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Nursing Role in Geriatric End of Life PlanningJames Harrington, Cheryl Howard, Lisa Sage, Andrea Scott, and Holley WestFerris State UniversityAbstractThis paper is a group project of Ferris State University Bachelors of Science in Nursing students, which explores four different articles of nursing research about nursing role in geriatric end-of-life planning. The articles that were researched covered evidence from different nursing areas; from medical-surgical nursing and oncology, to intensive care nursing and palliative nursing. The authors of this paper wanted to know: What are nursing responsibilities for end of life planning? Do nurses have the education to help with end of life planning? What factors or attitudes contribute to or hinder an individual planning for their death? Multiple studies are critiqued for viability of information related to end of life planning. Identification of attitudes affecting planning, recommendations for further research, and important information for end of life care plans and supporting documents, such as advanced directives, do not resuscitate orders, living wills, medical proxy, and durable power of attorney are noted. The research evidence is described in relation to the authors’ nursing practice experience. Recommendations are offered for utilizing the evidence. Group conclusion of this paper’s authors is that nurses play an important role in end of life planning for all populations, not just in geriatrics. There is a need for nurses to have increased knowledge, better communication and improved multidisciplinary teamwork for effective end of life planning.Keywords: advance directives, do not resuscitate, elderly, end of life planning, geriatric, nursing, palliativeNursing Role in Geriatric End of Life PlanningThe purpose of this paper is to ask what the research reveals about the nursing role in end of life (EOL) planning with the geriatric population. The geriatric population is growing in numbers and people are living much longer due to advancements in medicine (Ruff, Jacobs, Fernandez, Bowen, & Gerber, 2010). Identification of geriatric problems and nursing interventions for the geriatric community is necessary in all fields of nursing care. Death and dying is inevitable and nursing care is often hallmark in this stage of life. Patients and their families turn to nurses for information and guidance for quality of life and care issues. Nurses often help people understand advance directives and care choices (Trossman, 2009). The American Nurses Association (ANA) position statement supports the nurse’s role as an advocate for patients throughout their lifespan concerning EOL choices (ANA, 2010). The ANA is actively developing strategies to include EOL planning as a part of health care reform (Trossman, 2009). It is important to identify nursing roles, assess knowledge and evaluate nursing care trends in the area of EOL planning and advance directives. Description of Four Research ArticlesArticle 1 - Advance Directives: Evaluation of Nurse’s Knowledge, Attitude, Confidence, and Experience This journal article measures acute care registered nurses expertise in the area of advance directives (Putman-Casdorph, Drenning, Richards, & Messenger, 2009). The article was featured in the Journal of Nursing Care Quality which is a peer reviewed journal geared toward application-to-practice concepts for practicing nurses and nurses in leadership roles (Lippincott, Williams, & Wilkins, 2012). This study used a questionnaire method with 87 acute care registered nurses to assess their advance directive knowledge about advance directive laws as well as attitude, confidence and experience with advance directives. This questionnaire used a Likert-type scale and was based on an instrument developed in a previously done, larger study (Putman-Casdorph et al., 2009). The questionnaires’ data was collected and analyzed. Sample characteristics of nurses mean age was 39 years old, had a mean of 11 years’ experience and 85% worked in the inpatient medical-surgical nursing field. Results showed that sample had a strong general knowledge but poor state-specific knowledge about advance directive laws. Participants had a moderately negative attitude toward advance directive planning support & helpfulness in practice. Participants were only slightly too moderately confident and a majority of nurses felt advance directive participation was a part of their nursing role (Putman-Casdorph et al., 2009). The authors stated that this study supported previous studies that nurses need education and support with advance directives in order to improve quality patient care. The authors felt that increased knowledge and experience with advance directives would likely contribute to increased confidence and more positive attitudes (Putman-Casdorph et al., 2009). Article 2 - Practice of Expert Critical Care Nurses in Situations of Prognostic Conflict at the End of Life This journal article addresses the issues that critical care nurses face when patients facing end-of-life decisions continue to undergo treatments that nurses feel are unwarranted. This study was presented in the American Journal of Critical Care Nurses in September of 2006 and was peer reviewed and subsequently credentialed for continuing education credits through the American Nurses Credentialing Center (ANCC). The study was performed by means of face –to-face interviews of 21 critical care nurses representing seven health-care facilities in the southwestern region of the United States. Each of the critical care nurses selected for interview was nominated as an expert by peers in his/her individual facility (Robichaux & Clark, 2006). Peers of those deemed experts had first been exposed to guidelines describing what qualities represented an expert nurse as outlined in Benner et al. (1998). The results of this study indicated that expert nurses in critical care areas have the skills and motivation to educate patients and their family members about realistic expectations involved in further procedures and treatments aimed at prolonging life. Although nurses felt it necessary to give their patients an accurate picture of expected outcomes the general assumption in healthcare that life will be sustained by all means available often made it difficult for nurses to convey to the patients/family members the information they deemed appropriate in order for informed EOL decisions to be made (Robichaux & Clark, 2006).Article Three - Promoting Advance Directives Among Elderly Primary Care Patients This journal article looks at the effectiveness of having medical staff discuss advance directives with individuals ages 65 and older and their willingness to sign new directives for their care. The article was published in the Journal of General Internal Medicine which promotes improved patient care, research, and education in primary care, general internal medicine, and hospital medicine (Springer, 2003). ???????For this study the researchers used a one year quasi-experimental trial which looked into different ways to promote the use of advance directives in elderly ambulatory patients. The study looked at five different health centers in one region as well as one control center which acted as the control site. It looked at different ways in which to inform patients of advance directives which included discussion with health center staff, materials that were disturbed by mail, and discussion with educated versus non-educated physicians on advance directives. The study looked at a total of 2,120 patients who were asked to sign new advanced directives. Each participant was required to be over the age of 65 and had a health maintenance visit with their primary care provider (PCP) within the study year. If participants did not meet these criteria they were then removed from the study (Springer, 2003).???????The results of study showed that 7.8% of the patients at the intervention centers completed new advance directives, versus <1% at the comparison center (Wissow et al, 2004). Those individuals who are 75 years of age or greater as well as those whose median household income is over the state median had twice as much odds of signing new advance directives. Within the study physicians stated that lack of time and the willingness to breach the subject on advanced directives where factors which lead to refusal of signing new advance directives (Springer, 2003).???????When evaluated it was shown that if physicians took the time to discuss advance directives with patients then they typically were more likely to sign new ones. The final conclusion shows that physicians would benefit from further education with discussion on EOL care and the need for advance directives to allow patients to have autonomy even at death. It also demonstrated that the younger elderly (under the age of 74) population needs to be informed of the benefits of having an advance directive established while still healthy (Springer, 2003).Article Four - Factors Associated with Favorable Attitudes Toward End-of-Life Planning The aging population and increasing cost of health care for end-of-life (EOL) care has made EOL planning a medical priority (Ruff et al., 2010). This article aimed at identifying factors influencing EOL planning (Ruff et al., 2010). The review of literature preceding study conduction indicated correlations between EOL planning (use of hospice, Do Not Resuscitate (DNR) orders, durable power of attorney, living wills or advanced directives, and assigning a healthcare surrogates) and ethnicity, race, marital statuses, age, and spirituality (Ruff et al., 2010). This study expanded previous studies by increasing sample size and including a broader range of subjects in order to increase generalizability (Ruff et al., 2010).The convenience sample size of 331 people of south Florida was used for study analysis (Ruff et al., 2010). The population was diverse and provided valuable information regarding factors attributing to different attitudes toward EOL planning (Ruff et al., 2010). Researchers addressed four topics of concern relating to EOL; planning, health care preferences, knowledge and opinions about hospice, and comfort communication (Ruff et al., 2010). Participants were given a 40 item Likert-type survey that had been adopted from “Johnson, Kuchibhatla, and Tulsky in their 2008 study What Explains Racial Differences in the Use of Advance Directives and Attitudes Toward Hospice Care” and expanded to include identified areas of interest (Ruff et al., 2010, p. 177).Data analysis was performed using Pearson correlation analysis, creating multiple linear regression models, and ending with a compiled backward stepwise linear regression model (Ruff et al., 2010). The results indicate educating patients of all ages, not just the elderly, about EOL care planning increases advanced care planning and use of palliative care services (Ruff et al., 2010). Critical Appraisal of the EvidenceArticle 1 - Advance Directives: Evaluation of Nurses Knowledge, Attitude, Confidence, and Experience Overall the critique of this study is relatively strong. A majority of the required components were present in the article. However some major downfalls of this study were small sample size, non-existent theoretical model and potential bias of sample subjects. The authors clearly stated the study’s shortcomings and that resulted were not generalizable. The authors’ conclusions from the study did support results of previous studies to add to the evidence base that was established by the review of literature (Putman-Casdorph et al., 2009). A breakdown of critical appraisal of the evidence is presented in the following sections.Purpose and problem. The problem statement is stated clearly. The sentence that best identifies the purpose and problem was, “a need was identified to evaluate current practice in relation to appropriate discussion of advance directives” (Putman-Casdorph, Drenning, Richards, & Messenger, 2009, p. 250). The population in question is identified generally as “patients”. The study variables are clearly identified as a nurse’s knowledge, attitude, confidence and experience. The significance to the study of nursing is clearly apparent in the statement that, “the role of the nurse includes patient advocacy to ensure that patients are informed about their rights to complete advance directives” (Putman-Casdorph et al., 2009, p. 250). Much of the required information was included in the purpose and problem section. The problem statement was clearly stated although it could have been summarized with more detail. This section was reasonably strong. Review of literature. The literature review is comprehensive at 19 sources from reputable, critically appraised journals with data to support research. Sources focus on nursing but also include geriatric, critical care, palliative and internal medicine. The literature review of nursing journals includes a wide range of nursing disciplines: oncology, gerontology, administration, palliative, critical care and clinical nurse specialty (Putman-Casdorph et al., 2009). The sources appear to be primary sources and all appear in the article. Half of the sources cited were published earlier than the acceptable time range of five years from date of publication submission there for these outdated sources do not meet the standard to be considered current research. The explanation and interpretation of the literature review is thorough. Paraphrasing is used most often in a logically flowing manner which is easy to understand. Overall the review of literature was strong but could have used more recently dated sources.Theoretical/Conceptual model. There was no clearly identified theoretical or conceptual model explained in this article. This area was very weak because it was not included.Hypothesis and research questions. There were no clearly stated hypotheses in this article. However in the review of literature, the authors outlined that past research identified a need for further knowledge and experience within the nursing field regarding advance directives (Putman-Casdorph et al., 2009). The implied hypotheses was that the authors wanted to know if the results of past research regarding nursing knowledge about advance directives had changed compared to present day. Even though the study’s general focus could be understood, the hypothesis and research question section was weak because it was not clearly stated.Research design. The research design was clearly identified because it tested the four constructs of knowledge, attitude, confidence and experience. The design was appropriate to answer the research question because it measured those four variables using a Likert-type scale measurement tool (Putman-Casdorph et al., 2009). The design was non-experimental and appropriate for the variables being measured. There was no defined control for extraneous variables stated. Overall the research design was strong because was structured to measure the appropriate variables and the design was clearly explained.Sample and sampling methods. The sampling method was described clearly as using nurses work mailboxes for placement of tracked questionnaires. The non-probability sampling method was not named. The accessible population is identified as registered nurses in one large American teaching hospital. Associated demographics are included in detail. The accessible population was identified as 198 with a small, non-random sample size of 87. Potential bias is identified by the authors as the questionnaire respondents received a $10 gift card. The authors also identify that the sample size is not large enough to allow the results of the study to be generalizable (Putman-Casdorph et al., 2009). Overall the sampling methods section is strong because the sampling method, population and bias are clearly identified in this study. However the small, non-generalizable sample size is a major downfall. Data collection methods. This article explained in detail what data was obtained by clearly describing the questions and different sections of the questionnaires. It also explained that the data were collected by having the participating nurses return the questionnaires into a sealed box and envelope. It further explained that the completed questionnaires were collected “by the nonadministrative researchers on the research team to avoid a conflict of interest” (Putman-Casdorph et al., 2009, p. 253). It is explained that the questionnaire used was developed from three existing instruments and previously used in a large study with 719 participants (Putman-Casdorph et al., 2009). Reliability and validity of the questionnaire were not discussed. Overall this data collection methods section is a strong.Instrument. The instrument used to obtain the data was clearly explained as a questionnaire that had been previously used in a large study and was developed from three separate instruments. The different sections of the questionnaire were described in as a demographic section, a true/false section, a Likert-type scale section, and a section of open-ended and yes/no type questions (Putman-Casdorph et al., 2009). The demographic section described some of the information the researchers were hoping to obtain, but not a total number of questions asked. The true/false section consisted of 21 questions. The Likert-type scale section included nine questions. The number of questions asked in the yes/no and open-ended questions section were not listed. This information was obtained to answer the research questions pertaining to nursing knowledge, attitude, confidence, and experience with advance directives. The questionnaire was the only method listed for gathering the information. The response rate was listed as 44%. Confidentiality was provided by having the questionnaires returned via a sealed box and envelope, but each questionnaire had a number on it to identify those who participated so they could be compensated with a gift card (Putman-Casdorph et al., 2009). With more positives than negatives, this section of research is strong.Data analysis. The article states that “all the data were analyzed using SPSS for Windows, Version 16.0” (Putnam-Casdorph et al., 2009, p. 253). It further states that the “data were evaluated using descriptive statistics and the Pearson correlation coefficient” (Putnam-Casdorph et al., 2009, p. 253). The descriptive statistic of mean was used for the years of experience and the mean age. Some of the other parts of the demographic section were listed as percentages. The Likert-type scale question results were shown with a mean and a standard deviation listed, as were several of the open-ended questions. The only results shown in a table were the attitude scores of the Likert-type scale questions. These statistics were appropriate to use to obtain these results.The Pearson coefficient was used to analyze several relationships, showing that some variables had no relationship, such as no relationship between attitude, confidence, and experience with advance directive discussions. The Pearson coefficient was also used to show mild to moderate relationships among other variables, like confidence and experience with discussions with patients about advance directives. This was also an appropriate method to use to analyze the relationships between the variables. Overall, the data analysis section is a strong section since it used appropriate methods to describe and analyze the different parts of the data. Study findings. The study findings were separated into five main sections, with each section going into great detail of the results of that section. Other than the demographic section just providing some general information about the nurses who participated in the study, each of the four parts of the research design were addressed in their own sections. Since the information was analyzed using different statistical methods, each section appears to be stated objectively. The study findings, aside from the demographics section, were stated as being “consistent with many of the studies pertaining to advance directive discussions” (Putnam-Casdorph et al., 2009, p. 255). The article also states that “the findings of this study support conclusions from previous research related to educational implications for nurses” (Putnam-Casdorph et al., 2009, p. 255), further indicating that the results of this study are the same as previous studies of the same type. With all of the information provided, this section is a strong section.Study implications and recommendations. This study stated that more nursing education about advance directives is what is needed to help reduce nursing’s negative attitude and lack of confidence in discussing advance directives with their patients. This is consistent with other research that has been done over the last two decades. It states that “the End-of-Life Nursing Education Consortium has provided education in this area for faculty in schools of nursing and healthcare facilities nationwide” (Putnam-Casdorph et al., 2009, p. 255). The implications for nursing knowledge are implied, but for theory and practice they are not. There is a stated recommendation that more research needs to be done to determine what methods will help nurses feel more confident in discussing advance directives. Based on this evidence, this is a strong section.Conclusion. The conclusions of this study are clearly at the end of the paper, stating that nurses need the knowledge and confidence to initiate advance directive planning discussions with patients (Putman-Casdorph et al., 2009). These conclusions were appropriate based on the research done and the results of the data being analyzed. This section is strong.Article 2 - Practice of Expert Critical Care Nurses in Situations of Prognostic Conflict at the End of Life The sample size in this study was small, 21 critical care nurses from seven facilities. The authors’ process of selecting expert nurses indicated that data received would be of the highest clinical quality derived from those determined to be experts in the specific clinical area being studied. The results helped to support and build upon previous studies that were cited within the body of this article (Robichaux & Clark, 2006). The following sections outline a critical appraisal of this study.Purpose and problem. As relayed in the title, and further defined in the text, this study explored the clinical practices of critical care nurses engaged in assisting patients to make informed decisions related to end-of life planning. The problem being addressed was determining the ability of nurses to educate and advocate for patients when nurses felt that aggressive interventions were unwarranted (Robichaux & Clark, 2006). Stated in clear and concise terms, this section was a strong indicator of the validity of this study.Review of literature. A total of 41 references were cited within the text of this study- 18 of which were current within five years and 36 of which were current within 10 years. Thirty-one citations referenced articles found in professional peer reviewed publications directly related to critical care, gerontology, EOL planning and ethical standards. The seven texts cited were related to research design standards as well as analysis practices related to analyzing personal narratives in qualitative analysis. The sources were primarily nursing based but also included perspectives from the medical and psychological sciences. A thorough review of the sources used to support this study indicated a high degree of timeliness and relevance.Theoretical/Conceptual model. This article failed to clearly state the use of any specific theoretical or conceptual model. The lack of specificity in this area did not significantly detract from the value of this study in terms of relevance or quality.Hypothesis and research questions. The hypothesis stated that patient education and advocacy represent characteristics that define professional nurses, however, in the area of end-of life planning as related to interventions judged to be excessive and/or unwarranted by nurses- critical care nurses feel pressure to suppress their desire to educate and advocate by limiting their role in decision making and care planning (Robichaux & Clark, 2006). This hypothesis was clearly stated at the beginning of the article.Research design. The qualitative design of this study was clearly stated. This design was appropriate because it involved study of the subjective feelings that expert nurses had stated during individual interviews. These statements were based on a single introductory statement posed by an interviewer (Robichaux & Clark, 2006).Sample and sampling methods. Prior to being initiated, approval for the study as well as the sampling method was requested and subsequently granted through the American Association of Critical Care Nurses (AACCN). Once approval was granted local representatives of the AACCN were enlisted to help define the characteristics seen in expert nurses in the area being studied. From this definition a peer evaluation took place in member facilities which narrowed the selection of participants to those judged as expert critical care nurses (Robichaux & Clark, 2006). The use of representatives from a nationally recognized professional organization in addition to information obtained from multiple reference texts in order to define and select a relevant sample population made a very strong positive statement about the value of the sample population of expert critical care nurses selected.Data collection methods. Nurses who were selected to contribute to the study were informed of the purpose of the study and were read a standard statement. The statement related to ethical dilemmas faced by nurses in the critical care area when they disagreed with aggressive medical treatment proposed for a patient making end-of-life decisions. Nurses were asked if they experienced similar issues and what they had chosen to do (Robichaux & Clark, 2006). This method of data collection appeared to be less that optimum. Although the expectation would be that responses would be entirely accurate, due to the lack of anonymity and the open face to face style in which the question was posed to study participants, event descriptions may have been altered to portray the participating nurse as a strong patient advocate. Equally possible would be that nurses would fail to state actions taken for fear of liability or retribution from their facility’s medical staff.Instrument. During the interview process the subject expert nurses were read a standard statement concerning situations in which nurses believed that further interventions would not help patients achieve an acceptable quality of life. A question was then posed that asked if the nurse experienced such a dilemma and what was done to resolve the issue. Nurses were then encouraged to reflect and verbalize experiences; these experiences being recorded on audio tape (Robichaux & Clark, 2006).Data analysis. Audio-taped experiences verbalized by study participants were transcribed utilizing professional transcriptionists. These transcripts were compared across all interviews and similarities were obtained by means of division into segments. Segments were obtained by looking for descriptions of personal experiences that had a beginning, middle and end. From these segments three main and 12 sub-themes were derived (Robichaux & Clark, 2006). Further division of themes and sub-themes into individual plots increased focus on similarities and differences between individual responses. These responses were then organized into three repeating plots using established methods cited within the study. The three plots stated by McBride-Robichaux et al Robichaux & Clark were: “protecting or speaking for the patient, presenting a realistic picture, and experiencing resignation and frustration” (2006).Study findings. This study indicated several issues influencing nurses’ actions when dealing with patients facing decisions aimed at increasing quantity of life with no real chance to improve quality. As patient’s transition from treatments meant to cure to those of a palliative nature many nurses feel unsure as to the goal of many treatment choices. The nurses interviewed in this study indicated active involvement in the protection and advocacy of their patients regardless of whether or not their actions influenced patient decisions. Another major finding was that medical providers who were focused on using all available technologies to sustain life often offered significant opposition to nursing objections concerning continuance of treatments with no foreseeable chances for improving patient outcomes (Robichaux & Clark, 2006).Study implications and recommendations. The results of this study implied that there are conflicting views between members of the healthcare team. These views, often polarized in opposite directions, create additional stress and confusion concerning decisions on what is actually best for the patient. Patients are often pulled in different directions with this contradictory information and many opt to select additional therapies that, unbeknownst to them, offer little if any hope for improving their condition. In order to provide patients with correct the information that will help them to understand and make educated end-of-life decisions the study recommends the development of an integrated interdisciplinary model that sets realistic goals based on expected outcomes. The respondents of the study voiced a need for nursing support services to help nurses recognize the differences between curative and palliative care and to support frustrated nurses experiencing perceived ethical issues related to providing moral agency at the bedside versus functioning under organizational economic and political forces (Robichaux & Clark, 2006).Conclusion. This study served to build upon previous nursing studies in the area of ethical dilemmas related to end-of-life patient education and advocacy. As stated in the study: “Critical care units are environments of both promise and uncertainty” (Robichaux & Clark, 2006, p. 281). The results of interviews with expert nurses indicated that the uncertainty of presenting realistic outcomes to patients adds considerable confusion to potential patient education and advocacy efforts. While the central hypothesis was that critical care nurses were limited in their role of assisting patients in end-of-life decision making, the study indicated that many of the expert nurse participants provided pertinent information to patients but felt that outside factors and information often negated their impact (Robichaux & Clark, 2006).This study was performed using well established methods for participant selection and data analysis. Although the sample size was small the views expressed through the interview process were valid, measurable and presented conclusions that were timely and highly relevant to current nursing practices. Certain limitations were observed within the study; most notable was the choice of using only nurses considered as experts as participants. While the information obtained showed how these expert nurses felt it excluded the views of non-expert nurses, thereby limiting the ability to see the bigger picture of day-to-day activities of critical care nurses at all levels of proficiency.Article Three - Promoting Advance Directives Among Elderly Primary Care PatientsWhile this article demonstrates great critique, there are some aspects in the article that are either lacking or missing. Some problems with the study include a bias group of participants, manipulation of the study, and the lack of a theoretical model explaining a need for individuals having an advance directive. At the end of the research study the author’s clearly identified the limits of the study and that there were areas which may have been able to be altered if things had been a little different during the study. A closer look at the critical appraisal of the evidence is presented below. Purpose and problem. The article examines advance directives as a way for patients to have autonomy and reassurance during times when they are unable to make decisions due to health problems (chronic illnesses or traumatic events which have rendered patients unable to make decisions). They state that the “problem with advance directives is many patients wait until they are hospitalized with a serious illness when time may not allow them to state their wishes” (Wissow et al., 2004, p. 944). As stated clearly in the review of the article there were many factors which the researchers were unable to evaluate. This includes what was discussed between the patient and physician during the office visit therefore decreasing some of the validity of the study. The authors were able to present a strong purpose and problem to this article.Review of literature. There were a total of 29 references cited within the text of this article. Of them ten were published within five years of the study while the remaining 19 were published within a ten year time span. Eleven of the cited articles where retrieved from profession peer reviewed journals and three of them were related to geriatrics. There are also seven cited sources which discuss the communication abilities between physicians and patients regarding advance directives. Many of the sources used are in relation to geriatrics and advance directives, as well as physician ability to communicate with patients for the need to have an advance directive on file. Looking through these sources I feel that they do a great job in supporting the study, but the authors would have benefited more from having sources which were less than five years old from the study. This may have helped to develop more relevance and established a better time line for the study, but ultimately they provided a strong review of literature.Theoretical/Conceptual model. This article had no stated theoretical or conceptual model which was stated in the study. This is a weak area for the study since one was not included. Having a theoretical model may have strengthened this article to prove the importance of advance directives.Hypothesis and research questions. The hypothesis for this article was stated clearly within the article. The authors wanted to see “if it was possible to increase the use of advance directives among a socioeconomically heterogeneous group of ambulatory elderly patients” (Wissow et al., 2004, p. 945). They directed part of their study toward physician education on how to discuss advance directives with patients. This area demonstrated a strong hypothesis and research question for this article.Research design. The research design used for this article was a quasi-experimental design. This design was appropriate to the study because the researchers did not have complete control over the experiment. They also used a nonequivalent control group similar to a pretest-posttest design for comparison of the groups. The authors demonstrated strong information on their research design.Sample and sampling methods. In the article the researchers clearly identified the sample and the method of which the obtained the sample groups. The first sample identified was the patient population. This sample was required to meet the three criteria set forth by the researchers. The criteria included 1) age 65 or older, 2) continuously enrolled in the study, and 3) had an ‘extended health maintenance visit’ (a 45 minute screening to cover preventative care and chronic health issues) during the one year study. The second sample that was identified in the study was the physician population. The physicians were staffed at local medical centers which were overseen by the same medical chief. The facilities all together staffed twenty-two internists, two family physicians, and five certified nurse practitioners (Wissow et al., 2004). The article researchers were able to clearly define the sample and the sample methods which were used to establish the population for the study providing the article with strong definition.Data collection methods. Within this article it is clearly stated by the researchers how the data was collected. The researchers used many different ways to collect the data needed for the study. They looked at the computerized medical records of each patient to obtain their demographics, diagnoses, and baseline advance directive status. They then used the “International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10) codes to reflect patient diagnoses at each visit and categorized them by using Expanded Diagnostic Clusters (EDCs)” (Wissow et al., 2004, p. 947). The patient’s EDCs were compiled and divided into two groups: those with three or more chronic conditions and those with fewer than three chronic conditions. The researchers also conducted a brief eight question survey with the physicians involved in the study. This survey was conducted over the phone and the names of the physicians as well as the facilities they practice in were not obtained (Wissow et al., 2004). All the data was collected and then compared by the researchers. This area provided strong evidence for this article.Instrument. This study required the researchers to use different instruments to collect their data. They used the International Statistical Classification of diseases and Related Health Problems, tenth revision to code patient diagnoses. The Expanded Diagnostic Cluster was used to group the acute and chronic conditions together. To help prepare patients for their physician visit, they were all sent a letter which helped to prepare them for the discussion of advance directives (Wissow et al., 2004). Brochures were placed in the waiting areas to allow patients to look at when waiting for their appointment. For the physicians the chief medical director educated them on discussing advance directives with patients. After that the chief then presented the project to the core staff of the physicians practice which allowed them to understand what the study was striving to achieve. A book was given to the physicians who had multiple examples of scripting for them to use also when discussion advance directives with patients in the office. An eight question interview was also used to obtain information from the physicians (Wissow et al., 2004). These instruments aided the researchers in completing their study providing a strong addition to the article. Data analysis. The data for this study was analyzed by the researchers by dividing the groups. The two original groups consisted of those within the intervention group and those within the control group. They used logistic regression models to calculate the estimated equations. The provider was considered to be the clustering variable while the intervention sites where the dummy variables. To see the differences between the intervention sites the researchers divided up the patients into clinics and then within the clinics to their providers (Wissow et al., 2004).Study findings. The study findings were divided up into four different sections. Each section addresses a different part of the research study and the findings of the research conducted. The first section looked at the differences between the intervention and the comparison centers. It examined the types of patients as well as the number of patients with multiple chronic conditions. They also examined the number of patients who were known to have advance directives on file from both centers. In the second sections researchers looked at the patient characteristic that were associated with them creating a new advance directive. The researchers looked at age and gender to see if there was a correlation with those who signed new advance directives. Chronic conditions of patients were also looked at in this section.The third area looked at the overall effect of the intervention. The intervention center had approximately 10.3% of patients sign a new advance directive while the comparison center had 7.8%. Patients at both the locations who were over the age of 75 had a two-fold increase in signing new advance directives. Characteristics of the physicians were also examined and no change was noted in those that were female versus male or of those that held different degrees (Wissow et al., 2004).The final section examined the provider follow-up survey. Around half of the physicians felt that even though more time was added to the visits, they still felt that they did not have the time to discuss advance directives. The physicians questioned who the best individuals were to discuss the advance directives with the patients. The physicians found that they had problems with literacy levels in patients as well as feeling that this was something specialists should discuss with their patients and not them. It was felt though that the written materials were a good addition to patient education (Wissow et al., 2004). This section provided strong evidence in supporting this article.Study implications and recommendations. The researchers included in their article a discussion of the final results and what their recommendations are to try and improve the number of patients with advance directives on file. This section depicts how the study results are similar to other studies performed on this subject. The researchers look as how the study may have limits because of the simplicity of the organization and educational interventions. It was also seen that if this was not a priority to the physician then they did not make it a priority in their exam. Another implication with the study is that the researchers were not allowed into the exam room therefore they do not know what was discussed during that time frame. Recommendations were included to provide more education to physicians as well as provide them with more time during examinations. Providing patients with materials which may be geared more toward their literacy level were also discussed in the recommendations (Wissow et al., 2004). The researchers provided information which made this section strong for the article.Conclusion. The conclusion for this study is clearly stated in the last paragraph of the study. The researchers stated what the overall results of the study were and what could possibly be done to help increase the number of patients with advance directives (Wissow et al., 2004). This section was strong and provided a summary of what was found during the research.Article Four - Factors Associated with Favorable Attitudes Toward End-of-Life Planning Critical appraisal of this study was strong with only a few areas of weakness being identified. Major problems identified were sample size, population representation, and research process identifications were inadequate. Labeling of the purpose, problem, literature review, conceptual model, and research design sections and other sectional elements within the study were unclear or nonexistent. The mixed research processes incorporated both quantitative and qualitative approaches making critical appraisal and related analysis of necessary elements very difficult. Conclusions of the study followed the research processes and provided new applicable information about factors affecting EOL care planning. Study evidence related to research processes is analyzed in the following sections.Purpose and problem. The purpose and problem statements, though not clearly labeled, in the study titled “Factors associated with favorable attitudes towards end-of-life planning” conducted by Ruff, Jacobs, Fernandez, Bowen, and Gerber (2010) were identified within the introduction of the article. Increased complications and spending has been linked to the lack of EOL planning and non-use of palliative services (Ruff et al., 2010). The clearly written problem statement identifies that “little is known and less is understood about which factors affect planning for EOL and decisions about EOL care” (Ruff et al., 2010, p. 177). The purpose of the study and significance to the nursing profession is in order “to optimize the advantages of EOL planning and Hospice services, it is necessary to understand knowledge and opinions on EOL issues among persons who are not yet terminal” (Ruff et al., 2010, p. 177). The population and variable are noted following the purpose and problem statements as “large, ethnically diverse samples with large age ranges” (Ruff et al., 2010, p. 177). This section is strong and elementally inclusive.Review of literature. Within the context of the introduction multiple factors are identified as contributing to attitudes regarding EOL planning. The literature used by the researchers for identifying these factors are noted and cited throughout the paper. There is not a literature review section within this study’s text, yet most sources are identified as previous studies. The cited sources range from the year 2004 to 2009 with all having a direct application to the study research (Ruff et al., 2010). References used for this study are primary sources whose materials are paraphrased, not quoted directly, and can be found in the reference list. These references come from various backgrounds including hospice, social work, palliative nursing, internal medicine, oncology, gerontology, and the social sciences (Ruff et al., 2010). This section appears to be free of citation errors and provides a strong literary background for the conduction of this study. Theoretical/Conceptual model. There is not an identified theoretical or conceptual model used for this study. Generalized conceptual statements referencing the noted phenomenon related to lack of EOL planning within the United States despite proven benefits (Ruff et al., 2010). This section is extremely weak.Hypothesis and research questions. The directional hypothesis for this study is clearly written as “selected sociodemographics, previous knowledge, and experiences with EOL care may influence patients’ EOL planning” (Ruff et al., 2010, p. 177). There is a direct link to the identified study problem. The researchers hypothesize that specific factors influence EOL planning and without insight into these factors we as nurses and medical staff will have difficulty addressing this topic with our patients.Framework for this study is assumed in the introduction section through analysis of previous research studies addressing EOL planning within various populations, socioeconomic statuses, and belief systems (Ruff et al., 2010). This review of previous studies identifies what is known about the topic and what the researchers have identified as the contributing factors with limited research based knowledge. This strength of this section of the study is the in depth analysis of previous study findings for variable identification; such as studies focused on EOL perspectives of black, whites, religious beliefs, marital status, age, disease processes, and application of said variables as predictors for EOL planning (Ruff et al., 2010). The weakness is there is not a clearly identified theory or framework for this study, but rather an implicit framework limiting the study’s contribution to empirical knowledge. Overall this section of the study is strong. Research design. The author does not clearly define the design used for this study. Explanation of purpose, variables, and methods indirectly identify this study as a mixed quantitative descriptive correlational design based on a qualitative grounded theory research format. Critiquing of research design of this study is a difficult task due to the combination of research methods. When analyzing this study from a qualitative approach it appears to have a strong research design due to the detailed explanation of study relevance to nursing, participation selection, sample size determination, data collection and recording processes, efforts to minimize bias, and evaluation of study’s weaknesses, strengths, findings, and recommendations are presented in detail. Using a quantitative approach to critique this section of the study expresses a vaguely defined concept analysis. The purposes of causality for related factor correlations are examined along with analysis of instrument and method validity and weaknesses of study components. Overall analysis of this section is strong. Sample and sampling methods. The sampling method was explained as “an ethnically diverse community-based sample” (Ruff et al., 2010, p. 177). Probable participants were approached while at public venues and the 610 selected met these two identified criterion; 18 years or older in age and reside in either Broward or Miami-Dade counties (Ruff et al., 2010). This convenience sample was taken from the small geographical area of South Florida (Ruff et al., 2010). A monetary incentive of $1.00 US was given to participants for appreciation of their time.The sample characteristics reported from the final sample size of 331 included age ranges from 18 to 84 years, half the population were ages 18 to 49 years of age and the other half from ages 50 to 84 years of age with females comprising 62% of the sample (Ruff et al., 2010). Additional population statistics discussed were marital status, ethnicity, educational level, religious affiliation, annual income, and EOL planning (Ruff et al., 2010). Sampling biases and dropout rates were discussed as well as reasoning behind questionnaire disqualifications. The ample portion of this study is strong despite the sample population not being large enough and not representative of other populations within the United States. Data collection methods. This article explained in detail the data collected by describing the survey used and the numerous parts of the survey. The article states that data was collected over a six month time frame from multiple community venues. It states where the data was collected by listing the state and the two counties that the participants had to live in to be eligible to participate. The article also states that the researchers themselves approached potential participants, explained to and gave them the survey along with a privacy envelope to return in it. The questionnaire used had been previously used and was expanded for this research project. Reliability was confirmed by alpha scores for each of the three main sections. Overall this is a strong section.Instrument. The article describes the different parts of the questionnaire used – a demographic section, a section for participants to rate their feelings about hospice care, and two 5-point Likert-type scale sections for participants about EOL care and communication about death and dying. Each section was described in detail, with sample questions from every section except the demographic section listed. The total number of eligible participants was listed, along with the number who returned the survey, as a total number, not as a percentage. Confidentiality was assured by the researchers thoroughly explaining to the participants to not put any personal identifiers on the surveys and a manila privacy envelope was provided to mail the surveys in. These questionnaire sections were appropriate to use to obtain the desired information, thus making this section a strong section.Data analysis. The data were analyzed using SPSS v.18 software using multiple linear regression models. The article also states that Pearson correlation analyses were used, but showed no intercorrelations among variables. Mean and standard deviation were used for age. Other demographics were shown in percentages. The article has four different tables, one for showing the demographics and one each for showing the results of the regression analyses for the other three sections of the survey. Each table is fully explained in the article as to how the results were tabulated. Each statistic used was an appropriate method for analyzing this data, making this a strong section.Study findings. The study findings were broken into four detailed sections. Each section is clear on what the study findings were and how the researchers analyzed the data to get those findings. The findings were made as statements, not opinions, thus appearing to be objective. Some of the data reinforces the findings of other, similar, previous studies, but new information is also provided from this study. This new information is valuable for nurses, as it suggests what nurses can do to help more patients plan EOL care. This is a strong section.Study implications and recommendations. The strengths of this study were discussed, including comparing this study to previous similar studies while pointing out the differences. The limitations were also discussed in detail, explaining how each limitation weakened the overall study. A summary of the best information obtained from the data in this research project was also listed, stating what factors seem to influence EOL care planning for patients. The researchers recommend improving planning outcomes through increased initiation of EOL discussions with younger and middle aged adults and not just the elderly. The article implied what nurses can do to make patients feel more comfortable in discussing and planning for EOL care. These implications are for nursing practice, but no implications are indicated for nursing education or nursing research. Based on the information provided, this is a strong section.Conclusion. The conclusions for this study stated that nurses should initiate discussions about EOL care and planning with younger or middle-aged patients as opposed to waiting to discuss these options when patients are elderly to achieve better planning for patients. These conclusions are appropriate for the study’s purpose and results found. This is a strong section.How the Evidence is affected by ExperiencesThe authors’ differing fields of nursing provide a widely focused perspective on the research evidence gathered for this paper. Overall, the evidence reviewed aligns with the authors’ nursing experience concerning EOL issues in all populations, including geriatrics: Nurses do have an advocacy role concerning EOL issues and require more knowledge, direction and confidence in this area. The authors of this paper have a wide range of nursing backgrounds. Cheryl works in long term care and case management. Andrea works in critical care, medical surgical and obstetrics. James works as surgical services director. Lisa works in orthopedic surgical nursing. And finally, Holley works in the hospice field. In the authors’ experience in various nursing fields, confusion and misinformation exists with both patients and health professionals concerning EOL planning and implementation. The research evidence supports personal experience. Following are personal perspectives for each nurse’s practice experience.Cheryl’s PerspectiveIn my personal experience I have seen that some nurses are more knowledgeable in this area than others. Most are only generally acquainted with whatever protocol their work policies have set forth for advance directives such as certain forms to fill out or a few questions to ask. I have observed that many patients feel uncomfortable talking about EOL planning and advance directives. I have also observed that many nurses, including myself, sometimes gloss over this issue due to the topic being ambiguous and complicated. I feel that nurses have a unique opportunity to address this subject with their patients due to the more hands on role nurses generally play in health care. The research our group gathered supports my assumption that more knowledge, communication and clear practice guidelines are needed for nurses regarding their role in EOL planning. In my nursing practice I plan to strive for more nursing knowledge in this area. Andrea’s PerspectiveI do not know much about advance directives. Not every patient has them, and when a patient does have one, it seems to hardly ever get followed. Family members or spouses often step in when the patient is unable to voice or express their own opinions anymore and make choices for the patient that are not what the patient wants according to their advance directive. At our hospital, nursing used to ask every patient, on admission, some generic questions about being a DNR or not. A family complained about this and these questions were removed from the nursing admission set of questions, essentially telling me as a nurse that I am not qualified to ask such “delicate” questions. Now the doctors have to address it and it does not get done consistently. If the doctors asked every patient on admission, instead of waiting until the patient gets to a point where the questions need asked, I think it would go smoother for patients, their families, and nurses. I have seen patients go through procedures they did not want because of family choices and I have seen patients hold their ground and say “no more” and die a peaceful death. I applaud these patients for their courage to tell all us “experts” “I have had enough, let me go.” The longer I am a nurse the more I realize the difference between alive and living. I would be happy to have more education on advance directives so if need be, I can be the one to start the discussion about them with patients or families or to have the knowledge to answer questions for patients and families appropriately. James’ PerspectiveAlthough I am not a nurse functioning in the critical care area of my facility, the evidence presented in article two is relevant in my surgical area as well. Occasionally procedures are performed on elderly patients facing end-of life decisions. Some of these procedures, such as repairing fractured hips on elderly patients suffering from severe dementia and who have a DNR status pre-operatively are considered palliative in nature due to issues related to pain. These procedures are accepted by all members of the healthcare team as necessary. Issues related to surgical interventions involving certain elderly patients with known metastatic cancer are another story.Though becoming less frequent- there are still instances when tumors are removed to relieve obstructions or peg-tube placements are performed to provide nutrition to end-of-life patients. Confusion often exists between those measures considered as palliative and those that are curative in nature. If this confusion exists in the minds of healthcare professionals it will most likely also exist in the minds of patients and family members seeking guidance in their end-of-life decision making. When these types of procedures are scheduled the nursing staff may question amongst themselves the reasons for these measures but seldom are those questions posed to patients or medical providers. As stated in the conclusions of the second study presented- there is a need for better communication between all members of the healthcare team as well as collaborative efforts in developing education for staff and patients concerning end-of-life decision making.Lisa’s PerspectiveIn my practice the discussion of advance directives has become a major part of my everyday work experience. Within the last few months we have begun implementing a new system for code status. This system requires the physicians to discuss with patients what they would like to happen in the case of their heart or lungs stopping. This is now an order which goes into our system. On top of this we as nurses are now educated and trained on discussing with the patients who their next of kin is. Because many individuals do not realize who legally their next of kin are they sometimes presume that anyone can make a decision for them in the hospital. Unfortunately this is not the case and the person who is their legal next of kin is truly the one that they do not want making that decision. Between the nursing staff and physicians we discuss with patients the need to create an advance directive. This article relates to my practice since we are required to obtain information and inform patients of the importance of having an advance directive. It shows that it is possible with the right education to be able to properly inform each patient about advance directives and have them create one in case of future complications.Holley’s perspectivePalliative care is a difficult career path to follow in many ways. Hospice Registered Nurse is my current title. Application of evidence in my practice would be extremely beneficial. Educating the community early in life on death, dying, and topics related to planning for care at EOL would substantially decrease common misconceptions, biases, and chaos contributing to the lack of preparation and resource utilization. There are many opinions of hospice care out there in the community, some accurate and many false. The main goal of palliative care from my perspective is support and comfort. Medications are not used to expedite death; they are administered to provide relief from the multitude of symptoms associated with the dying process and chronic illness. In conversation with the community I do not let it be known I am a hospice nurse at first so that I may gain an unbiased insight into the perspectives others have of services offered. On more than one occasion I have heard stories of how hospice “killed” someone they knew. Individuals who have worked directly with palliative care agencies generally have a different opinion. Hands on experience with EOL services, such as hospice, increases knowledge and understanding, which in turn changes perspectives and attitudes towards EOL care. Most of our patients or their families have been directly involved with EOL services in the past and feel a sense of security in knowing we are there for them night and day.Hospice patients come in all ages, races, ethnicities, religions, cultures, and incomes. Those who have prepared in advance and have been educated on the different options for ensuring autonomy at EOL have less anxiety and better family communication at EOL than those who had left these important decisions up in the air. The major conflict I have noted with hospice patients and their families is in reference to life support measures and duration time of aggressive treatments. The use of advance directives, also known as Living Wills, in combination with the designation of a trusted durable power of attorney or health care proxy, which can be a lawyer or someone unrelated, will uphold an individual’s autonomy when they have become unable to make their own decisions regarding medical care. I feel everyone over the age of 18 years should have these documents completed in addition to their Last Will and Testament, which not only designates assets and other items an individual may value, but also a person’s final thoughts, feelings, and explanations. The planning for expiration of one’s life decreases the stress and confusion felt by loved ones when that emotionally exhausting time approaches.The responsibility of making life and death decisions for someone else is a hard thing to do. Medical professionals have an obligation to their patients to provide education and options pertaining to EOL planning. We as nurses get most of the bed-side time with patients and families, which increases comfort and trust, giving us an opportunity to address the patient’s wishes and questions related to EOL planning. Acute care settings are not addressing these issues, even when apparently necessary. Commonly newly admitted patients have conveyed desire for a DNR status. Inquiry has led me to notice the topic is not being addressed during the patient’s stay in various hospitals or other medical care facilities, despite current referral for hospice care.Make RecommendationsThe evidence gathered in this research project indicates a need for nurses to have more education and knowledge needed to provide their patient’s with the tools to begin EOL planning. Public education related to EOL planning needs to be increased. Additional studies need to be conducted to identify factors associated with planning for death, effectiveness of early education, and identification of the medical professional responsibilities for addressing EOL planning with their patients. The evidence found in the four research articles should be utilized in nursing practice because there is clearly a need for more nursing expertise in EOL planning for all populations.Although many nurses are able to easily determine a need for education and nursing input into a patient’s EOL decision making processes- there is often a conflict between nursing and medical opinions- making it difficult for nurses to play a significant role in this process. Further collaborative studies in the area of EOL planning, involving equal input from both medical and nursing specialties, must be performed in order for a more standardized process to be developed. Until all members of the healthcare team share a common, well-defined understanding of the differences between curative and palliative stages of care there will always be confusion in our minds and thus in the minds of our patients. ConclusionThe research we found as a group has pointed to the fact that nurses are, in fact, an important part of EOL planning. Nurses have varying degrees of expertise in this area depending upon their practice focus, experience and knowledge level. Advance directive planning can be a controversial and sensitive topic for patients. Nurses are such an integral part of health care; it is natural that nurses could play an important part in EOL planning. There is a need for nurses to have increased knowledge, better communication and improved multidisciplinary teamwork in EOL planning no matter what the age group.Advance directive planning can be a controversial and sensitive topic for patients. It is important for all ages, not just geriatric patients, to have knowledge for EOL planning due to evidence indicating better outcomes at EOL are observed when individuals have a plan in place and utilize available services. There is a need for nurses to have increased knowledge, better communication and improved multidisciplinary teamwork for effective EOL planning.ReferencesANA. (2010, June 14). Registered nurses’ roles and responsibilities in providing expert care and counseling at the end of life. Retrieved from American Nurses Association website: , K. A. (2009, January). Do-Not-Resuscitate orders in surgery: Decreasing the confusion. Association of Perioperative Registered Nurses Journal, 89(1), 140-150. Retrieved from CINAHL database.Benner, P., Tanner, C. A., Chesla, C. A. (1998). Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. New York, NY: Springer Publishing Co.Candy, B., Holman, A., Leurent, B., Davis, S., & Jones, L. (2010, August 12). Hospice care delivered at home, in nursing homes and in dedicated hospice facilities: A systematic review of quantitative and qualitative evidence. International Journal of Nursing Studies, 48, 121-123. Retrieved from CINAHL database.Kanaskie, M. L. (2011, April). Incorporating cafe design principles into end of life discussions: An innovative method for continuing education. Journal of Continuing Education in Nursing, 42(4), 166-171. doi:10.3928/?00220124-20101001-0Kopp, W., & Hanson, M. A. (2012, March). High-Fidelity and gaming simulations enhance nursing education in end-of-life care. Clinical Simulation in Nursing, 8(3), e97-e102. doi:10.1016/?j.ecns.2010.07.005Krok, J., Dobbs, D., Hyer, K., & Polivka-West, L. (2011, November). Nurse managers’ perspectives of structural and process characteristics related to residents’ advance directives in nursing homes. Applied Nursing Research, 24(4), e45-e50. doi:10.1016/?j.apnr.2010.11.004Lippincott, Williams, & Wilkins. (2012). About the journal. Retrieved from , C. M., Clark, A.P. (2006, September 1). Practice of Expert Critical Care Nurses in Situations of Prognostic Conflict at the End of Life. American Journal of Critical Care, 15(5), 480-491. Retrieved from Putman-Casdorph, H., Drenning, C., Richards, S., & Messenger, K. (2009, July). Advance directives: Evaluation of nurses’ knowledge, attitude, confidence, and experience. Journal of Nursing Care Quality, 24(2), 250-256. doi:10.1097/?NCQ.0b013e318194fd69Ruff, H., Jacobs, R. J., Fernandez, I. M., Bowen, S. G., & Gerber, H. (2010, September 11). Factors associated with favorable attitudes toward end-of-life planning. American Journal of Hospice and Palliative Medicine, 28(3), 176-182. doi: 10.1177/1049909110382770Springer. (2011). Journal of general internal medicine. Springer Science and Business Media. Retrieved from medicine/internal/journal/11606Trossman, S. (2009, March/?April). To sustain life, or not? ANA, nurse experts promote planning for care through advance directives. The American Nurse, 41(2), 1, 6. Retrieved from CINAHL database.Winter, L., & Parks, S. M. (2012, March). The reluctance to burden others as a value in end-of-life decision making: A source of inaccuracy in substituted judgment. Journal of Health Psychology, 17(2), 179-188. doi:10.1177/?1359105311414956Wissow, L.S., Belote, A., Kramer, W., Compton-Phillips, A., Kritzler, R. Weiner, J.P. (2004). Promoting advance directives among elderly primary care patients. Journal of General Internal Medicine, 19, 994-951. doi: 10.1111/j.1525-1497.2004.30117.xPaper #1 Evidence-Based Group Project PaperGrading Criteria30% of grade for paper can be deducted for APA errors including Spelling and grammar after paper graded.HeadingsPossible pointsPointsEarnedCommentsAbstract and Title Page10 10This paper is one to be proud of. Kudos and congrats. dh Introduction(What is the problem or question; Provide support for relevance of the question; Clearly describe the aim of the project & paper)10 10Not much to say except it was a great read, professional and a pleasure to read. A descriptive summary of the most relevant & best evidence to answer the research question (there is not analysis here, just a description of what you found in the literature)20 20That is once I figured out how to edit it!! Not even TAC knew the problem. An analysis of the evidence (this is a critical appraisal of the evidence and what you feel as a group the evidence suggests and whether there is strong or weak evidence to support the suggested findings)20 20 Describe how the evidence is affected by your experiences as nurses, patient preferences, nursing's or other's values and how these factors would influence your decision to utilize the evidence in practice20 20 Make a recommendation as to whether or not to utilize the evidence (support your recommendation with rationale)20 20 APA spelling andGrammar Deductions (can be up to 30% of paper grade ) Total points100 100 ................
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