title: Knowledge, attitudes, experiences, and confidence of nurses in completing advance directives: a systematic synthesis of three studies.
abstract: BACKGROUND
  Advance directives (ADs) are one of the few means for patients to indicate their end-of-life (EOL) treatment option preference. An effective and consistent solution for increasing the AD completion rate remains elusive. A literature search revealed three studies completed in the United States that employed an identical methodology and focused on registered nurses (RNs). These studies examined a variety of concepts, including nurses' knowledge, attitudes, experience, and confidence with regard to ADs.
  
  
  OBJECTIVE
  This review completed a systematic synthesis of reported results from three survey studies that focused, respectively, on oncology, critical care, and emergency RNs who were members of various professional nursing organizations.
  
  
  METHODS
  Our investigation addressed the following research questions: What are the knowledge, attitudes, experience, and confidence of RNs with regard to ADs, and what is the relationship among these study variables? Each study used the Knowledge, Attitudes, and Experiential Survey on Advance Directives Instrument to obtain findings.
  
  
  RESULTS
  Findings indicated that level of knowledge of nurses was about 60% correct and that nurses reported a moderate level of confidence related to ADs. Nurses stated they were experienced in AD discussions and agreed with attitude statements indicating support of ADs. Advocacy was a theme in the findings of these studies, as most nurses agreed with the statement that nurses should uphold patients' wishes. Time was identified as an impediment to AD completion. Critical care nurses had higher levels of awareness of ADs, as compared with oncology and emergency room nurses, although the cause of this difference is unclear. Although RNs provided AD education and explanations and described the various types of EOL care, these study subjects suggested that discussions of patients' prognoses may be an intervention more appropriate for nurses or other clinicians with advanced education and training. CONCLUSION/LIMITATIONS: The low Cronbach's alpha values in the attitude scales within the survey instrument posed limitations in the original research on the use of attitude scale scores in statistical analysis. The data examined in this study was obtained from published reports, which limited the synthesis and analysis of study findings. Nurses need to refine their role in AD discussions with patients. End-of-life discussions should be an interwoven process between RNs and the multidisciplinary team.
authors.affiliation: Graduate Program Director, Daemen College, Amherst, New York, USA. dryan@daemen.edu
authors.forename: Diane
authors.initials: D
authors.lastname: Ryan
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: Jezewski
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000523:psychology*; D000368:Aged; D002983:Clinical Competence / Q000706:statistics & numerical data; D003422:Critical Care / Q000592:standards; D016529:Emergency Nursing / Q000193:education / Q000706:statistics & numerical data; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D017533:Marital Status; D008875:Middle Aged; D015404:Nursing Methodology Research; D009741:Nursing Staff, Hospital / Q000193:education / Q000523:psychology* / Q000706:statistics & numerical data; D009859:Oncology Nursing / Q000193:education / Q000706:statistics & numerical data; D011594:Psychometrics; D012044:Regression Analysis; D014481:United States