1. Nurs 324 Evidence based practice group presentation
Presented by Angela Baird and Jennifer Totten

2. Introduction:
This presentation in on the use of the Peaceful End of Life (EOL) Theory within evidence based practice. This theory is new and continues to need further research to refine and improve it, but we will show how this theory has been used within nursing research. We will do this by presenting two research studies that utilized the theory as the framework to conduct the research.

3. Description of Theory:
The Peaceful End of Life (EOL) theory was developed by Cornelia M. Ruland and Shirley M. Moore. It was one of the first to be developed using standards of practice and was written by a team of experienced nurses on a gastroenterological floor where many patients were diagnosed with cancer . It is primarily based on the Donabedians model of structure, process, and outcomes (Tomey & Alligood).

4. Description con’t:
They identified a need for clinical guidance in taking care of these patients and giving them quality care. This resulted in the development of the theory for the Peaceful EOL by Ruland and Moore (Ruland and Moore 1998).

5. Description of Theory con’t:
The Peaceful EOL theory is structured around the family setting and includes the terminally ill patient and significant others that receive care from healthcare professionals. The process if defined by nursing interventions that promote positive patient/family outcomes. These outcomes are being free from pain, experiencing comfort, having dignity and respect, being at peace and being close to significant others and those who care (Tomey & Alligood 2006).

6. management (Ruland and Moore 1998).
Description con’t:
The focus was not on dying in itself but on peaceful and meaningful living during the final days that remained for the patients, significant others, and family members. It also reflected the complexity that is involved with taking care of the terminally ill patient and the need to have knowledge on pain relief and symptom
management (Ruland and Moore 1998).

7. Rationale for use of the Peaceful eol theory:
The reasons for choosing this theory for us was based on our current positions within nursing practice. We currently have positions that benefit from the understanding and use of this theory. With researching this theory we now have guidance and a resource to help care for patients and their families and give them the best experience for a peaceful end of life.

8. Research studies:
Practice areas/topics that have been studied using this theoretical framework/theorist work.
Critical Care units-Nurses are vital to end of life care and Critical Care nurses encounter death and dying every day. They provide patients and their families with end of life care and many feel responsible to provide them with the care that leads to a peaceful end of life (Kirchoff & Beckstrand 2000).

9. Research studies con’t:
Gastroenterological care unit-The Peaceful EOL theory was developed from the standard of care of peaceful end of life. The standard of care was developed by a experienced group of nurses in Norway. This was on a gastroenterological unit where half of the patients were diagnosed with cancer and dealing with terminal illness was on a daily basis (Ruland and Moore 1998).

10. Research studies con’t:
In one review article the Peaceful EOL theory was referred to the development of practice standard as a foundation for developing theory (Liehr & Smith1999).
In a second review by Baggs & Schmidt they discuss potential usefulness of the Peaceful EOL theory as a tool to improve end of life decision making for the critically ill adults.

11. Research Findings:
The next slides will discuss and show the research findings of research articles utilizing the Peaceful EOL theory as the framework

12. Research Findings con’t:
Critical Care Nurses’ Perceptions of End-Of- Life Care
Written by Lynn Anne Orser
August 2007
“The object of the study was to measure and describe critical care nurses’ perceptions of the intensity and frequency of the occurrence of obstacles and supportive behaviors that affect the provision of end-of-life care in critical care units” (Orser p.34).

13. Research Findings con’t:
The study was done by surveying those who had attended a local meeting of a local chapter of American Association of Critical Care Nurses. There was a total of 89 members who attended the meeting and those who were eligible was asked to take a survey packet and fill out prior to leaving the meeting. The survey took 20 minutes to complete and was a questionnaire by the name National Survey of Critical Care Nurses Regarding End-of-Life Care. The questionnaire included a list of obstacles and facilitators to end-of-life care. The participates were asked to respond to these questions by answering with a 0-5 response. 57 usable surveys were included in the study for a response rate of 71.29% (Orser 2008).

14. Research findings con’t:
Results of the study identified top obstacles of behaviors that nurses have no control over which were related to physicians and families. Supportive behaviors were identified as those that nurses had control over such as providing support to the patient and family (Orser 2007).

15. Research findings con’t:
Top rated obstacles :
Frequent call by family and friends of the critically ill patient. Nurses find these call frustrating as they remove them from the patients bedside and they are unable to provide care during these times.
Family members who do not understand the meaning of live-saving measures.
Communication among the family, patient and healthcare team. These could include physicians who are evasive and avoid conversations with the family and physicians who are overly optimistic (Orser 2007).

16. Research findings con’t:
Supportive behaviors:
Providing support to the dying patient and family.
Supporting the family after the death of the patient.
Providing a peaceful, dignified bedside scene and allowing the family adequate time to be alone with the patient after death.
Allowing the family to be close to the dying patient.
Teaching the family how to act around the dying patient.
Having all physicians agree on the direction of the care of the dying patient (Orser 2007).

17. Critique of The research:
Limitations of the Critical Care nurse study include:
Low response rate of those eligible to participate in the study which leads to a limit of the generalization of findings.
Biases from the nurses participating due to them attending a professional meeting and the investigator being a member of the local nursing organization.
Attendees may have answered the questionnaire to please the investigator.
Sample of nurses was not large enough to allow correlation of study results based on variations of demographic data (Orser 2007).

18. Critique con’T:
Another limitation to the Critical Care Nurse study is that there was nothing documented that took into account the different cultures and religions that encompass patients and nurses giving them appropriate end-of-life care depending on what their particular religion or culture was.

19. Research findings con’t:
Another study was performed to identify end of life care in intensive care units. Information was obtained by interviewing nurses in four focus groups from various hospitals. All of the participants were registered nurses who had two to twenty-two years of experience working in the ICU and all had previous nursing experience in other areas of nursing.

20. Research findings con’t:
The tools used were an ICU Nursing Questionnaire that addressed demographics such as years of experience in the field, age, sex, and experience with death, and a Focus Group for ICU Nurses Guide which addressed specific issues relating to end of life care, the challenges they have had in this area, and areas needing improvement (Kirchhoff, Psuhler, Walker, Hutton, Cole & Clemmer 2008).

21. Research findings con’t:
The results of the research showed that the nurses involved described good end of life care that closely followed the Peaceful End of Life Theory concepts proposed by Ruland and Moore. It identified main barriers to this care including difficulty identifying when to transition from curative to palliative care, communication between patients, their families and their physicians as well as mixed messages between various physicians, and lack of resources such as social services and chaplain.

22. Critique of the research:
Limitations of the research included different breadth of responses from different nurses, some have very little input while other had a lot to add, and the study only including nurses instead of a whole team approach with physicians, social workers, and input from families or patients (who might have received some end of life care but survived) (Kirchhoff, Psuhler, Walker, Hutton, Cole & Clemmer 2008).

23. Implications for practice:
Findings from the studies show that end-of-life care can be improved and are:
Improving staffing patterns
Improving communication between family and healthcare team
Educating family on interventions and treatments used in critical care units
Initiation of palliative care early in the ICU setting.
Supporting the nurse who participated in the emotional experience of providing end-of-life care (Orser 2007).

24. Description of how theory framed the research
Within the research studies the Peaceful EOL theory is a framework to the studies by supporting the obstacles and supportive behaviors. The questionnaire itself had many questions related to the outcomes of the theory and many of the obstacles and supportive behaviors identified were also based on the five outcomes of the Peaceful EOL theory. These outcomes include, no pain, experiencing comfort, dignity and respect, the patient being at peace and the patient experiencing closeness to significant others

25. Critical reflection:
With the major amount of information to be processed by nurses in any given day at work, theories serve as a reference for nurses to understand and organize their patient care. It also provides for a useful means of reasoning, critical thinking, and decision making in nursing practice. It gives the very reason why we do what we do and how we take care of patients. Since starting this class a lot of the theories are utilized in nursing practice without even knowing it. It has been an exciting journey to see all of these theories and where they fit into our nursing practice.

26. references:
Baggs, J.G. & Schmitt, M.H. (2000). End of life decisions in adult intensive care: current research base 158 and directions for the future. Nursing Outlook, 48(4), Kirchhoff, K.T., Psuhler, V., Walker, L., Hutton, A., Cole, B. & Clemmer, T. (2008). Intensive care nurses experience with end of life care. American Association of Critical Care. Retrieved April 12, 2009 fromhttp://classic.aacn.org. Liehr, P. & Smith, M.J. (1999). Middle range theory: spinning research and practice to create knowledge for the new millennium. ANS Advances in Nursing Science, 21(4), Orser, L. (2007). Critical care nurses’ perceptions of end-of-life care. Pp Ruland, C.& Moore, S. (1998).Theory Construction Based on Standards of Care: A Proposed Theory of the Peaceful End of Life. Nursing Outlook, 1998, 46 (4), p Tomey, A. & Alligood, M.(2006). Middle range theories: Peaceful end of life theory. Nursing Theorists and Their Work, (pp ). Missouri: Mosby.