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A Research Proposal: Staff Attitudes to POLST

Introduction

The proposed research study will critically analyze the attitude of staff towards physician orders for life-sustaining treatment (POLST), which is a program to elicit and honour the treatment goals of people with advanced progressive illness (Tolle et al., 1998). Additionally, despite there being a comprehensive policy in place regarding it use and the evidence base of its effectiveness in communicating so much more the study seek to examine possible barriers to implementing this tool as it was designed. More importantly, the study will also seek to come up with recommendation on how to overcome these barriers.

It is worth noting that the physician orders for life-sustaining treatment (POLST) is a program to elicit and honour the treatment goals of people with advanced progressive illness. It is a tool for translating patients’ goals of care into medical orders in a highly visible, portable way. Healthcare professionals discuss with seriously ill patients (or their surrogates) the available treatment options in light of their current condition, and help clarify the patient’s preferences. The clinicians must document those preferences on a standardized medical order form and ensure that it is travels with the individual if he or she changes settings of care. It differs from other health care directive in that is it is an actionable medical order dealing with the here and now needs and preferences of patients (Meyers et al., 2004). Ideally it is important to remember that the program was developed to go beyond the limited scope of the various traditional approaches for instance a living will and do not resuscitate order. Additionally, it offers a great deal of flexibility as well as control to very ill persons (Tolle et al., 1998). The main advantages associated with the program is that it offers sick individuals in consultation with their physicians to predefine the exact types of medications that the patient will receive in future even if the individual is unable to effectively communicate (Lynn, 2002).

The proposed study has a lot of relevance to my interests as a nursing student as well as the whole healthcare sector. As a nursing student, I am interested to know the attitude held by staff towards this program (POLST). It is also of interest to me and the entire health care sector establish why despite there being a comprehensive policy in place regarding it use, the tool is not being used as it was designed for.

Problem statement

It is no doubt that every country and for that matter every state in the United States of America is striving to ensure that their citizens are provided with high standard medical care. This has been purely based on the concept of a healthy nation is a rich nation. It is worth noting that this can be and has been attained through hundred if not thousands of program (Lynn, 2002). One such program has been the POLST which was developed with the sole purpose of ensuring that the patients’ wishes concerning a range of end-of-life treatment are identified and respected. Ideally the program has helped provide very clear instruction about the preference of treatment a patient would need, helps prevent unwanted hospitalization, help prevent unwanted resuscitation by EMS as well as act as a helpful mechanism for initiating conversation between the patient and the doctors with regards to treatment preferences (Meyers et al., 2004). It is important to remember that various studies have evaluated the effectiveness of this program and the findings have been amazing. Additionally, a substantial amount of efforts have been put in studying the implementation of the program in different settings. This has provided policy makers with important information on how to adjust the program to fit various scenarios.

However, it is important to remember that in all these studies no or very little efforts have been directed towards establishing the attitude held by medical and healthcare staff towards this program. I understand that the values, attitude, beliefs and perception held against such an important program will usually impact on its outcome. This thus forms the basis of this study; establishing the attitudes held by staff towards POLST program.

Justification of the study

The research (study) is of a lot of importance as it will evaluate the attitude of medical staff members on POLST program which is used by patients to guarantee them sound treatment in situation where they cannot even communicate. Additionally, the study will bring to light the major reasons why the POLST program is not being implemented as it was designed despite there being guiding and comprehensive policy on its application. It is a fact that the views, attitudes and perceptions of users of a given program ultimately affect the end results (Meyers et al., 2004). For this reason, the study is of importance since it will ensure that issues of concern are addressed and made known. There is no doubt that the findings will be of importance to various stakeholders such as the employees in medical and healthcare sector, patients and their family members, the government, Non-governmental Organization, employers, managers, scholars, as well as varied kind of organizations such as schools as it will be an eye opener to all these group of individuals.

It is worth noting that the findings of this study will call for measures to be taken by not only the healthcare and medical fraternity but also by the government and other interested and affected stakeholders in trying to boost the positive attitudes held by staff as well as derive ways of developing new strategies that will help reverse negative attitudes if indeed the same is being held by staff. Similarly plans will be put underway to ensure that the program is implemented as it was designed or some slight adjustments be made so that it fits the situation at hand. This will ensure better results for thousands of patients during acute setting. It is worth noting that the measures if well exercised and effectively implemented will ensure that health sector organization will have staff members who have a positive attitude towards POLST program hence a better outcome for patients (Hickman, 2004).

Not carrying out this research will clearly depict that the attitudes held by the medical staff towards POLST program will remain unknown. Additionally, the reasons why the program is not implemented as it was designed despite there being a comprehensive policy on how it should be done will only remain a mystery. On the same note, the benefits as well as drawbacks associated with the program will also not be brought to light hence making patients who would have benefit from such a program unaware. Additionally, subsequent studies especially inclined to staff attitude and perception which could have benefited from this study would not enjoy the knowledge brought forth through this study.

Aims and objective

The major aim of this study will be to critically evaluate the attitude of staff towards the POLST program. This will go hand in hand with examination of the challenges facing its implementation.

The specific objectives of the study include the following:

  1. To find out the attitudes of staff towards the physician orders for life-sustaining treatment (POLST), which is a program to elicit and honour the treatment goals of people with advanced progressive illness.
  2. To establish the reasons why the program is not being implemented despite their being policies that are comprehensive about its use.
  3. To develop workable recommendations on how to counter the challenges in objective two (above)
  4. To bring forth the advantages and disadvantages of the program to patients.

Literature review

POLST stands for physician’s order for life sustaining treatment is a form that ensures that an individual who is experiencing serious health complications can document their wish for life-prolonging treatment through a clear specific written medical document. This document ideally honours the desires that have been documented. It is worth to remember that the state of Oregon was the first state in the United States of American to adopt its use back in 1995-6. The constituent of the form the paradigm are immediately actionable signed orders on a standardized form, the orders usually tackles a variety of life sustaining treatment such as intubation, mechanical ventilation, use of antibiotics, nutrition through medical administration among others (Meyers et al., 2004).

According to Meyers et al., 2004 POLST was developed in order to overcome the shortcoming associated with the cardiopulmonary resuscitation. POLST made it possible for the wishes of patients to either receive life sustaining treatment or not regardless of their location. The form is usually completed by a thorough conversation between the patient and his or her doctors. Currently among the states that use the program include California, New York, north Carolina, Tennessee, Washington, Idaho, Pennsylvania, Wisconsin west Virginia to mention but a few. Ideally it is important to acknowledge that the program has been refer by various names based on the state for instance in the New York the program is referred to as medical orders for life sustaining treatment, physician orders for scope of treatment as in the case of west Virginia (Baumrucker, 2004).

A number of studies have been carried out to establish its efficacy. For instance, in Oregon out of about 200 patients who had the form, none of these patients receive resuscitation against their wish. Since its inception, tremendous efforts have been made by the relevant authorities for instance the government, local authority, non governmental organization to educate and disseminate information about POLST. The big question regarding who should use POLST is simple; those individuals having advanced life limiting health problems and who are already aware of the kind of treatment they desire. Ideally, even those with sound medical condition opt to use advance directives rather than POLST which will be very useful when they are cornered with life limiting diseases (Guba, 1994).

According to a study carried out in Oregon, it was established that majority of states healthcare facilities indeed use the program to help take care of their patients although its use significantly varied between and among states. Additionally, the same study found out that majority of the participants were of the view that POLST is useful when it comes to preventing unwanted resuscitation through EMS, it also forms a basis through which patients get to effectively communicate their desires in terms of treatment preferences, aid in ensuring that patients’ preferences in terms of treatment are honoured, offers a platform for the medical practitioners to fully understand patients’ preferences and more importantly it is useful in preventing unwanted hospitalization (Farber et al., 2006).

Studies previously carried out clearly indicate that patients derive a significant amount of benefits from the program. Additionally, in situations where patients are provided with a choice, majority of them will indeed go for a more aggressive type of treatment in a given condition (Baumrucker, 2004). Similarly, it has been documented that POLST has gained popularity thanks to the demands that and plans from Medicare as well as Medicaid programs that calls for individualized care plans (Schmidt, et al., 2004).

However, going through the various literatures, I have not come across information regarding studies conducted to evaluate the attitude held by staff towards the use of the program and the overall benefits and drawbacks associated with the program (Farber et al., 2006). For this reason, the proposed study will definitely help uncover such issues relating to staff attitude towards the program. On the same note, although this has been happening in the near past, there ahs been cases where the program is not being fully implemented despite there being a comprehensive policy and guideline on how it should be done. No substantial literature covers this issue (Schmidt et al., 2004).

Methodology

This chapter describes in details how the research will have accomplished. In addition, the issue of study design or approach is clearly brought forth. Similarly, the entire mechanisms used to identify the sample and the size, study area, ethical issues, mechanisms of data collection; analysis of the data collected and finally the interpretation of results from the analyzed data as well as presentation of the finding are addressed (Guba, 1994). Evaluation of staff attitude towards POLST program will guide the study.

The study approach or paradigm to be used is a qualitative approach using grounded theory. I selected this approach because nursing practice takes place within a multidisciplinary team and grounded theory focuses on the identification, description and explanation of interactional processes between and among individuals or groups within a given social context (Mahvash et al., 2009: 427). Additionally, based on Mahvash et al., 2009 views the various advantages of grounded theory approach which include; it gets researchers analyzing the data early, encourages systematic, detailed analysis of the data and provides a method for doing so, gives researchers ample evidence to back up their claims as well as its ability to describe repeated processes, for instance communications processes between the researcher and the staff members. Additionally, grounded theory encourages a constant interplay between data collection and analysis (Guba, 1994).

For this study, the participants will be healthcare staff members and POLST program coordinators. The choice of the staff is based in the fact that they are in a better position to bring forth what views and attitudes they hold towards the program. It is only those staff members who have primary responsibility when it comes to POLST who will form part of the sample. Additionally, the POLST program coordinator is in a position to provide me with desired data since he or she will be in a better position to understand all that appertains POLST implementation, benefits, challenges and the attitude held by staff members towards the program.

My study will be carried in hospital or healthcare facilities within Texas. I choose this state because it is more convenient to me in terms of accessibility. In fact I will concentrate in only two facilities. Concerning sample selection, I will employ careful biased sampling. As suggested by Beiske, 2002 this will be helpful in ensuring that the program coordinators are easily identified. Concerning the staff members, the best sampling strategy I will use is stratified sampling. This approach will help me subdivide staff in terms of years in service since I believe that the same will affect their attitudes towards the program. For each healthcare facility I will utilize one program coordinator while I intend to draw a sample of 10 staff from each healthcare facility hence making a total of 22 participants.

The tool of data collection I will employ in collecting data is through semi-structured interview. The interview will run for a period of 30 minutes and it will be tape recorded. Similarly, I will be taking notes when I deem necessary. My choice of using face to face interview was guided by the following advantages as suggested by Creswell, 2003; as a researcher I will indeed have directs contacts with the interviewee hence obtain first hand information, together with the participants I would be able to clarify on issues of the research done hence, being able to obtain information which is well elaborated and authentic, interviews is a flexible data collection tool as when questions are not well grasped by the interviewee I will be in a position to rephrase and elaborate them (Beiske, 2002). Additionally, interview will allow one to learn about things and facts that cannot be observed directly and finally it adds internal viewpoints to outward behaviours. However, the approach is a slow method because the process calls for interview of one person at a time, cannot fully trace events and trends that occurred in the past. Additionally, interview is an expensive tool to use; it is also subject to respondent and interviewer bias. This will be eliminated through a tight time and structural frame work that will ensure that everything is done on time and appropriately (Beiske, 2002).

To ensure validity and reliability of data to be collected I will attain this by taking notes from the field, memoing, having a prolonged contact with participants, reviewing of results as well as interpretation by experts in nursing research who have a stronger background in qualitative research method (Creswell, 2003).

Before all these are done, I will first seek permission to carryout the study from Internal Review Board of my university. Additionally, I will obtain consent from my participants. Data will be analyzed through thematic analysis and presentation of the results and finding done through use of tables as well as textual presentation. It is important to remember that the data collected will be augmented by already existing literature from secondary sources.

The major limitation of the study is time factor and the finding generated from the two healthcare facilities in Texas may not give the general view of attitude of staff members towards POLST in the region and in the entire United States of America.

References

Baumrucker, S. 2004, Physician orders for scope of treatment: An idea whose time has come. American Journal of Hospice and Palliative Care, vol. 21, no2, pp. 247-248.

Beiske, B. 2002. Research methods: Uses and limitations of questionnaires, interviews, and case studies. Manchester: University of Manchester.

Creswell, J. 2003. Research design: Qualitative, quantitative and mixed method approaches. Thousand Oaks: Sage publication.

Farber, S., Shaw J, Mero J. & Maloney, W. 2006, Withholding resuscitation: A new approach to prehospital end-of-life decisions. Annals of Intern Med, vol.145 no.10, pp. 788.

Guba, E. 1994, ‘Competing paradigm in qualitative research’, in Denzin, N & Lincoln, Y. (eds), Handbook of qualitative research, Sage Publication: Thousand Oaks, pp. 105-117.

Hickman, S., Tolle, T., Brummel-Smith, K. & Carley, M. 2004, Use of the POLST (Physician Orders for Life-Sustaining Treatment) program in Oregon: Beyond resuscitation status. J Am Geriatr Soc, vol.52, no. 3, pp. 1424–1429.

Lynn, J. 2002, Reforming care for persons near the end of life: The promise of quality improvement. Annals of Intern Med, vol. 137, no.5, pp. 117-122.

Mahvash, S., Mohammad, C. & Fazlollah, A. 2009, Organizational factors influencing knowledge transfer into practice in Iranian nursing context: A grounded theory approach, International Journal of Nursing Practice, vol.15, no. 1, pp: 426–436

Meyers, J., Moore, C., McGrory, A., Sparr, J. & Ahern, M. 2004, Physician Orders for Life-Sustaining Treatment form: Honoring end-of-life directives for nursing home residents. J Gerontol Nurs, vol. 30 no. 3, pp. 37–46.

Schmidt, T., S. Hickman, S. Tolle, S. & Brooks, H. 2004, The Physician Orders for Life-Sustaining Treatment (POLST) Program: Oregon emergency medical technicians’ practical experiences and attitudes. Journal of the American Geriatrics Society, vol. 52, no 6. 1430-1434.

Tolle, S., Tilden, V., Nelson, A. & Dunn, P. 1998, A prospective study of the efficacy of the PO(L)ST: Physician Order Form for Life-Sustaining Treatment. J Am Geriatr Soc , vol. 46, no. 8, pp. 1097–1102.

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