A Multicenter Qualitative Investigation of the Experiences and Perspectives of Substitute Decision Makers Who Underwent Organ Donation Decisions.

BACKGROUND: Organ donation research has centered on improving donation rates rather than focusing on the experience and impact on substitute decision makers. The purpose of this study was to document donor and nondonor family experiences, as well as lasting impacts of donation. METHODS: We used a qualitative exploratory design. Semistructured interviews of 27 next-of-kin decision makers were conducted, transcribed verbatim, and entered into qualitative software. We analyzed the process-based reflections using inductive coding and thematic analysis techniques. RESULTS: Four broad and interrelated themes emerged from the data: empathetic care, information needs, donation decision, and impact and follow-up. The donation experience left lasting impacts on family members due to lingering, unanswered questions. Suggested solutions to improve the donor experience for families included providers employing multimodal communication, ensuring a proper setting for family meetings, and the presence of a support person. DISCUSSION: We now have improved our understanding of the donation process from the perspective of and final impression from the next of kin. To our knowledge, this is the largest cohort interviewed in Canada. We have explored families' experiences, which included but did not end with donation. We learned that despite being appreciative of nurses, physicians, and organ and tissue donation coordinators, family members were often troubled by unanswered questions. CONCLUSION: This study described donor and nondonor family experiences with donation as well as lasting impacts. Addressing unanswered questions should be done in a place sufficiently remote from the donation event to enhance the family members' understanding and well-being.

The meaning of being an oncology nurse: Investing to make a difference.

The landscape of cancer care is evolving. Oncology nursing continues to develop and respond to the changing needs of patients with cancer and their families. There is limited understanding of what it means to be an oncology nurse, as well as the factors that facilitate or hinder being an oncology nurse. This study used an interpretive phenomenological approach. Six nurses from two in-patient units in a tertiary care teaching facility were interviewed. The overarching theme, Investing to Make a Difference, reflected how oncology nurses invested in building relationships with patients and their family members and invested in themselves by developing their knowledge and skills and, eventually, their identities as oncology nurses. In turn, these investments enhanced their role, and were seen to make a difference in the lives of patients and their family members by supporting them through the cancer journey. Implications of these findings for oncology nursing are highlighted as they relate to nursing practice, education, research, and leadership.

When Someone Dies in the Emergency Department: Perspectives of Emergency Nurses.

UNLABELLED: Emergency nurses work in a clinical area where treatment measures usually are provided quickly, and they have little time to establish relationships. In addition to performing life-saving interventions, emergency nurses provide care for patients who are dying. Little is known about the experiences of emergency nurses who care for patients who die in the emergency department in the Canadian context. METHODS: This study used a qualitative design with an interpretive descriptive approach. Semistructured interviews were conducted with 11 ED nurses from a large Canadian academic health sciences system. RESULTS: In-depth analysis of the data resulted in 3 major themes: "It's not a nice place to die," "I see the grief," and "Needing to know you've done your best." Findings revealed that emergency nurses believed the environment made it difficult to care for dying patients and their families because of unpredictability, busyness, noise, lack of privacy, and the need to manage many patients simultaneously. These nurses were also put in the position of caring for the suddenly bereaved family members, which was viewed as an especially challenging aspect of their role. DISCUSSION: Caring for adults who die in the emergency department is a difficult and challenging aspect of the emergency nursing role. Emergency nurses believed they did their best to provide end-of-life care interventions, which brought a sense of professional satisfaction. Recommended future interventions include advocating for ED design and physical layout to support compassionate end-of-life care, provision of policies and training to support families and family presence, and support of nursing staff.

Comprehensive assessment of critical care needs in a community hospital*.

OBJECTIVE: To design and implement a needs assessment process that identifies gaps in caring for critically ill patients in a community hospital. DESIGN, SETTING, SUBJECTS: This mixed-method study was conducted between June 2011 and February 2012. A conceptual framework, centered on the critically ill patient, guided the design and selection of the data collection instruments. Different perspectives sampled included regional leaders, healthcare professionals at the community hospital and its referral hospital, as well as family members of patients who had received care at the community ICU. Data sources included interviews (n = 22), walk-throughs (n = 5), focus groups (n = 31), database searches, context questionnaires (n = 8), family surveys (n = 16), and simulations (n = 13). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nine needs were identified. At the community hospital, needs identified included lack of access to human resources, gaps in expertise, poor patient flow and ICU bed use, communication, lack of educational opportunities, and gaps in end-of-life care and interprofessional teamwork. Needs were also identified in the interhospital interaction between the community and referral hospitals, which included an inadequate hospital network and gaps in transfer and repatriation of patients. The methodology uncovered the causes and widespread impact of each need and how they interacted with one another. Proposed solutions by the participants are presented including both organizational and educational/clinical solutions. CONCLUSIONS: This study captured needs in a complex, interprofessional, interhospital context, which can be targeted with tailored interventions to improve patient outcomes in a community hospital. Furthermore, this study provides a preliminary framework and rigorous methodology to performing a needs assessment in this setting.

Parents' experience of the transition with their child from a pediatric intensive care unit (PICU) to the hospital ward: searching for comfort across transitions.

Parents of children in pediatric intensive care units (PICUs) have many needs and stressors, but research has yet to examine their experience of their child's transfer from PICU to the hospital ward. Ten parents were interviewed following transfer from PICU to a hospital ward at a children's hospital in Canada. Parents' experience involved a search for comfort through transitions. The themes were: 'being a parent with a critically ill child is exhausting', 'being kept in the know', 'feeling supported by others', and 'being transferred'. Findings from this study can help nurses and health professionals working with parents during transitions.

Learning end-of-life care in ICU: strategies for nurses new to ICU.

The experience of critical care nurses caring for patients and families during the withdrawal of life support has recently been explored (Vanderspank-Wright, Fothergill Bourbonnais, Brajtman, & Gagnon, 2011). In that study, the nurses were able to find, using their developing knowledge and experience, their own way, over time, through the process of withdrawing life support. Challenges in caring for patients and families were described by the participants in themes such as "the runaway train of technology," which explored nurses' experience of caring in a technologically complex environment. In this current article, the authors will explore the importance of providing "good care" in relation to withdrawal of life-sustaining treatment. The principles of providing "good care" such as patient comfort, open and frequent communication with families, support by fellow co-workers and time to reflect on the care given are fundamental to the overall experience of providing quality end-of-life care in the critical care environment. Practical solutions will be offered to help both new graduates and nurses who are new to ICU, find their way to care for patients and families within this context.

Caring for patients and families at end of life: the experiences of nurses during withdrawal of life-sustaining treatment.

BACKGROUND: Withdrawal of life-sustaining treatment is a process in which active treatment and the accompanying technology are removed, ending in the death of the patient. PURPOSE: To understand the lived experience of critical care nurses who care for patients during the process of withdrawal of life-sustaining treatment. METHODS: A phenomenological study was undertaken and interviews were conducted with six critical care nurses. RESULTS: The essence of this experience was described by these nurses as "trying to do the right thing". Three major themes emerged: A journey--creating comfort along the way, working in professional angst, and providing memories.

Survey of educators' end-of-life care learning needs in a Canadian baccalaureate nursing programme.

AIM: To examine the potential need for faculty development in end-of-life care (EOLC) of theory and clinical educators in a collaborative bilingual undergraduate nursing programme in a Canadian university. METHOD: A purposive sample of 53 Anglophone and Francophone theory and clinical educators completed the Palliative Care Quiz for Nursing, the Frommelt Attitude Toward Care of the Dying Scale and an adapted Educators Educational Needs Questionnaire (Patterson et al, 1997). RESULTS: Results indicated that educators held positive attitudes towards caring for dying patients and had modest knowledge levels. Participants identified personal educational needs, preferred learning formats, support and barriers to teaching EOLC and to their participation in continuing educational programmes. Strategies to enhance the teaching and learning of EOLC content in the theory and clinical context were suggested. CONCLUSION: Nurse educators require time, opportunities and relevant resources to develop the competencies required to support the theoretical and experiential learning of students in EOLC. Recommendations include a variety of approaches for faculty development initiatives, including face to face and virtual, which allow nurse educators to share expertise.

Meaningful experiences and end-of-life care in the intensive care unit: A qualitative study.

OBJECTIVES: The purpose of this study was to provide a comprehensive exploration of nurses' meaningful experiences of providing end-of-life care to patients and families in the intensive care unit (ICU). The objectives of this research were: (1) To explore what is meaningful practice for nurses regarding end-of-life care; (2) To describe how nurses create a good death in the intensive care unit and (3) To identify the challenges that nurses face that affect their meaningful experiences and ultimately the creation of a good death. RESEARCH DESIGN: This study utilised an interpretive phenomenological approach using Van Manen's (1997) method. SETTING: In-depth, face-to-face interviews were conducted with six intensive care nurses employed in a 32-bed medical/surgical intensive care unit of an academic tertiary care centre in Canada. FINDINGS: The overarching theme from the analysis of this experience was "being able to make a difference" which was intricately woven around contributing to a good death. Three main themes were identified and included: creating a good death, navigating the challenges and making it work. CONCLUSION: The findings reveal how intensive care nurses provide good end-of-life care and create good deaths for patients and families.

Providing direction for change: assessing Canadian nursing students learning needs.

AIM: To examine the current curriculum content and learning needs of graduating nursing students related to end-of-life care (EOLC). DESIGN: A survey method was employed. SAMPLE: A purposive sample of 58 Anglophone and Francophone students completed the Palliative Care Quiz for Nursing (PCQN) and Frommelt's Attitudes Toward Care of the Dying Scale (FATCOD). Students responded to open-ended questions regarding perceptions of preparedness to care for terminally ill patients, and provided suggestions for changes to the curriculum. Key informant educators identified opportunities to include EOLC content in courses and clinical placements. RESULTS: Results indicated that students held positive attitudes towards caring for dying patients, had modest knowledge levels, and that one third did not feel adequately prepared to care for dying patients. Although EOLC education tends to be threaded throughout the program, the emphasis is dependent upon the commitment of individual professors and clinical instructors with experience and/or expertise in this area. CONCLUSION: Students and educators agreed more emphasis on EOLC was needed. Recommendations include development of teaching strategies and experiential learning in EOLC throughout the curriculum.

Battling a Tangled Web: The Lived Experience of Nurses Providing End-of-Life Care on an Acute Medical Unit.

Meeting the heath care needs of patients at the end of life is becoming more complex. In Canada, most patients with life-limiting illness will die in hospitals, many on medical units. Yet, few studies have qualitatively investigated end-of-life care (EOLC) in this context, or from the perspectives of nurses providing EOLC. The purpose of this study was to seek to understand the lived experience of nurses on a medical unit providing EOLC to patients. Interpretive phenomenology guided the method and analysis. Individual face-to-face interviews were conducted with 10 nurses from 2 hospital medical units. The underlying essence of these nurses' experiences was that of "battling a tangled web." Battling a tangled web represented their struggles in attempting to provide EOLC in an environment that was not always conducive to it. Seven themes were generated from the analysis: caring in complexity, caught in a tangled web, bearing witness to suffering, weaving a way to get there: struggling through the process, creating comfort for the patient, working through the dying process with the family, and finding a way through the web. The findings contribute to an understanding of the experiences of nurses in providing EOLC on a medical unit including perceived facilitators and barriers.

Health care providers' and patients' perspectives on care in HIV ambulatory clinics across Ontario.

This descriptive study represents one component of a larger project that examined the perceptions of current and best-care practices in HIV ambulatory clinics across Ontario by health care providers and patients living with HIV/AIDS. Focus groups were held with providers and patients at eight clinics. Results showed that providers' and patients' perceptions were similar. Participants were able to describe current care practices and identify two elements of best care: patient-focused care and access to care. However, both health care providers and patients acknowledged that financial constraints, appointment scheduling, and distance to clinics were some of the barriers to achieving best care. Case management and shared-care schemes are two strategies that are proposed to meet the challenge of providing collaborative integrated care that is accessible and equal to all, while still maintaining positive patient outcomes.

The nature of multidisciplinary HIV care in the ambulatory setting: a synthesis of the literature.

The purpose of this article is to provide a critical appraisal and synthesis of the literature relating to the provision of multidisciplinary HIV care in the ambulatory setting. As more people are living with HIV infection, and living longer, the demand for chronic care is great. Knowing what optimal care and treatment for people living with HIV/AIDS is and how to provide that care is an ongoing challenge. The literature suggests that the provision of care for HIV-infected individuals varies across and within HIV/AIDS clinics. This variability in care practices may influence the health and well-being of patients, and negatively impact on access to such care by people with HIV/AIDS. The goal of reviewing the literature on HIV-ambulatory clinics was to provide a description of a typical clinic, its staffing components, the care practices carried out at such a clinic (and by whom), and some barriers to providing optimal care. The ultimate goal of this review is to establish what is currently known about the provision of these services so that this information may build on existing knowledge and thereby standards of care for HIV-ambulatory clinics can be developed that could be implemented on a wide-scale basis.

Clinical judgments about endotracheal suctioning: what cues do expert pediatric critical care nurses consider?

Making accurate and timely judgments based on multiple ways of knowing is an essential skill in critical care nursing practice. Studies have proposed that positive patient outcomes are linked to expert judgments in a variety of critical care situations; however, little is known about clinical judgments related to specific critical care nursing interventions. This article presents a qualitative nursing research study which examined the cues that expert pediatric critical care nurses used in making clinical judgments about suctioning intubated and ventilated, critically ill children. The participants' words and actions attest that the 'sensing' and 'thinking' of the process of cue use, are interwoven with, and integral to, the 'doing,' which is the process of skilled performance.

The recovery mosaic: older women's lived experiences after a myocardial infarction.

OBJECTIVE: The purpose of this study was to examine the experience of recovery in women 65 years of age and older during initial recovery from acute myocardial infarction. DESIGN: The study was designed with Heideggerian phenomenology, purposive sampling, and unstructured interactive interviews. Data were analyzed with interpretive processes of hermeneutics. SETTING: The study was set in a Canadian metropolitan teaching hospital and in patient homes. PARTICIPANTS: Seven women who had had a first time myocardial infarction were recruited. Age ranged from 67 to 86 years (mean, 74 years). RESULTS: Analysis revealed that recovery for these women was highly contextual and consisted of life experience resembling a mosaic, in which the women described how they "created a new picture for themselves." The data were clustered into 4 substantive themes that included: life is scattered; trying to make sense of it; learning to live with it; and getting settled. CONCLUSION: The older women in this study underestimated their susceptibility to acute myocardial infarction, were avid planners and coordinators of their recovery, equated the loss of the homemaker role to job loss, used their ability to socialize as an indicator of the recovery progress, and lacked support to perform household duties, such as laundry, and those women with fewer symptoms "cheated" in relation to activity and diet. These findings may serve as a basis for the development of healthcare strategies reflective of older women's recovery.

The experience of taking multiple drug therapies for persons with HIV infection: the Canadian perspective.

Advances in the understanding of HIV pathogenesis, clinical assessment with viral load testing, and the availability of potent combination antiretroviral therapy regimens have led to significant benefits for persons with HIV infection. Currently, the therapeutic strategy to achieve high-level suppression of viral replication involves many pills and doses each day. This regimen could adversely affect the quality of life of these clients. In reviewing the literature, it is evident that little is known about the experience of taking multiple drug therapies from the perspective of the individuals. For example, with the introduction of triple drug therapies has come constraints associated with the regimens, as well as drug interactions and short-term and long-term adverse effects. Little is known about the social and emotional impact related to successfully taking these or other therapies. Less is known regarding this experience from a Canadian perspective. This research study answered the following question: What is the experience of taking multiple drug therapies for persons with HIV infection? A phenomenological inquiry was used. A purposive sample of 19 participants was drawn from a large immunodeficiency clinic in a tertiary hospital. In-depth interviews were followed by a return interview to verify themes from the analysis. The findings revealed the complex process that these regimens demand and the major impact on clients' lives. The essence of the experience described by the participants was "learning to live with this process."

The experience of family members caring for a dying loved one.

Qualitative nursing research into the experience of family members caring for a dying loved one has been limited. This study used a phenomenological approach to explore this experience. The pattern of caring for a dying loved one and its intertwined dimensions were described. Caregivers felt a sense of helplessness that was associated with illness progression, their inability to relieve pain and discomfort, and decision-making related to patient admission to a palliative care unit. Lack of support from health professionals and having to face personal limits were found to accelerate the decision to admit a patient. The role of a support person involved with the caregiver was also considered and found to be an area worthy of further investigation. Health professionals must provide information and support tailored to the caregivers' needs as they change along a patient's illness trajectory.

The experience of being a trauma nurse: a phenomenological study.

The lived experience of being a trauma nurse was explored using a phenomenological qualitative research approach. Seven registered nurses employed in a trauma unit from one large metropolitan Canadian teaching hospital participated in in-depth conversational interviews. Data analysis revealed four sub theme clusters embedded within the overarching theme of Seeing Through Cloudy Situations: being on guard all the time, being caught up short, facing the challenge and sharing the journey. Even though trauma nurses are able to find meaning and satisfaction in their work, the findings of this research reveal the need for support and the assurance of safe work environments as trauma nurses can live with violence and aggression in their daily nursing practice.

Teaching successful medication administration today: more than just knowing your 'rights'.

Medication administration is an important skill taught in undergraduate nursing programs. Student learning for this activity includes not only how to prepare and administer medications, but also includes interventions such as patient and family teaching. Students also are taught a series of 'rights' in order to prevent medication errors. There are many factors, both personal and system related, which contribute to medication errors in the health care environment. The purpose of this article is to provide strategies for teaching students medication administration that encompass the multiple factors involved to ensure safe practice. This opinion paper is based on the authors' considerable years of teaching experience (35 years clinical setting and classroom teaching with senior students in final year of baccalaureate program for 1st author and 16 years total for co-author). Recommendations put forth by the authors are: a) leveling students' clinical experiences in administering medications to include understanding of system factors, b) structured scenarios and purposeful linking of theory to clinical courses to advance students' knowledge and skills related to medication administration as they progress through the program, 3) revisiting math skills.