A broader understanding of care managers' attitudes of advance care planning: A concurrent nested design.
*Attitude of Health Personnel; *Health Knowledge; Adult; Advance Care Planning; Advance Care Planning/*standards; Attitudes; Case Managers; Chi Square Test; community health; Concurrent Prospective Studies; Convenience Sample; decision-making; Discussion; end of life; Female; Focus Groups; Funding Source; Health Services Accessibility/standards; Human; Humans; Male; Middle Age; Middle Aged; Midwestern United States; Multicenter Studies; Multimethod Studies; Nurse Attitudes; nurses; Practice; qualitative; Qualitative Research; quantitative; Questionnaires; Surveys; Surveys and Questionnaires; Thematic Analysis
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.
Aultman Julie; Baughman Kristin R; Ludwick Ruth
Journal of clinical nursing
2018
2018-10
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1111/jocn.14531" target="_blank" rel="noreferrer noopener">10.1111/jocn.14531</a>
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.
Ludwick Ruth; Baughman Kristin R; Jarjoura David; Kropp Denise J
The American journal of nursing
2018
2018-12
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/01.NAJ.0000549664.43827.ce" target="_blank" rel="noreferrer noopener">10.1097/01.NAJ.0000549664.43827.ce</a>
Development of a Scale to Assess Physician Advance Care Planning Self-Efficacy.
*Self Efficacy; Adult; advance care planning; Advance Care Planning; Advance Care Planning/*organization & administration; Attitude of Health Personnel; Attitudes; Chronic Disease; Communication; Cross Sectional Studies; Cross-Sectional Studies; end-of-life care; Exploratory Research; family medicine; Family/*psychology; Female; Health Knowledge; Human; Humans; Instrument Construction; Instrument Validation; Male; Middle Aged; Physician-Patient Relations; Physicians; Physicians – Psychosocial Factors; Practice; Reliability and Validity; scale development; Scales; self-efficacy; Self-Efficacy – Evaluation; Surveys and Questionnaires/*standards; Terminal Care/psychology; Validation Studies
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 alpha = 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 \textless .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.
Baughman Kristin R; Ludwick Ruth; Fischbein Rebecca; McCormick Kenelm; Meeker James; Hewit Mike; Drost Jennifer; Kropp Denise
The American journal of hospice & palliative care
2017
2017-06
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1177/1049909115625612" target="_blank" rel="noreferrer noopener">10.1177/1049909115625612</a>
Disentangling consumer and provider predictors of advance care planning.
*Advance Care Planning; *Long-Term Care; Adult; advance care planning; Advance Care Planning; Age Factors; area agencies on aging; Attitude of Health Personnel; care management; Caregivers; community-based care; Conceptual Framework; Consumers; Data Analysis Software; Discussion; Factorial Design; factorial surveys; Female; Human; Humans; Judgment; Long Term Care; long-term care; Middle Age; Multivariate Analysis; Quasi-Experimental Studies; Questionnaires; Random Sample; Registered Nurses; Social Workers; Surveys; Surveys and Questionnaires; Vignettes
Factorial surveys were used to examine community-based long-term care providers' judgments about consumers' need for advance care planning (ACP) and comfort levels in discussing ACP. Providers (448 registered nurses and social workers) judged vignettes based on hypothetical consumers. Hierarchical linear models indicated providers judged consumers who were older, had end-stage diagnoses, multiple emergency department visits, and uninvolved caregivers as most in need of ACP. These variables explained 10% of the variance in judgments. Providers' beliefs about ACP predicted judgments of need for ACP and comfort level in discussing ACP. Provider characteristics explained more variance in comfort levels (44%) than in judgments of need (20%). This study demonstrates the need for tailored educational programs to increase comfort levels and address ACP misconceptions.
Baughman Kristin R; Ludwick Ruth; Merolla David; Palmisano Barbara; Hazelett Susan; Allen Kyle R; Sanders Margaret
The American journal of hospice & palliative care
2013
2013-11
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1177/1049909112464692" target="_blank" rel="noreferrer noopener">10.1177/1049909112464692</a>
Managing in the trenches of consumer care: the challenges of understanding and initiating the advance care planning process.
*Health Personnel/psychology/standards; *Health Services for the Aged; *Long-Term Care/methods/organization & administration/psychology; *Patient Care Management/methods/organization & administration; Advance Care Planning; Advance Care Planning/*organization & administration; Attitude of Health Personnel; Case Management; Convenience Sample; Decision Making; Family Relations; Focus Groups; Funding Source; Human; Humans; Interpersonal Relations; Long Term Care; Needs Assessment; Nurse Attitudes; Ohio; Patient Education as Topic; Professional Role; Professional-Patient Relations; Qualitative Research; Qualitative Studies; Social Work/*standards; Social Worker Attitudes; Terminal Care/organization & administration/psychology; Thematic Analysis
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.
Baughman Kristin R; Aultman Julie; Hazelett Susan; Palmisano Barbara; O'Neill Anne; Ludwick Ruth; Sanders Margaret
Journal of gerontological social work
2012
1905-07
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1080/01634372.2012.708389" target="_blank" rel="noreferrer noopener">10.1080/01634372.2012.708389</a>
Narrative analysis of the ethics in providing advance care planning.
*Long-Term Care; Accountability; Advance care planning; Advance Care Planning – Ethical Issues; Advance Care Planning/*ethics; care managers; Case Managers; Courage; Decision Making/*ethics; Empowerment; end-of-life decisions; ethical dilemmas; Ethics; Focus Groups; Funding Source; Human; Humans; narrative analysis; Narratives; Nurses/*psychology; Ohio; Open-Ended Questionnaires; Patient Care Management/*ethics; Professional; Qualitative Studies; Questionnaires; registered nurses; Registered Nurses; Respect; Secondary Analysis; social workers; Social Workers; Thematic Analysis
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.
Baughman Kristin R; Aultman Julie M; Ludwick Ruth; O'Neill Anne
Nursing ethics
2014
2014-02
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1177/0969733013486795" target="_blank" rel="noreferrer noopener">10.1177/0969733013486795</a>
Prevention, detection and intervention with delirium in an acute care hospital: a feasibility study.
Background. The prevalence of delirium in acute care hospitals ranges from 5-86%. Delirious patients are at greater risk of negative health outcomes and their care is often more costly. Aim. To determine the feasibility of a full-scale trial to test the effectiveness of an intervention designed to improve delirium prevention, detection and intervention in an acute care hospital. Design. A delirium prevention protocol was designed by an interdisciplinary group of clinicians and implemented on intervention unit patients who passed a mental status screen, were at high risk for delirium according to the modified NEECHAM scale, and met other eligibility criteria. These patients were reviewed at daily interdisciplinary team meetings and team recommendations were placed in the patient's chart. On the usual care unit, physicians were notified if their patients were at high risk, but the delirium protocol was not implemented. Methods. The delirium protocol was pilot tested with 35 high risk patients on an Acute Care for Elders (ACE) unit. Outcomes were compared to 35 high risk patients on a similar medical unit without the delirium protocol. Results. The main outcome examined whether there is a difference in average day 3 modified NEECHAM scores comparing the intervention and control groups. The mean modified NEECHAMs on day 3 were not statistically significantly different (intervention group 3.76 and control group 3.24) (P= 0.368). Baseline NEECHAM scores did not correlate well with development of delirium (P = 0.204). A history of confusion during a previous hospitalization was the strongest predictor of developing delirium during the current hospitalization. Conclusion. This pilot study was not powered to detect an effect of the intervention, however, feasibility for a fully powered trial was established. Relevance to clinical practice. Completion of the NEECHAM screen every shift was not considered burdensome for either nurses or patients and may help identify acute delirium.
Benedict Lynn; Hazelett Susan; Fleming Eileen; Ludwick Ruth; Anthony Mary; Fosnight Sue; Holder Carolyn; Zeller Rich; Allen Kyle; Zafirau William
International journal of older people nursing
2009
2009-09
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1111/j.1748-3743.2008.00151.x" target="_blank" rel="noreferrer noopener">10.1111/j.1748-3743.2008.00151.x</a>
Surveying the hidden attitudes of hospital nurses' towards poverty.
*Attitude of Health Personnel; *Healthcare Disparities; *Poverty; Adult; Age Factors; Attitude Measures; attitudes; Coefficient Alpha; Convenience Sample; Cross Sectional Studies; Cross-Sectional Studies; Descriptive Research; Descriptive Statistics; Educational Status; Female; health disparities; health inequities; Health Status Disparities; Hospital; Hospital/*psychology; Human; Humans; Income; Job Experience; Male; Middle Age; Middle Aged; Multivariate Analysis; Nurse Attitudes – Evaluation; nurses; Nursing Staff; Ohio; Politics; poverty; Poverty; Registered Nurses; Regression; Regression Analysis; Summated Rating Scaling; Surveys and Questionnaires; Young Adult
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.
Wittenauer James; Ludwick Ruth; Baughman Kristin; Fishbein Rebecca
Journal of clinical nursing
2015
2015-08
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1111/jocn.12794" target="_blank" rel="noreferrer noopener">10.1111/jocn.12794</a>
The Relationship Between Organizational Characteristics and Advance Care Planning Practices.
Administrative Personnel; Adult; advance care planning; Advance Care Planning; Advance Care Planning/*organization & administration/standards; area agency on aging; Attitude of Health Personnel; care management; Case Management; Case Managers; Chi Square Test; Clinical Protocols/standards; community-based long-term care; Confidence Intervals; Cross Sectional Studies; Cross-Sectional Studies; Data Analysis Software; Descriptive Research; Descriptive Statistics; Female; Funding Source; Government Agencies; Human; Humans; Inservice Training/organization & administration; Interviews; Logistic Regression; Long Term Care; Male; Medicaid; Medicaid/statistics & numerical data; Middle Age; Middle Aged; Midwestern United States; Multivariate Analysis; nurses; Odds Ratio; Ohio; organizational characteristics; Organizational Culture; Practice Guidelines as Topic; Questionnaires; Registered Nurses; Rural Areas; social workers; Social Workers; Surveys; T-Tests; Telephone; United States; Urban Areas
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.
Baughman Kristin R; Ludwick Ruth; Palmisano Barbara; Hazelett Susan; Sanders Margaret
The American journal of hospice & palliative care
2015
2015-08
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1177/1049909114530039" target="_blank" rel="noreferrer noopener">10.1177/1049909114530039</a>