Opportunities for Nursing Science to Advance Patient Care in the Time of COVID‐19: A Palliative Care Perspective

Abstract

Nursing science and scholarship have consistently improved patient care and outcomes throughout history's most daunting times. Nightingale introduced statistical surveillance during the Crimean War to decrease deaths and reduce risk for infection among wounded soldiers (Kopf, 1916). Nurses like Angie Lewis, working on Ward 5B in San Francisco—the only U.S. special care unit for patients with AIDS in the early 1980s—were at the frontline of applying emerging evidence for a marginalized population (Austin, 2014). Any public health emergency impacting the welfare of society—Ebola, Hurricane Katrina, domestic violence, war, refugee crises—has seen nurses using science to provide care and leadership and improve the human condition. The coronavirus disease 2019 (COVID‐19) pandemic is no different. It has been stated that “nursing research is coronavirus research” (D'Antonio, Naylor, & Aiken, 2020, p. 215). We could not agree more. For many years, nurse scientists have been actively engaged in executing and shaping a research agenda for improving serious illness care (Ferrell et al., 2017; Naylor et al., 2018). These impactful investigations include examining cancer pain management disparities (Meghani, Thompson, Chittams, Bruner, & Riegel, 2015; Meghani et al., 2020) and how best to integrate palliative care and infection management at the end of life (Stone et al., 2019). Many of the challenges made evident during the COVID‐19 emergency can build upon these existing strengths. COVID‐19 has raised dilemmas across all care levels, in both acute and community‐based settings. Physically, complex clinical presentations have posed issues with symptom management, rapid functional decline, high mortality rates, and increased intensive care utilization. Emotionally and socially, family dynamics and support structures have been destabilized through quarantining, distancing, isolation mandates, and visitor restrictions in hospitals. Healthcare access due to financial fallouts of the pandemic may worsen. Legal and ethical dilemmas have become apparent in the context of limited resources, speedy advance care planning, nurse burnout, and morally distressing clinical scenarios. There is an urgent need for accessible models of universal palliative care as well as discourse on how best to leverage the palliative nursing role (The Lancet, 2020; Radbruch et al., 2020; Rosa et al., in press, 2020). Given the growing burden of serious health‐related suffering worldwide (Sleeman et al., 2019) in conjunction with lessons we are just learning from COVID‐19, we strongly recommend a palliative care lens in advancing the nursing research agenda to meet the global population health needs of our times and anticipated future health crises. Palliative care is rooted in a whole‐person and inherently interdisciplinary approach to science and care delivery aligned with patient and family values to optimize quality of life and comfort while mitigating distress of all types. Palliative care research reflects a commitment to improving and protecting our collective human future and the most vulnerable among us. National Academies of Sciences, Engineering, and Medicine (2020) workshop proceedings underscore challenges in creating a robust palliative care workforce in the United States. Obstacles for improving palliative care in low‐ and middle‐income countries are even greater. Thus, a global research strategy may include baseline assessments of the state of palliative care or any models of serious illness care in a particular context, identifying key opportunities for palliative care advancement of education or clinical integration. During COVID‐19, high‐ and low‐resource countries alike are struggling with repurposing their existing palliative care models for an unanticipated crisis. In managing the unfolding and next public health crisis, we must investigate how to adapt the skills associated with palliative care training, such as effective communication, therapeutic clarification of patient and family goals, assistance with advance care planning in the setting of complex clinical considerations, and tending to spiritual, existential, cultural, and psychological needs. Scientists should explore how best to manage symptoms in the face of acute crisis while ensuring continuity of care for patients with chronic conditions for secondary and tertiary prevention to reduce the burden on weak health systems. Successful models of telemedicine exist and can work in low‐resource settings; those opportunities are being leveraged during COVID‐19 (Coombs, 2020). Future research should examine how best to deliver these new and emerging models of palliative care. Policy‐oriented research is needed that promotes affordable access to essential medications such as opioids to alleviate added suffering. In the absence of such access, alternative and integrative cultural approaches are needed to deliver high‐quality palliative care. It will also be essential to conduct educational research to determine the ideal methods of scaling training for nursing students and practicing clinicians in the palliative care skills necessary for care during a time of crises, such as a future pandemic (End‐of‐Life Nursing Education Consortium, 2020). Outcomes of online education and the best methods for teaching essential content such as communication skills, symptom management, or psychosocial support should be determined. How would future global healthcare delivery look if our science was systematically able to prepare all nurses and other clinicians with the skills needed to provide primary palliative care (i.e., palliative care as a core skill of all practitioners regardless of their practice setting) for all patients, at all stages of illness, alone or in conjunction with curative treatment? Palliative care science ushers in an emphasis on quality of life over quantity; on communication and connectivity over isolation; and on a whole‐person paradigm over a biomedical model. These considerations are particularly relevant in instances where cure is not possible, and the predominant focus is on improving the lived experience of patients and families. The collective hope is probably similar among healthcare workers worldwide: We will be able to do better in the next public health emergency. But the old saying holds true: Nothing changes if nothing changes. Goethe wrote, “Knowing is not enough; we must apply. Willing is not enough; we must do” (Jensen, n.d.). Nurse scientists and scholars have a unique opportunity to translate what we have learned about the shortcomings of healthcare during COVID‐19 into strategic actions and investigations that reflect the needs of a rapidly changing society. Investing in the global culture of palliative care scholarship for nurses and health professionals across practice domains is one of the most accessible approaches to ensuring healthcare systems and delivery mechanisms—beyond cure‐centric care—also reflect a person‐centered and value concordant ethos in the face of a future public health crisis.