Role of the community matron in advance care planning and ‘do not attempt CPR’ decision-making: a qualitative study

The community matron (CM) is often the key worker caring for patients with chronic, life-limiting, long-term conditions, but these patients are not always recognised as palliative cases. This study explored the experiences of CMs with regard to advance care planning (ACP) and ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decision-making to understand whether or not they felt adequately prepared for this aspect of their role, and why. Qualitative data were generated from six CMs using a broad interpretive phenomenological approach. Face-to-face recorded interviews were analysed using template analysis. The study found that although participants faced complex ethical situations around ACP and DNACPR almost on a daily basis, none had received any formal training despite the emphasis on training in national and local guidelines. Participants often struggled to get their patients accepted on to the Gold Standards Framework. The research found variability and complexity of cases to be the main barriers to clear identification of the palliative phase

A website supporting sensitive religious and cultural advance care planning (ACPTalk): Formative and summative evaluation

Background: Advance care planning (ACP) promotes conversations about future health care needs, enacted if a person is incapable of making decisions at end-of-life that may be communicated through written documentation such as advance care directives. To meet the needs of multicultural and multifaith populations in Australia, an advance care planning website, ACPTalk, was funded to support health professionals in conducting conversations within diverse religious and cultural populations. ACPTalk aimed to provide religion-specific advance care planning content and complement existing resources. Objective: The purpose of this paper was to utilize the context, input, process, and product (CIPP) framework to conduct a formative and summative evaluation of ACPTalk. Methods: The CIPP framework was used, which revolves around 4 aspects of evaluation: context, input, process, and product. Context: health professionals’ solutions for the website were determined through thematic analysis of exploratory key stakeholder interviews. Included religions were determined through an environmental scan, Australian population statistics, and documentary analysis of project steering committee meeting minutes. Input: Project implementation and challenges were examined through documentary analysis of project protocols and meeting minutes. Process: To ensure religion-specific content was accurate and appropriate, a website prototype was built with content review and functionality testing by representatives from religious and cultural organizations and other interested health care organizations who completed a Web-based survey. Product: Website analytics were used to report utilization, and stakeholder perceptions were captured through interviews and a website survey. Results: Context: A total of 16 key stakeholder health professional (7 general practitioners, 2 primary health nurses, and 7 palliative care nurses) interviews were analyzed. Website solutions included religious and cultural information, communication ideas, legal information, downloadable content, and Web-based accessibility. Christian and non-Christian faiths were to be included in the religion-specific content. Input: Difficulties gaining consensus on religion-specific content were overcome by further state and national religious organizations providing feedback. Process: A total of 37 content reviewers included representatives of religious and cultural organizations (n=29), health care (n=5), and community organizations (n=3). The majority strongly agree or agree that the content used appropriate language and tone (92%, 34/37), would support health professionals (89%, 33/37), and was accurate (83%, 24/29). Product: Resource usage within the first 9 months was 12,957 page views in 4260 sessions; majority were (83.45%, 3555/4260) from Australia. A total of 107 Australian-based users completed the website survey; most felt information was accurate (77.6%, 83/107), easy to understand (82.2%, 88/107), useful (86.0%, 92/107), and appropriate (86.0%, 92/107). A total of 20 nurses (general practice n=10, palliative care n=8, and both disciplines n=2) participated in stakeholder interviews. Qualitative findings indicated overall positivity in relation to accessibility, functionality, usefulness, design, and increased knowledge of advance care planning. Recommended improvements included shortened content, a comparable website for patients and families, and multilingual translations. Conclusions: The CIPP framework was effectively applied to evaluate the development and end product of an advance care planning website. Although overall findings were positive, further advance care planning website development should consider the recommendations derived from this study

Chronic Pain Management With Opioids: An Assessment of Alaska Nurse Practitioner Practices

Presented to the Faculty of the University of Alaska Anchorage in Partial Fulfillment of the Requirements for the Degree of MASTER OF SCIENCEThe purpose of this project was to determine chronic opioid pain management practices of Alaskan Nurse Practitioners (NPs) in primary care, compare them to best practices, and describe perceived barriers to evidence-based guideline use. Participants included NPs in Alaska who work in primary care and currently have an active Alaska NP license and Alaska mailing address. This project answered the questions of to what extent primary care NP practices are consistent with current Federation of State Medical Boards (2013) guidelines when managing chronic non-cancer pain with opioid therapy as well as identified the perceived barriers to guideline use. A cross sectional, descriptive design was used. The principal investigator mailed a paper survey to a convenience sample of NPs in Alaska. Nurse practitioners in Alaska follow guidelines when initiating opioid therapy most of the time, with all but three guidelines being followed ‘very frequently’ by at least 50% of respondents. Respondents follow guidelines less often when managing opioid therapy with only one guidelines being followed ‘very frequently’ by at least 50% of respondents. Two major barriers to guideline use include resource and knowledge barriers. The findings of this project were used to make clinical recommendations for improved practice.Signature Page / Title Page / Abstract / Table of Contents / List of Figures / List of Tables / List of Appendices / Introduction / Significance to Alaska Advance Nursing Practice / Purpose / Literature Review / Research Question / Methods / Results / Discussion / Implications / Dissemination / References / Appendice

Spirituality in nursing practice

Spirituality is an important aspect of holistic care which is frequently overlooked owing to difficulty conceptualising spirituality and confusion about how to integrate it into nursing care. This article seeks to understand what is meant by spirituality and spiritually competent practice, it explores some of the attitudes towards spirituality and describes some of issues affecting integration of spirituality into nursing care

A Retrospective Study Describing Documentation of Advance Care Planning in a Long Term Care Setting

Problem: Increased life expectancy and aging baby boomers will increase the population of those 65 years of age and older to nearly 20% of the United States population by 2030. It is estimated that 40-70% of this population will need long term care during their lifetime, and by 2020, 40% of patients in long term care will die there. As patients age, advance care planning (ACP) and advance directives (AD) should be completed to make their wishes known to healthcare providers and family. Despite legal requirements for completion at entry to healthcare settings, less than 95% of hospitalized patients and 50% of long term care patients have an AD or ACP. Significance: Advance care planning increases patients’ quality of life, may decrease stress and ease decision making at end of life for patients and families. There is little research on the completion levels of ACP in long term care. Purpose: The primary purpose of this retrospective study is to describe the level of ACP documentation in a long term care setting. A secondary purpose is to describe potential relationships between demographic, past medical history (PMH) and ACP variables Design: Retrospective descriptive chart review Results: More than 76% of patients at the facility were over the age of 65. Less than 43% of patients had an AD listed in their chart, and less than 31% of patients had an AD completed prior to admission at the long term care facility. At admission to the facility, only 7 of 29 (12.7%) patients that came from the hospital had an AD or ACP documented. Seven patients at the facility were listed as Hospice patients, and only three of seven (42.8%) had ACP documented. Only 33% of patients had an ACP meeting at the facility listed in their chart. Of ACP meetings that occurred, there was a high level of patient and family involvement in end of life decision making. A correlation was found between Alzheimer’s disease and ACP completion, as well as Medicaid insurance and ACP completion

End-of-Life Heart Failure Education With Staff Nurses; A Quality Improvement Project

Presented to the Faculty of the University of Alaska Anchorage in Partial Fulfillment of the Requirements for the Degree of MASTER OF SCIENCEHeart failure (HF) is a serious diagnosis and a major public health concern. The symptoms can be exhausting and can vary from person to person with periods of acute exacerbations requiring hospital admission. It is important for hospital staff nurses to be able to speak with knowledge and comfort about end‐of‐life planning. The purpose of this quality improvement project was to increase nurses’ awareness of the functional classification systems of HF, options and timing for palliative care, and describe nurses’ intent to use the information in practice. Nurses reported planning on using the information to “Be more Sensitive and Listen.” The prevailing theme to barriers to implementing this into practice was “Not enough time and discomfort.” Nurses who were comfortable having end‐of‐life discussions did not feel they had enough time, and those who were not comfortable did not engage because of discomfort toward the topic. Furthermore, recommendations from this study were the addition of a supportive palliative care team to manage patients with HF.End-of-Life Heart Failure Education with Staff Nurses; A Quality Improvement Project / Abstract / Table of Contents / Project / Background and Significant / Project Purpose / Literature Review / Methods / Analysis and Findings / Dissemination / Discussion / Conclusion / Impact on Practice / References / Appendix A New York Heart Failure Classification System / Appendix B Plan-Do-Check-Act Cycle / Appendix C Consent Form / Appendix D IRB Approval Letter / Appendix E Permission Letter / Appendix F Pre-Education Survey / Appendix G Post-Education Survey / Appendix H Case Study #1 / Appendix I Case Study #2 / Appendix J 'Do' Phase Education Intervention Lesson Plan / Appendix K Themes from QI Projec

Analysis of Tobacco Use Vital Sign Assessment

There is a massive problem of tobacco-related cancer outcomes in patients that are affected by race and ethnicity. Although this is a known disparity, there continues to be a gap in care for asking patients if they use tobacco and in advising and assisting them in making a quit attempt. Health information technology requirements and meaningful use regulations require the utilization of systematic electronic documentation. In order to improve and support tobacco use screening, systematic tobacco use assessment and documentation are essential. There is a widespread belief that adding screening for tobacco use to the vital sign assessment will lead to an increase in health care staff offering smoking cessation support during an office visit (Boyle & Solberg, 2004). This project analyzed the effects of adding a tobacco use question to the vital sign assessment in the electronic health record (EHR). The goals were to increase nursing documentation of tobacco use and to increase patient participation in initial smoking cessation counseling during a routine office visit

Low Medicaid Spending Growth Amid Rebounding State Revenues: Results From a 50-State Medicaid Budget Survey State Fiscal Years 2006 and 2007

Examines the implementation of the new Medicare prescription drug benefit and the rate of Medicaid spending growth and enrollment in 2006. Identifies possible state level changes in eligibility requirements, program expansion, and enrollment processes