RMH ICU Nurses Perceptions and Care Practices towards Patients with Do Not Resuscitate Orders

Transcription

1 RMH ICU Nurses Perceptions and Care Practices towards Patients with Do Not Resuscitate Orders By: Marylie P. Cabaluna RMH- CC Educator GICU April 2011

2 Chapter 1 INTRODUCTION

3 Background of the Study Despite the vital role nurses play in the process of making a DNR orders few studies have looked at nurses role and attitudes toward DNR orders (Sulmasy et al., 2008). However, most studies have found that nurses either have limited involvement on the decision making or they are uncertain about their abilities to initiate discussions with patients and their families regarding DNR orders (Hosaka et al., 1999; Sulmasy et al., 2008).

4 In a descriptive study to examine health care professional beliefs and attitudes the process of DNR orders, Sulmasy et al. found that nurses are more likely than physicians to believe that they should initiate a discussion about DNR orders. Further, they found that nurses had more positive attitudes and were more confident in their abilities to discuss DNR orders than physicians. Similarly, Manias (1998)found that ninety one percent of the nurses agreed that nurses should be involved in determining the patients` DNR status. However, nurses believe that physicians usually are the one who are responsible for deciding whether to initiate CPR or not(manias, 1998; Sulmasy et al., 2008)

5 What might complicate the DNR decisions is the fact that many interacting factors seem to influence those decisions. These factors including but not limited to patients` preferences, probability of survival after CPR, and expected quality of life before and after performing CPR (Sham et al., 2007). Moreover, several studies have found that health care providers' attitudes and preferences have an impact on their decisions toward DNR orders (Kelly, Eliasson, Stocker, &Hnatiuk, 2002; Löfmark, 2000).

6 Physicians and nurses seem to be uncertain about the ethics and the decision process of DNR orders (Löfmark, 2000). Findings thus far suggests that there are differences in the practice of DNR orders, which might be related to the variances on the attitudes and knowledge of health care providers especially nurses; therefore, it would be worthwhile to examine perceptions and care practices with regards to DNR orders in the clinical setting.

7 Statement of the Problem Hypothesis Definition of Terms Scope and Delimitation

8 PARADIGM Antecedent Variable Independent Variables Dependent Variables Do Not Resuscitate Orders Nationality - Indian - Filipino - Saudi - Jordanian Nursing Degree -Diploma -BSN - Masters Length of Service -1-5 years years -11 years and up ICU Nurse s Perceptions On DNR And Care practices

9 Definition of Terms

10 Perception Practices Do Not Resuscitate Orders

11 Scope and Limitation This study was undertaken to determine the ICU nurses perceptions and care practices towards patients with DNR orders in Riyadh Military Hospital. The respondents are grouped according to the variables: Nationality ( Filipino, Indians, Saudis and Jordanians ), Nursing Degree ( Diploma, BSN and Masters ) and years of service in ICU (1-5 years, 6-10 years and 11 years and up ).

12 The respondents are limited to the Adult ICU nurses of RMH in different areas namely: SICU, GICU, Neuro ICU, RICU, HDU and CRNs. The target population are the 95 nurses whose on duty on the February- March 2011 Rota. Excluded are the nurses who are on vacation, emergency, study, sick and maternity leave, those on palace duty and who resigned within the rotation period. This study was conducted on February

13 Chapter 3 METHODOLOGY

14 Research Design One-shot Survey Respondent 95 ICU Nurses Purposive Sampling technique Instrument Self made Questionnaire- 2 sets 95 distributed/ 71 responded Statistical Tool Measures of Central tendency Chi- Square Test

15 Chapter 4 ANALYSIS AND INTERPRETATION

16 Distribution on ICU Nurses Nationality 6% 6% Legend: 21% 67% FILIPINO INDIAN SAUDI JORDANIAN NATIONALITY F % FILIPINO 48 67% INDIAN 15 21% SAUDI 4 6% JORDANIAN 4 6% TOTAL %

17 Distribution of ICU Nurses Nursing Degree DIPLOMA BSN MASTERAL 1% 6% 93%

18 Distribution of ICU Nurses Years Of Experience In ICU F % % 32% 14% 0-5 YEARS 6-10 YEARS 11 AND UP YEARS

19 Frequency Diploma % BSN % Masters % Filipino 0 0% 48 68% 0 0% Indian 2 4% 13 18% 0 0% Saudi 2 3% 1 1% 1 1% Jordanian 0 0% 4 6% 0 0% 4 7% 66 92% 1 1%

20 Frequency years 6-10 years 11 and up years Jordanian 1 1% 2 3% 1 1% Saudi 3 4% 1 1% 0 0% Indian 8 11% 5 7% 2 3% Filipino 26 37% 15 21% 7 10% 38 54% 23 32% 10 14%

21 Percentage Distribution of ICU Nurses Perceptions on DNR 120% 100% 80% 60% Series1 40% 20% 0% Perceptions

22 TOP 5 HIGHEST PERCEPTIONs of ICU NURSES ON DNR. Rank Perception on DNR % 1 DNR means no initiation of CPR. 99% 2 Basic care should continue. 98% 3 DNR orders should be made to patients when further treatment has no medical benefit. 4 NUrses role in providing support to the family of the dying patient. 5 Two physicians should sign the DNR form together with the primary consultant. 96% 95.5% 94%

23 Top 3 Lowest Perception of ICU Nurses on DNR Rank Perception on DNR % 1 The family members' opinion should not be included in decision making as they are unqualified to make such decision. 2 DNR order should be updated on a daily basis. 3.5 Nurses should participate in discussing the DNR orders to the family. 3.5 Nurses should discuss end of life issues with the family. 68% 79% 81% 81%

24 120% Percentage Distribution of ICU Nurses Care Practices 100% 80% 60% Series1 40% 20% 0% Care Practices

25 Top 5 Most Common Care Practices of ICU Nurses Rank Care Practices % 1 Giving complete handover. 99.6% 2 Promoting patients comfort. 99% 4 Allowing religious rituals/prayers for the patient. 98.5% 4 Maintaining privacy. 98.5% 4 Maintaining patient s airway. 98.5%

26 Top 3 Lowest Care Practices of ICU Nurses Rank Care Practices % 1 Open visitation without limiting the number of visitors. 61% 2 Passive ROM. 71% 3 Informing the family ( based on their level of understanding ) about the status of the patient. 71.8%

27 Chi Square Result : Relationship Between ICU Nurses Nationality, Nursing Degree and Length of Service to their Perceptions and Care Practices on DNR

28 Relationship of Experience, Nursing Degree and Nationality to Perception of ICU Nurses on DNR Variables X 2 Interpretation Experience 7.49 Nursing Degree 7.74 Non significant Non significant Nationality 19.9 significant

29 Relationship of Experience, Nursing Degree and Nationality to Care Practices of ICU Nurses Towards Patients with DNR Order Variables X 2 Interpretation Experience 22.7 Nursing Degree 6.83 significant Non significant Nationality 18.1 significant

30 Chapter 5 CONCLUSION AND RECOMMENDATION

31 Conclusion Based on the results the following conclusions are drawn: 1. Nationality has significant relationship on ICU nurses perception and practices to DNR patients thus null hypothesis is rejected. 2. Experience however doesn t have significant relationship with their perceptions but with practice, it was found out that there is a relationship. 3. Nursing degree doesn t have any significant relationship with either the perceptions and practices, thus null hypothesis is accepted.

32 Implication to Nursing Practice Nurses as stated in the ICN ( 1997 ) have a unique and primary responsibility for ensuring that individuals at the End of Life experience a peaceful death. Nurses have a moral obligation to honor the DNR decision. If health care providers cannot agree with the patient's desire to keep a DNR order the health care providers should be reassigned. Thus will not jeopardize the health care providers' professional licenses or conflict with their own personal beliefs. Policy and procedure of each institution will protect and guide practicing healthcare provider with the correct understanding of DNR concepts and its boundaries, it will create less confusion and stress to individuals and will promote quality care outcomes to the patient and the families.

33 Recommendations 1. Family support should be highly emphasized to the nurses, giving them trainings on how to deal with end of life issues. 2. A specialized, Family Care nurse should be assigned in the unit to assist the family in crisis management as they go along with the grieving process. A person in authority should be always available to discuss with the families their treatment options, the legal implications and their rights. 3. Appropriate ethics education should be offered by the institution to its nurses to develop their reflective ethical practices. 4. Increasing the awareness of the staff for the DNR policy and procedure. 5. Future studies should be done to explore other factors that may affect the nurses perceptions and practices towards DNR patients and to further investigate what is the effect of these perceptions to their practices.

34 References RMH DNR policy and Procedure, 2007 Morton, et al., Critical Care Nursing A holistic Approach,8 th Ed Johnstone, M.J., Bioethics: A Nursing Perspective, 5 th Ed., Elseveir Australia: Miranda DR. Quality of life after cardiopulmonary resuscitation. Chest. 1994; 106 (2): Compliance with DNR policy in a tertiary care center in Saudi Arabia King Abdulaziz Medical City (KAMCAlaa Gouda, Ahmad Al-Jabbary and Lian Fong, Nurses' attitudes toward do-not-resuscitate orders.purvis RJ, Law E, Still JM, Belcher K, Kito N, Dorman JB.Columbia Augusta Medical Center, Augusta, Ga., USA, Nurses' perspectives concerning do-not-resuscitate (DNR) orders.hosaka T, Nagano H, Inomata C, Kobayashi I, Miyamoto T, Tamai Y, Tamura Y, Tokuda Y, Yonekura S, Saito H, Mori T.Department of: Psychiatry and Behaviroal Science, Tokai University School of Medicine, Kanagawa, Japan. hosaka@is.icc.u-tokai.ac.jp Do Not Resuscitate (DNR) Orders Getting Emergency Responders to Honor Your WishesBy Rod Brouhard, About.com Guide.Updated September 11, NR+to+nursing&source=bl&ots=yWlhmbHrGN&sig=s9f_jBY2FoVAQl9DhLaiTbmyZ8k&hl=en&ei=s7q 1TbjGJcbX4waw9oWTDA&sa=X&oi=book_result&ct=result&resnum=5&ved=0CC0Q6AEwBA#v=one page&q&f=false

35 Perceptions ( 3 )Agree (2) Disagree (1 )Not Sure 1 DNR means no initiation of CPR. 2 DNR order is initiated by the primary consultant 3 2 Physicians should sign the DNR form together with the primary consultant. 4 DNR order is valid for one admission. 5 DNR order should be updated on a daily basis. 6 No Code or Do Not Attempt Resus is also termed used for No CPR. 7 Family should be involved in the care of the patient. 8 NUrses has role role to provide support to the family of the dying patient. 9 Basic care to patient is continued in patients with DNR orders. 10 Poor quality of life of patients before resuscitation is an indication of DNR order 11 All comfort measures should continue even the patient is on DNR orders. 12 Verbal/ Telephone orders from the treating physicians to nurses is unacceptable. 13 Nurses should partcipate in discussing the DNR orders to the family. 14 DNR orders should be made to patients when further treatment has no medical benefit. 15 In DNR, active management to patient can be withheld. 16 Anticipated poor quality of life of the patient after resuscitation needs DNR order. 17 No Further Resuscitation (NFR) should be made if patient failed in previous resuscitation. 18 No Further Resuscitation (NFR) is ordered when patient had failure of resuscitation. 19 The family members' opinion is not included in decision making as they are unqualified to make such decisions. 20 Nurses discuss end of life issues with the family.

36 Practices Always Sometimes Never 1 I give the patient medication on time. 2 I monitor my vital signs of my patient hourly. 3 I immediately refer any abnormal findings I see with the patient. 4 I render hygiene to my patient at least twice in my shift. 5 I monitor the vital signs of my patient as needed. 6 I turn the patient every 2 hours 7 I inform the family ( based on their level of understanding ) about the status of the patient. 8 I gave time and privacy to the family of the dying patient. 9 I allow the family members to do any religious rituals/prayers for the patient. 10 I guve complete handover to the incoming staff nurse on duty. 11 I am promoting patients of comfort. 12 I perform comprehensive assessment to my patient. 13 I do proper and timely documentation. 14 I maintain my patient's privacy. 15 I allow the family for open visitation without limiting the number of visitors. 16 I contiuously feed my patient. 17 I suction patient as needed. 18 I adhere with the infection control measures. 19 I render passive ROM. 20 I send routine blood samples.