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NATIONAL EDUCATIONAL VIDEO, INC. TM © 2002

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HCP33

PROGRAM GUIDE FOR HEALTHCARE PROFESSIONALS

National Educational Video, Inc.TM is an approved provider of continuing education. State Board provider numbers: Florida NCE2896, Alabama 5-97, California CEP8803, Kentucky 7-0045 and West Virginia WV96-0025RN. This activity provided by National Educational Video Inc. is approved as a provider of continuing education in nursing by Alabama State Nurses Association, which is accredited as an approver of continuing education in nursing by The American Nurses Credentialing Center's Commission on Accreditation.


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OUTLINE OFCOURSE CONTENT

CONTINUING EDUCATION Title of Educational Activity END OF LIFE Contact Hours 2 The presenter for our program are the script writers who write the program guide and the script for the program. The facilitator/subscriber/purchaser of our program can also be considered the presenter as he/she directs the class and the participants through the guide and the video. The distribution of handouts, glossary terms, taking of the pre-test/post-test and discussion of correct answers takes about 20 minutes. The discussion questions should take 30 minutes.


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OUTLINE OF COURSE CONTENT

CONTINUING EDUCATION Objectives Content (Topics) Time

Frame Faculty Teaching

Method List objectives in Operational and Behavioral terms

List each topic area covered and provide a description or outline of the content to be presented

State the time frame for the topic area

List the faculty persons or presenter for each topic

Describe the teaching method (s) used for teaching

Describe the importance of having an end of life care plan.

Definition of End of Life Care Plan. Reasons/purpose for having end of life care plan. Provides information on:

Spiritual beliefs and values that can be used in guiding decisions regarding treatment and care during last stages of life

Individual’s hopes and expectations to be considered in evaluating new treatments.

What is included in an end of life care plan:

Advance Directives / Living Wills Health Care Surrogate Do Not Resuscitate Orders Family concerns Where the person wants to die Concerns about pain and suffering Financial considerations Times for review and evaluation

25 minutes

Presenter Video, glossary, discussion questions

Identify situations when end of life care plans should be made and/or reviewed.

Situations identified when individual is facing significant life changes or health problems likely to result in decline and/or death:

Entering hospital for serious illness Admitted to long term care facility

5 minutes Presenter Video, discussion questions


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CONTINUING EDUCATION (continued) Objectives Content (Topics) Time


Method Differentiate between spirituality and religiosity.

Definition of spirituality Definition of religiosity Importance of differentiating between the two which allows for more open communication and ability to identify and meet needs of individual and family/ caregivers

5 minutes Presenter Video, discussion questions

Identify dimensions of the supportive role of the nurse in palliative care.

Definition of palliative care Pain management Nutrition Hydration Terminal hydration Sign and Symptoms Treatment

Dimensions of supportive care Valuing Connecting Empowering Facilitating Encouraging Defusing Mending Giving information

Doing for Pain and symptom control Making arrangements Lending a hand Team playing

Finding meaning Focusing on living Acknowledging death Preserving own integrity

20 minutes Presenter Video, discussion questions Follow up reference reading

Recognize significant characteristics of physiologic death.

Physiologic signs and symptoms of impending death caused by irreversible failure of vital body systems. Nurses role in guiding individual and family discussions and decisions

10 minutes Presenter


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CONTINUING EDUCATION (continued) Objectives Content (Topics) Time


Method Be able to identify spiritual needs of patients.

Define Spirituality Ways to express spirituality Identify spiritual resources Chaplains Priests / Ministers Lay Ministers from churches Bible Music Prayer Daily Devotions

Spiritual Assessment JAREL Well-Being Scale Taxonomy of Spiritual Diagnosis

Spiritual Distress Spiritual Pain Spiritual alienation Spiritual anxiety Spiritual guilt Spiritual anger Spiritual loss Spiritual despair

25 minutes Presenter Video, Discussion questions Video, discussion questions

Write an end of life care plan for a patient.

Blank sample form provided to practice. Can use the case presentation in discussion questions or have one of participants volunteer

15 minutes Presenter Video, discussion questions, Hand outs


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INTRODUCTION

OBJECTIVES At the end of the program the learner will be able to:

1. Describe the importance of having an end of life care plan.

2. Differentiate between spirituality and religiosity.

3. Identify situations when end of life care plans should be made.

4. Identify dimensions of the supportive role of the nurse in palliative care.

5. Recognize significant characteristics of physiologic death.

6. Be able to identify spiritual needs of patients.

7. Write an end of life care plan for a patient.


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GLOSSARY OF KEY TERMS

ADL’S Refers to activities of daily living such as bathing, eating, dressing,

toileting, and transferring. Advance Directives Written documents or oral statements in which instructions are given by

an individual expressing desires relating to health care and includes, but is not limited to a living will, designation of health care surrogate and in some states an anatomical gift.

Do Not Resuscitate Orders A written order by a physician to not institute cardio-pulmonary

resuscitation. End of Life Care Plan A way to set goals for medical treatment, social, emotional and spiritual

supports in all stages of a person’s care from the time they face serious illness or decline until their death. It provides a context within which new treatments can be considered in light of the patient’s personal goals.

Health Care Surrogate Any competent adult designated by another to make health care

decisions on behalf of that individual if the individual is unable to make the decision because he/she is incapacitated for any reason.

Holistic Refers to treating a person as a whole made up of several components

that are inter-related and interdependent on each other. They are mind, body, and spirit.

IADL’s Refers to Instrumental activities of daily living. Examples are ability to

use the telephone, prepare food, housekeeping, shopping, and responsibility for own medication.

Living Will One type of advance directive. An individual makes known specific

wishes regarding types of medical care to be made at the end of life regarding types of treatments/procedures to be made concerning life-prolonging procedures when the individual is not able to make their wishes and desires known.

Health Care Proxy A person appointed to make decisions for an individual regarding health

care decisions for that individual in situations in which the individual is not able to make the decision.


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(Continued) Palliative Care The comprehensive management of the physical, psychological, social,

spiritual, and interpersonal needs of patients. Palliative care is especially suited to the care of individuals who have incurable, progressive diseases.

Pre-Hospital Do Not Resuscitate Orders Orders written by a physician and signed by an individual or the Health

Care Surrogate/guardian that allow Emergency Management Personnel to NOT institute CPR in cases of cardiac or respiratory arrest. This is legal in some states, but not all. It does not eliminate other emergency or comfort treatments such as administration of oxygen or pain medication.

Religious Practice One of the ways individuals express personal spirituality. Generally

associated with organized religions. Spirituality An expression of how a person relates to a larger whole, whether it is

God, a higher power or the human family. The spiritual dimension of a person integrates and transcends the biological and psychosocial nature.

Spiritual Alienation Loneliness, or the feeling that God seems very far away and remote

from one’s everyday life; having to depend on self in times of trial or need; negative attitude toward receiving any comfort or help from God.

Spiritual Anger Frustration, anguish or outrage at God for having allowed illness or

other trials, the unfairness or God; negative about institutional religion and its ministers.

Spiritual Anxiety Fear of god’s wrath and punishment; fear that God might not take care

of one, either immediately or in the future; worry tat God is displeased with one’s behavior.

Spiritual Despair No hope of ever having a relationship with God, or pleasing God;

feeling that God no longer can or does care for one. Spiritual Guilt Feeling that one has failed to do the things which he or she should have

done in life, and/or things which were not pleasing to God; concerns about the kind of life one has lived.


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(Continued) Spiritual Loss Feeling of having temporarily lost or terminated the love of God; fear

that one’s relationship with God has been threatened; feeling of emptiness with regard to spiritual things.

Spiritual Pain Discomfort or suffering or lack of peace relative to one’s relationship

with God; having lack of spiritual fulfillment. Spiritual Well-Being A sense of harmonious interconnectedness between self, others/nature,

and Ultimate other that exists throughout and beyond time and space. Terminal Dehydration Refers to the process that occurs when a dying person's condition

causes the person to gradually reduce fluid intake. As the fluid intake decreases, circulating fluid volume decreases, resulting in dehydration.


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DISCUSSION QUESTIONS

1. HOW IMPORTANT DO YOU THINK PAIN CONTROL SHOULD BE IN TREATING

TERMINALLY ILL PATIENTS? WHO MAKES THE DECISIONS REGARDING THE EFFECTIVENESS OF PAIN CONTROL? Inadequate pain management or fear that pain will not be managed appropriately is probably the major reason that terminally ill patients desire euthanasia or assisted suicide. Patients in pain are unable to concentrate on other issues that may need to be addressed during the last stages of life. There may be other comments that can be discussed and are not necessarily incorrect. The primary response that needs to be concluded from the discussion is that pain management is at the top of the list for terminal patients especially those who have pain. Who makes decisions or who should make decisions regarding the effectiveness of main control. The patient is the person who should be making decisions regarding the effectiveness of pain control. Use of scales of 1 to 10, one being slight and ten being the most excruciating pain ever experienced, are one way in which an individual can express the extent of pain and the effectiveness of treatment.

2. WHAT IS YOUR GREATEST FEAR ABOUT DYING? WHAT INFORMATION OR SUPPORT WOULD EASE YOUR FEAR?

The answers to this question are personal and are aimed at having an individual face some of their own fears regarding death. There are no right or wrong answers. The key is to recognize ones own fears and understand that some patients may experience the same fears or may experience other fears. Recognizing that the patient has fears, helping them to identify those fears and then taking some action to reduce the fear is the goal of the nurse. Looking at self and personal fears is very important for staff in being able to work with patients.

3. DESCRIBE A GOOD DEATH. HOW DOES IT DIFFER FROM A BAD DEATH? HOW

CAN YOU HELP A DYING PERSON HAVE A GOOD DEATH? Answers to this question will vary according to individual perceptions about death. Some common responses that may be brought forward are: Good Death

Peaceful Painless With family or friends present


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(Continued)

At home In hospital Able to say good bye and no unfinished business Quick

Bad Death

Individual frightened Painful Alone In hospital or other institution At home Prolonged Unfinished business Spiritual suffering

How to help patient have a good death One of the first things the nurse should do is determine what the patient believes to

be a good death. Find out what the patient fears. Both of these can be learned by listening to what the patient says and asking

questions. Work with patient and family/support system to provide conditions and opportunities

to help the patient experience a “good death”.

4. WHAT KINDS OF INSTRUCTIONS WOULD YOU WANT TO PUT INTO AN ADVANCE DIRECTIVE? HOW WOULD YOU BRING UP THE TOPIC OF ADVANCE DIRECTIVES TO A SERIOUSLY ILL, BUT NOT IMMINENTLY TERMINAL PATIENT? Advance Directives should contain instructions to others about what an individual wants done or not done in situations where they are terminally ill and are unable to give personally communicate those instructions for whatever the reason. Frequently the decisions needing to be made are in relation to resuscitation and prolongation of life activities such as artificial / mechanical ventilation, artificial feeding via tubes, administration of IV fluids, etc. As medical science and technology continue to improve, it will be impossible for an individual to consider all future potential treatments.


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(Continued)

It is essential then that the individual designated to make decisions, know what the values of the individual are and what the individual defines as quality of life. This information can be used as a basis for making health care decisions. (--this is one of the reasons for an end of life care plan.) The opportunity to bring up the topic frequently occurs during the admission process to a healthcare facility. This is a good time for the nurse or social worker to introduce the subject. Other ways that it can be brought up are to acknowledge the seriousness of the illness and inquire if the individual has made any provisions for someone to make decisions for them if for some reason somewhere down the road they are unable to do it themselves.

USE THE INFORMATION IN THE FOLLOWING SITUATION TO DISCUSS QUESTIONS 5, 6, AND 7:

PATIENT SITUATION Mario G. is an 89-year-old married Italian male with End Stage Parkinson’s Disease admitted to the hospital with aspiration pneumonia. He lives with his wife Maria, age 91, who has been his primary care giver. Maria loves to cook and feels that food is the key to contentment and happiness. She measures her self worth by how much others in the family and friends eat. She and Mario have been married for 70 years. His daughter Eleanor lives close by. A stepson, Jack, retired, lives out of state and spends the winters nearby. Mr. G. has a living will, but it is not on his medical record. His initial care plan indicated that the goal of care was to return home with wife at functioning at previous level of ability to perform ADL’s and IADL’s. Appropriate evaluations and treatment were initiated. He was started on IV fluids and antibiotics. His Parkinson medications were given in applesauce or other thickened substance to ease swallowing and prevent aspiration. A swallowing evaluation determined that he would not be able to swallow for some time if ever without danger of aspiration. His temperature remained elevated. Mario was Roman Catholic, although he had not been to Church for some time due to his illness. He had much difficulty in ambulating, using a wheelchair most of the time. It was difficult for him, though to sit for long periods of time-he would “freeze”. He did receive The Sacrament of the Sick from a local priest while in the hospital.


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(Continued)

Several unsuccessful attempts were made to insert a feeding tube. Consultation with a gastroenterologist resulted in discussion with the family about PEG tube placement. The family wanted to talk with Mario about it, but did not know how to bring the subject up. A nurse, who had been working with Mario in a respite program, and friend, talked with him about it. Mario was alert and oriented and according to the law of the state he was living in was competent to make his own decisions. This was explained to both Mario and his family. The discussion was held in the presence of family members. Mario was offered options of re-attempting to insert a Keofed tube, PEG tube, or “leaving it in God’s hands”. Although he normally had difficulty making himself heard when speaking as a result of his Parkinson’s Disease, he very clearly stated “Leave it in God’s Hands.” The family agreed. Arrangements for discharge to the care of Hospice began.

5. WERE THERE ANY INDICATIONS THAT AN END OF LIFE CARE PLAN HAD BEEN MADE? There was an indication that a living will had been made, however it was not immediately available. There was no other evidence that there had been discussion with family regarding placement of feeding tube.

6. WHEN IT BECAME APPARENT TO FAMILY THAT HE WAS IN THE END STAGES OF PARKINSON’S, WHAT MIGHT HAVE OCCURRED DIFFERENTLY IF AN END OF LIFE CARE PLAN HAD BEEN MADE? Knowing that difficulty swallowing, resulting in aspiration is a significant aspect of end stage Parkinson’s Disease, the family and Mario could have discussed his feelings about eating, food, and nourishment via artificial means. They would also have known what quality of life meant to him. What he valued in life could be used in making decisions regarding treatment options. It would have been discussed in a non-crisis manner.


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(Continued) 7. IF THERE HAD NOT BEEN A FRIEND TO DISCUSS PEG PLACEMENT AND

ALTERNATIVES, WHAT COULD YOU HAVE DONE TO FACILITATE THE DISCUSSION? Staff could have talked with family explaining options to them. They could have discussed the legal requirement that a patient must be unable to express their wishes ad desires before a living will can be activated. Staff could have talked with Mario about the law and what that meant. Explaining or clarifying for him what it was that the physician was proposing and helped him make a decision.


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PRE-TEST

1. Palliative Care:

a. Is essentially the same as assisted suicide b. Is not legal in most states c. Facilitates growth at the end of life d. Is the same as curative end of life care

2. Which of these would you expect to see in a terminal patient who is near death and

dehydrated?

a. Excessive thirst b. Metabolic alkalosis c. Fluid overload d. Decreased blood volume

3. The most common symptom of terminal dehydration is:

a. Diarrhea b. Dry mouth c. Vomiting d. Unrelieved pain

4. A nurse must believe in God or a supreme being in order to meet the patients spiritual

needs.

a. True b. False

5. Nurse-patient relationship is an important component in end of life care

a. True b. False

6. Nurses providing bereavement support should:

a. Promise family that staff will attend the funeral b. Understand one's own feelings about death, dying, and grieving c. Send hand-written bereavement cards d. Instruct family that grief should end at the funeral service


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PRE-TEST

(Continued) 7. Palliative care is tailored to meet the needs of the patient and family system and focus

on symptom management. It involves which of the following.

a. Active listening b. Detailed assessment c. Ongoing evaluation d. All of the above

8. Palliative care refers to

a. Providing care and support to a person in the end stages of life b. Making funeral arrangements for someone who has died c. Helping a dying person write their last will and testament d. Searching for the latest in treatment for curing the illness

9. Spirituality refers to

a. How a person relates to a larger whole b. Religious practices c. Chaplain visits d. Attending church on a regular basis

10. Which of the following is true about End of life care plans?

a. It involves setting goals for medical treatment b. It involves setting goals for social, emotional and spiritual supports c. Includes a process for review and evaluation of goals d. All of the above


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ANSWER SHEET

PRE-TEST

1. c 2. d. 3. b 4. b 5. a 6. b 7. d 8. a 9. a 10. d


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SAMPLE END OF LIFE CARE PLAN

NAME:___________________________________________________ AGE_______ PRIMARY HEALTH PROBLEM_________________________________________________ NEXT OF KIN________________________________________________________________ SURROGATE_________________________________________________________________ DATE PLAN INITIATED_______________________________________________________ DATES PLAN REVIEWED______________________________________________________

Issue/Diagnosis

Action/Intervention

Evaluation/Revision


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SPIRITUAL DISTRESS

Spiritual Pain: Discomfort or suffering or lack of peace relative to one’s relationship

with God; having lack of spiritual fulfillment. Spiritual Alienation: Loneliness, or the feeling that God seems very far away and remote

from one’s everyday life; having to depend on self in times of trial or need; negative attitude toward receiving any comfort or help from God.

Spiritual Anxiety: Fear of God’s wrath and punishment; fear that God might not take

care of one, either immediately or in the future; worry that God is displeased with one’s behavior.

Spiritual Guilt: Feeling that one has failed to do the things which he or she should

have done in life, and/pr things which were not pleasing to God; concerns about the kind of life one has lived.

Spiritual Anger: Frustration, anguish or outrage at God for having allowed illness or

other trials, the unfairness of God; negative about institutional religion and its ministers.

Spiritual Loss: Feeling of having temporarily lost or terminated the love of God; fear

that one’s relationship with God has been threatened; feeling of emptiness with regard to spiritual things.

Spiritual Despair: No hope of ever having a relationship with God, or pleasing God;

feeling that God no longer can or does care for one.


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A TAXONOMY OF SPIRITUAL DIAGNOSIS

Definition: “Spirituality” - The Life principle that provides a person’s entire being, (their) volitional, emotional, moral-ethical,

intellectual, and physical dimensions, and generated a capacity for transcendent values:” “The spiritual dimension of a person integrates and transcends the biological and psychosocial nature.”

Spiritual Concerns Etiology: Spiritual Concerns arise from situational factors both external and internal to the patient, such as: Challenged belief system Separation from religious/cultural ties Anticipated role change Concern about relationships with God Unresolved feelings about the concept of death Search for more meaning or purpose in existence Disrupted religious practices Patients who present the desire and ability to cope with spiritual problems without additional resources are more likely to reflect concerns rather than the more crisis like state of distress.

Spiritual distress Etiology: Spiritual distress arises from both internal and external factors which significantly challenge an individual’s values and beliefs. “Distress” results from the individual’s difficulty in applying prior beliefs and values to the new situation, and is manifested in a broad range of emotional and psycho-somatic symptoms. Factors giving rise to spiritual distress include: Separation from religious-cultural ties Challenged belief and value system (loss of meaning and purpose) Sense of meaninglessness, purposefulness Feeling of remoteness from God Disrupted spiritual trust Questions regarding moral-ethical nature of therapy Sense of guilt or shame Intense suffering Unresolved feelings about death Anger toward God.

Spiritual Despair Etiology: A state of spiritual despair results when an individual’s efforts to resolve prior spiritual distress are unsuccessful. The result is a chronic state of spiritual suffering defined by generalized loss of hope and loss of sense of meaningful/purposeful life. Factors which may result in spiritual despair include: Self disintegration Lack of will to live Lost belief in self Lost belief in treatment Lost belief in value system and/or God

Defining Characteristics: A diagnosis of “spiritual concern” is considered when, upon interview, the patient’s subjective responses reveal the patient is: Investigating various beliefs Verbalizing inner conflict about beliefs Questioning credibility of religious/cultural system Discouraged Showing mild anxiety Bewildered Expressing Anticipatory Grief Questioning meaning of own existence Stating concerns about relationships with God/deity Unable to participate in usual religious practices, e.g. daily prayer, communion, meditation, worship services Attempting to substitute simplified rituals in place of usual worship Unable to obtain specific foods required faith/belief system.

Defining Characteristics: A diagnosis of “spiritual distress” should be considered when, upon interview, the subjective and objective evidence demonstrates the patient is: 1. struggling with meaning of life and

death and/or 2. seeking spiritual assistance and

one or more of the following are evident:**

Disturbance in concepts or perceptions of God or belief system Disturbance in sleep or rest pattern Moderate to severe anxiety Crying Depression Expression of anger Varying degrees of grieving Preoccupation psychosomatic manifestations Expressions of guilt

Defining characteristics: A diagnosis of spiritual despair may be considered when, upon interview the patient’s subjective and objective responses indicate one or more of the following: Loss of hope Sense of meaninglessness Loss of spiritual belief Death wish (escapism) Sense of exhaustion Sense of abandonment Suffering is meaningless Extreme effort required to function Social withdrawal Severe depression Flattening of affect Refusal or passive acceptance of therapy Refusal to communicate with loved ones Discontinued religious participation

Adapted from the “Spiritual Diagnosis Taxonomy” published in the proceedings of the National Committee for the Classification of Nursing Diagnosis: 1978. ** critical defining characteristics.


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RESOURCE ADVISOR

BETTY GAMEL, MS, RN, was graduated from Aultman Hospital School of Nursing in Canton, Ohio. She completed her undergraduate nursing program at Florida International University in Miami, Florida, and her graduate program at the University of South Florida in Tampa, Florida in Gerontologic Nursing. She has over 20 years of nursing experience in acute and long term care and served as a hospital safety officer for several years and has received a certificate in Health Care Safety Management from the American Hospital Association. Ms. Gamel was this program’s script writer. NEVCO® video educational programs are prepared using specific criteria designed by National Educational Video, Inc.™ All educational programs are coordinated and reviewed under the direction of the NEVCO® Director of Education, who is a master’s prepared nurse.


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REFERENCES

Agency for Health Care Administration (2000). Health Care Advance Directives: Your Right to

Decide and Make your Wishes Known. State of Florida AHCA. Ahronheim, J.C. (1993). Everything you wanted to know about CPR. Choice in Dying News, 2

(1). Partnership for Caring Inc. (edited in 09/00). Ahronheim, J.C. (1996). Understanding Palliative Care. Choices in Dying News, 5 (4),

Partnership for Caring Inc. (edited in 09/00). Davies, B. Oberle, K. (1900). dimensions of the supportive role of the urse in palliative care.

Oncology Nursing Forum, 17 (1), 87-94. Derrickson, B.S. (1996). The Spiritual Work of the Dying: A Framework and Case Studies.

The Hospice Journal, 11(2), The Hayworth Press. 11-30. Dunne, T. (2001). Spiritual care at the end of life. Hasting Center Report. 31 (2), 22-26. Durham, E. and Weiss, L. (1997). How patients die. AJN, 97 (12). 41-47. Findley, CD (1992). When Communication does not Happen. Choice in Dying News, (2),

Partnership for Caring Inc. (edited in 09/00). Jungelmann, J., Kenkel-Rossi, E., Klassen, L. Stollenwerk, R. (1996). Focus on spiritual well-

being: Harmonius interconnectedness of mind-body-spirit-use of the jarel spiritual well-being scale. Geriatric Nursing, 17 (6), 262-266.

Levin, J.S., Larson, D.B. Pulchalski C.M., (1997). Religion and spirituality in medicine:

Research and Education. J.A.M.A. 278 (9), 792-793. Meyer, M. Kaplan, K.O (1998). Good planning. Choice in Dying News, 7 (2), Partnership for

Caring Inc. (edited in 09/00). Panel for the Study of End-of-Life-Care (1999). Final Report Pepper Institute on Aging and

Public Policy: Tallahassee, Florida. Sheehan, S.J. (1997). Spirituality and care at the end of life. Choice in Dying News, 6(2),

Partnership for Caring, Inc. (edite in 09/00). Zerwekh, JV. (1997). Do dying patients really need IV fluids? AJN, 97 (3), 26-30.


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PARTICIPATION EVALUATION OF OBJECTIVES

Please evaluate this program by circling the number that best represents how well this program met the following objectives:

4=Excellent 3=Good 2=Average 1=Poor

1. Describes the importance of having an end of life care plan.

4 3 2 1

2. Differentiates between spirituality and religiosity. 4 3 2 1

3. Identifies situations when end of life care plans should be made.

4 3 2 1

4. Identifies dimensions of the supportive role of the nurse in palliative care.

4 3 2 1

5. Recognizes significant characteristics of physiologic death.

4 3 2 1

6. Identifies spiritual needs of patients. 4 3 2 1

7. Ability to write an end of life care plan. 4 3 2 1

Do you feel you met your personal objectives?

Time required to complete this program minutes COMMENTS:

Please return this form to the facilitator who distributed the learning materials. Thank you!!!

NEVCO® Account # _________________

REQUEST FOR CERTIFICATES FOR CONTACT HOURS TYPE the NAMES, LICENSE NUMBERS AND JOB TITLES (RN, LPN, MSW, CNA, PT, etc.) of the people who are to be issued a certificate for contact hours for attending the continuing education program: ________________________________________________________________________________________ (Facility Name) ________________________________________________________________________________________ (Title and Number of Video Program) This request must be submitted along with the completed roster and evaluation sheets for the above named program.

NAME LICENSE NO. JOB TITLE

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7.

8.

9.

10.

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TIB Bank Center 599 9th Street N., Suite 207

Naples, Florida 34102-5625 (800) 252-5604 Fax (888) 877-7255

www.nevcoeducation.com

FACILITATOR’S EVALUATION (NEVCO® Video Education Program)

Must be completed by the facilitator EVALUATION OBJECTIVES:

(1) To assess extent to which the program was appropriate, adequate and effective. (2) To identify, continue to develop and evaluate effective quality assurance activities.

Title of Program ________________________________________________________ Date _______________________ Place of Employment _________________________________________________Job Title _______________________ Please evaluate the presentation by circling the number that best describes your rating. 4 – Excellent 3 – Good 2 – Average 1 – Poor ORGANIZATION OF COURSE Material was organized to facilitate learning 4 3 2 1

The amount of material covered was adequate and accurate 4 3 2 1

There was effective use of time to cover the subject 4 3 2 1

CONTENT OF THE FACILITATOR’S GUIDE List total number of objectives in this facilitator’s guide _____________________

List by number the objectives that were met _____________________________

The test material reflected the objectives listed 4 3 2 1

Content can be used to improve nursing practice 4 3 2 1

Content reflected knowledge level and needs of learner 4 3 2 1

The material was current 4 3 2 1

Evaluate Test Questions

Pre-Test 4 3 2 1

Discussion Questions 4 3 2 1

Post-Test 4 3 2 1

FACULTY PRESENTING (Video) The presentation was 4 3 2 1

The presenter explained the material 4 3 2 1

The presenter demonstrated knowledge of material 4 3 2 1

OVERALL RATING I felt this teaching method was 4 3 2 1

COMMENTS – (Please make suggestions for future topics and additional comments about the presentation or instructor)

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Thank you for your time in completing this evaluation! We appreciate your comments and suggestions. The NEVCO® Educational Staff ©1995 Revised 10/2004

TIB Bank Center 599 9th Street N., Suite 207

Naples, FL 34102-5625 (800) 252-5604 Fax (888) 877-7255


EVALUATION (NEVCO® Video Education Program)

Must be completed by every participant EVALUATION OBJECTIVES:

(1) To assess extent to which the program was appropriate, adequate and effective. (2) To identify, continue to develop and evaluate effective quality assurance activities.

Title of Program ________________________________________________________ Date _______________________ Place of Employment _________________________________________________Job Title _______________________ OBJECTIVES Total number of objectives in program _________

Circle the number of objectives that WERE met 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Circle the number of objectives that were NOT met 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Please evaluate the presentation by circling the number that best describes your rating. 4 – Excellent 3 – Good 2 – Average 1 – Poor

ORGANIZATION OF COURSE

Material was organized to facilitate learning 4 3 2 1

The amount of material covered was adequate and accurate 4 3 2 1

CONTENT OF THE PRESENTATION

The test material reflected the objectives listed 4 3 2 1

Content and/or skills demonstrated can improve my ability to perform my job 4 3 2 1

Content reflected knowledge level and needs of learner 4 3 2 1

The material was current 4 3 2 1

Time for questions was 4 3 2 1

Effective use of time to cover subject was 4 3 2 1

Graphics were beneficial 4 3 2 1

NEVCO® FACULTY (who prepared the program and/or appeared in interviews)

The presentation was well prepared 4 3 2 1

The presentation explained the material well 4 3 2 1

The presenter demonstrated knowledge of material 4 3 2 1

OVERALL RATING

I felt this teaching method was 4 3 2 1

Facilities and classroom were adequate 4 3 2 1

COMMENTS – (Please make suggestions for future topics, content of program and instructors)

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________ Thank you for your time in completing this evaluation! We appreciate your comments and suggestions. The NEVCO® Educational Staff

©1995 Revised 10/2004

TIB Bank Center •· 599 9th. Street N., Suite 207 • · Naples, FL 34102-5625 (800) 252-5604 Fax: (888) 877-7255


CONTINUING EDUCATION ROSTER This form must be completed and returned to NEVCO®.

Keep a copy for your facility, but return the original to NEVCO®. PRINT OR TYPE Account # ____________________________________ Number and title of Video Program ___________________________________________

Dates Given _____________________________________________________________

Contact Hours ___________________________________________________________

Name of Facility __________________________________________________________

Address of Facility ________________________________________________________

City/State/Zip ____________________________________________________________

RN Facilitator ___________________Signature _________________________________

ROSTER OF PARTICIPANTS Participant Name Participant Signature License # Soc. Sec. #

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

National Educational Video, Inc.TM is an approved provider of continuing education. State Board provider numbers: Florida NCE2896, Alabama 5-97.0, California CEP8803 and Kentucky 7-0045. This activity provided by National Educational Video Inc. is approved as a provider of continuing education in nursing by Alabama State Nurses Association, which is accredited as an approver of continuing education in nursing by The American Nurses Credentialing Center's Commission on Accreditation.

Participant Name Participant Signature License # Soc. Sec. # 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32.

599 9th Street N., Suite 207 - Naples, FL 34102-5625

800-252-5604 Fax: 888-877-7255 – www.nevcoeducation.com

Certificate of Completion

This is to certify that

Attended and Completed

National Educational Video, Inc.TM Program Number and Title

For ______ contact hours

On _____________ Date

______________________________________________________________ Facility / Agency Name

______________________________________________________________ Facility / Agency Address

______________________________________________________________ RN / Facilitator

CERTIFICATE FOR ASSISTANTS ONLY

National Educational Video, Inc.TM is an approved provider of continuing education. State Board provider numbers: Florida NCE2896, Alabama 5-97.0, California CEP8803 and Kentucky 7-0045. This activity provided by National Educational Video Inc. is approved as a provider of continuing education in nursing by Alabama State Nurses Association, which is accredited as an approver of continuing education in nursing by The American Nurses Credentialing Center's Commission on Accreditation.

CERTIFICATE OF COMPLETION

For each participant who has successfully completed a continuing education program, please make a copy of the blank NEVCO Certificate (on reverse side) and fill in the following information:

1. Name of the learner 2. Program title and number 3. Number of contact hours 4. Date the program was completed 5. Name and address of your Agency / Facility 6. Signature of the RN / Facilitator responsible for

offering the program

Documents

END OF LIFE