Critiquing a qualitative Research Report

Critiquing a qualitative Research Report Critiquing a qualitative Research Report Complete the Guide to an Overall Critique of a Qualitative Research Report worksheet for the qualitative article you selected. article_2.pdf nrp513_r2_wk6_guide_to Journal of Perinatology (2008) 28, 771–778 r 2008 Nature Publishing Group All rights reserved. 0743-8346/08 $30 ORIGINAL ARTICLE End-of-life experiences of nurses and physicians in the newborn intensive care unit EG Epstein School of Nursing, University of Virginia, Charlottesville, VA, USA Objective: To explore nurses’ and physicians’ end-of-life (EOL) experiences in the newborn intensive care unit. Study Design: A hermeneutic phenomenology of health-care providers’ lived experiences with infant deaths in the newborn intensive care unit between January and August 2006 was conducted. Semistructured interviews were completed with individual providers. Demographic data were also collected. Analysis of themes and descriptive statistics were performed. Result: Twenty-one nurses and 11 physicians were interviewed. Providers described their experiences largely through an overall theme of ‘creating the best possible experience’ for parents. To support this theme, three subthemes (building relationships, preparing for the EOL and creating memories) were common between physicians and nurses. However, nurses and physicians articulated their roles and obligations differently within these subthemes. Additionally, three subthemes through which the providers described their personal experiences were found and these included moral distress, parental readiness and consent for autopsy. Conclusion: A primary finding of this study was that a common overall obligation among nurses and physicians was to create the best possible experience for parents. Despite this commonality, the two disciplines approached the EOL and accomplished their common obligation from different vantage points. Journal of Perinatology (2008) 28, 771–778; doi:10.1038/jp.2008.96; published online 3 July 2008 Keywords: health-care provider obligations; relationships; hermeneutic phenomenology; moral distress Introduction To date, newborn intensive care unit (NICU) and pediatric end-oflife (EOL) studies have focused primarily on specific areas associated with EOL, particularly decision-making1–6 and parent Correspondence: Professor EG Epstein, School of Nursing, University of Virginia, PO Box 800782, Charlottesville, VA 22908, USA. E-mail: [email protected] Received 7 December 2007; revised 21 May 2008; accepted 22 May 2008; published online 3 July 2008 experiences. 7–13 From these studies, it is clear that shared, informed EOL decision-making remains challenging and inconsistent, that infant death has long-term emotional effects on parents and that health-care provider practices can influence parents’ EOL perceptions. Despite health-care providers’ intricate and repeated involvement in EOL events, few studies have examined nurses’ or physicians’ EOL experiences.14–21 Rashotte et al.16 found that pediatric intensive care unit (PICU) nurses’ EOL experiences were heavily influenced by clashing philosophies. On the one hand, nurses had personal philosophies of what pediatric EOL should be. Critiquing a qualitative Research Report ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS On the other hand, PICU philosophies often focused on survival and aggressive care. These philosophies were in direct contrast, creating distress among nurses who could not provide the dignified and peaceful death they desired for their patients. Other studies17,18 have similarly found that nurses balance opposing issues such as following orders for aggressive treatment versus challenging those orders to provide a comfortable death,17,18 creating relationships versus keeping a professional distance17 and finding moral meaning at the EOL.17 Studies of physicians’ EOL experiences are few. DelVecchio Good et al.21 reported that physicians’ narratives of good deaths included those which were ‘timely,’ ‘peaceful’ and involved ‘rational’ decision-making, whereas narratives of bad deaths included ‘chaotic,’ ‘prolonged’ and ‘irrational’ concepts. A study by Farber et al.19 acknowledged that physicians tended to be less involved in caregiving at the EOL but that the EOL was deeply influential to them, including increased awareness of the fragile nature of life. Finally, a study of pediatric residents20 suggested that these physicians were vulnerable to feelings of guilt and powerlessness. An additional phenomenon experienced by caregivers at the EOL is moral distress. Defined as occurring ‘when one knows the right thing to do but institutional constraints make it nearly impossible to pursue the right course of action,22 moral distress has been repeatedly shown to be a significant factor among nurses.23–25 One study demonstrated the phenomenon among physicians.23 Prolonged, aggressive treatment at the EOL is a common cause of moral distress among both professions. Although the ultimate aim of EOL research is to improve EOL care, interventions to improve EOL care have been only partially NICU EOL experiences EG Epstein 772 successful.26–28 It is arguable that the current view of NICU EOL is too narrow, and that, by focusing on one particular population or aspect, other important variables are neglected. Thus, the purpose of the larger study29 from which this article was derived was to explore the EOL phenomenon in the NICU by combining and comparing the lived EOL experiences of parents, nurses and physicians. Study design The focus of this study was a specific interval of time, beginning after the decision was made to withdraw or withhold further aggressive treatment from an infant and ending after the completion of postmortem care. This interval was defined as the EOL period (EOLP). A phenomenologic approach was necessary as the NICU EOLP has not been explored and sufficient data do not exist to create a theoretical structure. Additionally, interpretive examination of cultural influences within the phenomenon (in this case, medicine and nursing) was deemed necessary. Thus, a hermeneutic phenomenology design was chosen. The setting was a 45-bed level III NICU in a mid-Atlantic university hospital serving a large rural area. In this NICU, residents rotate services monthly, attending and fellow physicians rotate frequently and the majority of the nursing staff is classified as ‘wage,’ meaning that they do not receive benefits and work on an hourly basis, although many do work 36 h per week. The study protocol was approved by the hospital’s institutional review board.Critiquing a qualitative Research Report The sample included NICU attending, resident and fellow physicians, as well as registered nurses and nurse practitioners who provided EOL care during the study period (January to August 2006). Parents of those infants who died after the withdrawal decision (n ¼ 21) were also included in the study. However, due to low participation (6 of 21, 28%) and potentially skewed perspectives, parent data are not presented here. Attending and fellow physicians were briefed on the study protocol before the start of the study, and a poster describing the study was placed in the NICU staff lounge, which is shared by the NICU nurses and physicians. After an infant’s death, contact information for those physicians and nurses caring for the infant at the time of death was reported by the NICU bereavement coordinator. Identified physicians and nurses were contacted by phone and/or email to determine their interest in participating in the study. Written informed consent was obtained for each participant. Semistructured interviews were completed between 1 day and 6 weeks following an infant’s death, with most occurring within 1 week of the death. Interview questions guided participants through their EOL experience, delved more deeply into particular aspects of the experience and compared current and previous experiences. The first question, ‘Tell me about your experience from the point at which the decision had been made to stop aggressive treatment Journal of Perinatology until the baby died,’ was followed by additional questions to clarify potential concepts and themes. Quantitative data were entered into SPSS for descriptive analysis. All interviews were coded and transcribed verbatim into Microsoft Word. Analysis of all interview data followed a hermeneutic circle approach.30 This included constant review of the significant small pieces of data within interviews as well as examination of larger concepts between interviews. The data were then analyzed for major emerging themes. Thematic analysis included a careful interpretation of each passage for meaning and a comparison of similar passages within the theme. Trustworthiness of this study was maximized using the guidelines of Lincoln and Guba.31 A significant threat to the credibility of this study lay in the fact that participants were interviewed only once. Member checking was pursued on several occasions, but second interviews regarding the same infant were not conducted. Interviews were grouped by infant (nurse–physician–parent). This system of triangulation helped to clarify and solidify themes and concepts and ensure consistency. Additionally, 92% of the interview data were reviewed by a peer for common categories and significant essences. At a later stage in analysis, the major themes and relevant passages were shared with a neonatologist and a NICU nurse, neither of whom had participated in the study. Critiquing a qualitative Research Report These reviewers reflected on their own professional and personal experiences to validate credibility of identified themes. Results Twenty-one infants died during the study period. Forty-eight percent (48%) of the infants were male and 71% were 36 weeks gestation or less. Twenty-three nurses were eligible to participate in the study. Two nurses declined, leaving a final cohort of 21 nurses (91% response rate), representing 19 infants. Almost all nurses in this study were female and Christian (Table 1). There was a wide variety of nursing experience (1 to 28 years). Most nurses (74%) had not had formal EOL education. Nineteen physicians were eligible to participate in the study. Eight physicians either could not be contacted or declined to participate, leaving a total of 11 participating physicians (58% response rate), representing all 21 infants. Five physicians were interviewed more than once. All of the physicians in this study were white and 64% were male (Table 1). There was a wide variety of experience (1 to 33 years) and role (resident, fellow, attending). Similar to nurses, most (82%) had not had formal EOL education. Temporal and thematic analysis The results of this study can be described temporally and thematically. Although the study aim was to focus on the EOLP, it was clear that providers’ EOL experiences were deeply influenced by time periods that preceded the EOLP, especially the period of NICU EOL experiences EG Epstein 773 decision-making. From a temporal perspective, therefore, provider EOL experiences included the active treatment phase, decisionmaking and the actual EOLP (Figure 1, top). Thematic analysis yielded an overarching theme, which was to create the best possible experience for parents. Several subthemes helped accomplish this goal including: building relationships, preparing for the EOL and creating memories. Three additional themes outside of creating the best possible experience were found, which applied more directly to providers’ personal experiences and included moral distress, parent ‘readiness’ and consent for autopsy (Figure 1, bottom). Neither the temporal nor the thematic analyses alone sufficiently describe the overall EOL experience. Instead, the identified themes were woven differently by nurses and physicians into the temporal fabric of the EOL (Figure 1, arrows), creating a complex EOL picture. For clarity, each theme is defined briefly and is then more fully articulated using provider quotes in their temporal context. Table 1 Descriptive statistics of nurse and physician participantsa Building relationships. Creating the best possible experience began with building relationships for both physicians and nurses. Almost without exception, providers qualified their relationships with parents as either good (‘I knew them very well’), nonexistent (‘I had never met these parents before’) or poor (‘Their agenda was very different than ours and they never communicated it to us’). Good relationships occurred in 42% of nurse cases (8 of 19) and 43% of physician cases (9 of 21).Critiquing a qualitative Research Report Nonexistent relationships occurred in 47% of nurse cases (9 of 19) and 28% of physician cases (6 of 21). Poor relationships occurred in 11% (2 of 19) of nurse cases and 28% (6 of 21) of physician cases. Three findings are of particular interest. First, good nurse– parent (eight of eight) and/or physician–parent (nine of nine) relationships were consistently paired with provider perception that there was good continuity of care. Conversely, poor physician– parent relationships were associated with perceived discontinuity of care in five of six instances (83%). However, this link was not found with poor nurse–parent relationships. Second, an association (six of six) was found between poor physician–parent relationships and parents who were unable to visit often. Finally, an association was found between poor physician–parent relationships and decisional or ethical conflict. In four of five instances of decisional conflict, when parents and providers disagreed on the best treatment for a specific infant, poor physician–parent relationships were present. In three of these cases, ethical conflict and moral distress among providers were also b Nurses (n ¼ 19) Age (years) (s.d.) Gender Race Caucasian African–American Biracial Asian Religion Christian Jewish Hindu None Physicians (n ¼ 11) 36.2 (9.3), range: 25 to 57 36.5 (9.4), range: 27 to 58 Female: 95 (18) Female: 36 (4) 84 5 5 5 (16) (1) (1) (1) 100 (11) 78 (15) 72 (8) 9 (1) 5 (1) 16 (3) 18 (2) Education Diploma 16 (3) AD 37 (7) BSN 32 (6) MSN 11 (2) Unreported 5 (1) Years of experience (s.d.) 12.6 (8.5), range: 1 to 28 End-of-life education? Yes: 26 (5) Attending 55 (6) Fellow 18 (2) Resident 27 (3) 6.9 (9.2), range: 1 to 33 Yes: 18 (2) Abbreviations: AD, associate degree; BSN, bachelor of science; MSN, master of science. a Expressed in % (n) unless otherwise noted. b Two questionnaires not returned. Active treatment Moral distress Building relationships Decision making Preparation for the EOL Creating memories EOLP Parent readiness Consent for autopsy Solid lines = nurse connections; dashed lines = physician connections Figure 1 Temporal context (top) and thematic context (bottom) experienced differently by nurses and physicians. Journal of Perinatology NICU EOL experiences EG Epstein 774 present. No ethical controversies emerged in cases where these relationships were characterized as ‘good.’ Although good relationships were stated by health-care providers to be important throughout hospitalization, both nurses and physicians believed that these relationships were particularly helpful at the EOL because they enabled parents to identify those involved in their infant’s care and helped to create an atmosphere of familiarity and trust. Additionally, relationship building was important not only for parents’ benefit, but for health-care providers’ benefit as well. For physicians, relationships were most important during the decision-making phase, when the trust that resulted from establishing relationships made giving bad news easier: ‘It’s much easier for me at least when I’ve been talking to a family for a while and there’s some trust or relationship that’s been established. When I say, ‘‘there’s really nothing more that can be done,’’ I feel comfortable that they’re going to accept that.’ [MD020] For nurses, exploring parents’ needs as the EOL approached was made easier when relationships had been established. Critiquing a qualitative Research Report For example, one nurse, who had built a relationship with the grandmother and mother of a baby over a long period of time, recalled a conversation just before withdrawal: ‘I always like to put a bow [in the little girls’ hair]y So [grandmother] said, ‘‘Oh, she’s not going to be your princess.’’ [I said], ‘‘No, she’s still going to be [my] princess.’’ [Grandmother] smiled, ‘‘You don’t have anybody to put a bow on anymore.’’ [I said], ‘‘I know, but we’ll put a bow on her.’’ ’[RN004] Having established a good relationship with this family, the nurse was able to understand the importance (for this grandmother) of not abandoning physical care for the baby. Despite the infant’s dying, the grandmother needed to know that the baby was still a ‘princess,’ still worthy of caring, and still beautiful. Preparing for the EOL The subtheme of preparation for the EOL occurred in several different ways. First, nurses appeared to have recognized the inevitability of an infant’s death before physicians or parents, which led to attempts to prepare for the EOL by (a) pushing physicians to talk to parents and (b) discussing options with parents directly. Six nurses noted that the nursing staff had pushed the physicians to talk to parents about withdrawal. Nurse participants generally viewed physicians as being reluctant to accept death or to give bad news to parents. One physician acknowledged the reluctance to give bad news: ‘Let’s go tell mom all the settings, the dopamine, you know. I’m not going to tell [her] that this is worthless, or that [this baby’s] never going to recover, she’s going to die, she’s not going home.’ [MD033] Another physician, however, viewed such delays differently. He noted that physicians allow time for parents to arrive at the dire realization of impending death: ‘It’s a fine line to reconcile our timeline as physicians for making that decision with the Journal of Perinatology family’s timeline and often the family’s timeline is much longer.’ [MD036] Three nurses recalled having gently discussed options with parents. This occurred particularly in situations where parents were having difficulty making decisions or acknowledging a grim prognosis: ‘I’d spent a lot of time talking with the parents after their last family meeting, explaining to them that it wasn’t just pulling the tube outythat they could make so many other decisions without making that decision. They could limit the care, they could limit the medications. They could say, ‘‘Please give her medication for pain or to control the seizures, but don’t do medication for blood pressure.’’ They could specifically say that they wanted her comfortable. They finally said, ‘‘We want her comfortable.’’ ’ [RN049] A second time of preparation occurred at family meetings, which were mentioned by several physicians as an important method of preparing parents to make EOL decisions and to help parents get ready for withdrawal itself. One physician noted that it was important to inform parents of the reason for the family meeting: ‘I don’t think it’s fair to continue on as if there’s nothing and then say ‘‘By the way, we need to have a family meeting,’’ and get them in a room and sort of get down both barrels and say, ‘‘Your baby’s going to die.’’ That’s not fairy They shouldn’t walk in blind.’ [MD044] EOL conversations during family meetings were described as being indirect first: ‘Sometimes you can dance around familiesythey know what you’re saying and you know what you’re saying and everybody’s on the same page.’ [MD033] When parents did not appear to understand their infant’s dire clinical situation, conversations were forced to become more direct: ‘But on this family, since I really didn’t know them and I knew that mom needed some very basic language to understand what was going on, I said, ‘‘There’s nothing we can do to keep him alive’’yI had to say the words, ‘‘He is going to diey.’’ ’ …Critiquing a qualitative Research Report Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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