Managing in the trenches of consumer care: the challenges of understanding and initiating the advance care planning process

Multi-Site Study of Provider Self-Efficacy and Beliefs in Explaining Judgments About Need and Responsibility for Advance Care Planning

BACKGROUND AND OBJECTIVES

We examined the impact of advance care planning (ACP) self-efficacy and beliefs in explaining skilled nursing facility (SNF) provider judgments about resident need and provider responsibility for initiating ACP conversations.

RESEARCH DESIGN AND METHODS

This observational multi-site study of 348 registered nurses, licensed practical nurses, and social workers within 29 SNFs used an anonymous survey in which providers judged vignettes with assigned situational features of a typical SNF resident. Mixed modeling was used to analyze the vignette responses.

RESULTS

Providers who had more negative beliefs about ACP were less likely to judge residents in need of ACP and less likely to feel responsible for ensuring ACP took place. Self-efficacy did not have a significant impact on judgments of need, but did significantly increase judgments of responsibility for ensuring ACP conversations. Providers with the highest levels of ACP self-efficacy were most likely to feel responsible for ensuring ACP conversations. In an exploratory analysis, these relationships remained the same whether responding to high or low risk residents (i.e., based on risk of hospitalization, type of diagnosis, functional status, and rate of declining health).

DISCUSSION AND IMPLICATIONS

Both negative beliefs about ACP and self-efficacy in one's ability to conduct ACP discussions were associated with professional judgments regarding ACP. The findings illustrate the importance of addressing negative beliefs about ACP and increasing provider ACP self-efficacy through education and policies that empower nurses and social workers.

Discrepancies among knowledge, practice, and attitudes towards advance care planning among Chinese clinical nurses: A national cross-sectional study

AIMS AND OBJECTIVES

To explore the Chinese nurses' knowledge and attitudes concerning advance care planning (ACP) and their engagement in ACP practice.

BACKGROUND

Nurses' knowledge, attitude, and practice of ACP are important in promoting ACP in patients, but little is known about knowledge, attitudes, and practice of ACP among nurses in countries where there are no national policies or regulations on ACP.

DESIGN

A descriptive study with a cross-sectional design.

METHODS

An online questionnaire survey was distributed to Chinese nurses who attended a national conference.

RESULTS

A total of 531 nurses completed the survey and were included in the final analysis. No nurses answered all questions correctly, while 31 (5.8%) answered all the survey questions wrong. The participants were most knowledgeable about the item "Once ACP is made, the content of advance directives cannot be revoked" and were least knowledgeable about the item "ACP is valid only when the patients are well informed of the medical condition". The implementation of ACP was favored by 92.5% of participants, but only 3.4% of them had actually engaged in all 5 ACP practices listed in the survey. Experience of dealing with death was positively associated with nurses' knowledge concerning ACP. The number of dying patients cared for in the past 6 months, school education of palliative care, knowledge of ACP, and age were related to engagement in the practice of ACP.

CONCLUSION

Chinese nurses have supportive attitudes towards ACP, but they have limited knowledge and little practice in ACP.

A self-reported survey on the confidence levels and motivation of New South Wales practice nurses on conducting advance-care planning (ACP) initiatives in the general-practice setting

Nurses are well positioned to initiate and conduct advance-care planning (ACP) conversations; however, there has been limited research on practice nurses performing this role in Australia. The aim of the present study was to understand the beliefs, attitudes, perceptions, confidence, training and educational needs of New South Wales practice nurses with regards to involvement in ACP. A cross-sectional online survey was conducted in August to October 2014. Nurses were recruited through nursing organisations and Medicare Locals. There were 147 completed surveys (n=147). Participants were mostly female registered nurses, with a median age of 50, and 6 years of practice-nurse experience. Practice nurses were generally positive towards their involvement in ACP and believed it would be beneficial for the community. Their confidence in initiating ACP increased as their familiarity with patients increased. They showed a high level of interest in participating in training and education in ACP. Barriers to their involvement in ACP included the lack of a good documentation system, limited patient-education resources and unclear source of remuneration. Nurses were also concerned over legalities of ACP, ethical considerations and their understanding of end-of-life care options. Nevertheless, they were highly receptive of integrating ACP discussions and were willing to enhance their skills. These findings uncover a need for further training and development of practice nurses for ACP discussions.

A broader understanding of care managers' attitudes of advance care planning: A concurrent nested design

AIMS AND OBJECTIVES

To examine barriers of advance care planning (ACP) experienced by care managers (CMs) through a mixed methods approach. A concurrent nested design was used to acquire a deeper understanding of ACP and to identify nuances between quantitative and qualitative data.

BACKGROUND

Past quantitative studies on providers have identified barriers related to time, culture, knowledge, responsibility and availability of legal documents. These barriers, and accompanying attitudes and feelings, have been taken at face value without rich qualitative data to identify under what conditions and to what extent a barrier impacts care.

DESIGN

A two-part multisite, mixed methods study was conducted using surveys and focus groups.

METHODS

Surveys were completed by 458 CMs at 10 Area Agencies on Aging and 62 participated in one of eight focus groups. Data were analysed using a concurrent nested design with individual data analysis and a merged data approach.

RESULTS

There were three main distinctions between the quantitative and qualitative data. First, while CMs reported on the survey that ACP was not too time consuming, focus group data revealed that time was an issue especially related to competing priorities. Second on the survey 60% of the CMS reported they had enough knowledge, but qualitative data revealed about more nuances. Last, the reported comfort levels in the quantitative data were less overt in the qualitative date where additional feelings and attitudes were revealed, for example, frustration with families, preferences for more physician involvement.

CONCLUSIONS

Care managers reported their attitudes about ACP, clarified through a rigorous mixed methods analysis. Care managers can successfully lead ACP discussions, but require further education, resources and team-based guidance.

RELEVANCE TO CLINICAL PRACTICE

Advance care planning is essential for reducing emotional, social and financial burdens associated with healthcare decision-making, and CMs can positively impact ACP discussions when appropriately supported by the clinical community. The many nuances in the ACP process that we found illustrate the need for ongoing discussions, education and research on this important topic.

Prospective comparative effectiveness cohort study comparing two models of advance care planning provision for Australian community aged care clients

OBJECTIVES

Conduct a prospective comparative effectiveness cohort study comparing two models of advance care planning (ACP) provision in community aged care: ACP conducted by the client's case manager (CM) ('Facilitator') and ACP conducted by an external ACP service ('Referral') over a 6-month period.

METHODS

This Australian study involved CMs and their clients. Eligible CM were English speaking, ≥18 years, had expected availability for the trial and worked ≥3 days per week. CMs were recruited via their organisations, sequentially allocated to a group and received education based on the group allocation. They were expected to initiate ACP with all clients and to facilitate ACP or refer for ACP. Outcomes were quantity of new ACP conversations and quantity and quality of new advance care directives (ACDs).

RESULTS

30 CMs (16 Facilitator, 14 Referral) completed the study; all 784 client's files (427 Facilitator, 357 Referral) were audited. ACP was initiated with 508 (65%) clients (293 Facilitator, 215 Referral; p<0.05); 89 (18%) of these (53 Facilitator, 36 Referral) and 41 (46%) (13 Facilitator, 28 Referral; p<0.005) completed ACDs. Most ACDs (71%) were of poor quality/not valid. A further 167 clients (facilitator 124; referral 43; p<0.005) reported ACP was in progress at study completion.

CONCLUSIONS

While there were some differences, overall, models achieved similar outcomes. ACP was initiated with 65% of clients. However, fewer clients completed ACP, there was low numbers of ACDs and document quality was generally poor. The findings raise questions for future implementation and research into community ACP provision.

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.

Enhancing the prospects for palliative care at the end of life: A statewide educational demonstration project to improve advance care planning

OBJECTIVE

Although patients want to participate in discussions and decisions about their end-of-life care, studies show that providers frequently fail to invite them to explore advanced care preferences or goals for living. The purpose of our demonstration project was to provide education and coaching to individuals, health providers, and organizations across the state of Indiana intended to facilitate these conversations, documenting and honoring individuals' life goals and preferences for care during the final stages of life.

METHOD

Education and training engaged community members as well as healthcare providers to: (1) improve participant comfort and facility discussing end-of-life issues; (2) improve knowledge of healthcare choices, including palliative and hospice care; and (3) prepare all participants to explore and document personal values, life goals, and priorities as well as goals of care.

RESULTS

Between January of 2013 and June of 2015, the team educated close to 5,000 participants. Participants' ratings of the quality and perceived usefulness of the educational events ranged from 4 to 5 (using a 5-point scale, with 5 = most effective). Participant comments were overwhelmingly favorable and indicated an intention to put the advance care planning resources, communication skills, knowledge of palliative and hospice care, and personal renewal techniques into practice.

SIGNIFICANCE OF RESULTS

Participant motivation to foster advance care planning, discussions of palliative care, and end-of-life conversations was facilitated by the reframing of these conversations as identifying goals of care and priorities for living well during an important stage of life. Successful strategies included helping providers and patients to adopt a broader meaning for "sustaining hope" (not for cure, but for engaging in highly valued activities), developing provider communication skills and comfort in initiating potentially difficult discussions, engaging a new community health workforce who will develop trusting relationships with patients in home-based services, and fostering self-awareness and self-care among palliative care providers.

Nurses' views regarding implementing advance care planning for older people: a systematic review and synthesis of qualitative studies

AIMS AND OBJECTIVES

To explore nurses' views regarding implementing advance care planning for older people.

BACKGROUND

Advance care planning is recommended as a way for older people to discuss their future care with family members and health professionals. Nurses play key roles in the process of advance care planning, including ensuring that patients are informed of their rights and that decisions are known to, and respected by, the health care team. Thus, understanding of nurses' experiences and perspectives regarding implementing advance care planning for older people is a significant topic for review.

DESIGN

Qualitative meta-synthesis.

METHODS

Four databases including CINAHL plus, Medline [EBSCOhost], EMBASE, and PsycINFO were searched, and 1844 articles were initially screened. Finally, 18 articles were critically appraised and a thematic synthesis was undertaken.

RESULTS

Four themes were identified regarding implementation of advance care planning: perceived disadvantages and advantages of advance directives; nurses' responsibility and roles; facilitators and barriers; and nurses' needs and recommendations. Nurses felt that advance directives provided more advantages than disadvantages. Nurses generally believed that they were well positioned to engage in advance care planning conversations. Nurses perceived barriers relating to older people, families, environment, time, culture, cost, language and knowledge of health care teams with regard to advance care planning. In nurses' needs, education and support were highlighted.

CONCLUSIONS

This study provides useful knowledge for implementing advance care planning through illustrating nurses' experiences and perspectives. The results showed that nurses were more concerned about barriers in relation to working environment, teamwork, time and knowledge of health care team members than older people's characteristics, when implementing advance care planning.

RELEVANCE TO CLINICAL PRACTICE

The findings provide nurses and administrators with information to develop related policies and education. Additionally, the appointment of nurses to formal roles related to advance care planning is appropriate and warranted.

Current advance care planning practice in the Australian community: an online survey of home care package case managers and service managers

BACKGROUND

Advance care planning (ACP) is the process of planning for future healthcare that is facilitated by a trained healthcare professional, whereby a person's values, beliefs and treatment preferences are made known to guide clinical decision-making at a future time when they cannot communicate their decisions. Despite the potential benefits of ACP for community aged care clients the availability of ACP is unknown, but likely to be low. In Australia many of these clients receive services through Home Care Package (HCP) programs. This study aimed to explore current attitudes, knowledge and practice of advance care planning among HCP service managers and case managers.

METHODS

An invitation to take part in a cross-sectional online survey was distributed by email to all HCP services across Australia in November 2012. Descriptive analyses were used to examine overall patterns of responses to each survey item in the full sample.

RESULTS

120 (response rate 25%) service managers and 178 (response rate 18%) case managers completed the survey. Only 34% of services had written ACP policies and procedures in place and 48% of case managers had previously completed any ACP training. In addition, although most case managers (70%) had initiated an ACP discussion in the past 12 months and viewed ACP as part of their role, the majority of the conversations (80%) did not result in documentation of the client's wishes and most (85%) of the case managers who responded did not believe ACP was done well within their service.

CONCLUSIONS

This survey shows low organisational ACP systems and support for case managers and a lack of a normative approach to ACP across Australian HCP services. As HCPs become more prevalent it is essential that a model of ACP is developed and evaluated in this setting, so that clients have the opportunity to discuss and document their future healthcare wishes if they choose to.

The Relationship Between Organizational Characteristics and Advance Care Planning Practices

Organizational characteristics may impede the uniform adoption of advance care planning (ACP) best practices. We conducted telephone interviews with site directors of a Midwestern state’s Medicaid waiver program administered by the Area Agencies on Aging and surveyed the 433 care managers (registered nurses and social workers) employed within these 9 agencies. Care managers at 2 agencies reported more frequent ACP discussions and higher levels of confidence. Both sites had ACP training programs, follow-up protocols, and informational packets available for consumers that were not consistently available at the other agencies. The findings point to the need for consistent educational programs and policies on ACP and more in depth examination of the values, beliefs, and resources that account for organizational differences in ACP.

Narrative analysis of the ethics in providing advance care planning

Our objective was to better understand the values and ethical dilemmas surrounding advance care planning through stories told by registered nurses and licensed social workers, who were employed as care managers within Area Agencies on Aging. We conducted eight focus groups in which care managers were invited to tell their stories and answer open-ended questions focusing on their interactions with consumers receiving home-based long-term care. Using narrative analysis to understand how our participants thought through particular experiences and what they valued, we identified seven themes representative of their work with consumers and families: humility, respect, responsibilities, boundaries, empowerment, courage, and veracity.

Disentangling Consumer and Provider Predictors of Advance Care Planning

Factorial surveys were used to examine community-based long-term care providers' judgments about consumers' need for advance care planning (ACP) and comfort levels in discussing ACP. Providers (448 registered nurses and social workers) judged vignettes based on hypothetical consumers. Hierarchical linear models indicated providers judged consumers who were older, had end-stage diagnoses, multiple emergency department visits, and uninvolved caregivers as most in need of ACP. These variables explained 10% of the variance in judgments. Providers' beliefs about ACP predicted judgments of need for ACP and comfort level in discussing ACP. Provider characteristics explained more variance in comfort levels (44%) than in judgments of need (20%). This study demonstrates the need for tailored educational programs to increase comfort levels and address ACP misconceptions.