Knowledge, attitudes and practices of nursing personnel regarding advance directives

The Challenges of Advance Care Planning for Acute Care Registered Nurses

STUDY BACKGROUND

The practice of acute care nurses is shaped by organizational factors such as lack of privacy, heavy workloads, unclear roles, lack of time, and lack of specific policies and procedures. We know little about the social and organizational structures and processes that influence nurses' uptake of valuable patient-centered discussions like advance care planning (ACP). ACP is beneficial for patients, their substitute decision makers, and healthcare providers.

PURPOSE

To describe the operational, organizational, and societal influences shaping nurses' ACP work in acute care settings.

METHODS

This ethnographic study purposively sampled 14 registered nurses and 9 administrators who worked in two acute care hospitals in Northeastern Ontario. Methods consisted of 23 open-ended, semi-structured interviews, 20 hours of observational fieldwork, and a collection of publicly available organizational documents. Data were inductively analyzed using an iterative constant comparative approach.

RESULTS

Nurses were challenged to meet multiple competing demands, leaving them to scramble to manage complex and critically ill acute care patients while also fulfilling organizational tasks aligned with funding metrics, accreditation, and strategic planning priorities. Such factors limited nurses' capacity to engage their patients in ACP.

CONCLUSIONS

Acute care settings that align patient values and medical treatment need to foster ACP practices by revising organizational policies and processes to support this outcome, analyzing the tasks of healthcare providers to determine who might best address it, and budgeting how to support it with additional resources.

Oncology nurses' knowledge, attitudes, and practice behaviours towards advance care planning: A nationwide cross-sectional study

BACKGROUND

With the increasing cancer prevalence in China, discussions surrounding end-of-life care have become more frequent within the purview of oncology nursing. Nonetheless, limited research has explored the current state of Advance Care Planning (ACP) among oncology nurses in China. Hence, it is essential to comprehensively assesses oncology nurses' ACP knowledge, attitudes, and practice behaviours, addressing existing literature gaps and revealing China's oncology nursing ACP status.

OBJECTIVES

To explore oncology nurses' knowledge, attitudes, and practice behaviours regarding ACP and identify factors impacting ACP practice behaviours.

DESIGN

A multi-centre, observational, cross-sectional study.

SETTINGS

The research is conducted in oncology hospitals across 22 provinces, 4 municipalities, and 5 autonomous regions across China.

PARTICIPANTS

Convenience sampling was used to recruit 1800 registered oncology nurses.

METHODS

Data were collected via an electronic questionnaire between December 2021 and January 2022. Univariate and hierarchical multiple regression analyses were used for data prediction (P < 0.05).

RESULTS

In the knowledge section, respondents achieved an average accuracy rate of 51.94 % and demonstrated moderate positive attitudes towards ACP. Their practice behaviour scores were moderately graded. Sociodemographic characteristics and attitude were included as predictors of practice behaviour in the hierarchical multiple regression analysis, explaining 12.2 % and 31.1 % of the variance, respectively. The final model accounted for 43.3 % of the variance. The results indicated that attitudes had a significant and positive impact on practice behaviours, indicating that nurses with more positive attitudes were more likely to engage in ACP practice.

CONCLUSIONS

Chinese oncology nurses seem to have more positive attitudes towards ACP, but they do not prepare adequately in practice. By enhancing workplace values, beliefs, and policies, it is feasible to enhance the attitudes of oncology nurses towards ACP and, consequently, promote practice behaviours. Furthermore, this study underscores the need for targeted interventions to bridge the gap between positive attitudes and actual ACP implementation among oncology nurses in China.

Knowledge, attitudes and practices towards advance directives among clinical nurses: Multicenter cross-sectional survey

AIMS AND OBJECTIVES

This study aimed to describe the knowledge, attitudes and practices (KAP) of nurses in implementing advance directives (ADs) for older patients and analyze the influencing factors before the establishment of the first advance directives act in China.

DESIGN

Multicenter cross-sectional survey. The standards for reporting the STROBE checklist are used.

METHODS

This cross-sectional study developed a self-designed structured questionnaire to assess nurses' knowledge, attitudes and practices about ADs. Nurses were recruited by stratified random sampling through the Nursing Departments of 12 hospitals in southwest China and were asked to fill out the questionnaire face to face about knowledge, attitudes and practices. Data were analyzed following descriptive statistics, rank-sum test and multiple linear regression.

RESULTS

This study included 950 nurses. The study found that nurses were extremely supportive of ADs. Unmarried nurses had better knowledge of ADs than married ones. Nevertheless, there was a discrepancy between the participants' knowledge, attitude and practice. The participants' practice was lower (4.3%) compared with their attitude (81.9%) and knowledge (42.2%). Knowledge on, attitudes towards and standardized procedures for ADs in the workplace affected nursing practice.

CONCLUSIONS

The study recommends that courses on ADs and appropriate support from medical institutions should be provided to nurses to increase their knowledge and confidence in implementing ADs. Healthcare professionals should be sufficiently equipped to implement ADs and handle their execution appropriately to provide adequate end-of-life care corresponding to patients' wishes.

RELEVANCE TO CLINICAL PRACTICE

The study results inform rich insights as it discusses the numerous interrelating factors influencing these three fundamental aspects that affect the success of any AD policy by surveying the knowledge, attitudes and practices of clinical nurses. Furthermore, our results hint at distinct areas of improvement in the nursing practice to facilitate the wider implementation and acceptance of ADs in China.

PATIENT OR PUBLIC CONTRIBUTION

This study involved no patient.

Advance Care Planning in Hong Kong

Hong Kong is a well-developed city with outstanding healthcare services, leading to the highest life expectancy in the world. Paradoxically, the quality of end-of-life care in this city lagged behind that of many other high-income regions. Possibly, the advances in medicine contribute to the death denial culture, hindering communication about end-of-life care. This paper discusses challenges arisen due to poor public awareness and professional training and local initiatives to promote advance care planning in the community.

Limitations in health professionals' knowledge of end-of-life law: a cross-sectional survey

BACKGROUND

Insufficient knowledge about end-of-life law can impede the provision of safe and high-quality end-of-life care. Accurate legal knowledge across health professions is critical in palliative and end-of-life settings given the reliance on multidisciplinary care. Most research has focused on doctors, finding significant knowledge gaps. The limited evidence about other health professions also suggests legal knowledge deficits.

OBJECTIVE

To determine and compare levels of knowledge about end-of-life law across a broad sample of Australian health professionals and medical students, and to identify predictors of legal knowledge.

METHODS

An online pre-training survey was completed by participants enrolled in a national training programme on end-of-life law. The optional survey collected demographic data and measured baseline legal knowledge and attitudes towards end-of-life law.

RESULTS

Response rate was 67% (1653/2456). The final sample for analysis (n=1564, 95% of respondents), included doctors, medical students, nurses and a range of allied health professionals. Doctors and nurses had slightly higher levels of legal knowledge than did medical students and allied health professionals; all had critical knowledge gaps. Demographic and professional characteristics predicted knowledge levels, with experience of end-of-life law in practice, confidence applying law and recent continuing professional development being positively associated with legal knowledge.

CONCLUSIONS

This study provides new evidence about legal knowledge across a broad range of health professions. While knowledge levels varied somewhat across professions, knowledge gaps were observed in all professional groups. Education and training initiatives to enhance knowledge of end-of-life law should be tailored to meet the specific needs of each profession.

Professional characteristics and the prevalence of advance directives among palliative care professionals: A cross-sectional study

OBJECTIVE

This study aimed to investigate the association between professional characteristics and the prevalence of advance directives among palliative care professionals.

METHODS

This is a descriptive cross-sectional study. A diverse sample of 327 healthcare professionals completed an online survey investigating demographic variables, length of time working in palliative care, post-graduate qualifications in palliative care, and development of their own advance directives.

RESULTS

The prevalence of advance directives among professionals working in palliative care was associated with factors such as higher academic qualifications, holding a post-graduate qualification in palliative care, and working in palliative care for a longer time. Furthermore, psychologists were most likely to have registered their own advance directives, compared with other healthcare professionals.

SIGNIFICANCE OF RESULTS

Post-graduate palliative care education and professional experience in this area appear to be important factors associated with palliative care professionals writing of their own advance directives. However, our study suggests that just being involved in or familiar with the context of palliative and end-of-life care does not guarantee that health professionals register their advance directives.

A Challenge for Palliative Psychology: Freedom of Choice at the End of Life among the Attitudes of Physicians and Nurses

This article considers a particular aspect of palliative psychology that is inherent to the needs in the area of attitudes concerning Advance Healthcare Directives (AHDs) among Italian physicians and nurses after the promulgation of Law No. 219/2017 on AHDs and informed consent in 2018. The study utilized a mixed-method approach. The group of participants was composed of 102 healthcare professionals (63 females and 39 males). The quantitative part utilized the following scales: Attitudes toward Euthanasia, the Religious Orientation Scale, the Balanced Inventory of Desirable Responding, and the Testoni Death Representation Scale. The results were mostly in line with the current literature, especially concerning a positive correlation between religiosity and the participants’ rejection of the idea of euthanasia. However, the qualitative results showed both positive and negative attitudes towards AHDs, with four main thematic areas: “Positive aspects of the new law and of AHDs”, “Negative aspects of the new law and of AHDs”, “Changes that occurred in the professional context and critical incidents”, and “Attitudes towards euthanasia requests.” It emerged that there is not any polarization between Catholics or religious people and secularists: Their positions are substantially similar with respect to all aspects, including with regard to euthanasia. The general result is that the law is not sufficiently understood, and so a quarter of the participants associate AHDs with euthanasia. Discussions on the opportunity for palliative psychologists to help health professionals to better manage these issues through death education courses are presented.

Enhancing Advance Care Planning Communication: An Interactive Workshop With Role-Play for Students and Primary Care Clinicians

INTRODUCTION

Increased clinician training on advance care planning (ACP) is needed. Common barriers to ACP include perceived lack of confidence, skills, and knowledge necessary to engage in these discussions. Furthermore, many clinicians feel inadequately trained in prognostication. Evidence exists that multimodality curricula are effective in teaching ACP and can be simultaneously targeted to trainees and practicing clinicians with success.

METHODS

We developed a 3-hour workshop incorporating lecture, patient-oriented decision aids, prognostication tools, small-group discussion, and case-based role-play to communicate a values-based approach to ACP. Cases included discussion of care goals for a patient with severe chronic obstructive pulmonary disease and one with mild cognitive impairment. The workshop was delivered to fourth-year medical students, then adapted in two primary care clinics. In the clinics, we added an interprofessional case applying ACP to management of dental pain in advanced dementia. We evaluated the workshops using pre-post surveys.

RESULTS

Thirty-four medical students and 14 primary care providers participated. Self-reported knowledge and comfort regarding ACP significantly improved; attitudes toward ACP were strongly positive both before and after. The workshop was well received. On a 7-point Likert scale (1 = unacceptable, 7 = outstanding), the median overall rating was 6 (excellent).

DISCUSSION

We developed an ACP workshop applicable to students and primary clinicians and saw improvements in self-reported knowledge and comfort regarding ACP. Long-term effects were not studied. Participants found the role-play especially valuable. Modifications for primary care clinics focused on duration rather than content. Future directions include expanding the workshop's content.

Nurses' self-efficacy, rather than their knowledge, is associated with their engagement in advance care planning in nursing homes: A survey study

BACKGROUND

Considering social cognitive theory and current literature about successful advance care planning in nursing homes, sufficient knowledge and self-efficacy are important preconditions for staff to be able to carry out advance care planning in practice.

AIM

Exploring to what extent nurses' knowledge about and self-efficacy is associated with their engagement in advance care planning in nursing homes.

DESIGN

Survey study as part of a baseline measurement of a randomised controlled cluster trial (NCT03521206).

SETTING/PARTICIPANTS

Nurses in a purposive sample of 14 nursing homes in Belgium.

METHODS

A survey was distributed among nurses, evaluating knowledge (11 true/false items), self-efficacy (12 roles and tasks on 10-point Likert-type scale) and six advance care planning practices (yes/no), ranging from performing advance care planning conversations to completing advance directives.

RESULTS

A total of 196 nurses participated (66% response rate). While knowledge was not significantly associated with advance care planning practices, self-efficacy was. One unit's increase in self-efficacy was statistically associated with an estimated 32% increase in the number of practices having carried out.

CONCLUSIONS

Nurses' engagement in advance care planning practices is mainly associated with their self-efficacy rather than their knowledge. Further research is necessary to improve the evidence regarding the causal relationship between constructs. However, these results suggest that educational programmes that focus solely on knowledge might not lead to increasing uptake of advance care planning in nurses.

What do Galicia's nurses know about living wills?

OBJECTIVE

To analyse the level of knowledge and attitudes concerning living wills of nurses working in 3 hospitals of Servizo Galego de Saúde (Spain).

METHOD

Descriptive, cross-sectional, multi-centre study. Stratified sampling was carried out with nurses from the University Hospital Complexes of Ourense, Ferrol and Vigo. A sample size of 239 individuals was calculated. The data was collected during the first semester of 2018 using a validated self-administered questionnaire («Cuestionario de conocimientos y actitudes de los profesionales sanitarios en el proceso de declaración de voluntades vitales»).

RESULTS

A total of 262 nurses participated. Fifty percent believe that health professionals are obliged to inform about living wills. Two percent consider that they have enough information on the subject, and this is demonstrated in the knowledge questions, where between 61%-93% fail in the questions related to the documentation, use, and their legal aspects. Eighty-four percent consider that they have the obligation to uphold the values and beliefs of patients, and 89% that patients have the right to receive and decide on the right care. Thirteen percent consider that patients are not well informed about living wills, and 83% would recommend to chronic patients that they complete a living will.

CONCLUSIONS

Nurses have a great lack of knowledge about the legal aspects and the use of living wills, which makes them feel unable to inform their patients about them. Despite of the lack of knowledge, their attitude is positive and most of them state that they would recommend them to their patients.

A systematic review of the effects of advance care planning facilitators training programs

BACKGROUND

Advance care planning (ACP) is the process of ongoing communication among patients, family and health care professionals regarding what plans for future care are preferred in the event that patients become unable to make their own decisions. Clinicians play an important role in ACP as both initiators and decision coaches. However, lack of training for clinicians has frequently been reported as the reason for low involvement in ACP discussions - hence the present review evaluates the effectiveness of ACP training programs for healthcare professionals to guide the development of novel training programs for them in the future.

METHODS

A literature search for intervention studies was conducted independently by two reviewers in July 2018. Participants included all healthcare professionals working with adult patients suffering from terminal illness. The primary outcomes were the professionals' knowledge of and attitudes towards ACP, and self-perceived competence in ACP conversations. The Effective Public Health Practice Project appraisal tool was used to examine the quality of the studies included.

RESULTS

A total of 4025 articles were identified, and ten eligible articles, covering 1081 participants, were included in the review. However, there is a lack of high quality randomized controlled trials of providing ACP training for nurses working in non-palliative care hospital settings. The overall quality of the intervention studies was moderate. All the studies included used instructional sessions in their interventions, while some contained group discussion, role-play and the use of advanced technology. The training programs increased the knowledge, attitudes towards shared decision-making, perceived communication skills, confidence, comfort and experiences concerned with discussing end-of-life (EOL) issues. Patient advocacy, job satisfaction and perceived level of adequate training for EOL care were improved. The use of 'decision aids' was rated as acceptable and clinically useful.

CONCLUSIONS

Training for healthcare professionals in ACP has positive effects on their knowledge, attitude and skills. The use of decision aids and advanced technology, instructional sessions with role play, training content focused on ACP communication skills and the needs and experience of patient in the ACP process, and a values-based ACP process are all those factors that made the ACP training programs effective.

'We have no crystal ball' - advance care planning at nursing homes from the perspective of nurses and physicians

Objective: To investigate clinicians' perspectives on the factors that shape the process of advance care planning in a nursing home context. Design: Interviews. Latent qualitative content analysis. Setting: Nine nursing homes in Sweden. Subjects: 14 physicians and 11 nurses working at nursing homes. Main outcome measures: Participants' views on advance care planning (ACP) at nursing homes. Results: The analysis of the interviews resulted in four manifest categories: Exploration of preferences and views, e.g. exploring patient wishes regarding end-of-life issues and restrictions in care at an early stage, and sensitivity to patient's readiness to discuss end-of-life issues; Integration of preferences and views, e.g. integration of patient's preferences and staff's and family member's views; Decision & documentation of the ACP, e.g. clear documentation in patient's medical records that are up-to-date and available for staff caring for the patient, and Implementation & re-evaluation of the ACP, e.g. nurse following up after ACP-appointment to confirm the content of the documented ACP. The latent theme, Establishing beneficence - defending oneself against tacit accusations of maleficence, emerged as a deeper meaning of all the four (manifest) parts of the ACP-process Conclusion: This study stresses the importance of involving patients, family members, and the team in the work with advance care planning in nursing homes. In addition, clear medical record documentation and proficiency in end-of-life communication related to advance care planning for physicians as well as nurses may also be factors that significantly shape advance care planning in a nursing home context. Key Points Advance care planning can help patients to receive care in line with their preferences and can positively impact quality of end-of-life care. Our results describe a process consisting of four manifest categories and one latent theme constituting the process of advance care planning, that may be considered in education in advance care planning. The significance of nurses and physicians perceiving beneficence as well as fear of accusations of maleficence are important factors to contemplate. The study has implications for healthcare staff caring for patients near the end of their lives, in particular patients in nursing homes.

Patient experiences of nurse-facilitated advance care planning in a general practice setting: a qualitative study

BACKGROUND

Advance care planning (ACP) can offer benefits to patients and their families, especially when delivered in outpatient settings, but uptake remains low. Common barriers for health professionals include a perceived lack of time and adequate training, experience, and confidence in conducting ACP. Patient-reported barriers include a lack of awareness of ACP or discomfort initiating or engaging in discussions about end-of-life.

METHODS

We aimed to explore patients' perspectives of an ACP intervention designed to address common barriers to uptake in the general practice setting. We provided training and support to doctors and general practice nurses (GPNs) to initiate and lead ACP discussions at their respective practices (2014 to 2015). Following the intervention, we conducted interviews with patients to explore their experience of engaging in ACP in the general practice setting. Thematic analysis was used to inductively code transcripts and identify key themes from semi-structured interviews with patients.

RESULTS

Six major themes relating to patient experiences of GPN-facilitated ACP were identified: working through ideas, therapeutic relationship with nurses, significance of making wishes known, protecting family from burden, autonomy in decision-making, and challenges of family communication. The patients valued the opportunity to speak about issues that are important to them with the GPN who they found to be compassionate and caring. The patients felt that ACP would lead to significant benefits not only to themselves but also for their family. Despite encouragement to involve other family members, most patients attended the ACP discussions alone or as a couple; many did not see the relevance of their family being involved in the discussions. Some patients felt uncomfortable or reluctant in communicating the results of their discussion with their family.

CONCLUSIONS

With adequate training and support, GPNs are able to initiate and facilitate ACP conversations with patients. Their involvement in ACP can have significant benefits for patients. Psychosocial and relational elements of care are critical to patient satisfaction. Our findings show that some patients may feel uncomfortable or reluctant to communicate the results of their ACP discussions with their family. A future larger study is required to verify the findings of this pilot study.

Rol de la Enfermería de Atención Primaria en la planificación anticipada de las decisiones

Objetivo: Determinar el conocimiento, actitud y participación de la enfermería de Atención Primaria en la planificación de la voluntad vital anticipada (VVA), e identificar factores asociados. Método: Estudio observacional descriptivo transversal multicéntrico. Población diana: enfermeros/as adscritos/as a 15 Unidades de Gestión Clínica del Distrito Sanitario Córdoba-Guadalquivir (España). Muestreo: Aleatorio simple cuya N=119. Instrumento: Cuestionario validado sobre conocimiento, actitud y planificación. Análisis estadístico: Descriptivo de los datos obtenidos. Resultados: Edad media de los profesionales 50,3 años (rango 28-63; Dt. 8,02) siendo mujeres el 71,4%. El 80,2% fueron propietarios y la media (años de servicio) fue 25,9 (Dt. 9,6). El 52,9% trabajaba en ámbito rural. La puntuación media del conocimiento fue 5,4 (Dt. 2,02). El 57,1% no había leído el documento de la VVA y el 73,9% no había leído la guía de planificación. El 68,7% no ubicó el registro de la VVA. Aunque una media del 9,2 (Dt. 1,29) de estos profesionales recomendaría a sus pacientes la VVA, el 90,9% no planifica en el último año y quien planifica lo hace <2 veces. Las creencias y valores (media: 2,83; Dt. 3,76) parecen no influir. Conclusiones: Pocos enfermeros planifican con el paciente la VVA, no identificándose factores independientes asociados al estudio.

Advance Care Planning: The Nurse's Role

: This series on palliative care is developed in collaboration with the Hospice and Palliative Nurses Association (HPNA; http://hpna.advancingexpertcare.org). The HPNA aims to guide nurses in preventing and relieving suffering and in giving the best possible care to patients and families, regardless of the stage of disease or the need for other therapies. The HPNA offers education, certification, advocacy, leadership, and research.

Are advance directives helpful for good end of life decision making: a cross sectional survey of health professionals

Background

This paper joins the debate over changes in the role of health professionals when applying advance directives to manage the decision-making process at the end of life care. Issues in relation to advance directives occur in clinical units in Lithuania; however, it remains one of the few countries in the European Union (EU) where the discussion on advance directives is not included in the health-care policy-making agenda. To encourage the discussion of advance directives, a study was designed to examine health professionals’ understanding and preferences related to advance directives. In addition, the study sought to explore the views of health care professionals of the application of Advance Directives (AD) in clinical practice in Lithuania.

Methods

A cross-sectional survey was conducted by interviewing 478 health professionals based at major health care centers in Kaunas district, Lithuania. The design of the study included the use of a questionnaire developed for this study and validated by a pilot study. The collected data were analyzed using standard descriptive statistical methods.

Results

The analysis of knowledge about AD revealed some statistically significant differences when comparing the respondents’ profession and gender. The analysis also indicated key emerging themes among respondents including tranquility of mind, the longest possible life expectancy and freedom of choice.

Further, the study findings revealed that more than half of the study participants preferred to express their will while alive by using advance directives.

Conclusions

The study findings revealed a low level of knowledge on advance directives among health professionals. Most health professionals agreed that AD’s improved end-of-life decision making while the majority of physicians appreciated AD as the best tool for sharing responsibilities in clinical practice in Lithuania. More physicians than nurses preferred the presence of advance directives to support their decision making in end-of-life situations.

Clinical nurse specialists perspectives on advance care planning conversations: a qualitative study

OBJECTIVE

The aim of the study was to identify the challenges experienced by clinical nurse specialists (CNSs) when facilitating advance care planning (ACP) conversations with terminally ill patients. This paper focuses on the factors that influence CNSs when they are deciding whether to open an ACP discussion.

METHODS

Semi-structured interviews were used to collect data from eight purposively selected palliative care CNSs working in two different community teams. The interviews were recorded, transcribed, and analysed to identify themes.

FINDINGS

ACP required the CNSs to 'walk a tightrope', balancing potential harm with purported benefit. The nurses identified that their decision to introduce an ACP discussion was influenced by three key factors: an assessment of the patient's readiness to discuss the topic, their physical condition, and the nurse's relationship with the patient and family.

CONCLUSION

ACP involves risk-taking on the part of those initiating it, owing to the potential for unforeseen or negative consequences. Further research is required to identify the factors that facilitate nurses involving patients in ACP.

Facilitating advance care planning in community palliative care: conversation starters across the client journey

This paper describes the development of a tool for palliative care nurses to initiate and facilitate advance care planning (ACP) conversations in community palliative care practice. Seven community palliative care services located across Australia participated in a multi-site action research project. Data included participant observation, individual and focus group interviews with palliative care health professionals, and medical record audit. A directed content analysis used a pre-established palliative care practice framework of referral, admission, ongoing management, and terminal/discharge care. From this framework a Conversation Starter Tool for ACP was developed. The Tool was then used in orientation and continuing nurse education programmes. It provided palliative care nurses the opportunity to introduce and progress ACP conversations.

Completion of Advance Directives Among Low-Income Older Adults

This study examined the prevalence of completion of advance directives (ADs) and the effects of race/ethnicity on AD completion using a cross-sectional design. Low-income older adults (n = 256) who were residents of supportive housing facilities or members of a senior center were interviewed in person. About 20% of the participants had completed ADs. Knowledge and attitudes toward ADs, income, and previous experience in an intensive care unit significantly predicted the completion of ADs after controlling for other factors. Those with higher levels of knowledge, positive attitudes, or those with higher incomes were more likely to complete ADs than their counterparts. Findings suggest that as a proxy for multiple socioeconomic, social and cultural factors, race, and ethnicity need to be considered in planning end-of-life care.

Experiences with advance care planning: nurses' perspective

AIMS AND OBJECTIVES

The aim of this paper is to report the findings of a case study that explored the phenomenon of advanced care planning and advance care directives in residential care settings in Australia. In particular, this paper focuses on the experiences of Registered Nurses with advanced care planning and advance care directives.

BACKGROUND

Nurses need to know how to engage with residents and families when they invest time and effort on advanced care planning and documentation of advance care directives.

METHODS

A case-study design involving participant observation, field note recording, semi structured interviews and document analysis was used. Data were collected over 7 months. Data analysis involved thematic content analysis.

FINDINGS

The factors that enhanced and inhibited the experiences of the Registered Nurses with advanced care planning were identified. The enhancing factors include; 'it is their essence of who they are', and 'back-up from family members and other nursing staff’. The inhibiting factors are 'lack of time', 'a culture of do everything and don't go there', and 'lack of family involvement'.

CONCLUSION

The findings of the current study provided nurses with evidence of the positive nature of experiences of older people, family members, and nurses themselves with advanced care planning in an attempt to better implement and practise advanced care planning.

Professional judgments about advance care planning with community-dwelling consumers

CONTEXT

There is limited research on how community-based long-term care (CBLTC) providers' personal characteristics and attitudes affect their decisions to initiate advance care planning (ACP) conversations with consumers.

OBJECTIVES

To examine judgments by CBLTC providers as to whether a consumer was in need of ACP and to compare the relative influence of situational features of the consumer with the influence of personal characteristics of the CBLTC provider.

METHODS

Factorial surveys with vignettes with randomly assigned situational features of a hypothetical consumer were obtained from 182 CBLTC providers at three Area Agencies on Aging located in the Midwestern U.S. Measures included the consumer's situational features, such as demographics, diagnosis, pain level, level of functioning, and caregiver involvement. Personal characteristics of the CBLTC provider included demographics, discipline, past experience with ACP, and attitudes toward ACP.

RESULTS

Hierarchical linear models indicated that most variability in ACP decisions was the result of differences among CBLTC providers (64%) rather than consumers' situational features. Positive decisions to discuss ACP were associated with consumers who needed assistance with legal issues and had a cancer diagnosis; these variables explained 8% of the vignette level variance. Significant personal characteristics of the CBLTC provider included a nursing background, less direct contact with consumers, past experience with ACP, and positive attitudes toward ACP; these variables explained 41% of the person-level variance.

CONCLUSION

This study shows the lack of normative consensus about ACP and highlights the need for consistent educational programs regarding the role of the CBLTC provider in the ACP process.

Advance care planning for people with dementia: a review

BACKGROUND

Few people with dementia have made advance plans for their health care. Advance care planning (ACP) is a process of discussion between an individual and their care providers that takes account of wishes and preferences for future care. We aimed to examine the facilitators and inhibitors to ACP in people with dementia. We also aimed to identify key themes in the literature and critically review the methodologies used.

METHODS

We systematically searched the English language literature including PubMed, CINAHL, AMED, PsychINFO, EMBASE and BNI. We included empirical studies which reported the characteristics of the patient population, the type of advance care planning used and the study setting, and which involved people with dementia, family members or professional carers.

RESULTS

We identified 17 studies (11 quantitative methods, one qualitative and five mixed methods). We found one ACP intervention which changed outcomes for people with dementia. Key themes were identified: there is a point at which cognition decreases critically so that an advanced care plan can no longer be made; factors present in family carers and professionals can influence decision-making and the ACP process; ACPs are affected by preferences for life sustaining treatments; ACP in dementia may differ from other illness groups; and there is a need for education relating to ACP.

CONCLUSION

The current evidence base for ACP in dementia is limited. Since UK government policy recommends that all people should engage in ACP, more evidence is needed to understand the feasibility and acceptability of advanced care plans for people with dementia.

Knowledge, attitudes, and practice behaviors of oncology advanced practice nurses regarding advanced care planning for patients with cancer

PURPOSE/OBJECTIVES

To establish initial reliability and validity of a Web-based survey focused on oncology advanced practice nurses' (APNs') knowledge, attitudes, and practice behaviors regarding advanced care planning, and to obtain preliminary understanding of APNs' knowledge, attitudes, and practice behaviors and perceived barriers to advanced care planning.

DESIGN

Descriptive, cross-sectional, pilot survey study.

SETTING

The eastern United States.

SAMPLE

300 oncology APNs.

METHODS

Guided by the Theory of Planned Behavior, a knowledge, attitudes, and practice behaviors survey was developed and reviewed for content validity. The survey was distributed to 300 APNs via e-mail and sent again to the 89 APNs who responded to the initial survey. Exploratory factor analysis was used to examine the construct validity and test-retest reliability of the survey's attitudinal and practice behavior portions.

MAIN RESEARCH VARIABLES

Respondents' demographics, knowledge, attitudes, practice behaviors, and perceived barriers to advanced care planning practice.

FINDINGS

Exploratory factor analysis yielded a five-factor solution from the survey's attitudes and practice behavior portions with internal consistency using Cronbach alpha. Respondents achieved an average of 67% correct answers in the 12-item knowledge section and scored positively in attitudes toward advanced care planning. Their practice behavior scores were marginally positive. The most common reported barriers were from patients' and families' as well as physicians' reluctance to discuss advanced care planning.

CONCLUSIONS

The attitudinal and practice behaviors portions of the survey demonstrated preliminary construct validity and test-retest reliability. Regarding advanced care planning, respondents were moderately knowledgeable, but their advanced care planning practice was not routine.

IMPLICATIONS FOR NURSING

Validly assessing oncology APNs' knowledge, attitudes, and practice behaviors regarding advanced care planning will enable more tailored approaches to improve end-of-life care outcomes.

Implementing advance care planning: a qualitative study of community nurses' views and experiences

BACKGROUND

Advance care planning (ACP) is a process of discussion about goals of care and a means of setting on record preferences for care of patients who may lose capacity or communication ability in the future. Implementation of ACP is widely promoted by policy makers. This study examined how community palliative care nurses in England understand ACP and their roles within ACP. It sought to identify factors surrounding community nurses' implementation of ACP and nurses' educational needs.

METHODS

An action research strategy was employed. 23 community nurses from two cancer networks in England were recruited to 6 focus group discussions and three follow up workshops. Data were analysed using a constant comparison approach.

FINDINGS

Nurses understood ACP to be an important part of practice and to have the potential to be a celebration of good nursing care. Nurses saw their roles in ACP as engaging with patients to elicit care preferences, facilitate family communication and enable a shift of care focus towards palliative care. They perceived challenges to ACP including: timing, how to effect team working in ACP, the policy focus on instructional directives which related poorly to patients' concerns; managing differences in patients' and families' views. Perceived barriers included: lack of resources; lack of public awareness about ACP; difficulties in talking about death. Nurses recommended the following to be included in education programmes: design of realistic scenarios; design of a flow chart; practical advice about communication and documentation; insights into the need for clinical supervision for ACP practice.

CONCLUSIONS

Nurses working in the community are centrally involved with patients with palliative care needs who may wish to set on record their views about future care and treatment. This study reveals some important areas for practice and educational development to enhance nurses' use and understanding of ACP.

Advance directives: evaluation of nurses' knowledge, attitude, confidence, and experience

This study assessed nurses' knowledge, attitudes, experience, and confidence in discussing advance directives with patients. Concepts were measured using a questionnaire administered to 87 acute care registered nurses. Results indicated lack of knowledge about laws regarding advance directives, moderately negative attitudes toward advance directives, moderate confidence, and moderate experience with advance directives. The study supports the need to explore ways to assist nurses to be comfortable with advance directives discussions to improve quality patient care.

The role of empirical research in bioethics

There has long been tension between bioethicists whose work focuses on classical philosophical inquiry and those who perform empirical studies on bioethical issues. While many have argued that empirical research merely illuminates current practices and cannot inform normative ethics, others assert that research-based work has significant implications for refining our ethical norms. In this essay, I present a novel construct for classifying empirical research in bioethics into four hierarchical categories: Lay of the Land, Ideal Versus Reality, Improving Care, and Changing Ethical Norms. Through explaining these four categories and providing examples of publications in each stratum, I define how empirical research informs normative ethics. I conclude by demonstrating how philosophical inquiry and empirical research can work cooperatively to further normative ethics.

Uncovering beliefs and barriers: staff attitudes related to advance directives

Although the 1990 Patient Self-determination Act was enacted to insure that patients' wishes regarding advance directives were known and respected, it has had little impact in quality or aggressiveness of care for patients nearing death. The purpose of this descriptive study was to explore staff attitudes related to Advance Directives. A short survey was distributed to 650 hospital, home care, hospice, assisted living, and long term professional and staff members. Analysis was completed on 413 surveys (return rate 63.3%). Findings suggest that although staff members believe that Advance Directives are an important tool, they have found both logistical and process challenges to following them. The results provide needed information for improving processes for completion and utilization of Advance Directives.