical appraisal is a study of hospice nurses and their ability to successfully communicate with patients and caregivers, with both comfortable and difficult topics. The article provided a clear abstract that was concise, accurate and readable. The abstract provided a brief outline of the article’s objectives, methods, results, and conclusions. The problem of the study focused on effective nurse communication, but was not clearly stated in the introduction of the article. The purpose of the study was clearly stated:

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Evaluate hospice nurse self-reported communication effectiveness overall, when discussing topics nurses perceived as difficult, and in relation to self-reported nursing stress, life events, and burnout, assess nurses’ desire for further communication skill training, and identify topics that hospice nurses consider comfortable and difficult to discuss with caregivers and patients” (Clayton, Iacob, Reblin, & Ellington, 2019, p. 1793).

The problem and purpose of this article is significant in addressing effective end-of-life communication, and is relevant to other health care disciplines because of the role various types of heath care professionals play in patients’ health management.

Review of Literature

In the article, the literature review provides minimal information. The information presented was relevant, and assisted in explaining the problem and purpose of the study. The review of literature focused on the changes evolving in hospice care, as well the potential stressors influencing the way nurses care for patients. According to Clayton et al. (2019), hospice care has changed widely over the last decade, lengthening the amount of time nurses care for specific patients. The National Consensus Project for Hospice and Palliative Care was one example of an evaluated source of literature in this article. Gaps of knowledge regarding communication between nurses and patients are evident. These gaps include a lack of understanding in the type of communication needed between nurses, patients and caregivers (Clayton et al., 2019, p. 1793). Gaps of knowledge are also related to the change in research involving communication between hospice nurses, and patients and caregivers. Research has frequently focused on interventions related to acknowledgment and understanding of advance directives, as well as aid in making choices regarding treatment (Clayton et al., 2019, p. 1793). The review of literature concludes with a brief summary addressing the importance of communication in end-of-life care, the lack of current research addressing this issue, and acknowledgment of the aims of the study (Clayton et al., 2019, p. 1794).


The study design focused on reporting of self-report data collected from home hospice nurses associated with a board approved project (Clayton et al., 2019, p. 1794). Data collected for the study includes audio-taped hospice visits, caregiver reports, bereavement experiences, and patient symptoms (Clayton et al., 2019, p. 1794). Nurses evaluated came from 11 different hospice companies, over four different regions in the United States during staff meetings. The population consisted of 181 hospice nurses. The recruitment process included an introduction and explanation of the study to be conducted, including that nurses would be required to wear an audio-recorder during visits and written informed consent was obtained (Clayton et al., 2019, p. 1794). The use of an Institutional Review Board approved project protected the rights of the subjects. Questions of self-report using Baile and Roberts, were used to assess communication of oncology providers and hospice nurses caring for admitted cancer patients (Clayton et al., 2019, p. 1794). Two questions were asked about their self-perceived communication effectiveness, and their effectiveness with difficult topics; these questions were asked using a rating of one to five with one being not at all effective, and five being very effective (Clayton et al., 2019, p. 1794). According to Clayton et al. (2019), the Homles and Rahe 41 item Social Readjustment rating scale was used for nurses to self-report issues related to stress at work and burnout. The Nursing Stress Scale was used to measure work related stress, as well as the Patient Death and Dying subscale. Maslach Burnout Inventory was the scale used to evaluate nurse burnout. Spearman’s rank and order correlation coefficients assessed the relationship between the outcomes of all of the previous listed rank and scaling systems linking communication variables, burnout, life events and nursing stress together (Clayton et al., 2019, p. 1794). An analysis was then conducted based on the received information, as well as nurses’ list of comfortable and difficult communication topics; from this, two coders discussed and evaluated the nurses’ responses and provided a calculated score of how many nurses listed a particular discussion topic, and who they listed (Clayton et al., 2019, p. 1794).

Researchers’ Interpretation of Findings

The conducted study yielded various results relating to participant characteristics, average level of burnout among hospice nurses, average level of stress associated with hospice nurses, average life events, communication effectiveness, and comfortable and uncomfortable discussion topics. The results of the study showed that the majority of hospice nurses are female, Caucasian, and experienced nurses. The nurses studied considered themselves effective communicators overall, with a desire to have additional communication training; nurses chose to have additional training by a workshop hosted during working hours, free text explanations, information by email, online classes, and physical handouts (Clayton et al., 2019, p. 1795). Nurses in this study had an average level of burnout of 33.98 out of a maximum 84, with low levels of emotional exhaustion (Clayton et al., 2019, p. 1795). Stress among the nurses was measured at 63.6 out of a maximum 136; these results had a wide range of variance in the level of stress some nurses were under, including topics of death and dying and overall workload (Clayton et al., 2019, p. 1795). 

The results of life events involving the nurses studied were relatively low, showing an average of five listed events out of a possible 41; the most frequent listed event was vacation, followed by death of a family member and changes in health and/or work responsibilities (Clayton et al., 2019, p. 1795). As previously stated, nurses considered themselves overall effective communicators with both difficult and comfortable topics, with this there was a positive correlation between burnout and stress, and effective communication. During the collection of data, hospice nurses listed topics that they felt most comfortable and uncomfortable discussing, and these topics were separated into subcategories. The most frequently listed topic that nurses were comfortable discussing with patients and their caregivers, was system management; the second most comfortable topic to discuss was the dying process (Clayton et al., 2019, p. 1796). Most subcategories that were listed in the comfortable topics were also listed in the uncomfortable topics, but with a different outlook. For example, the dying process was listed as both a comfortable and uncomfortable discussion topic. In the uncomfortable topics listed, however, it was the process of a patient actively dying and not just giving details on the process (Clayton et al., 2019, p. 1796). A patient actively dying, emotions when conflict or issues were present, and family dynamics were a few topics that hospice nurses found difficult to discuss with patients and their caregivers (Clayton et al., 2019, p. 1796).

Various tables were listed throughout the article to aid in explanation of the study. Table one revealed information regarding hospice nurse characteristics (Clayton et al., 2019, 1795). Variables such as age, gender, race, ethnicity, experience in years as a nurse, experience as a hospice nurse, and certification were evaluated. Variables were described with a result, and mean and median range. Table two showed hospice nurse’s self-reported communication effectiveness and desire for additional teaching (Clayton et al., 2019, p. 1796). Four questions were asked and required responses from not at all effective to very effective, as well as delivery methods for additional teaching. These responses were obtained both numerically and by a percentage. Table three listed variables associated with nursing burnout, stress, and life events (Clayton et al., 2019, p. 1796). Each topic listed subcategories requiring a numerical response that developed into an overall total score. The responses were statistically measured using mean and median ranges. Table four listed discussion topics and their subcategories that nurses were most comfortable discussing with patients and caregivers, along with a numerical figure of the nurses listing category (Clayton et al., 2019, p. 1797). Table five showed discussion topics that nurses considered to be most difficult to discuss with patients and caregivers, also showing a numerical figure of the nurses listing category (Clayton et al., 2019, p. 1797).

The study’s limitations were identified by the researcher. There was a lack of correlation between level of burnout and the number of life events, correlating with nurse’s self-perceptions and the ability to communicate effectively (Clayton et al., 2019, p. 1800). The study showed limitations in that the samples and overall related scoring methods were too generic, and did not offer nurses to provide adequate explanation. Another limitation in the study revealed that not all nurses listed the same general amount of topics, some listed very few while others listed many (Clayton et al., 2019, p. 1800). Of the sampled nurses, few held certifications or additional training in communication or experienced hospice care (Clayton et al., 2019, p. 1800). Aside from the limitations, the research proved to be effective in supporting the issue that nurses face communication challenges on both a personal and patient level.

Application to Professional Practice

The researcher listed no recommendations for the study conducted. The researcher identifies relevance in professional practice by discussing how hospice nurses communicate and interact with patients and their caregivers during end-of-life care. Without effective communication, hospice nurses are not able to care for patients in optimal functioning. End-of-life care is difficult, and communicating with patients, caregivers, family, and friends is all a part of providing the best possible care to their patients. The results from the conducted study should be applied to professional practice. Nurses identifying their own weaknesses in communication, allows for improvement. Nurses can seek additional communication training to better their communication in end-of-life care, which then improves overall patient care.


  1. Clayton, M. F., Iacob, E., Reblin, M., & Ellington, L. (2019). Hospice nurse identification of comfortable and difficult discussion topics: associations among self-perceived communication effectiveness, nursing stress, life events, and burnout. Patient Education and Counseling, 102, 1793-1801.

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