Dying in intensive care: An analysis of the perspectives of families and clinicians on end-of-life care.

BACKGROUND: Despite a growing body of research into end-of-life care (EOLC) in intensive care units (ICUs), few studies have concurrently explored the perspectives of families and clinicians. OBJECTIVE: The objective of this study was to identify the characteristics of high-quality EOLC in the ICU from family and clinician perspectives and by examining the care documented in medical records. METHODS: A convergent mixed-methods study incorporating electronic health record audits (n = 20), structured interview surveys with families (n = 20), clinician surveys (n = 189), and focus groups (n = 10) was undertaken at a 30-bed, level 3 ICU at a metropolitan public adult teaching hospital in Australia. Descriptive statistics were calculated from quantitative data, and inductive thematic analysis was used to analyse qualitative data. RESULTS: Overall, families were very satisfied with EOLC and the quality of communication yet, felt that earlier, clearer communication that the patient was dying was required. Families spoke of the attentiveness, or lack thereof, by ICU clinicians and the opportunity to be present for the patient's death. The majority of ICU clinicians felt EOLC could be improved. Nurses highlighted communication challenges when family meetings were delayed. Some nurses expressed a lack of clarity of how to withdraw care, resulting in hesitancy to cease potentially inappropriate care, and to provide EOLC outside ICU practice norms. In many instances, observations, invasive monitoring, and interventions were documented after EOLC commenced. A lack of documented personal cares was also noted. CONCLUSIONS: This study provides new insights into EOLC from the dual perspectives of families and clinicians. There is a need for institutional guidelines to support ICU clinicians' EOLC practices and education to improve clinician confidence with communication.

Towards the idea of 'clinical capital': A longitudinal study exploring nurses' dispositions and workplace manifestations in an Australian intensive care unit.

OBJECTIVE: To explore the concept of 'capital' through the study of successive interventions and outcomes (patient and staff) in a quaternity intensive care unit (ICU) across a 5-year time frame. DESIGN: A longitudinal intrinsic single site, a survey study was designed. The concept of 'capital' was explored through an adopted interpretive approach that involved understanding meanings from different sources, for example, discussions at compassion cafés, follow-up from staff-initiated activities, informal responses to organizational imperatives external to the unit (i.e. staff reductions and resource constraints), alongside empirical data about workplace climate and patient incidents. SETTING: A single ICU employing approximately 220 registered nurses at a quaternary hospital in Queensland, Australia. PARTICIPANTS: All nurses employed in the ICU at the time of compassion cafes participated in providing feedback to inform successive activities. All nurses in the unit had equal opportunity to complete surveys, participate in subsequent unit-based sessions, take-up options; and all nurses had a responsibility to complete incident data. RESULTS: Survey and incident data from 2015 to 2019 identify the complexity of workplace environments. Between 35% and 45% of nurses consistently completed the survey. Activities based on staff requests initially improved incident data but did not impact the work environment; negative perceptions of the work environment at the endpoint (2019) were associated with external factors. CONCLUSION: Quality care environments are labile; sensitive to both unit activity and external organization directives (namely staff reductions). Quality care can be sustained in adverse situations with increased nurse engagement in patient care dynamics in the short term. IMPACT: This study articulates a previously unidentified concept, 'clinical capital'. Activities facilitating nurse engagement in broad care dynamics gave rise to a more robust climate than just focusing on social and psychological well-being activities for nurses. Participation in issues of concern about patient care can promote resilience to short term fluctuations.

Conflicts and con-fusions confounding compassion in acute care: Creating dialogical moral space.

BACKGROUND:: Compassion, understood as empathy for another who is experiencing physical, mental, emotional and/or spiritual suffering, is an essential element of our shared understandings of nursing and the constitution of the professional nurse. THEORETICAL FOUNDATION:: Charles Taylor account of ethics which concerns 'what or who is it good to be' rather than the predominant analytical moral philosophy approach which concentrates on 'what ought one to do' is the core concern of this discussion. An ontological appreciation of our shared human condition is the premise upon which the discussion is based. DISCUSSION:: This article proposes that concept by opening a dialogical space, nurses can engage in reflection and sense making wherein they explore individually and collectively the conflicts and confusions encountered in their day-to-day work. Through their dialogues, nurses - individually and collectively - orient and reorient themselves and each other towards what they see as meaningful and purposeful in their lives and in doing so they are well positioned to reaffirm their commitment to compassion as a value which both anchors and orients their day-to-day work. IMPLICATIONS:: The provision of opportunities in the workplace, in the form of dialogue, to articulate often unspoken assumptions and frameworks in which nursing work is carried out can not only initiate the building of pathways of support but also assist nurses reaffirm their compassion - arguably the essence of their nursing practice.

The Role of the Nurse Educator in Sustaining Compassion in the Workplace: A Case Study From an Intensive Care Unit.

Intensive care unit (ICU) nurses are frequently exposed to emotional and stressful situations in the workplace, which has changed little over the decades. Compassion fatigue is caused by sustained exposure to situations that conflict with one's values and beliefs in the ICU, eroding clinical team relationships and ultimately the quality and safety of patient care. Continuing education in the intensive care setting is a priority, as ICU nurses need to remain abreast of the rapid developments in high-acuity care delivery; however, attention also needs to be directed to nurses' emotional well-being. Nurse educators are well positioned to create and sustain open dialogue that contributes to group cohesion and assists nurses' well-being. J Contin Educ Nurs. 2018;49(5):221-224.

Delivering compassionate care in intensive care units: nurses' perceptions of enablers and barriers.

BACKGROUND: Compassion is core to nursing practice. Nurses' expression of compassion is a complex interaction informed by the nurse, the patient and the practice environment. AIM: The aim of this study was to identify personal, professional and organizational factors, intensive care nurses, in a major metropolitan facility in Australia, identified as enabling or disabling them to be compassionate. DESIGN: Intensive care nurses (n = 171) reflected on their experiences during 'compassion cafés' conducted in 2015. METHOD: Qualitative, reflexive methods were used to explore ICU nurses' perceptions of enablers and barriers. Nurses documented their perceptions, which were thematically analysed. Meanings were subsequently verified with participants. RESULTS: The findings identified multiple factors both inside and outside the workplace that constrained or enabled nurses' ability to be compassionate. Two main factors inside the workplace were culture of the team, in particular, support from colleagues and congruency in work practices and decision-making, and connections with patients and families. Outside the workplace, nurses were influenced by their values about care and lifestyle factors such as family demands. CONCLUSIONS: Nurses capacity to be compassionate is a complex interplay between nursing knowledge and expectations, organizational structures and lifestyle factors. IMPLICATIONS: The responsibility for 'compassionate' care is a shared one. Nurses need to be cognizant of factors that are enabling or inhibiting their ability to be compassionate. Healthcare leaders have a responsibility to provide structural support (staffing, education and space) that assist nurses to deliver compassionate care and where appropriate cater for nurses needs so that they are better able to be compassionate.

Right person, right skills, right job: the contribution of objective structured clinical examinations in advancing staff nurse experts.

Recruitment processes need to discriminate among candidates to ensure that the right person with the right skills is selected for advancement opportunities. An innovative recruitment process using an objective structured clinical examination grounded in best practice guidelines resulted in improved recruitment practices for senior nursing clinical expert roles. Candidates' skills, knowledge, and attitudes in the areas of patient focus, clinical expertise, teamwork, and leadership were assessed using a clinical simulation. Candidates achieving advancement were assessed at 6 months to validate the efficacy of the process.