Amy O. Calvin

Family Presence During Invasive Procedures and Resuscitation: Hearing the Voice of the Patient

How do patients react to the presence of family during invasive procedures (IPs) or cardiopulmonary resuscitation (CPR)? Until recently, surprisingly little research had addressed the issue of family presence at all, and to our knowledge, no other studies have been published that delineate patients’ perspectives.In February 2000, we first reported in this journal findings from our pioneering study, which demonstrated numerous benefits that bedside visitation confers on the families of patients undergoing these procedures. This article presents our further investigation—aimed at describing the experiences of the patients—using a qualitative research approach to analyzing data collected during that study.The study took place in the emergency department (ED) of a university-affiliated, regional, level-I trauma center. The protocol for family presence was adapted from guidelines developed by the Emergency Nurses Association (ENA). Nine patients (eight who had IPs and one who underwent CPR) were also interviewed approximately two months after the emergency event. A semistructured questionnaire was used to determine their perceptions of the family presence experience.Seven themes emerged from the data. Three of these relate to the positive effects that family presence had on patients: it comforted them; provided help; and served, the patients believed, to remind providers of a patient’s “personhood”—he wasn’t just a patient; he was a person and had a family. Two themes involve how family presence reflects the reciprocal nature of patient–family bonds and the patient’s right to have family members present. The remaining two themes characterize how patients perceived the effects of the experience on their family members and on the health care environment. Patients saw both positive and negative effects on those who were present but believed the benefits to families outweighed the potential problems. Although further study is needed, family presence indeed appears to deliver many benefits, with apparently few drawbacks or adverse effects, to patients, their families, and their providers. In 1999, our institution, Parkland Health & Hospital System, approved a hospital-wide protocol for family presence during IPs and CPR.Corresponding author:Theresa MeyersPresbyterian Hospital of Dallas, Emergency Department8200 Walnut Hill LaneDallas, TX 75231TheresaMeyers@texashealth.org

Measuring patient opinion of pain management.

Pain management has been increasingly recognized as an important indicator of quality patient care. In this article, we describe the development of a measure of patients perception of pain management. Based upon the American Pain Societys guidelines, the six-item Patient Opinion of Pain Management (POPM) scale demonstrated promising internal consistency, reliability, and validity in a sample of 241 patients from 11 hospitals. The POPM is discussed in the context of previous research on the assessment of pain management.

The cardiovascular intensive care unit nurse's experience with end-of-life care: A qualitative descriptive study

PURPOSEnNurses in the cardiovascular intensive care unit (CVICU) informally expressed moral angst when caring for patients who are approaching the end of life. The purpose of this study was to better understand CVICU nurses perceptions about their roles and responsibilities in the decision-making process about change in intensity of care and end-of-life care for patients within the CVICU setting.nnnPARTICIPANTS AND METHODSnNineteen nurses from one CVICU consented to being interviewed individually regarding their experiences caring for patients approaching the end of life, and specifically regarding the initiation of a change in code status. Investigators used a qualitative descriptive approach to collect and analyse the data. Transcript data were analysed and as concepts emerged they were compared with those from earlier interviews to establish similarities and differences. Investigators reached consensus about the major themes.nnnFINDINGSnAnalysis revealed four major themes: (a) exhausting patient treatments; (b) promoting family presence; (c) acknowledging physician authority; and (d) walking a fine line.nnnCONCLUSIONSnThis research adds to the limited body of knowledge concerning CVICU nurses experiences with end-of-life care. Results of this study provide a basis for putting in place support systems for CVICU nurses.

Casting light on the concept of patient satisfaction by studying the construct validity and the sensitivity of a questionnaire

PURPOSEnThis study aims to explore the construct validity and the sensitivity of a patient satisfaction questionnaire for the purpose of gaining a better understanding of the concept, and of issues surrounding its measurements.nnnDESIGN/METHODOLOGY/APPROACHnSeveral statistical analyses were used to study the reliability, construct validity, and the sensitivity of a patient satisfaction questionnaire.nnnFINDINGSnThe study supported the construct validity, high internal consistency, and homogeneity of the instrument. Two factors were found; one consisted of negatively worded items and the other of positively worded items. The negatively worded items contributed more than the positively worded items to the sensitivity of the instrument. Items were identified that contribute little or nothing to the construct validity and/or the sensitivity of the questionnaire.nnnRESEARCH LIMITATIONS/IMPLICATIONSnThe effect of wording on the variability and sensitivity of the instrument can be explained both as a consequence of response set bias and with regard to the theories against which two phenomena were being measured - patient satisfaction and patient dissatisfaction. The development of two kinds of instruments is proposed: those that measure patient dissatisfaction and are sensitive to minute changes in nursing care and those that measure both concepts and capture what patients find important in their care.nnnORIGINALITY/VALUEnThe paper demonstrates how an analysis of the construct validity and the sensitivity of patient satisfaction instrument, can enhance understanding of the concept. It contributes to the debate about whether patient satisfaction and dissatisfaction are opposite ends of the same continuum or two different phenomena that require two different definitions.

Family Presence During Cardiopulmonary Resuscitation and Invasive Procedures

Family presence (FP) during resuscitation and invasive procedures appears to have beneficial effects on patients, family members, and health care providers. This article describes the phenomenon of FP and presents studies to date on the topic and makes recommendations for translating the research into practice. Implementation strategies are suggested to effect this paradigm shift in family-focused care. Unanswered questions needing further research are also proposed.

Understanding of advance care planning by family members of persons undergoing hemodialysis.

The purpose of this qualitative descriptive study was to explore hemodialysis patients’ family members’ understanding of end-of-life decision-making processes. The project aimed to address (a) family members’ constructions of advance care planning (ACP), including their roles and responsibilities, and (b) family members’ perceptions of health care providers’ roles and responsibilities in ACP. Eighteen family members of persons undergoing hemodialysis were recruited primarily from outpatient dialysis facilities and interviewed individually. Confirmed transcript data were analyzed, coded, and compared, and categories were established. Interpretations were validated throughout the interviews and peer debriefing sessions were used at a later stage in the analysis. The overarching construct identified was one of Protection. Family members protect patients by (a) Sharing Burdens, (b) Normalizing Life, and (c) Personalizing Care. Recommendations for future research include the need to explore ACP of persons undergoing hemodialysis who do not have a family support system.

Theory of Personal Preservation

Prior research has shown that only a minority of patients in kidney failure who require hemodialysis communicate their preferences to health care professionals.1,2 This study aimed to increase understanding of how people in kidney failure undergoing hemodialysis at three clinics in Texas make decisions regarding life-prolonging medical treatment (eg, cardiopulmonary resuscitation [CPR], mechanical ventilation). Twenty hemodialysis patients who attended dialysis outpatient centers in central Texas, nine family members, and 16 health care providers involved in these patients’ lives were theoretically sampled to discuss endof-life treatment plans and the use of advance directives (ie, living will and durable power of attorney for health care). Initial interviews with the first 12 patients were audiotaped and transcribed and detailed field notes were maintained on all interviews and observations. Transcript and field note data were analyzed using grounded theory research techniques.3,4 As data were collected, they were constantly compared until no new data emanated. Several concepts and their relationships to one another emerged during early stages of transcript and field note data analysis. Further analysis yielded more precise concept labels with better concept integration. The resultant theory is summarized in the following paragraphs. After patients are diagnosed with end-stage renal disease (ESRD), they often experience various degrees of depression as they begin dialysis; however, they know their odds for survival. They realize they have a disease that will significantly affect their lives, health, and longevity. Their personal knowledge and beliefs begin to interact in a way that defines their individuality as people receiving hemodialysis, hence the next phase of the process toward personal preservation: defining individualism. When faced with daily medical treatment decisions and further decisions such as end-of-life treatment, patients move into the final phase of personal preservation, which is an interactive paradox of being responsible and taking chances. The theory of personal preservation furthers understanding of illness behavior and patients’ end-of-life decision-making process. This theory could be used to sensitize health care professionals to patients’ desires and enhance patient-professional communication. Its concepts are in line with the position statement of the American Academy of Hospice and Palliative Medicine,5 which states that a chief aim of end-of-life care must be “upholding respect for patients’ and families’ values.” The Patient Self-Determination Act of 19906 requires acute care facilities that receive Medicare and Medicaid reimbursement to provide adult patients written information about their rights to accept or refuse medical treatment and to execute advance directives. Further, the Renal Physicians Association and American Society of Nephrology7 provide clinical practice guidelines for end-of-life decision-making in the ESRD patient population that specifically recommend the implementation of advance directives by