Evidence Based Practice Research Project

What does the research reveal about nursing roles in geriatric end of life planning? James Harrington, Cheryl Howard, Lisa Sage, Holley West, Andrea Scott Ferris State University NURS 350 Spring 2012 Final Grade: Evidence Based Practice Research Project

The geriatric population is growing in numbers and people are living much longer due to advancements in medicine (Ruff et al., 2010). Introduction • Identification of geriatric problems and nursing interventions for the geriatric community is necessary in all fields of nursing care. • Death and dying is inevitable and nursing care is often key in this stage of life.

The American Nurses Association (ANA) position statement supports the nurse’s role as an advocate for patients throughout their lifespan concerning end of life choices (ANA, 2010). • Patients and their families turn to nurses for information and guidance for quality of life and care issues. Nurses often help people understand advance directives and care choices (Trossman, 2009). • The ANA is actively developing strategies to include end of life planning as a part of health care reform (Trossman, 2009). American nurses association

It is important to explore research in order to identify nursing roles, assess knowledge and evaluate nursing care trends in the area of end of life planning and advance directives. Research Relevance

Advance Directives: Evaluation of Nurse’s Knowledge, Attitude, Confidence, and Experience (Putman-Casdorph et al., 2009) • Practice of Expert Critical Care Nurses in Situations of Prognostic Conflict at the End of Life (McBride-Robichaux et al., 2006) • Promoting Advance Directives Among Elderly Primary Care Patients (Springer, 2011) • Factors Associated with Favorable Attitudes Toward End-of-Life Planning (Ruff et al., 2010) Research Articles

Article 1 Summary Advance Directives: Evaluation of Nurse’s Knowledge, Attitude, Confidence, and Experience • Measures acute care registered nurses expertise in the area of advance directives • Used a questionnaire method with 87 acute care registered nurses to assess their advance directive knowledge about laws as well as attitude, confidence and experience with advance directives. • Participants: • had a moderately negative attitude toward advance directive planning support & helpfulness in practice • were only slightly to moderately confident • majority of felt advance directive participation was a part of their nursing role • Authors concluded that nurses need education & support with advance directives which may contribute to increased confidence & positive attitudes. (Putman-Casdorph, Drenning, Richards & Messenger, 2009)

OVERALL STRONG CRITIQUE • Purpose & Problem - STRONG • generally stated purpose that there is a need to evaluate current practice in relation to advance directives • Review of Literature - STRONG • has a wide range of comprehensive and well summarized sources although almost half are not within 5 years • Theoretical Model - WEAK • not stated • Hypothesis & Research Questions - WEAK • hypothesis was implied but not clearly stated • Research Design - STRONG • variables measured appropriately and described in detail • Sampling Methods - STRONG • clearly identified and described however there is a small sample size Article 1 Critical Appraisal

Data collection methods - STRONG • questionnaire returned into a sealed box for confidentiality • Instrument - STRONG • questionnaire with different sections & types of questions • Data analysis - STRONG • descriptive & inferential statistics used, statistical program used to analyze the data was also stated • Study findings - STRONG • 5 main study findings, each finding explained in great detail • Study implications & Recommendations - STRONG • more research needed on methods to help nurses feel more confident in advance directive discussions • Conclusion - STRONG • nurses need knowledge & confidence to have advance directive discussions with patients, need more education Article 1 Critical Appraisal cont…

Article 2 Summary Practice of Expert Critical Care Nurses in Situations of Prognostic Conflict at the End of Life • Addresses the issues that critical care nurses face when patients facing end-of-life decisions continue to undergo treatments that nurses feel are unwarranted. • Performed by means of face –to-face interviews of 21 critical care nurse experts representing 7 healthcare facilities in the southwestern region of the United States. (McBride-Robichaux et al., 2006)

Article 2 Critical Appraisal OVERALL STRONG CRITIQUE • Purpose & Problem - STRONG • Determine whether nurses can educate and advocate for patients when they felt aggressive interventions were unwarranted. • Review of Literature - STRONG • 41 studies, professional journal articles and texts cited • 18 references current within 5 years • References represented nursing, medical & psychological sciences • Theoretical Model - WEAK • not stated or implied • Hypothesis & Research Questions - STRONG • hypothesis clearly stated at beginning of article. • Research Design - STRONG • hypothesis clearly stated at beginning of article. • Sampling Methods - STRONG • Qualitative design • Based on responses to standardized question.

Article 2 Critical Appraisal cont… Data collection methods - Weak • Face to face interviews may have affected responses Instrument - STRONG • Standard question used to elicit specific subjective responses Data analysis - STRONG • Transcripts divided into segments, themes and sub-themes • 3 main “plots” derived to present realistic picture of reality. Study findings - STRONG • 5 main study findings, each finding explained in great detail Study implications & Recommendations - STRONG • more research needed on methods to help nurses feel more confident in advance directive discussions Conclusion - STRONG • nurses need knowledge & confidence to have advance directive discussions with patients, need more education

Article 3 Summary Promoting Advance Directives Among Elderly Primary Care Patients • Examines the affects physicians have on elderly patients creating advance directives • Uses a quasi-experimental design along with a nonequivalent control group to research the different variables which may affect patients desires to create an advance directive. • Participants included patients and physicians • Patients required to be 65 years old or greater • Have a routine check up within the year of the study • Physicians were required to attend classes on discussing advance directives • Authors found that having a physician discuss advance directives with patients that they were more likely to create one then if it was left up to the patient solely. (Springer, 2011)

Article 3 Critical Appraisal OVERALL STRONG CRITIQUE • Purpose & Problem – STRONG • Promote autonomy in patients with the creation of advance directives with physician guidance and education • Review of Literature – STRONG • Many sources were examined to evaluated this issue. Many of them though were greater then five years old from when this article was published • Theoretical Model – WEAK • No theoretical model was stated • Hypothesis & Research Question – STRONG • They hypothesis was included and clearly stated what was the intent of the study • Research Design – WEAK • The design was included as well as the many variables that were part of the study • Sampling Methods – STRONG • Clearly stated within the article & emphasized parameters for each group

Article 3 Critical Appraisalcont… • Data collection methods – STRONG • Explained the many ways data was collect from the different sources in the study including the International Statistical Classification of Diseases and Related Health Problems and an eight question survey for physicians. • Instrument – STRONG • Different instruments were used in the study for the various groups. A brochure was placed in the waiting area of the office and physician were given classes to educate on discussion of advance directives. • Data analysis – STRONG • Group data was divided between the control group and intervention group. Further data was then divided into the physicians and their clinics which they work in. • Study finding – STRONG • The study findings were clearly identified and categorized in four groups. • Study implications & recommendations – STRONG • There were aspects of the study which were unable to be controlled by the researchers. Providing physicians with more time to discuss advance directives was one recommendation given by the researchers • Conclusion – STRONG • It was concluded that if physicians took the time to discuss advance directives with patients then there was a higher likelihood of them creating one.

Article Four Factors Associated with Favorable Attitudes Toward End-of-Life Planning Study by Ruff, Jacobs, Fernandez, Bowen, & Gerber, (2010)

End of Life Planning • Study • Factors associated • Convenience sample • Questionnaire • Expanded population criterions • Provided valuable results Summary

Article 4 Critical Appraisal Overall Strong Critique Purpose and Problem: Strong • Problem identified as lack of knowledge and understanding • Purpose was to optimize advantages of EOL planning through factor identification Review of literature: Strong • Current, relevant research references paraphrased and gathered from multiple fields of study, no citation errors, inclusive literary background, comprehensive reference list • Lack of literature review section Theoretical/ conceptual model: Weak • Does not have an identified theoretical or conceptual model Hypothesis and research questions: Strong • Clearly written hypothesis with direct link to study problem and purpose • Framework implied during introduction through factor analysis • Lack of clearly defined framework and theory

Critical Appraisalcont… Research design: there is not a clearly identified research design and a mixed format was applied for study conduction • Qualitative: detailed explanation of concepts supporting grounded research • No control, study conducted in natural environment on one group of participants • Quantitative: protection of bias, examination of causality, and determination of validity Sample and sampling methods: Strong • Diverse sample of community. 610 approached – disqualified = 331 participants. Convenience sample, large age range, and multiple population statistics were analyzed Data Collection Methods: Strong • face-to-face approach by researchers, questionnaire, privacy envelopes to return questionnaires in Instrument: Strong • detailed questionnaire with different types of questions (Ruff et al., 2010, p. 177)

Data Analysis: Strong • multiple different statistics used, analyzed by statistical software Study Findings: Strong • detailed findings for each section of the questionnaire Study Implications and Recommendations: Strong • strengths/limitations discussed, implications for nursing discussed Conclusion: Strong • nurses need to discuss end of life planning with patients when the patients are younger to optimize how the patients will plan for end of life care as they get older Critical Appraisal Cont….

How the evidence is affected by experiences

PERSONAL perspectives • Authors’ work in varied fields of nursing with widely focused perspective on end of life issues • The research evidence supports personal experience • Personal nursing perspectives are offered in this presentation • Surgical Services Director • Case Management & LTC • Critical care, Med-Surg, & OB • Orthopedic Surgical • Hospice

James Surgical Services Director Although I am not a nurse functioning in the critical care area of my facility, the evidence presented in article #2 is relevant in my surgical area as well. Occasionally procedures are performed on elderly patients facing end-of life decisions. Some of these procedures, such as repairing fractured hips on elderly patients suffering from severe dementia and who have a do not resuscitate (DNR) status pre-operatively are considered palliative in nature due to issues related to pain. These procedures are accepted by all members of the healthcare team as necessary. Issues related to surgical interventions involving certain elderly patients with known metastatic cancer are another story.

James cont… Though becoming less frequent- there are still instances when tumors are removed to relieve obstructions or peg-tube placements are performed to provide nutrition to end-of-life patients. Confusion often exists between those measures considered as palliative and those that are curative in nature. If this confusion exists in the minds of healthcare professionals it will most likely also exist in the minds of patients and family members seeking guidance in their end-of-life decision making. When these types of procedures are scheduled the nursing staff may question amongst themselves the reasons for these measures but seldom are those questions posed to patients or medical providers. As stated in the conclusions of the second study presented- there is a need for better communication between all members of the healthcare team as well as collaborative efforts in developing education for staff and patients concerning end-of-life decision making.

Cheryl Case Management and Long Term Care Nursing • In my personal experience some nurses are more knowledgeable in this area than others • Most nurses in my field, including myself, are only generally acquainted with end of life issues • Many patients and their families feel uncomfortable or are confused about end of life planning and advance directives • The research our group gathered supports my assumption that more knowledge, communication and clear practice guidelines are needed for nurses regarding their role in end of life planning • In my nursing practice I plan to strive for more nursing knowledge in this area Photo credit: www.yourmedicinewithin.com

Andrea Critical Care, Medical Surgical, and Obstetrical Nursing I do not know much about advance directives. Not every patient has them, and when a patient does have one, it seems to hardly ever get followed. Family members or spouses often step in when the patient is unable to voice or express their own opinions anymore and make choices for the patient that are not what the patient wants according to their advance directive. At our hospital, nursing used to ask every patient, on admission, some generic questions about being a DNR or not. A family complained about this and these questions were removed from the nursing admission set of questions, essentially telling me as a nurse that I am not qualified to ask such “delicate” questions. Now the doctors have to address it and it does not get done consistently. If the doctors asked every patient on admission, instead of waiting until the patient gets to a point where the questions need asked, I think it would go smoother for patients, their families, and nurses. I have seen patients go through procedures they did not want because of family choices and I have seen patients hold their ground and say “no more” and die a peaceful death. I applaud these patients for their courage to tell all us “experts” “I have had enough, let me go.” The longer I am a nurse the more I realize the difference between alive and living. I would be happy to have more education on advance directives so if need be, I can be the one to start the discussion about them with patients or families or to have the knowledge to answer questions for patients and families appropriately.

Lisa Orthopedic Surgical Nursing • Current practice has changed to incorporate patient autonomy into care • Creation of advance directives allows for patients to have autonomy during a time when they are unable to make any decisions • At current employer we now ask each patient if they have an advance directive and if not we located their next of kin • Many individuals did not want their next of kin to be making decisions for them • Advance directives allow them to list whom ever they wish to make decisions for them • The creation of advance directives allows patients to make their own choices promoting autonomy in their care

Holley:Hospice R.N. Comfort • Application of evidence would be extremely beneficial • Early education on end-of-life planning promoted • Recommended documentation during planning: Advanced Directives, designation of health care proxy, and Last Will and Testament • Nurses are the faces of the healthcare system, thus we need to start putting our game faces on Faith Security Hospice TeamWork Compassion Support Respect Hope Family Autonomy

Recommendations • Need for nurses to have more education and knowledge in area of end of life planning. • Public education related to end of life planning needs to be increased. • Additional studies need to be conducted to identify factors associated with: • planning for death • effectiveness of early education • identification of the medical professional responsibilities for addressing EOL planning with their patients

Conclusion • Nurses are an important part of end of life planning. • End of life planning is important but can be a controversial and sensitive topic for patients. • Increased education and expertise for nurses in end of life issues is recommended

ANA. (2010, June 14). Registered nurses’ roles and responsibilities in providing expert care and counseling at the end of life. Retrieved from American Nurses Association website: https://fsuvista.ferris.edu/‌webct/‌cobaltMainFrame.dowebct?appforward=/‌webct/‌viewMyWebCT.dowebct McBride Robichaux,C., Clark, A.P., Practice of Expert Critical Care Nurses in Situations of Prognostic Conflict at the End of Life. Am J Crit Care September 1, 2006 vol. 15 no. 5 480-491 Retrieved from website http://ajcc.aacnjournals.org/content/15/5/480.full Putman-Casdorph, H., Drenning, C., Richards, S., & Messenger, K. (2009, July). Advance directives: Evaluation of nurses’ knowledge, attitude, confidence, and experience. Journal of Nursing Care Quality, 24(2), 250-256. doi:10.1097/‌NCQ.0b013e318194fd69 Ruff, H., Jacobs, R. J., Fernandez, I. M., Bowen, S. G., & Gerber, H. (2010, September 11). Factors associated with favorable attitudes toward end-of-life planning. American Journal of Hospice and Palliative Medicine, 28(3), 176-182. doi: 10.1177/1049909110382770 Trossman, S. (2009, March/‌April). To sustain life, or not? ANA, nurse experts promote planning for care through advance directives. The American Nurse, 41(2), 1, 6. Retrieved from CINAHL database. Wissow, L.S., Belote, A., Kramer, W., Compton-Phillips, A., Kritzler, R. Weiner, J.P. (2004). Promoting advance directives among elderly primary care patients. Journal of General Internal Medicine, 19, 994-951. doi: 10.1111/j.1525-1497.2004.30117.x References

Evidence Based Practice Research Project