JC 20-10-11

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A qualitative study

8/3/2019 JC 20-10-11


Donna Goodridgea, Wendy Dugglebya,

John Gjevreb, Donna Renniea.

College of Nursing, University of Saskatchewan, 107 Wiggins Road, Saskatoon, Saskatchewan, Canada S7T

5E5

Division of Respiratory and Critical Care Medicine,

Department of Medicine, University of Saskatchewan Royal University Hospital, 103 Hospital Drive,

Saskatoon, Saskatchewan, Canada S7N 0W8

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The purpose of this descriptive study was to

examine intensive care unit (ICU) clinicians’

perspectives on the challenges of providing quality

EOL care for individuals with COPD who diewithin the critical care environment.

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Critical care nurses have raised important concerns aboutthe quality of care for individuals dying in the technology-

rich, fast-paced setting of the ICU.

Emotional and organizational supports for staff are well-

recognized as a key component of ensuring the delivery of

quality care for those who are dying.

Critical care clinicians care deeply about facilitating high-

quality dying (Seymour, 2001). Nurses reported that

quality EOL care in the ICU was complicated by

disagreements among family members or amongclinicians, uncertainty about prognosis and communication

problems between physicians and between physicians and

family members (Kirchhoff et al., 2000).

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Design: Ethical approval was given by the researcher’s affiliated university

Behavioral Research Ethics Board and the local Health Region.

A qualitative focus group design with three groups of staff was used to

describe the experiences of critical care nurses and respiratory therapists

(RTs) in providing EOL care to patients with COPD dying in the ICU.

Each focus group met once and a follow-up interview was conducted with

one volunteer from each group to validate the themes emerging from the

focus group.

The interview consists of 1) Opening / Introductory Question,2) Transition Questions,

3) Key Question &

4) Ending Question.

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Setting:

The three ICUs were comparable in size, ranging from 10to 12 beds, although the number of admissions ranged

from 350 to 800 per year and overall mortality rates varied

from 9.5% to 21.2%.

Of the 1600 admissions to these ICU units in 2005,approximately 240 patients were admitted with a diagnosis

of COPD and invasive mechanical ventilation was required

by about 100 patients.

The nurses and respiratory therapists on these units havesignificant experience caring for patients with advanced

COPD.

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Participants:

1. Nurses

2. Respiratory therapists

3. Physiotherapists4. Physicians

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Data analysis

Transcripts were checked for accuracy against the

recordings. All transcripts were read by the research team members

individually and then collectively.

Qualitative data were stored and managed using N6

software.

The analysis of focus group data focused on the individual

and group levels.

The data (transcripts and field notes) for each focus group

were analyzed separately.

The analysis focused on challenges that participants

perceived as unique to, or especially pervasive in, caring

for people with COPD in the ICU.

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Seventeen ICU clinicians participated in the focus groups, a

total which included 15 registered nurses and two respiratorytherapists.

While 21 staff members had originally committed to

participate, four were unable to attend due to last minute

personal conflicts in scheduling (including being called intowork an over-time shift).

All participants were employed at least half time in one of the

three ICUs.

The mean age of the participants was 42.3 years, with a rangefrom 27 to 57 years.

Participants had a mean overall nursing experience of 19.6

years with a range of 5 — 36 years, with a mean ICU

experience of 12.3 years (range 1 — 21 years). Five

participants were male.

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Focus group sizes were four, six and

seven participants.

The focus groups lasted from 55 to

75 min and were tape-recorded and

transcribed.

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In this exploratory study, focus groups of nurses and

respiratory therapists working in three critical care settings

described some of the challenges to providing EOL care to

people with advanced COPD who were dying in the ICU.

The three themes of ‘‘managing difficult symptoms’’,

‘‘questioning the appropriateness of life-sustaining care’’

and ‘‘conflicting care priorities’’ were noted to besignificant challenges.

Dyspnea and anxiety were clearly the symptoms

participants associated most often with patients dying with

COPD in the ICU. Ethical considerations were central to the discussion of

end-of-life care for people dying with COPD in the ICU.

This study also revealed a number of areas that warrant

further research.

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The findings may reflect the particular culture and

idiosyncrasies of each ICU setting, although they lay the

foundation for future research in this area.

This study is limited by the relatively small number of participants as well as including ICUs from a single city.

However, credibility in a qualitative study is determined

more by the richness of data than by sample size.

The discussion relied on participants’ recollections of caring for individuals dying with COPD in the ICU setting.

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Providing expert critical care for the high acuity patient

with a diagnosis of COPD at the end of life is bothcomplex and challenging.

The purpose of this descriptive study was to examine

intensive care unit (ICU) clinicians’ perspectives on the

obstacles to providing quality care for individuals withCOPD who die within the critical care environment.

Transcripts of three focus groups of ICU clinicians were

analyzed using thematic analysis.

The three themes of ‘‘managing difficult symptoms’’,‘‘questioning the appropriateness of life-sustaining care’’

and ‘‘conflicting care priorities’’ were noted to be

significant challenges in providing high quality end of life

care to this population.

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The need to prioritize care to the most unstable

ICU patients meant that patients with COPD did

not always receive the attention clinicians felt they

should ideally have.

Organizational support must be made available for

critical care clinicians to effectively deal withthese issues.

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JC 20-10-11