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Running head: HEATHCARE WORKERS IN THE ICU 1

Knowledge and Perceptions among Healthcare Workers Caring for

Terminally Ill Patients in the Intensive care Unit

Elizabeth Johns, DNP(c), AGACNP-BC, CHPN

Submitted in Fulfillment of the

Requirements of the Doctorate in Nursing Practice

Maryville University

Saint Louis, Missouri

April 2018

HEALTHCARE WORKER IN THE ICU 2

Acknowledgments

There are not enough words to express my gratitude for all those who helped me through

this journey of completing my doctorate of nursing practice. My experiences in the last two years

have shaped me personally and professionally into a better nurse practitioner, a better educator

and a better person.

I would first and foremost like to thank my husband, George, in his unwavering support.

He was always there for me, providing ongoing encouragement as I started each course. Without

him I know I would not have made it through Statistics. There were times when I felt I could not

continue and George was there to push me along and remind that “you’ve got this”. My gratitude

for his support is immeasurable. I am also grateful for the support of my children, Stephen and

Henry. My hope is I have been a role model for my boys and they see that education is a

continuous process and dreams and goals can be achieved if one puts their mind to it.

I would like to thank my faculty chair, Dr. Cathy Hogan, for her support and guidance as

I moved through each course. Dr. Hogan’s guidance was always welcomed as I worried about

how I would get to the next step in my project. Just when I thought I would not make it, Dr.

Hogan’s calming reassurance made me realize I just needed to take each milestone one step at a

time.

I would like to thank my manager and mentor, Lisa Altland, for her words of advice and

guidance as I was choosing my doctorate project and then implementing the project. Finally I

would also like to thank everyone at my hospital who helped in the implementation of project

and participation in the project. I am so fortunate to have such a supportive work environment.

For everyone’s support at Memorial, I am truly thankful.

HEALTHCARE WORKERS IN THE ICU 3

Table of Contents

Title ……………………………………………………………………………… 1

Acknowledgements …………………………………………………………….. 2

Abstract …………………………………………………………………………. 7

Chapter I

Problem Description ……………………………………………………. 8

PICOT Question ………………………………………………………... 9

Purpose …………………………………………………………………. 9

Background …………………….…………………………………........ 10

Significance of the Problem:

Related to Nursing …………………………………………….. 11

Related to Healthcare ……………………………………….. 12

Related to Advanced Practice Nursing ……………………….. 13

Practice Support for Project ………………………………………….. 14

Benefit of Project to Practice ………………………………………… 14


Chapter II

Search History ………………………………………………………... 15

Integrated Review of Literature ……………………………………….. 16

End of Life Care Education …………………………………… 16

Advocate ……………………………………………………… 17

Emotional Toll and Distress of the Healthcare Team ………… 18

Critiquing the Evidence ………………………………………………. 18

Strengths ……………………………………………………… 19

Weaknesses …………………………………………………… 19

Gaps ………………………………………………………….. 19

Limitations …………………………………………………… 20

Concepts and Definitions ……………………………………………... 20

Theoretical Framework/Nursing Theory ……………………………… 20

Chapter III

Methodology ………………………………………………………….. 21

Needs assessment …………………………………………………….. 21

Design

Setting …………………………………………………………. 22


Sample ………………………………………………………… 22

Demographic Data Survey Tool – Table 1 ……………………………. 23

Inclusion and Exclusion Criteria ………………………………………… 24

Data Collection Instrument ……………………………………………… 24

Validity and Reliability …………………………………………. 24

End life Professional Caregiver Survey Tool – Table 2 ………… 25

Analysis Plan ……………………………………………………………. 26

Resources ……………………………………………………………….. 27

Budget …………………………………………………………………… 27

Project timeline ………………………………………………………….. 27

Protecting Human Subjects ……………………………………………… 28

Chapter IV

Demographic Data ……………………………………………………… 29

Table 3 – Years in Profession ………………………………….. 29

Table 4 – Years in Critical Care ………………………………..

Wilcoxon Signed Rank Statistical Test ………………………………… 30


Table 5 – Results ……………………………………………….. 31

Chapter V

Discussion ……………………………………………………………… 32

Limitations ……………………………………………………………… 32

Clinical Significance ……………………………………………………. 32

Application to practice ………………………………………………….. 33

Conclusion ……………………………………………………………… 33

References ………………………………………………………………. 35

Attachments

Attachment A: Recruitment Document ………………………………… 40

Attachment B: Letters of Permission from Hospital ………….………... 42

Attachment C: IRB Approval Letters ………………………………….. 45

Attachment D: End of Life Professional Caregiver Survey Tool

and Permission to use Survey Tool ……………………. 48

Attachment E: Demographic Form …………………………………….. 55

Attachment F: Informed Consent Form ……………………………….. 57

Attachment G: Citi Training Certificate ………………………………. 60

Attachment H: Education Program Outline and PowerPoint ………. 62


Abstract

Patients in the critical care units, defined as the intensive care unit (ICU) and intermediate care

unit (IMCU), are complex and need staff to advocate for patient’s goals of care. The lack of end

of life education for critical care staff, as well as how to conduct goals of care discussions is a

barrier to providing quality end of life care. It also is equally important to provide training on the

symptom management and ethical circumstances surrounding end of life care. As the end of life

for the patient approaches, staff may have concerns about hastening death and may face moral

distress when caring for a dying patient. Education aimed at holding conversations on end of life

care and symptom management is one intervention that can eliminate a barrier to quality end of

life care.


Chapter One

The patient population is aging and with new technology, living longer with chronic

diseases. Even though the quantity of life is increased, it does not necessarily mean the patient

has an improved quality of life. Discussions to clarify goals of care with patients and families in

the intensive care unit (ICU) and intermediate care unit (IMCU) are needed to ensure patient and

family wishes for care are being honored, especially when the patient is at the end of life.

Problem Description

Many times goals of care conversations do not take place due to the healthcare provider

not having the knowledge or confidence needed to discuss with patients and families. As a result,

patient’s wishes for care are not known and continued aggressive care may be provided when the

patient may not have wanted to continue with this treatment path. Quality goals of care

discussions can decrease health care costs, increase patient and family satisfaction and improve

the patient’s quality of life (You et al, 2014).

In the United States approximately 10% of the patients in a hospital are in the intensive

care unit (ICU) and 20% of healthcare costs are attributed to these patients. Furthermore,

approximately 20% of patient deaths occur in the ICU or shortly after a patient has transferred

out of this setting (Curtis, Engelberg, Bensink, & Ramsey, 2012). Patients and families continue

to seek aggressive care many times due to the lack of knowledge about the disease process or

poor communication from the healthcare team. Recently, the World Health Organization has

voiced an opinion that, “expert, palliative and end-of-life care are a top priority for global health

care” (Wu & Volker, 2011, p. 471). Healthcare providers can provide quality end of life care

that promotes an environment of trust and caring provided they have an adequate knowledge

base on communicating and care for patients who are dying.


A death in the ICU can be cold and seem impersonal due to the highly technological

environment. The various machine alarms do not lend well to having personal conversations at

the bedside when a patient is dying. The other challenge the providers may have is the ability to

have conversations on end of life care. The critical care staff are trained for the highly technical

aspects of patient care and may feel in conflict with having these discussions due to lack of

adequate education (Curtis, Engelberg, Bensink, & Ramsey, 2012). Education on effective

communication and active listening techniques will be beneficial for the patient and nurse as the

nurse-patient relationship is built on trust creates a healing and trusting environment where the

patient feels safe and secure.

PICOT Question

The scholarly project was a quality improvement project aimed at changing the practices

of healthcare providers in the critical care setting when faced with caring for a patient who is

considered at the end of their life. The purpose of the scholarly project was to answer the

question, “What is the effect on knowledge and perceptions of critical care providers caring for

terminally ill patients before and after a formal education program on end of life care?”

Purpose

This scholarly quality improvement project was aimed at changing the practices of

healthcare providers in the critical care setting when faced with caring for patients who are

considered at the end of their life. The purpose of the scholarly project was to determine the

baseline knowledge and attitudes of healthcare providers in the critical care setting and see if the

education provided impacted the knowledge and attitudes of the healthcare providers. The goal

of this project was to support a policy change and culture of attention to end of life care through

the delivery of an education program that all critical nurses and physicians will be required to


attend as part of orientation. The change in policy will be addressed through the delivery of an

education program for all critical care nurses, nurse practitioners, physicians and physician

assistants who work or round on patients in the critical care area. The statistical results of the

scholarly project support the need for change in policy to make the education mandatory during

orientation.

The data was on a population of adult healthcare providers (nurses, nurse practitioners,

physicians and physician assistants) who work in the critical care unit, defined as the intensive

care unit (ICU) and intermediate care unit (IMCU), at a community hospital. The data was de-

identified and aggregated. No patient specific information was obtained during this study

Background

Attending to critically ill patients can be demanding, physically and emotionally. It is

hard to be a patient care advocate when the patient or family are difficult to work with and are in

the critical care unit for a lengthy time. When a patient is considered end of life or terminal,

caring for the patient can be even more stressful for the healthcare providers. Conversations

regarding goals of care can be draining and time consuming. Sometimes the path of least

resistance seems to be easiest and not having these difficult discussions with patients or families

is easier, but it is not keeping the patient’s best interest in the forefront. Caring for patients and

remembering each has their own unique story and history is a way to humanize the patient and

encourage the healthcare provider to advocate for the best interest of the patient.

In the American Nurses Association (ANA) position statement regarding end of life care,

nurses should be able to provide end of life care that is compassionate and patient care focused.

Nurses should also work with other members of the healthcare team to establish patient goals for

care and ensure the patient’s wishes for care are being honored. Furthermore, the ANA states the


need for nurses to be able to talk about death and be comfortable with having these discussions

with the patient and family. (American Nurses Association, 2016).

Educating healthcare staff to provide end of life care individualized for the patient, is an

intervention in which increased patient and family satisfaction is seen due to staff engaging more

with the patient and family and being knowledgeable in communication techniques. The lack of

knowledge and training in end of life care on the other hand is a barrier for quality end of life

care in patients as key points about the patients care is many times not relayed to the patient or

family (Hebert, Moore, and Rooney, 2011). Training in end of life care and being proficient

requires the nurse to understand the ethical circumstances surrounding death as well as an

understanding what the disease process holds for the patient in the future. A healthcare provider

who is able to have these discussions with the patient and family are able to provide a caring and

calm environment that will support the decisions made (Curtis, Engelberg, Bensink, & Ramsey,

2012). The American Nurses Association (ANA) Code of Ethics, Provision 1 states, “the nurse

practices with compassion and respect for the inherent dignity, worth and unique attributes of

every person” (2015, p. 7).

Significance of the Problem

Nursing

Caring for a patient who is terminally ill can be emotionally distressing for nursing staff.

Nurses many feel a sense of loss when a patient dies and may also have feelings of conflict or

distress when caring for patients who are receiving futile care in the intensive care unit

(Kinoshita and Miyashita, 2011). Impediments to end of life care can just be due to the

conversion from curative care to end of life care (Kinoshita & Miyashita, 2011, p. 206).

Educating nurses on the provision of quality end of life care in the critical care areas will give


them the knowledge to advocate for their patients when faced with challenging situations

(Kinoshita & Miyashita, 2011; Anderson et al, 2016).

Improved communication can improve the distress of the family and reduce the intensity

of end of life care interventions when curative care becomes futile in the critical are setting

(Elsaman, 2017). The provision of quality end of life education for nurses will provide the nurse

with the needed knowledge to care for the end of life patient more proficiently and be in a

position to better advocate for the patient (Elsaman, 2017). Kinoshita and Mitsunori (2011)

developed a scale for assessing difficulties felt by intensive care nurses providing end of life care

(DFINE). Through this study it was identified when nurses are not comfortable caring for end of

life patients it can have a negative impact patients’ care as continued treatment is provided even

when the outcome is not likely to be favorable (Kinoshita and Mitsunori, 2011). The authors

used The Frommelt Attitudes Toward Care of the Dying Scale (FATCOD-B-J) and the Nursing

Job Stressor Scale (NJSS) to investigate the stress nurses are faced with when caring for a patient

who is at the end of life. (Kinoshita & Mitsunori, 2011). The study suggests that communication

with the family can reduce intensity of end of life care and can also improve the distress the

family is under when faced with end of life decisions.

Healthcare

Healthcare has become highly specialized and at times fragmented in the provision of

care. A patient in the critical care unit typically has multiple physicians caring for them, each

with their own specialty. Communication between providers and the patient and family can

prove to be challenging and frustrating at times in these situations. Many times the nurse at the

bedside finds themselves discussing the patient’s current health status as the provider is not in

the unit the entire shift. These crucial conversations are not ones that can typically be put off for


several hours as patients in the critical care setting can decompensate quickly. Nurses then

become the front line person when the patient is declining rapidly and decisions regarding the

patients care are needing to be made (McCleod, 2014).

Catastrophic and chronic diseases that once killed people swiftly are able to be prolonged

in the critical care setting. New procedures, medications and tests can now keep patients alive

well past their ability to make decisions regarding their care, leaving families to make decisions

about end of life care. Elsaman identified the lack of end of life education in nursing schools is a

worldwide problem; the first critical care book on end of life care was in 1998 and the second

was in 2001 (2017). Anderson et al stated 66% of nurses reported the barrier to providing

adequate end of life care was related to the need of further education on how to communicate

with patients and families experiencing end of life decisions (2016).

Advanced Practice Nursing

Advanced Practice Registered Nurses (APRNs) are qualified and in the position to

address the complex needs of the patient facing a progressive and terminal illness. The 2014

Institute of Medicine’s Dying in America - Improving Quality and Honoring Individual

Preferences at the End of Life report states five areas that will lead to quality palliative care: 1)

Delivery of Person Centered and Family Focused Care; 2) Clinician-Patient Communication and

Advanced Care Planning; 3) Professional Education and Development; 4) Polices and Payment

Systems; and 5) Public Education and Engagement (Hospice and Palliative Nurses’ Association,

2015). APRNs form relationships with patient and families overtime which can enhance

conversations about goals of care and end of life planning. Through interdisciplinary team work,

APRNs are positioned to provide professional education to the nursing staff and other health care


colleagues as well as the general public. Finally since APRN’s have the potential be reimbursed

for care provided they are engaged in payment systems to demonstrate their work

Practice Support for Project

There is significant support for my project within my practice. My organization is a

community hospital affiliated with a large teaching healthcare system. The palliative care

program I was hired to develop eleven years ago has been supported by administration and the

medical staff. Recently the palliative care team has grown as an additional palliative care

specialist (registered nurse) was hired. The education will be presented live during scheduled

education settings. Many of the healthcare providers have indicated their interest in attending the

program as they want the information on end of life care. The critical care unit of the ICU and

IMCU has been receptive to palliative care since the beginning of the program start. In

discussion with the nurse manager and director of these units, both have indicated strong support

and are willing to advocate for the proposed project

Benefit of Project to Practice

Quality end of life care for patients in the critical care unit is challenging. The pace of the

unit is fast paced and decisions regarding care sometimes need to be made quickly. It can be

highly stressful for the healthcare providers to discuss goals of care when medical care is not

working. The process itself of discussing end of life with patients and families may be a barrier

as some providers are facing their own personal beliefs and own experiences and may influence

how the discussion is handled. Consistency in practice and collaboration among the

multidisciplinary team is needed in order to provide quality end of life care. It is through the

education of the entire healthcare provider staff that patients and families should have peace and

dignity throughout the course of illness, including the dying process and time of death itself.


Death in the critical care unit remains commonplace. The baby boomers are getting older,

the technology to sustain life is more sophisticated. The traditional goals of the critical care unit

is to treat the patient and restore health. When this goal cannot be achieved the focus should turn

to comfort and end of life care. When healthcare providers are educated on communicating with

patients and families as well as providing quality end of life care the patient becomes the focus

of the care. It is the goal of this project to implement a new policy for end of life education for all

new healthcare providers to the critical care areas so patients’ dignity can be preserved and

conflict regarding goals of care can be prevented or resolved

Chapter Two

The patient population is aging and with new technology, living longer with chronic

diseases. Even though the quantity of life is increased, it does not necessarily mean the patient

has a quality life. Goals of care discussions with patients and families in the intensive care unit

(ICU) and intermediate care unit (IMCU) are needed to ensure patient and family wishes for care

are being honored, especially when the patient is at the end of life. It is through these discussions

that the creation of an advance directive or healthcare surrogate can be discussed and decisions

about health care can be made. Advance directives, being living will and health care power of

attorney and a surrogate, being a person identified to make decisions as the patient lacks the

decisional capacity to appoint a decision maker.

Search History

An extensive search using the databases through Maryville University Library,

CINHAHL, Medscape, Cochrane Library, University of Phoenix online Library and Google

Scholar was performed. The key words of ICU nurses, terminally ill patients in the ICU, goals of

care discussions, palliative care, end of life care education, end of life care, education for ICU


nurses, nurses’ knowledge on caring for patients at the end of life, knowledge and attitude test on

end life care for nurses, and patient advocacy was used to search for peer reviewed journal

articles published from 2007 to the present.

Integrated Review of Literature

Patients in the ICU and IMCU are complex and need staff to advocate for their wishes.

Through the literature search several themes emerged from the articles. The lack of end of life

education for nurses as well as how to conduct goals of care discussion is a barrier to providing

quality end of life care. Not having the expertise to initiate a family meeting can result in critical

decisions not being made by the family and lead to further frustration of the nursing staff.

(Peterson et al, 2010). It is through the studies of Peterson et al (2010) and White and Coyne

(2011) that the need for communication training programs have been identified as a necessity to

educate nurses on the best way to interact with patients and families faced with a terminal

diagnosis. White and Coyne (2011) discussed the topic of death and dying and discussing these

issues with patients and their families as being ranked in the top three of the core competencies

for end of life care.

End of Life Care Education

Healthcare providers who care for dying patients face complex medical situations

requiring comprehensive care plans that are time intensive to carry out. Symptom management in

a terminally ill patient can be challenging. If the provider lacks knowledge regarding intensive

symptom management, patients will be at a higher risk to be poorly managed. Along with quality

symptom management is the need for nurses to communicate in an effective manner with the

patient and family. Anderson et al stated 66% of nurses reported the barrier to providing

adequate end of life care was related to the need of further education on how to communicate


with patients and families experiencing end of life decisions (2016). It was also identified by

Aslakson, Curtis, and Nelson (2014) as well as Anderson et al (2016), education on end of life

care symptom management is a necessity for nursing staff.

The lack of end of life education in nursing schools and medical schools is a worldwide

problem; the first critical care book on end of life care was in 1998 and the second was in 2001

(Elsaman, 2017). Billings et al (2009) identified the limited exposure medical students have

with dying patients as being a barrier to communicating in the future with patients and families

confronted with a terminal diagnosis.

Advocate

Nurses in the critical care unit advocate for quality patient care. This role has evolved

overtime from indirect to active. The nurse may take the initiative to speak to the medical team

on behalf of the family or may speak to the family on behalf of the patient. The nurse helps the

patient and family to clarify goals of care and explain the implications of medical decisions.

Critical care nurses are able to present the overall picture of the patient condition and ensure the

patient’s wishes are being respected and carried out (Bach, Ploeg and Black, 2009; Barthow et al,

2009).

According to Weissman & Meier (2011) “The need to improve care for patients with

serious, complex, and potentially life-threatening or life limiting medical conditions is

unquestioned” (p.1). One of the recommendations from the Institute of Medicine (IOM) (2015)

was that “all clinicians across disciplines and specialties who care for people with advanced

serious illness should be competent in basic palliative care, including communication skills,

interprofessional collaboration, and symptom management…” (p.10). It is through patient

advocating that the healthcare provider builds the trusted relationships with patients and families.


Emotional Toll and Distress of the Healthcare Team

Healthcare providers are expected to care for patients who are dying. However providers

who are not emotionally prepared for death may experience emotional toll and distress or even a

sense of loss when a patient dies (Kinoshita and Miyashita, 2011). The fear of stopping

aggressive treatment and feeling responsible for the patient’s death is a concern identified by

Adams et al (2011). When care has become futile or potentially inappropriate, providers caring

for the patient nay feel conflicted about continuing care (Kinoshita and Miyashita, 2011; Silen,

Svantesson and Ahlstrom, 2008). Furthermore, when a provider cares for a patient dealing with

death and dying it can lead to more fear and anxiety as they are faced with examining their own

mortality (Harris, Gaudet, & O’Reardon, 2014). The amount of emotional stress placed upon an

ICU can lead to burnout and possible resignation of the job. Anderson et al (2016) identified

through interventions aimed at supporting the nurse educationally and emotionally, the ICU

provider is able to actively participate in goals of care discussion and continue to be an active

member of the patient’s care team.

Critiquing the Evidence

After reviewing the evidence, the need to educate health care providers on end of life care

and how to start conversations on difficult topics such as discussing goals of care in the ICU are

priorities for removing barriers to providing quality end of life care. The lack of education and

barriers the healthcare providers experienced were identified through direct surveys to the staff

in several studies (Elsaman, 2017; Selman et al, 2015; Billings et al, 2009). Overall

communication with families is apparent as a stress for healthcare providers. The process of

discussing end of life with patients and families is a barrier as some providers are facing their

own personal beliefs and past experiences which may in turn influence how the discussion is


handled. Consistency in practice and collaboration among the multidisciplinary team is

recommended in order to provide quality end of life care Billings et al, 2009: Elsaman, 2017).

Strengths

Resources to educate healthcare providers on end of life care are readily available and

discussed in several studies (Adams, 2011; Billings et al, 2010; Mack et al, 2017). The ELNEC

program, developed in 2000 by the American Association of Colleges of Nursing (AACN, 2014)

is a national education initiative called End-of-Life Nursing Education Consortium (ELNEC).

This program was created to train nurses on quality end of life care so could train then other

nurses. The Clinical Practice Guidelines for Quality Palliative Care were published in 2009 as

another educational guide that could be used in ICU (AACN, 2014). These tools promote quality

end of life care for patients.

Weaknesses

End of life care is difficult to find outcome measurements. Not very often will a facility

send out a patient satisfaction survey to a family whose loved one has recently died. Obtaining

data on patient care and satisfaction with the care after death is challenging. Dying patients are

not ideal to question about their satisfaction with their care and after death families may not be as

willing to complete a survey due to the emotional stress. Several studies relied on nursing

assessment of patient’s symptoms (Adams, 2011; Mack et al, 2017).

Gaps

There is an obligation to provide compassionate and comprehensive end of life care, yet

the evidence of interdisciplinary teams coming together to provide this level of care is very little.

Chiplaskey (2008) identified the need for improvement in communication with patients and

families as well as the health care team. Barriers to providing adequate end of life care is related


to the need for further education on communicating with patients and families experiencing end

of life decisions (Anderson et al, 2016, Aslakson, Curtis, and Nelson, 2014). Anderson et al

(2016) reported a small percentage of nurses discuss palliative care with physicians or other

members of the team (31%).

Limitations

Several of the studies relied on convenience sample. This is a helpful sampling plan but

selection bias can occur during the process (Anderson et al, 2016; Billings et al, 2009). Billings

et al (2009) discussed the survey for the study was completed in 2001 and curriculum changes

may have occurred since the study was published in 2009 making the results of the study not

helpful for current studies.

Concepts and Definitions

End of life care is defined as an approach to patient care that supports and treats a person

who is living with or dying from a chronic or life-threatening disease (Selman et al, 2015). This

kind of care can be provided in any level of care but for the purpose of this study the setting will

be in the ICU and IMCU.

Quality of life- “a broad ranging concept that is affected in a complex way by the

person’s health, psychological state, level of independence, social relationships, personal beliefs

and their relationship to salient features of their environment” (World Health Organization,

1997).

Theoretical Framework/Nursing Theory

Jean Watson’s theory of caring is relevant to this study as the theory states the patient is

unique and should be seen by the nurse as an individual whose dignity needs to be preserved

(Zamperetti, Bellomo & Ronco, 2008). The use of this theoretical concept of caring and


educating the nurses on key patient care concepts can promote quality patient care, compassion

as well as overall increased nursing staff satisfaction (Zamperetti, Bellomo & Ronco, 2008). Jean

Watson’s theory of caring is a grand theory with ten carative factors in which a caring

relationship is formed between patient and nurse and as a result a nurturing environment is

created (Zamperetti, Bellomo & Ronco, 2008). Watson’s (2007) theory of caring defines the

relationship between the nurse and terminally ill and their families needed when faced with

difficult decisions.

Chapter Three

Methodology

A convenience sample of critical care staff, to include nurses, nurse practitioners,

physicians and physicians, were invited to participate in the pre-test, education program and

post-test.

The project will answer the following questions.

1. What are the knowledge and attitudes of healthcare providers when caring for patients

who are dying?

2. Does the use of a policy that includes formal education programs change the healthcare

staff’s knowledge and attitude of the dying patient?

3. Will a change in policy alter perceived quality of care as shared by the healthcare

providers?

Needs Assessment

Death is often times seen as a failure of the healthcare system. Healthcare providers who

care for dying patients face complex medical situations requiring comprehensive care plans that

are time intensive to carry out. Symptom management in a terminally ill patient can be


challenging. If the healthcare provider lacks knowledge regarding intensive symptom

management, patients will be at a higher risk to be poorly managed. Along with quality symptom

management is the need for healthcare providers to communicate in an effective manner with the

patient and family (Anderson et al, 2016)

In 1998 the American Association of Colleges of Nursing (AACN) published the

“Peaceful Death: Recommended Competencies and Curricular Guidelines for End-of-Life

Nursing Care” (2016). This publication provided the groundwork for the development of The

End-of-Life Nursing Education Consortium (ELNEC) project. Palliative care clinicians across

the United States worked together to develop the ELNEC curriculum. It was in February 2000

the first ELNEC program began. Initially the project was funded by The Robert Wood Johnson

Foundation. Overtime the program became funded by several other organizations who have an

interest in quality end of life care education. The content is kept current through regular revisions

based on participant recommendations and new advances in the field (AACN, 2016).

Design

Setting

The setting is the critical care units (intensive care unit [ICU] and intermediate care unit

[IMCU]) at a single community based hospital in the Midwest, United States.

Sample

The sample population was all healthcare providers in the ICU and IMCU units at two

hospitals. The invitation was extended to physicians, advance practices nurses (APRN),

physician assistants (PA), and registered nurses (RN). The sample size was thirty participants.

See table one below for the specifics questions asked on the demographic data (the profession

title, length of time in their profession and length of time working in the critical care area).


Table 1 –

Demographic Survey Tool

Participants who are eligible for the scholarly project:

Any male or female with the professional title of nurse, physician, nurse practitioner or physician

assistant, who works on or rounds on patients in the critical care units.

1. Provider Title (Circle Choice)

1. 1 Nurse

1. 2 Physician

1. 3 Nurse Practitioner

1. 4 Physician Assistant

2. Years in your profession 3. Years in critical care (ICU/ IMCU)

(Circle Choice) (Circle Choice)

1. 0-5 1. 0-5

2. 6-11 2. 6-11

3. 12-17 3. 12-17

4. 18-23 4. 18-23

5. 24-29 5. 24-29

6. 30-35 6. 30-35

7. 36 Plus 7. 36 plus


Inclusion and Exclusion Criteria

The inclusion criteria for the project will be any male or female over the age of 18 with

the title of nurse, physician, nurse practitioner or physician assistant who works or rounds on

patients in the ICU or IMCU. There will not be a control group as the project is measuring

knowledge and perceptions before and after a formal educational offering. Any staff member

who does not work in the critical care area or who does not have the title of nurse, physician,

nurse practitioner or physician assistant will be excluded.

Data Collection Instrument

The data will be collected from the End of Life Professional Caregiver survey (EPCS)

form and placed into an excel spreadsheet. There is no need to randomize as the selection

process as it is a convenience sample. Since the pretest and posttest will be given on the same

day the return of survey should be close to 100%.

Validity and Reliability

The author will use the End of Life Professional Caregiver Survey (EPCS) for the pretest

and posttest to measure the critical care staff baseline educational needs and then their

knowledge after the formal education. The EPCS was developed as a tool to assess educational

needs across the profession, not just nurses. The multidisciplinary assessment strengthens the

results of this study further as the tool is shown to be valid in more than just the nursing

population (Lazenby, Ercolano, Schulman-Green, & McCorkle, 2011). The survey covers the

eight domains for the national palliative care guidelines and the curriculum modules for both

physician and nurse specific end of life education. The EPCS survey was examined for validity

and was found to exhibit strong internal reliability (Lazenby, Ercolano, Schulman-Green, &

McCorkle, 2011). The survey is being used with permission from Yale University with the


requirement of citation of the original article (Lazenby, Ercolano, Schulman-Green, &

McCorkle, 2011).

Table 2 –

End-of-Life Professional Caregiver Survey Tool (Used for both the Pre and Post Test)

Participant: _______________________ (***these will be coded with a number)

Below is a list of statements that other end-of-life professional caregivers have said are important. Please

circle one number per line to indicate your response as it applies to you today.

Not at all

A little bit

Some-what

Quite a Bit

Very Much

A I am comfortable helping families to accept a poor prognosis

0 1 2 3 4

B I am able to set goals for care with patients and families

0 1 2 3 4

C I am comfortable talking to patients and families about personal choice and self-determination

0 1 2 3 4

D I am comfortable starting and participating in discussions about code status

0 1 2 3 4

E I can assist family members and others through the grieving process

0 1 2 3 4

F I am able to document the needs and interventions of my patients

0 1 2 3 4

G I am comfortable talking with other health care professionals about the care of dying patients

0 1 2 3 4

H I am comfortable helping to resolve difficult family conflicts about end-of-life care

0 1 2 3 4

I I can recognize impending death (physiologic changes)

0 1 2 3 4

J I know how to use non-drug therapies in management of patients’ symptoms

0 1 2 3 4

K I am able to address patients’ and family members’ fears of getting addicted to pain medications

0 1 2 3 4

L I encourage patients and families to complete advanced care planning

0 1 2 3 4

M I am comfortable dealing with ethical issues 0 1 2 3 4


related to end-of-life/hospice/palliative care

N I am able to deal with my feelings related to working with dying patientsI am able to be present with dying patients

0 1 2 3 4

O I can address spiritual issues with patients and their families

0 1 2 3 4

P I am comfortable dealing with patients’ and families’ religious and cultural perspectives

0 1 2 3 4

Q I am comfortable providing grief counseling for families

0 1 2 3 4

R I am comfortable providing grief counseling for staff

0 1 2 3 4

S I am knowledgeable about cultural factors influencing end-of-life care

0 1 2 3 4

T I can recognize when patients are appropriate for referral to hospice

0 1 2 3 4

U I am familiar with palliative care principles and national guidelines

0 1 2 3 4

V I am effective at helping patients and families navigate the health care system

0 1 2 3 4

W I am familiar with the services hospice provides

0 1 2 3 4

X I am effective at helping to maintain continuity across care settings

0 1 2 3 4

Y I feel confident addressing requests for assisted suicide

0 1 2 3 4

Z I have personal resources to help meet my needs when working with dying patients and families

0 1 2 3 4

AA I feel that my workplace provides resources to support staff who care for dying patients

0 1 2 3 4

English (Universal) 19 April 2012 Copyright 2012

Analysis Plan

The data collected will be analyzed using SPSS. Dr. Michael Landry, Maryville

University Statistician, provided guidance in determining the appropriate statistical analysis.

After consultation with Dr. Landry, the Wilcoxon Rank Statistical Test was deemed the most

appropriate for the data collected. The Wilcoxon Signed Rank statistical test was used for the


scholarly project as it is a test used for matched or paired data that come from the same

participants. In this case the same survey tool was used for the pretest and the posttest. The

Wilcoxon Signed Rank is based on difference scores, but in addition to analyzing the signs of the

differences, it also takes into account the magnitude of the observed differences (LaMorte,

2017).

Resources

Regular meetings with the members of the doctoral project committee included a

representative from the hospital, committee chair and faculty took place to assure quality and a

functional process. Data analysis was performed collaboratively both within the facility and the

university. All communications via email took place through a secured server.

Budget

The survey tool is able to be used at no charge. Permission was granted by the primary

author, Dr. Mark Lazenby. Employees participating in the project were not compensated for

attending, however many of the staff were working on the day of the educational offerings and

were allowed to attend during work time.

Project Timeline

IRB approval was received from the Belleville Community Institutional Review Board

on November 2, 2017. Maryville IRB approval was received February 12, 2018. The data

collection was obtained from the time period February 12, 2018 through March 15, 2018. A

convenience sample of thirty participants was obtained during this time frame. The data was then

analyzed using the SPSS program with the assistance of Dr. Michael Landry, Maryville

University Statistician. The final DNP project was disseminated at Maryville University on

Thursday, April 12, 2018.


Protecting Human Subjects

The author has taken steps to protect the confidentiality of the participants. The survey

sheets were de-identified and did not ask for names, phone numbers or addresses. The project did

not use any patient subjects so no patient specific information was kept or used. The completed

survey forms were kept in a locked drawer until the completion of the data collection and then

shredded once the information was inputted into excel. The computer that has the excel

spreadsheet is secured by a login and password and is located in a locked office. Furthermore,

the following approvals will be granted before the beginning of any project

Maryville University Institutional Review Board approval.

Belleville Community Institutional Review Board approval (BCIRB).

Collaborative Institutional Training Initiative (CITI Program); valid affiliation with the

CITI Program subscribing institution. A requirement of Maryville University and BCIRB


Chapter Four

Demographic Data

The scholarly project yielded a sample size of thirty healthcare providers. Twenty

participants were nurses and ten were nurse practitioners. No physicians or physician assistants

participated in the project. The two charts below detail the demographic information of length of

time in their profession and length of time working in the critical care area.

Table 3 –

Years in Profession

0-5 6-11 12-17 18-23 24-29 30-35 36 Plus0

1

2

3

4

5

6

7

8

Years in Profession

Years

Heal

thca

re P

rovi

ders


Table 4 –

Years in Critical Care

0-5 6-11 12-17 18-23 24-29 30-35 36 Plus0

2

4

6

8

10

12

14

Years in Critical Care

Years

Heal

thca

re P

rovi

ders

Wilcoxon Signed Rank Statistical Test

There are three assumptions required for a Wilcoxon signed-rank test to a valid result.

The first two assumptions relate to the study design and the types of variables you measured. The

third assumption reflects the nature of the data. The first assumption is the dependent variable is

measured as the ordinal level. In the scholarly project the survey tool uses a Likert scale. The

second assumption is the variable should consist of matched pairs. In the scholarly project the

survey is given to the same people pre education and post education. Finally in assumption three,

the distribution of the differences between the two related groups needs to be symmetrical in

shape (LaMorte, 2017).

In the table below the pvalue is reported as this is value that determines if the hypothesis

is null. It is considered statistically significant if p is less than 0.005 (LaMorte, 2017).


Table 5 –

Wilcoxon Signed Rank

Survey Question pvalueI am comfortable helping families to accept a poor prognosis .000I am able to set goals for care with patients and families .005I am comfortable talking to patients and families about personal choice and self-determination

.035

I am comfortable starting and participating in discussions about code status .004I can assist family members and others through the grieving process .005I am able to document the needs and interventions of my patients .001I am comfortable talking with other health care professionals about the care of dying patients

.003

I am comfortable helping to resolve difficult family conflicts about end-of-life care .003I can recognize impending death (physiologic changes) .005I know how to use non-drug therapies in management of patients’ symptoms .000I am able to address patients’ and family members’ fears of getting addicted to pain medications

.000

I encourage patients and families to complete advanced care planning .003I am comfortable dealing with ethical issues related to end-of-life/hospice/palliative care .000I am able to deal with my feelings related to working with dying patientsI am able to be present with dying patients

.739

I can address spiritual issues with patients and their families .004I am comfortable dealing with patients’ and families’ religious and cultural perspectives .002I am comfortable providing grief counseling for families .001I am comfortable providing grief counseling for staff .000I am knowledgeable about cultural factors influencing end-of-life care .001I can recognize when patients are appropriate for referral to hospice .001I am familiar with palliative care principles and national guidelines .017I am effective at helping patients and families navigate the health care system .001I am familiar with the services hospice provides .003I am effective at helping to maintain continuity across care settings .000I feel confident addressing requests for assisted suicide .000I have personal resources to help meet my needs when working with dying patients and families

.005

I feel that my workplace provides resources to support staff who care for dying patients .046


Chapter Five

Discussion

Patients in the critical care unit are complex and need staff to advocate for their wishes.

The lack of end of life education for critical care staff, as well as how to conduct goals of care

discussions, is a barrier to providing quality end of life care. Not having the expertise to initiate a

family meeting can result in critical decisions not being made by the family and lead to further

frustration of the staff. (Peterson et al, 2010). End of life care can be costly. In 2015, Medicare

averaged the cost of care for a person who died to be approximately $34,529 per beneficiary.

This is almost four times higher than the average cost per capita for seniors who did not die

during the year (The Henry Kaiser Family Foundation, 2017). Education of staff who interact

with patients and families faced with a terminal diagnosis is necessary to provide patient

centered care and ensure the wishes of the patient are being honored (Peterson et al, 2010, White

and Coyne, 2011). The scholarly project has the potential to not only change the staff perceptions

but could also impact the cost of patient care, as well as patient and family satisfaction.

Limitations

Limitations to the scholarly project included a small sample size and no physician

respondents. Nurses and nurse practitioners were the two disciplines participating in the

scholarly project. Additional participants and disciplines would strengthen the results of the

project. The project also used a convenience sample of healthcare providers who either worked

or rounded on patients in the critical care areas. This could limit generalizability to other areas.

Clinical Significance

The clinical significance of this project is highlighted by the highly significant results of

the survey. The questions in the End of life Professional Caregiver survey (EPCS) reveal the


education is helpful to the staff and would be beneficial to staff in the future. Conducting follow

up survey questionnaires in 6 months to a year would help to establish sustainability of the

information and evaluate if knowledge and perceptions have changed over time.

Application to Practice

The project would be able to be replicated by another researcher as it uses a simple

demographic survey form, the End of Life Professional Caregiver Survey and modules from the

End of life Nursing Education Consortium Project (ELNEC). The scholarly project has

applicability to other nursing units as terminally ill patients are not just in the critical care areas.

This particular setting (critical care) was initially identified as the sample size would be easily

reached and several disciplines would be able to be surveyed as many physicians, nurse

practitioners and physician assistants round on patients in the critical care areas but it is very

feasible that this project could be reproduced again in other nursing units.

Using the ELNEC program will maintain consistency in the education program so all

staff are educated on the same topics and subsequently the annual updates to the education

program. Providing annual updates will be simple as the ELNEC program is kept current through

regular revisions based on participant recommendations and new advances in the field (AACN,

2016).

Conclusion

A policy change is currently being drafted to implement end of life education for all new

critical care staff as part of the orientation process. Further education will also be scheduled for

the current staff who were unable to attend the initial end of life training sessions. New staff

members will also be required to shadow with the palliative care team. The scholarly project is a

starting point to changing the practices of healthcare providers in the critical care setting when


faced with caring for a patient who is considered at the end of their life. It is through the

exploration of healthcare providers’ baseline knowledge and perceptions that statistical

significance was found after provision of education on end of life care.

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Adams, J., Anderson, R., Bailey, D. & Docherty, S. (2011). Nursing roles and strategies in end

of life decision making in acute care: A systematic review of the literature. Nursing

Research and Practice, 2011, 1-15. Doi: 10.1155/2011/527834

American Association of Colleges of Nursing. [AACN]. (2016). ELNEC fact Sheet. Retrieved

from http://www.aacn.nche.edu/elnec/about/fact-sheet.

American Association of Colleges of Nursing. [AACN]. (2014). Peaceful death: Recommended

competencies and curricular guidelines for end-of-life Retrieved from

http://www.aacn.nche.edu/elnec/publications/peacefuldeath

American Nurses Association [ANA]. (2016). Position statement: Nurses’ roles and

responsibilities in providing care and support at the end of life. Retrieved from

http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-

Statements/EndofLife-PositionStatement.pdf.

American Nurses Association [ANA]. (2015). Code of ethics for nurses with interpretive

statements. Retrieved from

http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-Nurses.html.

Anderson, W., Puntillo, K., Boyle, D., Barbour, S., Turner, K., Cimino, J., Moore, E., Noort, J.,

MacMillan, J., Pearson, D., Grywalski, M., Liao, S., Ferrell, B., Meyer, J., O'Neil-Page,

E., Cain, J., Herman, H., Mitchell, W., & Pantilat, S. (2016). ICU bedside nurses’

involvement in palliative care communication: A multicenter survey. Journal of Pain and


Symptom Management, 51(3), 589-596.

Aslakson, R. A., Curtis, J. R., & Nelson, J. E. (2014). The Changing Role of Palliative Care in

the ICU. Critical Care Medicine, 42(11), 2418–2428.

http://doi.org/10.1097/CCM.0000000000000573

Bach, V., Ploeg, J., & Black, M. (2009). Nursing roles in end of life decision making in critical

care settings. Western Journal of Nursing Research, 31(4), 496-512

Barthow, C. Moss, C., McKinlay, L., McCullough, L., & Wise, D. (2009). To be involved or not:

Factors that influence nurses’ involvement in providing treatment decisional support in

advanced cancer. European Journal of Oncology Nursing, 13(1). 22-28.

Billings, M., Engelberg, R., Curtis, J., Block, S., & Sullivan, A. (2009). Determinants of medical

students’ perceived preparation to perform end of life care, quality end of life care

education, and attitudes toward end of life care. Journal of Palliative Medicine, 13(3),

319-326. Doi: 10.1089/jpn.2009.0293

Chiplaskey, L. M. (2008). End-of-life care: Are nurses educationally prepared? RN Journal.

Retrieved from http://rnjournal.com/journal-of-nursing/end-of-life-arenurses-

educationally-prepared

Curtis, J. R., Engelberg, R. A., Bensink, M. E., & Ramsey, S. D. (2012). End-of-Life Care in the

Intensive Care Unit: Can We Simultaneously Increase Quality and Reduce Costs?

American Journal of Respiratory and Critical Care Medicine, 186(7), 587–592.

Retrieved from http://doi.org/10.1164/rccm.201206-1020CP.

Elsaman, S. (2017). Undergraduate critical care nursing students’ knowledge and attitudes

toward caring of dying patients. Journal of Nursing and Health Science, 6(1), 31-40.


Harris, M., Gaudet, J., & O’Reardon, C. (2014). Nursing care for patients at end-of-life in adult

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Hasheesh, M., Al-Sayed, S., El-Said, S., & Abdullah, A. (2013). Nurses’ characteristics and their

attitudes toward death and caring for dying patients in a public hospital in Jordan. Health

Science Journal, 7(4), 384-394.

Hebert, K., Moore, H., & Rooney, J. (2011). The Nurse advocate in end-of-life care. The

Ochsner Journal, 11(4), 325–329. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241064/

Hospice and Palliative Nurses Association. (2017). HPNA position statement: Value of the

advanced practice registered nurse in palliative care. Retrieved from

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Advanced-Practice-Registered-Nurse-in-Palliative-Care.pdf

Institute of Medicine (2015). Dying in America Improving quality and honoring individual

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Nursing, 27, 202-210.

LaMorte, W. (2017). Wilcoxon signed ranked test. Retrieved from

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BS704_Nonparametric6.html


Lazenby, M., Ercolano, E., Schulman-Green, D. & McCorkle, R. (2011). Validity of the end of

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What is so stressful about caring for a dying patient? A qualitative study of nurses'

experiences. International Journal of Palliative Nursing, 16(4), 181-187.

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Weissman, D. E., & Meier, D. E. (2011). Identifying patients in need of a palliative care

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2648.2011.05770.

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Zamperetti, N., Bellomo, R., & Ronco, C. (2008). Bioethical aspects of end-of-life care.

European Journal of Anaesthesiology Suppl., 42, 51-57. Retrieved from Medscape.com.


ATTACHMENT A

RECRUITMENT DOCUMENT: ADVERTISEMENT FOR HEALTHCARE STAFF


ATTACHMENT B

LETTERS OF PERMISSION FROM MEMORIAL HOSPITAL


ATTACHMENT C

IRB APPROVAL LETTERS


Date: February 9, 2018

To: Ms. Elizabeth Johns – Doctoral Candidate, Nursing Practice

From: Dr. Robert Bertolino, Chair, Institutional Review BoardDr. Tammy M. Gocial, Integrity Officer for Institutional Review Board

RE: IRB Review of Protocol #17-61Title: “Knowledge and Perceptions among Healthcare Workers Caring for Terminally Ill

Patients in the Critical Care Unit”

CC: Dr. Cathy Hogan – Assistant Professor of Nursing and Project Chair

This is to inform you that your application to conduct research has been reviewed and accepted by the Maryville University Institutional Review Board. You are now authorized to begin the research as outlined in your proposal.

It is understood that this project will be conducted in full accordance with all applicable sections of the IRB guidelines as published by Maryville University. It is also understood that the IRB will be notified immediately of any proposed changes that may affect the status of your research proposal. As the principal investigator(s), you are required to notify the Maryville University IRB of any adverse reactions that may develop as a result of this study. Finally, when your research has concluded (or if you conclude the study sooner than anticipated), please complete the Protocol Closure Form. If informed consent processes were a part of your proposal, an approved, stamped version is attached to this document.

Good luck on your research.


ATTACHMENT D

END OF LIFE PROFESSIONAL CAREGIVER SURVEY

(TO BE USED FOR BOTH THE PRE AND POST SURVEY)

AND

PERMISSON TO USE THE SURVEY


End-of-Life Professional Caregiver Survey: Pre Education Survey




Not at all

A little bit

Some-what

Quite a Bit

Very Much


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4

M I am comfortable dealing with ethical issues related to end-of-life/hospice/palliative care

0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4

Q I am comfortable providing grief counseling for families

0 1 2 3 4

R I am comfortable providing grief counseling for 0 1 2 3 4


staff


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4

W I am familiar with the services hospice provides 0 1 2 3 4

X I am effective at helping to maintain continuity across care settings

0 1 2 3 4


0 1 2 3 4


0 1 2 3 4

A

A

I feel that my workplace provides resources to support staff who care for dying patients

0 1 2 3 4


Reference

Lazenby, M., Ercolano, E., Schulman-Green, D., & McCorkle, R. (2012). Validity of the end-of-

life professional caregiver survey to assess for multidisciplinary educational needs.

Journal of Palliative Medicine, 15(4), 427-431


End-of-Life Professional Caregiver Survey: Post Education Survey




Not at all

A little bit

Some-what

Quite a Bit

Very Much


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4

M I am comfortable dealing with ethical issues related to end-of-life/hospice/palliative care

0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4

Q I am comfortable providing grief counseling for 0 1 2 3 4


familiesR I am comfortable providing grief counseling for

staff0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4


0 1 2 3 4

W I am familiar with the services hospice provides 0 1 2 3 4X I am effective at helping to maintain continuity

across care settings0 1 2 3 4


0 1 2 3 4


0 1 2 3 4

AA

I feel that my workplace provides resources to support staff who care for dying patients

0 1 2 3 4


Reference

Lazenby, M., Ercolano, E., Schulman-Green, D., & McCorkle, R. (2012). Validity of the end-of-

life professional caregiver survey to assess for multidisciplinary educational needs.

Journal of Palliative Medicine, 15(4), 427-431


Permission to Use Survey Tool

From: Lazenby, Mark [mailto:[email protected]]

Sent: Monday, October 30, 2017 2:07 PM

To: Elizabeth Johns

Subject: Re: End of Life Professional Caregiver Survey

Dear Ms. Johns

You have my permission to use the End-of-Life Professional Caregiver Survey.

Mark Lazenby

Yale University School of Nursing

100 Church Street South

New Haven, CT 06536

E-mail: [email protected]

From: Elizabeth Johns <[email protected]>

Sent: Monday, October 30, 2017 1:35:16 PM

To: Lazenby, Mark

Subject: End of Life Professional Caregiver Survey

Good afternoon Dr. Lazenby,

I am a DNP student who has chosen a project on education on end of life care in the critical care unit. I

found the End of Life Professional Caregiver Survey as well as the article validating the tool during my

literature search. I reaching out to you as I would like to use this tool in my project. I am in the process of

mailto:[email protected]



applying for the IRB at both my hospital and the University. I am needing to obtain permission in order to

use this tool. I completed the form on the Yale School of Nursing website, indicating I would share my

results. The IRB board is looking for something more formal in regards to using a copywrited tool. I am

reaching out to you as you were listed as the contact person on the journal article. I appreciate your help.

Sincerely,

Beth Johns

Beth Johns, MSN/ED, AGACNP-BC, CHPN

Complex and Palliative Care Nurse Practitioner

Memorial Hospital Belleville

4500 Memorial Drive

Belleville, IL. 62226

Office 618-257-4211

Cell 618-767-2667

Fax 618-257-6720

[email protected]



ATTACHMENT E

DEMOGRAPHIC FORM


Demographic Data

Participants who are eligible for the scholarly project:

Any male or female with the professional title of nurse, physician, nurse practitioner or physician

assistant, who works on or rounds on patients in the critical care units.

1. Provider Title (Circle Choice)

1. Nurse

2. Physician

3. Nurse Practitioner

4. Physician Assistant

2. Years in your profession 3. Years in critical care (ICU/ IMCU)

(Circle Choice) (Circle Choice)

1. 0-5 1. 0-5

2. 6-11 2. 6-11

3. 12-17 3. 12-17

4. 18-23 4. 18-23

5. 24-29 5. 24-29

6. 30-35 6. 30-35

7. 36 Plus 7. 36 plus


ATTACHMENT F

INFORMED CONSENT FORM


INFORMED CONSENTTitle of Project: Knowledge and Perceptions Among Healthcare Workers Caring

for Terminally Ill Patients in the Critical Care Unit.

You are being asked to participate in a project through Maryville University by Doctorate of Nursing Practice student, Elizabeth Johns, MSNed, AGACNP-BC, CHPN. This project is being overseen by Dr. Cathy Hogan, Assistant Professor of Nursing and Faculty Advisor. Prior to the start of the program the informed consent form, survey form and demographic sheet will be explained. The project will take place at Memorial Hospital where Elizabeth Johns currently practices as a Nurse Practitioner.

The purpose of the scholarly project is to determine the baseline knowledge and perceptions of healthcare providers in the critical care setting and see if the education provided impacts the knowledge and perceptions of the healthcare providers.

If you choose to participate you will be asked to sign an informed consent form and complete a demographic sheet. An educational program will be provided on communicating with patients and families facing a terminal illness and symptom management of the terminally ill. The amount of time needed for your participation will be 30 minutes. The surveys will be given before and after the educational session. A signed consent does not mean you are required to complete the survey.

To ensure confidentiality, a locked box will be placed in the back of the room to collect all surveys and demographics sheets following completion. The informed consent form will be collected and stored separately from any data related to the project. No identifying information will be placed on any of the surveys or demographic sheets.

Data will be stored in a locked office in a locked drawer. Data entered into the excel spreadsheet may be accessed by the Principal Investigator, Dr. Cathy Hogan and a Statistician. All surveys, demographic forms and consent forms will be shredded at the conclusion of the scholarly project.

The education is low risk to the participants but may elicit some emotions as topics of end of life care will be discussed. You may choose not to participate if you so wish. You may withdraw consent to participate at any time. No monetary gifts or compensation will be provided for completion of the surveys or program. At the completion of the project the results of the surveys will be disseminated in aggregate form through the student’s doctorate of nursing presentation, hospital newsletter and made available to the critical care staff at future staff meetings.

Page 1 Initials: __________ Date: ____________________


Some of the potential benefits for participating in the project include: 1) Changing how terminally ill patients are cared for in the critical care areas, 2) Feeling more educated on caring for patients who are terminal, and 3) Developing communication skills to discuss difficult topics in the critical care unit.

If you have any questions regarding this study, or if any problems arise, you may call the Principal Investigator, Elizabeth Johns at 618-257-4211 or Dr. Cathy Hogan, faculty adviser at 618-529-9219. You may also ask questions, state concerns regarding your rights as a research subject, or express any feelings of pressure to participate by contacting: Dr. Robert Bertolino, Chair of the Institutional Review Board at Maryville University, (314) 529-9659.

Maryville University recognizes its federally mandated responsibility to ensure that research be conducted in an ethical and scholarly manner, respecting the rights and welfare of all the human participants. Any research misconduct including but not limited to fabrication, falsification, or plagiarism in proposing, performing and reviewing research, or in reporting research results, should be reported to Dr. Tammy Gocial, the Research Integrity Officer at Maryville University at (314) 529-6893.

Maryville University investigators, and their colleagues who are conducting scholarly projects and research, recognize the importance of your contribution to the projects and research studies which are designed to improve therapeutic care and educational learning environments. Maryville University investigators and their staff will make every effort to minimize, control, and treat any complication that may arise as a result of this project.

By signing this form, you acknowledge that you are at least 18 years of age, that you have read and understand this form, and that you have had an opportunity to ask questions about the scholarly project. You are voluntarily agreeing to participate in a project based on the information presented to you. You may choose to withdraw at any time without prejudice or penalty. You will receive a copy of this form, which will include the name and phone number of the Principal Investigator and the IRB at Maryville University, should you have any questions.

Signed:

______________________________________________________________

Date:

________________________________________________________________

Principal Investigator’s Signature:

_______________________________________

Date:

________________________________________________________________


Principal Investigator’s Phone Number: __618-257-4211 (Elizabeth Johns) ______

The date approval stamp on this consent form indicates that the project has been reviewed and approved by the Maryville University Institutional Review Board.

ATTACHMENT G

CITI TRAINING CERTIFICATE

Institutional Review BoardProtocol #17-61Initiation Date: February 9, 2018Termination Date: February 8, 2019Approved by: Tammy M. Gocial, Ph.D.


ATTACHMENT H

EDUCATION PROGRAM OUTLINE

POWERPOINT PRESENTATION FOR STAFF


1. Outline for Education Program

a. Importance of the Topic

i. 10% of patients in the hospital are in ICU

ii. 20% of healthcare costs are ICU patients

iii. 20% of death occur in the ICU

iv. Challenges in the ICU for nurses

1. Highly technological Environment

2. Various stimuli are distracting

3. Lack of education on end of life care

4. Ethical concerns on end of life care

b. Definition of key terms

i. Terminal care

ii. Futile care

iii. Palliative Care

iv. Hospice Care

c. How to conduct family meetings

i. SPIKES mnemonic

d. Symptom management in the terminally ill patient

i. Comfort wean/compassionate wean order set

ii. Hospice care in the hospital setting

iii. Order sets for common issues in hospice

1. Pain

2. Nausea/vomiting


3. Anxiety

4. Constipation or diarrhea

e. Potentially inappropriate medical care

i. Formerly known as futile care

ii. When to stop and how to stop medical treatment

iii. Ethical Considerations

1. When to consult the ethics committee

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