Nurse-Led Education Program Leads to Threefold Increase in ACP Documentation

Designing an ACP Education Intervention

The nursing team leading the quality improvement project (https://doi.org/10.1188/23.CJON.27-32) included ONS members Anne Feaster, DNP, ANP-BC, CRNP, and Janine Overcash, PhD, APRN-CNP, FAANP, FAAN. They identified a need to increase ACP discussions and documentation to meet the Centers for Medicare and Medicaid Services (CMS) Merit-Based Incentive Payment System core quality measure, reduce unnecessary hospitalizations, and lower costs of care.

They conducted a literature review to identify evidence-based strategies to increase ACP documentation, such as:

• Implementing ACP processes, policies, and procedures; workflow designs; technical support; and infrastructure
• Educating healthcare staff about the importance of, CMS requirements for, and procedures for documentation

They created and implemented a multimodal education intervention centered around the second evidence-based strategy that included information on ACP documentation and elements, including do-not-resuscitate orders, healthcare powers of attorney, and living wills.

Specifically, the nursing education program consisted of (https://doi.org/10.1188/23.CJON.27-32):

• Watching ONS’s ACP video (https://www.ons.org/videos/advance-care-planning-video) and reviewing their institution’s ACP policy and procedures
• Attending a 10-minute narrated presentation that described the project and its relevance to nursing
• Participating in 10- to 20-minute small group meetings to review the educational material

After the training, nurses received ongoing updates and educational reminders through emails, nursing huddles, and face-to-face individual communication.

Measuring the Results

The implementation team compared 103 electronic health records preintervention to 114 postintervention and found that ACP documentation increased (https://doi.org/10.1188/23.CJON.27-32) from 0% to 63% between the two time points. Nurses’ mean self-reported comfort level scores on the Kolcaba Advance Directives Comfort Questionnaire grew from 226.2 preintervention to 240.4 postintervention (p = 0.14; Cohen’s d = 1.12). “Although results were not statistically significant, the increase in mean and median scores, as well as the large clinical effect size, indicate a clinically significant postintervention improvement in nurses’ comfort with discussing ACP with patients,” the authors wrote (https://doi.org/10.1188/23.CJON.27-32).

The nursing implementation team specifically pointed to the merits of the multimodal education approach. “Nurses reported that the evidence-based learning strategies of role-play, videos, case discussion, and supervised clinical practice used in this project were effective and enjoyable,” they wrote (https://doi.org/10.1188/23.CJON.27-32). “Strategies like role-play and group discussion can enhance comfort in clinical nursing situations because learners report feeling more comfortable asking difficult questions and addressing sensitive situations.”

Learn more about the education intervention by reading the full Clinical Journal of Oncology Nursing article (https://doi.org/10.1188/23.CJON.27-32). You can also earn 1.0 free NCPD contact hours by completing the evaluation after reading the full article.