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From Where Innovation Begins to Lessons From A Bad Boss: A Nursetopia Reading & Education Mashup [Part 22]

MashupMy reading list is filling back up again, and I’m absolutely loving it. I’m squeezing in chapters here and there, and you better believe free moments in between meetings and snippets of downtime have their fair share of bit-sized information and education. Here’s a little of what’s been passing through my brain lately:

What are you reading these days?

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Advanced Care Planning: How Does Current Practice Compare with Best Practice?

The Article: van der Spek, E. (2011). Advanced care planning: How does current practice compare with best practice? PACEsetterS, 8(3): 34-39.

Big Idea: This study examined the advanced care planning (ACP) within one Australian Residential Aged Care Facility (RACF), which sounds similar to the U.S. equivalent of a “nursing home.” The researcher found evidence of current best practices and then audited 71 patient charts and all 17 staff training records against six ACP practice and education questions. Once the audit was complete, the RACF changed ACP practices to match evidence-based interventions and then re-evaluated patient charts and training records to see if the interventions made a difference.

Survey Says!: All 71 patients had ACPs, but the author found less than 40% of them were completed correctly. In addition, none of the 17 nurses had completed regular, specialized education or training related to ACP. Needless to say, the researcher and team worked to improve the ACP documentation form to improve accuracy, and nurses received ACP training. The post-intervention audit did reveal improved results. 52% of patient charts/ACPs were accurate, and 88% of nurses completed ACP training and specialized education.

Quotable: “An advanced care plan completed by a competent individual enables them to extend their autonomy in decision making even when they are no longer able to make or convey decisions for themselves [references]” (p. 37).

“Given that the nurses initially described feelings of discomfort in discussing ACP, and that some residents and relatives had been reluctant to discuss end-of-life care, it was evident that there were barriers that needed to be addressed. The literature suggests lack of time, personal discomfort in talking about death, lack of knowledge about ACP, or a paternalistic view of end-of-life care decision making may all be barriers to ACP [references]” (p. 39).

So What?: These results may not seem like a big deal, but it is actually quite impressive considering the intervention – changing the ACP documentation form for improved accuracy and targeted education effort – occurred within a three-month time frame. The project timeline (on page 36) is lovely and ambitious, as the researcher began the project in January and finished the final audit and began drafting the article manuscript in June. “Research” can be very daunting, but this article and research study are beautifully simplistic, highlighting every nurse’s opportunity to contribute to the nursing body of knowledge. The author knew there was a problem. She proved it objectively, researched the evidence, implemented a few best practices, re-evaluated the original objective measures, and shared what she did and learned. Not only can we all learn from the author’s design and intervention to improve advanced care planning for the aged, but we can also find the underlying encouragement in her writing to do the same – do what we all went to school for: improve patient care utilizing evidence and then contribute right back to the evidence.

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Health Care Professionals’ Death Attitudes, Experiences, and Advance Directive Communication Behavior

The Article: Black, K. (2007). Health care professionals’ death attitudes, experiences, and advance directive communication behavior. Death Studies, 31: 563-572.

Big Idea: Healthcare professionals have been required to inquire about advance directive creation of all adults since the passage of the Patient Self-Determination Act of 1991. However, healthcare professionals’ personal attitudes toward death and dying may influence advance direction communication behavior. Dr. Black surveyed 135 healthcare professionals – 74 nurses, 32 physicians, and 29 social workers – about their attitudes toward death and their advance directive communication and behavior.

Survey Says!: Utilizing two different tools, the author found numerous correlations among healthcare professionals’ death and dying beliefs and self-reported advance directive communication behavior. For example, healthcare professionals more accepting of death and having a positive view of afterlife initiated more advance directive conversations with patients than their counterparts. Similarly, professionals experiencing the death of a close friend or family member within the past year reported sharing more advance directive information with patients, likely as a personal coping mechanism. Conversely, professionals with a negative or fearful view of death were less likely to collaborate with colleagues and engage in advance directive discussions.

Quotable: “Research suggests that inadequate professional training regarding death and dying is a barrier for effective practice in this area for physicians [references], nurses [references], and social workers [references]” (p.564).

So What? Dr. Black does mention the study results should be interpreted with caution as the response rate was low and self-report is subject to bias. However, this study does suggest healthcare providers’ personal views of death do impact advance directive discussions with patients and families. Healthcare professionals should be aware of their beliefs and attitudes of death and dying to better discuss and facilitate advance directive creation.

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Systematic Review of Educational Interventions for Improving Advance Directive Completion

Levels of Evidence

The Article: Durbin, C., Fish, A., Bachman, J., & Smith, K. (2010). Systematic review of educational interventions for improving advance directive completion. Journal of Nursing Scholarship, 42(3): 234-231.

Big Idea: Pay attention. This is a systematic review – the mother-load of research. Score! This article examines the results of 12 randomized and four non-randomized studies from numerous disciplines analyzing interventions to improve new advance directive completions, which remains a barrier for the majority of healthcare institutions.

Survey Says!: Bottom line, combined written and verbal interventions improved advance directive completion over single-method written interventions. Unfortunately, the research in this area is still rather weak. Durbin and colleagues point out researchers need to conduct more randomized-controlled studies with diverse patient populations before conducting additional studies comparing actual interventions.

Quotable: “Despite persistent efforts by healthcare providers and agencies, ADs [advance directives] are completed by fewer than one third of adults [references]” (p.234).

“The low numbers of studies per type of educational intervention preclude making prescriptive clinical recommendations” (p.240).

So What?: Both inpatient and outpatient healthcare facilities can learn from this systematic review and work to conduct combined written and verbal interventions and education to increase new advance directive completions. Nurse researchers should take note of the gaps within the literature and work to fill those gaps with randomized-controlled studies so we can better understand which interventions work best to improve care.

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[Poll] Healthcare Professionals, Have You Made Your Own Advanced Directives?

Today is National Healthcare Decisions Day. Your decisions matter.

As healthcare professionals, many of us know the importance of having advanced directives. A lot of us dance around the discussion, but it is an important one to have with all patients. I am a bit embarrassed to admit it, but I currently do not have an advanced directive myself. I know I need one, but I simply haven’t completed the process. My husband and I discuss it often as we are currently living through an unfortunate situation in which one of our family members doesn’t have an advanced directive and now we are facing difficult decisions as a family.

My own dilemma made me curious. As a healthcare professional, do you have your own advanced directive yet?

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Consider the Conversation

Advanced care planning is all-too-often overlooked by healthcare professionals and our society in general. Check out this great video about what many people want their death to be like. I wonder how many of them will have their wishes as reality? Maybe you’ll think of this video next time you admit a patient or talk with a family member. Consider the conversation.