Publication Date

2025

Document Type

Dissertation/Thesis

Degree Name

DNP (Doctor of Nursing Practice)

Department

School of Nursing

Abstract

Implementation of the Nurse-Driven Palliative Care Referral Protocol

Background and Purpose: Palliative care enhances quality of life, symptom management, and patient–family communication for individuals with serious illness. Despite strong evidence and national recommendations for early integration, referrals remain inconsistent and often occur late. At Advocate Sherman Hospital, only 17.9% of eligible oncology inpatients received palliative care consults. The absence of standardized referral criteria, reliance on provider discretion, and misconceptions equating palliative care with hospice contributed to delayed or missed consults. The purpose of this quality improvement (QI) project was to increase palliative care referrals by 20% within eight weeks through the implementation of a standardized, nurse-driven referral protocol on the inpatient oncology unit.

Model and Methods: This QI project was guided by the Iowa Model of Evidence-Based Practice to Promote Quality Care, which provided a systematic framework for identifying clinical gaps, implementing change, and evaluating outcomes. The project was conducted on a 24-bed oncology unit at Advocate Sherman Hospital, a 255-bed community hospital within the Advocate Aurora Health System. Two validated tools—the Surprise Question (SQ) and the Palliative Care Screening Tool (PCST)—were used to standardize identification of patients appropriate for palliative care referral. Oncology nurses screened all new admissions and inter-unit transfers each shift. When a patient scored ≥4 on the PCST, the nurse communicated findings to the attending physician or oncologist, indicating that the patient met referral criteria; the provider then placed the palliative care consult order. Data were collected from electronic medical records and paper screening logs. Pre- and post-implementation referral rates were compared using a chi-square test, and nurse self-efficacy was analyzed using a Wilcoxon signed-rank test (p < .05).

Process Change: Prior to implementation, the project lead conducted structured education sessions for oncology nurses on early palliative care principles, use of the SQ and PCST, and standardized communication strategies. Educational materials included a PowerPoint presentation, quick-reference guides, and informational flyers for nurses and families. During the eight-week intervention, screening forms were collected daily, and weekly audits and biweekly debriefings were conducted to ensure fidelity, address workflow challenges, and provide real-time feedback.

Results: Palliative care referral rates increased from 17.9% to 40.2% post-implementation (χ² [1, N = 244] = 12.58, p < .001), surpassing the target goal. Goals-of-care discussions were documented for 100% of referred patients, and screening compliance averaged 90%, demonstrating strong protocol adherence. Nurse self-efficacy scores improved significantly (p < .001), reflecting increased confidence in identifying and initiating referrals. The intervention required no additional cost and was seamlessly integrated into existing nursing workflows.

Conclusions: Implementation of a nurse-driven palliative care referral protocol significantly improved consult rates, communication, and nurse confidence in initiating palliative care discussions. The Iowa Model provided a structured framework that guided successful practice change. This nurse-led, cost-neutral intervention demonstrated feasibility, sustainability, and scalability across oncology and other acute care settings, promoting timely, patient-centered palliative care.

References

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