Date of Award

Summer 2022

Document Type

Final DNP Paper

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Dr. Lori McGrath


Dr. Jennifer Courtney


Background: The World Health Organization and the American Society of Clinical Oncology guidelines endorses mandatory communication skills training in care goals for seriously ill patients (Back et al., 2019). In one survey of primary care providers (PCP), 68% reported no formal training to discuss advance care planning (Comer et al., 2020). Advance care planning is essential to manage chronic conditions in our growing aging population to provide the best patient care. This manuscript aimed to discuss best practices and techniques in advance care planning and optimize skills to provide patient-centered care conversations that honor patient wishes, reduce unwanted hospitalizations, and focus on the patient’s quality of life.

Purpose: The Doctor of Nursing Practice (DNP) project was a process improvement initiative in the home-based community setting. The nurse practitioner/DNP candidate educated nurse practitioners who participate in advance care planning. This project utilized REMAP: Reframe, Expect emotion, Map out values, and Plan (Addressing Goals of Care: Smoothing Discussions About Prognosis and Treatment, n.d.). Outcome measurements were completed advance care planning documentation. These were measured pre-and post-project implementation.

Methods: The DNP project was a 9-week study examining ACP upload rates. Ten nurse practitioners participated in this project with a 100% participation rate. Each week, the number of patients with and without ACP uploads was recorded.

Results: According to a simple linear regression analysis, the trend noted was an increase in ACP document completion and uploads (See Table 3). The investigation noted that the B-coefficient weekly was positive (0.17), indicating that ACP upload rates increased as the study progressed. This project had a value of p=0.46. Therefore, the study did not reflect a statistically significant change in the ACP upload rates.

Conclusion: Using REMAP within provider training could increase ACP documentation over time. Although this 9-week intervention was not statistically significant, a lengthier timeframe could show significance.

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