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Advance care planning

Meeting a crucial need

Tully, Jessica, DNP, RN-BC, CMSRN, CNML, CENP

doi: 10.1097/01.NURSE.0000546456.63746.1b
Department: Nursing Research

Purpose. To improve the healthcare team's comfort and efficacy with end-of-life conversations at a 474-licensed bed community acute care hospital through training on advance care planning (ACP) and advance directives (ADs).

Methods. This instructional program utilized training sessions, including pre- and posttests, to demonstrate enhanced knowledge of and confidence in discussing ACP and ADs among healthcare professionals engaging in end-of-life conversations with patients and their families.

Results. There were 138 participants included in the program. A pretest and a posttest were completed by the attendees at the beginning and end of training, respectively. Data indicated improved preparedness for end-of-life conversations following the training sessions.

Conclusion. Training specific to ACP and ADs increases confidence with end-of-life conversations. With the proper knowledge and resources, the healthcare staff can foster these difficult conversations. Although the program exceeded expectations, the sample is considered small and more research will be needed.

How to improve advance care planning

Jessica Tully is the director of medical and surgical nursing at Midland Memorial Hospital in Midland, Tex.

The author has disclosed no financial relationships related to this article.

IN TODAY'S SOCIETY, people are living longer. Despite the prevalence of health issues related to aging, many American adults have not set up advance directives (ADs); data show that only 18% to 36% of the US population have completed one.1 Despite the growing need, education on advance care planning (ACP) and ADs is often nonexistent for healthcare professionals.1 ACP assists patients by shedding light on the various healthcare decisions they may have to make. It is a conversation that takes place between patients, family, and caregivers. ADs are the specific legal documents that outline the decisions made by the patient during instances in which the patient may be incapacitated.2 Because some members of the healthcare team can be uncomfortable discussing the topic, conversations about the importance of ACP or ADs do not happen often enough.3 Healthcare institutions must stress the value of ACP guidelines to clarify patients' wishes for future care—ideally before a period of hospitalization.4

Providing healthcare teams with ACP and AD training can increase the number of patients with completed ADs. Healthcare providers can then advocate effectively and treat patients according to their end-of-life wishes.3

A 2014 study of 49 nursing participants at a 325-bed regional acute care hospital demonstrated a critical need for education related to ACP and ADs based on surveys to confirm a knowledge deficiency.3 This article aims to disseminate information gathered from designing a training program for the healthcare team at a suburban community hospital. It was implemented to determine providers' knowledge and comfort levels related to ACP and ADs. Additionally, the program helped determine the probability of participants completing an AD if they did not already have one. The institutional review board granted exempt status for this study.

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ACP begins with a conversation between patients, their families, and their healthcare providers about treatment goals. It gives them power over their final months, making their wishes known and ensuring they have control over their treatment and the decisions involved in their care. The Patient Self-Determination Act of 1990 states that healthcare facilities should inform individuals about their right to enact ADs and make decisions regarding their treatment.1,5 Congress continues to provide proposals regarding ACP while encouraging individuals to complete ADs, which are associated with better patient care and a higher quality of life.1,6

Citing a perception that lack of knowledge is a barrier to completing ACP and ADs, multiple authors have found correlations between completion and comprehension.3,4,6-9 Limited resources lead to deficiencies in finalizing ACP and ADs, but educational plans for clinicians create an environment to foster these discussions.3,4,6-9 As such, it is vital to recognize and address the need to educate healthcare teams. The development of training sessions is one way to increase the number of completed patient ADs.

The ACP program leader at the study site completed a gap analysis on implementing an ACP program (see Glossary of terms). The leader concluded that relevant education for healthcare staff was nonexistent. According to the gap analysis, staff members would ask patients if they had an AD and then mark the corresponding check box to represent the answer. Patients were then asked if they would like additional information. If so, they were provided an AD book that was difficult to understand due to complicated health and legal jargon. Interactions between patients and the healthcare staff were lacking. When questioned, many nurses stated that they were uncomfortable with the ACP and AD subject matter. These issues prompted the need for appropriate training.

An instructional program was developed for the study site by an instructor with training in Respecting Choices, an evidence-based, person-centered ACP model that has been successfully replicated in other organizations.10 The instructor tasked with developing the program had also implemented one previously in another community. The program emphasized professional development regarding ACP and ADs and included information on end-of-life choices, basic and frequently asked questions, and value clarification techniques when discussing patient wishes.



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Study sample

A power analysis showed that a sample of at least 60 participants would be required for statistically significant results. Because many members of the healthcare team have the opportunity to discuss ACP and ADs with patients, the organization offered all hospital staff the opportunity to participate. Training was voluntary, and personal details were not collected as measurement tools. Those who attended the sessions included nurses, social workers, registrar staff, patient-care assistants, case managers, and chaplains.

The participating healthcare professionals were given an informational pamphlet, and instructors conducted an open dialogue and reviewed the information covered in the pamphlet. Time was allotted for a team discussion on increasing confidence and knowledge of ACP and ADs and suggestions on bringing up the subject with patients and their families. Sessions were capped at a maximum of 10 attendees and scheduled for an hour and a half for deliberation without rushing through discussion topics, but the average duration was 50 minutes or less.

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Study tools

Two different tools were used to evaluate the program: a pretest and a posttest completed by the attendees at the beginning and end of the training sessions, respectively. Both tests allowed for participant feedback and were approved by an expert panel, including specialists in ACP, research, and adult education. The experts conducted a content validity index and provided advice for improvement. Once the tools were revised accordingly, the ACP instructors used them in their educational sessions. Because two different ACP instructors provided training, the two sets of completed tests were kept separate for evaluation to identify any differences in their teaching methods.

The pretest consisted of six questions, two of which used continuum scale ratings of the participant's self-perceived knowledge and comfort regarding ACP and ADs. The test also included three yes or no questions about any previous training, whether they had an AD, and if they could describe the difference between ACP and AD. One question addressed how often (daily, monthly, yearly, or rarely) the participant encountered a patient who needed assistance with an AD. (See ACP pretest.)

The posttest consisted of four questions to be completed immediately after the training session. Like the pretest, it included two questions that used a continuum scale rating. The first asked about the participants' self-perceived knowledge regarding ACP and ADs. The second continuum scale question asked about the participants' self-perceived comfort level regarding ACP and ADs. The posttest also asked participants without a personal AD if they now planned to complete one. The final question determined if participants could now describe the difference between ACP and ADs. (See ACP posttest.)

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Participant data and analysis

A total of 138 attendees were included in the program—69 for each ACP instructor. The instructors submitted the completed tests to the project manager for data analysis, and answers from the individual participants were compared to measure changes in their knowledge and comfort level regarding ACP and ADs. The instructors were also compared using a statistical program and assistance from a statistician to ensure there were no differences in reported data.

The IBM Statistical Package for the Social Science (SPSS-30) computer software was used to determine values and statistical numbers, and a statistician aided with interpreting the results. Statistical significance was calculated with P value of less than .05 and measured the participants' comfort level, knowledge level, and ability to describe ACP and ADs. A pairwise comparison for all three values showed a significance of P = .000 with a 95% confidence interval.





Statistical analysis also showed attendees with previous ACP and AD training reported an increase in knowledge despite their prior experience. Data representing the members of the healthcare team showed that only a small percentage had an AD. Of the 89.8% without an AD, 84.1% stated they would get one, 4.3% said they would not, and 1.4% were unsure after the training session. The remaining 10.2% were those with an AD already in place. An analysis of the average number of encounters with patients that required ACP and AD assistance showed that 61% of participants reported yearly or rarely, while 39% reported daily or monthly encounters with this patient population.

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Instructor data

The instructor data were also analyzed using SPSS-30 with assistance from a statistician. It demonstrated that ACP and AD training can be initiated and sustained by more than one instructor over time. A comparison showed no significant difference between the instructors regarding the participants' knowledge level, comfort level, and ability to describe ACP and ADs. That said, the results did show significant improvement over time for interactions with both instructors, and the participants' initial comfort ratings and ability to describe ACP and ADs improved over time with each instructor.

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Implications for practice

Providing the training and education to communicate effectively regarding ACP and ADs is crucial. These conversations help to make patients' wishes known and impact the quality of care they receive. Without the tools for successful end-of-life care, the healthcare team cannot serve patients effectively.

Data from this study indicated an enhanced knowledge base and comfort level for healthcare professionals engaging in end-of-life discussions following training. Although this study demonstrated an increase in the knowledge and confidence necessary for ACP and AD discussions, further research is needed to determine whether additional training actually increases the number of conversations, including possible increases in the documented ADs in patients' medical records.

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This study has several limitations. Although it exceeded the power analysis, the sample is considered small. Additionally, participants did not provide their role within the healthcare community, making it impossible to verify which members of the staff saw the most benefit. Given the self-reported nature of this study, it is difficult to establish a link between the participants and any changed practice behaviors regarding end-of-life conversations with patients.

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The ACP and AD educational program provided healthcare staff with the knowledge and confidence needed to address end-of-life wishes. Training specific to ACP and ADs increases these skills. With the proper knowledge and resources, the staff can foster these difficult conversations with patients and family members. The study also showed a positive influence in study participants obtaining an AD following the educational program.

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          advance care planning; advance directives; end-of-life conversations

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