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EVIDENCE BASED PRACTICE RESEARCH PROJECT
James Harrington, Cheryl Howard, Lisa Sage, Holley West, Andrea Scott
Ferris State University NURS 350 Spring 2012
What does the research reveal about nursing roles in geriatric
end of life planning?Final Grade:
INTRODUCTION The geriatric population is growing in numbers
and people are living much longer due to advancements in medicine (Ruff et al., 2010).
Identification of geriatric problems and nursing interventions for the geriatric community is necessary in all fields of nursing care.
Death and dying is inevitable and nursing care is often key in this stage of life.
The American Nurses Association (ANA) position statement supports the nurse’s role as an advocate for patients throughout their lifespan concerning end of life choices (ANA, 2010).
Patients and their families turn to nurses for information and guidance for quality of life and care issues. Nurses often help people understand advance directives and care choices (Trossman, 2009).
The ANA is actively developing strategies to include end of life planning as a part of health care reform (Trossman, 2009).
AMERICAN NURSES ASSOCIATION
It is important to explore research in order to identify nursing roles, assess knowledge and evaluate nursing care trends in the area of end of life planning and advance directives.
RESEARCH RELEVANCE
RESEARCH ARTICLES
1. Advance Directives: Evaluation of Nurse’s Knowledge, Attitude, Confidence, and Experience (Putman-Casdorph et al., 2009)
2. Practice of Expert Critical Care Nurses in Situations of Prognostic Conflict at the End of Life (McBride-Robichaux et al., 2006)
3. Promoting Advance Directives Among Elderly Primary Care Patients (Springer, 2011)
4. Factors Associated with Favorable Attitudes Toward End-of-Life Planning (Ruff et al., 2010)
ARTICLE 1 SUMMARY
Advance Directives: Evaluation of Nurse’s Knowledge, Attitude, Confidence, and Experience Measures acute care registered nurses expertise in the
area of advance directives Used a questionnaire method with 87 acute care registered
nurses to assess their advance directive knowledge about laws as well as attitude, confidence and experience with advance directives.
Participants: o had a moderately negative attitude toward advance directive planning
support & helpfulness in practiceo were only slightly to moderately confident o majority of felt advance directive participation was a part of their nursing
role Authors concluded that nurses need education & support
with advance directives which may contribute to increased confidence & positive attitudes.
(Putman-Casdorph, Drenning, Richards & Messenger, 2009)
ARTICLE 1 CRITICAL APPRAISAL
OVERALL STRONG CRITIQUE Purpose & Problem - STRONG
o generally stated purpose that there is a need to evaluate current practice in relation to advance directives
Review of Literature - STRONGo has a wide range of comprehensive and well summarized sources
although almost half are not within 5 years Theoretical Model - WEAK
o not stated Hypothesis & Research Questions - WEAK
o hypothesis was implied but not clearly stated Research Design - STRONG
o variables measured appropriately and described in detail Sampling Methods - STRONG
o clearly identified and described however there is a small sample size
ARTICLE 1 CRITICAL APPRAISAL CONT…
Data collection methods - STRONGo questionnaire returned into a sealed box for confidentiality
Instrument - STRONGo questionnaire with different sections & types of questions
Data analysis - STRONGo descriptive & inferential statistics used, statistical program
used to analyze the data was also stated Study findings - STRONG
o 5 main study findings, each finding explained in great detail Study implications & Recommendations - STRONG
o more research needed on methods to help nurses feel more confident in advance directive discussions
Conclusion - STRONGo nurses need knowledge & confidence to have advance
directive discussions with patients, need more education
ARTICLE 2 SUMMARY
Practice of Expert Critical Care Nurses in Situations of Prognostic Conflict at the End of Life • Addresses the issues that critical care nurses face
when patients facing end-of-life decisions continue to undergo treatments that nurses feel are unwarranted.
• Performed by means of face –to-face interviews of 21 critical care nurse experts representing 7 healthcare facilities in the southwestern region of the United States.(McBride-Robichaux et al., 2006)
ARTICLE 2 CRITICAL APPRAISAL
OVERALL STRONG CRITIQUE
• Purpose & Problem - STRONG o Determine whether nurses can educate and advocate for patients when
they felt aggressive interventions were unwarranted.• Review of Literature - STRONG
o 41 studies, professional journal articles and texts citedo 18 references current within 5 yearso References represented nursing, medical & psychological sciences
• Theoretical Model - WEAKo not stated or implied
• Hypothesis & Research Questions - STRONGo hypothesis clearly stated at beginning of article.
• Research Design - STRONGo hypothesis clearly stated at beginning of article.
• Sampling Methods - STRONGo Qualitative designo Based on responses to standardized question.
ARTICLE 2 CRITICAL APPRAISAL CONT…
Data collection methods - Weak
o Face to face interviews may have affected responsesInstrument - STRONG
o Standard question used to elicit specific subjective responses Data analysis - STRONG
o Transcripts divided into segments, themes and sub-themeso 3 main “plots” derived to present realistic picture of reality.
Study findings - STRONGo 5 main study findings, each finding explained in great detail
Study implications & Recommendations - STRONGo more research needed on methods to help nurses feel more confident in
advance directive discussionsConclusion - STRONG
o nurses need knowledge & confidence to have advance directive discussions with patients, need more education
ARTICLE 3 SUMMARY
Promoting Advance Directives Among Elderly Primary Care Patients• Examines the affects physicians have on elderly patients creating
advance directives• Uses a quasi-experimental design along with a nonequivalent
control group to research the different variables which may affect patients desires to create an advance directive.
• Participants included patients and physicianso Patients required to be 65 years old or greatero Have a routine check up within the year of the studyo Physicians were required to attend classes on discussing
advance directives• Authors found that having a physician discuss advance directives
with patients that they were more likely to create one then if it was left up to the patient solely.(Springer, 2011)
ARTICLE 3 CRITICAL APPRAISAL
OVERALL STRONG CRITIQUE• Purpose & Problem – STRONG
oPromote autonomy in patients with the creation of advance directives with physician guidance and education
• Review of Literature – STRONGoMany sources were examined to evaluated this issue. Many of them though were greater then five years old from when this article was published
• Theoretical Model – WEAKoNo theoretical model was stated
• Hypothesis & Research Question – STRONGoThey hypothesis was included and clearly stated what was the intent of the study
• Research Design – WEAKoThe design was included as well as the many variables that were part of the study
• Sampling Methods – STRONGoClearly stated within the article & emphasized parameters for each group
ARTICLE 3 CRITICAL APPRAISAL CONT…
• Data collection methods – STRONGo Explained the many ways data was collect from the different sources in the
study including the International Statistical Classification of Diseases and Related Health Problems and an eight question survey for physicians.
• Instrument – STRONGo Different instruments were used in the study for the various groups. A brochure
was placed in the waiting area of the office and physician were given classes to educate on discussion of advance directives.
• Data analysis – STRONGo Group data was divided between the control group and intervention group.
Further data was then divided into the physicians and their clinics which they work in.
• Study finding – STRONGo The study findings were clearly identified and categorized in four groups.
• Study implications & recommendations – STRONGo There were aspects of the study which were unable to be controlled by the
researchers. Providing physicians with more time to discuss advance directives was one recommendation given by the researchers
• Conclusion – STRONGo It was concluded that if physicians took the time to discuss advance directives
with patients then there was a higher likelihood of them creating one.
Article FourFACTORS ASSOCIATED WITH FAVORABLE
ATTITUDES TOWARD END-OF-LIFE PLANNING
Study byRuff, Jacobs, Fernandez, Bowen, &
Gerber, (2010)
SUMMARY
End of Life Planning Study
Factors associated
Convenience sample
Questionnaire
Expanded population criterions
Provided valuable results
Purpose and Problem: Strong Problem identified as lack of knowledge and understanding Purpose was to optimize advantages of EOL planning through
factor identificationReview of literature: Strong Current, relevant research references paraphrased and gathered
from multiple fields of study, no citation errors, inclusive literary background, comprehensive reference list
Lack of literature review sectionTheoretical/ conceptual model: Weak Does not have an identified theoretical or conceptual modelHypothesis and research questions: Strong Clearly written hypothesis with direct link to study problem and
purpose Framework implied during introduction through factor analysis Lack of clearly defined framework and theory
Overall Strong Critique
ARTICLE 4 CRITICAL APPRAISAL
CRITICAL APPRAISAL CONT…
Research design: there is not a clearly identified research design and a mixed format was applied for study conduction Qualitative: detailed explanation of concepts supporting grounded research No control, study conducted in natural environment on one group of
participants Quantitative: protection of bias, examination of causality, and determination of
validity
Sample and sampling methods: Strong Diverse sample of community. 610 approached – disqualified =
331 participants. Convenience sample, large age range, and multiple population statistics were analyzed
Data Collection Methods: Strong face-to-face approach by researchers, questionnaire, privacy
envelopes to return questionnaires in Instrument: Strong detailed questionnaire with different types of questions
(Ruff et al., 2010, p. 177)
CRITICAL APPRAISAL CONT….
Data Analysis: Strong multiple different statistics used, analyzed by statistical software
Study Findings: Strong detailed findings for each section of the questionnaire
Study Implications and Recommendations: Strong strengths/limitations discussed, implications for nursing
discussed
Conclusion: Strong nurses need to discuss end of life planning with patients when
the patients are younger to optimize how the patients will plan for end of life care as they get older
HOW THE EVIDENCE IS AFFECTED BY EXPERIENCES
• Authors’ work in varied fields of nursing with
widely focused perspective on end of life issues
• The research evidence supports personal experience
PERSONAL PERSPECTIVES
• Personal nursing perspectives are offered in this presentationoSurgical Services DirectoroCase Management & LTCoCritical care, Med-Surg, & OBoOrthopedic SurgicaloHospice
JAMES
Surgical Services Director
Although I am not a nurse functioning in the critical care area of my facility, the evidence presented in article #2 is relevant in my surgical area as well. Occasionally procedures are performed on elderly patients facing end-of life decisions. Some of these procedures, such as repairing fractured hips on elderly patients suffering from severe dementia and who have a do not resuscitate (DNR) status pre-operatively are considered palliative in nature due to issues related to pain. These procedures are accepted by all members of the healthcare team as necessary. Issues related to surgical interventions involving certain elderly patients with known metastatic cancer are another story.
JAMES CONT…
Though becoming less frequent- there are still instances when tumors are removed to relieve obstructions or peg-tube placements are performed to provide nutrition to end-of-life patients. Confusion often exists between those measures considered as palliative and those that are curative in nature. If this confusion exists in the minds of healthcare professionals it will most likely also exist in the minds of patients and family members seeking guidance in their end-of-life decision making. When these types of procedures are scheduled the nursing staff may question amongst themselves the reasons for these measures but seldom are those questions posed to patients or medical providers. As stated in the conclusions of the second study presented- there is a need for better communication between all members of the healthcare team as well as collaborative efforts in developing education for staff and patients concerning end-of-life decision making.
CHERYL
Case Management and Long Term Care Nursing• In my personal experience some nurses are more knowledgeable in this area
than others• Most nurses in my field, including myself, are only generally acquainted with
end of life issues• Many patients and their families feel uncomfortable or are confused about
end of life planning and advance directives• The research our group gathered supports my assumption that more
knowledge, communication and clear practice guidelines are needed for nurses regarding their role in end of life planning
• In my nursing practice I plan to strive for more nursing knowledge in this area
Photo credit: www.yourmedicinewithin.com
ANDREA
Critical Care, Medical Surgical, and Obstetrical NursingI do not know much about advance directives. Not every patient has them, and
when a patient does have one, it seems to hardly ever get followed. Family members or spouses often step in when the patient is unable to voice or express their own opinions anymore and make choices for the patient that are not what the patient wants according to their advance directive. At our hospital, nursing used to ask every patient, on admission, some generic questions about being a DNR or not. A family complained about this and these questions were removed from the nursing admission set of questions, essentially telling me as a nurse that I am not qualified to ask such “delicate” questions. Now the doctors have to address it and it does not get done consistently. If the doctors asked every patient on admission, instead of waiting until the patient gets to a point where the questions need asked, I think it would go smoother for patients, their families, and nurses.
I have seen patients go through procedures they did not want because of family choices and I have seen patients hold their ground and say “no more” and die a peaceful death. I applaud these patients for their courage to tell all us “experts” “I have had enough, let me go.” The longer I am a nurse the more I realize the difference between alive and living. I would be happy to have more education on advance directives so if need be, I can be the one to start the discussion about them with patients or families or to have the knowledge to answer questions for patients and families appropriately.
LISA
Orthopedic Surgical Nursing•Current practice has changed to incorporate patient autonomy into care
•Creation of advance directives allows for patients to have autonomy during a time when they are unable to make any decisions
•At current employer we now ask each patient if they have an advance directive and if not we located their next of kin
oMany individuals did not want their next of kin to be making decisions for themoAdvance directives allow them to list whom ever they wish to make decisions for them
•The creation of advance directives allows patients to make their own choices promoting autonomy in their care
Holley:Hospice R.N.
Hospice
Hospice
ComfortComfort
SecuritySecurity
Compassion
Compassion
RespectRespect
SupportSupport
FaithFaith
Application of evidence would be
extremely beneficial
Early education on end-of-life
planning promoted
Recommended documentation
during planning: Advanced
Directives, designation of health
care proxy, and Last Will and
Testament
Nurses are the faces of the
healthcare system, thus we need to
start putting our game faces on
Application of evidence would be
extremely beneficial
Early education on end-of-life
planning promoted
Recommended documentation
during planning: Advanced
Directives, designation of health
care proxy, and Last Will and
Testament
Nurses are the faces of the
healthcare system, thus we need to
start putting our game faces on
Family
Hope
Autonomy
Team
Work
RECOMMENDATIONS
►Need for nurses to have more education and knowledge in area of end of life planning.
►Public education related to end of life planning needs to be increased.
►Additional studies need to be conducted to identify factors associated with: planning for death effectiveness of early education identification of the medical
professional responsibilities for addressing EOL planning with their patients
CONCLUSION
►Nurses are an important part of end of life planning.
►End of life planning is important but can be a controversial and sensitive topic for patients.
► Increased education and expertise for nurses in end of life issues is recommended
REFERENCESANA. (2010, June 14). Registered nurses’ roles and responsibilities in providing expert care and counseling at the end of life. Retrieved from American Nurses Association website: https://fsuvista.ferris.edu/ webct/ cobaltMainFrame.dowebct?appforward=/ webct/ viewMyWebCT.dowebct
McBride Robichaux,C., Clark, A.P., Practice of Expert Critical Care Nurses in Situations of Prognostic Conflict at the End of Life. Am J Crit Care September 1, 2006 vol. 15 no. 5 480-491 Retrieved from website http://ajcc.aacnjournals.org/content/15/5/480.full Putman-Casdorph, H., Drenning, C., Richards, S., & Messenger, K. (2009, July). Advance directives: Evaluation of nurses’ knowledge, attitude, confidence, and experience. Journal of Nursing Care Quality, 24(2), 250-256. doi:10.1097/ NCQ.0b013e318194fd69
Ruff, H., Jacobs, R. J., Fernandez, I. M., Bowen, S. G., & Gerber, H. (2010, September 11). Factors associated with favorable attitudes toward end-of-life planning. American Journal of Hospice and Palliative Medicine, 28(3), 176-182. doi: 10.1177/1049909110382770
Trossman, S. (2009, March/ April). To sustain life, or not? ANA, nurse experts promote planning for care through advance directives. The American Nurse, 41(2), 1, 6. Retrieved from CINAHL database.
Wissow, L.S., Belote, A., Kramer, W., Compton-Phillips, A., Kritzler, R. Weiner, J.P. (2004). Promoting advance directives among elderly primary care patients. Journal of General Internal Medicine, 19, 994-951. doi: 10.1111/j.1525-1497.2004.30117.x
