Advance care planning at life milestones.

Much progress has been made in advance care planning (ACP), especially related to end of life and palliative care. These advances have moved thinking about ACP from a checklist approach to an upstream recognition that ACP is an iterative process that should begin early in adulthood and be revisited with each milestone or life-changing event. It is recognized that there are many stages and milestones in adult life that contribute to changing loci of responsibility and life goals. These changes impact how individuals view their lives, the complexity of health care, and the myriad of health conditions they may encounter. ACP discussions should routinely be started and reexamined at the time of key life events like starting a career or a marriage and not delayed until hospitalization, the occurrence of a serious accident, or the development of a catastrophic illness.

Education, Policy, and Advocacy in Predicting Use of Do-Not-Hospitalize Orders in Skilled Nursing Facilities.

Nurses and social workers are uniquely positioned to advocate for patients' wishes for do-not-hospitalize (DNH) directives. The purpose of the current study was to explore the impact of DNH education, policy, and advocacy on the use of DNH orders by nurses (RNs and licensed practical nurses [LPNs]) and social workers employed in skilled nursing facilities (SNFs). This multisite secondary analysis used cross-sectional survey data and analyzed responses of RNs, LPNs, and social workers (N = 354) from 29 urban SNFs. Mixed model regression was used to examine possible predictors of frequency of DNH orders within SNFs while adjusting for random effects. Results showed that having a DNH written policy, education on DNH orders, and having an advanced care planning advocate in the facility were strongly associated with a higher reported frequency of DNH discussions with residents and their families (p < 0.01 for each variable). [Journal of Gerontological Nursing, 48(11), 45-52.].

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.

Surveying the hidden attitudes of hospital nurses' towards poverty.

AIMS AND OBJECTIVES: To explore the attitudes held by registered nurses about persons living in poverty. BACKGROUND: As a profession, nursing has strong commitment to advocating for the socioeconomically disadvantaged. The links among poverty and health disparities are well established and research demonstrates that attitudes of providers can influence how those in poverty use health services. Although nurses are the largest sector of healthcare providers globally, little research has been published on their attitudes towards patients they care for who live in poverty. DESIGN: Cross-sectional survey. METHODS: Used a convenience sample of 117 registered nurses who completed the Attitudes Towards Poverty Short Form that contained three subscales. Regression analysis was used to examine the associations between the nurses' age, education, and years of experience, political views and financial security with their total score and subscale scores. RESULTS: Nurses were more likely to agree with stigmatising statements than statements that attributed poverty to personal deficiency or structural factors. In the multivariate analysis, years of experience were associated with more positive attitudes towards those living in poverty. Nurses with the most experience had less stigmatising beliefs about poverty and were more likely to endorse structural explanations. Those with a baccalaureate education were also more likely to endorse structural explanations for poverty. CONCLUSIONS: Gaining knowledge about attitudes towards and the factors influencing those attitudes, for example, education, are important in helping combat the disparities associated with poverty. RELEVANCE TO CLINICAL PRACTICE: Nurses have a duty to evaluate their individual attitudes and biases towards those living in poverty and how those attitudes and biases may influence daily practice. Assessing nurses' attitudes towards poverty may aid in better means of empowering nurses to seek solutions that will improve health conditions for those living in poverty.

At Risk Care Plans: a way to reduce readmissions and adverse events.

The purpose of this article is to describe an "At Risk Care Plan." The goal of an At Risk Care Plan is to improve safety and quality care by proactively anticipating individual safety and care needs of patients at risk and to communicate those needs to the health care team. This innovative intervention has dramatically reduced hospital readmissions, costs, and adverse events for high-risk adult inpatients in a small community hospital.

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.

Impact of Chronic Conditions, Healthcare Utilization, and Demographics on Advance Care Planning.

Context: Unraveling the intricacies of what factors influence advance care planning (ACP) is an ongoing research challenge. Research shows much ACP is crisis-based and takes place at the end of life. Complicating this late-stage approach may be demographic differences based on race, ethnicity and socioeconomic status. Objective: We examined the relationship between demographic factors, chronic health conditions, and healthcare utilization in predicting who was most likely to engage in ACP activities, including designating a durable power of attorney for healthcare (DPOAHC), having a living will, and discussing wishes with family or others. Methods: We conducted a secondary analysis using 2018 Health and Retirement Study (HRS) exit data provided by a proxy for the deceased participant that matched the 2016 survey participant data (N = 884). Generalized linear mixed models were used for the analysis. Results: The number of chronic health conditions and healthcare utilization were not associated with ACP activities, but several of the demographic variables showed strong associations. Participants who were female, white, older, and from a higher socioeconomic status were more likely to have engaged in ACP. Conclusion: People continue to defer ACP discussions and documentation end of life or when facing medical crises. More needs to be done to reach out to younger adults, racial minorities, and those with lower socioeconomic status to encourage them to engage in ACP.

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

To better understand how community-based long-term care providers define advance care planning and their role in the process, we conducted 8 focus groups with 62 care managers (social workers and registered nurses) providing care for Ohio's Medicaid waiver program. Care managers shared that most consumers had little understanding of advance care planning. The care managers defined it broadly, including legal documentation, social aspects, medical considerations, ongoing communication, and consumer education. Care managers saw their roles as information providers, healthcare team members, and educators/coaches. Better education, resources, and coordination are needed to ensure that consumer preferences are realized.

Indicators of acute deterioration in adult patients nursed in acute wards: a factorial survey.

OBJECTIVES: The primary objective of the study was to determine which professional, situational and patient characteristics predict nurses' judgements of patient acuity and likelihood of referral for further review. A secondary aim was to test the feasibility of the factorial survey method in an acute area. BACKGROUND: There is increasing recognition that indicators of deterioration in acutely unwell adults are being missed and referrals delayed. The reasons for this are unclear and require exploration. Assessing nurses' clinical decision-making or judgements in a 'real-world' situation is problematic. DESIGN: The study used a factorial survey design where participants completed randomly generated paper-based vignettes on one occasion. METHODS: The dependent variables were assessment of patient acuity and likelihood of referral. Independent variables consisted of a number of patient characteristics, i.e. heart rate, blood pressure, nurse characteristics, i.e. clinical experience, and situational characteristics i.e. staffing. SETTING AND PARTICIPANTS: Participants were registered nurses working in acute areas excluding intensive care and theatre. Ninety-nine participants responded resulting in 1940 completed vignettes. RESULTS: An early warning score was the single most significant predictor of referral behaviour accounting for 9.6% of the variance. When this was not included in the vignette, nurses used physiological characteristics e.g. respiratory rate, urine output, neurological status. These explained 12% of the variance in the model predicting assessment of patient acuity and 9.4% or the variance predicting likelihood of referral. CONCLUSIONS: When given a series of vignettes, nurses appear to use appropriate physiological parameters to make decisions about patient acuity and need for referral. Our results support the use of early warning scoring systems. Education and professional development should focus more on developing and maximising clinical experience and expertise rather than knowledge acquisition alone. A factorial survey method is feasible to explore decision-making in this area. RELEVANCE TO PRACTICE: This study has several implications for practice. The emergence of an early warning scoring system as a significant individual predictor supports the use of such systems. However, the small amount of explained variance suggests that there are other influences on nurses' assessment of patient acuity and referral decisions that were not measured by the factorial survey approach. Educational provision might focus not just on knowledge acquisition but include educational delivery methods that incorporate or mimic real-ward settings.

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.

Advance Care Planning in Skilled Nursing Facilities: A Multisite Examination of Professional Judgments.

BACKGROUND AND OBJECTIVES: Lack of advance care planning (ACP) may increase hospitalizations and impact the quality of life for skilled nursing facility (SNF) residents, especially African American residents who may be less likely to receive ACP discussions. We examined the professional judgments of SNF providers to see if race of SNF residents and providers, and risk for hospitalization for residents influenced professional judgments as to when ACP was needed and feelings of responsibility for ensuring ACP discussions. RESEARCH DESIGN AND METHODS: Nurses and social workers (n = 350) within 29 urban SNFs completed surveys and rated vignettes describing eight typical SNF residents. Linear mixed modeling was used to examine factors that impacted ratings of need for ACP and responsibility for ensuring ACP. RESULTS: Neither the race of the provider, resident, nor the interaction of the two were associated with either outcome variable. In contrast, providers rated (on a 9-point scale) residents at high risk for hospitalization as more in need of ACP (estimate = 0.86, confidence interval [CI] 0.65, 1.07) and felt more responsible for ensuring ACP (estimate = 0.60, CI 0.42, 0.78). DISCUSSION AND IMPLICATIONS: Research on ACP is continuing to evolve and these results show the primacy of disease trajectory variables on providers' judgments about ACP. Differences between providers indicate a need for stronger policies and education. Further, research comparing rural, suburban, and urban SNFs is needed to explore possible forms of structural racism such as residential and SNF segregation.

Safety work: initiating, maintaining, and terminating restraints.

PURPOSE: This study examines the variations and complexities in nurses' decision making about the initiation, maintenance, and termination of physical restraints. METHODS: This qualitative research used a semistructured interview of registered nurses on medical-surgical units at a midsized hospital in the Midwest. RESULTS: All the nurse respondents easily recalled caring for a patient in restraints and detailed in their accounts a complex trajectory of care that centered on safety. However, most nurses reported that the trajectory of restraint use was started by other departments, shifts, or nurses. The findings revealed a forceful interplay of patient, nurse, family, healthcare worker, and organizational factors that influence nurses' decision making about restraint use. CONCLUSIONS: This article discusses how a deeper understanding of the intricacies of the decision-making processes related to restraints can help clinical nurse specialists tailor education, impact policy, and serve as role models to reduce the use of restraints in hospitals.

CE: Original Research: Advance Care Planning: An Exploration of the Beliefs, Self-Efficacy, Education, and Practices of RNs and LPNs.

: Objective: This study compared the advance care planning (ACP)-related beliefs, sense of self-efficacy, education, and practices of RNs and LPNs. METHODS: Data were extrapolated from a larger multisite study that was conducted across seven counties in one midwestern state. The sample consisted of RNs and LPNs working in 29 urban skilled nursing facilities in zip code areas with greater than 10% African American residents. The survey tool, a self-administered written questionnaire, gathered data on participants' demographics and ACP-related beliefs, sense of self-efficacy, education, and practices. The two main outcome variables were the percentage of residents with whom a nurse discussed ACP and the timing of the most recent such discussion. RESULTS: A total of 136 RNs and 178 LPNs completed the survey. Multivariate mixed-model analysis of the two main outcome variables showed that negative beliefs were not significantly associated with the percentage of residents with whom nurses discussed ACP but were significantly associated with the timing of the most recent ACP discussion. Having higher levels of ACP-related self-efficacy and education were significantly and positively associated with both outcome variables. RNs and LPNs did not differ significantly in their ACP-related beliefs, but RNs reported significantly higher levels of self-efficacy and education than LPNs did. CONCLUSIONS: There has been a paucity of research comparing RNs and LPNs regarding their ACP practices in skilled nursing facilities. Better education and policies that empower nurses to take a more active role are critical to increasing conversations about ACP. Further research exploring how the complementary roles of RNs and LPNs can be used to improve ACP processes and inform ACP policies is needed.

Comparing teaching practices about humor among nursing faculty: an international collaborative study.

Humor has been recognized by nurse researchers as a therapeutic intervention known to have positive psychological and physiological outcomes for patients. There is, however, no research that examines how nurses learn about humor. The purpose of this preliminary study was to examine nursing faculty members' teaching practices about humor education in the classroom and in clinical settings. Nursing faculty members from four nursing programs, two in the United States, one in Northern Ireland, and one in Taiwan, were surveyed about the inclusion of humor in the nursing curriculum. Findings revealed that substantially more humor education was included in clinical settings in the USA and Northern Ireland than in the classroom. In Taiwan, however, humor education was included more in the classroom than in clinical settings. Older and more experienced nurses with higher levels of education reported using less humor in teaching practices.

Development of a Scale to Assess Physician Advance Care Planning Self-Efficacy.

BACKGROUND: Although patients prefer that physicians initiate advance care planning (ACP) conversations, few physicians regularly do so. Physicians may be reluctant to initiate ACP conversations because they lack self-efficacy in their skills. Yet, no validated scale on self-efficacy for ACP exists. Our objective was to develop a scale that measures physicians' ACP self-efficacy (ACP-SE) and to investigate the validity of the tool. METHODS: Electronic questionnaires were administered to a random sample of family medicine physicians (n = 188). Exploratory factor analysis was performed to determine whether the scale was multidimensional. An initial assessment of the scale's validity was also conducted. RESULTS: The exploratory factor analysis indicated that a single factor was appropriate using all 17 items. A single, unidimensional scale was created by averaging the 17 items, yielding good internal consistency (Cronbach α = 0.95). The average scale score was 3.94 (standard deviation = 0.71) on a scale from 1 to 5. The scale was moderately correlated with a global single-item measure of self-efficacy for ACP ( r = .79, P < .001), and the scale differentiated between physician groups based on how much ACP they were doing, how recently they had an ACP conversation, formal training on ACP, and knowledge of ACP. In a multivariate analysis, the ACP-SE scale was a strong predictor of the percentage of patients with chronic life-limiting diseases with whom the physician discussed ACP. CONCLUSION: The final ACP-SE scale included 17 items and demonstrated high internal consistency.

Self-neglect: a proposed new NANDA diagnosis.

PURPOSE: To propose a new NANDA diagnosis, self-neglect. DATA SOURCES: Research studies and literature published from a variety of disciplines including nursing as well as primary research. DATA SYNTHESES: This diagnosis can be used to describe a constellation of self-care problems of varying severity and impact on the health and well-being of people who self-neglect. Included are two subtypes of self-neglect based on the degree of intentionality. Clarification of self-neglect is long overdue because self-neglect presents conceptual, identification, and intervention problems for nurses, healthcare workers, and for medicolegal systems across settings and in many countries. CONCLUSION: The proposed diagnosis, self-neglect, fills a gap in current standardized terminology. This diagnosis will contribute significantly to nurses leading the way in the explication of an interdisciplinary and international health concern. PRACTICE AND POLICY IMPLICATIONS: Developing self-neglect as a recognized nursing label is vital to clinicians and policy makers within and across countries. Appreciating less serious/non-life-threatening presentations will give nurses a care perspective to improve the health and well-being of those in earlier stages of self-neglect. Definitions for this phenomenon will contribute to care planning and interventions, leading to consistency in practice and research.

Humor in hospice care: who, where, and how much?

Humor has been identified as an intrinsic social phenomenon occurring in all groups throughout human history. It is among the most prevalent forms of human social behavior yet one of the least understood or defined. Although researchers in a number of disciplines have studied the effects of humor on patients, limited work has focused on end-of-life care. The present study investigated social interactions involving humor in hospice settings using nonparticipant observation. Results revealed that humor was present in 85 percent of 132 observed nurse-based hospice visits. Of these, hospice patients initiated humor 70 percent of the time. These findings were consistent regardless of hospice setting. Humor was spontaneous and frequent, and instances of humorous interactions were a prevalent part of everyday hospice work.

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.

An improved methodology for advancing nursing research: factorial surveys.

Clinical judgments and decisions are an integral component of nurse work and nurses are increasingly being challenged to account for their judgments and decisions. Nursing research is needed to help explain judgment and decision making in nursing, but most research in this area is almost exclusively characterized by descriptive studies. This article describes the use of the factorial survey method, which combines the explanatory power of a factorial experiment with the benefits of a sample survey. This hybrid technique is an excellent method for studying judgments and decisions across settings, roles, disciplines, and countries. This article outlines the steps of the method and demonstrates its applicability with an exemplar from a study across nurses from 3 countries.