The differing perspectives of doctors and nurses in end-of-life decisions in the intensive care unit: A qualitative study.

BACKGROUND: End-of-life (EOL) decision-making in the intensive care unit (ICU) can be emotionally challenging for both doctors and nurses, who are sometimes placed in difficult positions where they are required to make decisions on behalf of patients. With an ageing population and advances in medical technology, there is an increase in such decisions being made in ICUs. OBJECTIVES: The objective of this study was to explore the perspectives of doctors and nurses involved in the EOL decision-making process in an ICU. METHODS: This study used a qualitative methodology based on naturalistic inquiry. Intensive care nurses and doctors from a large Sydney metropolitan public hospital were purposively selected, and data saturation was reached after a total of eight nurses and four doctors were interviewed. Data were collected through semistructured interviews, either face-to-face or over the telephone. Interviews were then transcribed verbatim, and themes were identified and coded through a line-by-line analysis of each transcript (manual thematic analysis). FINDINGS: The findings revealed two main themes: 'Doctors' and nurses' roles in decision-making' and 'Managing family expectations'. These themes highlighted key differences in decision-making processes, in that doctors tended to aim to meet the family's needs, while the nurses tended to advocate on behalf of the patient and what they interpreted as the patient's best interests. Furthermore, nurses tended to feel undervalued in decision-making during family conferences, when in reality, the doctors were making decisions based on all information obtained, primarily from nursing staff. CONCLUSIONS: EOL decision-making is complex and affects doctors and nurses involved in different ways. More emphasis on interprofessional education and collaboration between the two disciplines may enhance future decision-making processes.

End-of-life decisions in the Intensive Care Unit (ICU) - Exploring the experiences of ICU nurses and doctors - A critical literature review.

BACKGROUND: End-of-life decision making in the Intensive Care Unit (ICU), can be emotionally challenging and multifaceted. Doctors and nurses are sometimes placed in a precarious position where they are required to make decisions for patients who may be unable to participate in the decision-making process. There is an increasing frequency of the need for such decisions to be made in ICU, with studies reporting that most ICU deaths are heralded by a decision to withdraw or withhold life-sustaining treatment. OBJECTIVES: The purpose of this paper is to critically review the literature related to end-of-life decision making among ICU doctors and nurses and focuses on three areas: (1) Who is involved in end-of-life decisions in the ICU?; (2) What challenges are encountered by ICU doctors and nurses when making decisions?; and (3) Are these decisions a source of moral distress for ICU doctors and nurses? REVIEW METHOD: This review considered both qualitative and quantitative research conducted from January 2006 to March 2014 that report on the experiences of ICU doctors and nurses in end-of-life decision making. Studies with a focus on paediatrics, family/relatives perspectives, advance care directives and euthanasia were excluded. A total of 12 papers were identified for review. RESULTS: There were differences reported in the decision making process and collaboration between doctors and nurses (which depended on physician preference or seniority of nurses), with overall accountability assigned to the physician. Role ambiguity, communication issues, indecision on futility of treatment, and the initiation of end-of-life discussions were some of the greatest challenges. The impact of these decisions included decreased job satisfaction, emotional and psychological 'burnout'. CONCLUSIONS: Further research is warranted to address the need for a more comprehensive, standardised approach to support clinicians (medical and nursing) in end-of-life decision making in the ICU.

Identifying strategies to assist final semester nursing students to develop numeracy skills: a mixed methods study.

BACKGROUND: It remains a grave concern that many nursing students within tertiary institutions continue to experience difficulties with achieving medication calculation competency. In addition, universities have a moral responsibility to prepare proficient clinicians for graduate practice. This requires risk management strategies to reduce adverse medication errors post registration. AIM: To identify strategies and potential predictors that may assist nurse academics to tailor their drug calculation teaching and assessment methods. This project builds on previous experience and explores students' perceptions of newly implemented interventions designed to increase confidence and competence in medication calculation. METHODS: This mixed method study surveyed students (n=405) enrolled in their final semester of study at a large, metropolitan university in Sydney, Australia. Tailored, contextualised interventions included online practice quizzes, simulated medication calculation scenarios developed for clinical practice classes, contextualised 'pen and paper' tests, visually enhanced didactic remediation and 'hands-on' contextualised workshops. Surveys were administered to students to determine their perceptions of interventions and to identify whether these interventions assisted with calculation competence. Test scores were analysed using SPSS v. 20 for correlations between students' perceptions and actual performance. Qualitative open-ended survey questions were analysed manually and thematically. RESULTS: The study reinforced that nursing students preferred a 'hands-on,' contextualised approach to learning that was 'authentic' and aligned with clinical practice. Our interventions assisted with supporting students' learning and improvement of calculation confidence. Qualitative data provided further insight into students' awareness of their calculation errors and preferred learning styles. Some of the strongest predictors for numeracy skill performance included (1) being an international student, (2) completion of an online practice quiz, scoring 59% or above and (3) students' self-reported confidence. CONCLUSION: A paradigm shift from traditional testing methods to the implementation of intensive, contextualised numeracy teaching and assessment within tertiary institutions will enhance learning and promote best teaching practices.