What is Hospice? An Evidence-Based Educational Video for Interdisciplinary Teams Caring for Residents Living in Long-Term Care

Objective: To identify gaps in knowledge, confidence, and training about hospice care among interdisciplinary team (IDT) staff in long-term care (LTC) communities and develop an evidence-based educational intervention to address these needs.; Background: As the population of older adults with life-limiting illnesses continues to grow in the United States, the demand for high-quality hospice care in LTC settings is rising. Effective hospice care depends on the knowledge, confidence, and communication skills of LTC staff. Addressing these gaps is critical to improving end-of-life care and supporting residents and their families during hospice transitions. Methods: This three-phase project culminated in the development and evaluation of a hospice education video tailored for IDT-LTC staff. • Phase 1: A needs assessment survey measured staff knowledge, confidence, and barriers to hospice training. • Phase 2: Qualitative feedback from three university faculty content experts guided revisions to the lesson plan and educational video. • Phase 3: Quantitative and qualitative feedback from three IDT-LTC staff members evaluated the video's quality, utility, and feasibility for future training. Results: The needs assessment revealed limited knowledge of hospice definitions (M = 2.0, SD = 0.5) and eligibility criteria (M = 2.5, SD = 0.7), as well as low confidence in discussing end-of-life topics with residents and families (M = 2.5, SD = 0.7). Expert feedback emphasized the importance of culturally inclusive language, accessible content, and addressing common misconceptions about hospice care. Community feedback rated the video highly in quality (M = 4.7, SD = 0.3) and utility (M = 4.6, SD = 0.4) but highlighted the need for greater clarity on hospice eligibility and service offerings.; Conclusion: This project identified critical gaps in hospice knowledge and training among LTC staff and developed an educational video informed by theoretical frameworks, including the Interdisciplinary Framework and Dual Channel Theory. The video, designed to be learner-centered and accessible, addresses these gaps while promoting compassionate, holistic care. The resource has potential applications in in-service training, academic settings, and public education, contributing to the broader goal of improving hospice care quality and accessibility in LTC communities.

WHAT IS HOSPICE? 1 What is Hospice? An Evidence-Based Educational Video for Interdisciplinary Teams Caring for Residents Living in Long-Term Care Oakli Jo McGary A project defense submitted to the faculty of The University of Utah in fulfillment of the requirements for the degree of Master of Science in Gerontology The University of Utah December 12, 2023 2 Table of Contents Introduction ............................................................................................................................................. 7 Background ............................................................................................................................................. 8 Clinical Gap ............................................................................................................................................. 8 Project Purpose ....................................................................................................................................... 9 Project Questions .................................................................................................................................... 9 Project Significance .............................................................................................................................. 10 CHAPTER 2 .............................................................................................................................................. 12 Literature Review ..................................................................................................................................... 12 Purpose .................................................................................................................................................. 12 Background ........................................................................................................................................... 12 LTC Hospice Education & Communication ...................................................................................... 13 Medical Students & Providers Lacking Confidence in EOL Care Discussions .............................. 14 Barriers to IDT—LTC Hospice Education & EOL Care ................................................................. 15 Resident, Family Care Partners, and Staff Knowledge about Hospice Care................................... 16 Family Engagement with EOL Care Decisions ................................................................................ 17 Barriers to Providing Hospice Care in LTC Communities ............................................................... 20 Perceptions about Hospice Care and Deaths in LTC Communities ................................................ 20 Barriers to Care Once in Hospice ........................................................................................................ 21 Perceptions about Hospice Care and Deaths in LTC Communities ................................................ 22 Staff & Resident Relationships During End of Life ......................................................................... 23 Hospice Education Resources and Curriculum ................................................................................. 24 Asynchronous Hospice Education ....................................................................................................... 25 Conclusion ............................................................................................................................................. 25 CHAPTER 3 .............................................................................................................................................. 26 Methods...................................................................................................................................................... 26 Project Purpose ..................................................................................................................................... 26 Project Questions .................................................................................................................................. 26 Theoretical Frameworks that Informed the Project.......................................................................... 27 Interdisciplinary Framework for Palliative Care and Hospice Education Practice ....................... 28 Dual-Channel Theory ........................................................................................................................ 29 Project Design............................................................................................................................................ 31 Phase 1: Assessing Knowledge Gaps ................................................................................................... 31 Phase 2: Curriculum Development and Evaluation .......................................................................... 31 3 Project Setting and Population ............................................................................................................ 32 Sampling & Recruitment ..................................................................................................................... 32 Ethical Considerations.......................................................................................................................... 34 Materials and Measures ...................................................................................................................... 34 Education Video Development ............................................................................................................. 36 Data Collection Procedures .................................................................................................................. 37 CHAPTER 5 .............................................................................................................................................. 39 RESULTS .................................................................................................................................................. 39 Overview ................................................................................................................................................ 39 Phase I Survey Results of LTC Staff ................................................................................................... 39 Demographic Survey .......................................................................................................................... 39 Needs Assessment Survey .................................................................................................................. 41 Integration of Theoretical Frameworks .............................................................................................. 43 Phase II Lesson plan Construction and Feedback on the PPT Educational Video ........................ 44 Lesson plan Feedback ........................................................................................................................ 44 Education Video Feedback ................................................................................................................ 45 Phase III Community Feedback .......................................................................................................... 46 Conclusion ............................................................................................................................................. 48 CHAPTER 6 .............................................................................................................................................. 49 Discussion .................................................................................................................................................. 49 Project Question 1 Discussion .............................................................................................................. 49 Integration and Impact of Theoretical Frameworks ......................................................................... 50 Impact of the Interdisciplinary Frameworks ..................................................................................... 51 Project Question 2 Discussion .............................................................................................................. 53 Project Question 3 Discussion .............................................................................................................. 55 Project Question 4 Discussion .............................................................................................................. 56 Project Limitations ............................................................................................................................... 57 Project Implications .............................................................................................................................. 59 Future Project Dissemination .............................................................................................................. 60 Future Training Opportunities ............................................................................................................ 61 CHAPTER 7 .............................................................................................................................................. 63 Conclusion ................................................................................................................................................. 63 References .................................................................................................................................................. 66 Appendix A ................................................................................................................................................ 71 4 Participant Waiver of Consent Form ...................................................................................................... 71 Appendix B ................................................................................................................................................ 73 Demographic Questionnaire .................................................................................................................... 73 Appendix C: ............................................................................................................................................... 75 Hospice Care Needs Assessment Questionnaire ..................................................................................... 75 Appendix D ................................................................................................................................................ 78 Appendix E: ............................................................................................................................................... 83 LTC Staff Community Feedback Survey ............................................................................................... 83 5 Abstract Objective: To identify gaps in knowledge, confidence, and training about hospice care among interdisciplinary team (IDT) staff in long-term care (LTC) communities and develop an evidence-based educational intervention to address these needs. Background: As the population of older adults with life-limiting illnesses continues to grow in the United States, the demand for high-quality hospice care in LTC settings is rising. Effective hospice care depends on the knowledge, confidence, and communication skills of LTC staff. Addressing these gaps is critical to improving end-of-life care and supporting residents and their families during hospice transitions. Methods: This three-phase project culminated in the development and evaluation of a hospice education video tailored for IDT—LTC staff. • Phase 1: A needs assessment survey measured staff knowledge, confidence, and barriers to hospice training. • Phase 2: Qualitative feedback from three university faculty content experts guided revisions to the lesson plan and educational video. • Phase 3: Quantitative and qualitative feedback from three IDT—LTC staff members evaluated the video’s quality, utility, and feasibility for future training. Results: The needs assessment revealed limited knowledge of hospice definitions (M = 2.0, SD = 0.5) and eligibility criteria (M = 2.5, SD = 0.7), as well as low confidence in discussing end-oflife topics with residents and families (M = 2.5, SD = 0.7). Expert feedback emphasized the importance of culturally inclusive language, accessible content, and addressing common 6 misconceptions about hospice care. Community feedback rated the video highly in quality (M = 4.7, SD = 0.3) and utility (M = 4.6, SD = 0.4) but highlighted the need for greater clarity on hospice eligibility and service offerings. Conclusion: This project identified critical gaps in hospice knowledge and training among LTC staff and developed an educational video informed by theoretical frameworks, including the Interdisciplinary Framework and Dual Channel Theory. The video, designed to be learnercentered and accessible, addresses these gaps while promoting compassionate, holistic care. The resource has potential applications in in-service training, academic settings, and public education, contributing to the broader goal of improving hospice care quality and accessibility in LTC communities. 7 CHAPTER 1 Introduction Hospice care is a critical service provided to residents in skilled nursing facilities (SNF) and long-term care (LTC) communities at the end of life (EOL) (National Institute on Aging, 2021). The Centers for Medicare and Medicaid define hospice as a "comprehensive, holistic program of care and support for terminally ill patients and their families," emphasizing comfort and palliative care over curing the illness (CMS, n.d., para 1). Hospice encompasses interdisciplinary teams (IDTs) offering a range of services, including medical care, nursing care, pain and symptom management, physical and occupational therapy, social work, grief counseling, and spiritual support (CMS, n.d.). Research indicated that hospice services significantly benefit older adults with life-limiting illnesses (e.g., advanced-stage cancer, endstage heart failure, advanced respiratory disease, and neurodegenerative conditions such as late Alzheimer’s disease) in LTC communities, enhancing EOL outcomes and care quality (Ersek et al., 2022). As the population of older adults in LTC communities requiring hospice services grows in the United States (Hospice Facts & Figures, 2022), the need for enhanced hospice education for IDT—LTC staff becomes increasingly apparent (Ersek et al., 2022). Ersek and colleagues (2022) highlight serious gaps in hospice knowledge and skills among nursing home staff, leading to poor symptom management and reduced quality of life for older adults at the EOL. Improved training for nursing home staff is essential to empower them for appropriate and effective EOL discussions and the delivery of skilled, person-centered care. 8 Background Between 2023-2025, an estimated 73 million individuals (about twice the population of California) aged 65 and older will exist, intensifying the demand for hospice services (CBO, 2023). This, coupled with a rising number of older adults with life-limiting illnesses, has led to a significant increase in the demand for hospice services (Cagle et al., 2020). In 2020, 1.72 million Medicare beneficiaries received hospice services from approximately 5,058 Medicare-certified hospices, marking a 7% increase from 2019 (Hospital Facts and Figures, 2022). Notably, Ersek and colleagues (2022) found that 17% of the 1.1 million Medicare beneficiaries who died in 2018 while receiving hospice services were residing in nursing homes (National Hospice and Palliative Care Organization, 2021), making these settings one of the fastest growing for hospice services. Previous research has highlighted significant deficits in palliative and hospice care training for nursing home staff, leading to decreased quality of care and life at the EOL (Ersek et al., 2022; Frearson, 2019). With the increased provision of hospice services in LTC communities, there is a parallel need for adequate training and support for nursing home providers and IDT-LTC staff responsible for hospice education and support to residents and their families (Frearson, 2019). Clinical Gap Despite the increasing demand for hospice services in LTC communities, there exists a significant gap in general hospice care education and training. A project among nursing home staff reported that 70% of certified nursing assistants (CNAs) felt unprepared to provide EOL care due to a lack of prior education and training (Mohlman et al., 2018). Another project demonstrated a positive association between nurses' knowledge of EOL care and their improved 9 attitudes toward providing palliative care, underscoring the importance of education in shaping positive attitudes among LTC nurses (Wilson et al., 2016). However, a persistent lack of hospice training among nursing home staff in LTCs negatively impacts both care quality and the quality of life for older adults in these communities (Ersek et al., 2022; Frearson, 2019; Griffiths, 2019). Project Purpose This project aimed to develop and evaluate a hospice education video addressing knowledge gaps and enhancing skills for IDT—LTC staff to engage in EOL discussions and provide skilled, person-centered care during and after a hospice transition. The development of the educational video was guided by two theoretical frameworks: the Interdisciplinary Framework for Palliative and Hospice Education and Practice by MacLeod-Dyess and colleagues (2020) and a video-based education model based on the Dual-Channel Processing and Cognitive Load Theory (Krum et al., 2022). Additionally, an Eight-Step Approach outlined by Krum and colleagues (2022) was employed. The product, an evidence-based hospice education video for IDT-LTC staff was created and evaluated by content experts and LTC staff in the community to gain insights into the video’s quality, utility, and feasibility for use in IDT—LTC staff training. The ultimate goal will be to disseminate the video to the Utah Geriatric Education Consortium (UGEC) website for use as an effective training tool to improve the care and quality of life of older adults living in LTC communities during and after a transition to hospice. Project Questions This project addressed four key questions: 1) What is the current hospice knowledge among IDT members working in LTC communities? 10 2) After reviewing the educational video lesson plan, objectives, and learning outcomes, what feedback and recommendations are provided by a palliative care content expert faculty panel? 3) After viewing the educational video, what feedback and recommendations are provided by a palliative care content expert faculty panel in terms of quality and appropriateness of the content? 4) After viewing the educational video, what feedback do LTC staff have in terms of the video’s quality, utility, and feasibility for staff training on hospice care? The project focused on hospice care knowledge and training deficits of IDT—LTC staff and the development and evaluation of a hospice care education video for this specific audience. Findings were limited to LTC communities, so cannot be generalized to other settings (e.g., private care or acute care settings). Additionally, the project's focus was on evaluating the video's quality, utility, and overall feasibility for training IDT—LTC staff rather than assessing its impact on learners' knowledge, skill acquisition, and implementation into practice, which fell outside the project's scope. Project Significance The increasing population of older adults in LTC communities in need of EOL care before and after a transition to hospice underscores the urgency of addressing knowledge and training deficits among IDT—LTC staff. Skilled EOL discussions and hospice care can significantly improve the quality of care and life for older adults and their families during this crucial time. This project aimed to pinpoint educational and training deficiencies within Interdisciplinary Team–Long-Term Care (IDT—LTC) staff. The goal was to leverage this information to create and assess a hospice education video tailored specifically to address the 11 learning requirements of IDT—LTC staff responsible for caring for individuals during and after a transition to hospice. The implications of this initiative extend to providing IDT—LTC team members, faculty, and trainers with access to an evidence-based, publicly available educational video tool. This resource has the potential to not only meet the learning needs of individuals at a novice to advanced beginner's level but also to enhance and complement other existing educational tools and training materials. Distant outcomes may include the dissemination of the education video across various disciplines and LTC settings, aiming to improve the quality of care and outcomes for older adults and their families during this critical end-of-life period. 12 CHAPTER 2 Literature Review Purpose The purpose of this literature review was to identify, appraise, and synthesize the evidence on the common knowledge barriers that interdisciplinary teams, long-term care (IDT— LTC) staff, residents, and family care partners have about hospice care and the variety of hospice care education formats that have been developed to teach in this setting. Background Hospice, a care model designed for individuals facing life-limiting illnesses at the end of life (EOL), emphasizes symptom management and compassionate support over curative measures (NHPCO, 2020). This person-centered approach tailors care to meet the individual's and their family's specific EOL needs and preferences, covering medical care, pain and symptom management, as well as social and spiritual support. The majority of hospice care is provided in private residences, nursing homes, and LTC communities (NHPCO, 2020); moreover, 25% of U.S. deaths occur in skilled nursing and LTC communities. However, despite this prevalence, Unroe and colleagues (2014) identified a knowledge gap among LTC staff in terms of EOL care, including the provision of adequate pain and symptom management. This highlighted the significance of timely and appropriate admission to hospice services, Unroe and colleagues (2014) stress symptom management to enhance outcomes and improved quality of life for LTC residents and their families. 13 LTC Hospice Education & Communication The demand for LTC hospice services has significantly risen in recent decades, yet utilization remains low, with approximately 67% of LTC decedents passing away without ever receiving hospice care (Unroe et al., 2014). Various circumstances determine when an LTC resident is deemed suitable for hospice admission, often involving a significant change in their physical or cognitive condition or a terminal illness diagnosis, leading to a preference for comfort care over curative measures (Shalev et al., 2018). In an ideal scenario, LTC medical providers and clinical staff would initiate early EOL hospice education and discussions with residents and family members, maintaining ongoing conversations as deemed appropriate. Effective relationships within these settings, involving the IDT staff and outside hospice companies, LTC residents, and their family care partners, play a crucial role in facilitating timely and appropriate EOL hospice conversations (Shalev et al., 2018). However, external hospice companies may often assume the role of providing comprehensive education about hospice due to potential deficiencies in knowledge, training, and time constraints among LTC providers and staff (Cross et al., 2022; Frearson, 2019). This reliance on external sources may lead to an inappropriate influence on the LTC resident's and family care partner's decisions regarding EOL hospice choices (Frearson, 2019). The need for LTC hospice care has increased dramatically over the past several decades; yet this service continues to be underutilized—with about 67% of LTC decedents dying without ever being admitted to hospice services according to Unroe and colleagues (2014). There are many scenarios when an LTC resident is considered appropriate for hospice, and this depends on a variable set of circumstances. Often, there is a drastic change in their physical and/or cognitive 14 state, or they have been diagnosed with a terminal illness and they are no longer wanting or able to continue curative care, and wish for comfort care (Shalev et al., 2018). Cross and colleagues (2022) identified discrepancies in EOL hospice discussions between providers and LTC residents and noted that LTC residents who had been referred to outside hospice companies had not received adequate prior hospice education or had comprehensive EOL discussions ahead of the referral and choice for a hospice provider. Additionally, many family care partners indicated that they and the resident lacked specific knowledge about what to expect with their disease course during EOL care, and in some cases were not aware that their prognosis was terminal. As a result, outside hospice staff found themselves having to educate and even give difficult news about disease trajectories and prognoses to LTC residents and families during at the time of the hospice admission (Cross et al., 2022)—signaling a critical gap in EOL care and informed decision support for LTC residents and their families. Other barriers to hospice discussions and transitions of care are related to a general lack of knowledge and confidence in EOL discussions, unrealistic expectations about hospice care, family engagement dynamics, and LTC residents’ and families’ expectations about hospice care. These are discussed later. Medical Students & Providers Lacking Confidence in EOL Care Discussions Navigating the complexities of initiating end-of-life (EOL) hospice care conversations and providing education on indicators for hospice admission can be challenging. However, the primary responsibility for initiating these discussions rests with medical providers, residents, and families, who collaboratively assess when curative treatment is no longer effective or appropriate, leading to medical providers signing hospice orders to initiate care (NHPCO, 2020). 15 Throughout the trajectory of EOL discussions, multiple gaps and barriers to hospice education and conversations may arise. Primary care providers, as highlighted by Cross and colleagues (2022), play a pivotal role in early and ongoing EOL conversations, education, and decision-making between LTC residents and family care partners. They clarify misconceptions and provide essential information crucial for decision-making during transitions to hospice. However, it's noteworthy that many primary care providers themselves may lack accurate knowledge about hospice, as noted by Frearson (2019). This knowledge gap often originates in medical school education and curriculum, where deficiencies exist in teaching students how to conduct EOL discussions. Consequently, the lack of comprehensive education may result in fragmented, limited, and rarely formally assessed hospice care discussions and transitions, leaving newly graduated doctors feeling unprepared, unsupported, and distressed when caring for a dying person (Frearson, 2019). Barriers to IDT—LTC Hospice Education & EOL Care Within LTC communities, a variety of IDT—LTC staff provide EOL care discussions and hospice care for older adults living in these communities and their family care partners. IDT members usually include medical providers, nurses, and social workers (Harasym et al., 2023). Despite the importance of this care, multiple studies have shown that IDT—LTC staff lack adequate knowledge and training to provide hospice education to residents and their families, which may result in significantly decreased quality of care transitions and quality of life outcomes for residents and their family care partners during this critical and important time (Harasym et al., 2023). Possible barriers to EOL care conversations between staff, residents, and family care partners have been noted in the literature and include a general lack of knowledge about hospice, 16 limited to no hospice training specific to resident and family care partner dynamics and support needs, residents’ having misperceptions and limited knowledge about EOL, and staff-resident relationship dynamics. There is also confusion about the clear division of roles and duties for the hospice staff and the LTC staff after a resident has been admitted to hospice but remains living in the LTC Community. Typically, hospice companies will have hospice nurses and Certified Nursing Assistants (CNAs) who will assume the majority of resident care needs, like bathing and pain management; however, without clear delineation of roles and duties, discontinuity of care can result—leaving residents with two scheduled baths in a day or not having a bath scheduled for a week, due to lack of knowledge and care coordination (Harasym et al., 2023). This example provides one of several reasons why improved hospice education and coordination are needed. Resident, Family Care Partners, and Staff Knowledge about Hospice Care Cross and colleagues (2022) highlighted a significant obstacle in the realm of hospice care—the pervasive misperceptions and assumptions held by residents, family care partners, and staff. The project unveiled a prevailing lack of knowledge about hospice among these groups, unveiling key misapprehensions concerning the nature and extent of hospice care. Notable misperceptions included misinformation about the purpose of hospice, its eligibility criteria, the nature of care provided, and the duration of hospice services. Among the apprehensions identified, a prevalent fear among residents and their families was the misconception that transitioning to hospice implied a cessation of all medical care. There was an overarching concern that the quality of care and treatments, crucial at the end of life, would be compromised. Another common anxiety centered on the notion that once a resident entered hospice service, they forfeited the option to revert to curative care if desired and deemed appropriate (Cross et al., 2022). 17 Addressing these misperceptions necessitates an enhancement of general knowledge among LTC staff regarding hospice coverage and services. Such improvements have the potential not only to rectify misapprehensions but also to positively influence residents' and family care partners' perceptions of hospice care, fostering more effective end-of-life hospice conversations and smoother care transitions. Family Engagement with EOL Care Decisions The literature discusses another significant barrier in the context of LTC communities, focusing on situations where residents require hospice care and EOL support, but lack direct involvement or availability of family care partners. The absence of a family care partner engagement, or the presence of strained relationships between LTC staff and family care partners, can detrimentally impact the quality of EOL hospice education, discussions, and care. These circumstances often elicit diverse emotional responses from residents and their family care partners (Munn et al., 2008). Munn and colleagues (2008) delved into issues related to family involvement in EOL care discussions and transitions, revealing varied responses among residents and family care partners based on the level of trust they had in staff during these crucial conversations. Notably, family care partners expressed the highest levels of distrust during such critical discussions, often stemming from unresolved complaints from previous visits to the LTC community. Mistrust or the absence of family involvement during EOL care decisions led to two primary barriers: 1) conflicts arising from differing opinions about EOL care, and 2) miscommunication during EOL care planning and service provision. Participants in the project shared personal experiences during hospice transitions, emphasizing the impact of relationship dynamics between LTC staff and family care partners. A 18 nurse underscored the role of family care partners, stating, "Families can help or hinder [EOL care planning]. If the family member has a grudge, I’ve had to assist family members out of rooms. Some of the families never come and visit and they just want to be there at the end, so instead of a peaceful time, it becomes very high anxiety" (Munn et al., 2008). Miscommunication emerged as a pivotal barrier, highlighting the need for enhanced training in EOL care and communication within LTC settings. Another obstacle arises when family care partners harbor unrealistic expectations regarding hospice care and its services. These misconceptions persist during EOL conversations, with family care partners anticipating precise information about the timing of their loved one's passing—a demand that heightens distress among LTC staff. Furthermore, families may grapple with accepting the reality of the prognosis and the necessity for hospice, clinging to beliefs in alternative curative treatments. This discord creates a division and delay in LTC staff delivering crucial conversations and EOL care tailored to the resident's quality of life and a serene passing (Harasym et al., 2023). In another facet discussed in the literature, challenges emerge when residents in LTC communities require hospice care and EOL support without direct involvement or availability of family care partners. The absence of family care partner engagement or the presence of relationship tension between LTC staff and families may compromise the quality of EOL hospice education and discussions. In such circumstances, discussions on EOL care and transitions of care needs can evoke a range of emotional responses from residents and their families (Munn et al., 2008). Munn and colleagues (2008) delved into issues related to family involvement during EOL care discussions and transitions, revealing varied responses among residents and family care 19 partners based on the level of trust they had in staff during EOL discussions. Remarkably, family care partners expressed the most distrust during these critical conversations, often stemming from prior mistrust due to unresolved complaints from previous visits to the LTC community. Munn and colleagues (2008) summarized the primary barriers when family members have mistrust or are not actively present during EOL care decisions: 1) conflicts arising from differing opinions about EOL care, and 2) miscommunication during EOL care planning and service provision. Themes evidenced in this project were noted through participants' personal experiences during hospice transitions and care. One nurse depicted the relationship dynamics between LTC staff and families, stating it this way: Families can help or hinder [EOL care planning]. If the family member has a grudge, I’ve had to assist family members out of rooms. Some of the families never come and visit and they just want to be there at the end, so instead of a peaceful time, it becomes very high anxiety (Munn et al., 2008). In these situations, Munn and colleagues (2008) highlighted miscommunication as a key barrier to effective EOL hospice conversations between LTC staff and families. These experiences illustrate how stress-inducing care and inter-relationship dynamics between LTC staff, residents, and families can be, emphasizing the need for enhanced training in EOL care and communication in this setting. Another identified barrier to effective EOL care and communication involves family care partners harboring unrealistic expectations regarding hospice care and its services. These misconceptions often persist during EOL discussions, contributing to communication breakdowns. Specifically, some family care partners hold impractical expectations, such as 20 seeking precise information about the exact timing of their loved one's passing or the final stages of life. This outlook may overlook the intricate and mysterious nature of the dying process. Such expectations not only increase distress among LTC staff but also erode their confidence in communicating and educating families about EOL care and outcomes (Munn et al., 2008). Furthermore, family care partners may grapple with accepting the reality of the prognosis and the necessity for hospice care. They may cling to the belief that there are still options for curative treatments, expecting LTC staff to provide therapies and medications with curative intent at the end of life. This divergence in expectations creates a divide and hinders LTC staff from engaging in crucial conversations and delivering EOL care tailored to the resident's quality of life and a peaceful passing (Harasym et al., 2023). Barriers to Providing Hospice Care in LTC Communities In the context of offering hospice education and facilitating crucial EOL conversations for LTC residents and family care partners contemplating a transition to hospice, there are notable barriers. This section outlines both common barriers and critical factors within LTC staff and resident relationships that influence perceptions and experiences of hospice care. Perceptions about Hospice Care and Deaths in LTC Communities Most cognitively capable residents considering a move to an LTC community and subsequently transitioning to hospice generally agree that such a shift is essential for adequate symptom management, support, maintaining quality of life, and ensuring safety when home living is no longer feasible. The understanding is that this transition might mark the place where the resident spends the remainder of their life, receiving EOL care (Kumar et al., 2020; Shalev et al., 2018). The topic of death might not be the initial focus during a resident's decision to move to an LTC community. However, in this setting, death is a common occurrence that residents are 21 likely to witness multiple times. Living in close proximity to one another, residents become inadvertent witnesses to others' deaths, leading to varying degrees of involvement in such occurrences (Munn et al., 2008, p 489). Some of these experiences can result in misperceptions about EOL care, death, and dying. Research by Shalev and colleagues (2017) revealed that many residents were unable to define palliative care and hospice care or fully understand their implications. This lack of knowledge led to the belief that hospice care was not suitable for their specific prognoses and circumstances. Such misperceptions, common among LTC residents, can instill fear about enrolling in hospice care, often associating it with imminent death (Cross et al., 2022). Barriers to Care Once in Hospice Apart from LTC staff's knowledge and ability to engage in EOL hospice discussions and educate residents and their family care partners, there are additional barriers once a resident transitions to hospice. Cross and colleagues (2022) identified concerns among LTC staff mirroring those of the residents they care for. Common misconceptions include the belief that hospice care only accelerates the dying process. Furthermore, staff sometimes use language that perpetuates misunderstandings and results in suboptimal care (Cross et al., 2022). LTC staff may describe hospice care as "hopeless" or refer to it as the "H-bomb" dropped on residents and their family care partners. Such sentiments are detrimental and may induce undue panic before hospice admission staff can fully explain the benefits of hospice care, causing undue anxiety during and before the admission process (Cross et al., 2022, p. 7). Following common barriers noted above to providing hospice education and holding critical EOL conversations to support LTC residents and families as they consider a transition to 22 hospice, there are also critical LTC staff and resident relationship factors that can affect hospice care perception and experiences, described below: Perceptions about Hospice Care and Deaths in LTC Communities Residents who are cognitively capable of participating in decisions regarding transitioning to a Long-Term Care (LTC) community and subsequently to hospice care often recognize the necessity of these transitions for adequate symptom management, support, quality of life, and safety. It is acknowledged that the move to an LTC community may become the resident's final place of residence, where they eventually receive end-of-life (EOL) care (Kumar et al., 2020; Shalev et al., 2018). (Kumar et al., 2020; Shalev et al., 2018). The topic of death may not be the first thing thought about or discussed during a resident’s decision to transition to an LTC community, yet it is a common occurrence in this setting, and one that is likely to be witnessed many times once an older adult has transitioned to an LTC community (Kumar et al., 2020; Shalev et al., 2018). As such, experiencing death in LTC communities becomes a “matter of normalcy derived from living in close proximity to one another—residents become accidental witnesses to the deaths of others” and so have varying degrees of involvement in such occurrences (Munn et al., 2008, p 489). Some of these experiences can lead to misperceptions by residents living in LTC communities about EOL care, death, and dying. Shalev and colleagues (2017) found that many residents were unable to define the term palliative care or even fully grasp what it entailed. Furthermore, as per Cross and colleagues (2022), residents lacked sufficient understanding of hospice care, leading many to perceive it as unsuitable for their specific prognoses and circumstances. These widespread misperceptions often instill fear in long-term care residents, deterring them from considering hospice care and associating it with imminent death (Cross et al., 2022). In addition, LTC may also hold some of their own misconceptions about hospice care, and inadvertently perpetuate misunderstandings about 23 hospice (Cross et al., 2022). Common sentiments and language used by LTC staff include describing hospice care as “hopeless” care or referring to hospice care as the “H-bomb” dropped on residents and their family care partners—such sentiments are thought to result in undue panic prior to and during hospice transitions—before hospice admission staff were able to admit a resident and fully explain the benefits of hospice care (Cross et al., 2022, p. 7). Staff & Resident Relationships During End of Life Long-Term Care communities serve as homes for millions of older adults in the U.S. (Find Assisted Living, Memory Care and Senior Living, 2023) fostering a unique blend of professional and personal relationships between LTC staff and residents. A pivotal project by Munn and colleagues (2008) highlights the integral role of these relationships among staff, residents, and family care partners in shaping the quality and delivery of EOL care and the overall dying experience. Residents in LTC communities, especially those on hospice care, often develop a reliance on staff, particularly nurses to execute care effectively and address arising issues. The connection between professional and personal relationships becomes fluid in these communities (Munn et al., 2008). As one nurse in Munn and colleagues' (2008) project expressed that the care provided can feel akin to caring for a family member: “…you’re caring for them and you’re making them comfortable, and it’s just like a family member because that’s the way I look at it." LTC staff often see themselves as surrogate family members for residents who lack nearby relatives. This involvement extends beyond work hours, with staff frequently sitting with dying residents during nonwork time. The emotional investment in their residents’ lives is evident as staff members express family-like grief and bereavement following a resident's passing (Munn et al., 2008). 24 To enhance the quality and delivery of EOL care, it is crucial to acknowledge the multifaceted roles that staff play when caring for LTC residents and families on hospice. This recognition should extend to understanding the specific knowledge and training needs of staff to ensure the provision of optimal EOL care. Special considerations include assessing resident status, addressing the needs of stable residents as well as those approaching death, and providing comprehensive grief support for both staff and families, as emphasized by the National Hospice and Palliative Care Organization (NHPCO, 2021). Hospice Education Resources and Curriculum The literature on hospice care education offers insights into various resources and curricula tailored for LTC staff (Booth et al., 2014; Kortes-Miller et al., 2007; Mayrhofer et al., 2016). These include Train the Trainer formats, emphasizing the training of identified leaders in LTC who can subsequently impart knowledge to future staff. The format integrates online and face-to-face sessions, group discussions, and mini sessions for practical implementation in daily care practices for LTC residents on hospice. Barriers to this method include the identification and ongoing commitment of trainers, time-intensive module completion, and ensuring trainers are adequately prepared for the required level of teaching and learning (Mayrhofer et al., 2016). Additional face-to-face formats also involve a substantial time commitment with multiple meetings (Booth et al., 2014). Another approach involves designing a training program based on assessing LTC staff's educational needs and preferred learning formats, constructing interprofessional curriculum tailored to the specific needs of learners in LTC care communities (Kortex-Miller et al., 2007). 25 Asynchronous Hospice Education A valuable alternative in asynchronous education involves the use of educational videos, which are audiovisual recordings that illustrate and explain a topic. These videos can be seamlessly integrated into individual, online, or in-person settings, whether as stand-alone modules or part of broader training sessions and in-services within LTC communities. The adaptability of education video extends to its potential incorporation of virtual reality (VR) components, offering a creative and versatile approach to conveying fundamental concepts about EOL and hospice care to LTC staff. This method of education serves as a dynamic complement to comprehensive training programs or stands alone as supplemental training. Particularly beneficial for online, asynchronous learning, it proves especially advantageous during times when social distancing measures, such as those imposed during pandemics, are necessary (Cruz-Oliver et al., 2020; Taubert et al., 2019). Conclusion In conclusion, the pivotal role of LTC staff in guiding residents through hospice care transitions emphasizes the need for robust training and staff support. Comprehensive EOL hospice training is crucial, enhancing education, decision-making, and staff-resident relationships for improved outcomes. Educational videos, particularly in asynchronous mode, stand out as a dynamic and adaptable method, supplementing traditional face-to-face training. This flexibility is essential, especially during times of social distancing, ensuring effective training in various settings and circumstances. Moreover, continued and enhanced hospice education for all LTC staff is likely to further improve residents' understanding of hospice, leading to enhanced decision-making and support during and after transitions to hospice care. 26 CHAPTER 3 Methods Project Purpose The purpose of this project was fourfold: 1) to identify the knowledge gaps that IDT— LTC staff have about EOL hospice care; 2) to gain early feedback from palliative care content experts (faculty at the University of Utah, College of Nursing) on a lesson plan for an educational video intended for IDT—LTC staff to increase their knowledge and confidence in EOL hospice care conversations and caregiving; 3) to gain feedback and recommendations from the palliative care content experts on the quality and appropriateness of content in the educational video; 4) to gain feedback from LTC staff on the quality, utility, and feasibility of the information for delivery and use among LTC staff who will be providing EOL hospice care discussions and support to LTC residents and their family care partners. Project Questions This project focused on the following Project Questions (PQ) questions and Aims: PQ-1 What do long-term care staff know about hospice care? Aim 1. Conduct a brief, focused literature review to identify the specific hospice knowledge gaps and training needs of IDT—LTC staff. Aim2. Survey IDT—LTC staff to identify their hospice knowledge gaps and training preferences. 27 PQ-2 What revisions and recommendations did palliative care content experts (faculty at the University of Utah, College of Nursing) have after reviewing a lesson plan for a hospice care education video designed for LTC staff? PQ-3 What feedback and recommendations for revisions did palliative care content experts have about an evidence-based hospice education video? Aim 3. Survey palliative care content experts to identify recommended revisions for the lesson plan and education video. PQ-4 What feedback did LTC staff have about the completed hospice education video in terms of its quality, utility, and feasibility for training IDT—LTC staff? Aim 4. Survey community LTC staff to identify feedback and recommendations for the educational video. Theoretical Frameworks that Informed the Project Two frameworks were identified to create an evidence-based educational video on hospice care for IDT—LTC staff, two primary goals for the video were identified: 1) the framing and conceptualization of hospice care education for an IDT—LTC team, and 2) the design principles and guidelines for video-based instruction to present the hospice content. 28 Interdisciplinary Framework for Palliative Care and Hospice Education Practice Development of the hospice care educational content for IDT—LTC staff working in LTC communities required foundational, interprofessional teaching/learning principles supported by a holistic educational framework to guide IDT values, competencies, and hospice care best practices. MacLeod-Dyess and colleagues (2020) presented an Interdisciplinary Framework for Palliative Care and Hospice Education practice, henceforth called The Interdisciplinary Framework. At the foundation of this model was the central concept of caring which explained the principles of caring in terms of other constructs—relational, holistic, and compassion—and brought together IDT best practice recommendations and values that align with EOL care objectives (Dyess, 2020). The Interdisciplinary Framework provides a holistic lens that was used to guide the construction of the IDT hospice education video to ensure key values and teaching principles could be threaded through the video—these include foundational values (e.g., autonomy, dignity, community), patient-family values (e.g., quality of life), and IDT values (e.g., personal grown and enlightenment, the collective “we”) (Dyess, 2020). As well, The Interdisciplinary Framework was selected because it supports the presentation of evidence-based guidelines for standards of care driven by the National Hospice and Palliative Care Organization (NHPCO) and the National Consensus Project, Clinical Practice Guidelines for Quality Palliative Care (NCPQPC). The Interdisciplinary Framework is illustrated below in Figure 1. 29 Dual-Channel Theory The Dual-Channel theory, as described by Krumm and colleagues (2022), provides that learning through video and multimedia necessitates simultaneous attention to both verbal and visual elements. This information is initially stored in sensory memory (short-term memory), where the brain processes and interprets audiovisual stimuli. According to this theory, each channel (audio and visual) possesses limited processing capacity but can be effectively processed in harmony. The integration of audio and visual stimuli into short-term memory, coupled with the application of prior knowledge from long-term memory, facilitates the association of information and its subsequent commitment to long-term memory. Consequently, education video emerges as an optimal tool for conveying abstract concepts and intricate clinical principles, delivered audibly and visually. 30 Krumm and colleagues (2022) advocate that video content should cover topics and information resistant to rapid change or information that may quickly become obsolete. To enhance the effectiveness of education video, they provide a specific eight-step guideline for crafting compelling and enduring video content. This guideline, known as the Eight-Step Approach, aligns with the principles of the Dual-Channel Theory, ensuring that video content not only captures attention but also facilitates the integration of information into long-term memory. Figures 2 and 3 below illustrate the Dual-Channel Theory and the Eight-Step Approach, respectively, providing a visual representation of the theoretical framework and practical guidelines recommended by Krumm and colleagues (2022) for creating impactful education video content. 31 Project Design The goal of this project was to target the improvement of hospice and EOL education for IDT—LTC staff, including those responsible for resident care and their family care partners navigating or transitioning to hospice care. The project unfolds in three sequential phases, each meticulously crafted to gather data that will inform targeted educational interventions. Phase 1: Assessing Knowledge Gaps The initial phase sought to answer Project Question (PQ) 1 by conducting a concise literature review and surveying LTC staff. This phase aimed to comprehensively understand barriers and facilitators among IDT—LTC staffs’ hospice and EOL care knowledge and training gaps. The insights gained in this phase laid the groundwork for developing targeted educational content. Phase 2: Curriculum Development and Evaluation Phase II was devised to address PQ 2 and PQ 3. The first part involved the development and evaluation of a comprehensive lesson plan and evidence-based curriculum. This curriculum, guided by the Interdisciplinary Framework, Dual-Channel Theory, and Eight-Step Approach. Faculty content experts in palliative care and hospice were used to provide qualitative feedback on the content and organization of the lesson plan—and a plan to incorporate their feedback into the creation of the hospice education video. The second part focused on the creation and evaluation of the Power Point (PPT) presentation that was used for the educational video. The intent was to implement the feedback and recommended revisions provided by faculty with palliative care expertise prior to the final edition of the presentation for the educational video on hospice. 32 Phase 3: Education Video Feedback The third phase involved gaining feedback from LTC staff who viewed the completed education video and answered a survey asking about the quality of the video, utility of the video, and feasibility of the video for training purposes in LTC facilities. By structuring the project into these well-defined phases, each addressing specific questions and objectives, the project aimed to systematically enhance hospice and EOL education for IDT—LTC staff and their family care partners. Project Setting and Population Phases 1-3 LTC staff survey data took place in three LTC facilities located in Utah. Phase I survey data were collected from LTC staff who were directly involved in EOL conversations and hospice care transition education and included Medical Directors, Directors of Nursing (DONs), Social Workers, Nurses, and CNAs. Phase II was the development of the lesson plan and construction of the PPT and educational video. Phases III data were collected from both the palliative care content experts and community LTC care staff to discern the quality, utility, and feasibility of the educational content presented in the video. Sampling & Recruitment Phases 1-3 In Phase I, the PI reached out to each LTC site to establish a relationship with the DON and gain access to potential participants. A purposive sampling strategy was used to recruit a total of 15 IDT—LTC staff participants to complete the survey. Phase I survey inclusion criteria consisted of the following: healthcare clinicians who work at least part-time in the designated LTC communities and are directly involved in EOL education and hospice care transitions (i.e., 33 Medical Directors, DONs, Social Workers, Nurses, and Physical and Occupational Therapists). Exclusion criteria included healthcare clinicians who work only as needed (PRN) or those who work for an agency as they likely do not participate in EOL conversations and hospice transitions and would not be available to provide feedback on the education tool. All Phase I participants received a $10 appreciation gift card for their time to complete the survey. Phase 1 recruitment involved establishing contact with DONs in LTC facilities who acted as the initial point of contact and internal support to gain authorization to conduct the project in each facility as well as provide appropriate referrals to prospective participants in the facility. Contact with the DONs involved phone calls, messages, and emails that introduced the project and established a relationship. Prospective participants were identified during this time and recruited via emails, and by texts. Phase 2 involved soliciting feedback from three faculty at the College of Nursing who are considered content experts for palliative and hospice care education. The feedback from these faculty were used to revise the lesson plan and begin the development of the hospice education video described next. Once a polished draft of the hospice education PPT was finalized, the PI asked the faculty content experts to review the PPT and provided feedback on the quality of the content in terms of organization, formatting, language, and content. As well, the accompanying script was evaluated to ensure clarity of the presentation and alignment of the script with what is presented on each slide. Phase 3 recruitment involved a purposive sample to recruit three IDT—LTC staff who completed the post-education video survey which asked questions about the video’s quality, utility, and feasibility for future IDT—LTC staff trainings. 34 Ethical Considerations Prior to the commencement of the project and data collection, the PI gained Institutional Review Board (IRB) approval (IRB # 00167440). All LTC community participants were provided with a waiver of consent form and educated on the purpose of the project, the potential risks, and benefits of participating in the project and contact information that followed up on potential concerns or issues during or after their participation in the project. All LTC community participants were informed that their identity would not be disclosed and the information they shared would be kept confidential. LTC community participants were informed that they could leave the project at any time with no negative consequences. Palliative care faculty content experts were utilized as mentor consultants for the development of the education video and were not required consent (Appendix A). Materials and Measures Phases 1-3 Phase I consisted of an IRB waiver of consent form (Appendix A) and demographic questionnaire that was provided to all participants (Appendix B). The demographic questionnaire collected data on the characteristics of the sample population for Phase I, IDT—LTC participants. Demographic data included categorical variables (i.e., race, identified gender, and healthcare discipline) and continuous variables (i.e., age, number of years in healthcare discipline, number of years working at the LTC community, and number of years of experience in EOL and hospice education). A quantitative needs assessment questionnaire was also constructed for Phase 1 to assess participants’ knowledge and beliefs about hospice and barriers to communicating with residents about hospice. Knowledge and beliefs were assessed using a 5-point Likert scale ranging in level 35 of knowledge of various hospice concepts (i.e., not knowledgeable at all to extremely knowledgeable), level of comfort in having EOL conversations with residents (i.e., very uncomfortable to very comfortable), and confidence in educating residents about hospice care (i.e., very unconfident to very confident. Other questions asked assessed the perceived benefit of future hospice training on a 4-point Likert scale (i.e., yes, maybe, no, unsure), and a future interest in receiving training on a 5-point Likert scale (i.e., very uninterested to very interested) (Appendix C). Additionally, Phase I consisted of an evidence table created from the focused literature review to organize and analyze the following variables: barriers and facilitators in providing hospice education, EOL communication, and care among IDT—LTC staff. Phase 2 consisted of a lesson plan (Appendix D) to organize the hospice education video content for each PPT slide. The Lesson plan contained a bulleted list of content pertaining to each PTT slide along with the ideal time allotment for presenting the information in each slide and was supported by references to the literature. Finally, the construction of a Power Point (PPT) presentation was constructed using the revised Lesson plan. The PPT contained a script for each slide that was visually represented. The PPT followed the Lesson plan structure and learning objectives and was animated. Animations provided a visual flow that aligned to the script. The video was designed to be a brief, 15-minute overview of hospice education and EOL care. Phase 3 consisted of an IDT—LTC community feedback survey to assess the educational video in terms of the video’s quality, utility, and feasibility for future trainings on hospice and EOL care. There was a total of three questions described next: Question 1 used a 4-point Likert scale to assess the quality of the content by assessing participants perceptions of enhanced knowledge from the video (i.e., yes, no, maybe, unsure). Question 2 used a 5-point Likert scale 36 (matrix) to ask 5 questions related to the utility of the video in terms effectiveness of the content in enhancing IDT—LTC staffs’ understanding about hospice (i.e., strongly effective to strongly ineffective). Question 3 asked about the feasibility of the education video for future trainings using a 5-point Likert scale to assess participants likelihood of recommending the video as a training tool (i.e., extremely likely to extremely unlikely) (Appendix E). Education Video Development The education video is next described in terms of the structure and process of developing this educational tool. The structure of the education was designed to be a brief, 15-minute PPT, animated, and voiced-over lecture that is intended to be stored in the University of Utah’s Utah Geriatric Education Consortium (UGEC) website as a public access document. Anyone who has access to this website and link can watch the video. The education video was developed from Phase I literature review data and survey outcomes, and Phase II lesson plan and PPT outcomes, and included key learning objectives based on Phase I-II findings. Included in the video were topics such as facts about EOL care transitions and expectations, services provided, equipment provided, insurance coverage, eligibility requirements, communication with residents and family care partners, and frequently asked questions that are intended to provide IDT—LTC staff with foundational knowledge about EOL hospice conversations and essential care competencies. The learning objectives were designed to be based on the findings from the focused literature review, Phase 1 survey responses, and Phase 2 content expert feedback about the Lesson plan. The learning objectives centered on the following: 1) defining hospice care and differentiating it from palliative and curative care, 2) common myths about hospice care and facts, 3) eligibility for hospice, services, and support, 4) IDT care team responsibility for caring for a person on hospice, 5) key takeaways, and 6) additional resources. 37 Data Collection Procedures Phases 1-3 Phase 1 –Literature Review and Survey of LTC Staff An evidence table was utilized to organize data from the literature specific to knowledge gaps, barriers, and facilitators to providing hospice education and EOL care as well as to determine attitudes about hospice among IDT—LTC staff. The data collected from this table were intended to inform the construction of the Lesson plan and educational video. Next, survey data were collected from IDT—LTC staff participants that further informed the educational video lesson plan and subsequent PPT construction. IDT—LTC staff participants were emailed instructions for providing data in Phase I along with an attached waiver of consent document and a unique Qualtrics link to the demographic and Needs assessment survey packet. Qualtrics is a free, online, and anonymous survey tool, data management system, and data analytics platform (QualtricsXM, n.d.). Participants were sent a reminder email to complete the survey packet twice (every two weeks for one month) during Phase I. Phase II consisted of data collection and inclusion of feedback from palliative care content experts (University of Utah faculty) who reviewed the Lesson plan, and the subsequent hospice educational PPT. Content experts were asked to provide open-ended, qualitative feedback to the lesson plan (design, content, and organization) and then to the educational PPT (design, content, and organization) that would form the foundation of the educational video about hospice care. Phase III data collection consisted of a purposive sample of three LTC staff who were recruited and consented into the project to give their feedback on the hospice education video in terms of the video’s quality, utility, and feasibility for future training purposes. A link to a 38 Qualtrics 3-item survey as well as a link to the hospice education video were sent via email to the three LTC staff who first viewed the educational video on hospice and then completed the brief survey. Data Management All quantitative data were managed using the Qualtrics platform and in the University Box system (UBox) and participants’ data had no unique identifiers. Qualitative data that came from the content experts (faculty) where provided via a secure university email and aggregated into a word document. All data were stored on a password-protected laptop in a locked room, data were permanently deleted upon the close of this project. Analytic Plan Phase 1 and Phase 3 quantitative survey data (i.e., demographic questionnaire and needs assessment questionnaire, and LTC community feedback questionnaire) were analyzed using descriptive statistics to identify means, standard deviations, and percentages using the Statistical Package for the Social Sciences (SPSS). This is a statistical software platform for storing and analyzing quantitative data (IBM, n.d.). Phase 2 qualitative feedback on the lesson plan, PPT video content and script from content experts’ responses were qualitatively analyzed by using general qualitative thematic analysis methods: Feedback was first combined from all three content experts into a Word document. Next, the feedback was broken into related categories, and finally, the categories were combined into larger themes. The PI met with her project chair to discuss the analytic strategy and outcomes to ensure transparency of the analytic process and improve the reliability of the thematic findings. 39 CHAPTER 5 RESULTS Overview This chapter presents the outcomes of a multi-phase project designed to improve hospice care education in long-term care (LTC) facilities. Initially planned as a survey across three states, data collection was ultimately limited to Utah due to a lack of responses from other regions. The project involved three phases: (1) assessing LTC staff knowledge, attitudes, and readiness for hospice care education through surveys; (2) developing an evidence-based lesson plan and educational video informed by feedback from content experts; and (3) evaluating the quality, utility, and feasibility of the video through community feedback. Together, these findings provide insight into knowledge gaps, the development of a tailored educational intervention, and its potential application in LTC settings. Phase I Survey Results of LTC Staff Demographic Survey Table 1 provides a snapshot of key demographic characteristics from the needs assessment survey involving 18 participants. The majority were females (83%) with a mean age of 28.39 years, reflecting a broad age range indicated by a large standard deviation of 9.6. Notably, Certified Nursing Assistants (CNAs) constitute most respondents (60%). White participants represent the largest racial group (83%) with Latinas following as a close second. On average, participants have 8 years of healthcare experience, showcasing a diverse range as indicated by a significant standard deviation (SD=8.62). The average time participants have spent 40 at their current facility is 3 years with a large variance (SD=4.2). Educational backgrounds are varied, with Certifications (28%) and High School Diplomas (28%) being the primary categories. This comprehensive profile underscores the diversity and interdisciplinary nature of the participants, with a focal concentration in the CNA role (Table 1, below illustrates the comprehensive demographic data results). Table 1. Demographic Data Characteristics n % Mean (SD) Gender Female 15 83 Male 3 17 Age (years) 28.39 (9.6) Race White 15 83 Asian 1 6 Native Hawaiian or 2 11 other Pacific Islander Job Title DON/ADON 1 6 Social Worker 1 6 Therapist (PT, OT, ST) 1 6 RN 3 16 LPN 1 6 CNA 11 60 Years in Healthcare 8 (9) Years at Current Facility 3 (4.2) Older Adult Professional Caregiver Experience 7.25 (8.62) Highest Education Degree Doctorate 1 6 Master’s 1 6 Bachelor’s 3 16 Associate’s 3 16 Certification 5 28 High School 5 28 Note: n= number of participants; SD=standard deviation 41 Needs Assessment Survey Analysis of the survey data were conducted using QualtricsXM, with details provided below. The survey received responses from a total of 18 participants. Unfortunately, 30% of the data were lost due to errors within the Qualtrics platform, rendering them unrecoverable. The missing data were identified as missing completely at random (MCAR), signifying that the absence of data occurred without any discernible pattern. To address the MCAR data, a listwise deletion approach was employed, resulting in the presentation of the final survey results from the modified dataset. A total of n=12 respondents’ data were analyzed. The needs assessment survey covered the knowledge factors, described below: 1) knowledge factors [5-point Likert scale to measure EOL care planning, services, eligibility, and definitions]: 1=very unknowledgeable to 5= very knowledgeable), 2) confidence factors (5-point Likert scale: 1= very unconfident to 5=very confident), 3) prior training (4-point Likert scale: yes, maybe, now, and unsure) on hospice and interest (5-point Likert scale: 1=very uninterested to 5=very interested) in hospice training factors. The domain of knowledge factors contained the following subset of four questions: 1) EOL care planning, 2) services, 3) eligibility, and 4) definitions (hospice vs palliative care). Reported below are the outcomes for each domain: 1) knowledge factors: EOL care planning (M=2.6; SD=0.8); services (M=3.0; SD=0.6); eligibility (M=2.0; SD=0.6); definitions (M=2; SD=0.5). The survey results from the knowledge domain revealed, overall, low to moderate levels of knowledge in EOL care planning (M=2.6, SD=0.8) and hospice eligibility criteria (M=2.5, SD=0.7), with a slightly higher understanding in hospice services (M=3.0, SD=0.6). Notably, the lowest mean score was observed in hospice definitions (M=2.0, SD=0.5), signaling a notable gap in understanding the distinctions between hospice and palliative care. 42 These findings underscore the importance of tailored training programs, focusing on clarifying hospice definitions and addressing specific knowledge gaps, to enhance the competency of longterm care staff and improve the quality of end-of-life care provided in these settings (see Table 1, below). Table 1. Descriptive Statistics for Needs Assessment Knowledge Questions Question Mean SD Q1: EOL Care Planning 2.6 0.8 Q2: Hospice Services 3.0 0.6 Q3: Hospice Eligibility Criteria 2.5 0.7 Q4: Hospice Definitions 2.0 0.5 *Note: SD=standard deviation. Scale is a 5-point Likert scale with 1=least knowledgeable; 5=most knowledgeable The needs assessment survey further explored the IDT—LTC staffs’ confidence levels, utilizing a 5-point Likert scale (1=very unconfident to 5=very confident). The findings indicate that staff members reported a medium level of confidence in 1) Working as part of an interdisciplinary team (M=3.5, SD=0.5), indicating room for growth in communication and collaboration within the care team. In contrast, confidence levels were comparatively lower for question 2) Providing hospice education (M=2.0, SD=0.9) and question 3) Discussing end-of-life and dying with residents/families (M=2.5, SD=0.7). These results emphasize the need for targeted training interventions that may improve confidence, especially in delivering hospice education and engaging in conversations about end-of-life matters with residents and their 43 families. Strengthening these aspects of interdisciplinary care can contribute to a more comprehensive and supportive approach to end-of-life care within long-term care settings (See Table 2, below). Table 2. Descriptive Statistics for Needs Assessment Confidence Questions Question Mean SD Q1: Working as part of IDT 3.5 0.5 Q2: Providing Hospice Education 2.0 0.9 Q3: Discussing EOL and dying with residents and families 2.5 0.7 *Note: SD=Standard Deviation Scale is a 5-point Likert scale with 1=least knowledgeable; 5=most knowledgeable Other questions asked assessed the perceived benefit of future hospice training on a 4point Likert scale (i.e., yes, maybe, no, unsure), and a future interest in receiving training on a 5point Likert scale (i.e., very uninterested to very interested). The majority (M=3.5, SD=0.8) reported having undergone some type of hospice training within the year. As well, the majority (M=3.0 out of a 5-point scale; SD=0.1) expressed an interest in future hospice training. These findings played a pivotal role in shaping the content and the overall approach that may be suggested for the future dissemination of this educational video. Integration of Theoretical Frameworks The development of the hospice care video was significantly shaped by the integration of the Interdisciplinary Framework (Dyess, 2020) and the Dual Channel Theory (Krumm, 2022). 44 The key constructs of the Interdisciplinary Framework—compassion, holistic care, transformation, and relational thinking—guided the narrative, emphasizing the importance of empathy, comprehensive care, educational transformation, and meaningful connections in endof-life discussions. Simultaneously, the application of the Dual Channel Theory in video construction ensured an engaging and dynamic learning experience, combining analytical and intuitive cognitive processes through balanced storytelling and strategic animations. Phase II Lesson plan Construction and Feedback on the PPT Educational Video Lesson plan Feedback Feedback was constructed to be received from faculty content experts in long-term care and palliative care research. The content experts where then given the lesson plan through and final PPT presentation via email then with the intent for their qualitative feedback to be provided by email. The data gleaned from Phase II would next be carefully analyzed and grouped into similar categories to identify overall themes based on the data extraction process. Information Overload. The most impactful feedback given by the content experts was the number of words and information on each slide. This feedback, coupled with the DualProcess Theory influenced the amount, specificity, and quality of information provided on each slide. If there was more information needed on a slide, transitions and pop-up icons were created to decrease the cognitive load of the learner and create smooth flow and transitions through each slide. Application to Learner. Feedback was given about how to include the learner within the video. An example of this would be asking a question about how they would feel or use this within their role. This helped engage the learner, as well as giving them the opportunity to understand how they could use the information. 45 Overall Delivery. The final feedback was to ensure that the content delivered and the way it was delivered was clear, concise, and understandable. This influenced the vocabulary used by using simple and basic terms that would allow a wide range of learned to understand. Because the target audience was all staff working in LTC setting the vocabulary used would need to be understood by the medical director, social worker, or housekeeping. This kept the content delivered clear, understandable, and concise. Education Video Feedback Feedback from content experts. Feedback was received from three content experts in the early stages of the lesson plan. Their feedback added vital information that included meeting the learner where they are at regarding the vocabulary used, being learner and resident-centric, using inclusive language and adding better clarity and explanation to hospice topics. An example of this would be using the word person, instead of patient, when appropriate. Giving examples of the types of illnesses and diseases that many individuals use hospice as a support such as Alzheimer’s or heart failure, not just cancers. Another essential piece of feedback is to give a more detailed explanation of the relationship between palliative and hospice care. The feedback given was vital in the videos' growth and development through different stages. The feedback received allowed the content to stay person-centered and allowed the content to be applicable to different job duties within a long-term care facility. Video structure and content. The video structure was heavily influenced by the barriers and gaps in knowledge found within the literature. The literature showed that many IDT-LTC staff lacked adequate training about hospice and how to educate families and residents about hospice (Harasym et al., 2023). There are also many misconceptions and myths about hospice that often leave staff, residents, and families questioning the true purpose of hospice and what it 46 stands for (Cross et al., 2022). Finally, the literature showed that due to the sensitive and emotional nature of end-of-life conversations, many families and staff have a disconnect or lack of trust as the decision to transition to hospice arrives. The way that this information was delivered was given to two content experts to give any final feedback. Feedback was received and a common theme was that the content and delivery was well-organized and visually appealing. Phase III Community Feedback The refined and final version of the hospice education video was shared with a targeted group of three (n=3) LTC staff. One who was a licensed social worker, a director of rehabilitation and an administrator accompanied by a Qualtrics survey link aimed at gathering insights on the video's quality , utility, and feasibility for training purposes. Survey outcomes are outlined across the three domains below. Respondents, after viewing the hospice education video, were presented with questions covering: 1) their perceived quality of the video in terms of improved knowledge and education, 2) the video's utility in terms of its efficacy in enhancing knowledge about hospice care among all IDT staff, and 3) the likelihood of utilizing the video for future training needs among IDT staff. Regarding question 1, which assessed respondents' overall perception of the hospice education video's quality in terms of knowledge improvement post-viewing, a unanimous 100% reported enhanced knowledge. In the domain of the video’s utility a 5-point Likert scale was used to assess five questions: 1) Understanding best communication practices (2) understanding hospice services, 3) Understanding hospice eligibility criteria, 4) Understanding IDT members’ responsibilities, and 5) Understanding palliative and hospice definitions. 47 The results from the assessment of the utility of the education video revealed highly positive feedback from the three participants. Across all five questions, the mean scores were notably high, indicating a strong agreement with the video's effectiveness in conveying key information. Participants reported a mean score of 4.7 with an SD=0.3 for questions related to understanding best communication practices, hospice services, and IDT members' responsibilities. The question assessing comprehension of eligibility criteria received a slightly lower mean score of 4.3 with an SD=0.6. Remarkably, for the question on understanding palliative and hospice definitions, participants gave the video the highest possible mean score of 5, SD=0.0 indicating unanimous agreement in their understanding. These findings suggest that the education video was effective in enhancing participants' understanding of various aspects related to hospice care, particularly in defining key concepts and outlining the roles and responsibilities of IDT members, with room for improvement most noted in question 3: hospice eligibility criteria (See Table 3, below). Table 3. Utility of the Education Video (Efficacy) Question Mean SD 1: Understanding Best Communication Practices 4.7 0.3 2: Understanding Hospice Services 4.7 0.3 3: Understanding Eligibility Criteria 4.3 0.6 4: Understanding IDT Members' Responsibilities 4.7 0.3 5: Understanding Palliative and Hospice Definitions 5.0 0.0 Note: SD=standard deviation. 48 The scale is a 5-point Likert scale 1=lowest efficacy, 5=highest efficacy In the domain related to the feasibility of using the video for training, 100% of respondents expressed a likelihood of recommending the video in future trainings. Conclusion In summary, while geographically confined to Utah, this project acts as a model for region-specific hospice care education interventions. The insights obtained not only address identified gaps but also highlight the transformative potential in elevating hospice care quality within long-term care settings. This exploration establishes a foundation for future research and advancements in hospice care education, emphasizing the necessity for context-specific strategies in regional healthcare contexts. 49 CHAPTER 6 Discussion This section delves into a comprehensive discussion of the multi-phase project, focusing on the development and evaluation of the hospice education video tailored for the IDT—LTC staff. Structured around the four project questions (detailed below) the discussion explores key findings and implications derived from the survey, lesson plan, video development, and community feedback. Each project question along with the Theoretical Frameworks are discussed individually to offer a detailed analysis of the insights gained, the impact on the lesson plan and subsequent development of the PPT and video production, and the direct implications for hospice care education within LTC settings. This organized approach provides a deeper understanding of the project's outcomes and their broader implications for regional healthcare contexts. Project Question 1 Discussion The discussion on Project Question 1 delves into the prevalent barriers and knowledge gaps observed among Interdisciplinary Team—LTC staff regarding hospice, a frequently discussed topic in LTC facilities. The focused literature review and the responses from the needs assessment survey confirmed what was identified in the literature—that there was a dearth of training specific to the requirements of IDT—LTC staff that could both improve their knowledge about hospice and EOL and their confidence in capably providing education and bolstering informed decisions by residents and family care partners in electing among choices provided during hospice care transitions and during care. 50 From the Phase 1 needs assessment we found a notable lack of knowledge and confidence among staff regarding hospice and EOL conversations. This finding is consistent across the literature where multiple studies have cited a significant lack of knowledge and confidence among nursing home staff in engaging in hospice care conversations and supporting residents who have transitioned to hospice care (Cross et al., 2022; Frearson, 2019; Harasym et al., 2023; Mohlman et al., 2018). Notable, the literature cited specific misconceptions surrounding hospice, death, and dying (Cross et al., 2022), as well as general confusion about the roles of hospice companies in LTC facilities (Harasym et al., 2023). These themes, derived from the literature seemed to reflect what was reported by the IDT—LTC participants in this project— reinforcing the existing gaps in hospice care in LTC settings and the continued need to provide training opportunities in flexible formats. Originally, the plan was to use the survey results to guide the construction of the lesson plan and education video. However, due to a Qualtrics survey issue resulting in about 40% missing data, the approach was adapted. Grounded in the literature review and the limited survey results, we recognized the necessity of providing learner-centric education which we believe addresses the noted knowledge barriers and time constraints and enhances confidence in facilitating hospice conversations. The identified knowledge gaps and barriers within IDT-LTC staff's understanding of hospice underscore the importance of tailored education. The constructed lesson plan and video presentation carry implications for future training programs, emphasizing the need for context-specific strategies to enhance hospice care quality within LTC settings. Integration and Impact of Theoretical Frameworks The foundation of the video and its development stems from The Interdisciplinary Framework (Dyess, 2020) and the Dual Channel Theory (Krumm, 2022). These two elements 51 played a pivotal role in shaping this evidence-based video, emphasizing the four key constructs of the framework (compassion, holistic care, transformation, and relational care) described below. The content not only focused on these constructs but also aligned with the principles of the Dual Channel Theory, guiding how information was presented and delivered (see below). Impact of the Interdisciplinary Frameworks The incorporation of the Interdisciplinary Framework for Palliative and Hospice Education and Practice (The IDT Framework) played a pivotal role in shaping the video content and production. The Interdisciplinary Framework, comprised of the following concepts for care—compassion, holistic approaches, transformation, and relational thinking, provided a structured foundation for developing the educational content (Dyess, 2020). By focusing on these broad constructs, we were able to make the video more applicable and deliverable to all staff working within a long-term care community, with an expanded opportunity to benefit individuals in need of hospice education who are outside of the long-term care setting. The four constructs of the framework and how they influenced development of the education video content are described in more detail below: Compassion The IDT framework underscored the importance of compassion in discussions with individuals and their families about hospice. By centering the video around compassion, learners are reminded that displaying empathy enhances both the quality of life and the care they provide (Dyess, 2020). Holistic Care The video was influenced by the framework's emphasis on holistic care, ensuring that all aspects of an individual's life are considered in hospice care (Dyess, 2020). Beyond addressing 52 physical symptoms, the video highlighted the significance of attending to spiritual, cultural, and emotional needs, viewing the person’s needs for comfort care. Transformation The goal of the video was to inspire learners to implement what they had learned and combine new learning with life experience. This construct guided the narrative towards encouraging transformation in education, designed not only for the learners themselves but also for the individuals and families they interact with before and during hospice care. Transformation, as a construct, includes explicit directives to professional and family care partners to utilize their own life experiences and drive to actually improve and even transform care by providing more personalized, informed and, compassionate (patient-centered) care from life experiences—that may improve the quality of care at the end of life (Dyess, 2020). Relational Care This construct sets the tone and provides the support and examples necessary to demonstrate this concept of relational care in the video, emphasizing that end-of-life care decisions and conversations required for time and cultivation for each individual and family care provider to process (Dyess, 2020). The transition to hospice was portrayed as a journey encompassing compassion, holistic care, and transformation for everyone involved. The integration and impact of the Interdisciplinary Framework on the development of the Lesson plan and subsequent education video was intended to address the concept of hospice but also to provide guidance on conducting EOL conversations with individuals and their families. By extending education to all staff, the intention would be to bridge barriers and gaps, enabling individuals and families to be better informed about hospice and, ultimately, enhancing the quality of life and dignity of those involved. 53 Dual Channel Theory Applying the Dual Channel Theory was essential in delivering this content. The video went from a 30-minute lecture to an engaged platform of learning in a shorter time span. The video construction was developed with the idea to provide a balanced storytelling and illustrative content for each slide, and descriptive content from the presenter. This was paired with a dynamic flow of video and auditory content-- strategically blending two vital cognitive processes: the analytical and intuitive. This idea was also envisioned to utilize strategically placed animations at the right time to continually engage the learner during key part of each slide. This emphasized the importance of the content being shared. Because the animations were in sync with the content being explained it created a dynamic flow that also aided in engaging the learners. This balanced approach may ensure that learners not only comprehend the technical facets of hospice care but also emotionally engage with the human side, fostering empathy and understanding. By successfully delivering this content, we are able to create an engaging space for many individuals from different backgrounds, experiences and education to learn in a meaningful way (Krumm, 2022). Project Question 2 Discussion The results of the lesson plan feedback impacted the quality of the content, tone, and overall delivery of the educational video. The advice was given to create more inclusive language when discussing concepts about hospice, death, and dying. As well, person-first language was recommended by content experts, for example the word “patient” was replaced with a more inclusive word “person” (when sensible) to look at the person as a whole and have more sensitivity and understanding when discussing EOL care topics. This feedback is in alignment with best education practices and served to elevate the content and delivery of the 54 education video and underscores the importance of tailoring education to the specific needs of LTC staff (Booth et al., 2014; Kortes-Miller et al., 2007). Similarly, the literature emphasizes the importance of designing training programs based on assessing the educational needs and preferred learning formats of LTC staff. This approach suggests a recognition of the diverse backgrounds, experiences, and learning styles within the LTC community (Booth et al., 2014; Kortes-Miller et al., 2007). Feedback was also given for the inclusion of other topics and to add more detail to topics that were already presented—which shaped the education content throughout the ongoing development and completion of the lesson plan including the culturally informed content, intentional vocabulary that can fit the needs of the learner, the tone of voice used during video production, and methods for creating learning-centric content for a wide range audience of IDTLTC staff. The feedback-driven refinements underscore the significance of language precision and providing culturally inclusive content when developing education materials for hospice care. The broader implications suggest a need for an iterative process in developing future training videos that emphasize the importance of continuous adaptations from constructive feedback that can enhance overall quality, inclusiveness, and effectiveness of educational resources for this population. Overall, this feedback was essential in the implementation of two ideas: 1) education language that needed to be culturally inclusive for the topic of hospice, and 2) education language needed to be culturally inclusive for the learner at their level. By successfully using these two ideas within the lesson plan and the subsequent development of the educational video, it was hoped that the learner might profit from the enhanced language and tone presented to 55 promote a more evidence-based, yet learner-specific and friendly training that meets learners at their various levels of knowledge. Project Question 3 Discussion The results of the video PPT were like that of the lesson plan, which included changing language, including specific topics, refinement of topics, etc. There were also feedback results based on the PPT and video in terms of the content experts’ advice on changing the language to be more inclusive of the learners’ needs and perspectives, inclusion of specific topics such as adding more detail about hospice care eligibility, and the inclusion of the resident and their family care partner as part of the care team. The finished education video reflected the success of implementing the Interdisciplinary Framework and the Dual Channel Theory—which added having it be visually pleasing, with smooth transitions and a natural flow of the content delivered (Krumm, 2022). This was achieved by using timely animations, an appropriate amount of wording and pictures, as well as a shortened video time as recommended by Krumm and colleagues (2022). In the evolving landscape of education, mastering the art of creating instructional videos within a virtual dominant learning system has become a crucial skill. The process involves delving into the Dual Channel Theory (Krumm et al., 2022), where the verbal and visual elements harmoniously complement each other to enhance the overall learning experience. This dynamic approach was applied, and the outcome seemed to create a seamless and engaging flow, ensuring that what was conveyed verbally aligned seamlessly with what was presented visually. Learning to strike the right balance between spoken information and visually compelling content was key to capturing and maintaining the attention of a virtual audience. As educators navigate this digital frontier, the ability to craft education videos that effectively leverage Dual Channel 56 Theory (Krumm, 2022) emerges as a powerful tool for delivering impactful and immersive learning experiences in the virtual realm. Project Question 4 Discussion The feedback received from the community LTC staff was predominantly positive, reflecting satisfaction with various aspects of the hospice services. However, notable areas for improvement surfaced during discussions on patient eligibility requirements and the need for enhanced clarity regarding the range of services offered from hospice care. These challenges align with findings in the literature, as observed by Ersek et al. (2022) and Frearson, (2019). To address these concerns and elevate the quality of care, strategic improvements to care should be proposed. First, there is a need for a deeper understanding and implementation of best communication practices when engaging with residents and their family care partners about hospice services. Second, an emphasis on comprehending the full spectrum of services provided by hospice care is essential. Third, a focused effort on clarifying hospice eligibility criteria is crucial for streamlining the admission process. Lastly, fostering a clear understanding of the responsibilities of IDT—LTC members is key to ensuring a collaborative and effective approach to caring for residents in these communities. These targeted areas of improvement aim to refine the overall hospice experience, aligning it with the best practices outlined in the literature and addressing the identified gaps in community IDT—LTC staff feedback. The implications of above sections are multifaceted and underscore the importance of refining hospice care training that is based on valuable feedback and existing literature. The predominantly positive feedback from community IDT—LTC staff signifies a commendable level of satisfaction with the provided hospice education video intended for future trainings. However, the identified areas for improvement, particularly related to patient eligibility 57 requirements and service clarity, point to the need for improvements in education content and delivery, as well as potential gaps that already exist in care knowledge and care delivery. The alignment of these challenges with findings in the literature, as highlighted by (Ersek et al., 2022; Frearson, 2019), emphasizes the universality of these issues within the broader context of hospice care. The proposed strategic improvements, encompassing better communication practices, a comprehensive understanding of services, clarification of eligibility criteria, and delineation of interdisciplinary team responsibilities, carry significant implications for care. By addressing these specific concerns, there is an opportunity to elevate the overall quality of hospice care. The call for a deeper understanding and implementation of best communication practices aims to enhance the interaction between healthcare providers, residents, and their family care partners, fostering a more supportive and informed environment. Emphasizing a comprehensive grasp of the full spectrum of services ensures that all aspects of residents’ needs are met effectively. Finally, fostering a clear understanding of LTC— IDT members' responsibilities promotes a collaborative approach, ultimately enhancing the overall quality of care and experiences of LTC residents. In summary, the proposed improvements have the potential to refine the hospice experience by aligning it with established best practices, addressing identified gaps, and fostering a more cohesive and patient-centric care model. Project Limitations The deliberate use of a purposive sample, while effective in surveying appropriate participants who could provide foundational insights for video development, significantly limits the generalizability of the project findings to the population and adds potential biases. While acknowledging its limitations for broader, research-based studies, this sampling method proved 58 instrumental in providing a necessary baseline understanding crucial for the initial phases of video development. Recruitment, conducted virtually rather than face-to-face, presented inherent challenges by limiting opportunities to establish rapport and engage prospective participants in learning about the project more deeply. This likely explained are small sample size in Phase 1 and Phase 3. However, due to the nature of this project being a pilot, education quality improvement intervention, it was determined that the number of participants were sufficient to gain initial understanding of the learners’ needs. In the future, it would be beneficial to include a large, more diverse sample set to confirm or refine the education video content structure and offerings. It is noteworthy that the survey population was confined to a single facility, which, although insightful for the specific context, may restrict the broader applicability of the findings. It was originally intended to survey three LTC facilities across three states to gain wider variation in participant demographics. However, the recruitment strategy (Asynchronous and via email correspondence) created challenges in garnering traction. Additionally, participants, immersed in a demanding and fast-paced work environment, may also face considerable time constraints, impacting their ability to complete the survey. While the PI of this project did establish contact with DONs in each facility, this effort did not achieve the intended result for recruiting in each facility. In the future, it would be useful to possibly establish relationships and connections over a longer time frame, and recruit face to face to provide participants with more context and garner more interest in the project. Another project limitation occurred from a substantial loss of data from the Qualtrics platform where the data were determined unrecoverable. This unanticipated setback underscores 59 the critical importance ensuring surveys are tested by several users prior to being sent to participants. This limitation prompted a cautious approach when interpreting survey results. Despite these limitations, this project has laid a crucial foundation for future endeavors in educational video development, offering valuable insights into the dynamics of the process. However, it is imperative to approach the project's outcomes with an awareness of these constraints, ensuring a nuanced and contextually sensitive interpretation. Project Implications The implications of this project unfold in three significant dimensions. Firstly, the educational video could be a potent instrument in effectively addressing barriers and knowledge gaps among IDT-LTC staff concerning hospice topics, education, and training. This success is intricately tied to insights derived from the focused literature review and the results from the needs assessment survey of IDT—LTC staff, affirming the video's relevance and impact. Secondly, the deliberate incorporation of a virtual aspect in the educational video extends its accessibility far beyond the immediate audience of IDT-LTC staff. This strategic move broadens the reach of valuable hospice education to universities, educators, and individuals at large, emphasizing a commitment to fostering a more informed and compassionate community. The third implication highlights the transformative potential of increased education and training for IDT-LTC staff. By elevating their understanding, this initiative has a ripple effect on the quality of care and overall experience for residents on hospice. The emphasis on patientcentered care ensures that individuals live out their final days with comfort and dignity, reflecting a profound commitment to honoring the sanctity of this critical life phase. Importantly, this enhanced approach does not only benefit the residents; it extends its compassionate 60 influence to encompass their family care partners and loved ones. As individuals navigate the transition to hospice or approach the end of life, improved education and training create an environment of peace and solace, contributing to a more supportive and comforting experience for all stakeholders involved in this delicate and significant journey. For future research the video could be implemented into long-term care staff training to evalute the effectiveness of the content delivered. Future Project Dissemination The educational video is set to be widely disseminated through the UGEC website, offering an inclusive platform for individuals seeking comprehensive insights into hospice care. By hosting the video on this accessible online hub, it becomes readily available to anyone interested in expanding their knowledge of hospice practices. This user-friendly resource not only caters to those pursuing self-directed learning but also provides a versatile tool for broader educational initiatives. Moreover, the video link can be efficiently shared with staff members, facilitating easy access for those within the healthcare sector eager to enhance their understanding of hospice protocols. Beyond internal staff distribution, the video holds great potential as an enriching addition to a variety of academic settings. Professors can seamlessly incorporate it into their classes to supplement existing curriculum content, fostering a deeper comprehension of hospice care among students. The versatility of the video extends even further as it serves as a valuable resource for individuals outside the immediate healthcare and academic realms. Anyone looking to broaden their understanding of hospice can access the video, thereby contributing to a more informed and compassionate community. 61 In essence, the dissemination strategy ensures that the educational video becomes a catalyst for continuous learning, reaching diverse audiences and promoting a broader understanding of hospice care within various spheres of interest. Future Training Opportunities The widespread dissemination of the video is not merely a singular event but a catalyst for ongoing advancements in the training and knowledge base of IDT-LTC staff. This strategic sharing of educational content opens avenues for future training initiatives, enriching staff members' orientation, training sessions, and in-service programs. Continuous access to such resources ensures that IDT-LTC staff can consistently update their knowledge, fostering a perpetual learning environment. As a result of this supplementary training, IDT-LTC staff members are poised to experience heightened levels of knowledge and confidence. This newfound competence translates into improved abilities to engage, educate, and provide compassionate care to residents on hospice, along with enhanced support for their families. The far-reaching impact extends to the overall quality of care received by residents, promising a more holistic and supportive hospice experience. Looking ahead, it is recommended that future endeavors include surveying long-term care staff after viewing the educational video used in training. This initiative aims to gauge their competency in hospice care and evaluate their engagement with LTC staff within facilities when a resident is on hospice. This comprehensive approach provides a unique opportunity to explore potential gaps and barriers between hospice providers and LTC staff. By understanding these dynamics, future initiatives can strategically address challenges and further enhance the 62 collaborative efforts between hospice and LTC staff, ultimately benefiting the residents under their care. 63 CHAPTER 7 Conclusion From its inception with four fundamental questions, this project has evolved into a transformative educational tool designed to empower and educate IDT—LTC staff about hospice care. This dynamic initiative holds immense potential to elevate the quality of care that can be provided to LTC residents and their family care partners. Beyond this immediate impact, the project promises to enhance the confidence, knowledge, and education of IDT—LTC staff, enriching their day-to-day routines and enabling them to better serve residents on hospice. The educational video may serve as a multifaceted resource, addressing various aspects of hospice care. IDT—LTC staff could benefit from targeted education and training on critical topics such as eligibility criteria, dispelling common myths, distinguishing between palliative and hospice care, and comprehending the range of services and supports provided within a hospice setting. This comprehensive approach equips them with the knowledge needed to educated residents and family care partners as well as to navigate the complexities of their roles, fostering a more informed and compassionate care environment. One of the key features of the video is its provision of a structured five-step framework for conducting end-of-life conversations with residents and their family care partners. This invaluable resource not only guides IDT-LTC staff through these sensitive discussions but also contributes to a more empathetic and supportive experience for all involved. In essence, this project has transcended its initial inquiries, culminating in a transformative educational resource poised to make a lasting impact on the lives of residents in hospice care and their families. By enhancing the knowledge and skills of IDT-LTC staff, the 64 ripple effect extends to create a more compassionate and informed community within the realm of long-term care. This final project stands as a testament to the potential for positive change through targeted education and training, paving the way for a brighter and more supportive future in hospice care. Concluding Reflections on Hospice Care Education Navigating the landscape of hospice care involves unraveling a complex tapestry of emotions, thoughts, and societal attitudes often entwined with the subjects of aging and the inevitable passage of life. In a culture that tends to avert discussions on aging and death, the urgency to openly address hospice, death, and dying has assumed unprecedented importance. As our population ages and the prevalence of chronic diseases and illnesses concurrently rises, the demand for hospice care becomes more pronounced than ever before. To meet this escalating demand and ensure the delivery of the highest standard of care, the IDT—LTC team must possess not only a comprehensive but also a nuanced understanding of hospice dynamics. This imperative is underscored by the need to equip healthcare professionals with the knowledge and skills essential for providing optimal care to residents on hospice, while simultaneously offering support to their families. This holistic approach is integral to fostering a compassionate end-of-life experience. Embracing the significance of hospice education transcends the mere acknowledgment of the inevitability of aging and mortality; it lays the foundation for a more empathetic, informed, and humanized approach to caring for our aging population and those facing the end of life. 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British Journal of Nursing (Mark Allen Publishing), 25(11), 600–605. https://doi.org/10.12968/bjon.2016.25.11.600 71 Appendix A Consent Form Participant Waiver of Consent Form The purpose of this education project is to assess your knowledge, attitudes, and perceived barriers and facilitators to providing hospice education and care to residents living in your longterm care facility and their family care partners. If you agree, you will complete an online, anonymous survey asking you demographic questions and questions about your knowledge, attitudes, barriers, and facilitators to providing hospice education and care in your facility. If you agree to participate, you will be emailed a link to the online surveys which should take about 30 minutes to complete. You can complete the online Qualtrics TM surveys in the privacy of your own home or any place of your choosing. Your participation in this educational project is completely voluntary. Upon completion of the online surveys, you will receive a $10 appreciation gift card for your time. If you choose not to participate it will not affect your job or the relationships with your supervisors in any way. If you decide to participate, you may also later withdraw at any time for any reason either before completing the surveys or after, and your survey responses can be excluded from this project. If you withdraw after completing the survey and have already received the appreciation gift card, you can keep the gift card for the time you spent. Withdrawing will also not affect your job or relationships with your supervisors or this project’s leader. This is a minimal risk project; however, you may experience some discomfort from the questions on the survey, this would be similar to participating in discussions about hospice care in your current job position. You also may experience a benefit in the form of increased knowledge about hospice care and confidence in providing hospice education after viewing the education video. You may also experience benefit from giving your time to this project and the potential to help others from the educational video produced by this project. The surveys will be anonymous and completed online in the privacy of your home or at a place of your choosing. No unneeded information is being collected, and the information collected about you is limited to the amount necessary to understand staff hospice education needs. 72 Your responses to all questionnaires will be anonymous, meaning that your name and identity will not be linked to your responses. Instead, the QualtricsTM survey will be linked to your email until you have completed the survey and deleted after. There will be no way of linking your responses back to you or your email after the survey has been completed. If you have any questions complaints or if you feel you have been harmed by this project please contact Rebekah Perkins, University of Utah, at [phone] or by e-mail at [e-mail]. Contact the Institutional Review Board (IRB) if you have questions regarding your rights as a research participant. Also, contact the IRB if you have questions, complaints or concerns which you do not feel you can discuss with the investigator. The University of Utah IRB may be reached by phone at [phone] or by e-mail at [e-mail]. Research Participant Advocate: You may also contact the Research Participant Advocate (RPA) by phone at [phone] or by email at [e-mail] THANK YOU FOR YOUR PARTICIPATION IN THIS PROJECT! 73 Appendix B Demographic Questionnaire DEMOGRAPHIC QUESTIONNAIRE Participant ID#__________ Facility ID:______________ Thank you for taking time to complete this questionnaire. Before you begin, please verify that you have read and signed the Consent Form agreeing to participate in this project about Hospice, End-of-Life Care, Hospice stigmas and education about hospice care within a Long-Term Care facility setting. Your responses to this questionnaire are voluntary and you can choose not to answer certain questions (by selecting the “Prefer not to answer” response choice). You will not be identified by your name in any research or publications resulting from this project. 1. What is your age range? (Select one) Input response________ 2. How do you identify your gender? (Select one) a. Female f. Transgender b. Male g. Cisgender c. Non-binary/third gender h. Agender d. Prefer not to self-describe i. Genderqueer e. Prefer not to answer j. A gender not listed 3. How do you identify your race? (Select one) a. American Indian or Alaskan Native e. White b. Asian f. Some other race, ethnicity, or origin c. Black or African American g. Prefer not to self-describe d. Native Hawaiian or Other Pacific Islander 4. How do you identify your ethnicity? Prefer not to answer Are you of Hispanic, Latino/a/x, or of Spanish origin? (one or more categories may be selected). 74 a. No, not of Hispanic, Latino/a/x, or Spanish origin e. Yes, Another Hispanic, Latino/a/x or Spanish origin b. Yes, Mexican, Mexican American, Chicano/a/x f. Some other race, ethnicity, or origin c. Yes, Puerto Rican g. Prefer not to answer d. Yes, Cuban 5. What is your job title? (Select one) a. Nurse b. Social Worker c. CNA d. Recreation 6. How long (months or years) have you worked in this position (Write response below): _______________ years _______________ months 7. How long (months or years) have you worked in this facility? (Write response below): _______________ years _______________ months 8. How many years of professional experience do you have working with older adults? (Write your response below) _______________ years _______________ months 9. What is your highest level of education? a. High-school diploma b. Bachelor’s degree c. Master’s degree d. Doctorate e. Certification f. Prefer not to answer Thank you for completing this questionnaire! 75 Appendix C: Hospice Care Needs Assessment Questionnaire SURVEY QUESTIONS FOR QUALTRICS 1. Is there a difference between palliative care and hospice care? A. Yes B. No C. Unsure 2. How familiar are you with the process of having a patient admitted to hospice care? A. Very familiar B. Somewhat familiar C. Neither familiar nor unfamiliar D. Somewhat unfamiliar E. Very unfamiliar 3. How knowledgeable are you about the kinds of treatments, therapies, and equipment offered on hospice care? A. Very knowledgeable B. Somewhat knowledgeable C. Neither knowledgeable nor unknowledgeable D. Somewhat unknowledgeable E. Very unknowledgeable 4. How comfortable would you be discussing end of life topics such as death and dying to individuals from other backgrounds, lifestyles, or beliefs than your own? A. Very comfortable B. Somewhat comfortable C. Neither comfortable nor uncomfortable D. Somewhat uncomfortable E. Very uncomfortable 5. How knowledgeable are you with the process of end of life care planning (Example, the steps a person takes to get affairs in order and make decisions about how to spend the end of their life)? 76 A. Very knowledgeable B. Somewhat knowledgeable C. Neither knowledgeable nor unknowledgeable D. Somewhat unknowledgeable E. Very unknowledgeable 6. Have you ever been asked by family, friends or residents about hospice care? A. Yes B. No 7. Do you feel you would have the time to educate someone about hospice during your shift? A. Yes B. No C. Unsure 8. Do you feel you have the knowledge and training to educate someone about hospice during your shift? A. Yes B. No C. Unsure 9. How confident are you to educate someone about hospice care? A. Very confident B. Somewhat confident C. Neither confident nor unconfident D. Somewhat unconfident E. Very unconfident 10. Have you received training or education about hospice care within the past year? A. Yes B. No C. Unsure 11. How supported do you feel by other team members working in other roles (e.g., dietician, social worker, physical therapist, etc.) when caring for patients on hospice? A. Very supported B. Somewhat supported 77 C. Neither supported nor unsupported D. Somewhat unsupported E. Very unsupported 12. Do you think you would benefit from future hospice training to help you in your position? A. Yes B. No C. Unsure 13. How interested would you be in watching a short educational video about hospice care? A. Very Interested B. Interested C. Neither interested nor uninterested D. Uninterested E. Very Uninterested THANK YOU FOR COMPLETING THIS SURVEY!! 78 Appendix D Lesson Plan: What is Hospice? An Evidence-Based Education Video for Interdisciplinary Health Care Teams Slide 1 (30 seconds): Introduction • Introduce self and topic. Slide 2 Teaching Objectives (30 Seconds) • Introduce Teaching Objectives: 1. The definitions of hospice and palliative care and their relationship. 2. Common myths and facts about transitioning to hospice care. 3. Eligibility requirements, services, equipment, coverage, and support in hospice care. 4. Responsibility of Care (Hospice Care Teams and LTC Teams), collaboration, and communication. 5. Key takeaways. 6. Available hospice resources to learn more. Slides 3—5 (Objective 1 – Definitions): Palliative and Hospice Care (2 ½ Minutes) • Define curative care. • Define palliative care. • Define hospice care. • Differentiate each type of care. • Discuss the phases and layers of palliative care. Reference: (Adkins, 2016; Medicare Resources, n.d.; NIA, n.d.; Providence Health Care, n.d.) Slides 6—10 (Objective 2): Four Myths and Four Facts (1 minute) • • • • • Myth 1: Hospice is giving up and losing hope. Fact 1: Hospice focuses on symptom management, comfort, and dignity. Myth 2: Hospice means death is a few hours away. Fact 2: A person can access hospice care up to 6 months before an expected death. Myth 3: Once a choice is made for hospice, there’s no turning back. 79 • • • Fact 3: A person can stop hospice care at any time without penalty. Myth 4: A person on hospice in a nursing home no longer needs care from the nursing home staff. Fact 4: The hospice care team provides scheduled visits 2-3 times per week. Reference: (Hospice Foundation of America n.d.-a) Slide 11 (Objective 3): Eligibility for Hospice Care (1 Minute) Present the following content: • They have a serious, progressive, and incurable condition, like cancer, heart failure, advanced dementia, or end-stage organ failure with a 6-month life expectancy. • They agree to stop treatments aimed at curing their condition and focus on comfort and quality of life. • A medical professional, often a doctor, must confirm the person's eligibility. • The person or their legal representative must agree to hospice care and understand that they're not pursuing curative treatments. • The specifics can vary depending on the hospice program and location. But the main goal is to provide comfort, support, and dignity to those with terminal illnesses in their final months. This includes managing pain, emotional and spiritual support, and improving life quality for the patient and their family. The recommendation to "Consult with a Healthcare Provider" is standard practice and aligns with healthcare guidelines from organizations like the American Cancer Society or the American Academy of Hospice and Palliative Medicine. Reference: (CMS, n.d.) Slide 12 (Objective 3): Hospice Care Services (1 minute) Present the following content: • • • • Medication for symptom control, including pain relief. Medical equipment like a hospital bed, wheelchairs or walkers, and medical supplies such as oxygen, bandages, and catheters. Therapies such as physical therapy, occupational therapy, speech language pathology services, and dietary counseling. *Access to these services is determined on a case-bycase basis depending on assessment of hospice team, goals of care as established by the hospice team, and disease progression and symptom burden. Short-term hospital care (inpatient care may be covered under hospice when adequate pain and symptom management cannot be achieved in the home setting). 80 And grief and loss counseling for the person on hospice and their loved ones. Grief counseling is provided to family members for up to 13 months after a death. Reference: (Hospice Foundation of America n.d.-b) Slide 13 (Objective 3) Hospice Care Coverage (30 Seconds) • Discuss the following: • Medicare, Medicaid, and Commercial Insurance Coverage Reference: (Hospice Foundation of America n.d.-c) Slides 14- 19 (Objective 4) Hospice Care in Nursing Homes (5 Minutes) Cover the following content: Care in nursing homes: A team effort. Discussion of key IDT members Collaboration Communication with residents and family care partners Reference: (Hospice Foundation of America n.d.-c) Slide 20 (Objective 5) Key Takeaways (1 Minute) • • • • Discuss the following: 1. Hope Shines in Hospice: 1. Remember, hospice isn't giving up; it's shifting the focus. 2. It's about making people as comfortable as possible when curing isn't an option anymore. 2. Comfort Comes First: 1. Hospice is all about keeping people pain-free and comfy. 2. Everything we do aims to give them a peaceful and painless time. 3. Connect with Compassion: 1. Every one of us can connect with those at the end of their lives. 2. Simple things like listening and being there can make a big positive difference. 4. Empathy Builds Strong Bonds: 1. Real connections mean understanding their feelings, values, and fears. 2. Empathy lets us imagine how they feel and assures them that their emotions are valid. 5. Respect for Dignity: 1. Older adults have different backgrounds and needs. 2. By respecting what they want and sharing their stories, we honor their humanity and help them live their last days with dignity. References: (Adkins, A., 2016; Hospice Foundation of America, n.d.; Medicare Interactive, 2019; Munn et al., 2008; Sokol-Hessner et al., 2019) Slides 21-22 (Objective 6) Additional Resources 81 Provide content links. Slide 23: References • Adkins, A. (2016, August 1). Palliative care vs. Hospice Care ⋆ Home Health & Hospice Care. Home Health & Hospice Care. https://hhhc.org/resources/news/general/palliativecare-vs-hospice-care/ • Centers for Medicare & Medicaid (n.d.). Hospice determining terminal status. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34538 • European Association for Palliative Care [EAPC] (2018, May 21). Cicely Saunders— celebrating a centenary. Cicely Saunders – celebrating a centenary | EAPC Blog (wordpress.com) • Harasym, P., Brisbin, S., Afzaal, M., Sinnarajah, A., Venturato, L., Quail, P., Kaasalainen, S., Straus, S. E., Sussman, T., Virk, N., & Holroyd-Leduc, J. (2020). Barriers and facilitators to optimal supportive end-of-life palliative care in long-term care facilities: a qualitative descriptive study of community-based and specialist palliative care physicians' experiences, perceptions and perspectives. BMJ Open, 10(8), e037466. https://doi.org/10.1136/bmjopen-2020-037466 • Hospice Foundation of America (n.d.-a). Dispelling hospice myths. https://hospicefoundation.org/Hospice-Care/Dispelling-Hospice-Myths. https://hospicefoundation.org/Hospice-Care/Dispelling-Hospice-Myths • Hospice Foundation of America (n.d. –b). What is hospice? https://hospicefoundation.org/End-of-Life-Support-and-Resources/Coping-withTerminal-Illness/Hospice-Services • Hospice Foundation of America (n.d.-c). Paying for hospice care. https://hospicefoundation.org/End-of-Life-Support-and-Resources/Coping-withTerminal-Illness/Paying-for-Care • Medicare Resources (n.d.,) What is curative care? https://www.medicareresources.org/glossary/curative-care/ • Munn, J. C., Dobbs, D., Meier, A., Williams, C. S., Biola, H., & Zimmerman, S. (2008). The end-of-life experience in long-term care: Five themes identified from focus groups with residents, family members, and staff. The Gerontologist, 48(4), 485–494. https://doi.org/10.1093/geront/48.4.485 82 • National Hospice and Palliative Care Organization [NHPCO]. (n.d.). What is the difference between palliative care and hospice care? https://www.caringinfo.org/types-ofcare/what-is-the-difference-between-palliative-care-and-hospice-care/ • National Institute on Aging [NIA] (n.d.). What are palliative care and hospice care? https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-care • Providence Health Care (n.d.) What is palliative care: The phases and layers of care. https://hpc.providencehealthcare.org/about/what-palliative-care • Sokol-Hessner L, Zambeaux A, Little K, Macy L, Lally K, McCutcheon Adams K. (2019). “Conversation Ready”: A framework for improving end-of-life care (Second Edition). IHI White Paper. Boston, Massachusetts: Institute for Healthcare Improvement. https://www.ihi.org/resources/Pages/IHIWhitePapers/ConversationReadyEndofLifeCare. aspx 83 Appendix E: LTC Staff Community Feedback Survey After watching this video do you feel more educated about hospice care? A. No B. Maybe C. Unsure How effective was the hospice training video in enhancing the understanding of hospice care for all staff working in a long-term care setting? 1) Understanding definitions of palliative care and hospice care? a) Strongly Effective b) Effective c) Neutral d) Ineffective e) Strongly Ineffective 2) Understanding of the care team members responsible for caring for a person on hospice who also lives in long-term care? a) Strongly Effective b) Effective c) Neutral d) Ineffective e) Strongly Ineffective 3) Understanding of the eligibility criteria required for a person to receive hospice care? a) Strongly Effective b) Effective c) Neutral d) Ineffective e) Strongly Ineffective 4) Understanding of the services that are commonly covered under hospice care? a) Strong Effective b) Effective 84 c) Neutral d) Ineffective e) Strongly Ineffective 5) Understanding best practices for communicating and educating a person and their family care partner about hospice care? a) Strongly Effective b) Effective c) Neutral d) Ineffective e) Strongly Ineffective How likely would you use this video for training or education with staff? A. Extremely Unlikely B. Unlikely C. Neither likely nor unlikely D. Likely E. Extremely Likely