Browsing by Author "DeKeyser Ganz, Freda"
Results Per Page
Sort Options
- ItemBullying and its prevention among a national sample of Israeli ICU nurses(2014-11-17) DeKeyser Ganz, Freda; Pi at-Large
Session presented on Friday, July 25, 2014:
Purpose: The purpose of this study was to describe the prevalence of bullying as well as what measures were taken to prevent it, as perceived by a national sample of Israeli ICU nurses. Background: 'Bullying refers to repeated, offensive, abusive, intimidating, or insulting behaviors; abuse of power; or unfair sanctions that make recipients feel humiliated, vulnerable, or threatened, thus creating stress and undermining their self-confidence (Embree, & White, 2010; Hutchinson, Wilkes, Jackson & Vickers, 2010; Murray, 2009; Rowell, 2005; Yildrim & Yildrim, 2007).' This phenomenon has been shown to be widespread within nursing in many different countries around the world (For example, Johnson & Rhea, 2009; RCN, 2002; Vessey, DeMarco, Gaffney & Budin, 2009; Yildrim & Yildrim, 2007). Bullying has been shown to have both physical and psychological consequences for the victim (Murray, 2009; Rowell, 2005; Katrini) and to affect patient care (Woelfle & McCaffrey, 2007), leading to decreased job satisfaction and increased burnout (Laschinger, Grau, Finegan & Wilk, 2010). 'There has been some literature that has described how to prevent bullying (Katrini, Atabay, Gunay & Cangarli, 2010).' These measures include increased awareness about the potential presence of bullying and the development of institutional protocols that call for the documentation of bulling with disciplinary action against it (Katrini, et al., 2010; Lewis, 2006; MacIntosh, 2006). At present there are no reports that describe the prevalence of bullying among nurses in Israel nor are there reports of what actions are taken to prevent its occurrence.' Furthermore, no study was found that investigated bullying only among critical care nurses, despite the fact that these units have been shown to have a high prevalence of bullying.'
Methods: This was a cross sectional, correlational, descriptive survey.
Sample: The sample was a convenience sample of 155 ICU nurses. Members of the Evidence Based Practice Subgroup of the Israeli Society of Cardiology and Critical Care Nursing recruited ICU nurses from five medical centers. As the primary purpose of the study was to describe the prevalence of bullying and its perceived prevention, it was determined that data collectors would try and recruit a maximum amount of respondents without concern for statistical power. Data collection: Data were collected after institutional and ethical approval at each institution. Head nurses were contacted and asked to approve participation of members of their units. A pilot test of the initial 25 respondents was conducted. Questionnaires were found to be clear and so the results of the pilot were included in the final results. Questionnaires were administered according to the preference of the local administration, either in staff meetings or participants were approached individually on their respective units. All responses were placed in an envelope at a central location and were anonymous.
Instruments: Three questionnaires were used: 'a. Demographic and work characteristics questionnaire, including personal demographic and work-related data. 'b. Negative Acts Questionnaire-Revised: a 22 item, Likert-style questionnaire developed by Einarsen, and colleagues in 1994 and revised in 2009 (Einarsen, Hoel & Notelaers, 2009) to measure the level of exposure to bullying in the workplace. It was found to have acceptable levels of reliability and validity. 'c. Bullying Prevention Questionnaire: developed by the investigators to determine measures currently available to prevent bullying.' This questionnaire contains 42 items on a 4 point Likert scale and lists measures conducted by institutions, units and individuals. The questionnaire is based on a review of the bullying literature and underwent content review.
Data Analysis: Descriptive statistics were conducted on all of the questionnaires. Bivariate analyses were conducted to determine if there are any demographic or work characteristic variables associated with bullying or perceived prevention. Those characteristics found to be significantly associated were used as predictor variables in a logistic regression model with bullying as the criterion variable.
Results: The sample consisted of 155 ICU nurses.'The majority of the sample was female (n=102, 69%), married (n=112, 77%) and Jewish (n = 96, 67%).'Most worked as staff nurses (n=111, 76%), had a baccalaureate nursing education (n=87, 60%) with post-basic ICU certification (n=122, 83%) with a mean age of 41.3 (SD= 9.9) and 11.5 years experience as an ICU nurse (SD=9.0).'Almost one third of the respondents (n= 43, 29%) reported being the victim of some bullying, although no one reported being bullied on a daily basis.'The mean total score on the NAQ-R was 33.3 (SD=11.6) with a mean item score of 1.6 (SD= 1.4) out of 5.'The mean Bullying Prevention total score was 96.8 (SD=14.4, range: 48-140, out of a possible 168) with an item mean score of 2.4 (out of 4) (SD= 0.3); Results for the subscale scores were: institutional prevention: item mean= 2.7 (SD= 0.5); unit prevention: item mean = 2.2 (SD=0.4) and individual prevention: item mean 2.4 (SD=0.3). A significant difference in the level of bullying was found between hospitals (F (4,155) = 2.7, p=.039). The mean scores on the Prevention Scale was found to differ between type of unit (F (5,143) = 3.4, p=.006) and hospital (F (4,155) = 2.9, p.026). However post-hoc Bonferroni analyses did not find significant differences between specific hospitals or units.'The Prevention Scale was found to significantly correlate with that of the NAQ-R (r= .58, p < .001). No other variables were found to be associated with either the bullying or prevention scores, therefore regression models were not created.
Conclusion: An alarming percentage of nurses were found to have been victims of bullying in their workplace.'The prevalence of bullying fell between levels presented in the literature (RCN, 2002; Johnson and Rhea, 2009; Yildrim & Yildrim, 2007).'This result is despite current policies of zero tolerance for bullying. On the other hand, those who reported being bullied, were not bullied on a daily basis and levels were low to moderate for specific bullying actions. The level of prevention was weak to moderate with little difference between measures taken by the individual, unit or institution. Prevention and perceived level of bullying significantly differed between hospitals and types of units while no other demographic or work characteristic was found to be associated. These results imply that bullying and its prevention happen for the most part at a unit and hospital level. Others have found some individual characteristics related to bullying but this finding was not seen in this study.
Implications: The results of this study suggest that on a policy and administrative basis, more measures must be taken and adhered to, related to prevention of bullying. Nurses must be educated to accept only a zero tolerance to bullying and to report bullying when confronted with it. More research should be conducted to determine what other factors are associated with bullying, and based on these results, to design interventional studies to prevent it.
- ItemA comparison of intensive care versus oncology nurses' knowledge, attitudes and behaviors of palliative care(2016-07-13) DeKeyser Ganz, Freda; Andrews, Caryn; Pi at-Large
Session presented on Thursday, July 21 2016 and Friday, July 22 2016:
Purpose: Approximately 30-40% of the deaths in the US occur in the Intensive Care Unit (ICU) or after ICU discharge1. Most of these deaths did not occur suddenly but were the final result of a process of physiological decompensation towards end-of-life 2. Palliative care is a treatment approach whose goal is to improve quality of life and relieve the suffering of patients and their families, often at end-of-life. 3. Its adoption has been met with resistance in the ICU, often due to the underlying culture (save life at any cost) and a sense of failure when moving from curative treatments to palliative care 4. Oncology nurses are not necessarily more adept at providing palliative care services to patients with cancer. Recently the emphasis on including palliative care services within general oncology services has been suggested as part of National Cancer Center Network (NCCN) guidelines for supportive care 5,6. In these guidelines it has been suggested that palliative care be a part of all cancer treatment, on a trajectory from cure to end-of-life. Therefore the purpose of this study was to compare the knowledge, attitudes and behaviors of intensive care with oncology nurses related to palliative care.
Methods:
Design: Web based survey Sample: The sample was a convenience sample of 126 members of the Israel Association for Cardiology and Intensive Care Nurses and of the Israel Oncology Nursing Society.
Data collection: Data were collected after institutional and ethical approval. An on-line survey using MySurveyLab was sent to all of the members of the two nursing associations. Responses were returned to the authors without any identifying information. Instruments: The survey included a questionnaire based on that of Montagnini, Smith & Balistrieri 7, based on self- efficacy theory that measures nurses' self- perceptions of their knowledge, attitudes and behaviors related to palliative care. Knowledge is defined as the confidence that a respondent possess the information necessary to perform end-of-life palliative care practices such as symptom control or spiritual support 7. Attitude is defined as a personal evaluation of end-of-life palliative care practices such as feeling comfortable discussing advance care directives with patients and families 7. Behaviors are defined as the confidence to perform of end-of-life palliative care practices such as initiating advance care planning with patients and families7. Cronbach's alpha reliability for the questionnaire in the current study was .90. A demographic and work characteristics questionnaire was also included in the survey.
Analysis: Descriptive statistics (including frequencies, means and standard deviations, medians) were calculated for the entire questionnaire as well as for its sub-sections (knowledge, attitudes and behaviors). Differences between oncology and intensive care nurses were determined using Independent t tests.
Results: The sample consisted of 126 nurses, 79 oncology and 47 intensive care nurses. The majority of the sample was female (n= 115, 91%), married (n=99, 79%), and Jewish (n=111, 88%). Almost half worked as staff nurses (n=58, 46%) with post-basic certification (n=102, 81%) with a mean age of 48.6 years (SD=10.6) and 10.0 (SD=10.3) or 15.0 (SD=8.9) years of experience as an oncology or intensive care nurse, respectively. Mean total scores for the knowledge section of the questionnaire were 45.1 (SD=7.9) and 41.7 (SD=10.6) (out of a possible 60) for the oncology and intensive care nurses, respectively. Mean attitude scores for the oncology nurses was 19.6 (SD=4.3) and 19.1 (SD=5.0) for intensive care nurses (out of a possible 25). Mean behavior scores were 26.8 (SD=13.0) and 27.2 (SD=9.7) for oncology and intensive care nurses, respectively (out of a possible 55). No significant differences were found between oncology and intensive care nurses on any of the sections of the questionnaire.
Conclusion: The oncology and intensive care nurses in this sample showed moderate levels of self-perceived knowledge and attitudes towards palliative care however the level of their self-reported behaviors was low. While oncology nurses tended to score slightly higher than those from critical care, these differences were not found to be significant. Results from the original study of self-perceived knowledge, attitudes and behaviors of American ICU nurses, found higher scores on all of the subscales 7. Others 8 from China found that nurses from intensive care units scored higher compared to oncology nurses on a measure of knowledge and attitudes on comfort care. Nurses (including intensive care and oncology nurses) from southeast Iran also scored low on knowledge about palliative care 9. Therefore, culture seems to play a role in the self-perceived knowledge, attitudes and behaviors related to palliative care. Efforts should be made to educate all nurses, including those in oncology, about palliative care. Further research should be conducted related to how to better introduce and implement palliative care.
- ItemExperiences of family members of dying patients receiving palliative sedation(2016-07-13) DeKeyser Ganz, Freda; Tursunov, Olga; Pi at-Large
Session presented on Sunday, July 24, 2016:
Purpose: The suffering of a dying patient sometimes includes 'refractory symptoms'. These symptoms are defined as severe symptoms, both physical and psychological, that cannot be treated for long periods, or their treatment leads to uncontrollable side effects 1, 2. Palliative care is meant to improve the quality of life of all patients and their families, including dying patients, and to relieve their suffering 3. The recommended treatment for a dying patient suffering from 'refractory symptoms' is palliative sedation 4. Family members remain with the patient in his last days, are involved and are influenced by medical treatment 5 and should understand the aim of medical care 3, 5. The suffering of the dying patient may cause distress to these family members 3, 5, 6. According to the principles of Family Centered Care, treatment for the dying patient and family members should take into consideration the physical and psycho-social state 3, 7 and provide emotional and physical support, medical advice and education both for the patient and relatives 3,6,7,8. It has been reported that the dying patient's family are often distressed and feel fear, helplessness, and exhaustion before the initiation of the sedation treatment 1, 5. These experiences can be the trigger to start palliative sedation in order to improve the patient's quality of life and to relieve the stress on family members who were watching the suffering of their loved one 9. On the other hand, it is postulated that family members may feel guilt and anxiety over making the decision to initiate palliative sedation, often thought to hasten death 6, 8. There have been few studies that have investigated the experiences of family members of terminal patients receiving palliative sedation and none were found that investigated these experiences over time. The purpose of this study was to describe the experience of family members of patients receiving palliative sedation at the initiation of treatment and after the patient has died and to compare these experiences over time.
Methods:
Design: Descriptive, comparative longitudinal study.
Sample: A convenience sample of 34 family members of dying patients receiving palliative sedation therapy on an Oncology ward in Israel were included in this study.
Data collection: After receiving approval from the Institutional Ethics Review Board, family members were requested to complete the study questionnaire and to agree to complete the same questionnaire again by telephone one to four months after the death of their loved one. Thirty eight family members were asked to participate in the study and 34 (89.5%) agreed. Of the 34 who agreed to fill out the first questionnaire (T1), 8 refused to answer the second data collection (T2) after the death of the patient (76.5% of the sample). Instruments: The study questionnaire was based on that of Morita et al. 10. The purpose of the original questionnaire was to describe the experiences of family members of patients receiving palliative sedation in Japan. The questionnaire consisted of four sections: a. demographic and background data of the family member study participant, b. demographic and background data related to the patient receiving the palliative sedation c. the participant's experience concerning the palliative sedation, d. experiences related to regret and satisfaction with the use of palliative sedation. Content validity of the questionnaire was checked by two experts in palliative care. Small changes were made to increase the questionnaire's sensitivity. Reliability was checked using Cronbach's Alpha with results for T1 =.87 and for T2 =.84. The test retest reliability for the fourth part of the questionnaire between T1 and T2 was found to be r=.70
Analysis: Descriptive statistics were used to describe the sample and results of the questionnaire. Differences between T1 and T2 were determined using the McNemar test for a dichotomous variable, the Marginal Homogeneity test for a nominal variable, the Wilcoxon Signed Ranks test for an ordinal variable and the Paired Samples T-test for continuous variables. Results: The average age of family member participants was 50.9 years (range 19-77; SD=15.4). Most participants were children or spouses of the patient. The average patient age was 62.27 years (range 21-89; SD=15.54), and almost all were Oncology patients excluding one with Leukemia. Most of patients were suffering from agitation, pain and dyspnea. Most relatives felt that their loved ones were in distress or great distress before starting palliative sedation (T1:91%; n=31, T2: 92%; n=24). The vast majority of participants were either satisfied or very satisfied with the medical care and with the use of sedation medication. At T1 the vast majority reported that the beginning of the sedation was properly timed (77%; n=26,) but at T2 this fell to 62% (n=16). Explanations about palliative sedation usually included the purpose of the sedation (T1: 88%, n=30; T2: 92%, n=24). However, occasionally this explanation did not adequately address the impact of the treatment on the patient's ability to communicate (T1: 29%, n=10; 23%, n=6), the patient's prognosis (T1: 38%, n=13; T2: 15%, n=4), nor its physical effect on the patient (T1: 38%, n=13, T2: 15%, n=4). In more than two thirds of the cases, the family perceived that the patient did not receive an explanation of the treatment (T1: 67.6% n=23; T2: 65.4% n=17). Most family members were not informed of this treatment option before the patient's status deteriorated and received an explanation of palliative sedation only on the same day that the decision to initiate treatment was made (T1: n=25, 73.5%; T2: n=19, 73.1%). Almost all of the participants (T1:100%; T2: 88%) felt that palliative sedation was an ethical way to decrease suffering and the vast majority felt that it was very important that the patient did not suffer any longer (T1: 88% n=30, T2: 92% n=24). Almost one third thought that the treatment shortened the patient's life (T1: 32% n=11; T2: 27% n=7) and a smaller proportion feared that it killed the patient (T1: 15% n=5; T2: 19% n=5). No significant differences were found between T1 and T2.
Conclusion: The primary purpose of palliative sedation is to relieve the suffering of the dying patient. This was achieved according to the participants of this study. Family members were involved in making the decision to initiate palliative sedation but were often burdened by the consequences of their choice. Communication was not as effective as it could have been. Family members reported that patients often did not receive an adequate explanation, particularly regarding the consequences of sedation. Further evidence of poor communication was not being prepared for the sudden change in the patient's condition and decreased ability to communicate. This is partially explained by the large percentage of participants who first discussed the use of palliative sedation on the same day it was initiated and that many had not heard of the use of palliative sedation at all before that time. It would seem that the explanation process might need more time. One of the more important ethical questions related to palliative sedation is whether the treatment may shorten the patient's life. Some participants agreed but fewer felt that the patient died because of sedation. However, most felt that there were no other means to relieve such suffering and most family members reported that they did not have legal or ethical concerns about the use of sedation. Over time suspicions associated with the legal aspects of the therapy remained stable. Therefore, it would seem that the majority of participants in this study were not conflicted on an ethical level about their decision to administer palliative sedation.
Summary: Most of the families were satisfied with the use of palliative sedation, the relief of suffering, and the support given by staff during the initiation of treatment and 1-4 months later. The results highlight the importance of communication between caregivers and family members, and the importance of providing timely and repeated explanations of palliative sedation. In addition, treatment should be started early enough to avoid unnecessary suffering of the patient and his family. Despite some fear of shortening the patient's life by use of sedation, all participants agreed that this is an ethical way to ease the suffering of the dying patient. More research, including qualitative and interventional studies, is needed to investigate this subject.