improving informed decision making is essential for supportive end of life care [ 15 ] . cardiopulmonary resuscitation
( cpr ) preferences are the most common end of life discussion but occur infrequently and vary in content [ 1 , 2 ] .
patients may not have the basic information needed and the timing for the discussion may be inappropriate [ 68 ] .
patient decision support focuses on providing the patient and families with practical information and resources .
cpr preferences may also be overlooked or set aside by practitioners because it is a value - sensitive decision or because it is not identified as a high priority discussion [ 1 , 3 , 6 , 9 ] .
value - sensitive decisions would benefit from a patient decision aid , where the patient is recognized as an expert in judging his / her own values [ 1013 ] .
patients who need to address cpr status would benefit from health care professionals comfortable and familiar with providing patient decision support .
cpr status is one of the most important health decisions and requires careful consideration of all alternatives and the consequences . for seriously ill patients ,
cpr preferences are commonly set aside and communication between the patient , family , and health care team is lacking information and followup .
this project took place at the ottawa hospital , acute monitor area ( ama ) unit .
this six - bed unit specializes in acute care , managing patients with a variety of complex medical conditions such as chronic obstructive pulmonary disease , congestive heart failure , pneumonia , and multisystem failure disorders .  
the goal of this project was to implement a publically available patient decision aid for cpr status and to identify any factors which limit or encourage its use .
the objectives were to identify nursing perceptions regarding patient decision support before and after using a patient decision aid regarding cpr , clarify any barriers and facilitators influencing the provision of a patient decision aid regarding cpr , and determine whether nursing perceptions of patient decision support can be positively influenced with a brief , theory - based , skill building educational intervention .
this pilot project has focused on the efficacy of providing nursing specific patient decision support .
a literature review was conducted to identify scholarly english publications pertaining to  cardiopulmonary resuscitation preferences ,   end of life treatment ,   patient decision support ,   decision making ,  and  patient decision aids  in pubmed , psycinfo , cinahl , proquest nursing and allied health , and the cochrane database of systematic reviews .
grey literature searches were also conducted through the registered nurses ' association of ontario ( rnao ) , college of nurses of ontario ( cno ) , and the ottawa hospital research institute ( ohri ) websites .
it has been identified by heyland and colleagues   through the canadian health care evaluation project ( canhelp ) that better planning for end of life care including enhanced relationships with physicians and improving communication and decision making needs to be addressed in many canadian hospitals .
reliable information regarding the patient 's condition , understandable explanations for their situation , and addressing patients psychosocial feelings were also rated as high priorities .
the cno practice guideline , guiding decisions about end - of - life care   indicates that clear communication between the patient , nurse , and the interprofessional team facilitates implementation of patient 's wishes regarding end of life treatment .
it is evidenced that a comprehensive and consistent way to address cpr status for seriously ill patients should be established and facilitated in the canadian hospitals .
it has been determined that seriously ill patients have poor knowledge about what cpr entails and their role in the decision making process regarding their cpr status [ 6 , 15 ] .
participants in any decision may not have all the necessary information to make an informed choice and the timing of the discussion may be inappropriate [ 6 , 8 ] .
cpr in particular is a sensitive subject in which all involved in the discussion can appraise differently , even the health care team .
the literature on patient decision support has increased a great deal since o'connor and colleagues published their work in 1998 .
patients want to be educated about their treatments and have an autonomous role in their care [ 5 , 16 ] .
there is a stress on the importance of knowing options and being able to provide that information to patients [ 16 , 17 ] .
nurses have a unique relationship with patients ; they can provide valuable support when they are faced with difficult decisions .
decisional conflict means that there is uncertainty about which course of action to take [ 10 , 18 ] .
many issues contribute to decisional conflict and patients are likely to experience uncertainty to some degree when a decision is difficult to weigh .
when one needs to consider risk , loss , or a challenge to their personal values conflict can arise .
improving informed decision making is essential for supportive end of life care where the patient 's goals of care are clear and communicated , thus reducing uncertainty [ 1 , 35 , 20 ] .  
patient decision aids reduce uncertainty , improve knowledge , generate realistic expectations , and clarify personal values .
these are evidence - based tools that can include outcome statistics and patient experiences for a variety of disease specific issues .
they help people in making difficult decisions that are consistent with their personal values [ 12 , 22 ] .  
however , shared decision making has not been embraced by all health professionals and barriers have been identified which limit the use of patient decision aids .
an evaluation of nurses ' perceptions with the use of a cpr patient decision aid can clarify issues with its use and can lead to sustainable utilization of the aid [ 13 , 24 , 25 ] .   the ottawa decision support framework odsf ( 1998 ) developed by annette o'connor and
this concrete , midrange theory focuses on decisional needs , decision quality , and decision support .
it can guide gaining decision support skills through a practical and structured approach [ 10 , 18 , 26 ] .
it uses a three - step process to  assess client and practitioner determinants of decisions to identify decision support needs , provide decision support tailored to client needs , and evaluate the decision making process and outcomes  .
the theoretical underpinnings of the odsf include decision theories in economics , psychology , social psychology , decisional conflict , and social support [ 32 , 33 ] .  
the main assumption of the odsf is that patients will likely select the choice that they believe is their best alternative which aligns with their personal values [ 10 , 26 ] .
access to all the necessary resources to realize their choice through clear information when the issues are discussed is also a part of the main assumption [ 10 , 26 ] .
personal ( patient ) and practitioner characteristics influence the decision making process as well , but knowledge is a key . providing information for patient options include specific information on benefits and harms , clarification of values associated with each option , ways to manage the views or pressures of others involved in the decision making process , and skills on implementing decisions .
decision aids clarify values and address unmet decisional needs or conflict by asking individuals to identify personal importance of issues and evaluate each risk and benefit that influences their decision [ 18 , 34 ] . specifically , patient decision aids need to include the following elements : ( 1 ) information tailored to the patients health condition , ( 2 ) a value clarification exercise , ( 3 ) examples from other patients in similar circumstances , ( 4 ) guidance toward shared decision making , and ( 5 ) a medium such as a paper tool or interactive computer guide to present the information [ 12 , 22 ] .
patient decision aids can guide tailored decision support which focuses on patient 's needs .  
decision support is provided until decisional conflict is resolved and a quality decision is reached . then aiding implementation and monitoring of the decision
occur [ 4 , 10 ] . during the evaluation stage of the odsf , an understanding of the quality of decision making and outcomes
informed decisions , ones that are consistent with personal values and that are determined by the patient to be the best alternative , are the result [ 10 , 26 ] . in theory , the patient completing this process as intended will lead to overall satisfaction with their choice , quality of life , and adherence with their decision because it is informed by their values and resources [ 4 , 34 ] .
quality decisions are informed by the best available evidence and are based on the values of the patient [ 22 , 35 ] .
specifically , the odsf guided this project to address unmet decisional needs or decisional conflict where uncertainty regarding the best choice for cpr status was identified in seriously ill patients .
realistic expectations were discussed , evidenced - based information was reviewed , support and resources were appraised , and patient values were considered [ 5 , 10 ] . appraising and articulating a patient 's cpr wishes through clear communication and implementation are congruent with this framework .
the criteria involved in the odsf are appropriate to the established project goal and objectives and thus are a straightforward justification for the choice of framework used . through the provision of decision support using a cpr decision aid in combination with decision coaching and counselling ,
the intervention design involved three steps including ( 1 ) conducting a pretest , ( 2 ) educating the nurses on patient decision support and the cpr decision aid , and ( 3 ) conducting a posttest .   
it was identified during discussions with nurses who work in the ama and their nurse educator ( the project advisor ) that frequently a patient 's cpr status is not addressed in a timely manner .
it was repeatedly suggested that an improvement needs to be made to address the patient 's information and communication needs regarding cpr status .
the discussions lead to an intervention focused on influencing nursing knowledge of patient decision support , uptake of a cpr decision aid , and identifying facilitators and barriers to its use [ 13 , 23 , 26 , 36 , 37 ] .
graham and colleagues   found that most health care practitioners are willing to use patient decision aids , given that adequate education and support are provided .   
all registered nurses who work in the ama unit were approached to participate in the education session . due to time constraints and that there were other quality improvement initiatives being implemented concurrently , it was decided that only a brief and basic education session would be offered .
the education session consisted of an introduction to why the project was being implemented , what patient decision support is , and an overview of the cpr patient decision aid . taking approximately 510 minutes ,
nurses were guided individually or in small groups through part one of the ottawa decision support tutorial , odst , and the decision support aid .
after having received the education , the nurses were requested to provide patient decision support for cpr preference using the patient decision aid based on clinical opportunities and appropriateness [ 17 , 26 , 37 ] .
basic knowledge regarding patient decision support is needed to work effectively with patient decision aids [ 13 , 23 ] . with background knowledge of patient decision support ,
the participants needed to identify using their clinical judgment if a patient would benefit from the cpr decision aid .
promotion of the patient decision aid was accomplished by going to the ama unit frequently to check on uptake and being available to answer questions .
two posters were also strategically placed on the unit , acting as a reminder .   each ottawa hospital form for code status was affixed with the cpr decision aid to prompt each nurse to its use .
nurses were advised that if a cpr decision aid was initiated and/or completed they were to write in the interprofessional progress notes in the patient 's medical record of this .
it was also asked that this information should be communicated to other team members in the patient 's daily care plan .
both qualitative and quantitative measures were used to collect information . before and after intervention questionnaires were the primary means of information collection .
consequently , the questionnaires developed were influenced by a study conducted by stacey and colleagues   to determine factors influencing decision support by call center nurses .
for this project , the number of questions was reduced due to the project scope and objectives and was modified to fit the clinical setting .
the questionnaire 's design reflects the current literature on health care professionals ' perceptions of patient decision support and decision aids [ 12 , 23 ] .
the questionnaires were designed to be clear and concise using a five - point likert scale to encourage the participation in attaining data .
the questionnaires also have a section to generate nurses ' views using an open - ended question format [ 40 , 41 ] .
questionnaires were used because of their ability to gather data easily and for their capacity to examine notable differences in responses after the initiated intervention [ 42 , 43 ] .
specifically responses were grouped into one of two categories , facilitators or barriers , and were grouped after each batch of questionnaires was received .
qualitative reports were used to gather data on the impacts on practice and participant 's views on the project which may not be captured with the questionnaires .
open - ended questions were directed to the ama nurses as appropriate , such as  what do you think of patient decision support ?  and  what has been your experience with patient decision support ?   
questionnaires were given to all ama nurses who signed consent and agreed to participate in the project immediately before each education session .
all nurses had an average of five weeks or more to use the patient decision aid .
all participants who agreed to complete the post questionnaire were entered into a draw for two gift baskets .
descriptive statistic methods were used to analyze questionnaire responses and content analysis was used in reviewing the qualitative reports .
there are currently 26 nurses who are trained to work in the ama . of those nurses ,
3 were on maternity leave , 2 declined to participate and 21 agreed to take part in the educational session and before intervention questionnaire ( n = 21 ) .
the age range of participants was 2552 years and the average age of participants was 37.8 years .
not all nurses who initially agreed to take part in the project continued their participation . sixteen agreed to participate in the after intervention questionnaire ( n = 16/21 ) .
age range was 2752 years , average age was 37.8 years , 19% were male , and the average amount of nursing experience was 11.3 years . to participate in the after intervention questionnaire
participants were asked to rate how strongly they agree or disagree with certain statements .  
the results indicate that most respondents agree or strongly agree that using a patient decision aid would be beneficial to the patient and that more education should be directed toward nurses to provide decision support .
the results were negatively skewed when asked if they felt confident in providing patient decision support .  
most nurses responded that they agree or strongly agree that decision aids for cpr was / is useful .  
the following points were recognized in the questionnaire and field note results for facilitators / benefits to patient decision support and aids : a team understanding of the patient condition and status , better communication , a standardized way to present information and a knowledge tool for nurses , supported by the literature , evidenced - based information , clear understanding of what cpr is and the risks / benefits , support for when patient is not able to make their own decision ( family involved ) . a team understanding of the patient condition and status , better communication , a standardized way to present information and a knowledge tool for nurses , supported by the literature , evidenced - based information , clear understanding of what cpr is and the risks / benefits , support for when patient is not able to make their own decision ( family involved ) .
the following points were recognized in the questionnaire and field notes results for barriers / limitations to patient decision support and aids : language barriers , cultural difference , not appropriate for all , family conflict , their lack of understanding or misconceptions , available time to discuss with patient and family , patient not emotionally ready for discussions , patient decision aid was too condition specific ; too rigid , patients / families not accepting nursing support on this ( not their role ) .
language barriers , cultural difference , not appropriate for all , family conflict , their lack of understanding or misconceptions , available time to discuss with patient and family , patient not emotionally ready for discussions , patient decision aid was too condition specific ; too rigid , patients / families not accepting nursing support on this ( not their role ) .
many nurses commented that they had limited opportunities to use the patient decision aid for cpr , but did identify that they used patient decision support for other issues .
a few nurses stated that cpr status should be determined on admission to hospital and be completed routinely for all patients .
there were varied views regarding evaluating cpr status on admission versus at a time of health crisis .
some said it should be addressed for every patient , despite health status , and some indicated that only when death may be imminent it should be discussed . some nurses stated that they did not see this as a part of their role or something that they wish to partake in .
others thought that this was completely within the nursing realm and were eager to support patients with making an informed cpr choice .
most nurses agreed with the components of a shared decision making model . after reviewing the data collected it was evident that most nurses were willing to use the patient decision aid because they see it as helping the patient make informed , value - based decisions .
when nurses feel they have the knowledge and skill to provide decision support they do so because they believe that they are helping the patient toward a better realization of their condition .
the education session and patient decision aid intervention did not seem to significantly influence questionnaire scores , but it was observed with qualitative observations that the nurses felt more knowledgeable and confident with providing patient decision support .  
specific barriers to providing patient decision support were identified as cultural or language influences , time constraints , rigid application , patient 's emotional adversity , and physician preference for this role .
these mirror what has been found in the literature [ 13 , 23 , 36 ] .
specific facilitators identified included communication enhancement , clear and understandable knowledge base , and the ability to include family in the decision making process .
there is a limited amount of literature that describes patient decision support facilitators and even less focus on family involvement .
data were collected from self - report and observations , not from a validated tool ; thus obvious sources of bias were present .
the information collected was helpful in this specific clinical setting but can not be generalized to others .
there were only six weeks where the patient decision aid was implemented and the opportunity for its use did not come readily .
most nurses welcomed this intervention but some were obviously stressed at the fact that they were approached to participate as evidenced by their body language and facial expressions .
this project may have been better received during a less demanding time for nurse involvement .  
this project identified that cpr status specifically can be appraised by a nurse to be a difficult topic , too patient specific to use a patient decision aid , or confident that this would be used as a guide to improve patients ' knowledge of options and the provision of support .
cpr status is value - sensitive topic , but it is not beyond what normally would be encountered by a practicing nurse . addressing unclear values , information needs , and resources
effectively will reduce nursing contributing factors to clouding difficult decisions [ 5 , 11 ] .
patient decision aids are designed to be evidenced based and patient focused and are intended to be used as a guide .
daily nursing practice should reflect a therapeutic relationship between the patient and nurse toward helping the patient make informed and supported decisions through the provision of patient decision support .
based on this quality improvement project , a practice change towards supporting patients to be more educated and involved in their decision making is a priority . since nurses work in close proximity with the patient and their families and spend much time involved in their care , they are the most appropriate professionals to discuss cpr preferences using a shared - decision making model [ 23 , 36 , 44 ]
. further education on when to implement a patient decision aid for values sensitive topics would be appropriate .
strategically educating certain nurses on patient decision support may create an effective role for its implementation . over time challenging traditional health care roles will allow nurses to support the patient effectively through the provision of patient decision support .   challenging the barriers to implementing patient decision support and enhancing the facilitating factors will eventually disclose the benefits of its use .
this project identified some of those factors within the acute monitor area at the ottawa hospital .
dedication and commitment to supporting patient decision support and the cardiopulmonary resuscitation decision aid will help to support patients facing these difficult situations .
 the decision whether to receive cardiopulmonary resuscitation ( cpr ) is a decision in which the personal values of the patient must be considered along with information about the risks and benefits of the treatment . 
 a decision aid can be used to provide patient decision support to a patient who is seriously ill and needs to consider cpr options . 
 the goal of this project was to identify the barriers and facilitators to using a cpr decision aid , through evaluating nursing perceptions on providing patient decision support . using a needs assessment , it was determined that implementing a patient decision aid for cpr status in the acute monitor area ( ama ) of the ottawa hospital would be an excellent quality improvement project . the nurses who chose to participate were given an education session regarding patient decision support . 
 questionnaires were distributed to evaluate their views of patient decision support and decision aids before and after the education session and implementation of the cpr decision aid . 
 questionnaire results did not indicate a significant change between before or after education session and decision aid implementation . 
 qualitative reports did indicate that nurses generally have positive attitudes toward patient decision support and decision aids . 
 the nurses identified specific barriers and facilitators in their commentaries . 
 this clinically relevant data supports the idea that patient decision support should be integrated into daily nursing practice . 
1. Introduction
2. Methods
3. Literature Review
4. Intervention
5. Evaluation
6. Results and Discussion
7. Conclusion