Advanced Research Application.
Quantitative Research
Detering, K. M., Hancock, A. D., Reade, M. C., & Silvester, W. (2010). The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ, 340(c1345), 1-9.
Article Areas
Background or introduction
The authors begin the article with a clear introduction of the subject stating the gaps in knowledge with regards to the end of life care. In addition, the authors define advanced care planning as an all-inclusive consultation that involves the patient, their health care providers, families, and any other persons that they deem impartment, concerning the future care of the patient (Detering, Hancock, Reade, & Silvester, 2010). This type of care planning has various advantages, most important of which is that it allows health care providers and the families of the elderly patient to make well informed decisions about the care of the patients, only upholding care approaches that are preferred by the patient as opposed to guessing what would be good for the patient (Stewart, Goddard, Schiff, & Hall, 2011). This is especially the case in situations where the patient is incapacitated. The authors proceed to state the objective of the study, which is to review advanced care planning’s impact on the care of the elderly during their end of life period.
Review of the literature
The authors do not engage in an in-depth review of literature with regards to the impact of advanced care planning on patient care during end of life stages. Instead, they take a general review of the basics of the subject with reference to secondary sources. Such basics include the evolution of the decision making processes in the care of the elderly, with insistence of lack of advanced care planning in some care stings to the present day (Detering, Hancock, Reade, & Silvester, 2010). The authors also identify that such lack of planning leads to the health care providers delivering their care services in ways that would not be preferred by the patients. The authors also define advanced care planning and its embedment in the Australian, United States’, and United Kingdom’s legislations. The authors also review the importance of advanced care planning, using literature to illustrate that such end of life planning reduces anxiety, depression, and stress in the surviving relatives (Detering, Hancock, Reade, & Silvester, 2010).
Discussion of methodology
The study design employed by the researchers was a prospective randomized control trial (Detering, Hancock, Reade, & Silvester, 2010). The setting of the study was a university hospital in Australia, from Melbourne. The study involved 309 participants, who were elderly inpatients with ages 80 and above, who were followed through their care for six months for some, and for others till death. Randomization of the participants was applied, with some being exposed to the usual care of the elderly, while others were subjected to such usual care and additional advanced care planning. Such planning was aimed at allowing the patients to: establish their values, goals, and beliefs; come up with their future treatment and care preferences; to select a surrogate; and document their preferences and wishes (Detering, Hancock, Reade, & Silvester, 2010).
Data analysis
To analyze the collected data, the authors used version 9.2 of the Stata software to carry out statistical calculations. The Stata software is an integrated package of statistical analysis, that allows the users to review all the aspects of data that may help them establish correlations between variables and hence establish evidence that would support the development of certain phenomena. This tool forms the perfect application for data analysis as it is easy to use, fast, and accurate, and it gives an individual control over all data types (Cameron & Trivedi, 2010). Continuous data was then graphically assessed for normality and Mann-Whitney U tests and t tests were used to compare the data. In addition, the authors used Fisher exact tests and X2 tests to assess categorical data. The statistical significance was defined as P≤0.05 and used as a point of reference as the authors reported the exact P values (Detering, Hancock, Reade, & Silvester, 2010).
Researcher’s conclusion
In their conclusion, the researchers established that advanced care planning was effective in improving care during the end of life stage among older adults, and that it improved the level of satisfaction among patients and their families (Detering, Hancock, Reade, & Silvester, 2010). It is also clear that such planning reduces the level of stress, depression, and anxiety among the surviving relatives (Fraser, Harris, Berringer, Prescott, & Finlay, 2010). As such, it is important for advanced care planning to be integrated into geriatric and palliative care in order to promote both evidence-based care and patient-centered care.
Researcher’s conclusion
Both the evidence established by the researchers in their review of literature and in their primary study support their conclusion. In the review of literature, the study by Winzelberg, Hanson, and Tulsky (2005) suggested that lack of advanced care planning led to caring of patients in a manner that they would not have otherwise preferred. On the other hand, the article by Romer and Hammes (2004), together with those of Hammes and Rooney (1998), Hammes and Romer (1999), Briggs (2004), Azoulay et al. (2005), Lautrette et al (2007), and Tilden, Tolle, and Nelson (2001) demonstrated that advanced care planning improved the outcomes of the patients and reduced anxiety, depression, and stress among the surviving relatives (Detering, Hancock, Reade, & Silvester, 2010). On the other hand, in their primary study, the authors observed increased involvement in the end of life decision making among the subjects assigned to the intervention group as compared to the control group, with levels of increased patients’ satisfaction being registered as high among the patients in the intervention group. The impact on family members was also observed to be favorable among the intervention group as compared to the control group (Detering, Hancock, Reade, & Silvester, 2010).
Protection and considerations
The researchers protected the involved participants using various approaches. To start with, the researchers obtained an informed consent from the participants, which included a signed document in agreement with the procedures and content of the study. In addition, during the intervention, the researchers applied the Respecting Patient Choices model that allowed them to only go by the decisions made by the patient and nothing else (Detering, Hancock, Reade, & Silvester, 2010). The intervention was also carried out by a trained facilitator, an aspect that promoted professionalism in the process.
Strengths and limitations
One of the strengths of the study is that the intervention was established to be logistically successful and possible in a population of patients that is representative of that found in most hospitals, making the findings generalizable. In addition, the researcher of the questionnaire was blinded to the allocation of the patients, an aspect that promoted objectivity in recording of the outcome measures (Detering, Hancock, Reade, & Silvester, 2010). On the other hand, the major limitation of the study is that it excluded non-competent patients, an aspect that makes the findings less applicable to these population, who form a majority of the admissions in hospital. Furthermore, in as much as the researcher was blinded to the allocation of the patients, occasional responses made by the patients made such allocation obvious.
Evidence application
The evidence provided by the study is highly applicable in general health care practice when dealing with elderly patients as it offers health care providers to determine the exact wishes of the patients and to make informed decisions in cases where the patients are incapacitated. Caring for the elderly is a major challenge especially when they are incapacitated and there is no one to make critical decisions on their behalf. Advanced care planning allows the patient to come up with a surrogate who would represent their voice and make such decisions if need ever arises.
Qualitative research
Seymour, J., Almack, K., & Kennedy, S. (2010). Implementing advance care planning: a qualitative study of community nurses’ views and experiences. BMC Palliative Care, 9(4), 1-9.
Article areas
Background or introduction
The authors introduce the subject of advanced care planning, providing the definition of the concept as a process that involves discussion of the future care goals and setting of preferences of a patient that is likely to lose communication ability or be incapacitated in future. The authors proceed to discuss the various outcomes of the advanced care planning process, which include the establishment of instructional directives which are like the ‘living wills’ of the elderly patient. This offer direction on what action ought to be taken in different situations (Seymour, Almack, & Kennedy, 2010). Another outcome involves choosing of a surrogate to make decisions for the patient. Lastly, the process results in the setting of views and values of the patient in order to ensure that any form of treatment adopted is in their best interests. In this section, the authors also set out the aim of the study, which is to review the understanding of Advanced Care Planning (ACP) among English palliative care nurses, and their roles in ACP.
Review of the literature
The authors reviewed various literature to determine trends in ACP research and practice. The authors determined that there was an increase in acknowledge of ACP not only as a source of guidelines created to assist the health care providers in making decisions, but as an avenue through which both the patients and their families adequately prepare for their end of life stage by establishing their goals and strengthening their relationships. Studies by Lorenz et al. (2004) and Caplan et al. (2006) as reviewed by the authors also revealed that ACP has been effective in increasing the accessibility of palliative care, promoting interventionist treatments, and minimizing hospital admissions. In addition, through the review of literature, the authors determine the impact of ACP in promoting satisfaction with the decision making process among members of the patient’s family.
Discussion of methodology
The authors employed an action research strategy that involved 23 community nurses, who worked with two England-based cancer networks (Seymour, Almack, & Kennedy, 2010). Six focus group discussions were established, into which the participant nurses were allocated. The research was conducted between 2007 and 2009. The nurses were expected to have taken part in ACP training. In the focused groups, the nurses were expected to discuss their end of life care experiences and general view concerning ACP. The researchers further engaged the nurses in follow-up workshop, which promoted identification of major themes, interpreting the data from the focus groups, and generating ideas concerning ACP educational resources collaboratively (Detering, Hancock, Reade, & Silvester, 2010). The researchers consulted the nurses and the available literature in the development of an aide memoire, which was used to guide the focus group discussions.
Data analysis
In the analysis of the data, the discussions of the focused groups were transcribed upon seeking the permission of the nurses, and the transcribed data was analyzed using the NVIVO package for qualitative data analysis (Leech & Onwuegbuzie, 2011). In addition, the author’s used the constant comparative method by Strauss and Corbin to come up with patterns, themes, and categories from the textual data that had been transcribed, relating to perceptions and experiences (Kolb, 2012). Initially, the data was analyzed by a single member of the team. The team subsequently verified the emerging themes and categories and a project meeting dedicated for this purpose, and later discussed in the follow-up workshops with the nurses. Such follow-up discussions acted as respondent validation and allowed for the development of new insights into the findings.
Researcher’s conclusion
The researcher’s concluded that community nurses interacted with palliative care patients who may desire to document their views concerning their future treatment and care (Seymour, Almack, & Kennedy, 2010). As such, the authors maintain that through educational and practice development, nurses can be able to develop a better understanding of ACP and use such an approach in promoting the care outcomes of patients during their end of life stages. Some of the areas that require development include: the inclusion of realistic scenario design and flow charts in the educational programs; practical advice concerning documentation and communication; and increased ACP practice supervision (Seymour, Almack, & Kennedy, 2010).
Researcher’s Conclusions
The evidence established through the review of literature by the authors supports their conclusion that ACP is important in promoting care during the end of life stages. According to the literature, there is a proper connection between ACP and increased accessibility of palliative care, interventionist treatment, and reduced admissions in the hospital (Seymour, Almack, & Kennedy, 2010). On the other hand, in the qualitative research carried out by the researchers, the nurses were able to identify the importance of ACP in facilitating care among the elderly and engaging both the patient band their families in the decision making process. In addition, the nurses were able to identify the various challenges they face in ACP practice, an aspect that supports the conclusion that there is need for increased supervision of the practice of ACP to facilitate its effectiveness (Seymour, Almack, & Kennedy, 2010).
Protection and considerations
The consent of the participants was obtained through a letter that was written to them, informing them of the study and the procedures involved, and providing them with details concerning the information that they will be required to share (Seymour, Almack, & Kennedy, 2010). In addition, transcription of the discussions involving the nurses were only transcribed after the nurses agreed to it to protect their right to object to any publication of such information or its use. The nurses were also not taken through any process that was bound to hurt them physically, psychologically, or emotionally as the researchers gained approval of the Ethical committee through the National Research Ethics Service of the UK (Seymour, Almack, & Kennedy, 2010).
Strengths and limitations
The major strength of the study is that it applied the action research strategy, which allowed the researchers to use actual data to address the issue of ACP practice in terms of the role of the nurses and the various challenges that they were facing in implementing such practice. This promotes the generalizability of the research findings in any palliative care setting. Nevertheless, the most important limitation in this case involves lack of randomization in sampling of the population, an aspect that exposes the gathering of information to bias (Pannucci & Wilkins, 2010).
Evidence application
The findings of the study are highly informative of
nursing practice, especially among the practitioners who deal with elderly
patients who are in need of palliative care. It is clear that through advanced
care planning, the health care provider, the patient, and the family are all
able to benefit in various ways. As such, by eliminating the barriers to
palliative care such as lack of awareness, and fears and taboos concerning
death, among others, health care providers would be able to engage their patients
in constructive discussions that would offer and individual-based model of
treatment that would concentrate on the needs and preferences of the patient.
References
Cameron, A. C., & Trivedi, P. K. (2010). Microeconometrics using stata (Vol. 2). College Station, TX: Stata Press.
Detering, K. M., Hancock, A. D., Reade, M. C., & Silvester, W. (2010). The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ, 340(c1345), 1-9.
Fraser, J., Harris, N., Berringer, A. J., Prescott, H., & Finlay, F. (2010). Advanced care planning in children with life-limiting conditions–the Wishes Document. Archives of disease in childhood, 79-82.
Kolb, S. M. (2012). Grounded theory and the constant comparative method: Valid research strategies for educators. Journal of Emerging Trends in Educational Research and Policy Studies, 31, 83.
Leech, N. L., & Onwuegbuzie, A. J. (2011). Beyond constant comparison qualitative data analysis: Using NVivo. School Psychology Quarterly, 26(1), 70.
Pannucci, C. J., & Wilkins, E. G. (2010). Identifying and avoiding bias in research. Plastic and reconstructive surgery, 126(2), 619.
Seymour, J., Almack, K., & Kennedy, S. (2010). Implementing advance care planning: a qualitative study of community nurses’ views and experiences. BMC Palliative Care, 9(4), 1-9.
Stewart, F., Goddard, C., Schiff, R., & Hall, S. (2011). Advanced care planning in care homes for older people: a qualitative study of the views of care staff and families. Age and ageing, 40(3), 330-335.
