Variations in reporting of nurse involvement in end-of-life practices in intensive care units worldwide (ETHICUS-2): A prospective observational study.

BACKGROUND: ICU nurses are most frequently at the patient's bedside, providing care for both patients and family members. They perform an essential role and are involved in decision-making. Despite this, research suggests that nurses have a limited role in the end-of-life decision-making process and are occasionally not involved. OBJECTIVE: Explore global ICU nurse involvement in end of life decisions based on the physician's perceptions and sub-analyses from the ETHICUS-2 study. DESIGN: This is a secondary analysis of a prospective multinational, observational study of the ETHICUS-2 study. SETTING: End of life decision-making processes in ICU patients were studied during a 6-month period between Sept 1, 2015, and Sept 30, 2016, in 199 ICUs in 36 countries. INTERVENTION: None. METHODS: The ETHICUS II study instrument contained 20 questions. This sub-analysis addressed the four questions related to nurse involvement in end-of-life decision-making: Who initiated the end-of-life discussion? Was withholding or withdrawing treatment discussed with nurses? Was a nurse involved in making the end-of-life decision? Was there agreement between physicians and nurses? These 4 questions are the basis for our analysis. Global regions were compared. RESULTS: Physicians completed 91.8 % of the data entry. A statistically significant difference was found between regions (p < 0.001) with Northern Europe and Australia/New Zealand having the most discussion with nurses and Latin America, Africa, Asia and North America the least. The percentages of end-of-life decisions in which nurses were involved ranged between 3 and 44 %. These differences were statistically significant. Agreement between physicians and nurses related to decisions resulted in a wide range of responses (27-86 %) (p < 0.001). There was a wide range of those who replied "not applicable" to the question of agreement between physicians and nurses on EOL decisions (0-41 %). CONCLUSION: There is large variability in nurse involvement in end-of-life decision-making in the ICU. The most concerning findings were that in some regions, according to physicians, nurses were not involved in EOL decisions and did not initiate the decision-making process. There is a need to develop the collaboration between nurses and physicians. Nurses have valuable contributions for best possible patient-centered decisions and should be respected as important parts of the interdisciplinary team. TWEETABLE ABSTRACT: Wide global differences were found in nurse end of life decision involvement, with low involvement in North and South America and Africa and higher involvement in Europe and Australia/New Zealand.

Illness perceptions of Israeli hospitalized patients with acute coronary syndrome.

BACKGROUND: Illness perceptions (IPs) can affect cardiac health behaviours and outcomes. AIMS AND OBJECTIVES: To investigate IPs among patients hospitalized with acute coronary syndrome (ACS). DESIGN: Longitudinal survey. METHODS: The ACS Israel Study is a national, biennial registry, enrolling all patients with ACS admitted to cardiac intensive care or cardiology wards in Israel within a 2-month period. Data includes demographics, medical history, and treatment for ACS using an electronic database. In 2018, a nursing component was added, including the Brief Illness Perception Questionnaire. Data were analysed using descriptive statistics and a two-stage cluster analysis. RESULTS: A total of 990 subjects were surveyed. Mean age was 62.8 (SD = 12.5) and most respondents were male and married. Mean IP scores ranged from 3.28 to 6.06. Three clusters were found; one only of women and two only of men (one cluster with lower IPs and little previous medical history and cardiac risk factors and the second with higher IPs, greater medical history, and cardiac risk factors. Those with higher education scored lower on several IPs. CONCLUSIONS: Subjects were moderately cognitively and emotionally impacted by their illness. Men tended to perceive their illness as having either a relatively strong or a relatively weak emotional and cognitive impact on their lives, where women were somewhere in-between. Participants with an academic education perceived less of an impact of the illness while those with a previous history of chronic disease reported the opposite. It is recommended that educational interventions and in-depth qualitative studies be designed that investigate the development of IPs during hospitalization to potentially improve cardiac health behaviours, especially among those without a previous medical history and cardiac risk factors. RELEVANCE TO CLINICAL PRACTICE: Those without a history of chronic disease or a lower level of education are less likely to absorb the full impact of a cardiac event while hospitalized and should, therefore, be monitored more closely and coached with greater intensity than other groups while still in-hospital.

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

OBJECTIVE: Comparison of nurse involvement in end of life decision making in European countries participating in ETHICUS I- 1999 and ETHICUS II- 2015. METHODOLOGY: This 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. SETTING: International e-based questionnaire completed by an intensive care clinician when an end of life decision was performed on any patient. SUBJECTS: Intensive care physicians and nurses, no interventions were performed. MEASUREMENTS: A 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. RESULTS: A 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. CONCLUSION: Based 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.

Distress among hospitalized patients with acute coronary syndrome.

BACKGROUND: Previous studies have demonstrated that those suffering from acute coronary syndrome (ACS) experience various physical and psychological symptoms. Few studies have investigated the multi-factorial, holistic, unpleasant experience of distress that includes physical, psychological, social, and spiritual factors among this patient population while still hospitalized. AIM: To describe the level of distress among patients hospitalized with ACS and its association with demographic and clinical factors and mortality. STUDY DESIGN: The study conducted a descriptive, cross-sectional survey. METHODS: The Acute Coronary Syndrome Israel Study is a national, biennial registry, enrolling all patients with ACS admitted to cardiac intensive care or cardiology wards in Israel within a 2-month period. Demographic and clinical data were retrieved from an electronic database. Distress was measured by the Distress Thermometer. Nurses collected distress data directly from patients before discharge. RESULTS: Nine hundred ninety participants (50.6% response rate) were surveyed. Mean age was 62.8 (SD = 12.5). Mean distress level was 4.8 (SD = 3.45) out of 10. The most frequently reported area of distress was physical, followed by emotional. Practical and family problems were less frequent. Emotional distress was found to differ based on educational level, marital status, smoking history, and previous medical history. Distress did not predict 7- or 30-day mortality. CONCLUSIONS: Respondents with ACS were in moderate distress. It is recommended that those at increased risk receive increased monitoring of emotional distress while still in hospital. Further studies should investigate this holistic view of distress among the ACS population using a variety of methods and methodologies.

The need for palliative and support care services for heart failure patients in the community.

BACKGROUND: Palliative care is a care option considered appropriate for those with heart failure, but is uncommon partially due to a lack of timely identification of those needing palliative care. A standard mechanism that triggers which heart failure patients should receive palliative care is not available. The Gold Standards Framework (GSF) identifies those needing palliative care but has not been investigated with heart failure patients. OBJECTIVES: To describe palliative care provided in the community and determine whether the GSF can identify heart failure patients in need of palliative care. METHODS: Descriptive study. A total of 252 heart failure patients in the community completed a demographic characteristics questionnaire, the Edmonton symptom assessment scale-revised and the Minnesota living with heart failure questionnaire. Clinical data were collected from the medical chart and the primary physician completed the GSF prognostic indicator guidance. RESULTS: Participants had a mean age of 76.9 years (standard deviation 10.9), most at New York Heart Association level III (n=152, 60%). Fewer than half received pain medications (n=76, 30%), anxiolytics (n=35, 14%), antidepressants (n=64, 25%) or sleep medications (n=65, 26%). Eight patients spoke with a psychologist or psychologist (3%). One had an advanced directive and 16 (6%) had a record of discussions with their family caregivers. Three (1%) had end-of-life discussions with their healthcare providers. Most healthcare providers responded 'no' to the 'surprise question' (n=160, 63%). Sensitivity and specificity of the gold standards framework was poor. CONCLUSIONS: Few community dwelling heart failure patients received most aspects of palliative care. The gold standards framework was not a good indicator of those who should receive palliative care.

A snapshot of clinical educational experiences for advanced practice nurses worldwide.

Using a convenience sampling, nurse educators representing 10 countries were surveyed to describe required clinical education for advanced practice beyond basic traditional nursing education. This article explores the many factors currently influencing the structure and diversity of these clinical experiences worldwide.

Introducing palliative care into the intensive care unit: An interventional study.

BACKGROUND: Many Intensive Care Unit (ICU) deaths include patient and family suffering. While there is a need to include palliative care in the ICU, such care is often unavailable. OBJECTIVES: To determine whether a course in ICU Palliative Care was associated with changes in participants' palliative care knowledge, attitudes and practices. METHODS: Four cohorts of a national Israeli course in ICU palliative care (N = 122) were followed. Data were collected on the first and last day of a six-month course and 2-5 years later. RESULTS: Statistically significant differences were found in palliative care attitudes and practices, with knowledge levels and quality of death and dying stable after course completion. Participants reported obtaining knowledge and skills necessary to introduce palliative care but were thwarted by organizational barriers. CONCLUSIONS: The course was successful in building participants capacity to provide palliative care however; barriers made introduction of palliative care into the ICU difficult.

Israeli Nurses' Palliative Care Knowledge, Attitudes, Behaviors, and Practices.

OBJECTIVES: To describe and compare self-perceived end-of-life (EOL) knowledge, attitudes, behaviors, and practices of intensive care unit (ICU) nurses compared to oncology nurses. SAMPLE & SETTING: 126 Israeli nurses (79 oncology nurses and 47 ICU nurses) who were members of the Israel Association of Cardiology and Critical Care Nurses and the Israeli Oncology Nurses Organization. METHODS & VARIABLES: This cross-sectional study used an online survey to gather demographic information, clinical setting, and study measures (EOL knowledge, attitudes, behaviors, and practices). RESULTS: Oncology nurses and ICU nurses showed moderate levels of self-perceived knowledge and attitudes toward palliative care; however, their self-reported behaviors were low. Oncology nurses scored slightly higher than ICU nurses on knowledge and attitudes but not behaviors, although the difference was not statistically significant. IMPLICATIONS FOR NURSING: Contrary to the current authors' expectations, oncology nurses and ICU nurses have similar levels of knowledge, attitudes, and behaviors regarding palliative care. Nurses in both settings need to be better trained and empowered to provide such care.

Design and Preliminary Testing of the Caregiver-Centered Communication Questionnaire (CCCQ).

The study objective was to develop and test a new survey instrument that measures caregiver-centered communication. We developed a questionnaire inspired by the National Cancer Institute framework on patient-centered communication, focusing on family caregiver communication for this tool. The questionnaire includes 5 subscales: exchange of information, relationship with team, emotions, managing care, and decision-making. The initial questionnaire was reviewed by domain experts for face validity and edited further to include 30 items. We administered the modified questionnaire to 115 family caregivers of patients with serious illness in various settings. Cronbach α for the entire scale was 0.97 and ranged from 0.82 to 0.93 for the 5 subscales. Participants found that the survey addressed important concepts and that items were in most cases easy to understand. This instrument provides a structured way to assess caregiver-centered communication, addressing a pressing need for tools that measure the extent to which communication is responsive to the needs and preferences of family caregivers. Further testing and refinement are needed to improve the ease of use and examine the reliability and validity of this measure.

Family-Centered Communication and Acute Stress in Israeli Intensive Care Units.

BACKGROUND: Intensive care unit stays can be stressful for patients' family members. Family-centered communication has 6 components: fostering relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient self-management. Whether these communication components decrease family members' stress is unknown. OBJECTIVE: To describe levels of family-centered communication and associations with acute stress while patients are in the intensive care unit. METHODS: A convenience sample of 130 family members of patients in 2 intensive care units in a Jerusalem, Israel, tertiary medical center received a family-centered communication questionnaire, the Perceived Stress Scale, and a personal characteristics questionnaire. RESULTS: Most respondents were women (n = 79, 60.8%), children of the patient (n = 67, 51.9%), and familiar with the patient's diagnosis (n = 111, 85.4%). Mean (SD) participant age was 45.7 (13.6) years. Most considered the patient medically stable (n = 75, 57.7%). Mean (SD) intensive care unit stay was 7.45 (5.8) days. Mean (SD) total and item scores for family-centered communication were 98.75 (18.21) and 3.80 (0.70), respectively; for the Perceived Stress Scale, 19.63 (5.92) and 1.96 (0.59), respectively. Relationship building (r = -0.31, P = .002), participation in care management (r = -0.32, P = .001), and emotional support (r = -0.29, P = .003), and were significantly related to stress. CONCLUSIONS: Stress levels were mild to moderate and communication scores were moderate to high. Better nurse communication with family members was associated with decreased acute stress, irrespective of personal characteristics or perceptions of the patient's medical status.

Improving Family Intensive Care Unit Experiences at the End of Life: Barriers and Facilitators.

Experiencing the end of life of a family member in the intensive care unit is clearly difficult. An important role of critical care nurses is to help family members through this challenging period. This article highlights a few clinically significant barriers and facilitators related to improving family experiences at the patient's end of life that have received less attention in the literature thus far. Facilitators include specific aspects of communication, the nurse's role as the coordinator of care, bereavement care, promoting a "good death," and caring for health care providers. Barriers include medical uncertainty and differences in values and culture.

A Conflict of Values: Nurses' Willingness to Work Under Threatening Conditions.

PURPOSE: The purpose of this study was to determine the willingness of Israeli registered nurses to work under threatening conditions, their perceived level of threat, and perceptions of peer willingness to report to work. DESIGN: This descriptive study was based on a convenience sample of registered nurses working in four hospitals throughout Israel from internal medicine, surgical, emergency, and intensive care units. METHODS: A questionnaire designed by the investigators was administered to registered nurses while on duty. The questionnaire consisted of three sections: personal characteristics, perceived level of personal threat from five situations (caring for a patient with a dangerous infection, terror attack, war, radiation or chemical disaster, or natural disaster), and perceived personal and peer willingness to work under these threats. FINDINGS: A convenience sample of 249 registered nurses from four hospitals responded. The highest level of perceived threat was a natural disaster (earthquake; M = 2.15, SD = 0.9). Terror (M = 0.83, SD = 0.6) and war (M = 1.01, SD = 0.6) received the lowest mean perceived threat scores. Most respondents were not willing to work during a natural disaster but were willing to care for patients with dangerous infections and during times of war. Weak positive statistically significant correlations were found between the level of perceived threat and willingness to work for all of the threats, except for terror (Spearman rank correlation = .16-.35). CONCLUSIONS: Local culture, perceptions of the level of threat, and perceived peer responsiveness are associated with registered nurses' willingness to work under threat. CLINICAL RELEVANCE: When faced with a threat to personal safety or security, many registered nurses might not be willing to work as usual. What is perceived as threatening is influenced by the local culture and environment. Therefore, managers should be aware of potential cultural and peer influences on this possible conflict of values.

Perceptions of slow codes by nurses working on internal medicine wards.

BACKGROUND: Cardio-pulmonary resuscitation is the default procedure during cardio-pulmonary arrest. If a patient does not want cardio-pulmonary resuscitation, then a do not attempt resuscitation order must be documented. Often, this order is not given; even if thought to be appropriate. This situation can lead to a slow code, defined as an ineffective resuscitation, where all resuscitation procedures are not performed or done slowly. RESEARCH OBJECTIVES: To describe the perceptions of nurses working on internal medicine wards of slow codes, including the factors associated with its implementation. RESEARCH DESIGN: This was a cross-sectional, descriptive study. Participants completed a personal characteristics questionnaire and the Perceptions and Factors of Slow Codes questionnaire designed for this study. PARTICIPANTS AND RESEARCH CONTEXT: The sample was a convenience sample of nurses working on internal medicine wards in two Israeli hospitals. ETHICAL CONSIDERATIONS: The study received ethical approval from both institutions, where data were collected and stored according to institutional policy. FINDINGS: Most reported that resuscitations were conducted according to protocol (n = 90, 76.2%). Some took their time calling the code (n = 22, 18.3%), or waited by the bedside and did not perform cardio-pulmonary resuscitation (n = 45, 37.5%). Factors most associated with slow codes were poor patient prognosis (mean = 3.52/5, standard deviation = 1.27) and a low chance of patient survival (mean = 3.37/5, standard deviation = 1.21). Two-thirds (n = 76, 66.8%) reported that slow codes were done on their unit and the majority (n = 80, 69%) perceived slow codes as ethical. DISCUSSION: This study confirms that slow codes are part of medical care on internal medicine wards, where most nurses perceive them as an ethical alternative. These perceptions are in contrast to most legal and ethical opinions expressed in the literature. CONCLUSION: Nurses should be educated about the legal and ethical implications of slow codes, and qualitative and quantitative studies should be conducted that further investigate its implementation.

Nurses' perceptions of intensive care unit palliative care at end of life.

BACKGROUND: Significant barriers can block the provision of palliative care at the end of life in the intensive care unit (ICU). However, the relationship between perceptions of ICU quality palliative care and barriers to palliative care at the end of life is not well documented. AIMS AND OBJECTIVES: To describe ICU nurses' perceptions of quality palliative end-of-life care, barrier intensity and frequency to palliative care and their association with one another. DESIGN: This was a descriptive, correlational, cross-sectional design. METHODS: A convenience sample of 126 ICU nurses from two hospitals in Israel was recruited for the study. Participants completed three pencil-and-paper questionnaires (a personal characteristics questionnaire, the Quality of Palliative Care in the ICU and a revised Survey of Oncology Nurses' Perceptions of End-of-Life Care). Respondents were recruited during staff meetings or while on duty in the ICU. Ethical approval was obtained for the study from participating hospitals. RESULTS: The item mean score of the quality of palliative end-of-life care was 7·5/10 (SD = 1·23). The item mean barrier intensity and frequency scores were 3·05/5 (SD = 0·76) and 3·30/5 (SD = 0·61), respectively. A correlation of r = 0·46, p < 0·001 was found between barrier frequency and intensity and r = -0·19, p = 0·04 between barrier frequency and quality palliative end-of-life care. CONCLUSIONS: ICU nurses perceived the quality of palliative care at the end of life as moderate despite reports of moderate barrier levels. The frequency of barriers was weakly associated with quality palliative end-of-life care. However, barrier intensity did not correlate with quality palliative end-of-life care at a statistically significant level. Further research that investigates other factors associated with quality ICU palliative care is recommended. RELEVANCE TO CLINICAL PRACTICE: Barriers to palliative care are still common in the ICU. Increased training and education are recommended to decrease barriers and improve the quality of ICU palliative care.

Experiences of Family Members of Dying Patients Receiving Palliative Sedation.

PURPOSE/OBJECTIVES: To describe the experience of family members of patients receiving palliative sedation at the initiation of treatment and after the patient has died and to compare these experiences over time.
. DESIGN: Descriptive comparative study.
. SETTING: Oncology ward at Shaare Zedek Medical Center in Jerusalem, Israel.
. SAMPLE: A convenience sample of 34 family members of dying patients receiving palliative sedation. 
. METHODS: A modified version of a questionnaire describing experiences of family members with palliative sedation was administered during palliative sedation and one to four months after the patient died. Descriptive statistics were used to describe the results of the questionnaire, and appropriate statistical analyses were conducted for comparisons over time.
. MAIN RESEARCH VARIABLES: Experiences of family members and time.
. FINDINGS: Most relatives were satisfied with the sedation and staff support. Palliative sedation was experienced as an ethical way to relieve suffering. However, one-third felt that it shortened the patient's life. An explanation of the treatment was given less than half of the time and was usually given on the same day treatment was started. This explanation was given by physicians and nurses. Many felt that they were not ready for changes in the patient's condition and wanted increased opportunities to discuss the treatment with oncology care providers. No statistically significant differences in experiences were found over time. 
. CONCLUSIONS: Relatives' experiences of palliative sedation were generally positive and stable over time. Important experiences included timing of the initiation of sedation, timing and quality of explanations, and communication.
. IMPLICATIONS FOR NURSING: Nurses should attempt to initiate discussions of the possible role of sedation in the event of refractory symptoms and follow through with continued discussions. The management of refractory symptoms at the end of life, the role of sedation, and communication skills associated with decision making related to palliative sedation should be a part of the core nursing curriculum. Nursing administrators in areas that use palliative sedation should enforce good nursing clinical practice as recommended by international practice guidelines, such as those of the European Association for Palliative Care.

Factors Associated With Full Implementation of Scope of Practice.

PURPOSE: To describe whether nurses fully implement their scope of practice; nurses' perceptions of future practice implementation; and the association between scope of practice implementation with professional autonomy and self-efficacy. DESIGN: A descriptive correlational study was conducted using a convenience sample of 145 registered nurses with post-basic certification from two Israeli university hospitals, from May 2012 to September 2013. METHODS: Five questionnaires were distributed: (a) Demographic and Work Characteristics, (b) Implementation of Scope of Practice, (c) Attitudes Towards Future Practice, (d) Practice Behavior Scale, and (e) Practice Self-Efficacy. Descriptive statistics for all demographic and questionnaire data were analyzed. Two regression models were developed, where current and future implementations were the criterion variables and demographic and work characteristics, professional autonomy, and self-efficacy were the predictors. FINDINGS: High levels of professional autonomy, self-efficacy, and attitudes towards future practice were found in contrast to low or moderate levels of current implementation of the full extent of scope of practice. Primary reasons associated with low implementation were lack of relevance to practice and permission to perform the practice. Significant associations were found between professional autonomy, self-efficacy, and attitudes towards future practice, but not with current implementation. CONCLUSIONS: Nurses wanted to practice to the full extent of their scope of practice and felt able to do so but were hindered by administrative and not personal barriers. CLINICAL RELEVANCE: Even though staff nurses with post-basic certification had high levels of professional autonomy and self-efficacy, many were not implementing the full extent of their scope of practice. Similar to findings from around the world, external factors, such as administrative and policy barriers, were found to thwart the full implementation of nurses' full scope of practice. Therefore, practicing nurses should be aware of these barriers and work towards reducing them.

Bullying and Its Prevention Among Intensive Care Nurses.

PURPOSE: International studies report that nurse bullying is a common occurrence. The intensive care unit (ICU) is known for its high stress levels, one factor thought to increase bullying. No studies were found that investigated bullying in this population. The purpose of this study was to describe the prevalence of ICU nurse bullying and what measures were taken to prevent bullying. DESIGN: This was a descriptive study of a convenience sample of 156 ICU nurses from five medical centers in Israel. Data collection was conducted over a 10-month period in 2012 and 2013. METHODS: After ethical approval, three questionnaires (background characteristics, Negative Acts Questionnaire-Revised, and Prevention of Bullying Questionnaire) were administered according to unit preference. Descriptive statistics were calculated for all responses and a Pearson product moment correlation was calculated to determine the relationship between bullying and its prevention. FINDINGS: Most of the nurses in the study were married, female staff nurses with a baccalaureate in nursing. No participant responded that they had been bullied daily, but 29% reported that they were a victim of bullying. The mean bullying score was 1.6 ± 1.4 out of 5. The mean prevention score was 2.4 ± 0.3 out of 4. Significant differences were found between hospitals on bullying, F (4,155) = 2.7, p = .039, and between hospitals, F (4,155) = 2.9, p = .026, and units, F (5,143) = 3.4, p = .006, on prevention. The Prevention Scale significantly correlated with the bullying scale (r = .58, p < .001). No other variables were found to be associated with either bullying or prevention scores. CONCLUSIONS: An alarming percentage of nurses were victims of bullying. Levels of bullying were low to moderate. Level of prevention was weak or moderate. The higher the level of bullying, the lower the level of prevention. The work environment as opposed to individual characteristics seems to have an impact on bullying and its prevention. CLINICAL RELEVANCE: More measures must be taken to prevent bullying. Nurses must be educated to accept only a zero tolerance to bullying and to report bullying when confronted by bullying.