Emergency Nurses' Knowledge, Attitudes, and

Emergency nurses' knowledge, attitudes, and experiential survey on advance directives," by Jezewski et al. (2007) is a qualitative paper. It seeks to assess the knowledge of emergency nurses about advance directives (AD) and how this correlates with their confidence and experience. The researchers use a device called the Knowledge, Attitudinal, and Experiential Survey on Advance Directives (KAESAD), developed in previous studies (Jezewski, 2005), to survey nurses belonging to the Emergency Nurse Association (ENA). The nurses surveyed resided in four different states in order to also assess knowledge of state laws regarding AD.

The researchers found that nurses' knowledge of AD was very poor ranging from 68% in general knowledge, 51% in knowledge about the Patient Self-Determination Act (PSDA), and 56% on state law knowledge. Nurses were experienced with AD, but not confident completing AD or assisting patients with AD. They also found significant correlation between nurses' confidence and the level of their education. Also, knowledge significantly decreased with providing direct care. Although these finding were statistically significant they were deemed not clinically significant by the researchers. The introductory material of this paper was very lacking.

This paper deals entirely with AD and the authors do not even define it. They simply list a few types of AD. It would have been very helpful talk about the history of AD, what they are and how they relate to nurses in the healthcare setting in at least one paragraph. Similarly, the authors refer to end of life (EOL) decision making, which they do not at all define or talk about in the introductory material. Another very lacking portion of the introduction was the literature review.

The authors state that very little work of this kind had been done previously. However, in the discussion the authors refer to numerous similar studies and their results and how they compare to the authors' findings. The problem statement and purpose were very clearly stated. The authors do not state a hypothesis, but do list their research questions as the aim of the research. The importance of this work was also talked about.

The authors assert that since emergency nurses work with patients in emergency settings that AD must be a part of their work and therefore assessing their knowledge and confidence in the subject would be important. It was also explained that this work attempted to go beyond other previous work by trying to correlate nurses' knowledge and confidence with experience and other factors. The research design used accepted methods of sampling to get a large enough response for meaningful statistical analysis.

An oversampling method was used due to generally low response to mail surveys. The data was collected from returned surveys and of those the usable surveys were analyzed. The authors did not discuss what made a survey usable or not. Ethical considerations were not mentioned. The authors used a device that was previously tested for reliability, content validity, internal consistency, and approved by the Health Sciences Institutional Review Board. Internal and external consistency was tested. A pilot study showed that there was internal consistency.

However, the results of the larger study indicate that more work on the KAESAD to improve the internal consistency of the scales used to measure the responses was needed. Data were statistically analyzed with an accepted value of statistical significance set at p < 0.05. Also, some data that was found to be statistically significant was determined by the authors to be clinically insignificant. How this was determined by the authors was not explained in the procedure. The results were presented in several helpful tables and also interpreted by the authors.

The authors discussed the results of each aspect of their research questions. None of the research questions were left out. The tables that were used were helpful, easy to read and agreed with the interpretations that the authors made about their results. The discussion was very well written. It was clear and concise and easy to read and understand. It is the strongest portion of this particular paper. Since the authors did not make a hypothesis one cannot say whether the findings support or do not support their hypotheses.

However, all of the research questions were answered. The authors did determine how much knowledge nurses have about AD, what their attitudes and experiences are regarding AD, and whether there is any correlation among these characteristics. The authors' discussion of the results is very clearly and logically written. They talk about the results and what they might mean. For example, many nurses disagreed with the statement that ethically there is no difference between starting life support treatment and then stopping it once it has begun.

The authors discuss how this is different from previous survey findings.