Freda DeKeyser Ganz

Nurse involvement in end-of-life decision making: the ETHICUS Study

ObjectiveThe purpose was to investigate physicians’ perceptions of the role of European intensive care nurses in end-of-life decision making.DesignThis study was part of a larger study sponsored by the Ethics Section of the European Society of Intensive Care Medicine, the ETHICUS Study. Physicians described whether they thought nurses were involved in such decisions, whether nurses initiated such a discussion and whether there was agreement between physicians and nurses. The items were analyzed and comparisons were made between different regions within Europe.SettingThe study took place in 37 intensive care units in 17 European countries.Patients and participantsPhysician investigators reported data related to patients from 37 centers in 17 European countries.InterventionsNone.Measurements and resultsPhysicians perceived nurses as involved in 2,412 (78.3%) of the 3,086 end-of-life decisions (EOLD) made. Nurses were thought to initiate the discussion in 66 cases (2.1%), while ICU physicians were cited in 2,438 cases (79.3%), the primary physician in 328 cases (10.7%), the consulting physician in 105 cases (3.4%), the family in 119 cases (3.9%) and the patient in 19 cases (0.6%). In only 20 responses (0.6%) did physicians report disagreement between physicians and nurses related to EOLD. A significant association was found between the region and responses to the items related to nursing. Physicians in more northern regions reported more nurse involvement.ConclusionsPhysicians perceive nurses as involved to a large extent in EOLDs, but not as initiating the discussion. Once a decision is made, there is a sense of agreement. The level of perceived participation is different for different regions.

Inappropriate Care in European ICUs: Confronting Views From Nurses and Junior and Senior Physicians

BACKGROUND ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power. METHODS We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations. RESULTS By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups. CONCLUSIONS ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.

Original ResearchCritical CareInappropriate Care in European ICUs: Confronting Views From Nurses and Junior and Senior Physicians

BACKGROUND ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power. METHODS We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations. RESULTS By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups. CONCLUSIONS ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.

Israeli nurse practice environment characteristics, retention, and job satisfaction

BackgroundThere is an international nursing shortage. Improving the practice environment has been shown to be a successful strategy against this phenomenon, as the practice environment is associated with retention and job satisfaction. The Israeli nurse practice environment has not been measured. The purpose of this study was to measure practice environment characteristics, retention and job satisfaction and to evaluate the association between these variables.MethodsA demographic questionnaire, the Practice Environment Scale, and a Job Satisfaction Questionnaire were administered to Israeli acute and intensive care nurses working in 7 hospitals across the country. Retention was measured by intent to leave the organization and work experience. A convenience sample of registered nurses was obtained using a bi-phasic, stratified, cluster design. Data were collected based on the preferences of each unit, either distribution during various shifts or at staff meetings; or via staff mailboxes. Descriptive statistics were used to describe the sample and results of the questionnaires. Pearson Product Moment Correlations were used to determine significant associations among the variables. A multiple regression model was designed where the criterion variable was the practice environment. Analyses of variance determined differences between groups on nurse practice environment characteristics.Results610 nurses reported moderate levels of practice environment characteristics, where the lowest scoring characteristic was ‘appropriate staffing and resources’. Approximately 9% of the sample reported their intention to leave and the level of job satisfaction was high. A statistically significant, negative, weak correlation was found between intention to leave and practice environment characteristics, with a moderate correlation between job satisfaction and practice environment characteristics. ‘Appropriate staffing and resources’ was the only characteristic found to be statistically different based on hospital size and geographic region.ConclusionsThis study supports the international nature of the vicious cycle that includes a poor quality practice environment, decreased job satisfaction and low nurse retention. Despite the extreme nursing shortage in Israel, perceptions of the practice environment were similar to other countries. Policy makers and hospital managers should address the practice environment, in order to improve job satisfaction and increase retention.

Moral distress and structural empowerment among a national sample of Israeli intensive care nurses

AIM The aim of this study was to determine levels of structural empowerment, moral distress, and the association between them among intensive care nurses. BACKGROUND Structural empowerment is the ability to access sources of power. Moral distress is the painful feelings experienced when a person knows the right thing to do but cannot do so due to external constraints. Several studies suggest a theoretical relationship between these concepts. DESIGN Cross-sectional, descriptive correlational study. METHODS Members of the Evidence Based Nursing Practice Committee of the Israeli Society for Cardiology and Critical Care Nurses recruited a convenience sample of intensive care nurses from their respective institutions and units. Nurses were asked to complete three questionnaires (demographic and work characteristics, Moral Distress Scale, and the Conditions of Work Effectiveness Questionnaire-II). Data were collected between May-September 2009. RESULTS Intensive Care nurses had moderate levels of structural empowerment, low levels of moral distress frequency, and moderately high moral distress intensity. A weak correlation was found between moral distress frequency and structural empowerment. No other structural empowerment component was associated with moral distress. Work characteristics as opposed to demographic characteristics were more associated with the study variables. CONCLUSIONS This study weakly supports the association between structural empowerment and moral distress. It also provides further evidence to the theory of structural empowerment as characterized in the critical care environment. Further studies are indicated to determine what other factors might be associated with moral distress.

Post-Traumatic Stress Disorder in Israeli Survivors of Childhood Cancer

PURPOSE/OBJECTIVES To investigate the prevalence, symptom severity, and risk factors associated with post-traumatic stress disorder (PTSD) in childhood cancer survivors. DESIGN Descriptive, correlational study. SETTING Follow-up clinic in Petach Tikva, Israel. SAMPLE Convenience sample of 70 adult Israeli survivors of childhood cancer. METHODS Questionnaires (the Post-Traumatic Diagnostic Scale and the Multidimensional Scale of Perceived Social Support) were distributed to participants, and demographic and clinical data were obtained from medical records. MAIN RESEARCH VARIABLES Post-traumatic stress, social support, and clinical and demographic data. FINDINGS Twenty (29%) of the participants met the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for PTSD; 10% experienced mild, 40% moderate, and 50% moderate to severe symptoms. Only 16% of the sample did not experience any symptoms of PTSD. A statistically significant negative relationship was found between PTSD symptom scores and the current age of the respondent (r(s) = -0.27, p = 0.03) and time since medical treatment (r(s) = -0.34, p = 0.004) but not any other demographic or clinical variables or social support. CONCLUSIONS Higher severity of PTSD symptoms was found, possibly because of local living conditions. Most clinical and demographic variables were not risk factors. This population should be studied further in an effort to prevent PTSD via early diagnosis. IMPLICATIONS FOR NURSING Oncology nurses should be aware of the potential risk factors (recent completion of treatment and younger current age) and the high prevalence and severity of PTSD among survivors of childhood cancer to identify patients at higher risk and develop programs that prevent, limit, and treat PTSD.

Nurse middle manager ethical dilemmas and moral distress

Background: Nurse managers are placed in a unique position within the healthcare system where they greatly impact upon the nursing work environment. Ethical dilemmas and moral distress have been reported for staff nurses but not for nurse middle managers. Objective: To describe ethical dilemmas and moral distress among nurse middle managers arising from situations of ethical conflict. Methods: The Ethical Dilemmas in Nursing–Middle Manager Questionnaire and a personal characteristics questionnaire were administered to a convenience sample of middle managers from four hospitals in Israel. Results: Middle managers report low to moderate levels of frequency and intensity of ethical dilemmas and moral distress. Highest scores were for administrative dilemmas. Conclusion: Middle managers experience lower levels of ethical dilemmas and moral distress than staff nurses, which are irrespective of their personal characteristics. Interventions should be developed, studied, and then incorporated into institutional frameworks in order to improve this situation.

The effect of humor on elder mental and physical health

A convenience sample of community-dwelling older people attending senior centers was asked to participate in a quasi-experimental study to examine the impact of a humor therapy workshop on physical and mental health. Participants were assessed at baseline and at six months for physical (general health and health quality of life) and mental (general well-being, anxiety, depression and psychological distress) health. The sample consisted of 92 subjects, 42 in the control group and 50 in the workshop. Compared to controls, subjects in the workshop had significantly lower follow-up levels of anxiety and depression and improved general well-being. No differences were observed for general health, health quality of life, or psychological distress. This humor therapy workshop was associated with a positive effect upon mental health. It is recommended that attendance at humor workshops be encouraged and that further investigations into the efficacy of such programs on mental and physical health be investigated.

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.

The quality of intensive care unit nurse handover related to end of life: A descriptive comparative international study

BACKGROUND Quality ICU end-of-life-care has been found to be related to good communication. Handover is one form of communication that can be problematic due to lost or omitted information. A first step in improving care is to measure and describe it. OBJECTIVE The objective of this study was to describe the quality of ICU nurse handover related to end-of-life care and to compare the practices of different ICUs in three different countries. DESIGN This was a descriptive comparative study. SETTINGS The study was conducted in seven ICUs in three countries: Australia (1 unit), Israel (3 units) and the UK (3 units). PARTICIPANTS A convenience sample of 157 handovers was studied. METHODS Handover quality was rated based on the ICU End-of-Life Handover tool, developed by the authors. RESULTS The highest levels of handover quality were in the areas of goals of care and pain management while lowest levels were for legal issues (proxy and advanced directives) related to end of life. Significant differences were found between countries and units in the total handover score (country: F(2,154)=25.97, p=<.001; unit: F(6,150)=58.24, p=<.001), for the end of life subscale (country: F(2, 154)=28.23, p<.001; unit: F(6,150)=25.25, p=<.001), the family communication subscale (country: F(2,154)=15.04, p=<.001; unit: F(6,150)=27.38, p=<.001), the family needs subscale (F(2,154)=22.33, p=<.001; unit: F(6,150)=42.45, p=<.001) but only for units on the process subscale (F(6,150)=8.98, p=<.001. The total handover score was higher if the oncoming RN did not know the patient (F(1,155)=6.51, p=<.05), if the patient was expected to die during the shift (F(1,155)=89.67, p=<.01) and if the family were present (F(1,155)=25.81, p=<.01). CONCLUSIONS Practices of end-of-life-handover communication vary greatly between units. However, room for improvement exists in all areas in all of the units studied. The total score was higher when quality of care might be deemed at greater risk (if the nurses did not know the patient or the patient was expected to die), indicating that nurses were exercising some form of discretionary decision making around handover communication; thus validating the measurement tool.