The Body of Nursing Knowledge - Case Study Example

April 12, 2008 NURSING ASSIGNMENT What is the Lived Experiences of Nurses with the DNR Order in Critical Care? Phenomenon, Purpose, and Aim The body of nursing knowledge lies within the discipline. In order to promote clinical practice, theory needs to be integrated. The study of phenomena adds dimension to the clinical knowledge of the nurse, and promotes understanding of that phenomena that has the potential to be universal. Toomey and Alligood (2002) stated “phenomena are the subject matter of a discipline” (p.7). The phenomenon of interest for this study is the implementation and understanding of the do not resuscitate (DNR) order in critical care. Within the discipline of nursing, there is not a general consensus as to the clinical treatment of clients with a DNR status. This confusion poses certain problems in the practice of critical care nursing. The nurse working in the hospice environment has a clear understanding of palliative care in allowing for natural death. But in the critical care area, this understanding is clouded and misinterpreted. The aim of this study is to investigate the lived experience of critical care nurses in relationship to their understanding and implementation of care based on their assumptions. Significance to Nursing Nurses, the primary caregiver to patients, are infrequently involved in the decision to terminate life saving measures. Many nurses question why a patient with a DNR order should be admitted into the critical care area, and what care is appropriate in light of a patient’s DNR status. The current economic crisis in health care is a very real and publicized problem. Hewitt & Marco, 2004, report that intensive care unit (ICU) costs have continued to climb and now total 20% of all hospital charges in the United States (p.19). Moreover, the growth rate of hospital beds has been 1.4% per year versus 6.2% for ICU beds (Hewitt & Marco, 2004). This issue is particularly relevant in patients with terminal illnesses where the goal of care and suffering are increasingly important issues. And should a DNR order influence other aggressive interventions that are only available to a patient in the ICU? Moreover, the term DNR has different meanings to different health care professionals, fostering a broad range of interpretation. The legal term DNR, indicates that cardiopulmonary resuscitation (CPR) not be initiated at the time of cardiac or respiratory arrest (Thibault-Prevost & Hodgins, 2000). However, there is confusion among nurse’s to interpret DNR as a measure to withhold all treatment (Puntillo, Benner, Drought, Drew, 2001). Critical care nurses are particularly affected by DNR orders because they aim to implement life-saving measures. Because nurses are so enmeshed with direct patient care, it is imperative that nurses accurately define what a DNR order means, and what interventions are appropriate as they relate to the order. If a nurse is not aware of the implications of DNR status, the nurse cannot be an advocate for the patient. The unique perspectives of critical care nurses toward DNR status will be captured in this study, and practice recommendations will be made based on their perspectives. Qualitative Study According to Speziale & Carpenter (2003), “phenomenology is as much a way of thinking or perceiving as it is a method. The goal of phenomenology is to describe lived experience” (p. 53). A descriptive phenomenological method will be utilized in order to discover patterns and themes about life events when the researcher has specific questions about a phenomenon. Therefore, the research question will ultimately guide the study to establish what knowledge and beliefs exist among critical care nurses’ as it pertains to the DNR order. Overview The aim of phenomenology is the description of an experience as it is lived by the study participants and interpreted by the researcher (Burns & Grove, 2001). Reviewing the relevant literature on phenomenology, the author was able to uncover the history and meanings of the method. Phenomenology as a discipline is distinct, but is related to other disciplines in philosophy such as ontology, logic, and ethics (Speziale & Carpenter, 2003). Also, phenomenology has been practiced for over 100 years, and continues to develop and spread. Furthermore, phenomenologists seek to discover patterns or ideas of phenomena, and shed light on their meaning. The meaning is clearly subjective and unique to the individual as it relates to human becoming (Burns & Groove, 2001). Philosophy Phenomenology is both a philosophy and a research method (Burns & Groove. 2001). The method was first described by Franz Brentano in the late 19th century. However, the historical movement of phenomenology began with Edmund Husserl, a student of Brentano, in the first half of the 20th century. The movement continued with such philosophers as Martin Heidegger, Maurice Merleau-Ponty, and Jean-Paul Sartre (Speziale & Carpenter, 2003). The methods and characterizations of phenomenology were debated by Husserl and his successors, and continue to the present day. The assumptions underpinning phenomenology as a scientific method are as follows: humans coconstitute situations; knowledge about human experience is expanded by allowing essences of phenomena to appear through descriptions without predictable prescriptions; and knowledge about human experience is gained from retrospective descriptions of lived experiences (Parse, 2001). Phenomenological issues of intentionality, consciousness, and first- person perspective have been prominent in the philosophy of phenomenology. Theoretical Literature Throughout the literature, there is a clear distinction that the DNR order means that only CPR should be withheld should the patient sustain cardiac or respiratory arrest (Hewitt & Marco, 2004). Hewitt and Marco revealed that nurses thought that less physical care should be given to DNR patients (p.20). This included weighing patients, drawing blood, or performing complete physical assessments. Furthermore, the critical care nurses stated that they would be less likely to notify the physician of changes in urinary output, hypotension, pupil size and reactivity (Hewitt & Marco, 2004). This survey of the critical care nurses also found that 65% thought admission to an ICU was inappropriate with a DNR order and that 72% thought DNR orders should limit aggressive interventions (Hewitt & Marco, 2004). As a contrast, some authors addressed the ethical issues of the DNR order by shedding light on the patient’s right to self-determination. Scanlon, 2003, defines some common words as they relate to decision making and the nurses role. The author goes on to inform the reader that a majority of nurses feel uncomfortable discussing such issues with patients and their families. In addition, she reported that the nurse should be committed to providing the patient with comfort and dignity in this difficult time, and believes that nurses need opportunities to discuss these complex issues. It is important to mention that The President’s Commission on Deciding to Forgo Life-Sustaining Treatment issued a statement in 1983 that stated “Any DNR policy should ensure that the order not to resuscitate has no implications for any other treatment decisions. Patients with DNR orders on their charts may still be appropriate candidates for all other vigorous care including ICUs.” (Hewitt & Marco, 2004). Curiously, if asked, would any of the critical care nurses know of this statement? And if so, would this help to clarify any confusion that currently exists among them? Empirical Literature Nurses perceptions of DNR When searching the literature on the lived experiences of the critical care nurse with DNR orders, a particular study was noted to be the main focus. A descriptive study, by Thibault-Provost, Jenson, Hodgins, 2000, set out to describe the perceptions of nurses regarding the DNR order in critical care. Four hundred and five surveys were completed and returned by critical care nurses who were accessed through the Alberta Association of Registered Nurses. The method used to obtain the perceptions of the critical care nurses was a survey questionnaire that utilized open-ended comments, a 3-point rating scale, and a 5-point Likert scale. It was interesting to find that almost half of the respondents could not correctly define the legal definition of DNR. Furthermore, it went on to state that nurses felt that they were rarely involved in the DNR decision even though they provided the vast majority of bedside care, that they perceived that it was the physician who held this role. Also, 72% of the critical care nurses thought that a DNR order should be a deterrent to initiating aggressive therapy, and 65% deemed patient admission to a critical care unit as inappropriate. Therefore, the study was ultimately able to uncover critical care nurses’ perceptions of DNR orders in that they are unsure of their roles, and indicated to the researcher that there is a need for education and direction on DNR orders. However, the study did have some drawbacks in that a majority of the nurses were women, had an average age of 37 years, were staff nurses, and had the diploma as their highest level of education. Also, the questionnaire used was helpful for collecting demographic and attitudinal data, but did not provide data about actual practices. The practices actually utilized by the critical care nurses related to the designation of DNR may increase the understanding of specific DNR situations. Another study of importance, even though dated, has been cited in many of the theoretical and empirical literature reviews, is a study by Sherman & Branum. This study is the first to quantitatively investigate both physical care and psychosocial support of the hypothetical patient with a DNR order by critical care nurses. This descriptive, cross-sectional study aimed to determine critical care nurses’ perceptions of appropriate care of patients with and without DNR orders. The setting was a large northeastern, metropolitan teaching hospital, in which a sample of 317 staff nurses was divided into DNR and non-DNR groups. The two groups were given a questionnaire describing one of two hypothetical patients, DNR or non-DNR. Only 87 questionnaires were returned from a possible sample of 317. The average age of the respondents was 33 years, worked between two different ICU’s, and had an average length of critical care nursing experience of 8.5 years. This result was poor in that the sample was too small to yield accurate results. However, the results showed a major difference between nurses in the DNR and non-DNR groups in their perceptions of ICU placement and appropriate monitoring for their respective patients. In addition, the study suggested a possible misunderstanding by nurses of the narrow confines of such orders, and that the root of the problem may be ambiguous DNR policies (Sherman & Branum, 1995). Ultimately, the study states that more research is needed to establish why nurses have these perceptions. Nursing care for DNR patients Another study, “End-of Life care, Intensive Care Nurses’ Experience with End-of-Life Care”, extends what is in the literature by adding information about why nurses feel the transition from curative to end-of-life care is so difficult in the ICU (Kirchhoff, Spuhler, Walker, Hutton, Cole, & Clemmer, 2000). A cross-sectional descriptive design with four focus groups was used to assess the experiences of ICU nurses in end-of-life care. The nurses in the groups were randomly selected from two teaching hospitals and met only once. A questionnaire composed of short- answers and closed-ended demographic questions was utilized. In addition, the questionnaire was reviewed by nurses, physicians, chaplains, and other workers who had expertise in either critical care or hospice care. The study found that the nurses experienced stress over the transition because the awareness of the need for the transition varied among nurses, patients, families, and various medical specialists. Furthermore, nurses had difficulty with the issue of communicating the prognosis to patients, and felt it was the physician’s responsibility to tell the patients. There were some limitations to the study such that the response rate was low in that only twenty-one nurses had participated in the study. Also, all of the respondents were women with a majority of them being members of the Church of the Latter-Day Saints. On the other hand, it was clear that the respondents were articulate and thoughtful about their comments. The conclusion was that the nurses tried to provide optimal care to dying ICU patients even in the most difficult situations. Again, as stated in the previously mentioned studies, the nurses felt that more education was necessary and that they should be more involved in the decision to terminate life saving measure. Similarly, Puntillo, Benner, Drought, and Drew, 2001, did a survey design study to investigate the knowledge, beliefs, and ethical concerns of nurses caring for dying patients in the ICU. A random sample was drawn from the American Association of Critical- Care Nurses (AACN) membership. The questionnaire had three sections that consisted of clinical scenarios, respondents’ knowledge and opinions regarding pain management and end-of-life practices, and specific demographic information about the survey sample. The researches had a response rate of 906 nurses. Most of the respondents were white women, diploma graduates, and worked full-time providing direct patient care. Many of the nurses reported concern that patients do not receive compassionate or humane care in ICUs because dying is prolonged by use of overly aggressive treatment. In addition, nurses were asked how often patients were transferred from their unit within one to two days after a DNR order was written and death was imminent. Such transfers occurred the majority of the time (80%). However, the findings loudly stated that nurses continued to give supportive care to their patients regardless of DNR status and that DNR orders do not translate to “do not provide care to the patient.” Thus, staffing should reflect a commitment to allow time for the nurses to provide the care that is needed at the end of life. Nurses conflict regarding DNR Mary Ann Jezewski, 1998, performed a grounded theory study to investigate the conflict that occurs during the process of consenting to DNR status and the strategies used by critical care nurses to resolve these conflicts. A sample of 22 critical care nurses from a variety of critical care settings were interviewed. The interviews were audiotaped and transcribed. The interview consisted of open-ended questions that were formulated to elicit nurses’ experiences in the context of interacting with patients and family members during the process of their deciding whether to consent to a DNR status. Jezewski found that the critical care nurses experienced conflict during the process of consenting to DNR status. Two major categories of conflict were identified: intrapersonal, which occurred while determining the appropriateness of DNR for the patient and coming to terms with the meaning of DNR status, and interpersonal, which was conflict that occurred between family members, patients, and staff. Most important, though, was that the critical care nurses felt that they played an active role in assisting patients and families with DNR-status decisions. Summary The continued use of the DNR order remains very confusing to nurses working in the critical care area. According to Burns & Groove, 2001, the ultimate goal of nursing is to provide evidence-based care that promotes quality outcomes for patients, families, health care providers, and the health care system (p. 4). How, then, can nurses provide this care when such confusion exists about the subject at hand. Thus, due to this misunderstanding, the author can determine that gaps do exist in the literature, and that more research is needed to “clear the muddy waters”. The results of this study will help to generate knowledge that will directly influence nursing practice. And hopefully shed some light on a very confusing topic. Works Cited Burns, N., & Groove, S. K. (2001). The Practice of Nursing Research: Conduct, Critique, &. Utilization. (4th ed.). Philadelphia, PA: W. B. Saunders. Hewitt, W. J., & Marco, C. A. (2004). DNR: Does it Mean “Do Not Treat?” [Electronic version]. American College of Emergency Physicians, June 2004, 19-20. Jezewski, M., A. (1998). Do-not-resuscitate status: Conflict and culture brokering in critical care. [Electronic version]. Heart & Lung, 23, 458-465. Kirchhoff, K. T., Spuhler, V., Walker, L., Hutton, Cole, B. V., & Clemmer, T. (2000). End-Of Life Care: Intensive Care Nurses’s Experiences With End-of-Life Care. [Electronic version]. American Journal of Critical Care, 9 (1), 23-45. Parse, R. R., (2001). Qualitative Inquiry: The Path of Sciencing. (1st ed.). Sudbury, MA: Jones and Barlett Publishers. Puntillo, K. A., Benner, P., Drought, T., & Drew, B. (2001). End-of Life issues in intensive Care units: A national random survey of nurses’ knowledge and beliefs. [Electronic version]. American Journal of Critical Care, 10 (4), 216-230. Scanlon, C. (2003). Ethical Concerns in End-of-Life Care. [Electronic version]. American Journal of Nursing, 103 (1), 48-55. Sherman, D. A., & Branum, K. (1995). Critical care nurses’ perceptions of appropriate care of the patient with orders not to resuscitate. [Electronic version]. Heart & Lung, 24 (4), 321-327. Speziale, H. J., & Carpenter, D. R. (2003). Qualitative Research in Nursing. (3rd ed.). Philadelphia, PA.: Lippincott Williams & Wilkins. Thibault-Prevost, J., Jensen, L. A., & Hodgins, M. (2000). Critical Care Nurses’ Perceptions of DNR Status. [Electronic version]. Journal of Nursing Scholarship, 32 (3), 259-265. Read More