1.  The Knowledge, Attitudes, Experience and Confidence of MPRNs and Advance Directives (ADs)

2. Significance  Provide the foundation for understanding the perspectives of MPRNs in the process of patient AD completion and their role in this process.

3. 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

4. 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

5. 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

6. (SDA) #4 Evaluate 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

7. SDA #4 Posthoc 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 R 2 of 0.10

8. 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

9. 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.

10. 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.

11. 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?

12. Select Confidence Scale Items  58. 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.

13. 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.

14. SDA -Data Preparation and Analysis  Data Preparation Responses need to be in a similar format prior to combining Likert responses  Attitudes Regarding EOL Decision- Making  Attitudes Towards Professional Experiences with EOL Decision-Making 4 pt – oncology MPRNs 6 pt --ER MPRNs Collapse categories into agree and disagree  Data Analysis

15. 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

16. 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%)

17. RQ#1 What are MPRNs ’ knowledge, attitudes, experience and confidence related to ADs? ScaleMean% 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)-----

18. Knowledge of MPRNs in regards to ADs

19. 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%)

20. 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%)

21. 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 certification Experience scores- Higher for those with ADs, having family members with ADs, or those who were certified Confidence 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)

22. 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

23. 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)

24. 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)

25. 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) 

26. 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%)

27. 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 MPRNsOncology 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%)

28. 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)

29. 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 (R 2 =.22**)  ER MPRNs- 17% of variance for knowledge (R 2 =.17**) Experience and knowledge  Oncology MPRNs- 49% of variance for confidence (R 2 =.49**)  ER MPRNs- 17% of variance for confidence (R 2 =.38**) (* p<.05; ** p<.01)

30. 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)

31. 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)

32. 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)

33. 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

34. 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

35. 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

36. 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

37. 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