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International Scholarly Research Network

ISRN Nursing
Volume 2012, Article ID 591541, 8 pages
doi:10.5402/2012/591541

Research Article
Evaluation of Nurses’ Perceptions on Providing Patient
Decision Support with Cardiopulmonary Resuscitation

Nicole Pyl and Prudy Menard
The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6

Correspondence should be addressed to Prudy Menard, prmenard@toh.on.ca

Received 12 September 2012; Accepted 5 October 2012

Academic Editors: R. Constantino, A. Green, R. C. Locsin, V. Lohne, and M. Miyashita

Copyright © 2012 N. Pyl and P. Menard. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

The decision whether to receive cardiopulmonary resuscitation (CPR) is a decision in which the personal values of the patient must
be considered along with information about the risks and benefits of the treatment. A decision aid can be used to provide patient
decision support to a patient who is seriously ill and needs to consider CPR options. The goal of this project was to identify the
barriers and facilitators to using a CPR decision aid, through evaluating nursing perceptions on providing patient decision support.
Using a needs assessment, it was determined that implementing a patient decision aid for CPR status in the Acute Monitor Area
(AMA) of The Ottawa Hospital would be an excellent quality improvement project. The nurses who chose to participate were given
an education session regarding patient decision support. Questionnaires were distributed to evaluate their views of patient decision
support and decision aids before and after the education session and implementation of the CPR decision aid. Questionnaire results
did not indicate a significant change between before or after education session and decision aid implementation. Qualitative reports
did indicate that nurses generally have positive attitudes toward patient decision support and decision aids. The nurses identified
specific barriers and facilitators in their commentaries. This clinically relevant data supports the idea that patient decision support
should be integrated into daily nursing practice.

1. Introduction CPR status is one of the most important health decisions
and requires careful consideration of all alternatives and
Improving informed decision making is essential for sup- the consequences. For seriously ill patients, CPR preferences
portive end of life care [1–5]. Cardiopulmonary resuscitation are commonly set aside and communication between the
(CPR) preferences are the most common end of life dis- patient, family, and health care team is lacking information
cussion but occur infrequently and vary in content [1, 2]. and followup [2]. Nursing influencing factors using patient
Patients may not have the basic information needed and the decision support for CPR status needs to be evaluated.
timing for the discussion may be inappropriate [6–8]. Patient
decision support focuses on providing the patient and fami- 2. Methods
lies with practical information and resources.
CPR preferences may also be overlooked or set aside by 2.1. Setting. This project took place at The Ottawa Hospital,
practitioners because it is a value-sensitive decision or Acute Monitor Area (AMA) Unit. This six-bed unit spe-
because it is not identified as a high priority discussion [1, 3, cializes in acute care, managing patients with a variety of
6, 9]. Value-sensitive decisions would benefit from a patient complex medical conditions such as chronic obstructive pul-
decision aid, where the patient is recognized as an expert monary disease, congestive heart failure, pneumonia, and
in judging his/her own values [10–13]. Patients who need multisystem failure disorders.
to address CPR status would benefit from health care pro-
fessionals comfortable and familiar with providing patient 2.2. Goal. The goal of this project was to implement a pub-
decision support. lically available patient decision aid for CPR status and

3–5. social psychology the discussion can appraise differently. Decisional Conflict. Facilitation of nurse involvement in improving communication and decision making needs to be end of life care is essential for comprehensive care. CPR theoretical underpinnings of the ODSF include decision the- in particular is a sensitive subject in which all involved in ories in economics [28]. understandable explana. Improving informed decision making is essential diopulmonary resuscitation preferences. CINAHL. It patients have poor knowledge about what CPR entails and uses a three-step process to “assess client and practitioner their role in the decision making process regarding their CPR determinants of decisions to identify decision support needs. and the Cochrane Data- base of Systematic Reviews. The objectives were to identify nursing perceptions cated about their treatments and have an autonomous role regarding patient decision support before and after using a in their care [5. Participants in any decision may not have all provide decision support tailored to client needs.2 ISRN Nursing to identify any factors which limit or encourage its use making in health care is important. psychology [29]. Decisional conflict means that there nursing specific patient decision support. Reliable information shared decision making has not been embraced by all health regarding the patient’s condition. decisional conflict [31]. and addressing patients psychosocial the use of patient decision aids [23]. skill building educational intervention. and the interprofessional team facilitates implemen- tation of patient’s wishes regarding end of life treatment. clarify any barriers and knowing options and being able to provide that information facilitators influencing the provision of a patient decision aid to patients [16. 3. 16]. When one needs to con- 3. 24. There is a stress on the importance of patient decision aid regarding CPR. 15]. They help people in making difficult decisions that are con- leagues [3] through the Canadian Health Care Evaluation sistent with their personal values [12. Patient decision tered Nurses’ Association of Ontario (RNAO). It has been identified by Heyland and col. However. [1. This concrete. 33]. CPR Status. can arise.7. 18]. for supportive end of life care where the patient’s goals of ment.” “decision making. She has become a leader part of the main assumption [10. 18.2.1. is uncertainty about which course of action to take [10. generate realis- Nurses of Ontario (CNO). Nurses have a unique relationship with regarding CPR. and determine whether nursing perceptions patients.4. 26].3. Informed decision practitioner characteristics influence the decision making . Literature Review are likely to experience uncertainty to some degree when a decision is difficult to weigh [19]. PsycINFO. status [6. It has been determined that seriously ill through a practical and structured approach [10. professionals and barriers have been identified which limit tions for their situation. Notable articles were screened by 3.6. perceptions with the use of a CPR patient decision aid can tice guideline. thus reducing uncertainty “patient decision aids” in PubMed. Patients want to be edu- [14]. The Ottawa Decision Support It is evidenced that a comprehensive and consistent way Framework ODSF (1998) developed by Annette O’Connor to address CPR status for seriously ill patients should be and colleagues guided this project. and decision support. An evaluation of nurses’ feelings were also rated as high priorities [3]. Conceptual Framework. The the timing of the discussion may be inappropriate [6. theory-based. 8]. Guiding Decisions about End-of-Life Care clarify issues with its use and can lead to sustainable utili- [1] indicates that clear communication between the patient. they can provide valuable support when they are of patient decision support can be positively influenced with faced with difficult decisions.” “end of life treat. 3. decision quality.” “patient decision support. 20].” and care are clear and communicated. They are “tools that help people literature searches were also conducted through the Regis. It can guide gaining decision support skills 3. 25]. to all the necessary resources to realize their choice through port has increased a great deal since O’Connor and colleagues clear information when the issues are discussed is also a published their work in 1998 [10]. Value sensitive issues are better addressed using a The main assumption of the ODSF is that patients will complete and understandable approach. Patient Decision Aids. theory focuses on decisional needs. and social support [32. and eval- the necessary information to make an informed choice and uate the decision making process and outcomes” [27]. or a challenge to their personal values conflict identify scholarly English publications pertaining to “car. evidence-based tools that can include outcome statistics and patient experiences for a variety of disease specific issues. team [9]. a brief. 17]. become involved in decision making” [18]. Proquest Nursing and Allied Health.5. Patient decision aids are a part of reviewing their reference lists for relevant publications. This pilot project has focused on the efficacy of providing 3. likely select the choice that they believe is their best alterna- tive which aligns with their personal values [10. addressed in many Canadian hospitals. Grey providing decision support. College of aids reduce uncertainty. CANHELP. even the health care [30]. Nurse Involvement.8. loss. nurse. Access 3. improve knowledge. 22]. and the Ottawa Hospital Research tic expectations. zation of the aid [13. 26]. Many issues contribute to decisional conflict and patients 3. Project (CANHELP) that better planning for end of life care including enhanced relationships with physicians and 3. 26]. Decision Making. A literature review was conducted to sider risk. and clarify personal values [21]. The CNO prac. midrange established and facilitated in the Canadian hospitals. The literature on patient decision sup. Personal (patient) and in the patient decision support realm. These are Institute (OHRI) websites. Search Strategy.

23. In theory. and (3) conducting a posttest. Taking approx- personal values and that are determined by the patient to imately 5–10 minutes. (2) educating the nurses on patient decision support and involved in the decision making process. The discussions lead to an intervention [18. facilitators and barriers to its use [13. and (5) a med. Logistics. and an overview of the CPR patient decision aid. plan. 23]. 26. Initially. Through the provision of deci- sion support using a CPR decision aid in combination with 4. and colleagues [38] found that most health care practitioners (4) guidance toward shared decision making. Consent was obtained from each participant and informa- mation for patient options include specific information on tion regarding the project was provided. Realistic expectations were discussed. values and resources [4. and identifying patients health condition. an understanding basic education session would be offered. but knowledge is a key [10]. choice of framework used.3. 26]. . the ODSF guided this project to address support for CPR preference using the patient decision aid unmet decisional needs or decisional conflict where uncer- based on clinical opportunities and appropriateness [17. Nurses were referred back to the ODST if more infor- rence with their decision because it is informed by their mation was needed. lemented concurrently.4. motion of the patient decision aid was accomplished by going gruent with this framework [1]. 35]. Pro- through clear communication and implementation are con. clarification of values associated with design involved three steps including (1) conducting a pre- each option. present the information [12. an advertisement of the Patient decision aids can guide tailored decision support educational intervention was posted. and skills on imp. the in small groups through part one of the Ottawa Decision patient completing this process as intended will lead to Support Tutorial. tainty regarding the best choice for CPR status was identified 37]. After Education Session. Decision aids clarify values status is not addressed in a timely manner. quality of life. Nurses were advised that if a CPR decision aid was initiated and/or completed they were to write in the inter- 4. are willing to use patient decision aids. and adhe- [14]. Basic knowledge regarding patient decision support is in seriously ill patients. and the decision support aid overall satisfaction with their choice. Patient decision support includes providing information and coaching to improve knowledge 4. They are not general guides for patients and they are not prescriptive in nature [35]. it was decided that only a brief and During the evaluation stage of the ODSF. Two posters were also strate- objectives and thus are a straightforward justification for the gically placed on the unit. there were other quality improvement initiatives being imp- mentation and monitoring of the decision occur [4. Each Ottawa Hospital form for code status was decision coaching and counselling. Ethical approval for this project was municated to other team members in the patient’s daily care obtained from The Ottawa Hospital Research Ethics Board. Quality decisions are informed by the best available evidence and are based on the values of the patient [22. 37]. nurses were guided individually or be the best alternative. Specifically. Education Intervention. 4. 10]. The intervention benefits and harms. and decision aids [10]. It was identified during discussions and abilities. The criteria involved in the to the AMA unit frequently to check on uptake and being ODSF are appropriate to the established project goal and available to answer questions. It was repeatedly and address unmet decisional needs or conflict by asking suggested that an improvement needs to be made to individuals to identify personal importance of issues and address the patient’s information and communication needs evaluate each risk and benefit that influences their decision regarding CPR status. the nurses were requested to provide patient decision Specifically. with nurses who work in the AMA and their nurse edu- Patient decision support is provided through counselling. 10]. support and With background knowledge of patient decision support. Due to time constraints and that resolved and a quality decision is reached. 34]. ways to manage the views or pressures of others test. what patient decision support is. 34]. needed to work effectively with patient decision aids [13.2.5. 34]. its use.1. the framework was used affixed with the CPR decision aid to prompt each nurse to to address decisional needs and uncertainty. given that adequate ium such as a paper tool or interactive computer guide to education and support are provided. the resources were appraised. 22].ISRN Nursing 3 process as well. 4. Graham (3) examples from other patients in similar circumstances. Providing infor. patient decision aids need to include focused on influencing nursing knowledge of patient deci- the following elements: (1) information tailored to the sion support. Intervention professional progress notes in the patient’s medical record of this. the CPR decision aid. who work in the AMA unit were approached to participate Decision support is provided until decisional conflict is in the education session. 26. Then aiding imple. cator (the project advisor) that frequently a patient’s CPR coaching. evidenced-based information was reviewed. uptake of a CPR decision aid. ODST [27]. acting as a reminder. lementing decisions [26]. It was also asked that this information should be com- 4. After having received the edu- cation. Ethics Approval. are the result [10. Need Assessment. The education of the quality of decision making and outcomes is established session consisted of an introduction to why the project was [27. 36. All registered nurses which focuses on patient’s needs. and patient values were considered participants needed to identify using their clinical judgment [5. Informed decisions. (2) a value clarification exercise. ones that are consistent with being implemented. Appraising and articulating a patient’s CPR wishes if a patient would benefit from the CPR decision aid.

81% worked in the AMA since inception (3 years). Evaluation 6. Questionnaire Results. Before and after intervention are trained to work in the AMA. port. The following points were recognized in the question- naires were given after six weeks of the first education session.8 years. Questionnaires were given to all AMA (v) support for when patient is not able to make their nurses who signed consent and agreed to participate in the own decision (family involved). Sixteen agreed to par- health care professionals’ perceptions of patient decision ticipate in the after intervention questionnaire (n = 16/21). agree or strongly agree that using a patient decision aid 43]. Procedures. For this project. such as “What do you think of patient decision support?” and “What has been your experience with patient decision (iii) supported by the literature. The following points were recogni- notable results. The results were negatively skewed when asked if they tion. years. Qualitative Evaluations. The aver- the number of questions was reduced due to the project scope age amount of nursing experience was 11. cultural difference. field notes were routinely collected in a designated journal. The questionnaires also have a section to generate 6. Descriptive statistic methods were used to analyze for all. Both qualitative and quantitative measures were 6. To participate in the after intervention questionnaire you must have received the 5. The questionnaires were reviewed and revised with the would be beneficial to the patient and that more education project advisor prior to use. naire and field notes results for barriers/limitations to patient All nurses had an average of five weeks or more to use the decision support and aids: patient decision aid.2. The postquestionnaire was con. Qualitative observations Participant characteristics were similar in comparison to the and field notes were also routinely used for data collection nonparticipant group. felt confident in providing patient decision support. 41]. Participant Statistics.8 by Stacey and colleagues [13] to determine factors influenc. The age range of participants was tionnaires developed were influenced by a study conducted 25–52 years and the average age of participants was 37. The ques. support and decision aids [12. 2 declined to participate and 21 agreed to lection. Qualitative reports were used to gather data on the impacts (i) a team understanding of the patient condition and on practice and participant’s views on the project which may status. questionnaire responses and content analysis was used in (ii) family conflict. their lack of understanding or mis- reviewing the qualitative reports [42]. The results indicate that most respondents differences in responses after the initiated intervention [42. and objectives and was modified to fit the clinical setting. not be captured with the questionnaires [39]. naire. better communication. Results and Discussion 5. project immediately before each education session. the ques.1. Most participants ing decision support by call center nurses. how strongly they agree or disagree with certain statements.2. Then the education session was given. Participants were asked to rate nurses’ views using an open-ended question format [40. Before and after Intervention Questionnaires. education session and took the before intervention question- tionnaires were designed to be clear and concise using a five. Table 2 identifies the results from the after intervention question- naire. All participants who agreed to complete the post questionnaire were entered into a draw for two gift (i) language barriers. age was 37. and the average amount of nursing experience was 11. Open-ended (ii) a standardized way to present information and a questions were directed to the AMA nurses as appropriate. conceptions.3. Not all nurses who initially agreed to take part in the The questionnaire’s design reflects the current literature on project continued their participation.3 years. 19% were male. 23]. point Likert scale to encourage the participation in attaining data [40]. Design.4 ISRN Nursing 5. These observations were analyzed for recurring themes and 6. should be directed toward nurses to provide decision sup- ducted after six weeks of patient decision aid implementa. Consequently. questionnaire (n = 21). maternity leave. Qualitative observations and agree that decision aids for CPR was/is useful. Most nurses responded that they agree or strongly 5. evidenced-based infor- mation. average [39]. There are currently 26 nurses who used to collect information. support?” (iv) clear understanding of what CPR is and the risks/ benefits. 16% of the participants were male. 5. knowledge tool for nurses. Age range was 27–52 years. not appropriate baskets. Questionnaires were used because of their ability to Table 1 identifies the results from the before intervention gather data easily and for their capacity to examine notable questionnaire. .1. and were benefits to patient decision support and aids: grouped after each batch of questionnaires was received.4. 3 were on questionnaires were the primary means of information col.3.8 years. Of those nurses. Qualitative Results. There were no pretested measurement tools found take part in the educational session and before intervention that fit the objectives of this project. Specifically responses were grouped into zed in the questionnaire and field note results for facilitators/ one of two categories. The after intervention question. facilitators or barriers.

Strongly disagree Disagree Neutral Agree Strongly agree Statements n = 16 (%) n = 16 (%) n = 16 (%) n = 16 (%) n = 16 (%) Most patients prefer to make decisions on their own — 4 (25%) 2 (13%) 8 (50%) 2 (13%) Most patients prefer to make decisions withothers — — 2 (13%) 7 (44%) 7 (44%) Most patients prefer to make decisions after considering their — — 1 (6%) 13 (81%) 2 (13%) health care team’s opinions Patient decision support will increase patient involvement in — — 2 (13%) 8 (50%) 6 (38%) making health decisions Nurses validate patient’s values when providing patient decision — — 3 (19%) 12 (75%) 1 (6%) support Patients should be referred to a specialized nurse educated in — — 5 (31%) 10 (63%) 1 (6%) decision support Nurses generally feel confident about providing patient decision — 2 (13%) 8 (50%) 6 (38%) — support The patient decision aid is a good resource (e. Many nurses commented that they had limited opportu- nities to use the patient decision aid for CPR. (v) patient decision aid was too condition specific. I feel that patient decision support/aids for CPR status is — — 3 (19%) 10 (63%) 3 (19%) useful (iii) available time to discuss with patient and family.ISRN Nursing 5 Table 1: Before CPR patient decision aid questionnaire results.. A few nurses stated that CPR status should be determined on admission (vi) patients/families not accepting nursing support on to hospital and be completed routinely for all patients.g. sional conflict and validating patients’ values. some nurses commented on identifying deci- rigid. this (not their role). Strongly disagree Disagree Neutral Agree Strongly agree Statements n = 16 (%) n = 16 (%) n = 16 (%) n = 16 (%) n = 16 (%) Most patients prefer to make decisions on their own — 6 (29%) 1 (5%) 12 (57%) 2 (9%) Most patients prefer to make decisions withothers — — — 20 (95%) 1 (5%) Most patients prefer to make decisions after considering their health — — 4 (19%) 15 (71%) 2 (9%) care team’s opinions Patient decision support will increase patient involvement in — — 3 (14%) 15 (71%) 3 (14%) making health decisions Nurses generally feel confident about providing patient decision 1 (5%) 4 (19%) 8 (38%) 8 (38%) — support Nurses understand patient decision support concepts — — 4 (19%) 16 (76%) 1 (5%) Nurses need to increase their knowledge of decision support — 1 (5%) 1 (5%) 14 (67%) 5 (24%) Nurses need to enhance their ability to provide patient decision — — 2 (9%) 16 (76%) 3 (14%) support There should be more education on patient decision support/aids — — — 16 (76%) 5 (24%) I feel more education on patient decision support/aid would benefit — — — 16 (76%) 5 (24%) the patient Table 2: After CPR patient decision aid questionnaire results. easy to — — 2 (13%) 13 (81%) 1 (6%) understand. There were varied views regarding evaluating CPR status . that they used patient decision support for other issues. but did identify (iv) patient not emotionally ready for discussions. or nonbiased) The decision aid was easily applied to the clinical setting — 1 (6%) 7 (44%) 8 (50%) — There was clear direction in providing patient decision support to — 1 (6%) 6 (38%) 9 (56%) — patients with the CPR decision aid Nurses prefer to have a clear step-by-step approach when — 2 (13%) 3 (19%) 10 (63%) 1 (6%) supporting patients on deciding CPR status The decision aid made it easier for nurses to identify patients — — 4 (25%) 12 (75%) — having difficulty in making a CPR choice Overall. too Specifically.

B. Most nurses agreed with supported decisions through the provision of patient deci- the components of a shared decision making model.” International Journal of aid. too patient specific to use a patient decision to find a balance at the end of life. Over time challenging 6. 38]. Strategically educating patient decision support. J. emotional adversity. This project may have been better received [3] D. and M. but it is not Adults Living with Chronic Kidney Disease. Myers. improvement interventions. Implications for Practice. Since nurses work support they do so because they believe that they are helping in close proximity with the patient and their families and the patient toward a better realization of their condition.cno. pp. and some of those factors within the Acute Monitor Area at The the ability to include family in the decision making process. pp. Time was also a limiting factor.5. A. improve patients’ knowledge of options and the provision [5] Registered Nurses Association of Ontario. but shared-decision making model [23. “Determining resuscitation preferences of elderly denced by their body language and facial expressions. Acknowledgment 6. Addressing unclear values.” Canadian Medical Association Journal. no. Findings versus Literature. and at the fact that they were approached to participate as evi. not from a validated tool. Chen. Some said it nurse. Toronto. Barriers and Facilitators. Nursing perceptions need to focus on positive implications. E747–E752. Others thought that this was completely within should reflect a therapeutic relationship between the patient the nursing realm and were eager to support patients with and nurse toward helping the patient make informed and making an informed CPR choice.org/Global/docs/prac/43001 the opportunity for its use did not come readily. Heyland. Specific barriers to providing traditional health care roles will allow nurses to support the patient decision support were identified as cultural or lan. This could be a spotlight for future quality difficult situations. Iwaasa. 44]. sion support. The information collected was helpful in this specific clinical setting but cannot be generalized to References others. There were only six [1] College of Nurses of Ontario. 8. This project identified enhancement. clear and understandable knowledge base. 2010.7. . The spend much time involved in their care. patient effectively through the provision of patient decision guage influences. Some nurses stated that they did not are designed to be evidenced based and patient focused and see this as a part of their role or something that they wish to are intended to be used as a guide [12]. and should be addressed for every patient. 270–277. M. and physician preference for this role. a practice change were consistent with the literature [13. This inpatients: a review of the literature. A. Murray. 2004. Further educa- it was observed with qualitative observations that the nurses tion on when to implement a patient decision aid for values felt more knowledgeable and confident with providing sensitive topics would be appropriate. information needs. thus obvious sources of bias were present. 23. 2009. K. Patient decision aids it should be discussed. 6. After reviewing the data col- lected it was evident that most nurses were willing to use 7. Specific facilitators identified included communication tually disclose the benefits of its use. 2003.. pp. Data were collected from self-report and The author thanks Dr. Frank. rigid application. time constraints. certain nurses on patient decision support may create an effective role for its implementation. G. 795–799. vol. Fiset. no. Heyland. Cook. beyond what normally would be encountered by a practicing 2009. K. Farquhar. Dedication and commitment to supporting There is a limited amount of literature that describes patient patient decision support and the cardiopulmonary resuscita- decision support facilitators and even less focus on family tion decision aid will help to support patients facing these involvement [23]. CPR status specifically can be appraised by a nurse to be a Jacobsen. vol. sion support and enhancing the facilitating factors will even- 36]. D. CPR status is value-sensitive topic. Conclusion the patient decision aid because they see it as helping the patient make informed. “Decision support: helping patients and families difficult topic.6. Decision Support for of support.” Canadian Medical Asso- intervention was not the only quality improvement project ciation Journal. resources effectively will reduce nursing contributing factors and some indicated that only when death may be imminent to clouding difficult decisions [5. 6. Miller. Canada. Challenging the barriers to implementing patient deci- These mirror what has been found in the literature [13. O’Connor. 16. When nurses towards supporting patients to be more educated and invol- feel they have the knowledge and skill to provide decision ved in their decision making is a priority. 11]. no. 6. patient’s support. http://www. despite health status. D. they are the most education session and patient decision aid intervention did appropriate professionals to discuss CPR preferences using a not seem to significantly influence questionnaire scores. value-based decisions. Guiding decisions about end of weeks where the patient decision aid was implemented and life care. vol. welcomed this intervention but some were obviously stressed [2] C. 23. 10.4. Rocker et al. being initiated. D. 182. priorities for improving end-of-life care in Canada.6 ISRN Nursing on admission versus at a time of health crisis. K.pdf. V. This project identified that [4] M. 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