As they execute their mandate, nurses are confronted with various challenges. Delivering end of life care is among the aspects of nursing practice that presents the most daunting challenges. In attending to the needs of patients who are terminally ill, nurses are forced to make difficult decisions. Their situation is compounded by the fact that they lack guidelines and clear policies that they can rely on to inform their decisions. Given the struggles that nurses encounter, the need for scholarship for evidence-based practice becomes evident. If nurses are to be effective in offering compassionate and impactful end of life care, they must integrate insights obtained through scholarship into evidence-based practice into their service delivery.
Scholarship for Evidence-Based Practice
In order to understand the role that scholarship plays in promoting evidence-based practice, it is necessary to begin with a definition of key terms and concepts. These definitions are provided in the following section.
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Evidence-Based Practice
In her article, Anne Woods sheds light on the meaning and importance of evidence-based practice (EBP). She defines EBP as a healthcare approach which allows practitioners to combine the best evidence obtained through rigorous clinical studies with their own expertise to deliver care that is consistent with the values of patients (Woods, 2013). The definition that Woods offers captures the basic elements of EBP. Thanks to EBP, nurses and other medical practitioners are able to leverage the best and latest technologies, interventions and insights to offer high quality care. According to Woods, EBP plays a critical role in improving quality of care while enabling providers to minimize the cost of operations. Agnes Black et al. (2015) confirm that EBP has a tremendous impact on healthcare delivery. They note that through training, nurses can become enlightened regarding the immense benefits that they can deliver to patients when they embrace EBP.
Evidence-Based Practice Models
To facilitate the adoption of EBP, various models have been developed. Basically, these models outline the procedure that practitioners should follow as they embrace EBP. Some of the most popular models include the Iowa model, the Stetler’s model, Rosswurn and Larrabee’s model, the John Hopkin’s nursing model, and the ACE star model (Gawlinski & Rutledge, 2008). While they differ in specific details, all these models help practitioners to leverage the power of research evidence to improve the quality of care. For instance, the John Hopkin’s model challenges nurses to define the problem requiring solution then proceed to gather evidence (Gawlinski & Rutledge, 2008). With the evidence collected, the nurses should conclude by incorporating the evidence into practice.
End of Life Care
As has been observed earlier, the delivery of end of life care is fraught with challenges. In the following section, the ethical and legal issues that practitioners face as they provide end of life care are explored.
Ethical Aspects
To successfully attend to the needs of terminally-ill patients, practitioners need to be familiar with the ethical issues that surround end-of-life care. Autonomy is one of the issues (Karnik & Kanekar, 2016). This matter is concerned with respecting the independence and the decisions of patients. When a patient makes it clear though a do not resuscitate (DNR) order or a living will that they do not wish to have their lives prolonged through treatment, practitioners have a mandate to respect and comply with this wish. Another ethical issue concerns avoiding harm and striving to provide services that benefit the patient. Even as they attempt to lengthen the life of the patient, practitioners need to ensure that the patient does not suffer any needless and unavoidable anguish.
Legal Aspects
In addition to the ethical issues explored above, nurses are also confronted with serious legal questions that they must consider while delivering end-of-life care. Capacity is one of these questions (Taylor, 2015). Essentially, capacity is concerned with whether the patient who is terminally ill is able to make decisions. The nurse needs to confirm that the patient does indeed possess the capacity to provide instructions regarding whether they would want treatment. Capacity leads to the question of agency. In the event that the patient cannot make decisions, an individual who acts on behalf of the patient is appointed (Taylor, 2015). Usually, this individual is a close family member. Another critical legal issue in end of life care regards determining when to withdraw treatment. Practitioners need to establish if the treatment is not having any significant impact and should therefore be withdrawn.
Discussion
So far, it has been established that end of life care presents complex challenges that nurses must address. EBP holds the key to addressing these challenges. Offered in the following section are insights into the role that EBP can play in enabling nurses to adhere to ethical and legal guidelines while delivering end of life care.
Before outlining the impact that EBP can have on end of life care, it is important to begin with a look at some of the challenges that are ailing nursing practice. Joining forces with two other scholars, Lesley Wilkes (2013) penned an article in which he decries the lack of adequate clinical research. He echoes the concerns of his collaborators who lament that not much is being done to conduct research in clinical scholarship. In their article, Wilkes and his team urge the medical community to dedicate more effort to providing nurses and other practitioners with insights that they can incorporate into their work. Basically, these scholars note that one of the hurdles that hamper EBP is the failure by practitioners and researchers to invest effort and resources into clinical research. It is therefore not surprising that the medical community has been unable to fully integrate research into practice.
It is only fair to recognize the few scholars whose effort has led to the establishment of the tremendous impact that EBP has on the wellbeing of patients receiving end of life care. O’Connor and Peters (2014) are some of these scholars. They set out to determine the impact that clinical scholarship has on how nurses deliver care. After conducting their study, O’Connor and Peters observed that there had been significant improvements in the capacity and capabilities of the nurses to offer effective and high quality palliative care. In a previous section, respecting the autonomy of patients was identified as among the ethical issues that surround end of life care. In order to recognize that patients are autonomous agents who have the right to make their own decisions, nurses need to possess the required capacity. As O’Connor and Peters observed, clinical scholarship enables them to attain this capacity. As regards EBP, scholarship also enhances capacity. The role that scholarship plays in promoting EBP by boosting the capacity of nurses is among the themes that Peterson and Stevens (2013) explored in their article. According to these scholars, clinical scholarship equips nurses and other medical professionals with the technical skills, insights and competencies that they need to adopt EBP. Michelle Klein-Fedyshin (2015) is yet another scholar whose work sheds light on the relationship between EBP and the capacity of nurses providing end of life care. The focus of her article is the need for nurses to translate evidence into practice. She observes that through EBP, nursing practitioners are able to satisfy their information needs. Basically, Klein-Fedyshin suggests that EBP provides nurses with the information that they need to become competent in delivering end of life care. With this information, the nurses are also able to comply with ethical and legal principles, values and guidelines.
The role of EBP extends beyond enhancing the capacity and competence of nurses. Another function that EBP serves is that it bolsters quality improvement. To understand how EBP allows practitioners to improve the quality of care that they offer, one simply needs to read the insightful article that Allison Slipka (2017) authored in collaboration with Karen Monsen (2017). The main message that these scholars convey in the article is that by scrutinizing available evidence, nurses are able to identify areas that require improvement. For example, EBP enables nurses to determine how they can minimize infections. Slipka and Monsen are not isolated in finding that EBP facilitates quality improvement. They are joined by such other scholars as Banerjee et al. (2012). According to these researchers, EBP allows medical practitioners to compare the best practices and gold standards with how they deliver care. The comparison enables the practitioners to determine if any improvements are needed. With regard to the ethical and legal issues surrounding end of life care, EBP challenges practitioners to avoid causing harm (maleficence) while striving to promote the welfare of patients (benevolence). For example, through EBP, nurses can identify interventions which minimize the pain that patients suffer. When they adopt these interventions, the nurses will be acting both legally and within the confines of ethical standards. While EBP presents opportunities for quality improvement, it should be understood that EBP can only have an impact when practitioners embrace scholarship. They should commit to life-long learning through which they gain insights and knowledge into the latest interventions, technologies and trends.
It is true that meeting the physical health needs of patients is the primary mandate of medical practitioners. However, as Visser, Hadley and Wee (2015) point out, the practitioners are also expected to offer holistic care. This type of care involves fulfilling the physical as well as the emotional and spiritual needs of patients. As they face death, the mental, emotional and spiritual needs of terminally ill patients become critical. It is vital for practitioners to secure the dignity of these patients. Dignified death is one of the basic ethical rights that all patients have. EBP makes it possible for practitioners to ensure that the patients meet a dignified death. Eus (2007) confirms that dignity should be at the center of end of life care. EBP provides practitioners with insights for delivering comfort and ensuring dignity. For example, thanks to EBP, practitioners recognize that they have an obligation to respect the wishes of patients. When a patient insists that they do not want treatment, practitioners must fulfill the patient’s desire. Essentially, when they adopt the best evidence which urges them to honor the wishes of patients, nurses manage to deliver compassionate care that safeguards patient dignity.
The ethical issues that define end of life care must be considered when attending to the needs of terminally ill patients. It is also vital for practitioners to ensure that their decisions and practice are informed by the legal issues. In an earlier section, it was mentioned that among the legal obligations of practitioners is to determine that patients have the capacity to make decisions about their health. Through EBP, the practitioners can comply fully with this obligation. In her text, Meyer (2016) observes that thanks to EBP, medical practitioners are able to enter into collaborative partnerships with lawmakers. The purpose of the partnerships is to create a legal framework that enhances the delivery of end of life care. For example, through the partnerships, it is possible for practitioners to persuade legislators to enact laws that shield the practitioners against legal liability when they honor their ethical and legal obligations while offering end of life care. However, as noted earlier, EBP’s impact is hampered when no effort is made to promote clinical scholarship. Nurses, physicians and other scholars need to expose themselves to existing knowledge through scholarship.
From the discussion above, it is evident that EBP holds the key to addressing the ethical and legal aspects of end of life care. However, for a clearer understanding to be gained, it is helpful to consider a real case that underscores the importance of EBP. The case of Terri Schiavo is among those that provide practitioners with important lessons regarding caring for terminally ill patients. Burt (2006) observes that thanks to this case, practitioners are now familiar with blunders and pitfalls that they should avoid. Moreover, the Schiavo case highlights the need for clearer laws and guidelines that will help practitioners to navigate end of life care ethical and legal questions. Basically, this case served as evidence that when they fail to consider all relevant ethical and legal issues, practitioners are likely to commit serious blunders. To avoid these blunders, they need to adopt clinical scholarship. The scholarship serves an essential functioning in cautioning the practitioners against violating ethical and legal principles that govern end of life care. Therefore, as they seek to advance healthcare, nurses should lead other medical professionals in making a commitment to lifelong learning.
How nurses can deliver appropriate care to patients facing death has been the focus of the discussion this far. While it is true that the nurses should focus their attention on the patients, the need to address the wishes of the patients’ families cannot be ignored. Sahan and Terzioglu (2017) contend that EBP is an effective approach for involving the families in the delivery of care. During their last moments, terminally ill patients desperately need the warmth and love of their families. They can receive this love when practitioners encourage the families to become active participants in the end of life care processes. Basically, EBP opens the eyes of healthcare professionals to the importance of family involvement. Therefore, EBP allows the professionals to offer the type of care that is in line with ethical and legal values and standards.
Ethics and the law remain the key factors that shape the conduct and practice of medical professionals. End of life care is one of the aspects of healthcare for which ethical guidelines and legal provisions present implications. When treating patients on the verge of death, nurses and other professionals need to adhere to relevant guidelines. In particular, they should ensure that they respect the autonomy of their patients. Furthermore, it is critical for the practitioners to confirm that the patients are competent and exhaust all available medical interventions. EBP is a useful approach for practitioners who are dedicated to attending to all the needs of the patients. Research shows that EBP enhances the quality of care and allows practitioners to sharpen their skills, thereby becoming more competent. Unless it is accompanied with clinical scholarship, EBP’s impact is severely limited. It is therefore critical for practitioners to join forces with other stakeholders with the goal of promoting scholarship so as to incorporate evidence into practice.
References
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Black, A. T., Balneaves, L. G., Garossino, C., Puyat, J. H., & Qian, H. (2015). Promoting evidence-based practice through a research training program for point-of-care clinicians. The Journal of Nursing Administration, 45 (1), 14-20.
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