Elephant in the Room Project is a research that was conducted for the purpose of improving the efficiency of care through effective and compassionate communication with palliative care patients. The research recognized that nursing is not only a science but also an art that requires the development of both aspects unlike the increased emphasis on the development of nursing science. As suggested by the definition of the art of nursing, the existence of effective caring requires the establishment of a trusting and therapeutic relationship between nurses and patients. Such a relationship can only be developed through effective communication that will enable the patients to view nurses as warm, genuine, and empathic professionals. In order to achieve its goals, the elephant in the room project consisted of evidence-based practice and use of various data collection strategies, methodology and sample. Evidence-Based Practice:

In palliative care, communication acts as an important factor in the provision of comprehensive care to patients because of its impact on prognosis, treatment options, and clinical goals of the patients (Betcher, 2010). The research was not only based on the recognition of palliative care as multi-faceted care provided to patients in life-threatening medical conditions but it also acknowledged the importance of communication in this kind of care. Generally, communication helps palliative care patients and their families to express their fears and concerns in order to assess their needs effectively and develop suitable care plans (Hudson et. al., 2008).

Some of the underlying factors behind the research include the fact that patients in life-threatening clinical conditions usually want and expect nurses to be open and have compassionate communication with them regarding the diagnoses and treatment options. These patients also want honest communication with nurses that don't destroy their hope even as they learn about treatment goals. Through the use studies of families of terminally ill patients who died in hospital, the research indicated that palliative care patients and their families expect an attitude of caring from nurses. The attitude of nurses towards these patients not only determines the patients' perspectives about them but it also has an impact on the effectiveness of care.

Elephant in the Room Project is a relevant study in the palliative care field because of its focus on improving care to terminally ill patients through enhancing communication between nurses and patients. The project was mainly developed to offer an opportunity for nurses to enhance confidence in the capability to be involved in emotional and spiritual discussion with terminally ill patients and their families. In addition to recognizing the importance of effective communication between nurses and patients, the project also revealed that nurses identify their wish to have been taught how to communicate with patients in life-threatening situations.

Literature Review:

There are various studies that have been conducted regarding the importance of effective and supportive communication between nurses and patients and families of terminally ill patients. According to a review conducted by Fineberg & Miller (2008), the need for enhanced communication in the care for palliative patients and their families has usually been mentioned in literature and appeared several times in past literature review on Integrated care. Based on various studies, the review by Fineberg & Miller (2008) states that positive medical outcomes for these patients is largely influenced by efficient and emphatic communication between nurses, patients, and patients' families. Additional literature have also suggested that effective communication enhances the quality of palliative care through lessening anxieties, improving situational control, and promoting the patients' quality of life. Therefore, the study suggests that effective and supportive communication play a crucial role in the delivery of care to individuals facing palliative and end of life care.

The importance of communication in palliative care is also revealed by de Haes & Teunissen (2005) who state that medical specialists have discovered that the quality of communication with patients, patients' families, and other staffs is essential to the quality of care for terminally ill patients. According to the findings of these researchers, ineffective communication is attributed to be one of the leading barriers and obstacles to optimal palliative care at the health care provider level. Moreover, the research identified that trust is the major contributing factor towards the establishment of effective communication in palliative care.

While past literatures have mainly focused on the importance of communication in palliative care, recent efforts have been directed towards identifying how these communication skills can be developed by nurses. Similar to Betcher (2010), Stevenson & Bramson (2009) have recognized the need for more education on communication in palliative care among health care professionals. The education of these professionals, particularly on nurses should focus on communication and coordination between hospice provider and the nursing home staff. Malloy et. al. (2010) recognizes that there is need to emphasize on the role...

The literature review has acknowledges the lack of skill-based learning and education that enable nurses to develop necessary communication skills for palliative care.
Methodology and Sample Used:

As previously mentioned, Elephant in the Room Project was conducted based on the use of a specific research methodology and sample. The project commenced through the establishment of an 18-month pilot of a hospital-based palliative medicine consultation service in a 208-bed hospital in southwest region in America. The pilot project in this hospital was a huge success since the Palliative Medicine Service was endorsed as one of the official services in the hospital two years after the commencement of the pilot project. This was followed by the hiring of a palliative medicine director at the hospital the following year due to the outcomes of the project in the hospital.

There are various research methodologies used in the health care field including descriptive, observational, intervention, and experimental research methods (Linden, n.d.). The Elephant in the Room Project basically used the observational research methodology since it involved the establishment of the 18-month pilot project at the hospital. The established palliative care program included the education of nurses and allied health care professionals on palliative care. Future initiatives that were developed and established in the hospital basically depended on the observations that were made on the 18-month palliative care pilot project.

Various research methodologies in the health care field use different data collection strategies, samples, study design, conceptualization, measurement, research ethics, modeling, and literature review ("Health Services Research Methodology," 2012). The sample used in Elephant in the Room Project was nurses, nurse practitioners, clinical nurse specialists, social workers, and case managers. Actually, the primary and basic audience of the project was the in-patient nurses at the hospital.

Data Collection Strategies:

The data collection strategy used in Elephant in the Room Project was a survey that was conducted at the hospital. Before the Palliative Medicine Service and Program was instituted at the hospital, a survey was distributed to the hospital's physicians, nurses, allied health staff, mid-level practitioners. The result of the survey was used as the basis for developing and establishing the Palliative Medicine Service and Program. According to the findings of the survey, 54% of the health care professionals didn't feel they provided enough palliative care while 63% believed they lacked adequate education in palliative care including communication.

Discussion:

The use of role-playing with replicated patients in Elephant in the Room Project is a method supported by literature on effective ways of learning communication skills in enhancing the efficacy of palliative care. The actors provided a considerably more realistic platform since nurses responded more realistically to the trained patients and families. The main aim of the project was for nurses to demonstrate enhanced caring after the intervention through scores on the Caring Efficacy Scale. The other focus of the project was for nurse practitioners at the hospital to learn effective and supportive communication methods about palliative care issues.

As demonstrated in the research, effective communication enables caregivers to deliver bad news, explain health care goals, and make decisions about complex treatment procedures for terminally ill patients ("Communication," n.d.). Furthermore, such honest communication that does not destroy the hopes of these terminally ill patients promotes the participation and contribution of their families in the decision-making processes ("Improving Palliative Care," 2009). The project was initiated to offer an opportunity for nurses to enhance their ability to engage in emotional and spiritual discussions with end-of-life care patients and their families.

Conclusion:

The Elephant in the Room Project is a clear example and study on the importance of effective communication in the quality of palliative care. Unlike previous literature review and studies, the project focuses and emphasizes on the need for improving education and learning for nurses to develop effective communication skills in palliative care.