Moral Distress Regarding End-of-Life Care Among Healthcare Personnel in Korean University Hospitals: Features and Differences Between Physicians and Nurses

Background@#Healthcare professionals often experience moral distress while providing endof-life care. This study explored how physicians and nurses experienced moral distress when they cared for critically and terminally ill patients in tertiary hospitals in South Korea. @*Methods@#This study used semi-structured in-depth interviews. A total of 22 people in two tertiary hospitals were interviewed, nine (40.9%) of which were physicians and 13 (59.1%) were nurses. The recorded interview files and memos were analyzed using grounded theory. @*Results@#Most physicians and nurses encountered similar feelings of anger, helplessness, and burden owing to a lack of appropriate resources for end-of-life care. However, the factors and contexts of their moral distress differed. Nurses mainly addressed poorly organized end-of-life care, intensive labor conditions without support for nurses, and providing care without participation in decision-making. Meanwhile, physicians addressed the prevailing misperceptions on end-of-life care, communication failure between physicians owing to hierarchy and fragmented disciplines, the burden of responsibility in making difficult decisions, and the burden of resource allocation. @*Conclusion@#Differences in moral distress between physicians and nurses leave them isolated and can affect communication regarding healthcare. Mutual understanding between job disciplines will enhance their communication and help resolve conflicts in end-of-life care.

Intensive Care Experience of Critical Care Patients and Its Related Factors : A Secondary Analysis Study / 중환자간호학회지

Purpose@#: This study investigates the experiences of patients in intensive care units (ICUs), and the factors influencing these experiences.Method : We used a cross-sectional survey design to analyze previously collected cohort data from 891 patients who spent over 24 hours in 19 ICUs across four university hospitals in Busan, South Korea between June 2019 and July 2020. Within a week of ICU discharge, participants completed the Korean version of the Intensive Care Experience Questionnaire, covering four areas: “awareness of surroundings,” “frightening experiences,” “satisfaction with care,” and “recall of experiences.” We used multiple linear regression to identify factors associated with the ICU experience. @*Results@#: Low income (β = -.08, p = .016), unplanned hospitalization (β = -.09, p = .006), sedation (β = -.16, p ＜ .001), and delirium (β = -.15, p ＜ .001) reduce patients’ awareness of their surroundings. Frightening experiences are associated with being female (β = -.07, p = .027), experiencing delirium (β = -.15, p ＜ .001), and longer stays in the ICU (β = -.14, p ＜ .001). Using sedatives decreases satisfaction with care (β = -.08, p = .048). Living alone (β = -.08, p = .013) and using painkillers (β = -.08, p = .020) reduces recall of experiences. @*Conclusion@#: Negative ICU experiences are significantly associated with being female, living alone, lower income, unplanned admission, using sedatives and painkillers, delirium, and longer stays in the ICU. Thus, improving ICU experiences requires interventions that address modifiable factors, such as delirium, medication, and length of ICU stays.

Use of the Monoclonal Antibody Regdanvimab to Treat Patients Hospitalized with COVID-19:Real-World Data during the Delta Variant Predominance

Regdanvimab is the only monoclonal antibody available in Korea that targets severe acute respiratory syndrome coronavirus 2. We retrospectively evaluated the clinical characteristics of 374 adults hospitalized with coronavirus disease 2019 (COVID-19) who were treated with regdanvimab from September through December 2021. In total, 322 (86.1%) patients exhibited risk factors for disease progression. Most patients (91.4%) improved without additional treatment. No patient died or was transferred to intensive care. This study shows that regdanvimab prevented disease progression in high-risk patients with mild to moderate COVID-19 infections during Delta variant predominance.

A Systematic Review and Meta-analysis on the Effect of Delirium Prevention Intervention in Korean Intensive Care Units / 중환자간호학회지

Purpose@#: This study aimed to systematically review the preventive interventions for delirium in Korean intensive care unit (ICU) patients and evaluate their efficacy. @*Methods@#: For this systematic review and meta-analysis, we searched the literature and selected studies from data sources that included the RISS, KISS, National Central Library, National Assembly Library, DBpia, Science on, MEDLINE, and Cochrane Library. We used Cochrane’s revised tool for risk of bias in randomized trials and non-randomized studies of intervention tools to assess the quality of the selected studies. The effect size of the intervention was calculated as odds ratio (OR) and standardized mean difference (SMD). @*Results@#: Preventive interventions reported in 23 studies with a total of 4,799 ICU patients were effective in reducing the occurrence of delirium (OR=0.64, 95% CI : 0.49~0.91, p=.011), but not the duration (SMD=–0.22, 95% CI : -0.51∼0.08, p=.148). As a result of a subgroup analysis, non-pharmacological interventions were effective in reducing the occurrence of delirium (OR=0.66, 95% CI : 0.47~0.94, p=.020), while pharmacological interventions had no effect (OR=0.68, 95% CI : 0.33∼1.40, p=.295). Among the non-pharmacological interventions, multi-component intervention had the largest effect size (OR=0.38, 95% CI : 0.26~0.55, p<.001). @*Conclusion@#: Non-pharmacological interventions were effective in reducing the occurrence of delirium. We recommend the development and application of multi-component interventions to prevent delirium in the Korean ICU patients.

Introduction to the Special Issue: “Nursing Education and Research in the Remote Era”

no abstract available.

Development and Feasibility Test of a Mouth Contactless Breathing Exercise Solution Using Virtual Reality: ARandomized Crossover Trial

Purpose@#The purpose of this study was to develop a novel mouth contactless breathing exercise solution based on virtual reality (VR), and to test its feasibility. @*Methods@#We developed the Virtual Reality-based Breathing Exercise System (VR-BRES), a self-regulating biofeedback breathing exercise with gaming characteristics and a soft stretch sensor. The feasibility and efficacy of the VR-BRES prototype were investigated through a randomized crossover trial. Fifty healthy adults participated in the trial, and their respiratory parameters and user evaluation of the VR-BRES were compared with conventional deep breathing (CDB) exercises. @*Results@#The respiratory parameters, forced vital capacity (Z = 4.82, 4.95, p < .001), forced expiratory volume in one second (t = 6.02, 6.26, p < .001), and peak expiratory flow (t = 5.35, 5.68, p < .001) were significantly higher during breathing exercises using the VR-BRES. User evaluation was also significantly higher for the VR-BRES in terms of efficiency (Z = 3.86, p < .001), entertainingness (Z = 5.00, p < .001), and intention to use (Z = 3.22, p = .001) compared to CDB. However, there was no difference in convenience between the two methods (Z = −0.90, p = .369). @*Conclusion@#The VR-BRES has the potential to be an efficient breathing exercise solution. We recommend a clinical study that evaluates the effects of the VR-BRES for a certain period of time for people who need breathing exercises.

Family’s Perception of Proxy Decision Making to Authorize Do Not Resuscitate Order of Elderly Patients in Long Term Care Facility: A Q-Methodological Study

Purpose@#This study aimed to distinguish and describe the types of perceptions of do not resuscitate (DNR) proxy decisions among families of elderly patients in a long-term care facility. @*Methods@#This exploratory study applied Q-methodology, which focuses on individual subjectivity. Thirty-four Q-statements were selected from 130 Q-populations formed based on the results of in-depth interviews and literature reviews. The P-samples were 34 families of elderly patients in a long-term care hospital in Busan, Korea. They categorized the Q-statements using a 9-point scale. Using the PC-QUANL program, factor analysis was performed with the P-samples along an axis. @*Results@#The families’ perceptions of the DNR proxy decision were categorized into three types. Type I, rational acceptance, valued consensus among family members based on comprehensive support from medical staff. Type II, psychological burden, involved hesitance in making a DNR proxy decision because of negative emotions and psychological conflict. Type III, discreet decisions, valued the patients’ right to self-determination and desire for a legitimate proxy decision. Type I included 18 participants, which was the most common type, and types II and III each included eight participants. @*Conclusion@#Families’ perceptions of DNR proxy decisions vary, requiring tailored care and intervention. We suggest developing and providing interventions that may psychologically support families.

Cut-Off Values of the Post-Intensive Care Syndrome Questionnaire for the Screening of Unplanned Hospital Readmission within One Year

Purpose@#This study aimed to assign weights for subscales and items of the Post-Intensive Care Syndrome questionnaire and suggest optimal cut-off values for screening unplanned hospital readmissions of critical care survivors. @*Methods@#Seventeen experts participated in an analytic hierarchy process for weight assignment. Participants for cut-off analysis were 240 survivors who had been admitted to intensive care units for more than 48 hours in three cities in Korea. We assessed participants using the 18-item Post-Intensive Care Syndrome questionnaire, generated receiver operating characteristic curves, and analysed cut-off values for unplanned readmission based on sensitivity, specificity, and positive likelihood ratios. @*Results@#Cognitive, physical, and mental subscale weights were 1.13, 0.95, and 0.92, respectively.Incidence of unplanned readmission was 25.4%. Optimal cut-off values were 23.00 for raw scores and 23.73 for weighted scores (total score 54.00), with an area of under the curve (AUC) of .933 and .929, respectively. There was no significant difference in accuracy for original and weighted scores. @*Conclusion@#The optimal cut-off value accuracy is excellent for screening of unplanned readmissions. We recommend that nurses use the Post-Intensive Care Syndrome Questionnaire to screen for readmission risk or evaluating relevant interventions for critical care survivors.

Cut-Off Values of the Post-Intensive Care Syndrome Questionnaire for the Screening of Unplanned Hospital Readmission within One Year

Purpose@#This study aimed to assign weights for subscales and items of the Post-Intensive Care Syndrome questionnaire and suggest optimal cut-off values for screening unplanned hospital readmissions of critical care survivors. @*Methods@#Seventeen experts participated in an analytic hierarchy process for weight assignment. Participants for cut-off analysis were 240 survivors who had been admitted to intensive care units for more than 48 hours in three cities in Korea. We assessed participants using the 18-item Post-Intensive Care Syndrome questionnaire, generated receiver operating characteristic curves, and analysed cut-off values for unplanned readmission based on sensitivity, specificity, and positive likelihood ratios. @*Results@#Cognitive, physical, and mental subscale weights were 1.13, 0.95, and 0.92, respectively.Incidence of unplanned readmission was 25.4%. Optimal cut-off values were 23.00 for raw scores and 23.73 for weighted scores (total score 54.00), with an area of under the curve (AUC) of .933 and .929, respectively. There was no significant difference in accuracy for original and weighted scores. @*Conclusion@#The optimal cut-off value accuracy is excellent for screening of unplanned readmissions. We recommend that nurses use the Post-Intensive Care Syndrome Questionnaire to screen for readmission risk or evaluating relevant interventions for critical care survivors.

The Structural Equation Model of Organizational Culture, Authentic Leadership, Self-Esteem, and Bullying in Nurses at Critical Care Units / 임상간호연구

PURPOSE@#The purpose of this study were to identify the influential factors of bullying of intensive care nurses and to suggest a final structural model based on identified relationships between nursing organizational culture, authentic leadership, self-esteem, and bullying in the workplace.@*METHODS@#Data were collected from 221 nurses at intensive care units in eight general hospitals using structured questionnaires and analyzed by structural equation modeling.@*RESULTS@#In this study, the average of bullying in the workplace was 1.34±0.40, nursing organizational culture was 3.31±0.47, self-esteem was 2.79±0.44, and authentic leadership was 3.61±0.60. The factors affecting nursing organizational culture were authentic leadership (β=.54, p<.001) and self-esteem (β=.24, p=.002) that had direct positive effects on the nursing organizational culture. The nursing organizational culture had also a direct effect on reducing workplace bullying (β=−.45, p<.001). Authentic leadership (β=−.24, p=.004) and self-esteem (β=−.11, p=.004) had indirect effects on workplace bullying, which was mediated by the nursing organizational culture.@*CONCLUSION@#To understand and reduce workplace bullying, evaluating a nursing organizational culture should be preceded. Based on the finding of this study, an intervention for increasing authentic leadership and self-esteem of nurses can positively help to create the nursing organizational culture and then reduce workplace bullying.

A Topic Modeling Analysis for Online News Article Comments on Nurses’ Workplace Bullying

Purpose@#This study aimed to explore public opinion on workplace bullying in the nursing field, by analyzing the keywords and topics of online news comments. @*Methods@#This was a text-mining study that collected, processed, and analyzed text data. A total of 89,951 comments on 650 online news articles, reported between January 1, 2013 and July 31, 2018, were collected via web crawling. The collected unstructured text data were preprocessed and keyword analysis and topic modeling were performed using R programming. @*Results@#The 10 most important keywords were “work” (37121.7), “hospital” (25286.0), “patients” (24600.8), “woman” (24015.6), “physician” (20840.6), “trouble” (18539.4), “time” (17896.3), “money” (16379.9), “new nurses” (14056.8), and “salary” (13084.1). The 22,572 preprocessed key words were categorized into four topics: “poor working environment”, “culture among women”, “unfair oppression”, and “society-level solutions”. @*Conclusion@#Public interest in workplace bullying among nurses has continued to increase. The public agreed that negative work environment and nursing shortage could cause workplace bullying. They also considered nurse bullying as a problem that should be resolved at a societal level. It is necessary to conduct further research through gender discrimination perspectives on nurse workplace bullying and the social value of nursing work.

The Relationship between Person-Centered Nursing and Family Satisfaction in ICUs / 중환자간호학회지

PURPOSE: This study aims to identify the relationship between person-centered critical care nursing (PCCN) and family satisfaction for intensive care unit (ICU) nurses.METHODS: This research used a cross-sectional survey. The participants were 142 nurses and 121 family members from 8 ICUs in 4 hospitals in B city. The questionnaire survey was conducted between December 2018 and March 2019. The eight ICUs were divided into those that scored high and those that scored low for person-centered care relative to the average score for PCCN, and the difference in family satisfaction between the ICUs with high and low scores was compared using t-test.RESULTS: The mean score of PCCN was 3.68±0.40 out of 5. In the subcategories of PCCN, “comfort”was the highest at 3.95±0.49, followed by “respect” at 3.73±0.57, “compassion” at 3.59±0.57, and “individuality” at 3.47±0.54. The average score of family satisfaction with the ICUs was 3.45±0.67 out of 5. In its subcategories, “emotion” was the highest at 3.69±0.72, followed by “information” at 3.61±0.75, “participation” at 3.30±0.79, and ”resources‘ at 3.20±0.80. The family satisfaction (3.75±0.54) with the ICU of the highest-scoring PCCN was significantly higher than the family satisfaction (3.25±0.53) with the ICU with the lowest-scoring PCCN (t=4.97, p<.001).CONCLUSION: The results suggest that the PCCN scores of ICU nurses should be promoted to improve family satisfaction. It is necessary to pursue a variety of ways to secure the provision of person-centered nursing practice in ICUs.

The Relationship between the Work Environment and Person-centered Critical Care Nursing for Intensive Care Nurses / 중환자간호학회지

PURPOSE: The purpose of this study was to investigate the effect of the perceived nursing work environment (NWE) on person-centered critical care nursing (PCCN) practices among nurses in intensive care units (ICUs).METHODS: A cross-sectional research design was adopted for this study; participants were 126 ICU nurses working in five hospitals in B city. From December 2018 to February 2019, a survey questionnaire on NWE and PCCN were conducted. The collected data were analyzed with a multiple hierarchical regression analysis.RESULTS: The mean score for NWE was 2.98±0.39. Among the factors, basic work system was the highest (3.39±0.41), followed by leadership of the head nurse (3.31±0.55), interpersonal relationships (2.77±0.62), and institutional support (2.58±0.52). The mean score for PCCN was 3.52±0.46. Among the factors, comfort was the highest (3.77±0.62), followed by respect (3.55±0.56), compassion (3.43±0.60), and individuality (3.38±0.56). The interpersonal relationship (β =.31, p=.001) and the number of patients per shift (β =−.23, p=.005) had a significant effect on PCCN, accounting for 25.9% of the total variance.CONCLUSION: These results suggest that it is necessary to enhance the relationship-oriented culture and reduce the workload of nurses in order to improve the quality of nursing care in ICUs.

Post-Traumatic Stress Disorder Symptoms and Quality of Life of Patients with Coronary Artery Disease / 중환자간호학회지

PURPOSE: The purpose of this study was to investigate the degree of post-traumatic stress disorder (PTSD) symptoms and the effect of PTSD on quality of life (QoL) among coronary artery disease (CAD) patients.METHODS: The participants were 135 CAD patients who visited outpatient clinics in a university hospital in B city of Korea. Their PTSD symptoms and QoL were measured by structured questionnaires and analyzed with multiple hierarchical regression analysis.RESULTS: Among the 135 participants, 20.7% were classified as moderate risk, and 3.7% as high risk for PTSD. PTSD symptoms were significantly higher in participants who were diagnosed with CAD within 6 months (t=26.02, p < .001). The physical component of health-related QoL was influenced by gender (β=-.25, p=.003), recurrence of CAD (β=.21, p=.008), and PTSD symptoms (β=-.33, p < .001). The mental component of health-related QoL was influenced by religion (β=-.17, p=.044), body mass index (β=.17, p=.033), and PTSD symptoms (β=-.37, p < .001).CONCLUSION: Patients who had had a CAD diagnosis for less than 6 months were found to be vulnerable to PTSD, and PTSD was found to have a negative impact on the physical and mental components of their QoL. It is necessary to develop an intervention program for the effective prevention and management of PTSD symptoms in patients with CAD.

A Topic Modeling Analysis for Online News Article Comments on Nurses' Workplace Bullying / 간호학회지

PURPOSE: This study aimed to explore public opinion on workplace bullying in the nursing field, by analyzing the keywords and topics of online news comments.METHODS: This was a text-mining study that collected, processed, and analyzed text data. A total of 89,951 comments on 650 online news articles, reported between January 1, 2013 and July 31, 2018, were collected via web crawling. The collected unstructured text data were preprocessed and keyword analysis and topic modeling were performed using R programming.RESULTS: The 10 most important keywords were “work” (37121.7), “hospital” (25286.0), “patients” (24600.8), “woman” (24015.6), “physician” (20840.6), “trouble” (18539.4), “time” (17896.3), “money” (16379.9), “new nurses” (14056.8), and “salary” (13084.1). The 22,572 preprocessed key words were categorized into four topics: “poor working environment”, “culture among women”, “unfair oppression”, and “society-level solutions”.CONCLUSION: Public interest in workplace bullying among nurses has continued to increase. The public agreed that negative work environment and nursing shortage could cause workplace bullying. They also considered nurse bullying as a problem that should be resolved at a societal level. It is necessary to conduct further research through gender discrimination perspectives on nurse workplace bullying and the social value of nursing work.

Development and Validation of a Person-Centered Perioperative Nursing Scale

PURPOSE: The purpose of this study was to develop a scale to measure person-centered perioperative nursing (PCPON) and validate its psychometric properties. METHODS: The preliminary items of the PCPON scale were developed through a literature review, in-depth interviews, and content validity analysis. A total of 459 nurses working in the operating rooms of 21 hospitals in Korea responded to the questionnaire from September to October 2017. The collected data were analyzed by exploratory factor analysis (EFA) and confirmative factor analysis (CFA) using SPSS and AMOS programs. RESULTS: The final PCPON scale consists of 20 items. Through EFA, five factors, compassionate interaction, respect, providing comfort, information sharing, and nursing expertise, were derived. The internal consistency of each factor of the PCPON scale, as represented by Cronbach α, was .76–.88. The model fit of the scale was satisfactory, and the items of the scale demonstrated convergent and discriminant validity. CONCLUSION: The evaluation of the new PCPON scale indicated good reliability and validity. The PCPON scale is easy to administer and implies factors of person-centered care. This scale can be used to assess the person-centered care in the perioperative nursing field.

Threats to Identity: A Grounded Theory Approach on Student Nurses' Experience of Incivility during Clinical Placement / 간호학회지

PURPOSE: This qualitative study aimed to explore the experience of incivility among nursing students. METHODS: Sixteen nursing students who had experienced incivility during their clinical placement were invited for one-on-one interviews until the point of theoretical saturation. The grounded theory approach of Corbin and Strauss was adopted to analyze transcribed interview contents. RESULTS: Incivility occurred in the context of a hierarchical organizational culture, due to nursing students' position as outsiders, non-systematic clinical education, and poor nursing work environment. The experience of incivility was identified as “being mistreated as a marginal person,” and nursing students responded to this phenomenon in the following three steps: reality shock, passive action, and submissive acceptance. This process caused students to lose self-esteem and undergo role conflict. Furthermore, nursing students' experience of incivility could eventually lead to workplace bullying in nurses. CONCLUSION: The results of this study suggest that nursing students' experience of incivility can be a process that threatens their identity. It is necessary to develop educational programs and provide appropriate counseling services so that nursing students can actively cope with the incivility. In addition, institutional plans are needed to ensure safe and supportive clinical learning environments.

A Qualitative Content Analysis of the Person-Centered Care Experienced by Critical Care Patients / 중환자간호학회지

PURPOSE: To explore the person-centered care (PCC) experienced by critical patients.METHOD: This qualitative study deductively examined the attributes of the PCC model proposed by Jakimowicz and Perry. The participants were 16 patients who were recently discharged from intensive care units at a university hospital. Data were collected through in-depth interviews and were analyzed using the deductive method of content analysis.RESULTS: A total of 4 categories, 16 subcategories, and 33 codes were generated from 171 meaningful statements. The final 4 categories were “compassionate presence,” “professional interaction,” “outstanding competency,” and “patient identity.” These were consistent with the main attributes of Jakimowicz and Perry's model. However, most of the codes belonged to the “compassionate presence” and “patient identity” categories. Among the attributes of the model, “continuity of nursing,” “therapeutic relationship,” “expert knowledge,” “clinical knowledge,” “evidence-based intervention,” and “patient's rights” were not derived as codes.CONCLUSION: These findings deepen the understanding of the PCC model from the patient's point of view. The main attributes of PCC identified in the current study can be applied to the development of practical guidelines for intensive care nursing. In addition, we recommend the development of a PCC measurement tool for critical care patients.

A Study of the Trends in Korean Nursing Research on Critical Care in the Last 10 Years (2008–2017) Using Integrated Review and Key Word Analysis / 중환자간호학회지

PURPOSE: The purpose of this study was to examine the possible direction of critical care nursing research in the future by analyzing the trends of recent Korean studies.METHOD: Using a database search, we selected 263 articles on critical care nursing that were published in Korean journals between 2008 and 2017. Then, we conducted an integrative review of the contents of the selected articles and analyzed the English abstracts using the relevant packages and functions of the R program.RESULTS: The number of studies concerning critical care nursing has increased over the 10-year period, and the specific topic of each study has diversified according to the time at which it was conducted. In terms of quality, the majority of the research was published in high-level academic journals. The key words regularly studied over the past decade were: knowledge, delirium, education, restraint, stress, and infection. Studies related to vancomycin-resistant enterococci infection, compliance, and standards have decreased, while studies related to death, communication, and safety have increased.CONCLUSION: Randomized controlled trials and protocol research for evidence-based critical care need to be conducted, as does research on family involvement. The key word analysis of unstructured text used in this study is a relatively new method; it is suggested that this method be applied to various critical care nursing research and develop it methodologically.

Sentiment Analysis of the Quotations of Intensive Care Unit Survivors in Qualitative Studies / 중환자간호학회지

PURPOSE: As the intensive care unit (ICU) survival rate increases, interest in the lives of ICU survivors has also been increasing. The purpose of this study was to identify the sentiment of ICU survivors.METHOD: The author analyzed the quotations from previous qualitative studies related to ICU survivors; a total of 1,074 sentences comprising 429 quotations from 25 relevant studies were analyzed. A word cloud created in the R program was utilized to identify the most frequent adjectives used, and sentiment and emotional scores were calculated using the Artificial Intelligence (AI) program.RESULTS: The 10 adjectives that appeared the most in the quotations were ‘difficult’, ‘different’, ‘normal’, ‘able’, ‘hard’, ‘bad’, ‘ill’, ‘better’, ‘weak’, and ‘afraid’, in order of decreasing occurrence. The mean sentiment score was negative (-.31±.23), and the three emotions with the highest score were ‘sadness’(.52±.13), ‘joy’(.35±.22), and ‘fear’(.30±.25).CONCLUSION: The natural language processing of AI used in this study is a relatively new method. As such, it is necessary to refine the methodology through repeated research in various nursing fields. In addition, further studies on nursing interventions that improve the coherency of ICU memory of survivors and familial support for the ICU survivors are needed.