University Of Central OklahomaDepartment Of Nursing Essay

, Research Paper

Nurse? s Attitudes TowardDo Not Resuscitate Orders

In Partial Fulfillment of the Requirementsfor Nursing 4522Nursing Research II

Presented toAllen Nottingham, R.N. , B.S.

ByMeggin BeanJessica BrownellShannon GenzerLeslie LoomanShanna McIntosh

April 20, 1998


I. INTRODUCTION? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 1 Background? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 1 Theoretical Framework? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? . 4 Problem Statement? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 5 Statement of Purpose? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ..5 Research Question? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ..6 Theoretical Definitions? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? .. 6 Operational Definitions? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ..7

II. REVIEW OF LITERATURE? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 9 Introductory Statement? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 9 Conceptual Framework? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ..101. Pre-Conventional Degree? ? ? ? ? ? ? ? ? ? ? ? ? 112. Conventional Degree? ? ? ? ? ? ? ? ? ? ? ? ? ? .. 173. Post-Conventional Degree? ? ? ? ? ? ? ? ? ? ? ? .. 21 Summary? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? .24

III. METHODOLOGY? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? .. 26 Introductory Statement? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? .. 26 Research Puting? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? . 27 Subjects? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? .. 27 Procedure? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 28 Instrumentality? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? .. 29 Assumptions related to Methodology? ? ? ? ? ? ? ? ? ? ? ? . 31

IV. Reference? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? . 32

V. APPENDICES? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? . 36 Appendix A? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 36 Appendix B? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 41 Appendix C? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 42 Appendix D? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 43 Appendix E? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 45

Chapter I


Background Many influences such as cultural background, values, ethical motives, and beliefs bring great force to bear upon about every determination a individual must do throughout an mean twenty-four hours whether it be a pick, thought, or action. These influences are used in the formation of attitudes about one? s ego in general, and approximately right or incorrect. All people have these childhood influences to recognition for our attitudes, picks, thoughts, and even beliefs that are held beloved. Attitudes developed during childhood and throughout life play a cardinal function in the manner people interact with one another, grip crises, or even cover with daily jobs that occur in their lives. These beliefs are cardinal to every human whether they be carpenter, politician, or registered nurse. So intermeshed in our day-to-day lives are these values, that really frequently their function in the determination procedure goes unnoticed. In fact, one can populate their full life and ne’er have consciousness as to what triggers certain emotions, feelings toward the other sex, or even what drives the way of idea. Yet, they are passed on to every coevals frequently blindly, with every gesture, every arched supercilium, and every faery narrative. The consciousness of their presence is secondary to the demand to hold them. They are the yarn that stitches communities together, brings people to a common land, and gives many a intent for life. Attitudes about decease and deceasing are derived from a womb-to-tomb procedure of sing life and the beliefs about decease that one accepts as their ain. In many civilizations beliefs and issues environing decease are the 1s held dearest and closest to oneself. Many, if non all, civilizations accept that decease is but another measure in the procedure of life. However, differences in how one may take to welcome or evade decease are varied and many. How one chooses to confront decease, what instrumentality, and even where to decease ( when 1 has the pick ) are all affairs of personal penchant. Use of Do Not Resuscitate ( DNR ) orders or thorough steps are besides affairs of penchant ( when there is a life will and these determinations are made in front of clip ) , and these penchants affect many lives runing from friend to caregiver. As a health professional, the nurse must cover with decease and those that are deceasing on an about day-to-day footing. As a nurse, one must be cognizant of his or her ain personal feelings and beliefs sing decease and be prepared to esteem the wants of the patient sing this issue. More frequently, the nurse will be the really individual to transport out a DNR order. This means that the nurse may hold to stand and watch or take the manus of a patient while he or she dies. The determination that a nurse will do will be based on attitudes toward decease and death, every bit good as the very impression of the DNR order. Some nurses may comprehend a DNR order as an easy manner out of expensive medical measures and a direct manus in the decease of the patient, while others may see it as a merciful terminal to a painful and anguished being. When confronted with the legality of DNR orders and the humanity of caring and desiring to continue life, the nurse is frequently confronted with a quandary. The nurse? s determination can be one that can impact her calling every bit good as the wants of the patient. Whatever the nurse? s feelings are, they must be addressed in order to better function the patient and to guarantee that the patient? s rights and best involvements are at the centre of the concern. By turn toing the nurse? s issues with DNR orders or merely decease itself, the patient benefits from the cognition that the nurse has an apprehension of why he or she may experience a certain manner about a peculiar subject. Understanding of where our values, beliefs, and perceptual experience originate can merely function to, assist us go stronger, more compassionate, and wiser.Researchers of this survey believe that consequences will lend to the already huge organic structure of nursing cognition by presenting an article that when read, may help the readers to look within oneself and find what beliefs, or deficiency of, are regulating their actions. In turn toing this issue, the research workers feel that a nurse will derive valuable penetration which may assist him or her to better header with the issues environing a patient that is near decease and has a DNR order attached to his or her chart. The research workers will besides present information on the procedure whereby formation of these attitudes or beliefs occurs and in making so will supply beginning from whence alterations and or apprehension of what we believe can be achieved. Furthermore, the research workers believe that the extent to which these findings can be generalized are non merely limited merely to certain floors or sections within a infirmary scene but, are available to everyone with the desire to understand what makes them care about certain issues. Still, these findings can be utile in countries of oncology, paediatricss, gerontologies, and or any country where DNR orders are in topographic point. Besides, these findings can be utile in alleviative, every bit good as healing scenes, within the place wellness community, and the retirement community. In general, the research workers hope that this information which may help anyone in their hunt for apprehension of who and what they are, will besides function as a tool to impact a alteration in how those that read this survey handle one another every bit good as what one says and does.

Theoretical FrameworkKohlberg? s Theory of Moral Development will be used as a conceptual model for this survey ( Wong, 1995 ) . Kohlberg? s theory consist of three degrees. Within each degree are two distinguishable phases of moral development. Within degree one, the Pre-moral degree, are the phases one and two which province that a individual obeys regulations to forestall penalty or to convey about wages severally. Within Kohlberg? s degree one is Piaget? s phase one of moral logical thinking called Moral Realism from which attitude formation, and attitudes about decease and deceasing are formulated ( Coffey & A ; March, 1983 ) .The 2nd Kohlberg degree is known as the Pre-Conventional degree. Within this degree are phases three and four. Stage three addresses the method whereby persons pursue the blessing of others by portraying themselves as good. Stage four provinces that people have regard for authorization and societal order and that people are oriented toward responsibility and regard for authorization. Besides within this degree is Piaget? s 2nd phase of moral logical thinking called Morality of Cooperation which deals with the manner cooperation is achieved in moral development and its deductions on developing ethical motives and attitudes.The last degree of Kohlberg? s theoretical account is the Post-Conventional degree. Within this degree are the 5th and 6th phases. Stage five references that people are receptive to obeying democratically accepted Torahs and regulations of behaviour, while phase six implies that morality is single scruples. Within this subdivision surveies will be presented that province that nurses map at this degree of Kohlberg? s Theory of Moral Development. It is because of this degree that one can be in touch with the emotions and attitudes that are responsible for how people feel and act sing a specific topic. These actions and the attitudes behind them are the foundations for what makes something right or incorrect ( at least in the head of the individual or individuals involved ) . Kohlberg? s theoretical account will be used to explicate the actions of persons based on the degree of development antecedently stated by the many degrees of Kohlberg? s theoretical account. It has been stated that nurses map at the phase 6 degree that states morality is single scruples. With all the phases holding been laid out rather specifically, a research worker should be really capable of delegating a specific topic to a specific phase of development and besides be able to find with some grade of truth the attitudes held by that individual by the manner a set of inquiries are answered ( Kohlberg, 1969 ) .Problem StatementWhat factors, moral and ethical, influence nurses? attitudes and determinations sing patient attention of a client with DNR orders? Statement of PurposeThe research workers believe that independent variables such as patient demographics, every bit good as physiological facets runing from age and sex to sharp-sightedness and nature of disease will hold an affect on the dependant variable, the nurses? attitude on decease and deceasing. This survey will research the nurses? attitudes about decease and death every bit good as specific issues about DNR orders which may hold deep rooted beginnings and may be affected by assorted factors such as familial wants and cultural issues that are out of the control of the nurse. In this descriptive survey, the research workers will try to add to the huge organic structure of nursing cognition by researching the attitudes that nurses have toward decease and death every bit good as their attitude toward the DNR order itself. The research workers believe that by look intoing the beginnings of one? s values and beliefs the nurse will go a better nurse and a better individual.This penetration into oneself will let the nurse to present better patient attention and develop a sense of who they are and where they come from.Research QuestionWhat factors that affect nurses? attitudes toward decease, the death, and the DNR order can be discovered and identified in a descriptive survey by the usage of a topic specific questionnaire such as a DNR questionnaire? Definition of TermsTheoretical DefinitionsDNR Order: & # 8220 ; A note written in the patient record and signed by a qualified, normally senior or go toing physician, teaching the staff of the establishment non to try to revive a peculiar patient in the event of cardiac or respiratory failure. This direction is normally merely given when a individual is so soberly ill that decease is at hand and inevitable & # 8221 ; ( Mosby? s Medical & A ; Nursing Dictionary, 1996 ) .Attitude: & # 8220 ; State of head, behaviour, or behavior sing some affair, as indicating sentiment or aim & # 8221 ; ( Britannica World Language Dictionary, 1995 ) .Nurse: & # 8220 ; A individual educated and licensed in the pattern of nursing ; one who is concerned with & # 8220 ; the diagnosing and intervention of human responses to existent or possible wellness jobs & # 8221 ; ( American Nurses? Association ) . The pattern of the nurse includes informations aggregation, diagnosing, planning, intervention, and rating with work forces in model of the nurse? s remarkable concern with the individual? s response to the job instead than to the job itself. The concerns of the nurse or therefore broader and less distinct and circumscribed than the traditional concerns of medical specialty. In a concerted participatory relationship with the client or patient, the nurse Acts of the Apostless to advance, keep, or reconstruct the wellness of the individual ; health is the end. A collegial collaborative of relationship with other wellness professionals who portion a mission and a common information base furthers the pattern of nursing. Guided by a human-centered, ethical rules, the nurse patterns in a personal, nurturing, and protective mode that promotes wellness in all ways. The nurse may be a Renaissance man or a specializer and, as a professional, is ethnically and lawfully accountable for the nursing activities performed and for the actions of others to whom the nurse has delegated duty & # 8221 ; ( Mosby? s Medical & A ; Nursing Dictionary, 1996 ) .Questionnaire: A written or printed signifier consisting a series of inquiries submitted to a figure of individuals in order to obtain informations for a study or study & # 8221 ; ( Britanni

ca World Language Dictionary, 1995 ) .

Operational DefinitionsDNR order: An order made by a doctor ( of one of the three infirmaries involved in the UCO DNR survey ) after audience with household members which entails the deficiency of attempt to resuscitate a patient that has of course ceased to breath or has experienced cardiorespiratory arrest.Attitude: An interior personal feeling toward a certain topic, individual, or doctrine that could be positive or negative held by one or more nurses involved in the UCO descriptive DNR study.Nurse: A alumnus of a 1 ( Accredited Practical Nurse ) , two, or a four twelvemonth, accredited nursing plan, or a alumnus of a certification plan and licensed by any province to pattern as a nurse and presently employed at any one of three metropolitan infirmaries in the Southwestern United States which are presently helping with the UCO DNR research project.Questionnaire: The tool used to determine attitudes and get information about DNR orders from take parting nurses employed at one of the three Southwestern United States Hospitals involved in the UCO DNR survey.

Chapter II

Reappraisal of Literature

Introductory Statement

The Review of Literature has been organized into Kohlberg & # 8217 ; s Theory of Moral

Development. Kohlberg & # 8217 ; s theory was used in this survey because it straight addresses

moral development in kids and grownups, and focuses on the grounds an person

makes a determination ; instead than the existent morality of their determination. Kohlberg & # 8217 ; s Moral

Development Theory progresses through three degrees and six phases.

The first degree, the Pre-Moral or Pre-Conventional, consists of two

phases. Stage one involves penalty and obeisance orientation. Phase two involves

instrumental-relativist orientation in which action is taken to fulfill one & # 8217 ; s demands.

Incorporated into this degree is Piaget & # 8217 ; s present one of moral logical thinking, which consists of

Moral Realism and attitude formation ( Coffey and March, 1983 ) . At this degree, nurses

attitudes begin to explicate in relation to deep frozen beginnings of beliefs and values.

Furthermore, these beliefs and values frequently influence nurses attitudes towards Do- non –

resuscitate ( DNR ) orders.

The 2nd degree, The Conventional Level, includes phases three and four.

Stage three involves interpersonal harmony, which focuses on persons adhering to

a good boy/nice miss morality. Stage four affecting jurisprudence and order orientation provinces that

right behaviour is obeying the jurisprudence and following the regulations. This degree includes Piaget & # 8217 ; s

2nd phase of moral logical thinking called Morality of Cooperation. As antecedently stated

nurses formulate attitudes, nevertheless at this flat ethical consideration takes precedency

over the DNR order.

The last degree of Kohlberg & # 8217 ; s theory is called The Post-Conventional, Autonomous,

or Principled Level. This degree consists of phases five and six. Stage five involves societal

contract and legalistic orientation, and focuses on adhering to Torahs

that protect the public assistance and rights of others. Stage six involves universal/ethical

rules. This focuses on the fact that cosmopolitan moral rules are internalized.

Nurses are frequently confronted with ethical quandaries due to resistances between their ain

scruples of what is right and incorrect and ethical considerations.

In retrospect, our Review of Literature has focused on Kohlberg & # 8217 ; s Theory of

Moral Development which may be the footing for a nurses moral logical thinking.

Conceptual Model

Moral development is a uninterrupted procedure in which a individual learns to

consciously accept right and incorrect, harmonizing to their ain beliefs and values.

An person learns throughout childhood a sense of what is right and what is incorrect.

Through this, a sense of morality is formed by their behaviour as & # 8220 ; good & # 8221 ; or & # 8220 ; bad & # 8221 ; . This is

established through wagess and penalties.

An single must understand how morality is formed throughout

childhood ( Kozier & A ; Erb, 1995 ) . A kid? s moral development is extremely influenced by

the parent or defender. A kid is rewarded for what a parent or guardian considers good

behaviour and punished for what a parent or guardian considers a bad or negative

behaviour. Therefore, a kid & # 8217 ; s belief of what is right or incorrect is developed by their

parent & # 8217 ; s disciplinary actions.

PRE- CONVENTIONAL LEVEL. Kohlberg developed a construction to organize a

theory of moral development. Moral development is a complex procedure, which involves

larning what ought to be and what ought non to be done ( Kozier and Erb, 1995 ) .

Harmonizing to Kohlberg, moral development progresses through each phase of each degree.

Degrees and phases are non ever linked to a peculiar developmental phase, because

some individuals progress to a higher degree of moral development that others ( Kozier & A ;

Erb, 1995 ) .

The first phase of the Pre-conventional degree is the Right of actual obeisance to

regulations and authorization, avoiding penalty, and non making physical injury ( Kohlberg,1927 ) .

This phase takes an egoistic point of position. A individual at this phase does non acknowledge

the involvements of others. They do non associate two points of position. Alternatively, they value their

ain beliefs. Actions are judged in footings of physical effects instead than in footings

of psychological involvements of others ( Kohlberg, 1927 ) . For case, a nurse follows a

physician & # 8217 ; s orders so as non to be fired, although many nurses may hold

conflicting beliefs it is their responsibility to transport out DNR orders. Many legislative acts provide

unsusceptibility to wellness attention suppliers who do. Failing to honour an DNR order could take to

a battery suit by the patient or his household, and disciplinary action by the Board of

Nursing ( Sloan, 1996 ) . Persons map in order to avoid penalty. Rules are

sacred and unchangeable, and those who violate regulations must be punished harmonizing to the

magnitude of their discourtesies ( Shultz, 1997 ) .

Health attention as a profession involves far more ethical rules than possibly any

other profession. Nurses, every bit good as other wellness attention professionals with a principle-

centered life and pattern, create an internal construction that will assist them systematically

run into ethical duties to themselves, patients, households, and communities. Developing

a cardinal set of Principles, encourages nurses to use the same set of moralss to

themselves every bit good as to their patient ( Moss, 1995 ) .

Jezewski ( 1994 ) conducted a survey to depict the struggle that occurs during the

procedure of accepting to do-not-resuscitate position and the schemes used by critical

attention nurses to try and forestall, minimise, and/or decide these struggles. His survey

consisted of a grounded theory design. Twenty-two critical attention nurses practising in

upstate New York in urban and rural, net income and non-profit-making infirmaries were involved in the

survey. Of the 22 participants, 21 were female and 1 was a male. The age scope was 26-53

old ages old, with a mean of 34 ( + or & # 8211 ; 6 old ages ) . Old ages in pattern ranged from 4-31 old ages.

Semi-structured, in-depth interviews were used to roll up informations. The interview agenda

consisted of open-ended inquiries and were formulated to arouse nurses & # 8217 ; experiences in

the context of interacting with patients and household members during the procedure of their

make up one’s minding whether to accept to a DNR position. The information was analyzed with the uninterrupted

comparative method of grounded theory. The consequences show that struggle occurred during

the procedure of accepting to DNR position. Two major classs of struggle were

intrapersonal ( interior struggle in coming to footings with DNR-status determination ) and

interpersonal ( struggle that took topographic point between persons involved in accepting to a

DNR position ) . Intrapersonal struggle, for the nurses occurred while finding the

rightness of DNR order for their patients and coming to footings with the significance

of DNR position. Nurses had to come to footings that a DNR order was appropriate or

inappropriate for the patient. To make this, the nurse assessed the patient & # 8217 ; s physical position

in concurrence with quality of life issues, conferred with other wellness attention professionals,

and talked with the patient and/or household. It was of import for the nurses to personally

decide any struggle about the rightness before they could optimally help patients

and households with the determination to accept to DNR position. Interpersonal struggle occurred

between household members, patients, and staff. Nurses descriptions of their function were

reflective of a civilization agent model integrating protagonism, dialogue, speculation,

and sensitiveness to patient? s and household? s demands. They would speak with household members to

seek to understand their feelings about accepting to a DNR position. The nurses

emphasized the importance of leting clip for household members to come to footings with

the patient & # 8217 ; s position and the significance of DNR for themselves separately and as a group

( Jezewski, 1994 ) .

Attitudes, values, and moralss set the phase for managed attention nursing ( Salladay,

1997 ) . Ajzen and Fishbein ( 1980 ) theorized that human existences base their actions on

rational, systematic usage of information ; individuals consider the deductions of their actions

before they decide to prosecute in a given behaviour. Attitudes are defined as the individuals

rating of the positive or negative effects of the results of specific behaviours or

actions taken. Whereas, Behavioral purpose is the reported grade of likeliness that the

nurse will execute a certain action ( Ajzen & A ; Fishbein, 1980 ) .

Nurses must make up one’s mind what their ain moral actions ought to be in a state of affairs

refering a DNR order. Because of the particular nature of the nurse-client relationship,

they must back up and prolong clients and households who are confronting hard moral

determinations. On the other manus, nurses must besides back up clients and households who are

populating out the determinations made for and about them by others, or themselves. Nurses can

do better moral determinations and have a positive attitude to any given state of affairs by

believing in progress about their beliefs and values ( Moss, 1995 ) .

Schaefer and Tittle ( 1994 ) conducted a survey to research the attitudes and

perceptual experiences of registered nurses ( RNs ) and doctors ( MDs ) sing the attention of

patients with do-not-resuscitate ( DNR ) orders in the intensive attention units ( ICU ) .

Structured interviews were conducted with 20 RNs and MDs from the ICUs of

25 Veterans Administration Hospitals. The questionnaire included four

conjectural instances which tested a statement as to who would outdo support the liberty

of the patient in doing a DNR determination: ( a ) when the patient is unqualified, ( B ) when

the patient is non competent and a close relationship exists with the household, ( degree Celsius ) when the

patient is non competent, has no close relationship with household but a curative

relationship exists between the doctor and the patient, and ( vitamin D ) when the patient is non

competent, has no close relationship with the household but a curative relationship exists

between the nurse and the patient. A sum of 226 ( 45.2 % ) questionnaires were received ;

160 ( 70.8 % ) from the RNs and 66 ( 29.2 % ) from MDs. The average age of RNs was 38.4

with a scope of 22-58. The average age of the MDs was 42.4 with a scope of 27-76. The

RNs and MDs did non hold who would outdo support patient liberty in any of the four

instances ( P

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