Advance Directives: The Clinical Nurse Specialist as a Change Agent

Thematic Analysis of Barriers to Completion of a Healthcare Proxy at a Comprehensive Cancer Center

Advance care planning is an important component of comprehensive oncology care. Advance directives serve to extend patient autonomy and empower patients to have their preferences and values honored when they cannot speak for themselves. This is a critical component when patients are facing cancer treatment that may challenge their ability to fully participate in their care. A review of institutional practices and procedures identified an opportunity to improve the process for obtaining healthcare proxy documentation, a critical but approachable component of advance care planning. A multi-level assessment was performed utilizing focus groups consisting of patients and community members, medical professionals, and hospital administrators. Areas of concern, misconceptions, and process weaknesses were identified by qualitative thematic analysis. This analysis was utilized to identify institution-specific barriers to completion of a health care proxy. They can then be tailored to develop staff specific education to overcome these barriers, in cooperation with ongoing patient education efforts. The analysis also identified process and workflow barriers to completion, implementation, and access; the result is the identification of multiple opportunities for quality improvement within the cancer care setting. Ultimately, multi-level intervention to improve knowledge and comfort with health care proxies and advance care planning will enhance patient care.

A Quality Improvement Project for Monitoring Surgical Patients With Obstructive Sleep Apnea

INTRODUCTION

Patients who have obstructive sleep apnea (OSA) are at a higher risk for opioid-induced respiratory depression postoperatively. Many patients who have OSA are not given a diagnosis before undergoing surgery and may not be monitored appropriately afterward.

PURPOSE

The purpose of this quality improvement project was to increase the number of preoperative patients screened for OSA and improve their postoperative monitoring through a novel OSA protocol order set through the implementation of evidence-based practices.

METHODS

Screening for OSA risk is performed preoperatively using the STOP-Bang instrument. High-risk patients, as well as patients with existing OSA, are monitored postoperatively using a bundle of evidence practices to identify early respiratory compromise. If respiratory events occur, a treatment intervention will be triggered.

OUTCOME

Postintervention chart reviews demonstrated 100% of the qualifying patients had OSA screening completed before surgery. The OSA protocol was ordered in 28 of the 100 charts reviewed. Patient harm may have been avoided through the implementation of the protocol's standing order for continuous positive airway pressure, which was triggered by respiratory events.

CONCLUSION

It is important to identify these high-risk patients before surgery through preoperative screening. These patients should be monitored closely postoperatively to identify early respiratory compromise.

Knowledge, attitudes, experiences, and confidence of nurses in completing advance directives: a systematic synthesis of three studies

BACKGROUND

Advance directives (ADs) are one of the few means for patients to indicate their end-of-life (EOL) treatment option preference. An effective and consistent solution for increasing the AD completion rate remains elusive. A literature search revealed three studies completed in the United States that employed an identical methodology and focused on registered nurses (RNs). These studies examined a variety of concepts, including nurses' knowledge, attitudes, experience, and confidence with regard to ADs.

PURPOSE

This review completed a systematic synthesis of reported results from three survey studies that focused, respectively, on oncology, critical care, and emergency RNs who were members of various professional nursing organizations.

METHODS

Our investigation addressed the following research questions: What are the knowledge, attitudes, experience, and confidence of RNs with regard to ADs, and what is the relationship among these study variables? Each study used the Knowledge, Attitudes, and Experiential Survey on Advance Directives Instrument to obtain findings.

RESULTS

Findings indicated that level of knowledge of nurses was about 60% correct and that nurses reported a moderate level of confidence related to ADs. Nurses stated they were experienced in AD discussions and agreed with attitude statements indicating support of ADs. Advocacy was a theme in the findings of these studies, as most nurses agreed with the statement that nurses should uphold patients' wishes. Time was identified as an impediment to AD completion. Critical care nurses had higher levels of awareness of ADs, as compared with oncology and emergency room nurses, although the cause of this difference is unclear. Although RNs provided AD education and explanations and described the various types of EOL care, these study subjects suggested that discussions of patients' prognoses may be an intervention more appropriate for nurses or other clinicians with advanced education and training. CONCLUSION/LIMITATIONS: The low Cronbach's alpha values in the attitude scales within the survey instrument posed limitations in the original research on the use of attitude scale scores in statistical analysis. The data examined in this study was obtained from published reports, which limited the synthesis and analysis of study findings. Nurses need to refine their role in AD discussions with patients. End-of-life discussions should be an interwoven process between RNs and the multidisciplinary team.