This chapter will introduce the subject of this project, i.e. improving the quality of life of patients receiving End of life care[EoLC] throughthe timely use of Advance Care Plan [ACP] and focusing on their mental capacity to make decisions towards their care. Chapter one will discuss the background of the chosen specific group discussed above. Chapter two will deliberate on the chosen clinical guideline and the supporting evidence of one recommendation will be retained. Chapter three will present the audit proposal.Finally, Chapter four will evaluate the leadership’s proposition for involving practitioners in an improvement project; most importantly, this evaluation will be used to substantiate my chosen clinical parameters – the importance of observing these guidelines to uphold egalitarianism and promote safe practice.

According to the Office of National Statistics [ONS] (2015), in the UK, half a million adults over the age of 65 years die every year. There is an expected rise of death between 2012 and 2030 by 17% (Gomes and Higgins 2008). ¾ of these deaths are anticipated and so there is need to improve care delivered to people in their last year of life and to their loved ones(National Council for Palliative Care [NCPC] 2012).The current English policy concludes that home death is more favourablethan hospital death (Pocock et al. 2016; Gomes et al. 2011). The number of home deaths from 2008 to now has risen from 38% to 44.5% (Public Health of England 2013).

EoLC is an integral part of palliative care which aims at advancing the quality of life of a person through the means of support, coordination of care, system relief, and guaranteeing of a “good death”(Sherwen 2014). A good death is one which occurs in a place of preference, where there are no symptoms of pain, anddignity and respect are upheld till death, with the patient surrounded by their loved ones at the time of death (Riley 2008).
There have been so many challenges in relating to delivering high quality care for people nearing their death. This led to the development of End of life care strategy (2008) which aimsat delivering high quality care to people nearing their death(in their last year of life) irrespective of their age socio economic status, gender, sexuality, religious belief, age, ethnicity and disability (DH 2008)
EoLC is defined by General Medical Council [GMC] (2010:8) as:

There are three triggers that identify when a person is nearing end of life (Thomas 2011). They are:
• The surprise question: would one be surprised if death of the person is expected in the coming days, weeks or months? (Lynn 2005).
• General indicators of decline: relates to deterioration of a patient which requires no further active care.
• Specific clinical indicators relating to certain conditions like cancer, dementia, motor neuron diseases, renal failure, and heart disease and so on.

From 2010 -11, the EoLC cost over £460 million , in the primary care EoLC cost between £186 -£213 per death, although most of the funding come from voluntary contribution gotten through fund raising (DH 2011).
NICE (2011) quality standard for EoLC presented a detailed expectation of what quality EoLC should look like (See appendix)Delivering high quality of care for people receiving EoLC in line with their wishes and values can be maximised through a timely ACP (DH 2009)
ACP involves voluntary conversations regarding the patient’s wishes and preferences for end of life and the phase of time between the consenting person and the healthcare professional in case of future decline in health(Royal College Of Physicians [RCP] 2009). It also serves as groundwork for quality for EoLC and should be adopted in a timely manner (DH 2009). The difference between ACP and careplanning is that ACP shows more clarity with regard to an individual’s wishes, choices and preferences in chosen place of death. This is in anticipation of a decline in the individual’s condition in the future that will incapacitate him/her in making or communicating decisions to others (Gardiner et al. 2010;Sudore 2010). A nurse is duty bound to act in the patient’s best interest by respecting the patient’s wishes and choices (Nursing and Midwifery Council [NMC] 2015). ACP should be reassessed when a patient’s medical condition changes (Gundersen Health 2016).Awareness of patients’ wishes and preferences through ACP reduces family distress (Teno 2000). The use of the Ideas Concerns Expectations [ICE] framework is recommended when assessing patients` wishes (Silverman et al. 2005):
 Ideas: For recognition ofpatients’ beliefs, values and perceptions about their health
 Concerns: For clarification of patients concerns over their care
 Expectations: For establishingpatient’s thoughts and expectations in the future (Slort et al. 2011).
An ACP can be written down in a document known as Advance statement and can be found in the nursing/medical notes. It can also be stored electronically in electronic palliative coordination systems; a popular one is coordinate my care which can be found in ( This has improved the chances of people dying in their preferred place of deaths (Smith and Riley 2011).

Mental capacity plays a vital role inadvance decision.A person who is over 18 years old is assumed to have capacity to consent to or refuse treatment if they find themselves in a situation where they are unable to make a decision (Mental Capacity Act [MCA] 2005). The current English law states that an individual is considered to have mental capacity until proven otherwise, excluding the cases ofillogical and perilous decisions(Hotopf 2005).
ACP includesa patient’s ailment, the probable consequences,a substantial comprehension of the law (particularly in capacity assessment), the advance care planning methods, and documentation (Fried and O`Leary 2008; Boody et al. 2013).Regrettably, some professionals still have restricted comprehension of ACP (Robinson et al. 2013; Boyd et al. 2010).
The MCA(2005) Legislates for England and Wales on the procedure of decision making by and on behalf of persons with impaired mental capacity. There are five principles and a legal framework which are aimed to shield patients with diminished capacity and their carers in the decision-making process regarding their care and treatment. This process is protected by the MCA(2005) Code of Practice and is legally binding on healthcare professionals (Office of the Public Guardian 2016).
A nurse is ethically bound (NMC 2015) be sensitive and willing to provide and discuss all vital information to patients to aid them in their decision especially concerning treatment refusal for the near future (Slort et al. 2011;Tapely and Jolley 2011). This includes assessment of a patient’sunderstanding of medical prognosis, treatment, and the aftereffects of the patient’s choice to refuse treatment. The nurse should consider the relevant guidelines to help ease the patient’s anxieties (Barry and Edgman-Levitan 2012).
The refused future treatments by the patient need to be documented, although there is usually no set format for making a record of ACP but its documentation proves to be very useful for future use, especially for those involved in care (Gardiner et al. 2010). This leads to the receipt of less intensive treatment when nearing death (Teno et al. 2007).
ACP also involves the use of lasting power of attorney [LPA]. This is a legal document that can be used as a substitute for the preceding power of attorney. Patients known as donors can appoint somebodyasthe attorney to whom they intend tobequeath with decision-making authority if they no longer have that capacity in the time to come (Mullick et al. 2013). This prepares the surrogate for decision making.The LPA is registered with the Office of the Public Guardian (at a charge) for it to be effective (Robinson et al. 2013).A donor can appoint more than one person as an attorney or appoint different people for different purposes (Hotopf 2005). The LPA can be legally challenged under the court of protection if the attorney is deemed to be acting not in the best interest of the donor. The court may appoint a new deputy or a person close to the donor who is believed to act in the interest of the donor (Livingston et al. 2010).
In other to establish patient’s wishes and deliver high quality care, effective and good communication is important. Communication is a process of enhancing opinions or information amongst persons through means of spoken words or written correspondence and through body language during which process each participant attempts to reason out their interpretation and chooses how to react and respond to it (Hargie et al. 1994).
Usually,discussing death and dying is difficult for healthcare professionals (Fallowfield et al. 2002) but good communication helps put across the significance of the illness in a humane manner.It is also a means for healthcare professionals to convey their empathy for dying patients and provide good quality EoLC (Buckley 2008).Good and effective communication aids nurses to address the ethical matters of confidentiality (NMC 2015). It also promotes best practice amongst Multi-disciplinary team [MDTs] and aids in identifying a person’s needs and comprehending the rationale behind the decisions taken (Bridges and Wilkinson 2011).The ACP involves communication between patients, their family, and healthcare professionals to suit thepatients’ values and culture (Garrett et al. 1993).

Nurses are encouraged to reflect on their delivery of care in practice and recognise well-informed lapses which will be converted into devised questions. There are a number of frameworks for this purpose but the one chosen here will be Patient, Intervention, Comparison and Outcome[PICO](Schardt et al. 2007).(Table 1). This is more popularand accurate than the other frameworks(Cooke et al. 2012). The aim of my project is to improve the quality of lives for patients in an acute ward receivingEoLC care by ensuring they have a timelyACP according to the guideline recommendation.

Table 1. PICO Framework
POPULATION Adults who are in receipt of end of life care in an acute ward
INERVENTION Use of Advance Care Plan
COMPARISON No communication tool was used
OUTCOME Improved quality of life for dying patients through the use of timely advance care plan to meet their needs and preferences


Evidence-based nursing involves the use of evidence collected from patients’ choices, clinical investigations and available means in order to develop clinical judgements. Therefore, the application of evidence-based practise in nursing is dependent on clinicaldata acquired from high-quality and current evidence (Polit and Beck, 2012; 2014). When applying a clinical guideline in nursing, a systematic method to assist healthcare professionals is adopted. This method leads to the determination of the appropriate action and care tailored for each individual so as to meet their care needs (Greenalg 2010).
Nurses are required to deliver excellent care at all times (NMC 2015). The reliability of a nurse’s skills and expertise depends on the extent of evidence-based care adopted (DH 2008). A clinical guideline improves patient care procedures and health consequences, but not all clinical guidelines are well structured;hence, it is important for a nurse to evaluate a clinical guideline before executing it (Wood and Haber 2010). Nurses are advised to use up-to-date and current evidence in practice in spite of the barriers encountered in implementing theseguidelines (Cowen et al. 2009).
The hierarchy of evidence adopted here was developed by Daly et al. (2007).

Figure 1. Hierarchy of Evidence

Source: Daly et al. (2007: 43)

A methodical evaluation was used to ascertain the importance of caring for a dying adult inline with their preferences values and wishes though the timely use of ACP. Only three qualitative studies were considered (Anselm 2005; Aslaksm 2012; Gutierrez 2012). Regrettably the evidence was thought weak and insubstantial as a basis for the recommendation. The recommendation for the use of ACP was hencefounded on expert opinions.
Critical appraisal is the methodical scrutinising of a research piece to evaluate its rigour, authenticity, and significance prior to using the evidence to arrive at a clinical decision (Cowen et al. 2009).For this sector, The Appraisal of Guidelines for Research & Evaluation [AGREE]will be applicable here tobe used to collect andreview the evidence, means involvedin rigour of development.

The objective of the guideline NICE NG31 (2015) is to deliver evidence based care for the dying adult (above 18 years) in the last days of their lives throughout the NHS. The clinical focus being on the
• The timely identification of adults whose deaths are likely to occur within the next few days.
• The shared decision making between the clinical staff, the dying adult and their loved ones.
• Pre-emptive prescribing in their last days of life.
• Clinical efficiency ofsupported hydration.
• Pharmacological pain management, breathlessness, fatal agitation, respiratory secretions, nausea, vomiting and anxiety.

In 1991, a distinctive NHS authority called as the National Institute of Care and Excellence [NICE] was established with the objective to reduce discrepancies in the quality of NHS care and treatment of patients in England and Wales (Hewitt-Taylor 2006). NICE plays an important role in effective treatment of patients, drug appraisal, and financial feasibility for preventing ill health and promoting good health (Robinson 2010). NICE has global acknowledgment and respect for its outstanding work and strength of its study and evidence. As a matter of fact, the institute is repeatedly seen as an ideal of noble practice worldwide (Haslam 2013).
The guideline chosen is NICE NG31 (2015) and Recommendation 6.6.10, p.108
“Care of dying adults in the last day of life”. It recommends the following:
“Explore with the dying person and those important to them:
• Whether the dying person has an Advance Care Plan or has stated preferences about their care or has stated their preferences about their care plan in the last days of life (including any anticipatory decision or advance decision to refuse specific treatment).
• Whether the dying person has understood and can remember the information given about their prognosis”.

With regard to the above recommendation, the guideline was developed using a PICO framework in other to be guided in the literature searching process (NICE 2015).
Before the development of this guideline, the Liverpool Care Pathway [LCP] for the care of the dying adult was in force in UK hospitals and hospices. Although the aim of the LCP was to give patients a good end of life, it was unpopular and was discontinued by 2014. This was because of protests and complaints from the bereaved about the untimely recognition of the issues facing dying adults by inexperienced clinicians. There was also a protest against undue sedation of patients as a result of injudiciously prescribed medication and withdrawal of hydration and other important medications as these factors were found to have a negative impact on the dying process.
Therefore this led to an independent review headed by Neuberger, calling for the use of evidence-based and individualised care plans. Following this review, the Leadership Alliance came into existence to detail changes in EoLC using five broad principles for the care of the dying people known as One Chance to Get it Right (Leadership Alliance 2014).
Another factor that prompted the review was the Francis report which condemned the failings of Mid-Staffordshire hospital. These failings included poor quality of care especially for the elderly, leading to lack of dignity and respect for the patients and those that matter to them (Francis Report 2013).
To address the above issues, NICE on the request of the National Health Service Executive [NHSE]and in collaboration with the National Clinical Guideline Centre [NCGE]created the guideline (NICE NG31 2015). A multi-professional Guideline Development Group [GDG] was assembled by the NCGC that was chaired by Sam Ahmedzai, a renowned professor in the Palliative Medicine Department of Oncology, School of Medicine and Biomedicine Science, at the University of Sheffield who worked with NHS Trusts and patient/carer organisations and a wide range of experts in EOLC. The NCGC was funded by the NICE, thus reinforcing the advancement of this guideline (NICE NG31 2015). An impartial appraisal board was alsoinvited to observe the quality of the guideline, but with no involvement of patients. Even though many reports endorse patient input in the course of guideline development so as to ensure they are patient-centred (Van de Bovenkamp & Trappenburg 2008). The GDG did not report any conflict of interests that impeded their guideline development efforts.

Three qualitativestudies (Anselm 2005; Aslaksm 2012; Gutierrez 2012) werecited as evidence by the guideline. They fit into level III of the hierarchy of evidence (Daly et al. 2007). They are descriptive because they allow for diversity of views and individualisation. Thisguideline can be adopted in EoLC because it accommodates individualised type of care and encourages open-ended questions and surveys, as seen in the two retrospective surveys (Sullivan 2007 and Houttekier 2014) cited by the guideline in this context.
A qualitative study is usually conducted with a small sample and even though it carries little evidential weight, it is still applicable to certain groups of people and not to everyone (Del et al. 2007).Qualitative studies are often linked with bias from the experimenter (Corbin and Strauss 2014). However,EoLC requiresadditional evaluation and comparative studies in order to determine the impact of various interventions (Deterring et al. 2010).
These three studies are discussed below:
Anselem(2005) targeted a focus group of 67 people in Canada comprising physicians, residents, and nurses, with the aim of eliciting the healthcare professionals’ perceptions of barriers encountered when discussing EoLC with patients, but the findings revealed no clarity on what EoLC discussions should entail.
Aslaksm (2012) study included a focus group ofintensive care unit[ICU] nurses in the USA. The aim was to identify the barriers in EoLC and optimal communication of theprognosis of dying patients. The finding showed that unfavourable prognosis implied likelihood of death in hospital.
Gutierrez (2012) focused on in-depth interviews with 20 members ofthe ICU who had a 50% chance of dying in the hospital. The aim of this research was to highlightthe experiences and the needs of family members present during discussion of patientprognosis (in case of patients who are most likely to die in the ICU). The finding was a success owing to comprehensive data collection analysis.
The above-mentioned studies were sampled with a purposive method.The studies used a standard based on the researchers’ perception and focused on people with first-hand experience and expertise,so the findings are not generalizable. In this context, not everyone has experienced the loss of a very close person and has been present in the EoLC of a loved one (Holloway and Wheeler 2010).
Four aspects are important when considering a qualitative research (Polit & Beck 2012):
• Credibility
• Dependability
• Conformability
• Transferability

The recommendationfrom NICE NG31(2015)aimed to ascertain whether there was an advance care plan in place and if the dying adult can understand and remember their prognosis but the evidence cited for this recommendation by the above guideline did not identify the perception of the dying adults concerning their advance wishes or the criteriarequired to be fulfilled a healthcare professional for communicating the prognosisand the impact of mental capacity in ACP but rather focused on opinions and experiences of dying persons’ relatives and healthcare professionals from the general ward and ICU.
Although Jackson et al. (2010) study cited by the guideline was the closest to identifying prognosis in EOLC, it did not focus on dying patients but included an in-depth interview with the carers and clinicians about people that have died in acute hospitals, the care they received, and communication of prognosis in the last 48 hours of their lives. However, the findings were poorly represented methodically despite the interview being conducted in a direct setting, and the theme was unclear.
These three studies (Anselm 2005; Aslaksm 2012; Gutierrez 2012) did not show if informed consent was gained from the participants or an assessment was made ascertaining their consent (Polit &Beck 2012). There should have been an external check on the participants to enhance the credibility of the research (Polit andBeck 2012). The method of analysis in a research should be based on a grounded theory for it to be dependable. Another issue identified in my chosen recommendation was to establish if there is any cognitive impairment in patients when planning their care in advance and prognosis communication but the cited evidence by the guideline did not identify sufficient and direct information on the procedure for planning advance care and communicating prognosis for patients with cognitive impairments.

The guideline (NICE NG31 2015) did not make provision for care after death, service delivery for out of hours care, palliative care before the last few days of life, case notes for identification of death and no specific training for staff on end of life care. It will be useful if provisions were made to accommodate these shortcomings.
Then the three studies cited as evidence were carried out outside the UK, whether the findings can be transferred and adapted tothe UKis questionable (Polit and Beck 2012). However, a qualitative study should not be judged on its transferability but rather on the capacity to enhance our understanding of the topic. Ethical approval should be considered during a research to ensure that harm is not done as per the principle of beneficence(Punch 2013). Even though qualitative studies have been criticised for not being universally applicable (Bryman 2015), the focus of this study, however, remains on the aims and objectives to get a better insight into a person’s needs and preferences. The three studies (Anselm 2005; Aslaksm 2012; Gutierrez 2012)focused less on the dying adults and more on their loved ones and investigated broader topics than the communication of prognosis.
These three studies (Anselm 2005; Aslaksm 2012; Gutierrez 2012)were carried out outside the UK;the quality of evidence was questionable because of the restrictions, the possibility of bias, and the use of the findings.Overall, these three studies,despite the limited scope and sample size with an outcome of low quality,were methodically sound.
Based on this low-quality evidence, a literature search was conducted andvarious published studies which identified the role of the nurse in ACP and the relationship of mental capacity act and ACP were found. The literature review of Hayhoe and Honer under the Mental Capacity Act (2005) identified the ethical and legal process involved in ACP and its significance in carrying out the dying person’s wishes. This review was in existence before the development of the guideline (NICE NG31) in this context but there was no reference to it in the guideline as a source of evidence.
Threemore studies were identified during the literature search:(Callaghan 1995; RCP 2009; Robin et al. 2013). These studies not only identified the importance of communication skills and the barriers faced by healthcare professionals in the sensitive communication about EoLCand the complex nature of ACP but also recommendedthat the healthcare professionals involved in EoLC have specific training to this effect.
The approaches in these studies could be adapted for use in EoLC in acute hospitals and in the community. If these resources were integrated in the Guideline, it would have given more evidential value to the evidence included in the recommendation.
The three qualitative studies cited (Anselm 2005; Aslaksm 2012; Gutierrez 2012) identified the communication barriers and facilitators between bereaved relatives and healthcare professionals involved in EoLC. This is a significant identification because communication is the most complained about issue in the NHS presently (RCP 2014). The addition of this evidence would have reinforcedthe chosenrecommendation and resulted in a stronger evidence-based practice.However, since the evidence produced by the guideline to support the recommendation is limited and the omitted evidence even though not cited by the guideline is still valuable and recognises that timely use of ACPimproves quality of life for EoLC patients.

The guideline was funded by NICE itself so no external influence was detected.

Clinical audit was first undertaken by Florence Nightingale during the civil war in the 19th century. It aided her to estimate the mortality rate in the British Army hospital. Later, in 1912, Ernest Codman enhanced the concept by auditing the treatment results, thus empowering the community to make their choices regarding these treatment results (Healthcare Quality Improvement Tool [HQIP] 2010).
Lord Darzi’s report “High Quality Care for all” (Darzi 2008; DH 2008) showed that the way to achieve quality improvement was by conducting quality measurement. This report identified the significance of adopting evidence-based practice standards to address changes in practice by focusing on patient-centred care.
Clinical audit [CA] is a process of improving quality by reviewing the efficiency of care and services in place and comparing them to acceptable and high-quality standards(Burgess 2011). In other words, it simply means comparing what is being done to what should have been done. CA helps one ascertain whether positive quality advancement has made positive changes in practice; this is attained by measuring existing practice to established criteria and standards (Reddy 2012). The difference between a research and an audit is that a researchaims to find the right thing to do while an audit is about guaranteeing that it is carried out rightly (Smith 1992).
There are different challenges encountered in quality enhancement both internally and externally, namelytime, cost, leadership methods, insufficient information, and poor communication (Mc Sherry and Pearce 2011). To counter these challenges in clinical settings, healthcare professionals have a duty to work towards effective change of policy. CA is universally recognised common practice in most common wealth countries particularly in the USA and Europe. It is the most recognised clinical regulatory tool when compared to others (HQIP 2010). Thus, CA aims to deliver the highest quality care to patients (Patel 2010).
Clinical guidelines [CGs] identify the duty of the NHS in ascertaining quality care and services are continuously carried provided to ensure delivery of high standard of care at all times (Haxyby et al. 2010; Mc Sherry and Pearce 2011). NHS groups are urged to adopt audit and the methods used in auditing to enhance practice efficiency and identify the sectors that need improvement, especially in terms of patient outcomes (Black 2013). However, CGshas a few drawbacks:
• Insufficient resources
• Rigidity in behavioural changes in practice (Hoomans et al., 2010).
• Lack of required equipment
• Lack of time for healthcare professionals to execute the appropriaterecommendation (Harrison et al. 2010).
CA is also known as a spiral, systematic process or a cycle. The CA cycle of six stages, recommended by Roche (2009) shall be adopted for this audit proposal.

The aim of this audit proposal is to improve the quality of lives for patients in an acute ward receiving EoLC care by ensuring they have a timely ACP according to the guideline recommendation (See Appendix 4 for the proposed audit plan).

STAGE ONE- Objective/Problem Identification
OBJECTIVE: To identifywhether patientsreceiving EoLCmake advance care decisions through the use of documentary evidence
This is the first process in any audit is to identify the audit`s objective by concentrating on the sector that has room for quality improvement. Patient care should be the focus of an audit (Moore 2008). It is recommended for the members of the audit team to contribute towards an audit. This expands the chances of implementing changes, these changes may not reflectimmediately inpractice (Ashmore et al. 2011a).Anaudit also helps one identify the possible changes and ways to implement these changes inorder to improve the quality of care delivered (UH Bristol 2009).
STAGE TWO- Criteria agreed and standard set
The terms criteria and standard are usually misconstrued by healthcare professionals (Benjamin 2008). Criterion, in this context, refers to the quality of care that should be assessed while standard refers to the level of quality that needs to be attained (UH Bristol 2009). These standards and criteria should be based on evidence (Dicenso et al. 2014). When there is lack of evidence, the members of the auditing team should decide the standards and criteria to be used (NHS clinical Governance Support Team, 2005). It is recommended to apply standards in public health audit because of its complexity and the difficulty in measuring its efficiency (NICE 2005).
Quality and Patient Safety Directive [QPSD] (2013) advises that criteria should be coherent with Specific, Measurable, Relevant and theoretically [SMART] tool to ascertain its cogency and chances for development.
The RCP (2009) states that advance care planning pertains to patients with various diagnoses but predominantly to patients with long-term conditions or patients who are receiving EoLC. The recommendation used in chapter two from NICE NG31 is of a qualitative nature because it focuses on the experiences of dying patients’ relatives and the healthcare professionals looking after the dying patients. The focus of this audit proposal is the presence of documentary evidence that EoLC patients have an advance care plan in place. The method adopted in the audit is quantitative as it is measurable (Cairns et al. 2013).
Stakeholders play an important role in a successful audit, so they should be involved from the beginning to the end of the audit (Ashmore et al. 2011). The stakeholders in this audit proposalare the Head of EoLC, EoLC champion nurse, sister-in-charge and ward nurse. In a CA, the active involvement of patients is also significant for a successful audit because the loopholes are identified by them and addressing these loopholes results in a high-quality audit (HQIP 2009).
This audit proposal focusedon elderly patients in an acute ward in a renowned hospital located in Portsmouth. Elderly patients are more likely to receive EoLC than other patients(Verhofstede et al. 2015). The staff nurses are usually the first point of contact, so it is essential that there is timely recognition of patients in need of EoLC. To achieve a successful audit, the setting must be a place where majority of the patients fit the set criteria. Samplingin areas with few EoLC patients may lead to an unsuccessful audit.
data from death registration and hospital episode of English residents who had been patients during the 12 months before death and aged 85 or above at death from 2008 to 2012 showed that 62% of these deaths were hospital deaths(Pocock et al. 2016).

Table 2. Example of Standard/Criteria for the Audit Proposal
All EoLC patients should have an advance care plan and be assessed for understanding
their prognosis

All EoLC patients preferences about where they would like to be cared for should be documented

The current record must indicate if it’sfrom this admission or not. 100%


100% Deceased or no consent from patients

Deceased or no consent from patients


NICE Guidelines NG 32(2015) – Care of the Dying Adult

NICE QUALITY STANDARDS [QS13] (2011) End of Life Care for Adults

NICE QUALITY STANDARD[QS13] (2011) End of Life Care for Adults

STAGE THREE- Data Collection
METHOD: Retrospective review of the medical notes of the patients receiving EoLC wasthe method used in this audit proposal.
Data collection methods include information retrieval for assessment of set criteria and standards. Data collection involves various processes like electronic information retrieval and hard paper information retrieval. Accuracy and relevancy of data are major criteria for a CA. This can be successfully achieved when data collection is done using a specific questionnaire or a simple data collection form.
Data collection can be retrospective or prospective. Retrospective data are those data that are collected after the course of treatment of service users while prospective data are collected during on-going treatment. In this audit proposal, the data collection was retrospective in nature; hence, the data were easily obtained and analysed for addressing the issues and required changes (HQIP 2010).
The retrospective data were taken from 20 to 50 cases for a process-based audit (UH Bristol 2009). This sample is adequate to determine whether EoLC patients have ACP in place. The medical notes of 50 elderly EoLC patients who were discharged and deceased were collected from the patients’ record database and NHS record database for the time span of last three months (Ashmore et al. 2011a).

Every audit proposal should aim to be beneficial to patients and be carried out in line with ethical principles (UH Bristol 2009).In an audit proposal, the six Caldicott principles (1997) should be applied. This is to evaluate patient information that is transferred between NHS sectors and non NHS sectors for uses that are not related to medical research, direct care, or legal purposes(UH Bristol 2009). The principles are outlined below:
• confidentiality of the data
• using only therequireddata
• using the minimum data required
• access to data should be on a stick to know basis
• understanding of responsibilities by all
• understand and comply with the law

The NHS confidentiality code of practice (2003) provides a practical guideline for healthcare professionals on how to respect and treat people’s data.
Nurses have a duty of confidentiality towards their patients (NMC 2015). They also have to comply with the Data Protection Act (1998) by not recording patients’ details including hospital number in the data sheet and the same applies to clinicians names in the audit, unless provision of personal data has been consented to (UH Bristol 2009).
STAGE FOUR- Data Analysis
This step identifies areas for improvement (Ashmore et al. 2011b; HQIP 2010) by converting data into useful information in order to ascertain whether standards have been met or not (UH Bristol 2009; Munhall 2012).
There are different methods available for data analysis, ranging from simply tally methods to high-technology methods. One does not need to be a statistician to analyse data. Data usually involves “YES” and “NO” responses to audit questions (Ward et al. 2013). Audit results should be shared amongst team members, clinicians, and public delegates to deliberate on the change procedureand avoid bias and blind spots (Cohen and Crabtree 2008).
STAGE FIVE- Implementing Changes
This step involves improving the underperforming sectors byimplementing relevant changes. These changes should be aimed at improving or maintaining standards. These changes could be further training for staff, new guidelines, and new strategies (Ashmore et al. 2011c).
For a change to be effective, good communication skills and team work need to be adopted (Mitchel 2013). The changes need to be systematic, documented, and have an action plan so that the responsibilities and time frame can be established (Hammer &Collison 2014).
The common barriers encountered when implementing changesinclude uneasiness of adopting new methods, insufficient resources, and inadequate staff (Spetz et al. 2012).
The proposed changes shall be discussed further in Chapter Four.
STAGE SIX- Re-audit
This concludes the cycle and connects back to the first stage of identifying the problem. It is a step used to determine whether standards have been met or if there is still room for improvement (Ashmore et al. 2011d;HQIP 2009). Data collected from the beginning to the end of the audit should be used with caution (Data Protection Act 1998).

In this chapter, the change management plan will be explored based on Kotter`s model (Kotter 2012).The plan includes the implementation and sustainedtimely use of ACPin adults receiving EoLC. Even though this proposed change is based on theory, it could offer a basis for discussion.
More than half of all organisation change projects usually fail, usually from the result of poor development plans, ineffective communication amongst team members, inefficient skills, and lack of leadership (O’Neal and Manley 2007). The complexity arising in change implementation is the result of the extensive relationship between various healthcare professionals, patients, and establishments (NICE 2007).
So therefore the success of a good change management depends on the leadership in place. A leadership is a method of influencingthe behaviour of a person in other toachieve a purpose set in a given time(Huber 2014). This involves influence, interactions, communications, and goal attainments. There are certain behaviours of leadership that will help a change/ improvement be successful and they include:
• Good interpersonal skills which includes delegation skills, team skills and effective conflict resolution (Zilembo and Monterosso 2008).
• Compassionate and supportive (Benson et al. 2008).
• Good management skills especially in relevant areas like finance, human resources and strategic planning and management (Jones and Sackett 2009).
• Broad and efficient knowledge in important aspects affecting the change like economic and finance management, administration processes, organisational and change theory, type of leaderships and the appropriate one to adopt and finally the legal and ethical implication of the proposed change (Heller et al. 2004).
NQN will develop leadership arise from conscious recognition of acceptable behaviours and qualities expected of a leader when in practice (Higgins et al. 2010). This can inspire them to be leaders in their future career (Daly et al. 2015). The perceptorshipprogramme offered to NQN boosts their confidence, competence and provides opportunity for skill development (DH 2010; Whitehead et al. 2013).
There are different types of leadership but only two will be discussed and one adopted. They are transactional and transformational leadership (Bass 1985).
It is believed that change is a slow and steady process (Giltinane 2013). In this type of leadership, an exchange occurs between the organisation and the worker in anticipation of a reward and knowledge that failure to deliver expected services can result in consequences and punishments (Lahovichien et al. 2009).
In this type, there is an improvement in the organisation because a relaxing environment has been created for each person to perform to their best of ability (Hutchinson and Jackson 2013). This type of leadership focuses on bringing about a positive change in a given situation (Burke 2008). According to Doody and Doody (2012), transformational skills are developed upon reflection, research on good leadership, and intellectual motivation (Huber 2014). This type of leadership, though complex, encourages effective communication and transparent leadership unlike transactional leadership (Thyer 2003).
It has been debated that successful leaders combine these two models ofleadership (Murphy 2005). This has been contradicted on its inapplicability inthe NHS because of the leadership can be from different health professionals (Mc Comb 2013). Good leadership is dependent on the ability of a leader to adjust to different circumstances which usually require the use of different management skills (Huber 2014). To implement a good and effective change proposed in the audit, the transformational leadership shall be adopted because it supports staff relationship, encourages the exchange of ideas amongst staff and impact positivity towards the proposed change.
It is recommended for the proposed change to be a planned change because a deliberate and joint effort brings about an improvement with the aid of a changeagent (Russell 2006).In nursing, planned change is the most popular and the recommended (Schifalacqua et al. 2009).Most change agents have been identified as nurse managers because of their skills in theory and implementation (Marquis and Huston 2008). Change theories are used to provide a structure for the implementation,management, and evaluation of successful change (Pearson et al. 2005). Nurses are mandated to deliver care based on best available evidence and practice (NMC 2015). This shows the need for a continuous change in practice to achieve the best practice.
The aim for change included treatment cost, lack of skilled power, new research, professional duties, the need to enhance patient satisfaction, and safe practice, bad leadership and poor communication(Burritt 2005; O`Neal and Manley 2007).
Change theory was first identified by Kurt Lewin. He developed a theory that identifies three stages to be completed for a successful change for a change to be successful it has to pass three stages (Lewin 1951). They are:
• Unfreezing- this is when change is needed
• Moving- this is when change is introduced
• Refreezing- this is when equilibrium is established
This model starts from scratch when building a new change and involves easy steps to follow. However it has been criticised for wasting time and staff exhaustion and will be suitable only for a small change (Burnes 2004).
Lewin’s theory was developed by two other theorists: Ronald Lippitt (Lippitt etal. 1985) and Everet Rogers (Rogers 1983).
Rogers (2003) identified five phases in a planned change, they include:
• Awareness
• Interest
• Evaluation
• Trial
• Adoption
While Lippitt et al. (1958) identified seven stages to be exhausted for a change to be effective. They include:
• Diagnose the problem
• Assess motivation/capacity for change
• Assess change agents motivation and resources
• Select progressive change objective
• Choose appropriate role of the chain agent
• Maintain change
• Terminate the helping relationship
Pearson et al. (2005) states that Lipitt’s theory is more detailed and supports the nursing process which are assessment,planning,implementation and evaluation. It also identifies that the Lappet’stheory involves a deeper understanding of change theory and will be more beneficial for nurse managers.
The last theorist to be discussed is JohnKotter (Kotter 1996). Fifty years after the introduction of Lewin’s (1947) three steps of change, John Kotter (Kotter 2012) developed these steps into eight steps for successful change. Kotter’s model has been applied to different sectors including healthcare to support a systematic change management. These eight steps are outlined below:
i. Establishing a Sense of Urgency:
The manager identifies and addresses the problem. The team is unified to move forward and implement the change (Kotter 2012). In this context EoLC demands urgency.
ii. Creating the Guiding Coalition:
The manager brings together the right people with the right skills for effective communication and to establish standards. The right people in my proposed audit are the ward managers, EoLC champion nurse, frontline nurses, patients, and their nominated representatives. The involvement of these stakeholders can help identify the barriers and facilitators to the planned changes. The facilitators are staff support and evidence of best practice that can improve the quality of life of EoLC patients and patient support. The barriers could be lack of cooperation and support from staff and patients, difficulty in getting consent from EoLC patients or their carers, and inappropriate documentation of ACP.
iii. Developing a Vision and Strategy:
The managerdevelops a strategy to underpin future possibilities. The proposed changes in this audit shall be discussed here with the stakeholders and a strategy will be developed on how to attain them. These changes are as follows:
• ACP should be completed upon admission
• Every EoLC patient should have a key worker
• A weekly meeting between EoLC champion nurse and the dying patients and their relatives.
• Regular re-auditing of ACP to sustain change
• ACP should show documentary evidence that the patients preferences on place of care till death
• ACP should indicate if the information displayed is for that admission or not.

iv. Communicatingthe Change Vision:
The manager communicates the vision to the staff on the need and importance for the change (Kotter 2012). In this regard, in my audit proposal, the chosen strategies and visions can be communicated during handover and discussed with patients and their relatives during the proposed weekly meeting with the EoLC champion nurses. In 1990, the Congress approved the Patient Self-Determination Act (PSDA) recommending hospitals, hospices, nursingservices and health maintenance establishments to carry out agendas that inform every adult patient upon admission about their legal rights concerning their healthcare decision-making (TheOmnibus Budget Reconciliation Act of 1989; 1990).
v. Empowering Employees for Action
The manager eliminates all barriers to enable staff to make changes. These barriers could be protocols, out-dated management policy, and bad language(Kotter 2012). It is recommended that solutions be broken down into smaller pieces than doing everything simultaneously(Cohen 2002).This applies to the changes in this audit proposal.

vi. Generating Short- Term Wins
It is recommended that managers should aim at achieving a number of small wins. This builds confidence and creates an opportunity for feedbackand evaluation of the project (Kotter 2012).
vii. Consolidating Gains and Producing more Change:
There is a risk of early celebration of success and stopping. To prevent this, the manager has to sustain a constant and balanced enthusiasm and remind staff how close they are to completing the project (Kotter 2012).
viii. Anchoring New Approaches in the Culture:
There is a risk of staff slipping back into old habits, so the manager should prevent this by recognising and rewarding new approaches and behaviours. New changes should be cultivated into daily practice and there should be regular staff orientation and revision of protocols and documents.
For an NQN, this model is easy and simple to follow.It has identified the gap between my recommendations in chapter two and practice, which could have a negative impact on patients. The involvement in team work will boost my confidence. It will alsofacilitate therealisation of the proposed changes in my audit proposal like incorporating the use of ACP into daily checklists, handovers,andpatient admission. This model creates room for orientation and further training for staff on EoLC.

Quality of life amongstacutely hospitalised aging patients receiving EoLCis recognised as a key clinical matter and can be tackled viaefficientuse of ACP according to the NICE NG31(2015).The proposed CAaudit outlinesan audit cycle and offers aframework where the recommendation makes a provision for supervision and changes implemented in practiceby means of good and efficient leadership,preferably a transactional leadership.An NQN is expected to experience challenges in practice, so it is recommended that the right change model and type of leadership be applied. Adopting Kotter’s theory (Kotter 2012) pre-emptively in practice will aid in eliminating and tackling those possible changes.



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National Institute for Health and Clinical Excellence, 2015.Care of dying adults in the last days of life. Available at: [Accessed 15th May 2016].

NICE NG31 (2015) Recommendation 6.6.10, p.108
“Explore with the dying person and those important to them:
•whether the dying person has an Advance Care Plan or has stated
preferences about their care in the last days of life (including any
anticipatory prescribing decisions or advance decisions to refuse
specific treatments)
•whether the dying person has understood and can remember the
information given about their prognosis.”


Audit Plan
Aim/Statement including client category and setting: to improve the quality of lives of patients receiving end of life care in an acute ward by ensuring they have an Advance Care Plan according to the guideline recommendation
Precise setting for audit:
An acute elderly ward in an NHS hospital

Guideline recommendation:
Explore with the dying person and those important to them:
•whether the dying person has an Advance Care Plan or has stated
preferences about their care in the last days of life (including any
anticipatory prescribing decisions or advance decisions to refuse
specific treatments)
•whether the dying person has understood and can remember the
information given about their prognosis.”

NICE NG31 (2015) PAGE 108
Standard Statement:
All dying adults should have an Advance Care Plan in place upon admission.

Patients receiving end of life care should be screened to ascertain if they have the capacity to make decisions.

Patients receiving end of life care should be communicated to about their prognosis to ascertain if they understood and can remember the given information concerning their prognosis.


Patients receiving end of life care preferences about where they would like to be cared for should be documented.

The current record about patient receiving end of life care must indicate if it’s from this admission
Audit Question(s)
• Is there documentary evidence that EoLC patients have an Advance Care Plan in place within 24 hours of admission to the ward?
. Are the EoLC patients’ preferences about where they would like to be cared for documented?
• Does the dying patient have a key worker?
• Is there a reminder to check for the Advance Care Plan in the daily handover for staff?
• Is the Advance Care Plan included in the daily task force as a reminder to the staff?
• Is there documentary evidence to establish that the dying patient and relatives were informed of a weekly meeting with the end of life care champion nurse?
• Is there documentary evidence showing that the patient was communicated to about her prognosis?
• Was the patient’s mental capacity established prior to planning her care?
• Was there a review of patients’ notes to check for an Advance Care Plan upon admission and a week later?
. Is this a current record from this admission?
Choice and meaning of

Patients receiving end of life care upon admissionshould have their Advance Care Plan in place to enable their care to be tailored according to their preferences and values.

This should be checked and documented daily to ensure patients preferences are considered when caring for them.
Main aspect is to determine if there is a Do Not Attempt Resuscitation (DNAR)
This shows the level of ward conformity with thestandards as identified by the NICE NG 31 (2006) Guideline
Source: Patients nursing/medical notes.
Data collection:

Retrospective review by end of life care champion nurse of medical/nursing notes and database of patients aged 65 years and above, who have been admitted in an acute ward for a month starting from April 7th 2016 till May 6th 2016. This is to check for documentary evidence of an Advance Care Plan.The data shall be validated by the ward manager after evaluating it for errors. • Recommended sample size should be between 20 and 50 for a qualitative study (UH Bristol, 2009) on end of life patients in an acute ward.
• Retrospective review means the medical/nursing notes are reviewed after treatment. This type of data collection is easily done since the data are already available (HQIP, 2010).Retrospective data collection reflects the standard of care delivered since the nurses are not observed when performing their duties.
• A major barrier in collecting data retrospectively is that the data may be irrelevant, out-dated(Ashmore et al., 2009a), and contain inaccurate statistics. This is because nurses use estimates when taking measurements (Geurden et al., 2012).

Analysis and Presentation:
Acompleted ACP ofpatients for the 4-week phase. This will include an advance statement stating patient’spreferences and wishes, lasting power of attorney, advance decision to refuse treatment and living wills(where applicable). Dataanalysis will show frequencies, values, meanand percentages of dying patients that have an advance care plan upon admission. These figures shall be displayed in Microsoft Excel two days after data collection and analysis.
• To ascertain how many patients receiving EoLC has an ACP in place in order to tailor their care in line with their preferences, wishes, and values.
• Collected data will be displayed on the ward board for the staff
• To create more awareness on how ACP can improve the quality of life of patients receiving end of life care.
• For all the stakeholders to recognise the essence of enhancing the practice in place so as to conform tothe standard of care statedin the recommendation (NICE NG31 2015)
Review evaluation:
Audit review will takeplace a week after the finalising the audit by the Leader of EoLC, EoLCchampion, and designated high-rankingmembers of staff, who make up the audit panel. The aim is to enhance the quality of service rendered in practice by:
• Evaluating the communication skills of staff when planning the patients advance care and when discussing their prognosis with them
• Discussing experiences and drawing lessons from them
• Recognising the sectors that require a change
Re-auditing Strategy:
Anaudit will be held every three months in order to make changes and maintain standards. According to Chamber & Wakle (2010),the aim of this strategy is to keep up with the service enhancement resulting from the audit cycle. This step involves the reassessment, evaluation and improvement of delivery of care to patients so as to improve the quality of life. This is usually done in a methodical process.

Stakeholder participation and the auditteam (includes ward manager, Head of EOLC, clinical staff in acute ward, EoLC patients, and their loved ones).
Audit meetings shall be held daily throughout the duration of data collection and analysis. • Stakeholders’ contributions are very important in an audit. It is recommended they get involved from the onset of the audit.
• The audit report is usually written by a nominated member of the staff and an audit facilitator.
• Ward manager has a duty of authenticating the data.
• Patients can be involved through the use of a questionnaire to voice their opinions.
• EoLC head and champion nurse have a duty to advice and make recommendations.
• All clinical staffs have a duty to comply and conform to policies and measures (NMC, 2015).

Ethical effects of an audit plan:
Right touse sensitive
data containedin patient medical
notes, confidential information,
storage, and locality of medical notes. A nurse has a duty of confidentiality towards her patients (NMC, 2015). This applies to all clinical staff, so patients’ sensitive details like name, date of birth and hospital numbers should never be recorded on the data collection form. This information should be recorded on a separate sheet.

Resources required to conduct an
Time needed for data collection and analysis.
Paper for recording and printing. To document and demonstrate data collected qualitatively and quantitatively


AUDIT: Advance Care Plan ACP completed upon Admission ACP completed in week 2 ACP completed in week 3 ACP completed in week 4
CODE Patient Name

Standard vs.Conformity
This is for demonstration purposes.

Weekly ACP Conformity % 93% 72% 70% 65%
Standard 100% 100% 100% 100%


My Myers-Briggs Type Indicator (MBTI) results

Extravert (9%) Sensing (9%) Feeling (53%) Judging (9%)

• You have slight preference of Extraversion over Introversion (9%)
• You have slight preference of Sensing over Intuition (9%)
• You have moderate preference of Feeling over thinking (53%)
• You have slight preference of Judging over Perceiving (9%)


• Good time keeping
• Hard worker
• Good team player
• Good organisation skills
• Excellent interpersonal skills
• Empathetic
• Very supportive
• Very friendly and warm to people
• Too emotional
• Displease myself to please others
• Cannot handle compliments
• Blames myself easily when something goes wrong
• Tries to do everything all by myself
• Uncomfortable

• I plan to utilise my 6th placement which is in the Accident and Emergency unit. I will improve my leadership skills and build more confidence in delegating duties to other clinical staff where applicable.
• I will try and get on training courses to acquire more skills.
• I will spend time with EoLC champion nurses to gain an insight into the skills in palliative care.
• I will be present in MDTs meetings and ward rounds to gain a deeper understanding of how other healthcare professionals work with each other.

• Fear of not getting enough support from my mentor
• Fear of not blending in with the rest of the staff
• Fear of not getting enough support from the staff
• Fear of not being supported in my perceptorship

Personal Development Plan (PDP)

There is a need to learn how to be an effective leader and enhance my management skills and apply them when delegating duties Leadership skills to boost confidence of a newly qualified nurse. This confidence will enhance my delegation skills to healthcare professionals and staff nurses

To be in charge of a bay with at least six patients and manage them effectively

During my placement 6:
31st May 2016 – 18th August 2016
Successfully accomplished the competencies required in the practice document assessment.

Delivering high-quality care safely by being confident and competent in my duties as a newly qualified nurse especially when delegating duties to other clinical staff

Need to learn to be courageous and assertive to advocate for patients and challenge bad practice Be courageous to voice my concerns in orthodox practice
Discuss concerns in practice with my mentor
To be a voice for patients when needed
To be a role model
To demonstrate my clinical skills

During my placement 6:
31st May 2016 – 18th August 2016
Confident, competent and courageous whenperforming any clinical skills in practice
The need to learn accountability, competency, responsibility and safe practice Showing accountability in practice and being responsible for delivering safe practice

Boosting my leadership skills, confidence,and competency in my perceptorship course.
During my placement 6:
31st May 2016 – 18th August 2016

During one month of perceptorship

Confident, competent and courageous when performing clinical skills in practice.

Accomplished the competencies required in the practice document assessment

1. People approaching the end of life are identified in a timely way.
2. People approaching the end of life and their families and carers are
communicated with, and offered information, in an accessible and sensitive way
in response to their needs and preferences.
3. People approaching the end of life are offered comprehensive holistic
assessments in response to their changing needs and preferences, with the
opportunity to discuss, develop and review a personalised care plan for current
and future support and treatment.
4. People approaching the end of life have their physical and specific psychological
needs safely, effectively and appropriately met at any time of day or night,
including access to medicines and equipment.
5. People approaching the end of life are offered timely personalised support for
their social, practical and emotional needs, which is appropriate to their
preferences, and maximises independence and social participation for as long as
6. People approaching the end of life are offered spiritual and religious support
appropriate to their needs and preferences.
7. Families and carers of people approaching the end of life are offered
comprehensive holistic assessments in response to their changing needs and
preferences, and holistic support appropriate to their current needs and
8. People approaching the end of life receive consistent care that is coordinated
effectively across all relevant settings and services at any time of day or night,
and delivered by practitioners who are aware of the person’s current medical
condition, care plan and preferences.
9. People approaching the end of life who experience a crisis at any time of day or
night receive prompt, safe and effective urgent care appropriate to their needs
and preferences.
10.People approaching the end of life who may benefit from specialist palliative care,
are offered this care in a timely way appropriate to their needs and preferences,
at any time of day or night.
11.People in the last days of life are identified in a timely way and have their care
coordinated and delivered in accordance with their personalised care plan,
including rapid access to holistic support, equipment and administration of
12.The body of a person who has died is cared for in a culturally sensitive and
dignified manner.
13.Families and carers of people who have died receive timely verification and
certification of the death.
14.People closely affected by a death are communicated with in a sensitive way and
are offered immediate and on-going bereavement, emotional and spiritual support
appropriate to their needs and preferences.
15.Health and social care workers have the knowledge, skills and attitudes
necessary to be competent to provide high-quality care and support for people
approaching the end of life and their families and carers.
16.Generalist and specialist services providing care for people approaching the end
of life and their families and carers have a multidisciplinary workforce sufficient in
number and skill mix to provide high-quality care and support