Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Sandra L. Spoelstra PhD, RN, FGSA, FAAN

Second Advisor

Dianne Slager, DNP, FNP-BC,


Objectives: The quality improvement project objectives were to honor documented Do Not Resuscitate wishes in emergency departments by examining and improving workflow during primary care to emergency department transitions. A location for advance care planning documentations was designated for advanced directives, yet not utilized.

Methods: Mixed method, pre-/post-comparison, and thematic design examined clinicians and patients in a primary care office and two emergency departments in a Midwest healthcare system. Data was collected from patient records, clinician surveys, and observation of workflow. Descriptive statistics, frequency counts and non-parametric tests were used to analyze data.

Results: Patient charts were audited (N=261 [pre=124; post=137]), mean age 79.2 years, 59% female. Clinician surveys included 32 emergency department providers (30=pre; 2=post) and 59 registered nurses (38=pre; 21=post). Patient chart audit (N=137) found 97% had a primary care code status with 2.9% in emergency department records. Provider (mean 2.93) and registered nurse (mean 3.14) moral distress was moderate. Pre/post barriers to discuss advanced directives increased from 80.2% to 100%; comfort discussing advanced directives improved from 43.2% to 100%; and providers (13.3-100%) and registered nurses (3-19%) were more aware of where to document advanced directives.

Conclusions: Gaps in care placed patients with Do Not Resuscitate at risk for harm due to challenges with documentation. Post-implementation knowledge improved yet workflow and placement of Do Not Resuscitate orders in the record did not change. A clinically significant improvement in clinician knowledge of patient safety and location of advance care planning documents may lead to improved care.