Utilizing Advance Directives with Malcolm Knowles’ Adult Learning Theory Alina Collins University of Central Florida NGR 5800

Background  Patient Self Determination Act (PSDA)- passed in 1990 to facilitate autonomy in health care decision making for individuals.  Advance Directives- Legal written documents clarifying individuals wishes pertaining to health care decisions  Living Will- Written document outlines a persons wishes  Power of Attorney- Person appointed by individual to make health care decisions on his/her behalf if he/she is unable to do so. Main goal of the PSDA is to execute these documents before emergencies arise to resolve discrepancies in end of life wishes. Duke et al., 2007; Goodman et al., 1998; Fleming & Scanlon, 1994; Johnson et al., 2012; Meyers, 2000.

Background Continued  Do Not Resuscitate Order (DNR)- Legal Document stating the patient has decided to forgo CPR in the event their heart stops Despite increased awareness, the completion rates of advance directives have shown to be only %. Duke, et al., 2007; Johnson et al., 2012; Meyers, 2000

Common Barriers to Completion of Advance Directives Fear of death and dying Poor knowledge pertaining to end of life rights and advance directives among patients AND nurses has revealed to be the most common barrier Clabots, 2012; Cox et al, 2006; Duke et al, 2007; Johnson et al., 2012; Meyers, 2000; Searight et al., 2005; Smith et al., 2008

Problem Statement Advance Directives are very useful in facilitating autonomy in patient decision making and clarifying a patient’s end of life wishes to family and medical staff but completion rates of these documents remains very low.

Significance  A study by Johnson et al. (2012) showed 33.8% of people when asked to complete an advance directive declined because they did not understand the question  Fleming & Scanlon (1994) conducted a study which revealed only 28.4% of questions regarding advance directives directed toward the nursing staff  A study by Cohen-Mansfield et al., (1991) found that denial of illness and advanced age negatively impacted a patient’s willingness to complete an advance directive  In another study, nursing knowledge of the PSDA was 51% even though 77% of nurses surveyed stated that they should be actively involved in helping patients complete advance directives –Jezewski & Feng 2007

Aim To incorporate Malcolm Knowles’ Adult Learning Theory into bedside education between the nurse, patient and patient’s family to better educate patients on advance directives thus increasing the rate of completion and utilization of these documents

 Malcolm Knowles’ Adult Learning Theory is an educational theory. Although, its foundation is not in nursing, it has been used extensively in the nursing world do to its usefulness in education.  It is based on the principle that the adult learns differently than a child does with the adult learner being autonomous and self-directed.  The adult learner has to have a motivation to learn and they have to be given the choice and responsibility in the learning process. The theory focuses on learning as a process rather than the content of learning and is based on comfort, trust, mutual respect, and openness McEwen & Wills, 2011; Meyer, 2000; Mitchell & Courtney, 2005; Syx, 2008

Major Concepts  For the adult learner, new knowledge has to immediate and practical application to them. This need to know stems from the experience of the learner  Adults are self directed in learning and want to be seen as being able to make their own decisions when given all the facts  Experience of the learner has been proven beneficial when incorporated into learning  Readiness to learn- adults are problem oriented learners and learn best when they feel it is necessary to do so  Immediacy of application of learning grows as a person ages  Motivation is the most influential- the level of desire to solve an immediate problem Knowles et al., 2005; McEwen & Wills, 2011; Meyer, 2000; Syx, 2008

Application to Nursing  Provide written information to patients (pamphlets, brochures). Beneficial because it provides self direction and gives the patient to information to learn on their own  Encouraging conversations regarding reflection of past life experiences  Assess readiness to learn by solving patients more pressing issues before conversation regarding advance directives  Recognize “teachable moments”  Assess cultural diversity by encouraging open and nonjudgmental conversations about religious and cultural beliefs with patients and their families. Advocate for patients by communicating to health care team cultural and religious belief differences McEwen & Wills, 2011; Meyer, 2000; Mitchell & Courtney; 2005

References Clabots, S. (2012). Strategies to help initiate and maintain the end-of-life discussion with patients and family members. Medsurg Nursing, 21(4), Cohen-Mansfield, J., Droge, J.A., Bilig, N. (1991). The utilization of durable power of attorney for health care among hospitalized elderly patients. Journal of the American Geriatric Society, 39(12) Cox, C., Cole, E., Reynolds, T., Wandrag, M., Breckenridge, S., & Dingle, M. (2006). Implications of cultural diversity in Do Not Attempt Resuscitation (DNAR) decision-making. Journal of Multicultural Nursing & Health, 12(1), Duke, G., Thompson, S., & Hastie, M. (2007). Factors influencing completion of advance directives in hospitalized patients. International Journal of Palliative Nursing, 13(1), Fleming, C. M., & Scanlon, M. C., (1994). The role of the nurse in the patient self- determination act. Journal of The New York State Nurses Association, 25(2), Goodman, M., Tarnoff, M., & Slotman, G. (1998). Effect of advance directives on the management of elderly critically ill patients. Critical Care Medicine, 26(4),

References Jezewski, M. A., & Feng, JY., (2007). Emergency nurses’ knowledge, attitudes, and experiential survey on advance directives. Applied Nursing Research, 20, Johnson, R. W., Zhao, Y., Newby, L., Granger, C. B., & Granger, B. B. (2012). Reasons for noncompletion of advance directives in a cardiac intensive care unit. American Journal of Critical Care, 21(5), doi: Knowles, M., Holton, E. F., & Swanson, R. A. (2005). The adult learner: The definitive classic in adult education and human resource development (6 th ed.). Burlington, MA: Elsevier. McEwen, M., & Wills, E. M. (2011). Theory development: Structuring conceptual relationships in nursing. In McEwen, M., & Wills, E. M. (3 rd Ed.), Theoretical basis for nursing (pp ). Philadelphia: Lippincott Williams & Wilkins. Meyer, R. (2000). Using adult learning concepts to assist patients in completing advance directives. Journal of Continuing Education In Nursing, 31(4), Mitchell, M. L., & Courtney, M. (2005). Improving transfer from the intensive care unit: The development, implementation and evaluation of a brochure based on Knowles’ adult learning theory. International Journal of Nursing Practice, 11, Searight, R. H., & Gafford, J. (2005). Cultural diversity at the end of life: Issues and guidelines for family physicians. American Family Physician, 71(3),

References Scanlon, C. (2003). Ethical concerns in end-of-life care. The American Journal Of Nursing, 103(1), 48-50, doi: / Smith, A., McCarthy, E., Paulk, E., Balboni, T., Maciejewski, P., Block, S., & Prigerson, H. (2008). Racial and ethnic differences in advance care planning among patients with cancer: Impact of terminal illness acknowledgment, religiousness, and treatment preferences. Journal Of Clinical Oncology, 26(25), Syx, R. L., (2008). The practice of patient education: The theoretical perspective. Orthopaedic Nursing, 27(1), doi: /01.NOR b