Changes in intensive care unit nurse involvement in end of life decision making between 1999 and 2016: Descriptive comparative study

ObjectiveComparison of nurse involvement in end of life decision making in European countries participating in ETHICUS I- 1999 and ETHICUS II- 2015.MethodologyThis was a prospective observational study of 22 European ICUs included in the ETHICUS-II and I. Data were collected as per the ETHICUS-I and ETHICUS-II protocols. Four questions within the ETHICUS protocols related to nurse involvement in end of life decision making were analyzed. This is a comparison of changes in nurse involvement in end of life decisions from 1999 to 2015.SettingInternational e-based questionnaire completed by an intensive care clinician when an end of life decision was performed on any patient.SubjectsIntensive care physicians and nurses, no interventions were performed.MeasurementsA 20 question survey was used to describe the decision making process, on what basis was the decision made, who was involved in the decision making process, and what precise decisions were made.ResultsA total of 4592 cases from 22 centres are included. While there was more agreement between nurses and physicians in ETHICUS-I compared to ETHICUS-I, fewer discussions with nurses occurred in ETHICUS-II. The frequency of end of life decisions that were discussed with nurses decreased in all three regions between ETHICUS-I and ETHICUS-II.ConclusionBased on the results of the current study, nurses should be further encouraged to increase their involvement in end of life decision-making, especially those in southern Europe.     

Critical care nurse satisfaction with levels of involvement in clinical decisions

This research reports the results of a survey of 230 Australian critical care nurses The respondents were asked to rate how frequently they were involved in 10 common critical care decisions and their levels of satisfaction with their involvement for each decision task It was found that level of task satisfaction was positively correlated with level of task involvement, thus supporting the hypothesis that nurse task decision autonomy is associated with nurse task satisfaction The paper argues for the importance of differentiation between task satisfaction and work satisfaction in research of these issues     

End-of-life care in the intensive care unit: a challenge for nurses.

Results from several research studies combined with increasing public tensions surrounding physician-assisted suicide have fueled a growing awareness of the inadequacies of end-of-life care. Investigators also suggest that intensive care unit nurses have a limited role in end-of-life decision making and care planning. This article explores cultural issues influencing end-of-life care in intensive care units, explores factors surrounding the limited involvement of critical care nurses in end-of-life decision making and care planning, and offers recommendations for changing nursing practice. Because improving end-of-life care will require cultural changes, an understanding of the cultural issues involved is needed. Recommendations for changing nursing practice include a model of end-of-life care that incorporates the goals of both cure and comfort care, as well as a shared decision-making process. Nurses are essential to improving end-of-life care in today's intensive care units.     

The impact of the nurse-physician professional relationship on nurses' experience of ethical dilemmas in effective pain management.

The aims of the current investigation were (1) to examine the ethical and professional conflicts experienced by Tasmanian registered nurses in attempting to provide optimal pain management, and (2) to examine nurse satisfaction with their professional relationship with physicians and with their level of involvement in pain management. A total of 1,015 registered nurses completed a 21-item survey examining ethical and professional conflicts encountered during patient pain management. Data also were gathered investigating nurse satisfaction with their involvement in and professional relationship with physicians during pain management. The respondents who felt adequately consulted by physicians were significantly more likely to instigate the consultation process than the respondents who felt that they were not adequately consulted by physicians about their patient's pain status. This was marked in relation to the need for increased pain relief medications. Nurses who did not feel adequately consulted by physicians were significantly more likely to experience ethical conflicts such as concerns about undermedication and patient reluctance to report pain. Nurses' concerns related to ethical conflicts concerning effective pain management are affected by their relationship with physicians. Education, for both nurses and physicians, concerning the role of the nurse in the workplace will help to ensure that these conflicts do not arise. Guidelines concerning the level of patient care at which consultation is necessary will ensure fewer conflicts and greater nurse satisfaction in the workplace.     

Being an intensive care nurse related to questions of withholding or withdrawing curative treatment

Aims and objectives. The aim of the study was to acquire a deeper understanding of what it is to be an intensive care nurse in situations related to questions of withholding or withdrawing curative treatment. Background. Nurses in intensive care units regularly face critically ill patients. Some patients do not benefit from the treatment and die after days or months of apparent pain and suffering. A general trend is that withdrawal of treatment in intensive care units is increasing. Physicians are responsible for decisions concerning medical treatment, but as nurses must carry out physicians’ decisions, they are involved in the consequences. Design and methods. The research design was qualitative, based on interpretative phenomenology. The study was carried out at an adult intensive care unit in Norway. Data were collected by group interviews inspired by focus group methodology. Fourteen female intensive care nurses participated, divided into two groups. Colaizzi's model was used in the process of analysis. Results. The analysis revealed four main themes which captured the nurses’ experiences: loneliness in responsibility, alternation between optimism and pessimism, uncertainty – a constant shadow and professional pride despite little formal influence. The essence of being an intensive care nurse in the care of patients when questions were raised concerning curative treatment or not, was understood as ‘being a critical interpreter and a dedicated helper.’ Conclusions. The findings underpin the important role of intensive care nurses in providing care and treatment to patients related to questions of withholding or withdrawing curative treatment. Relevance to clinical practice. The findings also show the need for physicians, managers and intensive care nurses themselves to recognize the burdens intensive care nurses carry and to appreciate their knowledge as an important contribution in decision making.     

From cure to palliation: staff communication, documentation, and transfer of patient

In the transition from curative treatment to palliative care of a general end-of-life patient population, the internal communication of the acute care staff seems to be less than optimal. The communication had reference to the dialogue within the staff both before and after the decision to concentrate on palliative care, and possible transfer of the patient. This survey of Swedish nurses and physicians showed that most of 780 respondents wanted more internal communication, and a more individualized procedure of decision-making. All staff should be informed about the decision made but full agreement was not seen as realistic. The largest difference of opinion between nurses and physicians concerned the involvement of nurses in the decision-making about the transition. A uniform documentation of the decision to transfer care focus was the ideal. Approximately every fourth patient in acute care is transferred to receive palliative care. Only approximately half of the respondents had any training in palliative care and the majority wanted more training. There seems to be a need for more palliative care training, perhaps somewhat different for each specialty. Furthermore, a common language to enable nurses and physicians to communicate more easily may improve the transition process.     

Limiting life-sustaining treatment in German intensive care units: A multiprofessional survey

Purpose

Deciding about the limitation of life-sustaining treatment (LST) is a major challenge for intensive care medicine. The aim of the study was to investigate the practices and perspectives of German intensive care nurses and physicians on limiting LST.

Methods

We conducted an anonymous, self-administered questionnaire survey among the 268 nurses and 95 physicians on all 10 intensive care units of the Munich University Hospital, Germany.

Results

The response rate was 53%. Of all respondents, 91% reported being confronted with the topic at least once a month. Although all reported limiting cardiopulmonary resuscitation, almost no one reported limiting artificial hydration. Half of nurses and junior physicians felt uncertain about the decision-making process. Junior physicians were most dissatisfied with their training for this task and expressed the highest fear of litigation. Nurses were less satisfied than physicians with the communication process. Both nurses and relatives were not routinely involved in decision making. There is no standardized documentation practice, and many notes are not readily accessible to nurses.

Conclusions

Limiting LST is common in German intensive care units. The major shortcomings are team communication, communication with the patient's family, and documentation of the decision-making process.     

Essential Professional Nursing Practices in mental health: A cross‐sectional study of hospital inpatient care

Quality organizational structures and nursing practices are key to positive patient outcomes. Whereas structures have been largely studied over the past few decades, less is known of the nursing practices that account for patient outcomes, such as patient satisfaction. This is especially true in psychiatric, mental health care settings. The aim of the present study is to determine the relative importance of eight Essential Professional Nursing Practices (EPNPs) on the satisfaction of hospitalized patients on mental health care units. A cross‐sectional design was selected; 226 point‐of‐care mental health nurses completed the online EPNP questionnaire in Spring 2015. Statistical analyses included MANOVAs and a 2‐step linear regression. A significant relationship was found between university preparation and scores on two EPNP subscales: autonomous decision‐making and practicing with competent nurses. Scores on patient advocacy and control over practice subscales were significantly related to nurse‐rated patient satisfaction. The findings reinforce the positive link between university education and the work of nurses and highlight the power dynamics that are salient in mental health care. The pertinence of EPNPs in psychiatric settings is brought to the fore, with practices of patient advocacy and nurse control over care examined in relation to empowerment. Implications for clinical and administrative leaders are addressed, with a focus on strategies for empowering patients and nurses.     

Safety work: initiating, maintaining, and terminating restraints

PURPOSE: This study examines the variations and complexities in nurses' decision making about the initiation, maintenance, and termination of physical restraints. METHODS: This qualitative research used a semistructured interview of registered nurses on medical-surgical units at a midsized hospital in the Midwest. RESULTS: All the nurse respondents easily recalled caring for a patient in restraints and detailed in their accounts a complex trajectory of care that centered on safety. However, most nurses reported that the trajectory of restraint use was started by other departments, shifts, or nurses. The findings revealed a forceful interplay of patient, nurse, family, healthcare worker, and organizational factors that influence nurses' decision making about restraint use. CONCLUSIONS: This article discusses how a deeper understanding of the intricacies of the decision-making processes related to restraints can help clinical nurse specialists tailor education, impact policy, and serve as role models to reduce the use of restraints in hospitals.     

Critical care nurses' participation in ethical decision making

Critical care staff nurses' participation in ethical decision making was studied in relation to the perceptions of environmental social support of 45 female staff nurses. Data obtained measured perceived environmental social support from six organizational subgroups and individual participation in ethical decision making. Validity and reliability testing was done on the instrument. When involved in an ethical situation, critical care nurses perceived low levels of environmental social support from hospital administrators, nursing administrators, and physicians. Co-workers were consistently perceived as most supportive across all aspects of social support. The majority of the nurses surveyed (74%) reported that ethical decisions were made by physicians or with reference to hospital policy, and that there were limited roles for individual, family, or nurse participation in such decision making. It was concluded that critical care nurses perceive a lack of free agency necessary to engage in ethical decision making in hospital environments or to act in an advocacy role in such situations.     

The Acute Care Nurse Practitioner in Collaborative Practice

Nurse-physician relationships remain, for the most part, hierarchical in nature. A hierarchical structure allows the person at the top, most notably the physician, the highest level of authority and power for decision making. Other health care providers are delegated various tasks related to the medical plan of care. One role of nonmedical health care providers, including nurses, is to support the medical plan of care and increase the productivity of physicians. Medical centers have house staff, usually interns and residents, who work collaboratively with the attending physicians in care delivery. At one medical center, a shortage of medical house staff for internal medicine prompted the development and evaluation of an alternative service. The alternative service utilized master prepared, certified nurse practitioners on a nonteaching service to provide care for selected types of medical patients. Physicians consulted with nurse practitioners, but retained decision-making authority concerning patient admission to the service. This paper describes the development and evaluation of an alternative service based on a collaborative practice model and the role of nurse practitioners working under such a model. Discussion includes suggestions for process guideline development for organizations that want to improve collaborative practice relationships between unit nursing staff, nurse practitioners, and physicians.     

Using a patient satisfaction survey to close the theory-practice gap

AIM: The objective of this study was to determine whether a patient satisfaction survey could be used as a research tool to improve nursing practice. METHOD: A postal questionnaire was sent to patients after discharge. Questions covered primary nursing, information, ward environment, discharge planning and social activities. RESULTS: A number of respondents were dissatisfied with the information they had received and with their lack of involvement in decisions about care. This was often correlated with lack of primary nurse recognition. The role of the associate nurse was poorly understood. There were high levels of satisfaction with discharge procedures, but little enthusiasm for the introduction of an activities programme. CONCLUSION: The results highlighted areas where changes were needed. This resulted in a nurse-led programme of managed change, including making all experienced D and E grade nurses primary nurses, improving information provision, and involving patients in the decision-making process.     

Discrepant attitudes about teamwork among critical care nurses and physicians

OBJECTIVE: To measure and compare critical care physicians' and nurses' attitudes about teamwork. DESIGN: Cross-sectional surveys. SETTING: Eight nonsurgical intensive care units in two teaching and four nonteaching hospitals in the Houston, TX, metropolitan area. SUBJECTS: Physicians and nurses who worked in the intensive care units. MEASUREMENTS AND MAIN RESULTS: Three hundred twenty subjects (90 physicians and 230 nurses) responded to the survey. The response rate was 58% (40% for physicians and 71% for nurses). Only 33% of nurses rated the quality of collaboration and communication with the physicians as high or very high. In contrast, 73% of physicians rated collaboration and communication with nurses as high or very high. By using factor analysis, we developed a seven-item teamwork scale. Multivariate analysis of variance of the items yielded an omnibus ( [7, 163] = 8.37; p <.001), indicating that physicians and nurses perceive their teamwork climate differently. Analysis of individual items revealed that relative to physicians, nurses reported that it is difficult to speak up, disagreements are not appropriately resolved, more input into decision making is needed, and nurse input is not well received. CONCLUSIONS: Critical care physicians and nurses have discrepant attitudes about the teamwork they experience with each other. As evidenced by individual item content, this discrepancy includes suboptimal conflict resolution and interpersonal communication skills. These findings may be the result of the differences in status/authority, responsibilities, gender, training, and nursing and physician cultures.     

Factors influencing decision making among ambulance nurses in emergency care situations

The aim of this study was to investigate which factors that influences decision making among Swedish ambulance nurses in emergency care situations. Nurses in ambulance are sometimes forced to make decisions without adequate information. Data collected from interviews with 14 ambulance nurses was analyzed. The informants described 30 incidents during which they had to make fast decisions. A qualitative content analysis of the text was made, from which different categories were identified. It was found that when nurses are called to an emergency, the extent and degree of difficulty of the incident is decisive for how decisions are made. In addition, the nurses’ experience is important for decision making, because the experience factor constitutes a qualitative difference between a novice nurse and a more experienced nurse’s influence on decision-making. Furthermore, external factors, such as the uncertainty of a prehospital environment, expectations and pressures from an environment in which one is working while being observed by other people, and collaborating with many different operators, all contribute to making decisions in an urgent situation even more complex. Further studies are needed to understand the complexity of decision making in emergency situations.     

The relationship between nurse practice environment,nurse work characteristics,burnout and job outcome and quality of nursing care: A cross-sectional survey

Aim

To explore the mechanisms through which nurse practice environment dimensions are associated with job outcomes and nurse-assessed quality of care. Mediating variables tested included nurse work characteristics of workload, social capital, decision latitude, as well as burnout dimensions of emotional exhaustion, depersonalization, and personal accomplishment.

Background

Acute care hospitals face daily challenges to their efforts to achieve nurse workforce stability, safety, and quality of care. A body of knowledge shows a favourably rated nurse practice environment as an important condition for better nurse and patient outcome variables; however, further research initiatives are imperative for a clear understanding to support and guide the practice community.

Design

Cross-sectional survey.

Method

Grounded on previous empirical findings, a structural equation model designed with valid measurement instruments was tested. The study population was registered acute care nurses (N = 1201) in two independent hospitals and one hospital group with six hospitals in Belgium.

Results

Nurse practice environment dimensions predicted job outcome variables and nurse ratings of quality of care. Analyses were consistent with features of nurses’ work characteristics including perceived workload, decision latitude, and social capital, as well as three dimension of burnout playing mediating roles between nurse practice environment and outcomes. A revised model adjusted using various fit measures explained 52% and 47% of job outcomes and nurse-assessed quality of care, respectively.

Conclusion

The study refines understanding of the relationship between aspects of nursing practice in order to achieve favourable nursing outcomes and offers important concepts for managers to track in their daily work. The findings of this study indicate that it is important for clinicians and leaders to consider how nurses are involved in decision-making about care processes and tracking outcomes of care and whether they are able to work with physicians, superiors, peers, and subordinates in a trusting environment based on shared values. The involvement of nurse managers at the unit level is especially critical because of associations with nurse work characteristics such as decision latitude and social capital and outcome variables. Further practice and research initiatives to support nurses’ involvement in decision-making process and interdisciplinary teamwork are recommended.     

Managing pain in chronic kidney disease: patient participation in decision-making

AIM: This paper is a report of a study to examine how decisions about managing pain were made between patients with chronic kidney disease and nurses, what affected the decision style and the types of analgesics and adjuvant therapies given for pain relief in relation to a particular decision style. BACKGROUND: While pain often accompanies chronic kidney disease, little is known of how decisions are made about managing pain in clinical practice. Lack of patient involvement in decision-making may lead to inadequate care provision. In some care situations, nurses have been more concerned with medication side effects than giving effective pain relief. METHOD: An exploratory study was conducted, using observations and interviews with a purposive sample of 14 nurses and 53 patients in five adult renal units in Australia. The data were collected during 2004. FINDINGS: Of the 103 pain activities observed, 78 involved a passive decision style between the nurse and patient, 19 involved a collaborative decision style, and six used an active decision style. The majority of routine analgesic and adjuvant medications administered involved a passive decision style. Most importantly, 25.6% of passive style decisions observed resulted in no administration of an analgesic or adjuvant medication; however, all collaborative and active style decisions observed resulted in administration of an analgesic or adjuvant medication. CONCLUSION: Nurses need actively to encourage patient involvement in treatment decisions because this promotes effective pain control. More research is needed into how specific detailed information about pain treatments could improve patient participation in decision-making.     

Impact of nurse staffing on intent to leave,job satisfaction,and occupational injuries in Korean hospitals: A cross‐sectional study

The purpose of this study was to examine nurse staffing in comprehensive nursing care units in Korea and examine the corresponding nurse outcomes, including intent to leave, job satisfaction, and occupational injuries. A total of 356 nurses working in comprehensive nursing care units at eight small‐medium sized Korean hospitals participated in this cross‐sectional study. In the day, evening, and night shifts, nurse staffing ranged from 9.00 to 24.82, 9.04 to 24.26, and 9.02 to 25.80, respectively. The nurse staffing on each shift did not have a significant impact on nurses? intent to leave, job satisfaction, and occupational injuries. However, workload had a strong relationship with intent to leave and job satisfaction. Voluntary overtime was related to occupational injuries. These findings demonstrate that workload is an important factor for intent to leave and job satisfaction among nurses working in comprehensive nursing care units. Improvements of the work environment, as well as rearrangement of nurse workload to account for patient acuity and nursing needs, are required for the future expansion of comprehensive nursing care services.     

The decision-making process in critical care of the aged

Nurses in a critical care setting are challenged daily to provide safe, effective quality care for elderly patients. The decision process underlying this care is complex because of the amount, diversity, and uncertainty of information that must be processed. Some variables associated with the client, the nurse, and the critical care environment are irrelevant to the decision process, yet continue to influence nurses' decision making. Suboptimal and erroneous diagnoses and interventions may result. Awareness of factors that adversely affect decision making should assist nurses in enhancing their information processing. Use of objective and systematic decision-making techniques also can improve the efficiency and quality of decision making in the critical care of aging people.