Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2024


Doctor of Nursing Practice (DNP)

Primary Advisor

Karen Kesten, DNP, APRN, CCNS, CNE, FAAN


Background: Current practice for advance care planning (ACP) in oncology patients does not align with best practice, which is early, repeated, and interdisciplinary.

Objective: The purpose of this quality improvement project was to evaluate the process, feasibility, acceptability, and appropriateness of a nurse-driven ACP workflow in an outpatient breast cancer clinic. The project team further sought to evaluate the impact of the workflow on advance directives and ACP notes.

Methodology: This project followed the Plan-Do-Study-Act quality improvement framework. Breast cancer patients seen by two outpatient physicians received an email to assess interest in completing the Our Care Wishes (OCW) advance directive. Interested patients met with trained nurses to discuss OCW. Completed advance directives were scanned into the medical record. Physicians and nurses participating in the project completed surveys including the Acceptability of Intervention Measure, Feasibility of Intervention Measure, and Intervention Appropriateness Measure. Process and outcome measures were tracked via chart review and control charts.

Results:Advance directives increased from 9.88% at baseline to 12.8% post-project. ACP notes increased from 17.85% at baseline to 20.43% post-project. Special cause was found at three time points post-implementation for advance directives. Of the 416 screening emails distributed, 85.8% of patients read the emails and 8.4% responded as interested. Of interested patients, 48.6% met with the nurses. The average score on surveys sent to clinic staff on the AIM, FIM, and IAM was 20 post-project.

Conclusion and Implications for Practice: In an outpatient breast cancer clinic, a nurse-driven workflow was feasible, acceptable, and appropriate. The workflow was associated with increased advance directives and ACP notes. Future cycles should expand the program, document interactions with patients bringing the advance directive from home, automate patient emails, increase patient education, and instruct patients to upload their advance directives into the medical record.

Open Access




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