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The Knowledge, Attitudes, Experience and Confidence of MPRNs and Advance Directives (ADs). Significance. Provide the foundation for understanding the perspectives of MPRNs in the process of patient AD completion and their role in this process. Study Assumptions. Bioethical Principles - PowerPoint PPT Presentation
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The Knowledge, Attitudes, Experience and Confidence of MPRNs and Advance Directives (ADs)
Significance
Provide the foundation for understanding the perspectives of MPRNs in the process of patient AD completion and their role in this process.
Study Assumptions
Bioethical Principles Autonomy
Pts have the right to direct their health care Beneficence
Dying with Dignity MPRN has advanced skill set in the field of nursing Knowledge, professional attitudes regarding EOL
decision-making, experience with ADs, confidence with ADs, and attitudes based on professional experiences in EOL decision-making are the basis for MPRN’s interventions with ADs
Purpose and Method
To understand MPRNs’ knowledge, attitudes, experience, confidence regarding EOL decision-making (study variables) and any predictive relationships among them
The comparison of oncology and ER MPRNs on the study variables was also investigated
Method Secondary Data Analysis (SDA) Two prior research studies as foundation
Secondary Data Analysis (SDA) Methodology Intent-Test new hypotheses or examine new
research questions with pre-established data sets Steps in the process
1. Qualifications of investigators
2. Theoretical orientation
3. Definition of terms
4. Evaluate sample selection
5. Review measurement procedures
6. Data preparation
7. Data analysis
(SDA) #4Evaluate Sample Selection Subjects- registered nurses (RNs)
Emergency Room Nurses Association - Jezewski & Feng (2007)
Oncology Nursing Society- Jezewski, Brown et al. (2005)
Sampling Stratified, national, random samples
California, Illinois, New York, and Texas Self identified subset of MPRNs in both
studies
SDA #4Posthoc Power Analysis Actual Sample size = 410
- 264 oncology MPRNs - 146 ER MPRNs
Power analysis - 20 variables
-Alpha .05- Need a sample size of 252 to achieve power of .90 and R2 of 0.10
SDA #5 - Review Measurement Procedures Knowledge, Attitudinal and Experiential Survey
on Advance Directives (KAESAD) Instrument 115 items- including demographics Content Validity & Reliability
Scales (Study Variables) Knowledge-General/Patient Self Determination
Act/State Attitudes Regarding EOL decision-making Attitudes Based on Professional Experience with
EOL decision-making General Experience Confidence
Select Knowledge Scale Items
1.An AD is a legal document which allows people to exercise their rights to accept or refuse medical care, even when they can no longer make their own decisions.
2.An AD is a term used to describe living wills, health care proxies, and/or durable powers of attorney for healthcare.
11.The New York state law defines “qualified patient” as someone 21 years of age or older
18.The PSDA requires that health care facilities advise patients of their rights regarding ADs.
Select Items from Attitudes Regarding EOL Decision-Making
32.Nurses should uphold the patient’s wishes even if they conflict with the nurse’s own views.
33.It is sometimes best to withhold information from patients.
34.Most of the time patients are sufficiently informed to prepare ADs.
Select Items from Experience Scale
51. Have you cared for a patient with an AD?
52. Have you read your institution’s policies or procedures concerning ADs?
53. Have you been a witness for an AD for a patient?
Select Confidence Scale Items58. Knowing the provisions of the
Patient Self-Determination Act.59. Initiating AD discussions with
patients.60. Answering patients’ questions about
ADs.61. Answering family members’
questions about ADs.
Select Items from Professional Experiences with EOL Decision-Making Scale
69. Most patients are approached early enough in their terminal illness to allow them time to make informed decisions about EOL care.
70. Patients and their health care providers generally agree about what constitutes medically futile treatment.
71. An impediment to making good decisions about EOL care is difficulty communicating with patients and their families.
72. Very often there is not enough time to discuss ADs with patients.
SDA -Data Preparation and Analysis Data Preparation
Responses need to be in a similar format prior to combining
Likert responsesAttitudes Regarding EOL Decision- MakingAttitudes Towards Professional Experiences
with EOL Decision-Making 4 pt –oncology MPRNs 6 pt --ER MPRNs Collapse categories into agree and
disagree Data Analysis
Cronbach’s alpha
Knowledge – 0.61 Confidence – 0.93 Experience - 0.68 Attitudes Regarding EOL Decision-Making -
0.43 and 0.55 Professional Experiences Regarding EOL
Decision-Making -0.57 and 0.62
MPRNs - Demographic Information on Study Sample
Female n=389 (95%) Practice Mean 22; range 2-51 years Age - Mean- 47 years; range 26-73 years Caucasian n=374 (92%) Married n=83 (69%) Christian n=248 (85%) Having an AD
Self n=153 (37%) Family member n=236 (58 %)
Direct patient care n=186 (46%) Employed full-time n=353 (86%) Certification n=250 (61%)
RQ#1 What are MPRNs’ knowledge, attitudes, experience and confidence related to ADs?
Scale Mean % Correct
Total Knowledge (0-30) 17.84 (3.3) 59.5%
General AD Knowledge (0-10) 7.03 (1.3) 70.32%
Knowledge of the PSDA 3.84 (1.3) 54.88%
Knowledge of State Laws 6.98 (2.2) 53.66%
Confidence (11-55) 39.65 (9.3) -----
Experience (0-5) 3.92 (1.1) -----
Knowledge of MPRNs in regards to ADs
020406080
all
TotalGeneralPSDAState
RQ #1 Attitudes Regarding EOL Decision-Making Scale Items
Item % Agree
Nurses should uphold the patient’s wishes. 388 (95%)
All patients should complete ADs. 383 (93%)
It is always appropriate to give a patient pain medication
400 (98%)
Nurses should help inform patients about their treatment options.
389 (95%)
Withholding information from patients is sometimes indicated.
33 (8%)
ADs will lead to euthanasia. 23 (6%)
RQ #1. Attitudes Towards Professional Experiences
with EOL Decision Making Scale
Item % Agree
Living will encourages EOL discussions. 338 (83%)
It is difficult to communicate with patients and families about EOL care.
314 (77%)
The information in an AD will guide rx. 221 (54%)
Nurses know patient’s wishes regarding EOL care. 203 (50%)
Most patients are approached early enough to make informed decisions about EOL care.
74 (18%)
Nurses spend enough time discussing ADs with patients. 35 (8%)
RQ #2. What are the relationships between MPRNs’ demographic characteristics and their knowledge, attitudes , experience, and confidence regarding ADs?
Confidence scores were correlated with educational hours on ADs (r = .21*), years of practice (r = .15*), age (r = .16*)
Knowledge was also found to correlated with age (r = .12*)Knowledge scores -Higher for those with ADs and professional
certificationExperience scores- Higher for those with ADs, having family
members with ADs, or those who were certifiedConfidence scores -Higher for those with ADs, older age and more
years in practice; lower for those MPRNs with family members with ADs
Attitude Items- Having an AD, having a family member with an AD and certification were more likely to agree with attitude items (2)
(*p<.05; **p<.01)
RQ #2. What are the relationships between MPRNs’ demographic characteristics and their knowledge, attitudes , experience, and confidence regarding ADs?(cont)
Knowledge scores Higher for those with ADs and certification
Experience scores were higher for Those with ADs with family members with ADs MPRNs who were certified
Confidence scores Higher for those MPRNs with ADs, older age and
more years in practice Lower for those with family members with ADs
Attitude items (2) agreement Having an AD, family member with an AD Certification
RQ #3. What are the intercorrelations or predictive relationships among MPRNs’ knowledge, attitudes, experience and confidence regarding ADs?
Correlations Knowledge and confidence (r = .43**) Experience and confidence (r = .56**) Knowledge and experience (r = .17**)
Predictive relationships Confidence and experience
19% of variance in total knowledge Knowledge and confidence
32% of variance in total experience Knowledge and experience
43% of variance in confidence(*p<.05; **p<.01)
RQ #3. What are the intercorrelations or predictive relationships among MPRNs’ knowledge, attitudes, experience and confidence regarding ADs?
Greater confidence were more likely to agree (7): (a) Nurses should go against relatives’ wishes if they
conflict with the patient’s ( OR 1.045*) (b) Nurses should help patients with ADs (OR 1.042*) (c) Actively assisting patients to die should be made legal
( OR .986) (d) Patients should always be consulted on Do-Not-
Resuscitate decisions (OR 1.084*) (e) The information on an AD is usually sufficient to guide
treatment (OR 1.046*) (f) The presence of a living will encourages discussion
between a patient and providers (OR 1.044*) (g) Nurses know the decisions of their patients regarding
their advance-care planning (OR 1.050**)
* p< .05; ** p<.01)
RQ #3. What are the intercorrelations or predictive relationships among MPRNs’ knowledge, attitudes, experience and confidence regarding ADs?
Agreement with attitude items: Greater experience
(a) Providers usually know the wishes of their patients regarding advance-care planning (OR 1.44*)
(b) The amount of time nurses spend discussing ADs with patients is sufficient (OR 1.85*)
Greater confidence and experience: Nurses can answer patient’s questions about ADs. (OR 1.063**;
1.323*) Knowledge :no agreement with attitude items
(* p< .05; ** p<.01)
RQ #4. What are the differences between oncology and ER MPRNs’ with respect to knowledge, attitudes, experience and confidence regarding ADs?
Items from the Attitudes Regarding EOL Decision-Making Scale
ER MPRNs Oncology MPRNs
Patients have a right to refuse life support. 136 (93%) 230 (87%)
Withholding information from patients is sometimes indicated.
20 (14%) 13 (5%)
Patients are sufficiently informed to prepare ADs.
47 (32%) 98 (37%)
Nurses should go against relatives’ wishes if they conflict with the patients
108 (74%) 210 (80%)
ADs will lead to euthanasia. 13 (9%) 10 (4%)
All patients should complete ADs. 131 (90%) 252 (96%)
RQ #4. What are the differences between oncology and ER MPRNs’ with respect to knowledge, attitudes, experience and confidence regarding ADs?
Items from the KAESAD Professional Experiences with EOL decision making scale
ER MPRNs Oncology
MPRNs
There is not enough time to discuss ADs. 90 (62%) 144 (54%)
Nurses can answer questions about ADs. 84(58%) 177 (67%)
Some patients are inappropriately judged to lack capacity to make decisions
104 (58%) 152 (71%)
Nurses know patient’s wishes regarding end –of-life care.
66 (45%) 137 (52%)
RQ#5.What are the differences between oncology and ER MPRNs’ in intercorrelations or predictive relationships with respect to knowledge, attitudes , experience and confidence regarding ADs?
Correlations Knowledge and Confidence
oncology MPRNs r = .44** ER MPRNs r =.41**
Knowledge and Experience oncology MPRNs r = .13*ER MPRNs r = .27**
(* p< .05; ** p<.01)
RQ#5. What are the differences between oncology and ER MPRNs’ in intercorrelations or predictive relationships with respect to knowledge, attitudes , experience and confidence regarding ADs?
Ordinary least squares regression Confidence and experience
Oncology MPRNs- 22% of variance for knowledge (R2 = .22**)
ER MPRNs- 17% of variance for knowledge (R2 = .17**)
Experience and knowledge Oncology MPRNs- 49% of variance for confidence
(R2 = .49**) ER MPRNs- 17% of variance for confidence
(R2 = .38**)
(* p< .05; ** p<.01)
RQ #5. What are the significant differences between oncology and ER MPRNs’ in intercorrelations or predictive relationships with respect to knowledge, attitudes , experience and confidence regarding ADs?
Confidence Oncology MPRNs 4/25 attitude items
Nurses’ should go against relatives’ wishes if conflict with patient’s (OR-1.05*)
Nurses should help patients complete ADs (OR-1.05*)Nurses can answer patients’ questions about ADs
(OR-1.08**) Nurses know patients’ end –of-life wishes (OR- .06**)
ER MPRNs 2/25 attitude items It is always appropriate to give pain medication
(OR-1.16*) Most patients have enough knowledge to prepare ADs
( OR_1.07*)
(* p< .05; ** p<.01)
RQ #5. What are the significant differences between oncology and ER MPRNs’ intercorrelations or predictive relationships with respect to knowledge, attitudes , experience and confidence regarding ADs? Experience
Oncology MPRNs 0/25 attitude items ER MPRNs 5/25 attitude items
It is sometimes best to withhold information from patients (OR-1.81*)
Actively assisting some patients to die should be made legal (OR- 1.56*)
Healthcare providers usually know the wishes of their patients (OR-1.76*)
Most patients have enough knowledge to prepare ADs Assisting patient to complete ADs is emotionally draining
(OR-0.76*)
(* p< .05; ** p<.01)
RQ #5. What are the significant differences between oncology and ER MPRNs’ intercorrelations or predictive relationships with respect to knowledge, attitudes , experience and confidence regarding ADs?
Oncology MPRNs Knowledge (1/25)
An impediment to making good decisions about EOL care is difficulty communicating with patients and their families (OR- 1.10*)
ER MPRNs Knowledge (0/25)
(* p< .05; ** p<.01)
RQ #5. What are the significant difference s between oncology and ER MPRNs’ in intercorrelations or predictive relationships with respect to knowledge, attitudes , experience and confidence regarding ADs?
Confidence Oncology MPRNs 4/25 attitude items ER MPRNs 2/25 attitude items
Experience Oncology MPRNs 0/25 attitude items ER MPRNs 5/25 attitude items
Knowledge Oncology MPRNs 1/25 attitude items ER MPRNs 0/25 attitude items
Limitations
Original data were not collected with the intent of surveying MPRNs
Several dissimilarities of instrument in parent studies
Oncology Nursing Society and Emergency Nurses’ Association
Psychometric properties of the KAESAD tool Attitudes regarding professional attitudes
EOL decision making Attitudes based on professional experience
on EOL decision-making
Summary of Findings
While confidence was moderate and MPRNs were experienced, knowledge level was less than adequate Having an AD and a family member with an AD,
along with certification was likely to be associated with higher knowledge scores.
Supported patient advocacy and the use of ADs Did not think they had adequate time to address this issue
with patients Confidence and experience were more likely to predict
attitudes, while knowledge was least likely to do so
Recommendations for Future Research
Test interventions which may enhance knowledge, confidence and experience for MPRNs
Focus on specialty groups of MPRNs such as nurse practitioners and clincial nurse specialists who are largely focused in patient care
Examination of interventions with MPRNs as part of multidiscplinary team focus
Conclusions
SDA was completed to understand the knowledge, attitudes, experience and confidence of MPRNs regarding ADs
Efficient and economical research methodology
Understand the perspective of MPRNs in regards to ADs
Findings can be used to enhance MPRNs involvement with patients and ADs