Nurse managers' perspectives of structural and process characteristics related to residents' advance directives in nursing homes

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Applied Nursing Research 24 (2011) e45–e50www.elsevier.com/locate/apnr

Nurse managers' perspectives of structural and process characteristicsrelated to residents' advance directives in nursing homesJessica Krok, MAa,⁎, Debra Dobbs, PhDa, Kathryn Hyer, PhD, MPPa,

LuMarie Polivka-West, MSPbaUniversity of South Florida, School of Aging Studies and Florida Policy Exchange Center on Aging, Tampa, FL 33612, USA

bFlorida Health Care Association, Tallahassee, FL 32302-1459, USA

Received 27 August 2010; revised 17 November 2010; accepted 30 November 2010

Abstract This article examines associations between nursing home structural and process characteristics and

⁎ Corresponding aE-mail addresses:

(D. Dobbs), khyer@us

0897-1897/$ – see frodoi:10.1016/j.apnr.201

presence of advance directives and trends over 5 years of advance directives in Florida nursinghomes. Our results underscore the importance of nursing homes' processes in facilitating discussionsof nursing home residents' end-of-life care preferences.

Resident-centered care in nursing homes (NHs) isrequired by federal law and industry practice since theimplementation of the Omnibus Budget Reconciliation Actof 1987 (Omnibus Budget Reconciliation Act, 1987). Withthe implementation of the new Minimum Data Set 3.0assessment forms in October 2010, which requires residentinterviews to ascertain preferences, the Centers for Medicareand Medicaid once again assert the importance of resident-centered care for the 1.5 million older adults who live in NHs(Harrington, Carrillo, & Blank, 2009). Another federalmandate that encourages a resident-centered approachspecific to end-of-life (EOL) care is the 1990 Patient Self-Determination Act (PSDA), which requires NHs to informresidents of their rights regarding decisions toward their ownlife-sustaining medical care and ensures these rights arecommunicated by the NH (Greco, Schulman, Lavizzo-Mourey, & Hansen-Flaschen, 1991).

Although the PSDA was enacted nationwide two decadesago, studies on the prevalence of advance care planning(ACP) documents in NHs have indicated great variationregarding the implementation of advance directives (ADs).Prevalence rates of living wills among NH residents havereportedly increased from 20.9% to 21.8%, and do notresuscitate orders have increased from 49.9% to 54.9%

uthor. Tel.: +1 813 974 [email protected] (J. Krok), [email protected] (K. Hyer), [email protected] (L. Polivka-West).

nt matter © 2011 Elsevier Inc. All rights reserved.0.11.004

between 2000 and 2004 (McAuley, Buchanan, Travis,Wang, & Kim, 2006). According to the 2004 NationalNursing Home Survey, of a national representation of1,492,200 NH residents, 271,900 (18.2%) had living willsand 834,500 (55.9%) had do not resuscitate orders (Centersfor Disease Control and Prevention, 2004). Other dataregarding the prevalence of do not resuscitate orders rangefrom 39.4% to 74% among NH residents (Dobalian, 2006).Inconsistencies may be due to differences in study samplesizes, socioeconomic status, and cognitive status.

A key component of resident-centered care for nurses isACP. Given that 30% of all deaths occur in NHs, ACPshould be included in all NH plans of care. Establishing ADsas part of ACP has become an important measure of qualityof care for NHs. ADs consist of written treatment preferencesfor EOL care and delegation of a surrogate decision maker inthe event that an individual cannot make important medicaldecisions for himself or herself. The structure–process–outcome (SPO) model proposed by Donabedian (1966)posits health care quality outcomes result from structuralvariables and processes of care. The SPO model has beenapplied to practices in NHs focusing on how structures andprocesses relate to quality outcomes of care. A recent reviewarticle of the measurement of NH quality provides acomprehensive list of NH quality outcomes, includingreduced pressure ulcers and feeding tubes; medication errorsand medication use; changes in mental, clinical, andfunctional status; infection rates; hospitalization use; staff

e46 J. Krok et al. / Applied Nursing Research 24 (2011) e45–e50

turnover; staffing; and resident and family satisfaction(Castle & Ferguson, 2010). Although these outcomes areimportant, attention also needs to be given to the quality ofEOL care within NHs.

Research regarding the predictors of the likelihood ofhaving ADs has examined individual-level factors such asrace, gender, mental status, religion, and age. Fewer studieshave explored facility-level factors that influence thepercentage of NH residents with ADs. Although quality ofEOL care is a priority in NHs, researchers find inadequateACP including a lack of written ADs among residents, a lackof knowledge about ADs among nurses, and resident andproxy misunderstanding of AD preferences (Allen et al.,2003; Jezewski & Feng, 2007).

First, this study uses Donabedian's SPO model toinvestigate what NH structural and process factors areassociated with the quality outcome of residents with threeADs (living wills, health care surrogates, and do notresuscitate orders). Second, Florida trend data are usedover a 5-year period to examine changes over time in thereported prevalence rates of living wills, health caresurrogates, and do not resuscitate orders of NH residents.The study also reports which specific NH staff members areinvolved in AD discussions with residents. This study isunique to the literature because it is based on the self-reportof directors of nursing, licensed practical nurses, andregistered nurses who are responsible for resident caregiven by the NH staff.

1. Methods

1.1. Sample

This study reports secondary data from an annual surveyof nurses collected by the Florida Health Care Association(FHCA), a state NH association representing approximately90% of all Florida NHs. In 2005, the anonymousrespondents were directors of nursing (63%) and othernurse leaders (37%) including licensed practical nurses (9%)and registered nurses (26%), each representing a Florida NH.The survey was developed by a consensus panel of expertsformed by the FHCA Quality Foundation. Responses fromthe surveys were used to explore the structural and processcharacteristics associated with ADs. This sample was alsoused to examine the specific staff member's level ofinvolvement in ACP. The survey uses identical items sinceits inception in 2002 and is voluntarily completed by nursesattending the conference.

The anonymous participants from 2005 (n = 249), 2006(n = 137), 2007 (n = 119), 2008 (n = 100), and 2009 (n =88) were involved to examine the prevalence of NHresident ADs (living wills, health care surrogates, and donot resuscitate orders) over a 5-year period. The totalsample for the 2005–2009 data included 693 participants.For each year, our response rates were 95%, 62%, 53%,58%, and 57%.

1.2. Measures

1.2.1. Dependent variablesThree quality of care outcomes (ADs) were examined

using the 2005 data. All outcomes are estimates reportedby nurse managers. The first outcome is NHs with low,moderate, and high percentages of residents with livingwills. The second dependent variable is NHs with low,moderate, and high percentages of residents with healthcare surrogates. The third outcome is NHs with low,moderate, and high percentages of residents with do notresuscitate orders. The responses were ordinal, where 1 =less than 20%, 2 = 21%–40%, 3 = 41%–60%, 4 =61%–80%, and 5 = 81%–100%, and then later combinedinto 1 = low (0%–40%), 2 = moderate (41%–60%), and3 = high (61%–100%).

1.2.2. Independent variablesStructural predictors from the 2005 data included NH size

(measured by number of beds), number of deaths in the lastmonth, and NH profit status. We expected both size of theNH and the number of deaths to reflect the NH's exposureand experience with resident deaths. We hypothesize thatlarger NHs and NHs with more deaths would be more likelyto have ACP practices in place, encouraging residents tomake their preferences for ACP known. Studies have shownfor-profit status to influence quality, and we have included itto determine if there are differences in ACP associated withfor-profit status (Castle & Ferguson, 2010).

The response categories for numbers of beds were 50 orless beds, 51–100 beds, 101–150 beds, and more than 151beds, which were given the values of 1, 2, 3, and 4,respectfully, for coding purposes. These were later dichoto-mized to 1 = 0–100 beds and 2 = 101 or more beds. Theresponse categories for the number of deaths were 1 = none toone death per month, 2 = two to three deaths per month,3 = four to five deaths per month, and 4 = five or moredeaths per month. The answers for NH profit status werecoded “for profit” = 2 or “not for profit” = 1.

The process predictors included from the 2005 data arefactors that promote discussion and decision making aboutACP: (a) staff and family involvement in ACP, (b) numberof hospice patients per month, and (c) the presence of ethicscommittees. Staff and family involvement was examined bythe question, “Who is involved in the discussion withresidents about their wishes related to ADs?” Theindividuals considered were the NH's medical director,admissions director, social services, directors of nursing,charge nurse, certified nursing assistant, family members,and clergy. All answers regarding involvement were on ascale that ranged from 1 = never to 5 = always. Theresponse categories for the number of hospice patients caredfor by the NH were 1 = 0–1 patient, 2 = 2–5 patients, 3 =6–10 patients, and 4 = 11 or more patients. The number ofhospice patients per month was included as a processvariable because the presence of hospice and their staff's

Table 12005 and 2005-2009 descriptives

Variables 2005, % or M (SD) 2005–2009, % or M (SD)

StructuralLarge NH (101+ beds) 76.0 76.6For-profit status 57.3 64.2No. of deaths last month 1.99 (1.16) 1.59 (0.60)ProcessIndividual presence during ACP

(scale: 1 = never to 5 = always)Attending physician 3.11 (1.03) 2.98 (1.02)Medical director 3.85 (1.04) 3.83 (1.06)Admission director 3.27 (1.21) 3.34 (1.23)Social services 4.29 (0.61) 4.28 (0.63)Director of nursing 3.26 (0.91) 3.22 (0.92)Charge nurse 3.31 (0.88) 2.32 (0.92)CNA 1.90 (0.94) 1.79 (1.02)Family members 4.54 (0.72) 4.59 (0.77)Clergy 3.16 (0.97) 3.14 (0.98)Presence of ethics committee 39.3 41.4No. of hospice patients (2–5 per month) 47.1 48.2

2005 outcomes Low 0%–40% Moderate 41%–60% High 61%–100%

Living wills 35.0% 39.9% 25.1%Health care surrogate 36.4% 39.5% 24.1%Do not resuscitate order 36.7% 40.6% 22.7%

Note. n = 249 (2005), n = 693 (2005–2009).

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knowledge and skills can sometimes “spill over” to the NHstaff, which can improve facility EOL care practices (Miller& Han, 2008). A greater number of hospice patients are alsoexpected to be related to NHs with processes in place toencourage explicit discussions about ACP.

The final factor analyzed was the presence or absence ofethics committees within the NH. The answers for ethicscommittees were coded 1 = no and 2 = yes. Ethicscommittees are thought to play an important role in theNH related to processes of EOL care. The ethics committeecommonly consists of nurses, a physician, social worker,

Table 2Multinomial logistic regression analyses between variables and percentages with l

Predictors b M

Living willsSocial services presence during ACP 0.89 1Hospice patients cared for per month 0.44 1Health care surrogateFamily presence during ACP 0.80 1Charge nurse presence during ACP – –Do not resuscitate orderCharge nurse presence during ACP 0.52 1Family presence during ACP 0.78 1Medical director presence during ACP – –Social services presence during ACP – –

Note. Based on reference group 0%–40% of residents with living wills, health careOR = odds ratio.

⁎ p b .05.⁎⁎ p b .01.⁎⁎⁎ p b .001.

administrator, lawyers, family members, and an ethicist andother lay community members. Their main functions consistof policy development, education, consultation, case review,and aiding in decision-making processes related to terminalillness and assistance with living wills. NHs with ethicscommittees are predicted to have more processes in place toencourage ACP.

1.2.3. Statistical analysisAll analyses were performed using SPSS version 18.0.

Descriptive analyses were conducted to check for missing

iving wills, health care surrogates, or do not resuscitate orders (2005 data)

oderate, OR (SE) b High, OR (SE)

.49 (1.63)⁎⁎⁎ – –

.86 (0.89)⁎⁎⁎ 0.93 1.93 (0.81)⁎⁎⁎

.65 (0.21)⁎ – n.s.0.58 1.28(0.94)

.94 (0.47)⁎⁎ – –

.53(0.79)⁎⁎⁎ 1.21 1.98 (0.77)0.27 0.53 (0.39)⁎

0.98 1.06 (0.57)⁎

surrogates, or do not resuscitate orders. Model: Nagelkerke R2 = .46, p = .03.

e48 J. Krok et al. / Applied Nursing Research 24 (2011) e45–e50

values and outliers. All descriptive findings for the 2005sample are reported in Table 1. Pearson's correlations at p b.05 and p b .01 levels were conducted to determine aparsimonious model (p b .05). From those variables found tobe significant, multinomial logistic regression analyses wereconducted to identify which characteristics were associatedwith NH moderate (41%–60%) or high (61%–100%)percentages of residents with ADs, with the low percentages(0%–40%) as the reference group.

Descriptive analyses were conducted to check for missingvalues and outliers in the 2005–2009 data. All descriptivefindings for the combined 2005–2009 sample are reported inTable 2. Paired t tests (p b .05) were computed to determinewhether there was a significant change between 2005 and2009. General linear modeling was conducted to determineany significant trends from 2005 through 2009 regarding theprevalence of NH resident living wills, health caresurrogates, and do not resuscitate orders.

100

80

60

40

20

02005 2006 2007 2008 2009

Per

cent

age

of A

dvan

ce D

irec

tive

s

Living Wills Health CareSurrogate

DNRO

Fig. 1. Univariate analysis of variance of resident living wills, health caresurrogates, and do not resuscitate orders from 2005 to 2009.

2. Results

2.1. Descriptives

Table 1 provides descriptive statistics on the 2005 SPOvariables used in the analyses. The NHs represented by thenurse leaders were typical of Florida NHs using OSCARdata with regard to size and profit status (χ2 = 13.49, p =.14); 76% had more than 101 beds and 58% were for-profitstatus. Family members (M = 4.54, SD = 0.72) were mostcommonly involved in the discussion with residents abouttheir wishes related to ADs. Of the NH staff, social services(M = 4.29, SD = 0.61) and medical directors (M = 3.85, SD =1.04) had the highest level of ADs involvement; leastinvolved in discussions were certified nursing assistants (M= 1.70, SD = 1.02). The certified nursing assistant and thedirectors of nursing reported similar levels of involvementwith these discussions but were less involved than medicaldirectors (M = 3.31 compared to 3.26). Thirty-nine percent offacilities were reported to have an in-house ethics committee.Close to half of the facilities (47%) responded that they hadtwo to five hospice patients per month.

The average percentage of NH residents with a living willwas reported by nurse managers as 42.4%, 42.1% for healthcare surrogates, and 41.5% for do not resuscitate orders. Thepercentages of NHs with low, moderate, or high percentagesof residents with ADs were almost distributed equally withslightly larger percentages in the lowest and moderatepercentage groups of ADs.

Table 2 provides descriptive statistics on the combined2005–2009 data. The trend data are very similar to the 2005descriptive findings with the exception that the chargenurse's involvement in ACP discussions reportedly onaverage decreased. The NHs represented by the nurseleaders were typical of Florida NHs; 76.6% had more than101 beds and 64.2% were for-profit status. Familyinvolvement was reportedly high (M = 4.59, SD = 0.72).

Of the NH staff, social services (M = 4.28, SD = 0.63) andmedical directors (M = 3.83, SD = 1.06) were mostcommonly present during advanced care planning, andcertified nursing assistants were the least commonly presentstaff members (M = 1.79, SD = 1.02). With regard to nurseinvolvement, as expected, directors of nursing had an aboveaverage mean score for involvement (M = 3.22, SD = 0.92)compared with charge nurses (M = 2.32, SD = 0.92). Forty-one percent of the nurse leaders reported having an in-houseethics committee, and 48% responded that they had two tofive hospice patients per month.

2.2. Multinomial logistic regression

Table 2 presents the findings for the three logisticregression models from the 2005 data. The involvement offamily members, social service, charge nurses, and medicaldirectors increased the probability of being in the category ofmoderate and high percentages of residents with a livingwill, health care surrogate, and do not resuscitate order. Thenumber of hospice patients per month also proved to be asignificant predictor of being in the category of moderatepercentages of living wills (b = 0.44, p b .001).

2.3. General linear modeling

Fig. 1 illustrates the trends of NH resident living wills,health care surrogate, and do not resuscitate orders from2005 through 2009. The models for change over time forliving wills, health care surrogates, and do not resuscitateorders were found to be significant F(1, 4) = 18.55, p b .001;F(1, 4) = 15.15, p b .001; F(1, 4) = 13.44, p b .001. Post hoctests found a significant difference between 2005 and 2006data and the 2007 through 2009 data. Overall, there was anincrease in ADs from 2005 to 2009, with significantincreases between 2006 and 2007.

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3. Discussion

This study provides information about the prevalence ofliving wills, health care surrogates, and do not resuscitateorders in NHs in Florida from the perspective of nursemanagers. The 2005 through 2009 data demonstrated asignificant increase in the reported prevalence of ADs amongNH residents, which is consistent with the increasedprevalence of NHs as a site of death. Sometimes, a triggeringevent can explain trend increases. The triggering event thatcould potentially explain the significant increases between2005 and 2006 in Florida NHs is the well-publicized case ofTerri Schiavo, a Florida resident who did not have ADs inplace prior to the loss of her individual decision-makingcapability. Terri's Law, which allowed the governor toprevent the withdrawal of artificial hydration and feeding if apatient does not have a written AD, was initially passed butthen later found unconstitutional on appeal in 2005. Thelegal battle that pursued all the way to the federal courtsystem had a lasting effect on the discourse of the importanceof completing ADs, particularly in the state of Florida.However, both the increase in the prevalence of ADs in NHsand the increasing prevalence of NHs as the site of death fortheir resident population continue beyond the Schiavo case.Both trends are also consistent with the federal mandates thatrequire an emphasis on resident-centered care.

Table 2 presents the findings for the three logisticregression models from the 2005 data. The involvement offamily members, social service, charge nurses, and medicaldirectors increased the probability of being in the category ofmoderate and high percentages of residents with a livingwill, health care surrogate, and do not resuscitate order. Thenumber of hospice patients per month also proved to be asignificant predictor of being in the category of moderatepercentages of living wills (b = 0.44, p b .001).

The finding related to family involvement in residentdecisions about ADs is consistent with other research,particularly because a majority of the NH population havecognitive impairments that prevent them from making theirown decisions (Osman & Becker 2004). The findings aboutthe NH staff involvement have implications for which staffto target and include in an interdisciplinary team (IDT) forpalliative care staff training interventions. The IDT model isbased on different disciplines assessing and planning carecollaboratively with shared leadership and role overlap(Fulmer, Flaherty, & Hyer, 2003). The value of IDT isreiterated in research, affirming its value in communication,information sharing, shared decision making, and acknowl-edgement of residents' treatment preferences. The improvedinformation sharing and decision making results in lessaggressive interventions and less suffering for loved ones inNHs. Researchers may want to target those who are mostinvolved in ACP, such as the social service director, thecharge nurse, and the medical director. The trend dataindicate decreased involvement over time by the chargenurse, whereas the directors of nursing involvement

remained stable over time. The nursing staff division oflabor and resources for involvement in resident ACPdiscussions should be assessed in light of these findingsand the fact that there was an association between chargenurse involvement and higher percentages of ADs.

Although involvement in ACP discussions by parapro-fessional staff (e.g., Certified Nursing Assistant) was notsignificant, finding ways to increase engagement in the ACPprocess among paraprofessional staff should be considered.Paraprofessional staff are responsible for monitoring thedaily care of residents and are well positioned to alert socialservice and nursing staff about changes in resident status,pain, anxiety, and preferences for palliative care (Roscoe &Hyer, 2008).

The number of hospice patients was shown to be asignificant predictor of higher percentages of residents withADs. As shown in previous research, collaboration betweenhospice staff and NH staff may lead to more effectiveassessment and treatment for nonhospice NH residentsbecause hospice staff's knowledge, skills, and strategies mayspill over to the NH staff (Miller & Han, 2008). Hospicecollaborates with the IDT in NHs and is known to provide aneducational component about the importance of documen-tation of ADs because it is a central component ofcomprehensive EOL care. The collaboration betweenhospice and IDTs has been shown to result in NHs beingmore equipped to address the growing need for competent,coordinated, compassionate, and comprehensive EOL care(Miller & Han, 2008).

This study examines the presence of ADs, a necessarystep to identify resident's EOL preferences. Honoring ADsand achieving a good death are optimal goals for NHs,residents, and their families. Prior studies identify thediffering opinions regarding EOL treatment between resi-dents, families, and clinicians (Winter, Parks, & Diamond,2010). These varying opinions for treatment can create acomplex and burdensome task for the health care surrogate.

For those older adults who have already documentedEOL preferences, their preferences should be reviewed andunderstood by the staff, family, and resident in light of theNH admission. As evidenced in this study's results,directors of nursing should encourage care processes topromote the discussion of treatment preferences. Our studysupports the involvement of an IDT with family members inACP as a necessary first step to the adherence of EOLtreatment preferences of NH residents. However, ADpresence also does not ensure adherence to these preferences(Winter et al., 2010).

There are some notable limitations of this study. Becausethis is an anonymous survey of nurse managers, we do notknow the specific facility of the responder and are thereforelimited in the structural factors that can be included in theSPO model. For example, hours of staffing per day andresident case mix are commonly included as structuralfactors in NH studies. However, because our study includesthe presence or absence of specific staff (medical director,

e50 J. Krok et al. / Applied Nursing Research 24 (2011) e45–e50

social service) involvement in AD discussions as processvariables, it is potentially more explanatory than the merecounting of staffing levels. As Castle and Ferguson (2010),in a review of quality of NH care, contends, “staffing levelsare viewed as extremely important, but how staff are used(i.e., process) may be just as inherently linked to quality.”Thus, our study reports on process of ACP in NHs. Thisstudy is also limited because it is based on the estimatedreports from nurse managers and not actual resident chart,thus limiting the precision of the reported data. However,other published research also uses nurse's report forprevalence of ADs in NH and assisted living communities(Daaleman et al., 2009). A future validation study on arandomly selected sample of some of the same NHs usingchart review to compare the prevalence rates of what wasreported from the nurse managers will enable us to validatethis particular method of data collection. Finally, becausethis is a survey of Florida NHs, the results are limited in theirgeneralizability to other states. However, AD research inFlorida NHs has a number of strengths. Florida has a largepercentage of elders and more than 650 NHs with 70,000 NHbeds, ranking it as the sixth largest state for NH beds.Because Florida initiated a moratorium on new NH beds in2001, Florida's occupancy rate of 87.8% during this period ishigher than the national average of 85.4%, and the acuity ofresidents is also higher, decreasing the likelihood that fraillong-term residents are able to live outside the NH(Harrington et al., 2009). Florida maintains a certificate ofneed to establish new hospice programs. The desire to fendoff other hospice competitors has created large hospices thatare generally well integrated with NHs. Consequently, thepractices of nurse leaders in Florida NHs with regard to ACPand meeting residents' wishes are likely to reflect significantfindings that are important to disseminate as other states facean aging population.

4. Conclusion

This study assessed structural (NH size, profit status,number of deaths) and process (specific staff involvementin AD discussions with the resident ethics committees)variables associated with the EOL quality outcomes(estimated percentages of residents in NHs with livingwills, health care surrogates, or do not resuscitate orders) asreported by nurses in Florida NHs. This study offersspecific process characteristics that can potentially appear toinfluence the percentages of residents likely to have ADs.

Trends of residents' ADs over time are reported. ACP is achallenge for NHs requiring an interdisciplinary staff,family presence, and communication with residents withregard to their wishes. This research underscores theimportance of NH processes in facilitating the discussionof NH residents' wishes.

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