Research Project Proposal Essay
An Investigation into the Barriers to Advance Care Planning, And the Effects of Advance Care Planning on End-of-life Care Experience and Length of Hospital Stay
INTRODUCTION: BACKGROUND AND RATIONALE FOR THE STUDY
Background of The Study
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Advance care planning has been one of the most critical conversations in healthcare, more so in end-of-life care. Advance directives are documents stating a patient’s preferences in care, which should be followed if they are in a condition whereby they become seriously ill, are incapacitated and unable to speak or make decisions for themselves (CDC, n.d.). Advance care planning involves conversing with family members and the care provider to prepare for decisions on an individual’s future care. Efforts have been made to get more people to complete advance directives, but the outcome is still low. According to the CDC (n.d.), only 1 in 3 people have completed advance directives in the U.S. Therefore, a gap exists in getting more people to complete advance directives. This study attempts to address the gap by assessing the impact of advance care planning on end-of-life care and length of hospital stay and establishing the existing barriers to advance care planning.
Every patient has a right to get their preferred treatment in end-of-life care, despite being incapacitated. However, not all patients have expressed their end-of-life preferences by completing advance directives. The conversation is uncomfortable, especially since it mainly involves end-of-life care. Offering quality end-of-life care involves observing the patient/family’s preferences, even though family members may face a moral dilemma on whether they are making the right healthcare decisions for the patient. Therefore, the lack of advance directives is a major problem. No one knows the future, and anything tragic may happen, leaving an individual incapacitated and unable to make healthcare decisions. The solution is getting more people to engage in advance care planning and complete advance directives.
Significance and Prevalence of the Problem
Advanced care planning is essential to explore because all patients need an advance directive on file, not knowing when something tragic can happen, and it becomes too late to make those life-changing decisions on their own. Advanced care planning and communication can eliminate uncertainty and make end-of-life transition smoother (Jones et al., 2019). Additionally, having completed advance directives saves the family members from the moral dilemma of wondering whether the healthcare decision they make for their patient was the best for them and whether they would make the same decision if they were not incapacitated. Therefore, advance care planning and completing advance directives are vital, especially for terminally ill and older patients in nursing homes. The findings of this study will significantly contribute to the field of advance practice nursing. They will identify the barriers to advance care planning and inform nurses on how to ensure more people plan their care in advance. As a form of health promotion, this research is needed to determine how advance care planning can be promoted more effectively across different health populations, especially among terminally ill and old patients.
The study’s general objective is to establish how more people can be made to plan their care in advance by completing advance directives.
The specific study objectives include the following:
To establish the barriers in advance care planning.
To assess how advance care planning affects patients and their experience in end-of-life care.
To determine whether advance care planning affects the length of a patient’s hospital stay.
The following research questions will be used in the study:
How would advance care planning affect patients and their experience with end-of-life care? What kind of barriers exists with early care planning?
Would advance care planning affect the length of a patient’s hospital stay?
Based on existing research, the health belief model is the theoretical underpinning of advance care planning. The theory will therefore be applied to understand the concepts of the research study. The key concepts that will be understood using the theory are the problem statement, objectives and research questions.
Problem: many people have not planned care in advance by completing advance directives
Objectives: To establish the barriers in advance care planning. To assess how advance care planning affects patients and their experience in end-of-life care. To determine whether advance care planning affects the length of a patient’s hospital stay.
Research questions: How would advance care planning affect patients and their experience with end-of-life care? What kind of barriers exists with early care planning? Would advance care planning affect the length of a patient’s hospital stay?
The health belief model is used to predict health behavior. Wang et al. (2021) note that the theory assumes that an individual’s willingness to change health behavior depends on their perception of the disease. Additionally, a person’s beliefs about health and health conditions impact health and health-related behaviors. An individual’s health beliefs are influenced by their perceived barriers, susceptibility to illness, consequences of illness and perceived benefits of engaging in healthy behaviors, and information that prompts an individual to take action. Based on this theory, people are more likely to engage in advance care planning by completing advance directives when they are aware of the perceived severity, susceptibility to illnesses, perceived benefits of completing advance directives and the perceived barriers to completing advance directives. Therefore, the research questions will be used to identify the perceived barriers in completing advance directives and the perceived benefits, including the experience in end-of-life care, patient/family preferences followed, and the length of hospital stay. According to Wang et al. (2021), the health belief model has been successfully used to understand and develop health promotion initiatives. Therefore, the health belief model will be used as the theoretical framework since it best suits the research study, given that it is mainly a health promotion.
Advance care planning is an essential aspect of healthcare, especially in end-of-life care. Advance care planning is considered in old and younger ages since an illness crisis may leave individuals unable to make healthcare decisions and directives themselves. At this point, the family and close relatives decide for them, but if they had planned their directives before the crisis, the directive and decisions they had made would have been used. This section reviews the available literature regarding advance care planning. The review will focus on the literature on engaging more patients to complete health directives, the effect of advance care planning on end-of-life-care experience, barriers in advance care planning, and the relationship between advance care planning and a patient’s length of hospital stay.
Advance Care Planning Strategies
According to Gallagher, Bolt & Tamiya (2020), less than 30% of all US residents have completed an advance directive to guide care when seriously ill, meaning that only 1 in 3 adults have planned care. Although the number is low, care provider-focused efforts have brought more people to have this uncomfortable conversation and get more people to complete advance directives (Fahner et al., 2019). Some of the strategies that have been used to facilitate the increase in the number of people completing advance directives include Medicare payment for advance care planning and the use of self-service platforms to indicate preferences for future care. The methods have been effective, even though the number is still low.
Fahner et al. (2019) note that communication and extensive patient education is also a strategy that can help increase the number of people using advance care planning and completing advance directives. According to Wasserman et al. (2019), communication between the care providers and the patient is essential in advance care planning and completing advance directives. The care providers are responsible for providing information on advance care planning to patients, especially terminally ill and geriatric patients. 3 Information on the available options in end-of-life care and their consequences would increase the number of people completing advance directives, given that inadequate information, awareness, and knowledge on the same is a significant barrier to advance care planning (Wasserman et al., 2020).
Additionally, health promotion through patient education is another strategy for getting people to engage in the conversation about advance directives and care planning. According to McMahan, Tellez & Sudore (2021), advance care planning is a requirement for both ill and healthy people, old and young, since any medical crisis may occur, leaving an individual incapacitated and unable to make care decisions or select a directive. Therefore, health promotion initiatives focusing on advance care planning in the community and patient education to patients and their families can be used to get more people to engage in advance care planning.
Advance Care Planning and Patient Experience in End-of-Life Care/Length of Hospital Stay
Advance care planning has been found to contribute positively to patient satisfaction in end-of-life care, decreased healthcare cost utilization, decreased chances of demise in hospitals, and increased use of life-sustaining treatment (Xu et al., 2021). Awareness that if anything happens and leaves a person in a situation, they cannot speak for themselves. Yet, knowing that their preferences and wishes will be considered raises a patient’s confidence and enhances satisfaction. It also gives the patient and the family members peace of mind, thus improving the end-of-life care experience. According to Gallagher et al. (2020), patients who have engaged in advance care planning and have advance directives have a shorter hospital stay than patients without advance directives since most prefer not to get life-sustaining care.
Barriers to Advance Care Planning
There are various barriers to advance care planning. Research shows that some potential barriers to the completion of advance directives include inadequate awareness of advance care planning, lack of knowledge about advance care planning in many patients, and lack of time four dedicated by physicians to deliver patient education and counseling on advance care planning (Xu et al., 2021). Although state laws nationwide support advance care planning, the movement of awareness creation and education on advance care planning and advance directives is low. Time allocated for counseling and patient education on advance care planning is also considerably low, thus a major barrier to the completion of advance directives (Xu et al., 2021).
The other barriers to completing advance directives include confusion, denial, and cultural differences (CDC.gov, n.d.). Many people would prefer quality end-of-life care. However, there is confusion and worry between personal wishes and potential conflicts regarding the best action to take to extend a patient’s life and, at the same time, ensure quality in end-of-life care. A study by Sean Morrison (2020) found that most people worry that making decisions on end-of-life care may interfere with doing what is required to extend their lives, thus better not complete advance directives. The confusion can be addressed by engaging patients in a conversation on preparing end-of-life care and helping them understand the different directives and their influence on their care and end-of-life.
Denial of death and dying and being in a circumstance whereby a person is incapacitated and unable to speak for oneself is another barrier to completing an advance directive. Due to denial, people do not embrace that life closures are as important as life. Providing information and preparation of the process, especially for chronically ill patients, would help deal with the denial and bring more people to embrace advance care planning and complete advance directives.
In a review, Orlovic, Smith & Mossialos note a positive relationship between racial and ethnic differences in end-of-life care and advance care planning. Most Medicare beneficiaries 5 (who have completed advance directives) from all ethnic and racial groups prefer to die at home without life-sustaining treatment. For instance, compared to whites, blacks are more likely to use intensive care and life-sustaining treatment, while whites prefer directives such as do not resuscitate for reasons such as avoiding high end-of-life costs. Cultural differences are, therefore, a barrier to advance care planning and directives.
Literature Synthesis in Relation to Advance Care Planning in the Study
Based on the literature reviewed above, advance care planning is essential for both ill and healthy individuals. Despite the low number of people completing advance directives, there have been efforts to get more people complete advance directives (Fahner et al., 2019; Wasserman et al., 2019). However, researchers agree that the existing barriers to advance care planning significantly contribute to fewer people completing advance directives (Sean Morrison, 2020; Xu et al.,2021). Furthermore, advance care planning enhances patient satisfaction in end-of-life care, reduces the length of hospital stay, and prevents unnecessary costs in life-sustaining care (Xu et al., 2021). Therefore, it is essential to use the available strategies to bring more people to complete advance directives.
The literature review has also depicted the importance of advance care planning in end-of-life care, especially for terminally ill patients. However, there is a gap in the available research on nursing home research. Most deaths approximately 25% of older adults die in nursing homes, and the number is projected to increase with the aging population (Jones et al., 2019). Therefore, extensive research must identify how advance care planning can be enhanced in nursing homes and other long-term care facilities.
DESIGN AND METHODOLOGY
Definition of Variables
The study has an independent variable and dependent variables. The research questions in the study were used to formulate the independent and dependent variables. The research questions are How would advance care planning affect patients and their experience with end-of-life care? What kind of barriers exists with early care planning? Would advance care planning affect the length of a patient’s hospital stay? Therefore, the independent variable in the study is advanced care planning. The dependent variables include the length of hospital stay and patient experience with end-of-life care.
Population and Sample Identification
The population of interest in this study includes people from Long Beach, ca. The population-specific demographics include middle-aged and elderly males and females from the city and healthcare providers working with patients from these populations. Socioeconomic backgrounds will not matter, even though the special focus will be given to individuals from low-income and middle-class incomes, given that they have insufficient knowledge in advance care planning and a majority of them have not filed advance directives. A sample will be drawn from a population of 133 patients and care providers, specifically from Long Beach memorial hospital and a local long-term care facility/nursing home. The inclusion criteria for the sample include patients with terminal or chronic illnesses such as dementia and Alzheimer’s disease.
The method of sampling that will be used is simple random sampling. It is a probability sampling method in which a researcher randomly selects a subset of participants from a population. The method will be used to ensure that each member of the population stands an equal chance to be included in the sample. The sample size will be calculated using Yamane’s sampling formula, which is as follows n = N/(1+N(e)2 whereby n=sample size, N= population size, and e=error/level of precision
The sample size is, therefore, 100
Process for Obtaining Consent/Informed Consent Form
The study aims to obtain all participants’ consent before participating in the research. The informed consent form will include formally written information on the study, including why the study is being conducted and how the participants’ involvement will assist in meeting the study objectives. Additionally, it will be noted that participants are only allowed to participate after understanding the information on the informed consent form and can voluntarily participate.
Data Collection Procedures
The sample will be divided into two groups, whereby one group will include people who have participated in advance care planning and have advance directives in file and the other group including people who have not filed advance directives or engaged in advance care planning. The data collection tools that will be used include questionnaires to the patients and surveys from the Long Beach Memorial hospital and long-term care facility records. The questionnaires will be distributed in these care facilities.
T-test is the analysis type that will be conducted to test the research hypothesis. T-test is the statistical test used to compare the means of two groups (Kim & Park, 2019). It tests a hypothesis by determining whether the process or intervention affects the population of interest. In this care, the intervention is advanced care planning. The T-test analysis method will identify whether it affects the length of hospital stay and patient experience with end-of-life care. The T-test analysis type is most appropriate for my research since the research hypothesis tested aims at determining the effect of advanced care planning on the population of interest.
The null hypotheses are that advance care planning does not influence the length of hospital stay and patient experience in end-of-life care is not influenced by advance care planning. The research hypotheses are: advance care planning influences the length of hospital stay, and advance care planning affects patient experience with end-of-life care. The significance level in this study will be 0.05 since the confidence interval will be used at 0.95. The significance level is determined from 1 minus the confidence level. A significance level of 0.05 means the mean will be greater than the null hypothesis.
The expected results of the quantitative study are that advanced care planning affects the length of hospital stay and patient experience in end-of-life care. The null hypothesis will be rejected if the results are random and there is less than a 5% chance of producing a positive value. The research hypothesis will be accepted if the t-value exceeds 5%. Mishra et al. (2019) note that if the t-score value computed is beyond the critical value in either direction, the null hypothesis is rejected, and the research hypothesis is accepted.
Validity and Reliability
According to Lu et al. (2022), the validity and reliability of a study involve how effectively the methods used measure the objectives. Additionally, validity refers to the accuracy of a measure, while reliability refers to the consistency of a measure. The appropriate data collection methods and samples will be used to ensure the validity of the study results. In addition, the population and its descriptive characteristics are well-defined, and the research process will be standardized as much as possible to prevent the influence of external factors, which may lead to variations in the results. To ensure reliability, the measurement tools used are mainly used in primary care settings and go through reliability and fairness audits. Additionally, sensitivity and specificity, confidence intervals for performance, and predicted outcomes will be used together with positive values to ensure consistency in reliability.
Ethical Considerations/Study Limitations
The ethical considerations in this study include voluntary participation, informed consent, confidentiality and anonymity, and results communication. To begin with, participants will be allowed to participate voluntarily after informed consent is acquired. More so, the questionnaires will not include personal identification information to ensure anonymity and confidentiality. A significant limitation of this study is that it intends to cover a small population in only two care facilities. However, the issue of advance care planning is extensive and requires extensive research covering diverse populations and settings. At the end of the research, the results and findings will be shared with the Long Beach Memorial Hospital participants and the long-term care facility. After that, the care providers at these facilities will communicate the findings with patients and their families as a form of health promotion and get more people to participate in advance care planning and complete advance directives.
Centers for Disease Control and Prevention. (n.d.). Advance Care Planning: Ensuring your Wishes Are Known and Honored When You are Unable to Speak for Yourself. Retrieved from https://www.cdc.gov/aging/pdf/advance-care-planning-critical-issue-brief.pdf
Fahner, J. C., Beunders, A. J., van der Heide, A., Rietjens, J. A., Vanderschuren, M. M., van Delden, J. J., & Kars, M. C. (2019). Interventions guiding advance care planning conversations: a systematic review. Journal of the American Medical Directors Association, 20(3), 227-248. https://doi.org/10.1016/j.jamda.2018.09.014
Gallagher, J., Bolt, T., & Tamiya, N. (2020). Advance care planning in the community: Factors of influence. BMJ Supportive & Palliative Care, bmjspcare-2020-002221. https://doi.org/10.1136/bmjspcare-2020-002221
Jones, K., Birchley, G., Huxtable, R., Clare, L., Walter, T., & Dixon, J. (2019). End of life care: a scoping review of experiences of advance care planning for people with dementia. Dementia, 18(3), 825–845. https://doi.org/10.1177/1471301216676121
Kim, T. K., & Park, J. H. (2019). More about the basic assumptions of t-test: normality and sample size. Korean Journal of Anesthesiology, 72(4), 331–335. https://doi.org/10.4097/kja.d.18.00292
Lu, J. H., Sattler, A., Wang, S., Khaki, A. R., Callahan, A., Fleming, S. L., Shieh, L., Chobot S., Fong, R., Elhert, B., Li, S., Smith, M., Steven, M., Michael, A., Winifred, T. & Shah, N. H. (2022). Considerations in the reliability and fairness audits of predictive models for advance care planning. MedRxiv, 2022-07. https://doi.org/10.3389/fdgth.2022.943768
McMahan, R. D., Tellez, I., & Sudore, R. L. (2021). Deconstructing the complexities of advance care planning outcomes: what do we know and where do we go? A scoping review. Journal of the American Geriatrics Society, 69(1), 234-244. https://doi.org/10.1111/jgs.16801
Mishra, P., Singh, U., Pandey, C. M., Mishra, P., & Pandey, G. (2019). Application of student’s t-test, analysis of variance, and covariance. Annals of Cardiac Anaesthesia, 22(4), 407. https://doi.org/10.4103%2Faca.ACA_94_19
Orlovic, M., Smith, K., & Mossialos, E. (2019). Racial and ethnic differences in end-of-life care in the United States: Evidence from the Health and Retirement Study (HRS). SSM-Population Health, 7, 100331. https://doi.org/10.1016/j.ssmph.2018.100331
Sean Morrison, R. (2020). Advance directives/care planning: clear, simple, and wrong. Journal of Palliative Medicine, 23(7), 878–879. https://doi.org/10.1089/jpm.2020.0272
Wang, M., Huang, L., Pan, C., & Bai, L. (2021). Adopt proper food-handling intention: An application of the health belief model. Food Control, 127, 108169. https://doi.org/10.1016/j.foodcont.2021.108169
Wasserman, J., Palmer, R. C., Gomez, M. M., Berzon, R., Ibrahim, S. A., & Ayanian, J. Z. (2019). Advancing Health Services Research to Eliminate Health Care Disparities. American Journal of Public Health, 109(S1), S64–S69. https://doi.org/10.2105/AJPH.2018.304922
Xu, C., Yan, S., Chee, J. Lee, E. P., Lim, H. W., Lim, S. W. & Low, L. L. (2021). Increasing the completion rate of the advance directives in primary care setting – a randomized controlled trial. BMC Family Practice, 22, 115. https://doi.org/10.1186/s12875-021-01473-1
All components of this project have been completed in previous weeks, so your final research proposal project paper should be cohesive, polished, and incorporate feedback from your instructor from the previous weeks. Your research proposal should be between 10 and 15 pages. Follow proper APA format and style and include a cover page, reference page, and any applicable tables or appendices. Your research proposal should have a nursing theoretical foundation.
Your research proposal must include the following sections:
Background and rationale for the study
Review of the relevant literature
Design and methodology
You must include the following components:
Section One: Introduction
The research proposal should:
Start with a statement of the problem and objective for the study, which articulates the main objectives that the study desires to achieve.
Include a description of the theoretical framework to be utilized and a rationale for choosing a framework.
Describe the significance and relevance of the problem. Why is this particular study needed? How will findings contribute to the field of advanced practice nursing? Why is this research needed?
Section Two: Literature Review
The literature review should:
Be a synthesis of the major concepts from recently published research findings.
Be organized by themes and not just a report about what each author discovered in his or her research findings.
Identify no fewer than six relevant research articles.
Synthesize the literature in relation to where the study fits within the context of the proposed study.
Section Three: Design and Methodology
In this section, what is to be done, and who, what, how, and where are all to be included in your proposal. The methods should be relevant to the question that is to be answered as a result of the research study. There should be information included about the study design, the setting and sample, data collection methods, and data collection analysis procedures. Ethical considerations should also be addressed in this area. Limitations and a plan for communicating the research findings should also be included in this section.
All critical elements of design and methods should be detailed, including:
Definitions of the variables
Identification of the population and sample
Procedures for sampling
Processes for obtaining consent to do the study
Informed consent form to be given to research participants
Data collection procedures
A clearly stated method of data analysis
An explanation on why your data analysis method is appropriate for your research
Issues related to validity and reliability
Ethical considerations (including plans for the protection of human subjects as appropriate)
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