The Lived Experience of Respiratory Therapists During Withdrawal of Advanced Life-Sustaining Therapies at End of Life in the ICU.

BACKGROUND: The act of withdrawing advanced life-sustaining therapies, more specifically mechanical ventilation, is performed in hospitals all over the world. Success involves coordination of several members of the patient care team, including nurses, providers (physicians nurse practitioners, or physician assistants), and respiratory therapists (RTs). The experiences of RTs surrounding this procedure are not well documented. The aim of this study was to explore the lived experience of RTs who have participated in withdrawal of advanced life-sustaining therapies, utilizing a hermeneutical phenomenological approach. METHODS: Individual interviews were conducted with experienced RTs that were audio recorded and transcribed. The data were analyzed by 4 health professionals, and data were triangulated. RESULTS: Three themes emerged from the study: (1) impact of power relations surrounding the process, (2) needing tools to provide quality withdrawal of advanced life-sustaining therapies, and (3) emotional involvement/exposure. It was clear from the analysis that RTs desire more education, to be part of the decision-making, and to be appreciated for their role in this emotional process. CONCLUSIONS: Through this study, the role of RT in withdrawal of advanced life-sustaining therapies is better understood, which can only lead to improvement in the overall process for health care team, patient, and families.

Exploiting Technology to Popularize Goals-of-Care Conversations and Advance Care Planning.

BACKGROUND: Goals-of-care conversations are a central component of high-quality patient-centered care. However, clinicians may not engage in such conversations until patients are critically ill. OBJECTIVE: To assess the frequency and quality of goals-of-care conversation documentation among patients who died in an intensive care unit, and then to develop and implement mechanisms to improve the quantity and quality of such conversations. METHODS: A baseline retrospective medical records review of intensive care unit deaths that occurred within 1 year was conducted to assess the barriers to high-quality goals-of-care conversations. A nurse-led inter-professional task force was formed to address possible solutions. INTERVENTIONS: A new electronic health record tab, note type, and preformatted template known as a SmartPhrase for goals-of-care conversations were created. Nurses and physicians were educated and encouraged to perform and document goals-of-care conversations. RESULTS: Before implementation of the initiative, the electronic health record lacked a consistent place to document goals-of-care conversations, and such conversations were not occurring until patients required intensive care. Moreover, the content of documentation of the conversations was inconsistent. Three years after implementation of the initiative, the goals-of-care conversation documentation tab was used for 75% of hospital deaths, and 67% of goals-of-care conversation notes included use of the SmartPhrase template. CONCLUSIONS: Electronic health record platforms can be used to improve the frequency, consistency of documentation, and quality of goals-of-care conversations. A standardized process coupled with effective work tools can foster a culture of advance care planning.

Educational experience of male students in a baccalaureate nursing program in China.

Hampered by culture norms and social values, the proportion of male nursing students in China is low. Their learning experience will add weight to culturally valid nursing education. This study explored Chinese male nursing students' educational experience in a baccalaureate nursing program. A qualitative approach was used, with a purposive sample of 14 participants. Data were collected through semi-structured interviews and analyzed for thematic content. Four theme clusters emerged from the findings: choosing nursing as a career, challenges to studying nursing by gender, dilemma to nursing profession and personal benefits of studying nursing. Most of the participants passively chose nursing major. The data provided evidence that Chinese culture hindered male engaged in nursing. Low admission scores of nursing in NCEE provide an opportunity to recruit male student. Positive aspects of gender neutral portrayal of nursing help to recruit more male nursing students.

Case Study Investigation Decreases Burnout While Improving Interprofessional Teamwork, Nurse Satisfaction, and Patient Safety.

Prevention of burnout is a national imperative, and blame-free investigations of clinical events are advocated. Reflective inquiry techniques are helpful in processing adverse events while minimizing blame. The purpose of this project was to develop an interprofessional peer review program (Case Study Investigation) to process emotions, improve teamwork, and optimize patient outcomes. This evidence-based practice project was conducted in a 12-bed intensive care unit using reflective inquiry techniques to perform peer case review across disciplines. Significant improvements were seen in percent strongly agree to the 2 satisfaction questions asked: "I feel free to speak up regarding issues that may affect patient care" (increased from 37% to 73%, χ = 6.19, P < .05), and "There is open communication between physicians and nurses" (rose from 33% to 73%, χ = 7.53, P < .05). In total, 95% perceived improvement in interprofessional teamwork. Burnout decreased significantly at 6 months (n = 22, M = 18.40, SD = 3.36) from baseline scores (n = 27, M = 21.96, SD = 4.47), F2,72 = 4.48, P < .02. Central line-associated infections decreased from 3.6 per 1000 to 0 per 1000 catheter-days. Catheter-related urinary tract infections decreased from 2 per 1000 to 0 per 1000 patient-days. Both were sustained below benchmark. Reflective inquiry decreases nurse burnout while improving perceived interprofessional teamwork and employee satisfaction, and measurements of patient safety.

Exploring the human emotion of feeling cared for in the workplace.

AIM: To explore the emotion of feeling cared for in the workplace. BACKGROUND: The emotion of feeling cared for drives health-promoting behaviours. Feeling cared for is the end-product of caring, affecting practice, environment and outcomes. Identifying behaviours that lead to feeling cared for is the first step in promoting caring practices in leadership. METHOD: A survey with open-ended questions was designed, validated and electronically distributed. Data from 35 responses were thematically analysed. RESULTS: Unit culture and leadership style affect caring capacity in the workplace. First level coding revealed two caring behaviour categories: recognition and support. Themes emerged aligned to Chapman's model of workplace appreciation: words of affirmation, receiving gifts, quality time and acts of service. The importance of being treated as a whole person was reported: being appreciated personally and professionally. Feeling cared for drives outcomes such as feeling valued, important, teamwork and organisational loyalty. CONCLUSIONS: This study generalises the applicability of Chapman's model developed for workplace appreciation in the health-care setting. IMPLICATIONS FOR NURSING MANAGEMENT: Concrete examples of how leaders stimulate feeling cared for are provided. Caring leadership behaviours have the potential to improve retention, engagement, the healing environment and the capacity for caring for others.

Preoperative education on postoperative delirium, anxiety, and knowledge in pulmonary thromboendarterectomy patients.

BACKGROUND: Delirium is the most common postoperative psychiatric condition in intensive care settings and can lead to increased complications and costs. OBJECTIVES: To evaluate the impact of multifaceted preoperative patient education on postoperative delirium, anxiety, and knowledge and to explore predictors of postoperative delirium, days of mechanical ventilation, and days in the intensive care unit (ICU) in patients undergoing pulmonary thromboendarterectomy. METHOD: A prospective, randomized controlled trial was conducted on consented patients from October 2011 to April 2013. Patients were randomized in a 1 to 1 ratio to receive either an individualized 45-minute multifaceted preoperative education (experimental group, n = 63) or standard education (control group, n = 66). Participants completed the State-Trait Anxiety Inventory and Knowledge Test before and after the education. Data on incidence of delirium, days of mechanical ventilation, ICU days, and cardiopulmonary parameters were collected. RESULTS: The experimental group had significantly more knowledge about postoperative care (P< .001) and fewer days of mechanical ventilation (P = .04) than the control group. The 2 groups did not differ significantly in anxiety, incidence of delirium, or ICU days. In exploratory multivariate analyses, hearing impairment was a positive predictor for days of delirium (P = .009), days of mechanical ventilation (P< .001), and ICU days (P= .049), whereas the posttest knowledge was a negative predictor for days of mechanical ventilation (P = .02). CONCLUSION: The patient education appeared to be effective in improving knowledge and reducing days of mechanical ventilation. Hearing impairment was an unexpected predictor of adverse outcomes for patients but may be amenable to nursing intervention.