1. 0 INTRODUCTION I propose to study the attitude, knowledge and experiences of nurses on prioritizing comfort measures in care of the dying patient in an acute hospital setting. I am particularly interested in this field as I worked in a hospice during semester break where palliative care of the dying concentrated on the quality of life of the patient. When the prognosis for the patient was imminent death, care was focused on reducing the severity of the disease symptoms rather than vainly trying to stop or delay development of the disease itself or provide a cure.
When the prognosis for a patient is imminent death, hospice care concentrates on the quality of life of the patient, reducing the severity of the disease symptoms rather than vainly trying to treat the disease itself. To assist in delivery of this type of quality end-of-life care to patients in acute hospitals the Alor Setar Hospital developed a Hospice Friendly Hospital programme (HFH). This HFH developed the Quality Standards for End-of-Life Care in Hospitals to set out a shared vision for the type of end-of life care that each hospital should aim to provide.
This development is significant as almost 50% of those who die in Kedah die in hospital and care of the dying in Alor Setar hospitals, while regarded as good, is described as ‘care at the end of life’ rather than ‘end-of-life care’ because the care seems to lack an effective palliative care component” LITERATURE REVIEW To investigate international perspectives on end-of-life care, the current international literature was reviewed using the key themes of identifying the dying phase, comfort care and symptom control for the dying patient.
It was conclude from the literature review that nurses and medical staff often differed in their approach to care of the dying patient and this hindered effective delivery of end-of-life-care. Education on end-of-life care was recommended in the literature as being a solution to the problems in delivering this care even though research had not been done on the status quo in education. RESEARCH PROBLEM
Before planning such specific education programmes, it would seem necessary to conduct research studies to establish the education and training levels of nurses and doctors in end-of-life care and to establish if attitudes and experience also influence the medical and nursing models in the delivery of this care. This research proposal is concerned with the nursing model and it proposes to establish what influences the nurse’s approach in delivering end-of-life care. METHODOLOGY A quantitative approach using a descriptive design is proposed for this study.
Questionnaires will be used as the data collection method with a simple random sample of 200 staff nurses employed in a Alor Setar hospital being selected as participants in the study. RESEARCH QUESTION The research problem leads to the following research question: “What are the attitude, knowledge and experience of nurses on prioritizing comfort measures for dying patients in an acute hospital? ” OBJECTIVES (i) To establish the attitude of nurses on prioritizing comfort measures for dying patients. ii) To establish if nurses’ knowledge of prioritizing comfort measures for dying patients is adequate. (iii) To establish if nurses’ experience in prioritizing comfort measures for dying patients is significant. 2. 0 METHODOLOGY Introduction to Research Methodology The methodology selected for the proposed study will be detailed here. The planned research design, methods of sample selection, data collection and analysis of results will be explained. Ethical considerations for this particular research study will also be detailed.
It is hoped that the chosen methodology will generate useful information through the collection and analysis of data on the attitude, knowledge and experiences of staff nurses
The quantitative approach arises from the belief that human phenomena and variables in human behaviour can be studied objectively (Parahoo 2006) and so this approach has been chosen as an appropriate research method. Quantitative research uses a fixed design that organises in advance the research question and a detailed method of data collection and analysis (Robson 2007). It is proposed that this survey will collect details of the current attitude, knowledge and experience of nurses on comfort care of the dying patient.
The method of data collection chosen is a written questionnaire, allowing large sample size without major expense, to produce quantitative data that can be analysed by statistical computer programmes, Population/sample Parahoo (2006, p. 258) defines a population as “the total number of units from which data can potentially be collected”. The population in this study will be staff nurses working in the acute hospital setting in Ireland. This population will be delimited to a homogenous group of subjects through inclusion/exclusion criteria. Inclusion criteria • Registered general staff nurses who work in the acute-care setting.
Exclusion criteria • Staff nurses working with children • Agency staff nurses Staff nurses, fitting the above criteria, from a large Dublin acute hospital will be chosen as a smaller convenience group of the target population. It is then proposed to select a simple random probability sample (from the convenience sample). Proctor et al. (2010) maintain that the use of probability sampling in quantitative research reduces errors and biases in the study. Sampling is the process by which researchers select a proportion of the target population, as the study population, to represent the entire unit.
It is more practical and economical to work with samples rather than with large target populations (Polit & Beck 2010). The researcher will obtain the names of all eligible nurses from the Human Resources Department in the hospital. This list of nurses will form a sample frame from which the researcher will select nurses at random by assigning a number to each name and ‘picking the numbers out of a hat’. Data collection Quantitative data are collected to classify and describe attributes, behaviours and activities of populations according to Parahoo (2006).
Data collection should be objective, systematic and repeatable (Lacey 2010). Robson (2007) maintains that a researcher should use the simplest manner of collecting the data to get answers to the research question and should not collect any more data than necessary. Mindful of these conditions the data collection instrument selected for this study is a questionnaire. Questionnaires A questionnaire is a method of data collection that asks participants to give written or verbal replies to a written set of questions (Parahoo 2006).
It is a quick,convenient and inexpensive method of collecting standardised information . A questionnaire can be used to collect information on attitudes,knowledge and experience of staff (Parahoo 2006). A structured writtenquestionnaire that uses a quantitative self-report technique, as outlined by Polit & Beck (2010), will be used to collect data in this study. The questionnaire will have three parts (see Appendix ). Part A of the questionnaire will use a Likert-type scale to gather data on the attitudes of nurseson the effect of comfort in care of the dying.
The questionnaire will consist of positively and negatively worded statements with six different response options ranging from strongly disagree to strongly agree. Positive statements are scored one to six (one for strongly agree through to six for strongly disagree) and scores are reversed for negative statements. The score for each item will be reported individually. Parts B and C will use a fill the box format and will gather data on the knowledge and experience of nurses on comfort care of the dying respectively. ETHICAL CONSIDERATION
According to Polit and Beck (2010), researchers must deal with ethical issues when their intended research involves human beings. Ethical approval will be requested in writing from the Director of Nursing (as gatekeeper) and the Hospital Ethics Committee of the hospital involved in the research . As gatekeeper, the director of Nursing must be made aware of all nursing research taking place in the organisation to monitor the effect of all such projects taking place. She will also need to be convinced of the value of the research and the competency of the researcher (Lee 2005).
The main ethical principles that will be considered in conducting this research study are respect for persons, confidentiality and beneficence /non-maleficence. 3. 0 PROPOSED OUTCOME Following this proposed study, a report will be compiled discussing all aspects of the research process including the results, limitations and benefits. It is anticipated that the results of the study will give an indication of nurses’ attitude, knowledge and experience in the domain of comfort care of the dying in Ireland and indicate where interventions are needed through education, training or management.
It is also anticipated that the findings of the research study will reveal if other factors such as attitude or experience impact on the effective delivery of care of the dying patient. It is anticipated that these results will contribute to recommendations in future nursing practice, nurse education and research and that this will in turn move palliative care higher up on the agenda of the nursing profession in general. This study will have limitations as it will be conducted in only one acute hospital. It will give a general overview of the current attitude, knowledge and experience of nurses in this hospital.
The researcher recommends that other studies, both quantitative and qualitative be carried out in hospitals in other Irish cities so that a more general picture could be established of end-of-life nursing care in acute hospitals in Ireland. Qualitative research is explanatory and descriptive in nature and so it could help in determining the nature of the phenomena being studied (Barroso, 2010) and consequently give a more complete picture of care of the dying. It is the intention of the researcher to share the findings of the study with management of the partaking hospital and the schools of nursing and midwifery in Ireland.
It is hoped that this will highlight the necessity of planning on-going education and training for nurses in end-of-life care. To present the research report to a broader audience the researcher intends applying for publication of the study report in relevant nursing journals. Time Scale A clear and practical time scale is necessary to facilitate the organisation and coordination of each stage of the research process and the successful integration of the stages (Cormack, 1991). An 18 month period is proposed as the time frame for this study and a detailed integrated time plan is included in appendix .
Resources An estimated budget account for the proposed study is outlined in appendix. 4. 0 APPENDIX Part A: Questionnaire on attitudes Directions: Write your opnion whether agree or not. 1. Nurses are capable of identifying that a patient is dying. 2. I would not like the responsibility of identifying a patient as dying. 3. Nurses cannot cease routine care for the dying patient without permission from a doctor. 4. The length of time taken to care for a dying patient is vitally important. 5. Nurses should not give dying patients honest answers about their condition. 6.
End stage palliative care does not do anything for the patient. 7. The focus of care should be adapted when death becomes imminent. 8. When a patient has been identified as dying a ‘do not resuscitate order’ should be placed on his/her chart. 9. Nurses play a key role in helping patients die in comfort. 10. Comfort care for the dying patient should not replace routine nursing practice. 11. I would not like to care for a dying patient. 12. Comfort care will enhance the dying patient’s quality of life. 13. Specialist palliative care teams are never necessary to deal with a dying patient. 14.
Symptom control for the dying patient is not the nurse’s responsibility. 15. When nursing a dying patient it is good practice, when possible, to frequently ask them about symptom control. 16. Symptom control guidelines are necessary for delivering optimal end-of-life care. 17. Nurses cannot manage symptom control in the dying phase. 18. The dying patient’s physical needs should be decided by them when possible. 19. Dignity of a patient is not more important that effective care. 20. Administration of opioids by means of a syringe driver is often an essential measure in symptom control. Part B: Knowledge Questionnaire
Please answer all the following questions by ticking the appropriate box to indicate the answer you consider to be correct. Tick one box only. 1. The decision that a patient is dying should be made by a multidisciplinary team. Correct __ Incorrect__ 2. There is a need for specialist palliative care teams to be involved with every dying patient. Correct__ Incorrect__ 3. The dying person should not be allowed to make decisions about his/her physical care. Correct__ Incorrect__ 4. Treatment procedures should be continued even when the patient is dying. Correct__ Incorrect__ 5.
Routine nursing practice should not take precedence over a patient’s comfort. Correct__ Incorrect__ 6. Dehydration is a normal part of the dying process. Correct__ Incorrect__ 7. Frequent repositioning of a dying patient is not always desirable. Correct__ Incorrect__ 8. When a patient is diagnosed as dying current medication should be reassessed and non-essentials discontinued. Correct__ Incorrect__ 9. Use of opioids is appropriate to control pain for the dying patient. Correct__ Incorrect__ 10. Symptoms of increased chest secretions and terminal agitation are unavoidable in dying patients. Correct__ Incorrect__ 1. Regulation of bowel movements is often a problem for a dying patient. Correct__ Incorrect__ 12. Retention of urine is more likely than urine incontinence in the dying patient. Correct__ Incorrect__ 13. All dying patients will be at high risk of skin breakdown. Correct__ Incorrect__ 14. Breathless is a common symptom in the dying phase. Correct__ Incorrect__ 15. General comfort care should not take precedence over skin care. Correct__ Incorrect__ 16. Maintaining a fluid balance record for the dying patient is important. Correct__ Incorrect__ 17. The dying patient should not be coaxed to eat.
Correct__ Incorrect__ 18. It is appropriate to control pain in the dying phase by use of both analgesia and sedation. Correct__ Incorrect__ 19. An acute episode in a chronically ill patient may represent a terminal event. Correct__ Incorrect__ 20. Reducing the respiratory rate can relieve breathlessness for the dying patient by reducing anxiety. Correct__ Incorrect__ Part C: Experience survey Section 1 Please answer each question by ticking the appropriate box. 1. Please indicate your number of years nursing experience. 1-5 years 5-10 years 10-15 years 15-20 years >20 years 2.
Have you received pre-registration education in end-of-life care? Yes No 3. Have you received post-registration education in end-of-life care? Yes No Section 2 35 The following section concerns your experience in delivering comfort care to dying patients. Please indicate your answer to the question by placing a number in the box which corresponds to your experience (see answer guide). Answer guide: 0 1 2 3 4 5 never 1– 5 times 5–10 times 10–15 times 15– 20 times > 20 times 1. I have been present as a nurse when a patient has died. 2. I have been in charge of nursing care for a dying patient. 3.
I have used an integrated care pathway for end-of-life care. 4. I have been part of an interdisciplinary team that identified a patient as dying. 5. I have collaborated with an interdisciplinary team in delivering end-of-life care for a dying patient. 6. I have nursed a dying patient with a do not resuscitate order. 7. I have set up a syringe driver for subcutaneous administration of anticipatory prescribed medications to a dying patient. 8. I have administered prescribed opiate drugs to a dying patient to control pain. 9. I have administered prescribed drugs to a dying patient to control respiratory secretions. 0. I have administered prescribed drugs to a dying patient to control breathlessness. 11. I have been involved in cessation of artificial hydration for a dying patient. 12. I have been involved in cessation of artificial feeding for a dying patient. 13. I have dealt with nausea and vomiting episodes for a dying patient. 14. I have managed constipation problems for a dying patient. 15. I have inserted a urinary catheter to manage urine retention for a dying patient. 16. When caring for a dying patient I have been involved making the decision to cease routine care and focus on comfort care. 7. I have managed physical comfort measures for a dying patient with the provision of an air mattress. 18. I have discussed the prognosis of dying with a patient in the dying phase 19. I have acted as advocate for a dying patient when he/she needed their wishes to be heard regarding treatment. 20. I have negotiated a cessation of diagnostic interventions for a dying patient Thank you for taking the time to complete this questionnaire. I sincerely value the important contribution that you have made to knowledge development in this area.