PowerPoint Presentation

Evidence Based Practice Research Project

James Harrington, Cheryl Howard, Lisa Sage, Holley West, Andrea Scott

Ferris State University NURS 350 Spring 2012What does the research reveal about nursing roles in geriatric end of life planning?Final Grade:

1IntroductionThe geriatric population is growing in numbers and people are living much longer due to advancements in medicine (Ruff et al., 2010).

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.

2The American Nurses Association (ANA) position statement supports the nurses 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

3It 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

4Research ArticlesAdvance Directives: Evaluation of Nurses 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)5Article 1 SummaryAdvance Directives: Evaluation of Nurses Knowledge, Attitude, Confidence, and Experience Measures acute care registered nurses expertise in the area of advance directivesUsed 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 practicewere 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)6Article 1 Critical AppraisalOVERALL STRONG CRITIQUEPurpose & Problem - STRONGgenerally stated purpose that there is a need to evaluate current practice in relation to advance directivesReview of Literature - STRONGhas a wide range of comprehensive and well summarized sources although almost half are not within 5 yearsTheoretical Model - WEAKnot statedHypothesis & Research Questions - WEAKhypothesis was implied but not clearly statedResearch Design - STRONGvariables measured appropriately and described in detailSampling Methods - STRONGclearly identified and described however there is a small sample size7Article 1 Critical AppraisalcontData collection methods - STRONGquestionnaire returned into a sealed box for confidentialityInstrument -STRONGquestionnaire with different sections & types of questionsData analysis -STRONGdescriptive & inferential statistics used, statistical program used to analyze the data was also statedStudy findings -STRONG5 main study findings, each finding explained in great detailStudy implications & Recommendations - STRONGmore research needed on methods to help nurses feel more confident in advance directive discussionsConclusion- STRONGnurses need knowledge & confidence to have advance directive discussions with patients,need more education8Article 2 SummaryPractice 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)9Article 2 Critical AppraisalOVERALL STRONG CRITIQUEPurpose & Problem - STRONGDetermine whether nurses can educate and advocate for patients when they felt aggressive interventions were unwarranted.Review of Literature - STRONG41 studies, professional journal articles and texts cited18 references current within 5 yearsReferences represented nursing, medical & psychological sciencesTheoretical Model - WEAKnot stated or impliedHypothesis & Research Questions - STRONGhypothesis clearly stated at beginning of article.Research Design - STRONGhypothesis clearly stated at beginning of article.Sampling Methods - STRONGQualitative designBased on responses to standardized question.10Article 2 Critical Appraisal contData collection methods - WeakFace to face interviews may have affected responsesInstrument -STRONGStandard question used to elicit specific subjective responses Data analysis -STRONGTranscripts divided into segments, themes and sub-themes3 main plots derived to present realistic picture of reality.Study findings -STRONG5 main study findings, each finding explained in great detailStudy implications & Recommendations - STRONGmore research needed on methods to help nurses feel more confident in advance directive discussionsConclusion- STRONGnurses need knowledge & confidence to have advance directive discussions with patients,need more education11Article 3 SummaryPromoting Advance Directives Among Elderly Primary Care PatientsExamines the affects physicians have on elderly patients creating advance directivesUses 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 physiciansPatients required to be 65 years old or greaterHave a routine check up within the year of the studyPhysicians were required to attend classes on discussing advance directivesAuthors 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)12Article 3 Critical AppraisalOVERALL STRONG CRITIQUEPurpose & Problem STRONGPromote autonomy in patients with the creation of advance directives with physician guidance and educationReview of Literature STRONGMany sources were examined to evaluated this issue. Many of them though were greater then five years old from when this article was publishedTheoretical Model WEAKNo theoretical model was statedHypothesis & Research Question STRONGThey hypothesis was included and clearly stated what was the intent of the studyResearch Design WEAKThe design was included as well as the many variables that were part of the studySampling Methods STRONGClearly stated within the article & emphasized parameters for each group13Article 3 Critical AppraisalcontData collection methods STRONGExplained 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 STRONGDifferent 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 STRONGGroup 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 STRONGThe study findings were clearly identified and categorized in four groups.Study implications & recommendations STRONGThere 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 researchersConclusion STRONGIt was concluded that if physicians took the time to discuss advance directives with patients then there was a higher likelihood of them creating one.14Article FourFactors Associated with Favorable Attitudes Toward End-of-Life PlanningStudy byRuff, Jacobs, Fernandez, Bowen, & Gerber, (2010)15SummaryEnd of Life PlanningStudyFactors associated Convenience sampleQuestionnaireExpanded population criterionsProvided valuable results16Purpose and Problem: StrongProblem identified as lack of knowledge and understandingPurpose was to optimize advantages of EOL planning through factor identificationReview of literature: StrongCurrent, relevant research references paraphrased and gathered from multiple fields of study, no citation errors, inclusive literary background, comprehensive reference listLack of literature review sectionTheoretical/ conceptual model: WeakDoes not have an identified theoretical or conceptual modelHypothesis and research questions: StrongClearly written hypothesis with direct link to study problem and purposeFramework implied during introduction through factor analysisLack of clearly defined framework and theory

Overall Strong CritiqueArticle 4 Critical Appraisal17Critical AppraisalcontResearch 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 researchNo control, study conducted in natural environment on one group of participantsQuantitative: protection of bias, examination of causality, and determination of validitySample and sampling methods: StrongDiverse sample of community. 610 approached disqualified = 331 participants. Convenience sample, large age range, and multiple population statistics were analyzedData Collection Methods: Strongface-to-face approach by researchers, questionnaire, privacy envelopes to return questionnaires in Instrument: Strongdetailed questionnaire with different types of questions

(Ruff et al., 2010, p. 177) 18Critical Appraisal Cont.Data Analysis: Strongmultiple different statistics used, analyzed by statistical software

Study Findings: Strongdetailed findings for each section of the questionnaireStudy Implications and Recommendations: Strongstrengths/limitations discussed, implications for nursing discussed

Conclusion: Strongnurses 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 older19

How the evidence is affected by experiences20

Authors work in varied fields of nursing with widely focused perspective on end of life issuesThe research evidence supports personal experiencePERSONAL perspectivesPersonal nursing perspectives are offered in this presentationSurgical Services DirectorCase Management & LTCCritical care, Med-Surg, & OBOrthopedic SurgicalHospice

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JamesSurgical 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.

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James contThough 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.

23Cheryl

Case Management and Long Term Care NursingIn my personal experience some nurses are more knowledgeable in this area than othersMost nurses in my field, including myself, are only generally acquainted with end of life issuesMany patients and their families feel uncomfortable or are confused about end of life planning and advance directivesThe 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 planningIn my nursing practice I plan to strive for more nursing knowledge in this areaPhoto credit: www.yourmedicinewithin.com24AndreaCritical Care, Medical Surgical, and Obstetrical NursingI 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. 25LisaOrthopedic Surgical NursingCurrent 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 kinMany individuals did not want their next of kin to be making decisions for themAdvance 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

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Holley:Hospice R.N.

HospiceComfortSecurityCompassionRespectSupportFaithApplication of evidence would be extremely beneficialEarly education on end-of-life planning promotedRecommended documentation during planning: Advanced Directives, designation of health care proxy, and Last Will and TestamentNurses are the faces of the healthcare system, thus we need to start putting our game faces on

FamilyHopeAutonomyTeam Work27RecommendationsNeed 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 deatheffectiveness of early educationidentification of the medical professional responsibilities for addressing EOL planning with their patients

28Conclusion

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

29ReferencesANA. (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 CareSeptember 1, 2006vol. 15 no. 5480-491Retrieved from website http://ajcc.aacnjournals.org/content/15/5/480.fullPutman-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

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