The knowledge, attitudes, experience and confidence of master's prepared registered nurses with advance directives
Ryan, Diane P.
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Manuscript I was a systematic review of nurses and ADs, the purpose of which was to synthesize the knowledge, attitudes and experiences of nurses in facilitating patient completion of ADs. Qualitative approaches used in these studies included grounded theory methods, as well as several secondary analyses and one ethnographic study. The majority of quantitative studies used a survey approach. A total of 13 different survey instruments were used to collect study data. Findings revealed that nurses had experience with ADs, but had less than adequate knowledge on this topic. While nurses were found to have attitudes supportive of patient autonomy, nurse practitioners reported a higher level of confidence regarding AD discussions with patients. Confidence, education, and experience related to ADs were not only correlated with each other, but were related to greater knowledge and more positive attitudes concerning ADs. Manuscript II was a synthesis of three studies that examined the perspectives of critical care, oncology, and ER nurses concerning ADs. The purpose of these studies was to understand the perspectives of the general population of nurses and ADs. Membership in state and national professional associations was used to survey oncology, emergency, and critical care nurses. Findings from these studies which used the KAESAD instrument to obtain information from nurses revealed that though nurses were supportive of and experienced with ADs, they had minimal knowledge and moderate confidence in this area. Insufficient time was reported for AD discussions, though further analysis did not reveal any significant relationships between the attitude of lack of time and knowledge, confidence, or experience. Experience and confidence predicted agreement with various attitude items concerning ADs. An identified limitation in these investigations included low Cronbach’s alpha values on the attitude scales in the KAESAD instrument, which limited analysis to items only from these scales. Manuscript III was an SDA of responses obtained from 410 emergency and oncology MPRNs who were surveyed using the KAESAD instrument. Power analysis based on medium effect indicated that this number of subjects was more than adequate for planned statistical analysis. Demographic information revealed that the majority of subjects were female, Caucasian, Christian, married or living as married, and with a mean age of 47 years and an average of 22 years of practice. Over 50% of these subjects worked full time in an urban setting, and were certified in their specialty area. While 58% of MPRNs had a family member with an AD, only 37% of these same subjects had ADs themselves. These MPRNs had mean total knowledge scores of 59% correct, with higher scores on knowledge of general information on ADs, and lower scores pertaining to knowledge of state laws and the Patient Self Determination Act. Master’s prepared registered nurses felt confident on the topic of ADs, were experienced with ADs, and were likely to agree with attitude statements supportive of patient advocacy. Those MPRNs who had an AD had greater knowledge and increased confidence and experience with an AD, as compared to those without an AD. While confidence and experience explained 19% of the variance in knowledge, confidence and knowledge had a greater impact on experience, explaining 32% of the variance in these scores. Subjects with greater confidence and more experience were more likely to agree with 9/25 attitude items analyzed. Oncology and ER MPRNs tended to agree with similar attitude items, but differences were noted between these two groups of MPRNs on topics such as (a) assisting some terminally ill patients to die should be made legal and (b) some are excluded from making end-of-life decisions. Those ER MPRNs who were experienced with ADs were more likely to have positive attitudes concerning ADs, while oncology MPRNs with greater confidence were more likely to agree with attitude statements. Though these MPRNs have advanced educational degrees, their total knowledge concerning ADs was a little over 50% correct which does not provide an adequate foundation for clinical practice. Differences in several attitudes among MPRN specialty groups may reflect the nature of clinical practice in different settings, distinguishing different practice perspectives in oncology and ER practice areas. (Abstract shortened by UMI.)