University of Central Oklahoma Department of Nursing Nurses Attitudes Toward Do Not Resuscitate Orders In Partial Fulfillment of the Requirements for Nursing 4522 Nursing Research II Presented to Allen Nottingham, R.N., B.S. By Meggin Bean Jessica Brownell Shannon Genzer Leslie Looman Shanna McIntosh April 20, 1998 TABLE OF CONTENTS I. INTRODUCTION1 Background1 Theoretical Framework. 4 Problem Statement 5 Statement of Purpose.5 Research Question.6 Theoretical Definitions. 6 Operational Definitions.7 II. REVIEW OF LITERATURE9 Introductory Statement9 Conceptual Framework.10 1.
Pre-Conventional Level11 2. Conventional Level. 17 3. Post-Conventional Level. 21 Summary.24 III. METHODOLOGY. 26 Introductory Statement.
26 Research Setting. 27 Subjects. 27 Procedure 28 Instrumentation. 29 Assumptions related to Methodology. 31 IV.
REFERENCES. 32 V. APPENDICES. 36 Appendix A 36 Appendix B 41 Appendix C 42 Appendix D 43 Appendix E 45 CHAPTER I Introduction Background Many influences such as cultural background, values, morals, and beliefs bring great force to bear upon almost every decision a person must make throughout an average day whether it be a choice, idea , or action. These influences are used in the formation of attitudes about ones self in general, and about right or wrong. All people have these childhood influences to credit for our attitudes, choices, ideas, and even beliefs that are held dear.
Attitudes developed during childhood and throughout life play a key role in the way people interact with one another, handle crises, or even deal with day-to-day problems that occur in their lives. These beliefs are central to every human whether they be carpenter, politician, or registered nurse. So enmeshed in our daily lives are these values, that very often their role in the decision process goes unnoticed. In fact, one can live their entire life and never have awareness as to what triggers certain emotions, feelings toward the other sex, or even what drives the direction of thought. Yet, they are passed on to every generation often blindly, with every gesture, every arched eyebrow, and every fairy tale.
The awareness of their presence is secondary to the need to have them. They are the thread that stitches communities together, brings people to a common ground, and gives many a purpose for living. Attitudes about death and dying are derived from a lifelong process of experiencing life and the beliefs about death that one accepts as their own. In many cultures beliefs and issues surrounding death are the ones held dearest and closest to oneself. Many, if not all, cultures accept that death is but another step in the process of life. However, differences in how one may choose to welcome or elude death are varied and many. How one chooses to face death, what instrumentation, and even where to die (when one has the choice) are all matters of personal preference.
Use of Do Not Resuscitate (DNR) orders or exhaustive measures are also matters of preference ( when there is a living will and these decisions are made ahead of time), and these preferences affect many lives ranging from friend to caregiver. As a caregiver, the nurse must deal with death and those that are dying on an almost daily basis. As a nurse, one must be aware of his or her own personal feelings and beliefs regarding death and be prepared to respect the wishes of the patient regarding this issue. More often, the nurse will be the very person to carry out a DNR order. This means that the nurse may have to stand and watch or take the hand of a patient while he or she dies.
The decision that a nurse will make will be based on attitudes toward death and dying, as well as the very notion of the DNR order. Some nurses may perceive a DNR order as an easy way out of expensive medical bills and a direct hand in the death of the patient, while others may see it as a merciful end to a painful and tormented existence. When confronted with the legality of DNR orders and the humanity of caring and wanting to preserve life, the nurse is often confronted with a dilemma. The nurses decision can be one that can affect her career as well as the wishes of the patient. Whatever the nurses feelings are, they must be addressed in order to better serve the patient and to ensure that the patients rights and best interests are at the center of the concern. By addressing the nurses issues with DNR orders or just death itself, the patient benefits from the knowledge that the nurse has an understanding of why he or she may feel a certain way about a particular topic. Understanding of where our values, beliefs, and perception originate can only serve to, help us become stronger, more compassionate, and wiser.
Researchers of this study believe that results will contribute to the already vast body of nursing knowledge by delivering an article that when read, may aid the readers to look within oneself and determine what beliefs, or lack of, are governing their actions. In addressing this issue, the researchers feel that a nurse will gain valuable insight which may help him or her to better cope with the issues surrounding a patient that is near death and has a DNR order attached to his or her chart. The researchers will also present information on the process whereby formation of these attitudes or beliefs occurs and in doing so will provide source from whence changes and or understanding of what we believe can be achieved. Furthermore, the researchers believe that the extent to which these findings can be generalized are not just limited only to certain floors or departments within a hospital setting but, are available to everyone with the desire to understand what makes them care about certain issues. Still, these findings can be useful in areas of oncology, pediatrics, geriatrics, and or any area where DNR orders are in place. Also, these findings can be useful in palliative, as well as curative settings, within the home health community, and the retirement community.
In general, the researchers hope that this information which may aid anyone in their search for understanding of who and what they are, will also serve as a tool to affect a change in how those that read this study treat one another as well as what one says and does. Theoretical Framework Kohlbergs Theory of Moral Development will be used as a conceptual framework for this study (Wong, 1995). Kohlbergs theory consist of three levels. Within each level are two distinct stages of moral development. Within level one, the Pre-moral level, are the stages one and two which state that a person obeys rules to prevent punishment or to bring about reward respectively. Within Kohlbergs level one is Piagets stage one of moral reasoning called Moral Realism from which attitude formation, and attitudes about death and dying are formulated ( Coffey & March, 1983).
The second Kohlberg level is known as the Pre-Conventional level. Within this level are stages three and four . Stage three addresses the method whereby individuals pursue the approval of others by portraying themselves as good. Stage four states that people have respect for authority and social order and that people are oriented toward duty and respect for authority. Also within this level is Piagets second stage of moral reasoning called Morality of Cooperation which deals with the way cooperation is achieved in moral development and its implications on developing morals and attitudes.
The last level of Kohlbergs model is the Post-Conventional level. Within this level are the fifth and sixth stages. Stage five addresses that people are receptive to obeying democratically accepted laws and rules of behavior, while stage six implies that morality is individual conscience. Within this section studies will be presented that state that nurses function at this level of Kohlbergs Theory of Moral Development. It is because of this level that one can be in touch with the emotions and attitudes that are responsible for how people feel and act regarding a specific subject. These actions and the attitudes behind them are the foundations for what makes something right or wrong (at least in the mind of the person or persons involved). Kohlbergs model will be used to explain the actions of individuals based on the level of development previously stated by the many levels of Kohlbergs model. It has been stated that nurses function at the stage 6 level that states morality is individual conscience.
With all the stages having been laid out quite specifically, a researcher should be very capable of assigning a specific subject to a specific stage of development and also be able to determine with some degree of accuracy the attitudes held by that person by the way a set of questions are answered (Kohlberg, 1969). Problem Statement What factors, moral and ethical, influence nurses attitudes and decisions regarding patient care of a client with DNR orders? Statement of Purpose The researchers believe that independent variables such as patient demographics, as well as physiological aspects ranging from age and sex to acuity and nature of disease will have an affect on the dependent variable, the nurses attitude on death and dying. This study will explore the nurses attitudes about death and dying as well as specific issues about DNR orders which may have deep rooted origins and may be affected by various factors such as familial wishes and cultural issues that are out of the control of the nurse. In this descriptive study, the researchers will attempt to add to the vast body of nursing knowledge by exploring the attitudes that nurses have toward death and dying as well as their attitude toward the DNR order itself. The researchers believe that by investigating the origins of ones values and beliefs the nurse will become a better nurse and a better person .This insight into oneself will allow the nurse to deliver better patient care and develop a sense of who they are and where they come from. Research Question What factors that affect nurses attitudes toward death, the dying, and the DNR order can be discovered and identified in a descriptive study by the use of a subject specific questionnaire such as a DNR questionnaire? Definition of Terms Theoretical Definitions DNR Order: “A note written in the patient record and signed by a qualified, usually senior or attending physician, instructing the staff of the institution not to attempt to resuscitate a particular patient in the event of cardiac or respiratory failure.
This instruction is usually only given when a person is so gravely ill that death is imminent and inevitable” (Mosbys Medical & Nursing Dictionary, 1996). Attitude: “State of mind, behavior, or conduct regarding some matter, as indicating opinion or purpose” (Britannica World Language Dictionary, 1995). Nurse: “A person educated and licensed in the practice of nursing; one who is concerned with “the diagnosis and treatment of human responses to actual or potential health problems” (American Nurses Association). The practice of the nurse includes data collection, diagnosis, planning, treatment, and evaluation with men in framework of the nurses singular concern with the persons response to the problem rather than to the problem itself. The concerns of the nurse or thus broader and less discrete and circumscribed than the traditional concerns of medicine. In a cooperative participatory relationship with the clien …