questions

Michele Hopkins

University of Michigan

NURS 950: DNP Residency

Dr. Mary Franklin, PhD., RN, ACNP-BC

January 21, 2024

Palliative care refers to alleviating and relieving the symptoms and pain of an incurable medical condition the patient is experiencing (Schlick & Bentrem, 2019). It is troubling that many individuals who could benefit from palliative care do not enroll in such programs due to a lack of awareness therefore there is a delay in getting the patients symptoms treated (Hawley, 2019). This information gap typically originates from misconceptions about palliative care being hospice or end-of-life care. Thus, many patients need to take advantage of palliative treatments' holistic care. Research shows many people with life-limiting illnesses do not receive palliative treatment (McCarthy, 2021). This reluctance is due to misconceptions, fear of the unknown, and a belief that palliative care means giving up curative treatments (Hui et al., 2019). Healthcare practitioners may only sometimes successfully convey the benefits and extent of palliative care to patients, thus reducing awareness and readiness. Thus, patient readiness for palliative care requires a multidisciplinary strategy. Improve patient education and awareness as well as the provider's ability to appropriately communicate palliative care's importance. Comment by Elizabeth Duffy: What is the incidence of palliative care consults or patients, patients that receive the service annually. You are jumping right to the problem at your site without providing essential background information on palliative care in general. Comment by Elizabeth Duffy: https://scholar.google.com/scholar?q=palliative+care+utilization+annually&hl=en&as_sdt=0&as_vis=1&oi=scholart Did a cursory Google Scholar Search. Comment by Elizabeth Duffy: https://www.liebertpub.com/doi/full/10.1089/jpm.2015.0119?casa_token=sNFyb0weCUEAAAAA%3AS11OUBSp4pt0WQkbU39zeXukhuJua5XZlgDwuml_mYyUJ1ka5u6r0YCd4DQzsVxS84iiP9rhp6M Review how the introduction/background and sig are summarized as an example. Comment by Elizabeth Duffy: You state this later in the paragraph, I suggest synthesizing this paragraph. The word thus is used repetitively, simply state the ideas. I suggest restructuring the sentence order. Make an outline of points that you want to cover overall in the intro/background/sig and then tie the ideas together.

Often, when entering palliative care, it is the provider’s responsibility to determine patient readiness. Readiness has been defined as both a state and a process of fully preparing for something and the wiliness to do something. It is important for HCPs (health care providers) to identify the state of readiness of patients and their families and to understand the dynamic process of readiness that influences these clinically important conversations (Wiener et al., 2021).

There may still be misconceptions and knowledge gaps about palliative care among patients and providers despite the growth of palliative care programs and needs over the past few decades. Patients (and caregivers) who were eligible for palliative care may not be well-informed about it (Cardenas et al., 2021). There is a need for more palliative care education among seriously ill patients (and their caregivers) and the significance of ensuring that patients are referred to home-based palliative care (HBPC) by reliable sources as strategies for increasing palliative care utilization (Cardenas et al., 2021). Interviews were conducted by Huo et al. (2019) to determine how participants felt about palliative care. Approximately 71% of the 3,194 participants surveyed by Huo et al. (2019) needed to be made aware of palliative care. Additionally, many of the 10% of participants who self-reported having adequate knowledge of palliative care had misconceptions or could not correctly respond to simple questions about it (Huo et al., 2019). Patient education has been shown to be effective, with a 31% increase seen due to implementing an educational intervention for patients regarding palliative care (Taibanguay et al., 2019). Education interventions can help reduce the mortality rate in palliative care and improve the quality of care (IAHPC List of Essential Practices in Palliative Care - International Association for Hospice & Palliative Care, 2022). To dispel the myths and misconceptions about palliative care, education is essential. The best outcome occurs when the palliative care team members can establish a rapport with patients and their families, sit down with them, and first fully understand their perspective on their medical condition and prognosis. Patients and families are more at ease pursuing palliative care when they understand they do not have to forgo their curative care (Vossel, 2023). Comment by Elizabeth Duffy: Tie the misconceptions to potentially a lack of knowledge to improving patient education during the initial visit to improve patient readiness. You are not focusing upon the mortality rates among palliative care this is not related to your projects. Remove sentences that do not apply to the outlined components of your project.

There are educational tools currently in place that patients receive prior to their initial consultation. However, according to the providers, the materials are often not being read, or being misunderstood and they are not effective in educating their patients and families. The intervention uses provider feedback to develop material intended to help the providers do more assessment and management and less introductory education at the initial visit. Comment by Elizabeth Duffy: Same comment as before this describes the individual site., this would be under methods

Problem Statement Comment by Elizabeth Duffy: Problem Statement This is the “so what”. This section is concise and clearly articulates the breadth and depth of the problem, why is it is a concern, why it should be evaluated due to the nature and severity of the problem. Include the importance to nursing and tie to the DNP essentials. Your introduction section should smoothly transition into a problem statement. It should flow logically from the information you provided. Take all that you have written about your population, problem, and what is lacking in practice and encapsulate it into one to three sentences that succinctly summarize the problem. Then, lastly, explain your quality improvement (QI) project approach and how your approach will address the problem. This section includes project pre-data not a summary of the overall problem. Review your abstract where you succinctly describe the overall problem in general. This section should be under methods or results.

Patients face obstacles, misconceptions, and knowledge gaps regarding palliative care services (Huo et al., 2019). Approximately 97% of patients and families at Briarwood Palliative Clinic receive a primer educational document introducing palliative care prior to their first consultation through their patient care portal or via email. Providers report spending the majority of the initial consultation educating patients and families about palliative care. Providers are not able to spend their time doing essential assessments and developing patient management plans. Clinic providers suggest that the introductory educational document seen by nearly all patients is ineffective in improving their readiness for PC.

Cancellation and no-show rates were examined and compared for select periods in 2022 and 2023. There are a total of 56 patients, showing 27 cancellations and 29 no/shows prior to the primer document being distributed between January through June 2022. Another report was run showing 84 cancellations or no-shows from January 2023 through June 2023 for a total of 84 patients. There were 26 no-shows since January 1, 2023, and 57 cancellations, and one left prior to being seen. The report showed that the majority of no-show/cancellation patients, a total of seventeen, were deceased, and the second was a total of twenty-three patients, nothing was documented as to why the no show in the chart. This could be due to patients needing to understand what palliative care can offer. Deceased patients show from the data that referring providers misunderstand the difference between palliative and hospice care. These patients should have been referred to hospice care. In conclusion, judging by the reports ran at Briarwood Clinic from 2022 to the present, there has yet to be any improvement post-primer document.

Providers at the clinic made important observations about the effectiveness of the existing primer document. According to the providers at the clinic, there has been no improvement since the primer document was handed out to patients at the clinic. The misconception that palliative care is hospice or homecare is still prevalent.

This project aligns with many DNP essentials. For example, DNP Essential One is a Scientific underpinning for practice, integrating different sciences with nursing science, such as psychosocial, organizational, and analytical (American Association of Colleges of Nursing, 2006). DNP Essentials Three is a clinical scholarship and analytical method for evidence-based practices, which states that nursing practice should be advanced by incorporating new evidence-based practices concluded from research and analytical methods (American Association of Colleges of Nursing, 2006). These two DNP essentials are relevant as they emphasize integrating scientific evidence into advanced nursing practice by analyzing the data collected for research purposes. In the proposed project, evidence-based practices and provider feedback will assist in revising patient education materials and ensure they are grounded in scientific knowledge. Nurses play a pivotal role in customizing educational material and empowering patients to make informed decisions. This would help bridge the gap, reduce health disparities, and enhance patient understanding, engagement, and adherence to the treatment plan.

Literature Review Comment by Elizabeth Duffy: Statistics regarding palliative care is missing here. The patient population of interest needs to be in the literature review. Comment by Elizabeth Duffy: How is the content highlighted in yellow relevant?

Brief Educational Interventions

There are several ways in which providers may attempt to educate their patients regarding palliative care. A written palliative care information page from Vanderbilt Health was adapted to have the same information as the video (Kozlov et al., 2017). The goal was to ascertain if a brief education intervention can enhance laypeople's knowledge of palliative care. After patients were presented with the video or information page, both tested with a higher confidence level than pre-presentation. This research showed that a straightforward information page or a quick educational video could improve understanding of palliative care and confidence in that knowledge (Kozlov et al., 2017). The first primer document utilized in phase one was more generalized and less detailed than the video and documents used in the previously referenced article. Comment by Elizabeth Duffy: Synthesize the literature review, and remove any components that do not have to do directly with the project.

Brief educational interventions improve patients' knowledge gaps about palliative care by giving them accurate and thorough information and could reduce patient no-shows/ cancellations. Clinical outcomes are negatively impacted, healthcare costs rise, and access to care and provider productivity are reduced when outpatient clinics have a high no-show rate (Lagman et al., 2020). These adverse trends may be due to patients' lack of palliative care knowledge. For example, a busy palliative care outpatient clinic started a quality improvement project that involved staff members calling patients to confirm appointments to lower the no-show rate.

The study's objectives were to ascertain how this intervention affected the no-show rate and evaluate the financial implications of a lower no-show. It concluded that of the 1224 completed visits from September 1 to December 31, 2015, 271 were no-shows with an average rate of 11.8%. After the intervention, there were 4368 completed visits and 562 no-shows (Lagman et al., 2020). The no-show rate for 2016 averaged 6.9% (p < 0.001), down 4.9% from the last four months of 2015 (Lagman et al., 2020). Estimated opportunity costs were about 396 no-show visits avoided, equivalent to an annual savings of about $79,200. In an outpatient palliative medicine clinic, the no-show rate was decreased by calling patients to notify them of their appointment 24 hours before their consultation (Lagman et al., 2020).

The Effectiveness of Posters as a Health Education Method

The distribution of health-educational posters is recommended when it is necessary to reach a broad audience for a long time if the poster's site is protected (Hasanica et al., 2020). Educational posters are more effective educators than written or verbal instruction (Li et al., 2019). Since patients value palliative care as person-centered and patient-led, educational posters may be especially well-suited to spread awareness of this subject by placing information within the context of a unique patient journey (Li et al., 2019). One thousand eight hundred fifty-three students were exposed to health education through posters. The percentage of correct answers increased by almost 5% following the poster distribution a month later (Hasanica et al., 2020).

Posters have a significant impact and provide long-term benefits when compared to other methods of educating the public about health, diseases, and lifestyles (Zhang, 2021). There is a reason why the walls of doctors' waiting rooms and hospital areas are always covered with posters endorsing healthy behaviors like getting immunized, practicing healthy eating, exercising, giving up smoking, and getting regular checkups: they work (Zhang, 2021). Well-placed posters, such as those in hospitals, waiting rooms for doctors, consultation rooms, and clinics, effectively communicate health messages to their target audience when they are more likely to absorb the message (Zhang, 2021).

Data have supported the success of posters. In academic and public health fields, poster presentations are among the most frequently used formats for information dissemination, according to a study published in the Health Information and Libraries Journal (Mimeo, 2015). About 97% of respondents to a survey conducted by the Journal of Pakistan Medical Association ( Journal of the Pakistan Medical Association, 2019) aid they understood why a medical facility poster urged them to check their blood pressure. Of those, 86% had their blood pressure checked in less than 30 days (Mimeo, 2015). Posters offer a succinct summary of a subject, ensuring speakers only share necessary information. This encourages active learning because of the audience's desire to participate and ask questions, according to the study in the Health Information and Libraries Journal that was previously mentioned (Mimeo, 2015).

Provider Perspectives and Feedback

An investigation was made into the nurses' viewpoints on the issues that could be raised to enhance patient education. According to one nurse, a simple statement from a doctor is more effective than ten statements from a nurse (Fereidouni et al., 2019). It concluded that nurses strengthening total commitment to the patient's needs, reconstructing the structure of the education plan, developing motivational factors, and facilitating change are some of the effective strategies to enhance the effectiveness of patient education (Fereidouni et al., 2019).

Emphasis on the importance of engaging the patients in the clinical context and maximizing the transfer of learning to the patient can improve the outcomes of the education plan (Jeyakumar et al., 2021). Feedback from the patient can also be used to improve the education plans for the coming patients. Improved education leads to a higher standard of care and a higher level of patient safety (Fereidouni et al., 2019).

Implementation Model

The Ottawa Model of Research Use (OMRU) is selected to build a structured framework for implementing evidence-based intervention (Logan & Graham, 1998). This six-step process was developed in the context of innovations in continuity of care. Applying this model to the proposed project on improving patient education through provider survey feedback involves some key components discussed individually. The OMRU is directing this project and was chosen because it is adaptable and suitable for the interdisciplinary components of the project (see Figure 2).

The first is assessing the current practice and setting clear goals. Gaining a thorough understanding of the issue and the stakeholders' perspectives requires evaluating the current practice. Gaps and challenges in the education process will be identified. This information will be used to define the objectives of the project that would be aligned with principles of patient-centered care and improvement in patient outcomes.

The second component is the development and implementation of the intervention, which would be the addition of posters in patient rooms. It would also involve designing a provider pre and post-appointment survey that collects essential feedback on phase one, Welcome Letter, and its effectiveness. The surveys will be administered via email or in-person to the palliative care clinic healthcare providers involved in patient care. This is why the appropriate data collection methods, and the surety of confidentiality and anonymity will be used.

The third component is analyzing and using the data to guide further. The pre- and post-appointment surveys will be compared to determine the effectiveness of the intervention. It is important to consider the practice environment at this time and look for areas where improvements can be made moving forward. Suitable statistical methods, tools, and qualitative analysis techniques will be used to identify common themes, patterns, and response gaps. Based on the findings of the survey comparison, the education material will be modified per the provider's suggestions.

The fourth component would be to evaluate the intervention's effectiveness in enhancing patient readiness and understanding the meaning of palliative care. The knowledge will be disseminated in the final step, and further improvements will be made.

Project Purpose and Objectives

The project’s purpose is to improve patient readiness for palliative care before the initial appointment. The objectives are to: 1. Use provider feedback to evaluate introductory information needed by patients from providers during the initial appointment prior to the educational intervention and 2. Develop educational resources to improve patient knowledge prior to the initial appointment with palliative care providers. 3. Evaluate and measure the effectiveness of the intervention using provider analysis for potential modifications and improvements for future patient readiness.

Project Description

Implementation Plan

The educational intervention will be at Briarwood Palliative Care clinic over an 8-week timeframe.  PI is a DNP student and not an employee at the Briarwood Palliative Care clinic in Ann Arbor. Dr. April Bigelow, as the co-investigator, is a nurse practitioner at the clinic. The patient population: new patients aged 18 or older, of any race, ethnicity or gender, with serious or life-limiting conditions. The pre-intervention survey will be given to providers to establish the current level of patient knowledge and common questions and concerns regarding palliative care. The post-intervention survey will be given to the providers to determine the effectiveness of the educational material after eight weeks. Pre-post- anonymous survey utilizing Qualtrics through email. Providers were allowed to participate in the survey after being informed of its goal. Providers were informed that survey responses would remain anonymous, and no patient-identifying information was collected. Both surveys were designed using a 5-point Likert Scale for the convenience of the participants. During this project, both quantitative and qualitative data will be collected. Descriptive statistics will be used to analyze the quantitative data, and the closed-ended questions will be thematically analyzed for the providers after both sets of surveys have been completed.

A short-term outcome consists of a more productive use of provider consultation time. The long-term outcome may include better informed patients further improving provider productivity. The sample size limits generalizability. The sample is limited to the new patients only attending Briarwood Palliative Care Clinic in Ann Arbor during the 8-week timeframe. This project is a pilot program being used to test effectiveness in a single setting. Pilot studies are usually intended to determine whether a project is feasible. They are not designed to develop generalizable knowledge per se (Bienkowski, PhD, CIP, 2016). A QI project uses a specific process, measures, and existing data to improve outcomes in a specific group (Faiman, 2021). The goal of this project is to improve provider productivity by improving patient readiness at the clinic.

Methodology

For this project, providers will be given a pre-and post-survey. The surveys were developed using information gathered from the providers. The provider will receive a survey (Appendix A) via email by Qualtrics Software, portal, or in person at their initial appointment to assess their readiness for palliative care. The post-appointment provider survey (Appendix B) will evaluate why the gaps in knowledge exist and what can be done to improve patient readiness. This information is being gathered to determine why the Welcome Letter alone needs to impart more information the patients need for their first appointment. The nurse care navigator and palliative care professionals at the Palliative Care Clinic will review and approve the proposed content. A poster will be developed and placed in all the rooms utilized by palliative care patients (Appendix C).

Ethical Considerations

Institutional review board (IRB) approval will be obtained before the project's initiation, ensuring the protection of participants' rights and privacy. All providers will obtain survey information, and anonymity and confidentiality will be maintained during data collection and analysis. Identifying information will be kept confidential, such as not asking for provider's names. Providers will be informed that they can opt out of the survey and will be educated about the purpose of the survey.

Setting

The project will be conducted at the Briarwood Palliative Care Clinic setting. The setting will provide an appropriate context to implement the intervention. The ambulatory clinic has three physicians, two nurse practitioners, and one nurse navigator specializing in Palliative Care. They see, on average, seven patients a day, both online and via Zoom.

Participants

The participants will include healthcare providers, two medical doctors, two nurse practitioners, and one nurse care navigator involved in patient education in palliative care.

Intervention

This pre-existing poster will define what palliative care is for the average patient. The posters show how revolutionary palliative care initiatives nationwide are raising the standard of care for patients with life-threatening illnesses ( Palliative Care Seminar Posters, n.d.). The posters will be placed in the patient rooms in a prominent position where they can be easily seen and read. The educational poster's visual and narrative design will be influenced by comments received from palliative care patients during the development process (Li et al., 2019).

Measures/Tools/Instruments

The post-intervention survey will be given to the providers to determine the effectiveness of the poster. The survey will be distributed using Qualtrics software through an email link. The questionnaire was designed using a 5-point Likert Scale for the convenience of the participants. A post-appointment survey will be given to the providers inquiring if they noticed an improvement in patient knowledge with the poster in the patient rooms. Providers were allowed to participate in the survey after being informed of its goal. Providers were informed that survey responses would remain anonymous, and no patient-identifying information was collected.

Timeline

`The intervention was put into practice, and data was gathered over an eight-week period. The results evaluation and data analysis will be finished in the months of February and March 2024.

Data Collection Procedures

The first step involved selecting a variety of posters for physicians and nurse practitioners to choose from. Providers received the initial pre-survey and responded using Qualtrics. Following that, providers selected the intervention poster via email. The chosen poster was then installed in patient rooms for an eight-week period. Providers will later respond to a post-survey through Qualtrics after the completion of the eight weeks.

Data Analysis

During this project, both quantitative and qualitative data will be collected. Descriptive statistics will be used to analyze the quantitative data, and the closed-ended questions will be thematically analyzed for the providers. The qualitative data will be used for the initial provider survey using the 5-point Likert Scale and analyzing the responses. The data from the 5-point Likert Scale will be examined to determine the effectiveness of the poster.

The objectives are to 1. Survey key stakeholders about patient readiness and knowledge to engage in PC, using the Likert 5-point Scale to evaluate the responses and 2. Develop an educational intervention for the patients and families. 3. Evaluate and measure the effectiveness of the intervention using pre- and post-surveys for providers to assess patient's knowledge and readiness for palliative care; utilizing descriptive statistics will be used to analyze the quantitative data, and the closed-ended questions will be thematically analyzed for the providers.

Sustainability plan

Potential for the Project to Endure

The potential for the project to endure lies in its success in integrating the poster into the office environment as well as receiving feedback from the providers as to how to improve the intervention. To ensure sustained implementation of the project outcomes, the healthcare providers at Briarwood Palliative Care Clinic must be convinced that the poster aids them in effectively educating the patients and getting the provider's cooperation in filling out the pre- and post-survey that will help with patient readiness at the clinic. Collaboration and engaging the stakeholders will also be needed for smooth and continued implementation.

Dissemination Plan

The project report will be prepared containing findings, outcomes, and recommendations for the project. It will highlight the methodology used, key findings obtained, and implications for practice. Presentation of the findings will also be shared at local, regional, and national conferences. These platforms will engage the stakeholders and the policymakers to influence healthcare policies.

Results

(Pending post-survey results)

Results of the presurvey were as follows 67% of providers somewhat disagreed that the patients have a clear baseline of what palliative care is and what to expect at their initial visit. Whereas 33% somewhat agreed that the patients do have an understanding of palliative care. Additionally, 100% of providers somewhat disagreed that their patients comprehended the distinction between palliative care and hospice.

Discussion

The providers have viewed the installation of the posters positively. However, there were obstacles that arose before the posters could be installed. One unforeseen barrier I encountered with this project was with the copyright compliance officer before emailing the selected companies for the posters. He advised me on approaching them, mentioning they might request a monetary fee for the material usage. He recommended including details such as my name, university, clinic name, the number of rooms, duration of display, and clarifying it's for a research project, promising full credit to the company if the poster is chosen. This information, he stressed, would be valuable before reaching out to physicians and nurse practitioners. If a chosen poster incurs a high cost, I might have to reconsider. After emailing, most companies generously allowed educational use without any charges. Following the poster selection, Dr. Chargot, the assistant professor and physician lead at Briarwood Clinic, informed me to obtain approval from the Medical Director and Interim Manager at Briarwood Clinic. They quickly approved hanging the posters in clinic rooms but advised discussing the matter with the Administrative Assistant for assistance in patient rooms. Comment by Elizabeth Duffy: Do not use first person. Hold on results and discussion until the project is complete. Keep these items in your notes.

Conclusion

(Pending project completion)

Palliative care holds substantial benefits for numerous patients. Regrettably, a knowledge gap hinders its optimal utilization. The introduction of educational posters aims to bridge this gap by informing patients. However, since the study is still ongoing, definitive conclusions about the effectiveness of the poster cannot be drawn at this point. References