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Unsuccessful patient resuscitation: understanding aspects of the critical care nurse's experience Isaak, Cheryl Lynn 1995

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UNSUCCESSFUL PATIENT RESUSCITATION: UNDERSTANDING ASPECTS OF THE CRITICAL CARE NURSE'S EXPERIENCE by CHERYL LYNN ISAAK B.Sc.N., University of V i c t o r i a , 1985 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n FACULTY OF GRADUATE STUDIES THE SCHOOL OF NURSING We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA February, 1995 ® Cheryl Lynn Isaak, 1995 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) 1 1 Abstract This study describes aspects of c r i t i c a l care nurses* experience of unsuccessful patient r e s u s c i t a t i o n . The study was guided by the philosophical perspective of phenomenology i n the t r a d i t i o n of Benner (1984, 1994) and Benner and Wrubel (1989) because of the intent to understand the commonalities and differences of the experience. C r i t i c a l care nurses (CCNs) frequently care for patients who are unsuccessfully resuscitated, however, there i s a lack of research concerning t h i s phenomenon. The purpose of t h i s study was to explore and describe the experience of CCNs who p a r t i c i p a t e i n unsuccessful patient r e s u s c i t a t i o n . Data were c o l l e c t e d through twenty seven interviews with nine p a r t i c i p a n t s who work i n an urban t e r t i a r y c r i t i c a l care area i n one Canadian c i t y . The paradigm case interview focused on the participant's narrative account of an unsuccessful patient r e s u s c i t a t i o n . The researcher sought to understand the CCN's experience through hearing and analyzing the paradigm case. The interviews were analyzed using constant comparative analysis and substantive coding. The theme of "knowing" was central to the p a r t i c i p a n t s ' accounts of unsuccessful patient r e s u s c i t a t i o n . Knowing involved three themes: knowing the case, knowing the patient, and knowing the person. Each of the c r i t i c a l care nurses began to know the in d i v i d u a l through "knowing the case". Knowing the case was s i g n i f i c a n t as i t allowed the I l l p a r t i c i p a n t s to care competently and confidently f o r the case as they developed a relat i o n s h i p with the patient. "Knowing the patient" involves a rel a t i o n s h i p characterized by professional concern and r e s p o n s i b i l i t y , between the c r i t i c a l care nurse, the patient, and the patient's s i g n i f i c a n t others. The nurse's understanding of the patient allows her or him to i d e n t i f y and anti c i p a t e the patient's i n s t a b i l i t y and the unsuccessful r e s u s c i t a t i o n . The nurses valued knowing the patient as a mechanism for preparing themselves to be emotionally stable during and a f t e r an unsuccessful patient r e s u s c i t a t i o n . "Knowing the person" involved a strong connection between the patient and nurse that created an emotional attachment to the patient and h i s or her s i g n i f i c a n t others. The c r i t i c a l care nurses• involvement with the person and h i s or her s i g n i f i c a n t others was frequently p a i n f u l as they experienced the loss of a person they had come to know and care for p r i o r to the re s u s c i t a t i o n e f f o r t . L / i v TABLE OF CONTENTS Abstract i i Table of Contents i v Acknowledgements v i i CHAPTER ONE: INTRODUCTION 1 Background to the Problem 1 Purpose 3 Research Question . . . . . . . 3 D e f i n i t i o n of Terms 3 Assumptions 3 Philosophical Perspective 4 Summary 6 CHAPTER TWO: REVIEW OF THE LITERATURE 7 Embodied Intelligence . . . . 9 Background Meaning 10 The Situation 13 Concern 14 Summary 16 CHAPTER THREE: METHODS 18 Research Design 18 Sample and Setting 20 Character i s t i c s of the Sample 22 The Setting 2 3 Data C o l l e c t i o n 24 Pre-interview 24 Paradigm Case Interview 24 Fi n a l Interview 27 F i e l d Notes 28 Data Analysis 29 Human Rights and E t h i c a l Considerations 32 J V Summary 33 CHAPTER FOUR: FINDINGS . 34 The Context of Knowing 35 The Nature of the Setting 35 Lack of Time and Competing Roles 37 Cultural Patterns 40 Physiological/Psychological E f f e c t s . . . . . 41 Knowing 42 Knowing the Case 43 Aspects of Knowing the Case . . . . . . . 43 Manifestations . . . . . 46 What does Knowing the Case Do? 50 How does Knowing the Case Do What i t Does?53 Significance of Knowing the Case . . . . 55 Knowing the Patient .55 Aspects of Knowing the Patient . . . . . 55 Manifestations 62 What does Knowing the Patient Do? . . . . 68 How does Knowing the Patient Do What i t Does? .70 Significance of Knowing the Patient . . .73 Knowing the. Person 74 Aspects of Knowing the Person 75 Manifestations 77 What does Knowing the Person Do? . . . . 82 How does Knowing the Person Do What i t Does? . . . . . . . . . . 85 Significance of Knowing the Person. . . .86 R e l i a b i l i t y and V a l i d i t y 87 Hearing the Voice of the Participant . . . . . 88 Accurately Presenting the Participant's Voice. 91 Summary . . . . . . . . . . . . . . . 93 CHAPTER FIVE: DISCUSSION 95 Exhaustive Description of Knowing as i t Relates to Unsuccessful Patient Resuscitation 95 Knowing the Case 98 Knowing the Patient 101 Knowing the Person 110 v i Future Imperatives . . . . . 116 Nursing Practice 116 Nursing Education . . . . 120 Nursing Research 124 CHAPTER SIX: SUMMARY AND CONCLUSIONS 127 Summary 127 Conclusions 133 REFERENCES 134 APPENDICES Appendix A. Research Pertaining to Causes of CCNs1 Stress 141 Appendix B. Research Related to CCNs' Coping Strategies. 144 Appendix C. Participant Information Letter . . 147 Appendix D. Demographic Data 149 Appendix E. Consent Form 150 Appendix F. Participant Letter to Accompany Transcripts. 152 Appendix G. Examples of S i g n i f i c a n t Statement and Their Formulated Meanings . 153 v i i Acknowledgements I would l i k e to take t h i s opportunity to acknowledge the people who have made the completion of t h i s study possible. To begin with, I would l i k e to thank the nine c r i t i c a l care nurses, who shared t h e i r " l i v e d experiences" with me. I admire these nurses' commitment to care f o r c r i t i c a l l y i l l p atients and h i s or her s i g n i f i c a n t others. Secondly, I wish to thank the members of my thesis committee for t h e i r contributions to t h i s study. To Dr. Barbara Paterson, the chairperson of my thesis committee, whose mentoring and encouragement has inspired me countless times. To Dr. Sonia Acorn whose precise feedback has been invaluable. To Dr. Joy Johnson whose perspective has challenged me to constantly question and reexamine. F i n a l l y , to my family and friends whose support has been invaluable throughout my graduate studies, I thank you sincerely. My husband, Terry, deserves sp e c i a l t r i b u t e f o r his f a i t h , patience, and encouragement. 1 CHAPTER ONE INTRODUCTION Background to the Problem Cardiopulmonary arrest and re s u s c i t a t i o n are frequent events within c r i t i c a l care settings. Inevitably some re s u s c i t a t i o n e f f o r t s are unsuccessful and r e s u l t i n the patient's death. The c r i t i c a l care nurse's (CCN's) perception of unsuccessful patient r e s u s c i t a t i o n and the e f f e c t of t h i s event on the nurse have received l i t t l e attention i n the l i t e r a t u r e . The personal experience of the author i n the c r i t i c a l care s e t t i n g suggests that unsuccessful r e s u s c i t a t i o n e l i c i t s powerful responses i n nurses involved i n the re s u s c i t a t i o n of patients. Research indicates that death and dying are among the top stressors experienced by CCNs (Anderson & Basteyns, 1981; Bailey, Steffen, & Grout, 1980; Huckabay & Jagla, 1979; Norbeck, 1985) . Bailey et a l . (1980) contend that health care professionals derive much of t h e i r s a t i s f a c t i o n from seeing patients recover. The nurse may perceive a loss of investment i n time, energy, and emotions when a patient dies (Stickney & Gardner, 1984). According to Tucker (1992), the primary r o l e of the CCN i s to save the l i v e s of seriou s l y i l l patients by providing interventions, including continuous observations and aggressive treatments. An unsuccessful patient r e s u s c i t a t i o n may be perceived by the 2 CCN as a professional f a i l u r e . Many authors agree that what i s perceived as s t r e s s f u l by an i n d i v i d u a l depends on a v a r i e t y of personal and environmental factors (Antonovsky, 1979; French, Rodgers, & Cobb, 1974; Lazarus & Folkman, 1984). Two in d i v i d u a l s that experience the same s i t u a t i o n may or may not perceive the event as s t r e s s f u l . The complex factors involved i n an unsuccessful patient r e s u s c i t a t i o n may influence the CCN's responses to the s i t u a t i o n . According to Lazarus and Folkman (1984), an ind i v i d u a l copes with a s t r e s s f u l s i t u a t i o n by depending on several resources: p o s i t i v e b e l i e f s , health and energy, problem solving s k i l l s , and s o c i a l support. Several authors have suggested that reduced morale, absenteeism, increased turnover, and burnout may be related to consistent exposure to stress i n the c r i t i c a l care s e t t i n g (Anderson & Basteyns, 1981; Bailey, 1980; Cronin-Stubbs & Rooks, 1985; Kel l e r , 1990). Unsuccessful patient r e s u s c i t a t i o n may be one consistent source of stress for CCNs, and thus may contribute to decreased morale, absenteeism, and burnout. Understanding CCNs1 experience with unsuccessful patient r e s u s c i t a t i o n can have implications for nursing practice and education that could ease the problems of increased turnover, absenteeism, and reduced morale. Consequently, i t i s important to explore the CCN's experience with unsuccessful patient 3 r e s u s c i t a t i o n , and to understand how t h i s s i t u a t i o n influences nurses. Purpose The purpose of t h i s study was to explore and describe the experience of c r i t i c a l care nurses who p a r t i c i p a t e d i n unsuccessful patient resuscitations. Research Question The following question guided t h i s study: What are the l i v e d experiences of c r i t i c a l care nurses who p a r t i c i p a t e i n unsuccessful patient resuscitation? D e f i n i t i o n of Terms C r i t i c a l Care Nurse - A f u l l - or part-time registered nurse working within a cardiac, cardiac s u r g i c a l , or intensive care unit (ICU). Unsuccessful Patient Resuscitation - The outcome of the cardiopulmonary arrest and re s u s c i t a t i o n r e s u l t s i n the patient's death, despite basic and advanced cardiac l i f e support provided by the health care team members. Assumptions The assumptions that underlie the study are as follows: 1 . Unsuccessful patient r e s u s c i t a t i o n i s a c r i t i c a l event for CCNs. 2 . Unsuccessful patient r e s u s c i t a t i o n e l i c i t s emotional responses from CCNs. 3 . Unsuccessful patient r e s u s c i t a t i o n has psychological e f f e c t s on CCNs. 4 4. Individuals may experience the same event d i f f e r e n t l y (Lazarus & Folkman, 1984). 5. CCNs who p a r t i c i p a t e i n unsuccessful patient r e s u s c i t a t i o n w i l l have strong perceptions of the s i t u a t i o n . 6. CCNs p a r t i c i p a t i n g i n the study w i l l be receptive to sharing t h e i r experiences of unsuccessful patient r e s u s c i t a t i o n . Philosophical Perspective This study was guided by the philosophical perspective of phenomenology i n the t r a d i t i o n of Benner (1984, 1994) and Benner and Wrubel (1989). According to Benner and Wrubel (1989), the researcher's concern i n t h i s phenomenological approach to research i s to " . . . illuminate what kind of knowing occurs when one does not stand outside of a si t u a t i o n , but i s involved i n i t " (p. 41). Consequently, research using t h i s approach focuses on understanding the phenomenon and i t s context from the par t i c i p a n t ' s perspective. There are d i f f e r e n t interpretations of phenomenology within the l i t e r a t u r e . According to Benner (1994), "The int e r p r e t i v e researcher creates a dialogue between p r a c t i c a l concerns and l i v e d experience through engaged reasoning and imaginative dwelling i n the immediacy of the p a r t i c i p a n t s ' worlds" (p. 99). "The goal of in t e r p r e t i v e phenomenology i s to uncover commonalities and differences, not private i d i o s y n c r a t i c events or understandings" (Benner, 1994, p. 5 104). Benner and Wrubel (1989) i d e n t i f i e d and described four sources of commonality explored i n t h i s approach to research. These concepts provide a framework to explore the nature of our humanness. The concepts are: embodied i n t e l l i g e n c e , background meaning, the s i t u a t i o n , and concern. Embodied Intelligence: "Embodied i n t e l l i g e n c e r e f e r s to the fac t that the body i t s e l f i s a knower and an inte r p r e t e r " (Benner & Wrubel, 1989, p. 409). Individuals have the capacity to be i n situations i n meaningful ways because of embodied i n t e l l i g e n c e . The body learns to be i n the world through c u l t u r a l meanings, use of tools, and perceptual and emotional responses. Embodied i n t e l l i g e n c e includes recognition of objects and people, integration of past experiences, and maintaining posture and moving our bodies without conscious thought. Background Meaning: "Background meaning i s what culture gives a person from b i r t h . I t i s that which determines what counts as r e a l for that person" (Benner & Wrubel, 1989, p.46). An individual's perception and understanding of the world are shaped by the culture, subculture, and family to which that i n d i v i d u a l belongs. The Situation: "Situations have the capacity to engage us and to constitute i n d i v i d u a l s " (Benner & Wrubel, 1989, p.42). In the r e a l world, contexts change and previously unnoticed background meanings, habitual body understanding, ' ' 6 and concern are seen to no longer allow for smooth functioning. The i n d i v i d u a l i s able to r e f l e c t on and bring new meaning to the s i t u a t i o n . Concern: A person's concern for people and things moves an i n d i v i d u a l to be involved i n a context (Benner & Wrubel, 1989). Concern constitutes what matters to the person (Benner, 1994). Summary Background to the study and the research question are provided i n t h i s chapter. Additionally, the need and purpose of the study were described. Furthermore, the philosophical perspective of the study was introduced. The thesis i s organized into s i x chapters. An overview of research related to unsuccessful patient r e s u s c i t a t i o n and the issues surrounding CCNs' experience with unsuccessful patient r e s u s c i t a t i o n are presented i n Chapter Two. Chapter Three outlines the research design, methods, sample, and e t h i c a l considerations pertaining to the research. Chapter Four describes the CCNs' perspectives of unsuccessful patient r e s u s c i t a t i o n . Chapter Five discusses the implications of the research findings for CCNs and f o r further study. Chapter Six summarizes the research study. 7 CHAPTER TWO REVIEW OF THE LITERATURE The issue of conducting a review of the l i t e r a t u r e i s controversial within phenomenological research. The proponents of not performing a l i t e r a t u r e review p r i o r to research postulate that additional information may contribute to researcher bias. For example, Ornery (1983) supports approaching subjects with complete naivete. Other phenomenological researchers believe that t h i s p o s i t i o n lacks pragmatism and i s not r e a l i s t i c i n the research world (Benner, 1984; Rather, 1992). Furthermore, these authors recommend providing a review of the l i t e r a t u r e to e t h i c a l review boards and funding agencies to increase understanding of the phenomenon of i n t e r e s t . Phenomenological researchers who have chosen to conduct reviews of the l i t e r a t u r e contend that examining others' descriptions of the phenomenon under study a s s i s t s researchers to i d e n t i f y and bracket, or set aside, t h e i r personal biases (Benner, 1984; Rather, 1992). Sandelowski, Davis, and Harris (1989) assert that the researcher does not embark on a project without p r i o r b e l i e f s and knowledge that influence the researcher's view of the subject of inquiry. The l i t e r a t u r e review a s s i s t s the researcher to i d e n t i f y and bracket h i s or her pre-existing b e l i e f s and perceptions. Thus, a review of the l i t e r a t u r e pertinent to the conceptualization of unsuccessful patient r e s u s c i t a t i o n i s 8 presented. As the philosophical framework of phenomenology d i r e c t s the research process for t h i s study, the review of the l i t e r a t u r e i s organized according to Benner and Wrubel's (1989) approach to phenomenology that explores four sources of commonality: embodied i n t e l l i g e n c e , background meaning, the s i t u a t i o n , and concern. Many of the studies c i t e d i n t h i s review are dated i n the l a t e 1970s or the early 1980s. Although the research studies related to CCNs' stress and coping were conducted a number of years ago, they are pertinent to the research question. The inves t i g a t i o n of the experience of CCNs regarding the deaths of t h e i r patients was primarily conducted approximately twenty years ago. There have been few e f f o r t s since that time to r e p l i c a t e or extend t h i s c l a s s i c early research. Within t h i s l i t e r a t u r e review, the terms stress and coping are referred to frequently. For the purposes of t h i s l i t e r a t u r e review, stress i s defined as " . . . disruption of meanings, understanding, and smooth functioning so that harm, loss, or challenge i s experienced, and sorrow, interpr e t a t i o n , or new s k i l l a c q u i s i t i o n i s required" (Benner & Wrubel, 1989, p. 59). Coping i s defined as what one does about a disruption (Benner & Wrubel). Coping includes "strategies for engagement and involvement as well as strategies for increased control and distance" (Benner & Wrubel, p. x i i i ) . 9 Embodied Intelligence The CCN's body has learned to know and inte r p r e t s i t u a t i o n s through the c u l t u r a l meanings one attaches to a si t u a t i o n , past experiences, use of sp e c i a l i z e d t o o l s , s k i l l e d behaviours, and perceptual and emotional responses (Benner & Wrubel, 1989) . Quint (1966) contends that CCNs have learned s p e c i f i c behaviours and s k i l l s that are directed towards saving l i v e s and patient recovery. As a re s u l t , CCNs view t h e i r r o l e as primarily involved with l i f e saving. When the death of a patient occurs, they "are faced with the r e a l i t y of professional f a i l u r e " (Quint, p. 51). A CCN's i n a b i l i t y to ,save a patient's l i f e i s often associated with feelings of negligence. Although not s p e c i f i c a l l y addressed i n the l i t e r a t u r e , an unexpected death may carry an exacerbated threat to the nurse's self-confidence because i t may imply that the nurse's care was inadequate. CCNs' proficiency with s k i l l s may influence how the body interprets and responds to a s i t u a t i o n . In a desc r i p t i v e study of 4 6 CCNs, Huckabay and Jagla (1979) concluded that the s k i l l s acquired with experience as a CCN are h e l p f u l i n a s s i s t i n g CCNs to cope with the stressors of caring for c r i t i c a l l y i l l patients. In t h e i r study, beginning CCNs reported a higher l e v e l of work related stress than did the experienced CCNs i n t h e i r sample. No other study was located that examined the e f f e c t of expertise on a CCN's a b i l i t y to cope with stress. 10 Background Meaning The c r i t i c a l care unit represents a unique culture i n nursing; one which shapes the perceptions and understandings of the nurses who work i n i t . Some research has investigated the experience of health care workers i n si t u a t i o n s of unsuccessful patient resuscitations (Jimmerson, 1988; M i t c h e l l , 1983, 1988a, 1988b). This body of research has been used to j u s t i f y the need f o r stress reduction and c r i t i c a l incident stress debriefing programs among rescue personnel, emergency health care workers, and CCNs. The researchers do not appear to have considered the fundamental differences that may e x i s t i n the background meaning of the experience of CCNs v i s a v i s other health care workers. The CCN has often developed a r e l a t i o n s h i p with the patient and family, p r i o r to unsuccessful r e s u s c i t a t i o n . A paramedic, however, would r a r e l y know either the patient or the family before a r e s u s c i t a t i o n was i n i t i a t e d . A p r i o r r e l a t i o n s h i p with the patient and h i s or her s i g n i f i c a n t others may heighten the meaning of an unsuccessful patient r e s u s c i t a t i o n for the CCN. Fo x a l l , Zimmerman, Standley, and Captain (1990) investigated the differences between the frequency and sources of stress experienced by 138 ICU, hospice, and medical-surgical nurses. The authors reported no s i g n i f i c a n t differences among the three groups of nurses on t h e i r t o t a l job stress scores. However, ICU and hospice 11 nurses experienced more stress related to death and dying than medical-surgical nurses. The authors suggest that death and dying are more s t r e s s f u l for those who deal with i t on a d a i l y basis. The l i t e r a t u r e related to stress and CCNs subdivides into three categories concerning the types and severity of stressors (causes of s t r e s s ) , the e f f e c t s of stressors, and coping with stressors. The types and severity of c r i t i c a l care stressors have been studied over the l a s t three decades. The research i n t h i s f i e l d has been pr i m a r i l y l i m i t e d to exploratory and descriptive studies. These studies have attempted to quantify stressors using questionnaires or inventories. Eight of the t h i r t e e n quantitative studies related to c r i t i c a l care stressors described the survey t o o l and reported the r e l i a b i l i t y and v a l i d i t y of the tools i n the research reports (Bartz & Maloney, 1983; Cronin-Stubbs & Rooks, 1985; Dewe, 1987; Foxall et a l . , 1990; Huckabay & Jagla, 1979; Lewis & Robinson, 1986; Norbeck, 1985; Stone, Jebsen, Walk, & Belsham, 1984). The lack of information i n the other studies regarding the nature of the survey too l s and t h e i r r e l i a b i l i t y and v a l i d i t y l i m i t s the usefulness of t h e i r findings (Anderson & Basteyns, 1981; Lewis & Robinson 1992; Schaeffer & Peterson, 1992; Spoth & Konewko, 1987; Vincent & Coleman, 198 6). The sources of stress for CCNs have been the subject of 12-seven research studies (Anderson & Basteyns, 1981; Foxall et a l . , 1990; Huckabay & Jagla, 1979; Lewis & Robinson, 1992; Spoth & Konewko, 1987; Vachon, 1987; Vincent & Coleman, 1986) summarized i n Appendix A. A l l but one of these studies (Vachon, 1987) i d e n t i f i e d the death of a patient within the top three s t r e s s f u l events i n the experience of CCNs. Vachon's study was unique i n that the researcher conducted i n d i v i d u a l and group interviews with health care workers i n both p a l l i a t i v e and c r i t i c a l care settings. The caregivers i n Vachon's sample reported that the top f i v e occupational stressors consisted of team communication problems, patient/family personality or coping problems, the nature of the unit, r o l e ambiguity, and ro l e c o n f l i c t . Although the death of a patient was not reported as a s p e c i f i c stressor, the participants discussed t h e i r stressors i n r e l a t i o n to the anticipated death of t h e i r patients. High l e v e l s of stress are associated with a v a r i e t y of psychological symptoms i n CCNs (Norbeck, 1985) and contribute to diminished work performance (Huckabay & Jagla, 1979) and burnout (Bartz & Maloney, 1986; Cronin-Stubbs & Rooks, 1985). Consequently, study of stressors surrounding unsuccessful patient r e s u s c i t a t i o n and nurses' response to t h i s event i s important to those concerned with optimal patient care and the psychological well being of CCNs. 13 The Situation The CCN's a b i l i t y to cope with the stressors associated with the care of c r i t i c a l l y i l l patients i s l a r g e l y determined by the context of the patient care s i t u a t i o n and the nurse's coping strategies. Stress i s an i n t e g r a l part of c r i t i c a l care units. I t stems from the high-tech environment, the acuity of patients' conditions, and the need fo r c r i s i s decision-making (Lewis & Robinson, 1992). Unsuccessful patient r e s u s c i t a t i o n may be associated with CCNs' stress i n the c r i t i c a l care s e t t i n g . The research l i t e r a t u r e reveals that CCNs use a v a r i e t y of methods to cope with s t r e s s f u l s i t u a t i o n s . Several researchers found that CCNs use p a r t i c u l a r coping strategies frequently. Ehrenfeld and Cheifetz (1990) c o l l e c t e d data at a one day workshop related to coping with stress for approximately 2 60 cardiac nurses. The workshop was designed to encourage nurses to share t h e i r experiences and ideas related to stress and was not planned as a research project. Although the cardiac nurses used a v a r i e t y of coping strategies, the nurses' reported the following primary coping modes i n s p e c i f i c s i t u a t i o n s : 32.6% used active coping s k i l l s toward solving a problem, 11.7% diverted the r e s p o n s i b i l i t y of problem solving to others, 37% were passive, and 18.6% participated i n some a c t i v i t y not directed toward resolution of the s i t u a t i o n . Although the investigation by Ehrenfeld and Cheifetz 14 (1990) was not intended to be a formal study, t h e i r findings are congruent with those of f i v e research projects (Dewe, 1987; Lewis & Robinson, 1986; Oskins, 1979; Schaeffer & Peterson, 1992; Stone et a l . , 1984), which investigated how CCNs cope with work-related stress. These studies are summarized i n Appendix B. The findings from these surveys indicate that CCNs prefer d i r e c t , active coping measures, such as t a l k i n g to coworkers about the s i t u a t i o n . Concern A CCN's concern for a patient a f f e c t s his/her willingness and a b i l i t y to be involved i n the patient's care. Caughill (1976) addresses the issue of dying i n acute care settings, based on findings i n the l i t e r a t u r e and c l i n i c a l experiences. She emphasizes that nurses working within intensive and coronary care units develop close r e l a t i o n s h i p s with t h e i r patients. The development of the rel a t i o n s h i p i s influenced by the low patient to s t a f f r a t i o and the almost continuous demand for nursing care. As the patient's s o c i a l history unfolds and the patient i s seen as a unique person, the nurse's personal involvement grows. According to Caughill, when a close r e l a t i o n s h i p has been formed between the nurse and the patient, a patient's death may constitute a personal loss and a f e e l i n g of professional f a i l u r e . The CCN's concern for a c r i t i c a l l y i l l patient may p r e c i p i t a t e e t h i c a l c o n f l i c t s within the nurse. Nursing '74 15 (1974a, 1974b) reported that nurses involved i n patient r e s u s c i t a t i o n e f f o r t s experienced d i s t r e s s associated with prolonging l i f e through a r t i f i c i a l means. A survey of 205 nurses conducted by Davis (1981) found that one of the most frequent e t h i c a l dilemmas i d e n t i f i e d by nurses was "prolonging l i f e with heroic measures" r e s u l t i n g i n e t h i c a l d i s t r e s s (p. 402). E t h i c a l d i s t r e s s i s related to the concept of moral d i s t r e s s . Jameton (1984) reports that moral d i s t r e s s occurs when moral choices cannot be translated into moral action. A CCN's concern for a patient may r e s u l t i n both e t h i c a l and/or moral d i s t r e s s f o r the nurse. An ind i v i d u a l ' s responses to moral d i s t r e s s may include feelings of g u i l t , anger, f r u s t r a t i o n , and powerlessness (Jameton). The CCN's concern for a patient may influence h i s or her a b i l i t y to p a r t i c i p a t e i n e t h i c a l decision making. Rodney (1987) explored the experiences of CCNs' e t h i c a l decision-making with prolongation of l i f e . She found that moral d i s t r e s s was a component of nurses' experiences. The " . . . moral d i s t r e s s was associated with some s i g n i f i c a n t feelings for nurses, including resentment, f r u s t r a t i o n , and sorrow" (Rodney, 1988, p. 10). Moral d i s t r e s s i s h e l p f u l i n understanding the complex dimensions of e t h i c a l s i t u a t i o n s and may r e l a t e to CCNs• experiences with unsuccessful patient r e s u s c i t a t i o n . The CCN's reaction to a patient's death may vary with 16 each s i t u a t i o n . The following feelings have been i d e n t i f i e d within the l i t e r a t u r e : professional f a i l u r e , negligence, hopelessness, helplessness (Caughill, 1976; Quint, 1966), personal loss (Caughill, 1976), resentment, f r u s t r a t i o n , and sorrow (Rodney, 1988) . Summary No research was located that s p e c i f i c a l l y investigated the experience of CCNs with unsuccessful patient r e s u s c i t a t i o n . The research findings pertaining to stress among CCNs imply that the death of a patient i s s t r e s s f u l and, at times, emotionally d i f f i c u l t f or nurses to manage. The research i s li m i t e d by the use of the survey t o o l as a primary data c o l l e c t i o n method as t h i s technique may not illuminate the complex nature of a s i t u a t i o n and people's responses. The lack of information about the nature of the survey t o o l used, or the r e l i a b i l i t y and v a l i d i t y of the t o o l l i m i t s the usefulness of some research findings. The research i n t h i s area i s also l i m i t e d because several researchers have investigated stress i n r e l a t i o n to a va r i e t y of health care workers, not s p e c i f i c a l l y CCNs. I t may be postulated that the unique r o l e of CCNs w i l l r e s u l t i n experiences that are not c h a r a c t e r i s t i c of other health care workers. For example, the nature of the CCN's rel a t i o n s h i p with the patient and family may i n t e n s i f y the nurse's responses to a re s u s c i t a t i o n e f f o r t and the death of a patient. 17 The actual experience of CCNs i n regard to unsuccessful patient r e s u s c i t a t i o n has not been explored to date. Although some authors (e.g., Quint, 1966) have suggested that an unsuccessful r e s u s c i t a t i o n i s a traumatic and c r i t i c a l event for CCNs, there i s lack of empirical data to support that assumption. There i s a need for explorative and d e s c r i p t i v e study that seeks to understand the meaning of the experience of unsuccessful r e s u s c i t a t i o n for CCNs. 18 CHAPTER THREE METHODS The research design, sample and set t i n g , data c o l l e c t i o n , data analysis, and e t h i c a l considerations of the study are outlined i n t h i s chapter. Research Design The research design was guided by the philosophical perspective of phenomenology i n the t r a d i t i o n of Benner (1984, 1994) and Benner and Wrubel (1989). According to Benner (1994), the goal of i n t e r p r e t i v e phenomenology i s to uncover commonalities and differences of the phenomenon. "The phenomenon and i t s context frame the i n t e r p r e t i v e project of understanding the world of p a r t i c i p a n t s or events" (Benner, 1994, p. 99). A phenomenological perspective i s appropriate for the inves t i g a t i o n of previously unexplored areas because, through t h i s approach, the researcher seeks to understand the essence of a phenomenon. This method was suitable for the purpose of t h i s study because l i t t l e i s known about the CCN's experience with unsuccessful patient r e s u s c i t a t i o n , and no previous studies were located i n which researchers investigated t h i s topic. The phenomenological approach described by Benner (1984, 1994) and Benner and Wrubel (1989) provided methodological strategies for the data c o l l e c t i o n and data analysis i n t h i s study. Data c o l l e c t i o n involved paradigm 19 case interviews that allowed the pa r t i c i p a n t to r e l i v e and describe the experience of unsuccessful patient r e s u s c i t a t i o n during the interview process. According to Benner (1984), paradigm cases are narrative accounts of c l i n i c a l s i t u a t i o n s that open up new areas of pra c t i c e or teach the nurse something new about nursing p r a c t i c e . The researcher creates a dialogue between p r a c t i c a l concerns and l i v e d experience through engaged reasoning and imaginative dwelling i n the immediacy of the pa r t i c i p a n t s ' world (Benner, 1994). Diekelmann (1990) contends that, through paradigm case dialogue, we are f u l l y engaged i n the si t u a t i o n and we seek to get the story x r i g h t ' . "Reflecting and probing, we search for words that d i s c l o s e and bear witness to our understanding" (Diekelmann, p. 301). The opportunity for CCNs to t e l l t h e i r s t o r i e s of unsuccessful patient r e s u s c i t a t i o n allowed these nurses to bring meaning to t h i s experience. A phenomenological approach was used i n t h i s study to gain insight into the experiences of CCNs involved with unsuccessful patient r e s u s c i t a t i o n . The data generated from the paradigm case interviews were analyzed using paradigm analysis. Paradigm analysis i s based on narrative inquiry. The narrative approach i s inductive and uses paradigm cases to explicate issues, concerns, meanings, and understanding from the informant's perspective (Benner, 1994). Individuals' experiences can be brought to a l e v e l of 20 awareness by enabling nurses to r e f l e c t upon t h e i r experiences and to t e l l t h e i r s t o r i e s (Benner & Wrubel, 1989; Diekelmann, 1990; Krysl, 1991). The researcher used four strategies congruent with t h i s t r a d i t i o n of phenomenological research to i n t e r p r e t the p a r t i c i p a n t s ' s t o r i e s . These strategies are analysis, synthesis, c r i t i c i s m , and understanding. They were used to a r t i c u l a t e the meanings of the text and to generate i n t e r p r e t i v e commentary (Benner, 1994; Taylor, 1985, 1993). These strategies are described i n the sections on data c o l l e c t i o n and analysis. Sample and Setting The f i r s t step i n gathering the interview data was i d e n t i f y i n g the population from which the informants could be selected. The designated population was CCNs who had experienced caring for patients who were unsuccessfully resuscitated. The sample size was nine CCNs. This sample si z e was considered adequate as participants* narratives revealed meaningful patterns and the participants• repeated concerns that allowed interpretation of the paradigm interview texts (Benner, 1994). The sample was selected to meet the following i n c l u s i o n c r i t e r i a : 1. E l i g i b l e Registered Nurses were currently employed i n a f u l l - or part-time capacity i n the selected c r i t i c a l care units, s p e c i f i c a l l y cardiac, cardiac s u r g i c a l , and intensive 21 care units . The sample was l i m i t e d to these settings to ensure that the context of the nurse-patient r e l a t i o n s h i p was s i m i l a r . The nature of the nurse-patient r e l a t i o n s h i p may be d i f f e r e n t i n other c r i t i c a l care settings, such as emergency and post-anaesthetic care units. 2 . E l i g i b l e nurses p a r t i c i p a t e d i n at l e a s t one unsuccessful r e s u s c i t a t i o n of a patient for whom they had cared f o r p r i o r to the r e s u s c i t a t i o n attempt. The researcher believes that attending r e s u s c i t a t i o n attempts as part of the cardiac arrest team, i n order to resuscitate patients unknown to them, i s a d i f f e r e n t s i t u a t i o n with d i s t i n c t issues for CCNs. In r e c r u i t i n g the informants, the researcher contacted the Head Nurses of the c r i t i c a l care units to explain the study, answer questions, and arrange to present the study to the s t a f f at a meeting. The purpose of the study and the research design was explained at each s t a f f meeting. A l e t t e r explaining the study and requesting p a r t i c i p a t i o n was d i s t r i b u t e d to each CCN who attended an information session or s t a f f meeting (Appendix C). The l e t t e r included information regarding how to contact the researcher i f the nurse was interested i n p a r t i c i p a t i n g i n the study. The nurses interested i n p a r t i c i p a t i n g i n the study contacted the researcher. 22 C h a r a c t e r i s t i c s of the Sample CCNs were recruited from one t e r t i a r y l e v e l h o s p i t a l i n Vancouver, B r i t i s h Columbia. The p a r t i c i p a n t s were employed i n cardiac, cardiac s u r g i c a l , and intensive care units . The nine p a r t i c i p a n t s had between eight and nineteen years of experience as a Registered Nurse, and between three and , fourteen years of experience as a c r i t i c a l care nurse. The pa r t i c i p a n t s included one male and eight females. The anonymity of the one male pa r t i c i p a n t i n the study has been protected by r e f e r r i n g to a l l the p a r t i c i p a n t s as female. The p a r t i c i p a n t s were employed i n cardiac care (3), intensive care (4), cardiac and intensive care (1), and cardiac, cardiac s u r g i c a l and intensive care (1). The educational preparation of the part i c i p a n t s included: a Baccalaureate i n Nursing (5); a Baccalaureate i n Arts (1); and C r i t i c a l Care Specialty C e r t i f i c a t e s (5). Two of the p a r t i c i p a n t s who held a Baccalaureate i n Nursing had also completed a C r i t i c a l Care Specialty C e r t i f i c a t e . The age range was between t h i r t y and forty years. The paradigm s t o r i e s that the p a r t i c i p a n t s selected to r e l a t e to the researcher were from recent ( i . e . , within the past two years) experience (8) and from past ( i . e . , fourteen years prior) experience (1). The unsuccessful patient resuscitations described i n the narratives occurred both i n cardiac and intensive care settings and took place on day (5) and night (4) s h i f t s . In each of these s i t u a t i o n s , the 23 nurse had cared for the patient p r i o r to the cardiac and/or respiratory arrest and unsuccessful patient r e s u s c i t a t i o n . The Setting The CCNs who p a r t i c i p a t e d i n the study worked within t e r t i a r y l e v e l intensive and cardiac care u n i t s . I t i s s i g n i f i c a n t to the purposes of t h i s study to i d e n t i f y the unique c h a r a c t e r i s t i c s of each s e t t i n g . These units are considered busy by the CCNs with a f a i r l y rapid turnover of patients. The nurse-to-patient r a t i o ranges from one nurse to one to three patients. In the cardiac care unit the patients can communicate verbally to the nurses; however, i n the intensive care unit, patients may not be able to communicate ver b a l l y for a v a r i e t y of reasons (e.g., intubation or altered l e v e l of consciousness). In both settings, the patient's family members are able to v i s i t the patient at any time with the exception of when patient treatments or emergency situations were occurring. Family members tend to v i s i t frequently for short periods. The CCNs i n the cardiac and intensive care units work with a v a r i e t y of physicians to provide care f o r patients. The physicians include house s t a f f (e.g., c a r d i o l o g i s t s and i n t e n s i v i s t s ) and residents and interns covering the s p e c i f i c areas. These CCNs work with the house s t a f f on an ongoing basis and work with residents and interns for short periods (e.g., one to three months). According to the CCNs, the nurses and physicians are expected to work as a team 24 during r e s u s c i t a t i o n s i t u a t i o n s . Data C o l l e c t i o n Data were c o l l e c t e d from each CCN through a pre-interview, a paradigm case interview, and a f i n a l interview. Pre-interview ' The pre-interview was conducted i n person or by phone. The interviewer reviewed the purpose of the study, answered the p a r t i c i p a n t ' s questions related to the research interview, and introduced the interview plan to the CCNs. According to Benner (1994), the p a r t i c i p a n t must be coached that narrative accounts of events, s i t u a t i o n s , feelings, and actions are needed. Introducing the interview plan to the p a r t i c i p a n t s allowed them to select a paradigm case that they chose to share. Paradigm Case Interview The researcher sought to understand the CCN's l i v e d experience through the c o l l e c t i o n and analysis of paradigm case exemplars. A paradigm case exemplar has been described as "a c l i n i c a l episode that a l t e r s one's way of understanding and perceiving future c l i n i c a l s i t u a t i o n s " (Benner, 1984, p. 296). Benner (1984) states that exemplars become part of the c l i n i c i a n ' s "perceptual lens" (p. 297). The c l i n i c i a n ' s "perceptual lens" influences the nurse's perceptions and a b i l i t y to make q u a l i t a t i v e d i s t i n c t i o n s i n pract i c e . The paradigm method has been used i n nursing to study c h a r a c t e r i s t i c s of novice and expert nurses (Benner, 25 1984), the ro l e of experience i n e t h i c a l p r actice (Benner, 1991), the d i f f e r e n t c l i n i c a l worlds of beginning and expert CCNs (Benner, Tanner, & Chesla, 1992), the experience of being a returning registered nurse student (Rather, 1992), and patient perceptions of caring i n interactions with nurses (Rieman, 1986). The paradigm case interview i s l i k e the t e l l i n g of a story. "The ro l e of story t e l l i n g i s central to int e r p r e t i v e phenomenology because when people structure t h e i r own narrative accounts, they can tap into t h e i r more immediate experiences . . ." (Benner, 1994, p. 108). In t h i s phenomenological approach to data c o l l e c t i o n , the researcher appreciates that knowledge revealed through s t o r i e s i s contextualized, personal, never r e p l i c a b l e , and f u l l of l i f e experience (Bergum, 1989). The perceptions of the CCNs regarding t h e i r experiences of caring for patients who were unsuccessfully resuscitated originated from l i v i n g through c e r t a i n s i t u a t i o n s and experiences. The paradigm case interview involved asking the CCN to share an exemplar that was a s i g n i f i c a n t or memorable experience with unsuccessful patient r e s u s c i t a t i o n . The researcher s t r i v e s to understand the world of parti c i p a n t s or events through dialogue and l i s t e n i n g that allow the voice of the other to be heard or to reveal silence (Benner, 1994). The interview focused on obtaining the ind i v i d u a l CCN's perspective, and required the 26 researcher to ask questions to c l a r i f y the CCN's meaning and to understand the experience. The paradigm case interview was based on the method reported by Benner (1984). The p a r t i c i p a n t s were given the following i n s t r u c t i o n s : 1. Describe an incident or s i t u a t i o n from your experience with unsuccessful patient r e s u s c i t a t i o n that was s i g n i f i c a n t to you. 2. Describe the context of the s i t u a t i o n . 3. Include why the incident was s i g n i f i c a n t to you. 4. Include your concerns at the time. 5. Include what you were f e e l i n g during and a f t e r the s i t u a t i o n . The interview was audiotaped by the researcher and transcribed by a s e c r e t a r i a l transcriber. Demographic information was also requested (Appendix D). Several of the participants described the experience of t e l l i n g the story as "a clea r memory", " v i v i d " , "a c l e a r picture", and "through the dim l i g h t i n g of nights". One par t i c i p a n t described the s i t u a t i o n as "a l i t t l e moving picture and you, you see the whole thing evolving i n your mind." Through the process of story t e l l i n g , the par t i c i p a n t s r e l i v e d the experience of the unsuccessful patient r e s u s c i t a t i o n . The researcher asked open ended questions to c l a r i f y aspects of the interview and to explore aspects of the unsuccessful patient r e s u s c i t a t i o n not discussed by the 27 p a r t i c i p a n t . Many of the partic i p a n t s stated that through t e l l i n g the story, they were able to r e c a l l aspects of the re s u s c i t a t i o n that they had not previously remembered. Ad d i t i o n a l l y , many of the partic i p a n t s expressed that the interview process helped them to make sense of the experience. F i n a l Interview A f i n a l interview was arranged to c l a r i f y interpretations of the paradigm interview and to discuss the emerging themes with the c r i t i c a l care nurse. A t r a n s c r i p t of the paradigm interview was mailed to the pa r t i c i p a n t s p r i o r to the f i n a l interview. Instructions regarding the reading of the t r a n s c r i p t s and the aim of the f i n a l interview accompanied the t r a n s c r i p t s (Appendix F). I t was assumed that mailing the interview t r a n s c r i p t s the week before the f i n a l interview provided the CCN time to consider the accuracy of the description of her experience. The par t i c i p a n t s were asked to review the t r a n s c r i p t s p r i o r to the f i n a l interview. The CCNs were informed that within the f i n a l interview both they and the researcher would have an opportunity to review, c l a r i f y , and expand on statements from the paradigm interview. The partic i p a n t s were also given an opportunity to ask the researcher questions regarding the research process. The t r a n s c r i p t s were pre-coded by the researcher. Pre-coding involves i d e n t i f y i n g general themes and categories 28 within the t r a n s c r i p t s . The researcher shared the emerging interpretations of the data with the par t i c i p a n t s to val i d a t e the researcher's interpretation and to check for errors i n interpretations of the paradigm case (Benner, 1994). The CCN was asked to r e f l e c t on the researcher's i n t e r p r e t a t i o n of the experience. Sharing the emerging themes with the CCN allowed the researcher to c l a r i f y interpretations and permitted the CCN to va l i d a t e the researcher's int e r p r e t a t i o n of her paradigm case (Benner, 1994). C l a r i f y i n g and v a l i d a t i n g the emerging themes enables the researcher to accurately present the voice of the pa r t i c i p a n t s (Benner). F i e l d Notes The researcher recorded her observations, methodological notes, and personal notes following each interview. May (1989) advises that researchers use f i e l d notes to capture important information that i s discussed a f t e r the formal interview has ended. The f i e l d notes assisted the researcher to r e c a l l the context of the interviews, to c r i t i q u e her interview techniques, and to discover common meanings and differences. According to Benner (1984), "Common meanings make i t possible for persons to communicate d i r e c t l y and understand one another without i n t e r p r e t a t i o n or t r a n s l a t i o n " (p. 292) . Common meanings are embedded i n CCNs' work practices and expectations (Benner, 1984). 29 Data Analysis The phenomenological strategies of analysis, c r i t i c i s m , understanding, and synthesis are used to a r t i c u l a t e the meanings of the text and generate i n t e r p r e t i v e commentary (Benner, 1994; Taylor, 1985, 1993). The nine transcribed interviews were analyzed using the framework developed by C o l l a i z i (1978). C o l l a i z i ' s framework i s congruent with the phenomenological approach described by Benner (1994). The search for themes involves not only the discovery of commonalities, but also the search for differences i n the data (Benner, 1994). The steps i n C o l l a i z i ' s framework are as follows: 1. The t r a n s c r i p t s of the interview are read as a whole. 2. Statements are extracted from the t r a n s c r i p t s that d i r e c t l y r e l a t e to the phenomenon under study. 3. Meanings of the extracted statements are determined by i n d i c a t i n g the meaning while using the o r i g i n a l words and descriptions of the p a r t i c i p a n t . 4. Clusters and themes are formulated from these meanings. The themes are validated by r e f e r r i n g to the p a r t i c i p a n t ' s o r i g i n a l description. The o u t l i e r s and discrepancies between themes are noted. 5. An extensive description of the phenomena under study i s produced from integration of the above process. 6. The t r a n s c r i p t s of the paradigm interview with the 30 analysis of emerging themes related to the phenomenon i s returned to the pa r t i c i p a n t s . The researcher validates that the themes/descriptions capture the true meaning of t h e i r statements. The f i r s t step i n the data analysis was to read each t r a n s c r i p t to envision the s i t u a t i o n . Next, the researcher extracted s i g n i f i c a n t statements from each t r a n s c r i p t , r e l a t i n g to CCNs1 experience with unsuccessful patient r e s u s c i t a t i o n . Meanings were attached to the s i g n i f i c a n t statements, which were then organized into c l u s t e r s of themes. Examples of s i g n i f i c a n t statements and t h e i r formulated meanings are provided i n Appendix G. The clu s t e r s of themes were validated by r e f e r r i n g to the o r i g i n a l t r a n s c r i p t . O u t l i e r s and discrepancies between themes were i d e n t i f i e d . The process of analysis involved c r i t i c a l l y reading texts - questioning, comparing, and imaginatively dwelling i n the parti c i p a n t ' s s i t u a t i o n (Benner, 1994). To analyze the phenomenon within i t s context, the researcher c r i t i c a l l y r e f l e c t e d on the ways the ". . . methodological strategies, personal knowledge, and s o c i a l context create a t h e o r e t i c a l and perceptual access that influences understanding" (Benner, 1994, p. 99). Studying the p a r t i c i p a n t s ' s r e a l i t y required the researcher to ". . . move back and f o r t h between foreground and background, between si t u a t i o n s , and between the p r a c t i c a l worlds of the p a r t i c i p a n t s " (Benner, 31 p. 100). In addition, the researcher c r i t i c a l l y r e f l e c t e d on biases and b l i n d spots that may e x i s t and why she thought the questions that she was asking were relevant (Benner, 1994). C r i t i c a l r e f l e c t i v e exercises created openness and the a b i l i t y to hear questions and challenges (Benner, 1994). The researcher sought to hear and understand the voice of the pa r t i c i p a n t (Benner, 1994). The f i n a l interview provided the researcher with the opportunity to review the tape and text p r i o r to the f i n a l interview. According to Benner (1994), t h i s technique allows the researcher and pa r t i c i p a n t a second chance to ensure that understanding has occurred. "Understanding i s h i s t o r i c a l and must, be understood h i s t o r i c a l l y " (Benner, 1994, p. 101). The researcher tracked changes i n thinking and understanding i n f i e l d notes and a journal. Analyzing the text from d i f f e r e n t perspectives often changed the researchers 1 understanding of data. Writing the findings c l a r i f i e d understanding of the commonalities and differences i n the phenomenon. The f i n a l strategy of t h i s approach to phenomenological research consists of synthesizing the themes associated with the paradigm cases. The themes should be universal enough to apply to each informant but do not require a t o t a l systems account nor a si n g l e - f a c t o r theory (Benner, 1994). The description of the themes i s the focus of chapter four. 32 Human Rights and E t h i c a l Considerations Several procedures were used to ensure the protection of human subjects i n t h i s study. The study proposal was approved by The University of B r i t i s h Columbia Behavioral Sciences Screening Committee and the Hospital Internal Review Board. To ensure the p a r t i c i p a n t s ' r i g h t to informed consent, a l l p a r t i c i p a n t s were given a l e t t e r of information that explained the purpose of the study (Appendix C) and an opportunity was provided to r a i s e questions or concerns with the researcher. A written consent was obtained at the time of the f i r s t meeting (Appendix E). The written consent form contains the following components that F i e l d and Morse (1985) recommend: 1. an explanation of the study, including i t s purpose, the taping of interviews, and the number and duration of interviews, 2. an assurance of c o n f i d e n t i a l i t y and that only anonymous quotes w i l l be used i n any publication, 3. a statement i n d i c a t i n g that the study w i l l hopefully heighten awareness regarding nurses• experience with unsuccessful patient r e s u s c i t a t i o n , 4. a statement that the participant i s free to refuse to answer any question without consequence, 5. an i n d i c a t i o n that the p a r t i c i p a n t i s free to withdraw from the study at any time or to withdraw some or a l l provided data without repercussion. 33 The c o n f i d e n t i a l i t y and anonymity of the informants were protected by i d e n t i f y i n g a l l p a r t i c i p a n t s with a code number on a l l t r a n s c r i p t s and i n the f i n a l report. The researcher w i l l be the only person that knows the i d e n t i t i e s of the pa r t i c i p a n t s . The l i s t i d e n t i f y i n g the pa r t i c i p a n t s , the audiotapes, and tr a n s c r i p t s was stored i n a locked drawer. Summary The lack of research related to nurses' experience with unsuccessful patient r e s u s c i t a t i o n may have consequences for CCNs i n the c l i n i c a l s e t t i n g . This research design was based upon the phenomenological approach described by Benner (1984, 1994) and Benner and Wrubel (1989). The c h a r a c t e r i s t i c s of the sample and set t i n g are outlined. In addition, the data c o l l e c t i o n and analysis processes are described. Furthermore, the human ri g h t s and e t h i c a l considerations related to t h i s study are summarized. The c r i t i c a l care nurse's experience with unsuccessful patient r e s u s c i t a t i o n requires study i n order to uncover na t u r a l l y occurring concerns and meanings associated with such experiences. 34 CHAPTER FOUR FINDINGS The nine part i c i p a n t s i n t h i s study shared paradigm s t o r i e s of unsuccessful patient r e s u s c i t a t i o n from recent or past experiences as CCNs. One p a r t i c i p a n t relayed a paradigm story from fourteen years ago but discussed t h i s s i t u a t i o n i n contrast to her usual response i n s i m i l a r , current s i t u a t i o n s . The participants of t h i s study described paradigm situations that were s i g n i f i c a n t to them. Many of these experiences changed the CCN's thinking and pr a c t i c e i n c r i t i c a l care nursing. The central theme of knowing emerged from the accounts of CCNs1 experiences with unsuccessful patient r e s u s c i t a t i o n . The context of knowing was i d e n t i f i e d by the p a r t i c i p a n t s as s i g n i f i c a n t i n determining how knowing was enacted i n t h e i r r o l e i n an unsuccessful r e s u s c i t a t i o n . Knowing entailed three themes: knowing the case; knowing the patient; and knowing the person. The boundaries of these themes were often determined to be overlapping and, at times, i n d i s t i n c t by the CCNs. The p a r t i c i p a n t s used the words "knowing the patient" and "knowing the person" frequently i n t h e i r narrative accounts of unsuccessful patient r e s u s c i t a t i o n . These themes have been previously i d e n t i f i e d by Fonteyn and Fisher (1994) i n a study of CCNs who cared for unstable post-operative patients. The framework of themes i d e n t i f i e d i n the study conducted by 35 Fonteyn and Fisher was compared to the c l u s t e r s of themes related to CCNs* experience of unsuccessful patient r e s u s c i t a t i o n . In many instances these themes are p a r a l l e l to those of CCNs who care for patients that were unsuccessfully resuscitated. This chapter includes the description of the findings as they r e l a t e to CCNs1 experience with unsuccessful patient r e s u s c i t a t i o n . The context i n which knowing occurred i s described, followed by a detailed description of the three theme c l u s t e r s i d e n t i f i e d i n the data analysis. A discussion of the r e l i a b i l i t y and v a l i d i t y of the findings of the study concludes the chapter. The Context of Knowing The Nature of the Setting The contextual factors that are unique to c r i t i c a l care nursing (e.g., the r o l e demands and the structure of the unit) were viewed by the p a r t i c i p a n t s as a f f e c t i n g the nature of t h e i r l i v e d experience i n cases of unsuccessful patient r e s u s c i t a t i o n . The participants stated that the nature of the c r i t i c a l care s e t t i n g provides unique challenges to CCNs, p a r t i c u l a r l y i n cases of unsuccessful r e s u s c i t a t i o n . The acuity of the patients, as well as the goals and pace of care, influence CCNs1 knowing. The c r i t i c a l care environment i s structured to provide care to c r i t i c a l l y i l l patients. The goal of both the nursing and medical s t a f f i s 36 to s t a b i l i z e c r i t i c a l l y i l l patients. When a patient i s or becomes unstable ( i . e . , a s i g n i f i c a n t change i n v i t a l signs, oxygenation and/or l e v e l of consciousness occurs), the patient care goal s h i f t s from one of monitoring and restoration to l i f e saving. I f the i n d i v i d u a l i s unable to be successfully resuscitated, the l i f e saving goals are thwarted. She came up (from emergency) and we began. I t was ju s t f u l l bore. With the c a r d i o l o g i s t c a l l i n g out orders r a p i d l y and, within a short space of time of her being i n the unit - from putting her on the monitor, seeing that she was tachycardiac, hypertensive and then she also went into V tach (ventricular tachycardia), then the crash cart and the beginning of r e s u s c i t a t i v e e f f o r t s . The s e t t i n g of the c r i t i c a l care unit i s d i f f e r e n t than many medical-surgical units i n that patients are often able to witness the care that others i n the unit receive. A concern expressed by the participants was for patients witnessing an unsuccessful cardiac and/or respiratory r e s u s c i t a t i o n . The participants stated that the close proximity of patients to one another i n a c r i t i c a l care unit makes i t d i f f i c u l t to ensure privacy during a cardiopulmonary arrest and caused patients' d i s t r e s s when they were able to recognize that another patient was not successfully resuscitated. Participants described strategies such as p u l l i n g the bedside curtains, c l o s i n g doors, and speaking s o f t l y to avoid other patients becoming anxious about the res u s c i t a t i o n . 37 Lack of Time and Competing Roles The contextual factors of lack of time and competing roles and r e s p o n s i b i l i t i e s were i d e n t i f i e d by the p a r t i c i p a n t s as common constraints to CCNs' knowing the patient. A l l participants perceived that a c e r t a i n amount of time was required for them to begin to know the case, patient, and person e f f e c t i v e l y . I f t h i s time was not available, the participants reported that they often f e l t compromised i n t h e i r a b i l i t y to provide i n d i v i d u a l i z e d care for the patient and to recognize s i g n i f i c a n t changes i n the patient's condition. When an unfamiliar patient was unsuccessfully resuscitated, the p a r t i c i p a n t s stated they f e l t the i n d i v i d u a l ' s care had been compromised because they had not known him/her well enough to provide the i n d i v i d u a l i z e d care they had required. I did not r e a l l y know the man as an i n d i v i d u a l because he wasn't r e a l l y with i t and I had only nursed him that evening so he had been my patient for f i v e hours. The whole thing probably took an hour and a h a l f from the time he came i n the door u n t i l he died and he was pretty well almost coding when he came i n . The goals of care i n the c r i t i c a l care unit and the acuity of patients determine the roles enacted by CCNs i n a r e s u s c i t a t i o n e f f o r t that was unsuccessful. The CCN may assume multiple roles during and a f t e r an unsuccessful r e s u s c i t a t i o n procedure. Each of these roles requires d i f f e r e n t s k i l l s and a b i l i t i e s of the nurse. Some part i c i p a n t s described the l e v e l s of stress associated with 38 the d i f f e r e n t r o l e s . Interestingly, doing the CPR (cardiopulmonary resuscitation) i s the lea s t s t r e s s f u l job i n an arrest procedure. I t ' s pretty simple and basic and you don't have to think beyond the task. Other jobs l i k e giving the drugs and d e f i b r i l l a t i n g are anxiety provoking because they require more thinking and decision making. The part i c i p a n t s stated that t h e i r job was one of multiple demands, requiring constant p r i o r i t i z a t i o n and juggling of needs. In many instances, the pa r t i c i p a n t s f e l t that they were unable to care for the patient and his/her s i g n i f i c a n t others adequately because of these multiple demands. Other than the technical roles assigned i n the re s u s c i t a t i o n procedure (e.g., documenting the interventions given, monitoring the cardiac rhythm, and d e f i b r i l l a t i n g the patient), the CCN's roles commonly included caring for the patient, performing s k i l l s (e.g., giving intravenous medications, drawing a r t e r i a l blood gases, i n s e r t i n g a nasogastric tube), decision making, i n t e r a c t i n g with family members, delegating to others, overseeing other patients, accessing resources, and advocating for the patient. Beyond these t r a d i t i o n a l aspects of c r i t i c a l care nursing, some pa r t i c i p a n t s ' roles included: serving as the charge nurse or acting head nurse and orienting a s t a f f nurse. When the re s u s c i t a t i o n e f f o r t s were unsuccessful, the pa r t i c i p a n t s stated that they regretted that t h e i r multiple r o l e demands had compromised the qual i t y of care they gave to the in d i v i d u a l and his/her s i g n i f i c a n t other p r i o r to the arrest procedures. 39 Clearly, i n my mind, the number one place at t h i s point i n a sense, was with the family and, yet, I kept thinking, "Oh. But i f you want t h i s woman to survive, you've got to get those gases sent o f f . " And (laughing) you know. And so, i t ' s a crazy p o s i t i o n . You are torn and you ju s t don't f e e l there's enough of you. Several of the participants commented that an added complexity of the multiple r o l e demands i n a c r i t i c a l care unit i s that each r o l e requires d i f f e r e n t approaches, s k i l l s , and behaviour. For example, a focused, assertive, unemotional, and e f f i c i e n t manner was required i n a re s u s c i t a t i v e e f f o r t . A calm and compassionate manner was required when int e r a c t i n g with families a f t e r the re s u s c i t a t i o n had proven to be unsuccessful. Two d i s t i n c t modes of int e r a c t i o n were described as part of the CCN•s experience with unsuccessful re s u s c i t a t i o n , one mode of int e r a c t i o n was reguired to function i n the r e s u s c i t a t i o n e f f o r t and another mode to in t e r a c t with family members. It' s tough. You almost have to be an actress, don't you? Your emotions come up to the surface with the family and then you have to switch and become more c l i n i c a l and objective to deal with the patient's care ( r e f e r r i n g to care provided i n the patient's r e s u s c i t a t i o n ) . The p a r t i c i p a n t s stated that they had learned and grown in t h e i r various CCN roles by r e f l e c t i n g on the unsuccessful r e s u s c i t a t i o n experience, following the arrest procedure. A common feature of the par t i c i p a n t s ' s t o r i e s was that CCNs conducted a "post mortem" of the re s u s c i t a t i o n e f f o r t and t h e i r r o l e i n i t . The participants analyzed t h e i r performance during the arrest procedure i n terras of t h e i r 40 s k i l l s , knowledge, and e f f i c i e n c y . The post mortems go on. Like, how could I have < done t h i s better? How come t h i s happened? I should have been more assertive. The old, d i d I miss something, or could we have anticipated t h i s , that sort of thing. The post-resuscitation analysis often resulted i n new learning and a change i n t h e i r nursing p r a c t i c e . Often t h i s new learning was based on mistakes or omissions committed by the CCN during the r e s u s c i t a t i o n e f f o r t . One p a r t i c i p a n t described the change that resulted from her post-r e s u s c i t a t i o n analysis as "a determination to be the patient's advocate." She had learned t h i s because the e f f e c t s of her not advocating strongly to the c a r d i o l o g i s t regarding her concern about the patient•s condition p r i o r to the arrest procedure influenced the patient's treatment p r i o r to h i s cardiac arrest and death. Cultural Patterns The p a r t i c i p a n t s agreed that, p a r t i c u l a r l y following an unsuccessful resuscitation, the CCN spends a great deal of time "normalizing" the physical environment of the c r i t i c a l care unit i n order that the s e t t i n g appear calm and ordered to onlookers. Normalizing included preparing the patient who had been unsuccessfully resuscitated for the morgue, cleaning up the r e s u s c i t a t i o n debris, and restocking the supplies i n the room. Cleaning up and restocking the area ensured that the room and equipment was ready for subsequent patients. Preparing the patient for the morgue involved 41 " t i d y i n g up" the patient, and s h i f t i n g from l i f e saving techniques to removing the intravenous l i n e s and tubes that were inserted during the re s u s c i t a t i o n e f f o r t . And then you have to change, and there's a l l those, you know, IV's and that, you know, tubes that took so much time and e f f o r t putting i n , you ju s t s t a r t p u l l i n g them out and that part i s hard sometimes too, you know. The p a r t i c i p a n t s stated that normalizing the environment also assisted them to deal with the inner turmoil they experienced a f t e r an unsuccessful r e s u s c i t a t i o n . One par t i c i p a n t described the time spent preparing the body and normalizing the environment as important for "private debriefing" or processing the emotional aspects of the re s u s c i t a t i o n e f f o r t . , I think part of i t i s that you sort of need to put time in between the event and getting onto your next job whether i t s taking a new patient or helping someone. I'm not saying they, I don't think they do i t consciously but I think i t ' s sort of a l i t t l e private debriefing or something that people do. Physiological/Psychological E f f e c t s The physiological and psychological e f f e c t s of p a r t i c i p a t i n g i n an unsuccessful r e s u s c i t a t i o n were deemed by the partic i p a n t s to s i g n i f i c a n t l y influence the CCN's experience. P a r t i c i p a t i n g i n an unsuccessful r e s u s c i t a t i o n was viewed by the participants as a f f e c t i n g them p h y s i o l o g i c a l l y . Each of the participants described a "rush of adrenalin" when they were required to p a r t i c i p a t e i n a re s u s c i t a t i o n e f f o r t ; t h i s rush was sustained u n t i l the re s u s c i t a t i o n team pronounces that the i n d i v i d u a l i s dead. 42 The p a r t i c i p a n t s stated that the i n i t i a l adrenalin rush allowed them to think c l e a r l y and focus on the r e s u s c i t a t i o n e f f o r t . Your adrenalin goes, kicks i n and you're almost switching to a d i f f e r e n t mind set that you at the time, I don't think you see or you're aware j u s t how much you're seeing, but a f t e r when you s t a r t r e c a l l i n g i t , you s t a r t to think a l l the d i f f e r e n t things at the time. You're so, so focused. You perform those things that you learned, from memory. When the i n d i v i d u a l was pronounced as dead, the CCNs described the d i s s o l u t i o n of the adrenalin rush, as "a l e t down". They characterized t h i s period as f e e l i n g t i r e d , weak, and exhausted. Several p a r t i c i p a n t s commented that t h e i r a b i l i t y "to take anything else i n " a f t e r an unsuccessful r e s u s c i t a t i o n was severely compromised. They stated that, i f the r e s u s c i t a t i o n occurred early i n a work s h i f t , they generally were exhausted and d i s t r a c t e d f o r the remainder of the s h i f t . A f t e r the event, i t was, mind shut down. I t was sort of that, a numbness. Just get me to seven t h i r t y . Knowing Three main theme clust e r s emerged from the data: knowing the case, knowing the patient, and knowing the person. The presentation of the findings i n t h i s chapter i s adapted from the thematic inquiry developed by van Manen (1990) to f a c i l i t a t e the data analysis i n a phenomenological study. Each of the theme cl u s t e r s i s presented within the thematic organization adapted from van Manen's data analysis framework: aspects of the theme, manifestations of the 43 theme, i s o l a t i n g what the theme does, describing how the theme does what i t does; and the s i g n i f i c a n c e of the theme for nursing. The f i r s t theme refers to knowing the case. Knowing the Case According to the participants of the research study, CCNs must know the case i n order to provide competent care to c r i t i c a l l y i l l patients who may become unstable and require r e s u s c i t a t i o n . Knowing the case ref e r s to nurses u t i l i z i n g t h e i r t h e o r e t i c a l knowledge and past experience of the diagnosis, physiology, and t y p i c a l responses associated with the diagnosis to anticipate the interventions and outcomes associated with r e s u s c i t a t i o n of the case. Aspects of Knowing the Case CCNs* experience with unsuccessful patient r e s u s c i t a t i o n revealed the following aspects of knowing the case: diagnosis, assessment of physiological responses, recognizing indicators of cardiac and/or respiratory arrest, expected responses to interventions, and interventions associated with cardiopulmonary arrest. The CCN's interventions i n a cardiac and/or respiratory arrest are based on t h e o r e t i c a l knowledge of s p e c i f i c r e s u s c i t a t i o n protocols and knowing the case. Resuscitation protocols are learned i n basic and advanced cardiac l i f e support c e r t i f i c a t i o n classes (BCLS and ACLS) and i n u n i t o r i e n t a t i o n . As the participants began to t e l l the story of an 44 unsuccessful patient resuscitation, each highlighted some basic information about the case. This information included the patient's diagnosis and pertinent p h y s i o l o g i c a l responses. Patient diagnoses i n the paradigm s t o r i e s included: an abdominal a o r t i c aneurysm repair, a fractured leg, a thoracic a o r t i c aneurysm, AIDS, chest pain, myocardial i n f a r c t i o n , sepsis, cancer of the breast, and cardiogenic shock. Additionally, the GCNs rela t e d the degree of s t a b i l i t y or i n s t a b i l i t y associated with the case and the relevant physiological responses. He had been admitted to hospital with myocardial i n f a r c t i o n . Now I'm assuming i t was an i n f e r i o r i n f a r c t i o n because, uh, he had s i g n i f i c a n t l e f t v e n t r i c u l a r f a i l u r e . Several p a r t i c i p a n t s described the diagnosis, ph y s i o l o g i c a l responses, and interventions as " t y p i c a l " for the case. These cases were considered stable and the CCNs' envisioned routine care. He'd had a large MI and so, he was i n with the monitoring and l e t ' s say he was sick, but stable. The CCNs stated that they learned to know the case by comparing i t to the routine care provided to other patients with the same diagnosis. He was HIV p o s i t i v e , had AIDS and he was i n severe respiratory d i s t r e s s . And I think he hadn't previously had PCP (Pneumocystis c a r i n i i pneumonia) because we won't intubate somebody i f t h i s i s a second bout because a l l of the data show that they don't make i t o f f the v e n t i l a t o r and s t u f f . The nurse draws on her t h e o r e t i c a l knowledge, assessment s k i l l s , and previous experience with l i k e 45 s i t u a t i o n s to determine the patient's s t a b i l i t y . For example, i n the following s i t u a t i o n , the nurse knew that the patient had a fractured leg, however, i t was unknown why h i s condition had deteriorated to c r i t i c a l status. They (r e f e r r i n g to the ward s t a f f ) wanted to get him down as quickly as possible. He was on a hundred percent oxygen and one thing I j u s t remembered about him was that he was purple from the nipple l i n e up. He had that mottled, um well, he was pale a l l the way from hi s h i s extremities were l i k e cyanotic but he had that mottled embolus look from the nipple l i n e up. They get that funny mottled look and a f a i r amount of JVD (jugular venous distention) and he was conscious, was t a l k i n g and seemed quite calm about everything. In t h i s dramatic case, the patient arrived i n the ICU and the nurse assessed h i s s t a b i l i t y and p o t e n t i a l for cardiopulmonary arrest rapidly. (I) could t e l l when you looked at him that he was an imminent arrest. You could j u s t t e l l that he wasn't going to do well. The indicators of t h i s cardiopulmonary arrest were apparent to the CCN almost i n s t a n t l y . In two of the nine paradigm narratives, the CCN's knowledge of the patient's diagnosis, t y p i c a l p h y s i o l o g i c a l responses, and assessment findings assisted the nurse to determine the patient's s t a b i l i t y and to anticipate a cardiac and/or respiratory arrest. I t appears that knowing the case a s s i s t s nurses to anticipate a cardiac and/or ' j -respiratory arrest i n selected s i t u a t i o n s . The a b i l i t y to anticipate an unsuccessful patient r e s u s c i t a t i o n altered the emotional tone of the experience for the CCN. For example, one p a r t i c i p a n t stated that she "expected the a r r e s t " and 46 that the unsuccessful r e s u s c i t a t i o n "was not a surprise". This p a r t i c i p a n t expressed feelings of sadness for the family but l i t t l e emotion was expressed for the patient. Knowing the patient as a case l i m i t e d the CCNs emotional response to the patient's death. The par t i c i p a n t s concurred that knowing the patient i s often more h e l p f u l i n pre d i c t i n g an arrest than knowing only the case. The concept of routine interventions and predicted responses to interventions i n a re s u s c i t a t i o n e f f o r t contributed to the nurses' knowing the case. The par t i c i p a n t s stated they were able to predict the outcome of res u s c i t a t i o n e f f o r t s because they had learned that the length of time that was required to resuscitate people, the procedures used, and the responses of the patient were predictors of success i n a re s u s c i t a t i o n e f f o r t . I think time and ju s t the way the arrest went and how he needed to be shocked so many times and, urn, you know a f t e r using a l o t of l i n e s and drugs and nothing was r e a l l y working, I mean there's not too much you can do about that. Manifestations Knowing the case manifests i t s e l f i n the baseline data that the CCN c o l l e c t s and reports to others; the CCN's perception of the range of patient outcomes; the CCN's recognition of an impending cardiac and/or respiratory arre s t ; the conventional care provided by the CCN p r i o r to, during, and a f t e r the res u s c i t a t i o n e f f o r t ; and the CCN's confidence i n the s i t u a t i o n . 47 CCNs reveal t h e i r knowledge of the case by the way i n which they are able to d e t a i l the facts of the case to others. This i s i l l u s t r a t e d i n one pa r t i c i p a n t ' s story involving a patient who experienced severe chest pain and was thought to be i n the midst of a myocardial i n f a r c t i o n when he arrested. The rhythm changed into VT (re f e r r i n g to v e n t r i c u l a r tachycardia) and quickly into V Fib (r e f e r r i n g to ve n t r i c u l a r f i b r i l l a t i o n ) . Successive shocks were delivered and the patient had a v e n t r i c u l a r escape rhythm. Within one minute, the rhythm degenerated back to asystole and the external pacemaker was t r i e d . Knowing the case i s manifested by the range of patient outcomes that the CCN anticipates. Knowledge of the diagnosis, physiological responses, and common responses to therapeutic interventions a s s i s t the nurse to anticipate a range of patient outcomes. One pa r t i c i p a n t described a patient with progressive l e f t v e n t r i c u l a r f a i l u r e that was unresponsive to standard interventions. I knew they couldn't help him out because he had t h i s terminal type of condition with his heart. Several participants described a sense of the patient's i n e v i t a b l e death during the re s u s c i t a t i o n procedure. One pa r t i c i p a n t described the length and the patient's response to r e s u s c i t a t i v e e f f o r t s i n connection to "digging" f o r interventions to save the patient's l i f e and to a sense of desperation. When you get to that point — - l i k e twenty-five minutes into a f u l l blown arrest where you're digging now and, uh, you know, you're j u s t not getting anything back and, uh, you know, from experience as well. 48 In three paradigm narrative s i t u a t i o n s , the CCNs stated they d i d not want the patient to survive the r e s u s c i t a t i o n . The nurses viewed some situations as f u t i l e , and i n other sit u a t i o n s there was concern about the patient's q u a l i t y of l i f e i f they survived the re s u s c i t a t i o n . One pa r t i c i p a n t described the re s u s c i t a t i o n of a patient that was i n end stage cardiac f a i l u r e . The nurse had no desire to resuscitate the patient, but the c a r d i o l o g i s t had not written a "do not resuscitate" order. In t h i s s i t u a t i o n the CCN described f e e l i n g "angry and frustrated" and that i t "seemed to take forever for the physicians to make a decision". No one r e a l l y could make the decision to stop because they hadn't gotten ahold of the c a r d i o l o g i s t , and everyone, everyone knew the f u t i l i t y of t h i s but they kept on anyway. Another p a r t i c i p a n t described a r e s u s c i t a t i o n event i n which she hoped the patient would not survive. This nurse was concerned with the patient's q u a l i t y of l i f e following a cardiac and/or respiratory arrest. The main thing was that the consequences of him surviving t h i s arrest are too devastating or p o t e n t i a l l y devastating ... which maybe to look at the other side of that coin - maybe c r i t i c a l care nurses tend to be too s c e p t i c a l sometimes, you know, I do. Knowing the case manifests i t s e l f i n the CCN's expectations of the s i t u a t i o n and her a b i l i t y to provide rapid and appropriate nursing care, p r i o r to and during cardiac and/or respiratory arrest. The CCN must plan, implement, and evaluate interventions based on her knowledge 49 and experience with the case and r e s u s c i t a t i o n procedures. Several p a r t i c i p a n t s described technical p r o f i c i e n c y i n terms of how quickly care was provided. You're going as fast as you can. I mean you're over compensating, by doing things as quickly as you can and, urn, you know, ju s t t r y i n g to be as t e c h n i c a l l y as good as you can be. Knowing the case i s fundamental to the CCN's a b i l i t y to provide care and to p a r t i c i p a t e i n the r e s u s c i t a t i o n e f f o r t with a degree of confidence. Confidence i n caring for c r i t i c a l l y i l l patients and p a r t i c i p a t i n g i n resuscitations i s b u i l t , i n part on knowledge of the case, knowledge of re s u s c i t a t i o n protocols, and experience with r e s u s c i t a t i o n e f f o r t s . Knowing the case i s i l l u s t r a t e d i n the par t i c i p a n t s ' descriptions of recognizing the cardiac and/or respiratory arrest and i n the routine care provided i n the re s u s c i t a t i v e e f f o r t s . Each r e s u s c i t a t i o n requires the CCN to know the protocols or algorithms for various l i f e threatening heart rhythms and situa t i o n s . With knowledge and experience, CCNs develop a sense of comfort and confidence with cardiopulmonary resuscitations. A l l of a sudden, the algorithms take over and people f a l l into t h e i r roles and, I think people f e e l more, uh, that know what to do next. The p a r t i c i p a n t s ' confidence was r e f l e c t e d i n t h e i r assessment of data, planning, implementation, and evaluation of interventions. I thought j u s t by looking at the ECG that they should r e a l l y take a look at i t , and maybe consider something l i k e thrombolytics. Like I thought - There was a major 50 event happening. What does Knowing the Case Do? Knowing the case provided the par t i c i p a n t s with baseline information about the case that i s e s s e n t i a l to the determination of s t a b i l i t y , the a n t i c i p a t i o n of responses to interventions, and the a n t i c i p a t i o n of the range of patient outcomes. Knowing the case enhances CCNs1 competence and feelings of being i n control i n the provision of care. The p a r t i c i p a n t s agreed that knowing the case influenced t h e i r decision making and confidence. For instance, one experienced CCN was able to u t i l i z e her knowledge of the case and cardiorespiratory arrest to rap i d l y assess the s i t u a t i o n , categorize the c r i s i s , plan and implement care. He was i n respiratory d i s t r e s s - uh... we better get some help. F i r s t , I pressed the patient c a l l b e l l , and then I said, "Oh, no! This i s too serious j u s t to press the patient c a l l b e l l , and get someone to answer one minute l a t e r . We better press the s t a f f a l e r t button" - meaning look we need some help r i g h t away, could someone come down to t h i s room? And I r e a l i z e d , "Oh, no! He's one more step further than that. I'd better press the cardiac arrest button." That whole procedure probably took 10 seconds. Knowing the diagnosis and physiological responses of the case assisted the partic i p a n t s to appraise the degree of patient s t a b i l i t y . Repeated exposure to patients with s p e c i f i c diagnoses and physiological responses may allow CCNs to i d e n t i f y predictable patterns of phy s i o l o g i c a l responses and to anticipate some cardiac and/or resp i r a t o r y arrests. 51 The p a r t i c i p a n t s valued knowing the case as a way of preparing themselves for the s i t u a t i o n i n order that they be "protected" from unexpected occurrences. The CCN's a b i l i t y to anticipate an unsuccessful patient r e s u s c i t a t i o n i s influenced by her a b i l i t y to contrast the case with previous experience with s i m i l a r diagnoses and responses to interventions. The participants agreed that, i f a CCN i s prepared for the eventuality of an unsuccessful r e s u s c i t a t i o n , the nurse i s better able to protect h e r s e l f emotionally from the trauma of the patient's death. And there are d i f f e r e n t ways of approaching c e r t a i n diagnoses and patients. I t ' s important that the nursing s t a f f know that, to protect themselves and understand what's going to happen. Knowing the case a s s i s t s the nurse to contemplate the range of patient outcomes. The p a r t i c i p a n t s described the patient outcomes from a v a r i e t y of perspectives. For example, several participants stated that " i f a patient was stable and progressing normally" the CCN expected recovery. Another p a r t i c i p a n t described l i s t e n i n g to report from another nurse where she had a sense of the patient•s unsuccessful r e s u s c i t a t i o n and death. In the case the patient had "repeated set backs" and he was "getting worse". I was pretty sure that t h i s was a l l j u s t an ICU admission, a morphine drip and sedation induced kind of s t u f f . I assume that h i s aneurysm burst and that he had l o s t h i s volume before he l o s t h i s rhythm. You know the patients that aren't going to make i t long before they don't make i t . 52 The p a r t i c i p a n t s stated that knowledge of the case, derived from past experience with and learning about r e s u s c i t a t i o n cases, enables the CCN to be t e c h n i c a l l y p r o f i c i e n t during the arrest procedure. Many of the part i c i p a n t s described t h e i r knowing the case as r e s u l t i n g i n comfort and s a t i s f a c t i o n with the technical care provided i n the r e s u s c i t a t i o n procedure. I did CPR for a long time and was giving drugs and I f e l t comfortable with what I had done. Technically, i t went r e a l l y well and things were done l i k e r i g h t away, you know. He was intubated and you know, l i n e s were put i n and drugs were given. And the surgeon came down and did kind of what he could. Several of the participants described t h e i r s a t i s f a c t i o n with the technical care i n terms of "smoothness", " e f f i c i e n c y " , and "control". They emphasized that f e e l i n g confident about one's role i n the technical aspects of a re s u s c i t a t i o n e f f o r t enabled them to experience control i n the s i t u a t i o n . Control was defined as knowing what to do, an t i c i p a t i n g interventions, and experiencing a consistent flow i n thinking. The perception of "smoothness" and "control" provided the CCNs* with a sense of s a t i s f a c t i o n even when they f a i l e d to save the patient's l i f e . Several p a r t i c i p a n t s expressed that they did not f e e l " g u i l t y " when they had done everything could for the patient. Even i f i t ' s (resuscitation) unsuccessful, and i f i t ' s controlled, you f e e l l i k e , well, I've done everything. You f e e l more p o s i t i v e about the experience because i t ' s j u s t l i k e sort of that w e l l - o i l e d machine. I t ' s working and things are going the way they should. You know, l i k e everything i s being done. Things aren't 53 being missed. How does Knowing the Case Do What i t Does? Knowing the case provides the CCN with fundamental information that a s s i s t s the nurse to make nursing care decisions. The CCN's confidence and expectations are influenced by her t h e o r e t i c a l or textbook knowledge of the case and past experience with the case. The nurse compares and contrasts the textbook case and her previous experiences with the current case. This a c t i v i t y reveals the s i m i l a r i t i e s and uniqueness of the case. In some paradigm narratives, the CCN concluded that the case was "routine", consistent with usual patterns of patient response, interventions and nursing care. Such a conclusion enabled the CCN to f e e l confident that she could predict the outcomes of the case. The CCN's a b i l i t y to predict the pot e n t i a l outcomes of the case, s p e c i f i c a l l y unsuccessful patient r e s u s c i t a t i o n was p i v o t a l to her perception of the experience. An MI being monitored but no invasive monitoring, j u s t on the monitor watching his rhythm, and such and on, you know, a n i t r o infusion and heparin that sort of thing and, he had been stable a l l day. Just the usual, a l i t t l e diaphoretic here and there but no complaints of pain or anything a l l day and so I thought we were going along pretty good here. In two paradigm s t o r i e s , the par t i c i p a n t s reported that they were f a m i l i a r with t h e o r e t i c a l aspects of the case, but had no personal experience to draw upon. In both cases, the par t i c i p a n t s were unprepared for the turn of events and 54 patient outcomes. Both situations caused the par t i c i p a n t s to experience much angst and g r i e f . One p a r t i c i p a n t described an early experience i n c r i t i c a l care nursing when she was caring for a patient with a thoracic a o r t i c aneurysm. I t was her f i r s t exposure to that diagnosis and to the medical management of an a o r t i c aneurysm. The aneurysm ruptured and the nurse was involved i n the re s u s c i t a t i o n e f f o r t when the surgeon arrived. The surgeon was standing there, and not saying anything, and he was sort of, you know, pensive looking and, urn, you know, not ac t u a l l y scratching h i s head but almost and you sort of f e l t , "Well - God, do something." Urn, but he didn't. But i t wasn't even so much "do something", but "say something" and he didn't, for quite awhile, and I could see by the anxiety on the resident's face too, urn, and we had been working r e a l l y hard t r y i n g to resuscitate him and t h i s guy (the surgeon) arrived and ju s t sort of stood there. Anyway, f i n a l l y I think the resident said to the surgeon "What would you l i k e us to do?" Because, you know, the man was dying and his he was deteri o r a t i n g and h i s rhythm was becoming completely i r r e t r i e v a b l e , and t h i s surgeon said, "He's dead." And he walked away and, uh, he didn't say, "He's dead." He said, "He's dying. There's nothing more we can do." He said, "He's dying for sure. I f not, he's dead." And he walked away and we were a l l l e f t standing there. The p a r t i c i p a n t stated she had not understood the goals of care i n t h i s case and f e l t uncertain, helpless, and angry. The p a r t i c i p a n t described f e e l i n g confused and abandoned i n t h i s case when the surgeon did not act i n the way she had anticipated. The CCN had anticipated that the surgeon would "rush the patient to surgery and attempt to repair the aneurysm". This s i t u a t i o n altered the pa r t i c i p a n t ' s thinking and practice because i t taught her that, i n cases 55 such as t h i s one, you may not always be able to "save people" and that i t i s extremely important to understand the medical plan at the onset of a re s u s c i t a t i o n i n order to anticipate the poten t i a l interventions and outcomes. Significance of Knowing the Case Knowing the case gives meaning to the s i t u a t i o n . I t allows the nurse to make some assumptions about the patient's physiological responses and to anticipate interventions and patient outcomes associated with the diagnosis and the re s u s c i t a t i o n procedure. I t also enables the CCN to anticipate her role i n the re s u s c i t a t i o n . The par t i c i p a n t s concurred that knowing the case heightens the p r e d i c t a b i l i t y of the res u s c i t a t i o n experience for the CCN and, thus, her sense of control i n the s i t u a t i o n . Knowing the Patient "Knowing the patient" was perceived by a l l p a r t i c i p a n t s i n the research study to be s i g n i f i c a n t i n meeting the care needs of both the patient and his/her s i g n i f i c a n t others. Knowing the patient entailed knowing d e t a i l s about the patients (e.g., age, gender, past medical h i s t o r y ) , r o l e s (e.g., father, unemployed) i n order to provide nursing care to the patient. Aspects of Knowing the Patient The CCNs viewed the following aspects of knowing the patient as c r i t i c a l to providing e f f e c t i v e nursing care before, during, and following an unsuccessful r e s u s c i t a t i o n : 56 the patient's age, gender, past medical history, roles (e.g., father, unemployed), s i g n i f i c a n t others, l o c a t i o n of residence, and current physiological status. Knowing the patient's past medical h i s t o r y often revealed whether the patient was l i k e l y to undergo an arrest and how successful a re s u s c i t a t i o n might be. In several paradigm narratives, the patient had been healthy p r i o r to admission and the CCN was aware of t h i s p r i o r to the arrest. In s i t u a t i o n s where the nurse knew aspects of the patient's h i s t o r y and current physiological status and she d i d not expect the patient's unsuccessful r e s u s c i t a t i o n i t caused her to question why the arrest had occurred, and at times, i t caused the par t i c i p a n t to assume blame for not an t i c i p a t i n g and preparing herself for the unsuccessful r e s u s c i t a t i o n . I think i t was something l i k e an i n f e r i o r i n f a r c t i o n . But, p r i o r to h i s admission to hos p i t a l , he'd never been admitted to hos p i t a l before. And i t was one of h i s f i r s t h o s p i t a l admissions. He was i n extremely good health. In other narratives, the patient's h i s t o r y was c r u c i a l to the outcome of the re s u s c i t a t i o n e f f o r t but was not known u n t i l during or following the arrest procedure. I t turned out that he had broken h i s leg a month before that. But he was out of the hos p i t a l and had come i n the night before with complaints of chest pain, and i t turned out he had microemboli throughout. Each of the paradigm s t o r i e s t o l d by the CCNs included an approximation of the patient's age. In the paradigm 57 s t o r i e s , the patient's age ranged from eighteen to eighty years old. The participants agreed that knowing the patient's age created expectations regarding the outcome of the r e s u s c i t a t i o n e f f o r t . The younger the patient, the more CCNs1 expected the patient to survive a r e s u s c i t a t i o n attempt and the more affected they were by the event of an unsuccessful r e s u s c i t a t i o n . The p a r t i c i p a n t s i n t h i s research study defined a young patient as eighteen to early s i x t i e s i n years. While fo r t y ( r e f e r r i n g to the patient's age) you're thinking, "Oh, i t w i l l be Okay, s h e ' l l survive." I n i t i a l l y when you, i t s crazy how much weight you put on the age before other things. You know, urn, had we a l l taken more time, to just r e a l l y delve into her h i s t o r y and look at what was happening, urn, i t wasn't probably that surprising that t h i s had happened (ref e r r i n g to the unsuccessful r e s u s c i t a t i o n ) . A r e s u s c i t a t i o n of a young patient created a sense of i n t e n s i t y and s i g n i f i c a n c e for the p a r t i c i p a n t s of the research study. The younger the patient the greater the investment of the nurse i n the patient's s u r v i v a l and the stronger the feelings associated with the patient's death. The CCNs' described f e e l i n g extreme sorrow and pain when they were unable to successfully resuscitate a young patient. The fact that she was forty was j u s t , you f e e l the i n t e n s i t y of the time because she's, uh, young. Es p e c i a l l y when i t s somebody who i s , you know, young. And you think, you know, his time maybe r e a l l y shouldn't have come yet. One p a r t i c i p a n t described an eighteen year old male who had 58 been previously healthy. This CCN c r i e d as she described the unsuccessful r e s u s c i t a t i o n attempt. The unsuccessful r e s u s c i t a t i o n of t h i s patient was described as "devastating" by the CCN. Participants of the research study perceived that the interventions used i n the r e s u s c i t a t i o n procedures of young patients were more aggressive than those with older patients. One paradigm case focused on a patient i n h i s l a t e f o r t i e s or early f i f t i e s who had a myocardial i n f a r c t i o n . During the course of the r e s u s c i t a t i o n e f f o r t , the patient received d e f i b r i l l a t i o n , drugs, a thoracotomy, v i s u a l inspection of the heart, and open cardiac massage. The r e s u s c i t a t i o n e f f o r t continued for over a hour. The p a r t i c i p a n t described f e e l i n g a sense of "desperation" as the t r a d i t i o n a l interventions were i n e f f e c t u a l . And everybody, I remember, l i k e no matter what sort of the next suggestion was, you know, to carry on further, you know. Everybody was r e a l l y , "Yes, l e t ' s go ahead." You know, "Let's t r y t h i s . " You sort of t r y anything. Knowing the patient also included knowing the gender, loc a t i o n of residence, and roles of the patient. The most s i g n i f i c a n t of these to the participants was the family roles enacted by the patient. Occupational rol e s , l o c a t i o n of residence, and gender were considered i d e n t i f i e r s of the patient. For example, several of the p a r t i c i p a n t s said that, at the time of the unsuccessful r e s u s c i t a t i o n , they had been aware of what the patient did for a l i v i n g but could not r e c a l l that information during the interview. 59 Data concerning where the patient l i v e d (e.g., out of the c i t y ; i n the ci t y ) were generally provided i n the research interview i n r e l a t i o n to the patient's s i g n i f i c a n t others (e.g., how long i t would take the family members to be with the patient once the arrest had occurred). The p a r t i c i p a n t s consistently r e c a l l e d , and emphasized i n the research interview, the patient's role(s) i n the family. Family roles of the patients described i n the paradigm narratives included mother, father, and son. The patient's age and roles within the family provided the CCN with an i n d i c a t i o n of the si g n i f i c a n c e of the i l l n e s s and the unsuccessful r e s u s c i t a t i o n for the patient and his/her s i g n i f i c a n t others. Knowing the si g n i f i c a n c e of the unsuccessful r e s u s c i t a t i o n e f f o r t created meaning for the CCN. The partic i p a n t s were able to understand the experience from the patient and his or her s i g n i f i c a n t other's perspective and empathize with the anguish the patient's death caused. A young man probably i n his l a t e f o r t i e s , urn, or early f i f t i e s , you know, wife and children. He was from out of town and he'd had a large MI. We were t o l d that her (patient) c h i l d was i n the waiting room with the dad. Oh, suddenly the whole emotions changed rapidly. You know. So we what I did was, I did t r y . I l e f t the s i t u a t i o n because I had to spend I kept thinking that each, i f we could get her back, i f we could get her back so he (child) could, the c h i l d could come i n and see his mom. This was more than just an eighteen year old boy. This was somebody's son. Knowing the patient i n an unsuccessful patient 60 r e s u s c i t a t i o n frequently included knowing the patient's s i g n i f i c a n t others. The p a r t i c i p a n t s stated that information regarding s i g n i f i c a n t others was provided by the patients, from the s i g n i f i c a n t other during v i s i t s to the c r i t i c a l care unit, and from one nurse to another during report. He talked a l o t about hi s children. He talked a l o t about h i s c h i l d or children. There might have been two because I noticed him using the word "children". Anyways, he talked a l o t about his children and, uh, how loving they were. The p a r t i c i p a n t s agreed that one of t h e i r roles was to provide information and support to s i g n i f i c a n t others before, during, and following unsuccessful patient r e s u s c i t a t i o n . Knowing the s i g n i f i c a n t others of the patient was perceived by the participants to be necessary i n order that they be able to f u l f i l t h i s r o l e e f f e c t i v e l y . The p a r t i c i p a n t s had met the s i g n i f i c a n t others p r i o r to the r e s u s c i t a t i o n i n only three of the nine paradigm cases. In two of these situations, the s i g n i f i c a n t others had been with the patient just p r i o r to the arrest and were asked to wait i n the waiting room during the arrest procedure. In the t h i r d s i t u a t i o n , the nurse had met the patient's wife the day before the arrest. One p a r t i c i p a n t reported that she found i t very "bothersome" that the patient's wife had witnessed the patient seizuring, a l e r t e d the nurse, and, when the patient subsequently arrested, was asked to wait out of the unit i n the hallway. The CCN 61 explained that t h i s event was "bothersome" because the wife's d i s t r e s s over her husband's seizure and arrest was uppermost i n her mind during the re s u s c i t a t i o n e f f o r t . Yeah, yeah, that she was there. And of course then knowing that, you (the wife) know what's going on and the arrest i s c a l l e d . I mean i t ' s d i f f e r e n t than c a l l i n g somebody at home. In the other s i x paradigm cases, the s i g n i f i c a n t others were not known to the CCN p r i o r to the r e s u s c i t a t i o n attempt. In these situations, the s i g n i f i c a n t others were n o t i f i e d of a deterioration i n the patient's condition and were asked to come to the ho s p i t a l . These p a r t i c i p a n t s described the d i f f i c u l t y of supporting s i g n i f i c a n t others whom they had not met p r i o r to the re s u s c i t a t i o n e f f o r t . I t was hard. F i r s t of a l l , i t ' s a b i t hard when you hardly know the family. I f you've developed a b i t of a rel a t i o n s h i p with the family, uh, I f i n d i t a l i t t l e easier to, to be supportive. I don't know. I t ' s , i t ' s something that you do a f a i r b i t , t r y i n g to be some form of emotional support for the family so - but i t ' s always hard. I t ' s a very sad time. Some of the participants stated they had personalized the loss of the patient, following an unsuccessful re s u s c i t a t i o n , when they knew the patient's gender, rol e s , and family. One participant discussed the unsuccessful patient r e s u s c i t a t i o n of an eighteen year old i n r e l a t i o n to maternal i n s t i n c t and the focus of professional nursing. I t stood out for a l l of us, you know, i t was, urn, I don't know so much for the physician, he j u s t f e l t generally bad. I think he saw i t quite d i f f e r e n t l y as upsetting. And I'm not sure because we were females and have t h i s maternal i n s t i n c t . Although I was the only one with kids or, urn, whether i t ' s j u s t the difference i n our focus profe s s i o n a l l y . 62 Knowing the patient also encompassed knowing the d e t a i l s of the patient's recent physiological status. Details of the patient's s t a b i l i t y within the past twenty-four to forty-eight hours were provided i n the paradigm narratives. Frequently, t h i s information related to the CCN's and s i g n i f i c a n t others' expectations of the outcome of the r e s u s c i t a t i o n . I look back now. I t had been only i n the l a s t twenty-four or forty-eight hours that there had been a r e a l acuteness to her i l l n e s s . And so, i t was l i k e okay, well, s h e ' l l recover. She's been through other things l i k e t h i s . Manifestations Knowing the patient i s manifested i n the CCN's rel a t i o n s h i p to patients and s i g n i f i c a n t others and i n the detachment or distancing they enacted i n an unsuccessful r e s u s c i t a t i o n . Knowing the patient was evident i n the p h y s i o l o g i c a l and psychological care that the p a r t i c i p a n t s of t h i s study provided for t h e i r patients and t h e i r s i g n i f i c a n t others. This care incorporated what the CCN knew about the patient ( i . e . , the aspects of knowing the p a t i e n t ) . The CCNs' relationships with t h e i r patients were described by many of the participants as a sense of concern for the patient and a perception of r e s p o n s i b i l i t y f o r t h e i r care. Frequently, t h i s role was described by the p a r t i c i p a n t s as "advocating" for the patient. One p a r t i c i p a n t described a s i t u a t i o n i n which a patient 63 developed severe chest pain that was unremitting. The patient's chest pain was unaffected by conventional treatment. The physicians were alerted to t h i s patient's condition but did not assess the patient immediately. I was a l i t t l e worried about the patient and I was frustrated that I thought t h i s patient r e a l l y needed to be looked at. And there were a number of doctors there but the intern was placing, our intern was placing the wire (a pacemaker wire), and the c a r d i o l o g i s t was supervising her and didn't f e e l i t was appropriate to leave her, even though there were, you know (other physicians there). Knowing the patient was revealed i n the p a r t i c i p a n t s • interactions and relationships with s i g n i f i c a n t others. Because the p a r t i c i p a n t s knew that the patient was connected to s i g n i f i c a n t others, the CCNs incorporated the needs of these s i g n i f i c a n t others i n the plan of care. The CCNs i d e n t i f i e d the needs of families by assessing the families coping strategies and resources, a n t i c i p a t i n g patient outcomes, and drawing on t h e i r past experience with families experiencing c r i s i s and g r i e f . I mean i t ' s not that you don't s h i f t your focus of care but you have, I think you widen the scope of your caring not to just include that patient that probably won't make i t but also too the family whose going to be i n the aftermath of the whole s i t u a t i o n . You have to widen i t rather than r e s t r i c t i t , i t ' s so much easier to r e s t r i c t your focus. Caring for s i g n i f i c a n t others entailed providing information and emotional support, as well as accessing appropriate resources to meet the needs of the s i g n i f i c a n t other. At times, t h i s included preparing the family members for the patient's death. 64 One pa r t i c i p a n t described a paradigm case that involved her i n t e r a c t i o n with the partner of a patient with AIDS. The CCN t o l d the partner that the patient would be more comfortable a f t e r he was intubated and asked the s i g n i f i c a n t other to wait i n the waiting room during the intervention. The patient arrested following the intubation and died. The pa r t i c i p a n t spoke of f e e l i n g that she had betrayed the partner because she had not prepared him for the eventuality of the patient's death. The CCN described f e e l i n g g u i l t y that she had not anticipated the patient's unsuccessful r e s u s c i t a t i o n , and that she had deceived or " t r i c k e d " the partner into b e l i e v i n g that the patient would be more comfortable a f t e r his intubation. The p a r t i c i p a n t s stated that, although the patient was t h e i r p r i o r i t y i n an unsuccessful r e s u s c i t a t i o n , there were times when i t became apparent that the s i g n i f i c a n t others had needs that required a r e f e r r a l to other h o s p i t a l departments and/or the a l l o c a t i o n of resources. So when I went i n I r e a l l y made an e f f o r t of sort of t a l k i n g with the l i t t l e boy, t a l k i n g with the dad j u s t because I thought t h i s i s n ' t going to work. Well, l e t ' s b u i l d that rapport as f a s t as you can i n a short space of time. And, uh, the boy was a l i t t l e , he was a t a l k a t i v e fellow and he li s t e n e d as I talked to the dad but he was very much a part of what was going on. And I thought, oh that was. in t e r e s t i n g - that obviously the dad didn't f e e l that he had to shelter him, or say, or say, "Well, I'd l i k e to t a l k to you alone." There was nothing l i k e that. They were a group the two of them and so, urn, I began to l e t them know what was happening to, uh, t h e i r loved one and, uh, they were okay and there was t h i s f e e l i n g of yeah, she's been through some tough s t u f f , i t ' s okay, i t 65 was almost as i f one says i t s okay, s h e ' l l p u l l through because you know we've been there. Following t h i s i nteraction, the CCN asked the unit c l e r k to c a l l a s o c i a l worker and she apprised the s o c i a l worker of the s i t u a t i o n . Knowing the patient was also manifested by the pa r t i c i p a n t s ' use of professional distancing and detachment when in t e r a c t i n g with patients. Professional distancing was defined as concern and care for the patient and family members while maintaining some emotional distance and protecting oneself. Knowing that the patient was l i k e l y to die because of his/her poor physiological status and knowing that the death of the patient would be devastating to his/her s i g n i f i c a n t others were the most common reasons given by the partic i p a n t s for detachment to occur i n an unsuccessful r e s u s c i t a t i o n . The partic i p a n t s concurred that detachment i s a strategy that reduces the impact of the CCN's loss and g r i e f associated with unsuccessful patient r e s u s c i t a t i o n . There was a part of me that also distanced myself from him because I knew he wasn't going to make i t . We could see that happening. (I) t r y and be empathetic and care for the patient but not allow the emotions to — — to get so much involved. A l i t t l e , yeah, professional distance. From the emotional part of i t , you know, I mean you c e r t a i n l y that's your job to show concern and care but there i s a point that you've got to care about yourself too. Several p a r t i c i p a n t s stated that they used detachment so that they could support the family more e f f e c t i v e l y . The CCNs1 explained that when they were emotionally "controlled" they f e l t they were more supportive to family members. If you are a l i t t l e more detached i t makes i t a l i t t l e easier and you're a l i t t l e more e f f e c t i v e with the family. T e l l i n g family members "bad news" about the patient was viewed as one of the most s t r e s s f u l aspects of the CCNs r o l e i n an unsuccessful r e s u s c i t a t i o n . One p a r t i c i p a n t t o l d of how she had to put on a professional mask before she prepared the s i g n i f i c a n t others for the patient's death. Another reported that she had learned " l i n e s " to help her d e l i v e r the news i n a professional but caring manner i n such si t u a t i o n s . I think okay "Nurse", I almost have to mentally because inside I'm ju s t churning. So I r e a l l y t r y to be as slow thinking and t a l k i n g when I see them, you know, because I'm t r y i n g to think of them. Their anxiety l e v e l ' s up to here. I remember going out and t e l l i n g them that i t r e a l l y wasn't looking very good, you know, that she was r e a l l y unstable. I always do - those are my l i n e s , when I know that there's the impending doom, j u s t i n the old preparation work and making the point when I, when I had t h i s gut f e e l i n g that the person's not going to make i t . Two partic i p a n t s stated that past experiences involving the death of a patient p r e c i p i t a t e d t h e i r deliberate use of detachment to protect t h e i r emotional i n t e g r i t y . E a r l i e r i n my career I'd gotten r e a l l y quite involved with a family and a patient and when the patient died, i t was l i k e the whole nursing s t a f f was there crying t h e i r eyes out. The doctor was there. We were a l l holding hands and i t was ju s t the most emotionally draining thing that ever happened. So I've t r i e d to 67 put a l i t t l e b i t of professional distance ever since then. I went home a basket case for two days. I t was l i k e , oh, I was so depressed. One p a r t i c i p a n t stated that she chose to be detached because she had seen too many CCNs become "burnt out" as they were "too emotionally involved" with patients who died. Two other p a r t i c i p a n t s described becoming "businesslike" during a r e s u s c i t a t i o n , p a r t i c u l a r l y when the arrest had been expected and the outcome was predicted to be negative. Then I'm pretty sure I f e l t business l i k e . Okay,now what i s the next task? This man has died. Emotional detachment was abandoned, however, when the CCNs interacted with s i g n i f i c a n t others following an unsuccessful patient r e s u s c i t a t i o n . The p a r t i c i p a n t s described "looking into" themselves for feelings when they were required to t e l l a s i g n i f i c a n t other that the patient might not l i v e . This "getting i n touch with f e e l i n g s " was viewed as necessary to support and care for s i g n i f i c a n t others i n an empathetic manner. You see the hope f a l t e r i n g , urn, then somehow the old emotions take over and you f i n d i t hard and, harder as you f i n d yourself getting more and more clo s e r to them and f e e l i n g what they're f e e l i n g and, uh, so yeah, toward the end, I found i t very d i f f i c u l t . Several participants stated that i t was much easier from an emotional perspective not to have to i n t e r a c t with the family following an unsuccessful patient r e s u s c i t a t i o n . I t would have been easier i f I had not had the family. I t would have been very guick and over with. I guess that made i t easier on us i n a way, that we didn't have to deal with the family. Because that's 68 c e r t a i n l y a s t r e s s f u l thing to deal with and sometimes I f i n d i t more s t r e s s f u l dealing with the family than, you know, with the patient dying and whatever. One p a r t i c i p a n t described a s i t u a t i o n where she had anticipated that the charge nurse would inform the family of the patient's death. The charge nurse, however, was absent from the unit when the family arrived. Having the charge nurse t e l l the family of the patient's death was a strategy used within t h i s unit to reduce the CCN's stress and allow the nurse to remain detached from the s i t u a t i o n . T y p i c a l l y , the way i t runs i n our unit - i s the doctor would be the one to inform them or the charge nurse. We have assistant head nurses who are always on duty and they usually perform that function, one of those two people. In fact, i n our area, the bedside nurses do not get put i n that position. That•s sort of rare for me. Although the CCN began to t e l l the news of the patient's death to the family i n a detached manner, she recognized that she would have to discard her cloak of detachment before she could r e l a t e to the family i n an empathetic way. I've had many patients die - I didn't have a l o t of feelings l i k e emotions, or I wasn't caught up i n my emotions, or I wasn't caught up i n my emotions at a l l about t h i s man having died. But, so i t was more, a l i t t l e , um, d i f f i c u l t for me to remove sort of - I had to sort of force myself to say the f i r s t few words -knowing that I was d e l i v e r i n g to t h i s family t h i s news. What does Knowing the Patient Do? Knowing the patient improves the CCN's a b i l i t y to plan and implement care that i s s p e c i f i c to the patient and family. The nurse i s able to use her knowledge of the patient and the case to i d e n t i f y p a r t i c u l a r patient 69 responses. In many of the paradigm narrative s i t u a t i o n s , the CCNs stated that they had customized t h e i r care based on t h e i r knowledge of the patient. Knowing the patient's t y p i c a l responses altered the CCN's assessment and l e v e l of concern f o r the patient. I asked him to describe the pain, where i t was and I saw that he was i n , you know, he was i n obvious d i s t r e s s . So, I sort of - r e a l l y l i m i t e d what I asked him, uh, checked h i s blood pressure, gave him n i t r o g l y c e r i n , urn, c a l l e d for a s t a t twelve lead. Knowing the patient's roles within the family assisted the CCNs to r e l a t e to how i t would f e e l to lose a c h i l d , father, or mother. This was deemed necessary to be t r u l y empathic with s i g n i f i c a n t others during and following an unsuccessful patient r e s u s c i t a t i o n . How was she ( s i g n i f i c a n t other) going to manage, and you know, yeah and, "How do you t e l l the children?" And they're children now and they love t h e i r dad. This was unexpected for the family. They did not expect her to suddenly, urn, pass away. I went out to, you know, to see the family. I t r y to be aware of the fact that i t ' s the longest f o r t y minutes of t h e i r l i f e or, however, long i t i s . The p a r t i c i p a n t s agreed that knowing the patient influenced CCNs' g r i e f responses i n unsuccessful patient resuscitations. CCNs experienced an increased sense of loss with unsuccessful patient r e s u s c i t a t i o n of young patients. In the end you say, "Oh forget i t , i t ' s a woman, she's forty, she's dying". You know, the emotions are there. In a few paradigm narratives, the p a r t i c i p a n t s were able to cope with t h e i r feelings about an unsuccessful r e s u s c i t a t i o n of an older patient by r e f e r r i n g to the patient's age. 70 I t ' s a l o t easier most of the time i f somebody i s l i k e very old and has been very sick for a long period of time. I'm not saying that's r i g h t , but for me i t ' s , i t ' s not the same, you know, I r e a l l y think you know t h i s i s maybe a good time for that person to die. Knowing the patient frequently resulted i n the CCN experiencing personal emotions that were "draining" when the patient was not successfully resuscitated. The pa r t i c i p a n t s concurred that the unsuccessful r e s u s c i t a t i o n of a patient created a sense of loss for the CCN. Several p a r t i c i p a n t s described f e e l i n g the "loss of hope" and emotionally "upset" following an unsuccessful r e s u s c i t a t i o n . One pa r t i c i p a n t described a sense of "defeat" with the unsuccessful r e s u s c i t a t i o n of a patient that she had grown to know. During the re s u s c i t a t i o n procedure, the CCNs often experienced alternating feelings of hope and hopelessness followed by emotional exhaustion. I t ' s emotionally draining to go, to go through, through the process and those couple of times when there was a rhythm. There's, "Oh, there's a b i t of hope." Then there's not. So i t , i t ' s very emotionally draining to go through a long, complicated arrest. How does Knowing the Patient Do What i t Does? Knowing the patient creates a rel a t i o n s h i p between the CCN and the patient. The patient i s no longer a "case". The t r a n s i t i o n from case to patient i s marked by the creation of a r e l a t i o n s h i p between CCN and patient. The nature of t h i s r e l a t i o n s h i p and the value that the CCN placed on the patient's a b i l i t y to l i v e influenced the nurse's g r i e f response i n unsuccessful patient r e s u s c i t a t i o n . Knowing 71 patients who are unsuccessfully resuscitated aroused a va r i e t y of feelings including loss, hope and hopelessness, ambivalence, and pessimism. In an e f f o r t to protect themselves from the loss they would experience when the patient died following an unsuccessful r e s u s c i t a t i o n , the part i c i p a n t s practised emotional detachment or distancing. Knowing the patient created a connection between the patient and the CCN. The implications of t h i s connection became apparent i n the partic i p a n t s desire to protect t h e i r patient from "poor" outcomes. These nurses defined poor outcomes i n a contextual way. In some sit u a t i o n s , the CCN wanted to protect t h e i r patients from death. For example, the CCN who cared for the previously healthy middle age man that suffered a myocardial i n f a r c t i o n had a strong desire for the patient to l i v e because she f e l t he had the pote n t i a l to f u l l y recover. In other paradigm cases, a peaceful or "good" death was desired. For instance, the par t i c i p a n t that cared for the patient i n h i s 70's or 80's who had suffered a myocardial i n f a r c t i o n and then developed worsening cardiogenic shock f e l t that the patient had l i v e d a " f u l l " l i f e and desired a peaceful death. In the event of long and complex re s u s c i t a t i o n e f f o r t s , the CCNs d i d not want the patient to l i v e i f his or her qu a l i t y of l i f e would be diminished. Because they knew the patient, the CCNs were able to recognize the importance of including s i g n i f i c a n t others i n I 72 t h e i r plan of care. The r e l a t i o n s h i p between the CCN and the patient and s i g n i f i c a n t others involved caring, concern, and a sense of r e s p o n s i b i l i t y for the patient and s i g n i f i c a n t others. At times, t h i s r e s p o n s i b i l i t y and concern generated both moral and e t h i c a l concerns for the CCN. The moral and e t h i c a l concerns of knowing the patient are i l l u s t r a t e d i n two paradigm cases. In one s i t u a t i o n , the CCN appreciated the way the s i t u a t i o n was managed by the physician, family, and health care team. The patient i n t h i s s i t u a t i o n had an underlying history of cancer of the breast and was septic upon admission to the ICU. During the r e s u s c i t a t i o n e f f o r t , the i n t e r n i s t telephoned the patient's oncologist, a f t e r consultation with the oncologist, family, and nursing s t a f f , the decision was made to discontinue the r e s u s c i t a t i v e e f f o r t s . The p a r t i c i p a n t described a moral and e t h i c a l f i t to the s i t u a t i o n because the interests of the patient were considered paramount. Another thing I was r e a l l y impressed with was the physician, the i n t e r n i s t who decided, who took a minute, who took the time to j u s t stop and think about what was doing. What was happening? What was best for the patient? Talking, taking time to phone the oncologist - to say t e l l me a l i t t l e b i t more about t h i s woman, I don't know her, what do you think? And being assured immediately that whether we do, the aggressive e f f o r t s were probably not the wisest. In the second s i t u a t i o n , the CCN's concerns for a patient experiencing severe chest pain were disregarded by the c a r d i o l o g i s t . The patient subsequently arrested and died. The nurse f e l t that she had not advocated strongly 73 enough for the patient, and she believed that she had a moral obli g a t i o n to the patient. This p a r t i c i p a n t f e l t s i g n i f i c a n t r e s p o n s i b i l i t y for the patient's death and personal d i s t r e s s . The most s i g n i f i c a n t thing for me was that sense of f r u s t r a t i o n and almost helplessness that we didn't do everything that could have been done. So I was, that, that was going through my and I f e l t abandoned. This paradigm case influenced both the CCN's thinking and pra c t i c e . The pa r t i c i p a n t learned through her moral concern-for t h i s patient to t r u s t her own judgement and she renewed her commitment to patient advocacy. Significance of Knowing the Patient Knowing the patient gives meaning to CCNs' experience of unsuccessful patient r e s u s c i t a t i o n . The nurse's knowledge of the patient's age, past medical history, and current physiological status created expectations surrounding the potential for the patient to be unsuccessfully resuscitated. In si t u a t i o n s , where the CCN predicted the patient's i n s t a b i l i t y and unsuccessful r e s u s c i t a t i o n , she frequently used detachment or professional distancing to protect herself emotionally from the loss of a patient. The parti c i p a n t s valued knowing the patient as a mechanism for preparing themselves to be competent, as well as emotionally stable, during and a f t e r an unsuccessful patient r e s u s c i t a t i o n . This p r e d i c t a b i l i t y , also enabled the nurse to prepare the patient and his/her s i g n i f i c a n t others for the anticipated outcome of the 74 r e s u s c i t a t i o n . The CCN's rel a t i o n s h i p with the patient created a sense of professional r e s p o n s i b i l i t y for the patient's care and for the consequences of the re s u s c i t a t i o n e f f o r t . The par t i c i p a n t s ' f e l t a sense of r e s p o n s i b i l i t y to protect t h e i r patients from "poor" outcomes. The CCN's desire f o r the patient was contextual i n nature based on her knowledge of the patient and his or her circumstances. The CCNs' described f e e l i n g sadness, pain, upset, hopeless, defeated, and emotionally drained during and following unsuccessful r e s u s c i t a t i o n of a patient they knew. Knowing the Person The p a r t i c i p a n t s of t h i s research study shared paradigm narratives that entailed caring for patients whom they perceived they did not know well as a person. Knowing the patient as a person, and not simply as a case or a patient, was deemed c r u c i a l to providing i n d i v i d u a l i z e d , compassionate care to patients and to s i g n i f i c a n t others i n unsuccessful r e s u s c i t a t i o n e f f o r t s . The p a r t i c i p a n t s defined knowing the person as knowing the unique personality, responses, and needs of the i n d i v i d u a l . Although the contextual factors associated with a re s u s c i t a t i o n i n the c r i t i c a l care unit (e.g., lack of time to know the patient as a person and the unresponsiveness of many patients) constrained the participants* a b i l i t y to know the person to the extent they desired, many of the CCNs 75 related d i s t i n c t and unique c h a r a c t e r i s t i c s of the patients they described i n t h e i r paradigm interviews. Aspects of Knowing the Person The p a r t i c i p a n t s stated that knowing the person entailed the following aspects of the in d i v i d u a l patient: h i s or her character, s p e c i f i c and in d i v i d u a l responses ( i . e . , p h ysiological and behavioral) to his/her c r i t i c a l status and/or interventions, and primary need(s). The part i c i p a n t s of the study frequently described the character of the person i n t h e i r interactions with the person p r i o r to the res u s c i t a t i o n . Descriptions of the nature of the person included "nice", "cooperative", "loving", "pleasant", and "a b i t of a f i g h t e r " . In several of the paradigm situations, the patient was unable to ver b a l l y communicate due to intubation or diminished l e v e l of consciousness. In these situations, the par t i c i p a n t s amassed an understanding of the person through i n t e r a c t i o n with s i g n i f i c a n t others during the re s u s c i t a t i o n e f f o r t and following the patient's death. I began to get to know her, j u s t from her husband and her son, what they said about her. What her health -she had her f i g h t through her breast cancer, and I thought, "Well, t h i s woman's a f i g h t e r . " There's c e r t a i n things, you know, you begin to admire about her. The CCNs gained further insight into the person's character through understanding the person's unique responses to h i s or her s i t u a t i o n . The CCN's knowledge of the person includes recognizing and understanding the 76 person's usual and at y p i c a l physiological and behavioral responses. Recognizing the unique phy s i o l o g i c a l and/or behavioral responses of the person alerted the pa r t i c i p a n t s to the person's i n s t a b i l i t y and the imminence of cardiac and/or respiratory arrest. In several paradigm cases, the CCN noted a s i g n i f i c a n t change i n the person's normal pattern of responses p r i o r to the patient's arrest. The f i r s t incident happened that morning, and i t probably happened around nine t h i r t y or ten. Where, because he was getting progressively confused, even though the side r a i l s were up on the bed, he f e l l out of bed. I c a l l e d some of the docs over and I said, "Yeah, t h i s i s something new. His limbs are a l l mottled and t h i s hasn't happened before." The p a r t i c i p a n t s defined knowing the person as recognizing patients' i n d i v i d u a l responses to interventions, both p r i o r to and during unsuccessful patient r e s u s c i t a t i o n . The CCNs frequently described the person's unique responses to interventions as a short term improvement or a rapid d e t e r i o r a t i o n i n the person's condition. He was getting more distressed and more distressed, as soon as you put him into trendelenburg. And, through t h i s we had to put the star wars ( r e f e r r i n g to a s p e c i a l i z e d oxygen mask) on because he wasn't doing well and more oxygen. He was becoming more distressed and r e s t l e s s , and he wasn't complying. In some paradigm cases, knowing the person enta i l e d i d e n t i f y i n g the person's primary need(s). The CCN required an understanding of the person's d i s t i n c t i v e behaviour, character, fears, and goals to recognize the person's need(s). In one paradigm case, the pa r t i c i p a n t related the 77 story of an eighteen year old male i n severe respiratory d i s t r e s s who repeatedly asked f o r h i s mother. I t was c l e a r to the CCN, because of the unusual i n t e n s i t y i n the patient's voice, that seeing h i s mother was t h i s person's primary need. This nurse was to l a t e r regret that she had not acted on t h i s knowledge because other members of the r e s u s c i t a t i o n team had believed that l i f e s a v i n g e f f o r t s should be the p r i o r i t y . The patient died without seeing h i s mother. She ( r e f e r r i n g to h i s mother) went over and started t a l k i n g to him and t e l l i n g him (after h i s death) how much she loved him and k i s s i n g him on the forehead and j u s t sort of rubbing h i s head. And t e l l i n g him probably everything she would have t o l d him had she had the opportunity to come i n and see him and I think that r e a l l y h i t me hard. Because I knew that she'd missed t h i s opportunity to t e l l him. And what kinds of thoughts went through h i s mind waiting for h i s mother? It ' s so u n f a i r that they (mother and son) should be separated at that time. I mean i t j u s t shows a l i t t l e b i t of how technical we've become and we're going to save despite everything and yet what he needed he wasn't going to be saved, you could almost t e l l that r i g h t from the very beginning. What he needed was h i s family. He didn't get that contact. Manifestations Knowing the person i s manifested i n the CCN's caring connection to patients and s i g n i f i c a n t others, as well as the CCN's emotional response to the person's s u f f e r i n g and death. Knowing the person was apparent i n the CCN's respect for and admiration of the person as an i n d i v i d u a l , as well as the desire to protect the person from s u f f e r i n g and to maintain the person's dignity. The CCN's connection with the person included a 78 dimension of caring that was not evident i n the paradigm narratives of participants who only knew the person as a patient. The nurse's sense of connection and her respect and compassion for the person was evident i n the empathetic dialogue between the CCN and the person. A very, very nice man, very warm. He happened to have a name that was the same as one of our former prime ministers, so he found that quite amusing that he'd been i n p o l i t i c s i n d i r e c t l y . I had him for a couple of days and, uh, and he'd r e a l l y been through a l o t and uh, I think anybody that can survive the shock study i s amazing (laughs), most of them are pretty sick, most of them are pretty sick, most of them die. Frequently, connection involved respecting the character of the person. In several situations, the pa r t i c i p a n t s stated that they had learned to admire the q u a l i t i e s of the patient as they "got to know" the person. He was ju s t the most pleasant man, very t a l k a t i v e , urn, very warm. He'd l i v e d . He kept t a l k i n g about h i s f u l l l i f e that he'd l i v e d . Not everybody's wonderful but he, he was j u s t t r u l y a wonderful son too. And i t was just devastating f o r h i s father and his father j u s t couldn't even comprehend i t . Knowing the person was revealed i n the CCN's desire to protect the person from su f f e r i n g . The pa r t i c i p a n t s used t h e i r knowledge of the person's c h a r a c t e r i s t i c behaviour to gauge the person's degree of d i s t r e s s . Because they f e l t connected to the patient, the CCNs stated that they experienced feelings of helplessness, anxiety, and emotional d i s t r e s s when the person suffered. 79 I mean helplessness. I think no matter what had happened, there would have been some sense of helplessness because there's nothing much you can o f f e r these people. But i t was i n t e n s i f i e d by pain which i s n ' t always that evident i n cardiac arrest and i n h i s pre-arrest. Several p a r t i c i p a n t s described paradigm cases i n which the CCN was unable to r e l i e v e the person's emotional and/or physical d i s t r e s s . These situations aroused feelings of powerlessness i n the CCN. In one paradigm case, the CCN admitted that she was relieved when the person became unconscious and she did not have to watch h i s s u f f e r i n g any longer. I t was written a l l over h i s face. Yes, so that was upsetting and you don't ever l i k e to see that and to not be able to do anything, you know. (There were) Sort of standard, you know, standard things I might do to t r y to reassure and to calm someone, to help him, (like) touching them and t a l k i n g to them. You know, I think we had enough of a rel a t i o n s h i p that he should have connected with me and we would have made eye contact and we would have been okay but nothing worked. He, he couldn't communicate, I mean he looked at me and s t u f f but he was ju s t shaking h i s head and writhing. So I was almost glad when he became unconscious. When the partic i p a n t s knew the person who was unsuccessfully resuscitated, they experienced loss and g r i e f . Frequently, the participant's loss and g r i e f was expressed i n tears and sadness. In some of the narrative accounts the CCNs• used laughter to ease the t r a g i c nature of the patient's death. One par t i c i p a n t described the undignified way the patient had died as "upsetting", she further explained, that she "didn't l i k e to see anyone die t h i s way". And so, when they stopped i t and said, "Okay, l e t ' s f i n i s h now. We've had i t " , I immediately burst into tears and ran out of the room. And i t was i n t e r e s t i n g because one of the c a r d i o l o g i s t s said, "Is she upset because we stopped the arrest (laughs)?" And I thought, "No - I'm just upset that he had to die t h i s way". In one paradigm case interview, the CCN stated she had gained her knowledge of the person through h i s mother. In t h i s s i t u a t i o n , the participant's g r i e f was shared with the mother. I remember her (referring to h i s mother) ju s t saying, "I don't know how I'm going to do t h i s . I can't walk out of here and leave him." and, I was crying and hugging her (laughs). I don't know who was comforting who by the end and but, uh, I remember saying, "I'm sorry, so sorry t h i s happened." Several of the participants expressed d i f f i c u l t y " l e t t i n g go" following the death of a person they knew. This l e t t i n g go included both the person and the s i g n i f i c a n t others. The idea of l e t t i n g go often involved a paradox i n that the CCN did not want the patient to s u f f e r ; however, she did not want to l e t go of the person. I t was hard to say goodbye to him too. I t would have been nice i f he had survived (chuckles) you know, at l e a s t for a l i t t l e while longer but that would have been u n r e a l i s t i c . Knowing the person was manifested i n the ways i n which the CCNs maintained the dignity of the person throughout the r e s u s c i t a t i o n experience. Respect for the d i g n i t y of the person was maintained even a f t e r the patient had died. Respect was evident i n the nurse's care of the patient following death. 81 I often f i n d that I I think the body i s s t i l l that person and that I s t i l l want to have a c e r t a i n amount of respect or consideration for that person, even though they're not a l i v e . The p a r t i c i p a n t s consistently described " t i d y i n g up" the person following the unsuccessful r e s u s c i t a t i o n . "Tidying up" included cleaning and normalizing the deceased patient. This action was seen as being respectful to the person and to protect the s i g n i f i c a n t others from viewing the ravages of the re s u s c i t a t i o n e f f o r t s . There was blood everywhere. There was, you know, we t r i e d to get as much of i t done as quickly as possible before the family came i n . We c e r t a i n l y spent some time ju s t t i d y i n g him, the patient, up and t r y i n g to get some of the worst blood o f f him, but we had to leave a l l of the l i n e s i n unfortunately. The p a r t i c i p a n t s i d e n t i f i e d a number of active and passive strategies for dealing with the loss of a patient to whom they had become connected, the most pervasive of which was to cry i n i t i a l l y and then to put the incident "behind you". Most of the participants described the need for private tears to manage t h e i r g r i e f . I had a moment (referri n g to tears) out by the hopper. It' s funny how you can choose these l i t t l e places (laughter). They're such lovely spots. —.- I f e l t myself l o s i n g i t just a l i t t l e b i t so I went to the bathroom, pulled myself together because i t wasn't quite over and I knew I had to get through t h i s . I grab a book or a hot bath, go and have a good, good, hard cry and that's i t . I mean, I leave i t a f t e r that and usually go to bed, early to bed and get up. I'm drained for the next day. But I leave i t a f t e r that. I jus t don't want to t a l k to anybody. I don't want to l i v e i t again. One pa r t i c i p a n t stated that she was "uncomfortable crying i n 82 the unit because tears are often considered a weakness" by her colleagues. Some participants stated that the memory of s p e c i f i c person's unsuccessful r e s u s c i t a t i o n can be triggered unexpectedly by a sight, sound, or smell. At these times, the CCN's sorrow and loss remain strong. Some partic i p a n t s described a t r a n s i t i o n that occurs i n the CCN's thinking about the person, following an unsuccessful r e s u s c i t a t i o n , i n which the deceased patient becomes a s h e l l of the person he/she once was. I often think, you know, just a few minutes ago t h i s was a person here but now i t ' s sort of not any more, you know. Like whatever that person was i s n ' t there any more and that's r e a l l y sometimes you know, you are j u s t awed by that. The p a r t i c i p a n t s acknowledged that they also experienced feelings of loss when they observed s i g n i f i c a n t others leave the hospital a f t e r the death of the patient. I t f e l t so awkward seeing them leave. You know, you sort of thought (makes sighing sound) then they l e f t the hospital sort of that's i t . That was very d i f f i c u l t . To sort of say goodbye as well, yeah, I remember that. What does Knowing the Person Do? Knowing the person enhances the CCN's a b i l i t y to assess the person by providing data, which are not evident i n knowing the case and knowing the patient, regarding the unique c h a r a c t e r i s t i c s and responses of the person. In some paradigm cases the CCNs were able to i d e n t i f y the person's i n s t a b i l i t y and impending cardiac and/or respiratory arrest based on the person's unique physiological and behavioral 83 responses. This knowledge of the person 1s unique responses assisted the CCN to judge the severity of the s i t u a t i o n and to predict the outcome of the re s u s c i t a t i o n e f f o r t . Knowing the person's unique behaviour and responses often a l e r t e d the p a r t i c i p a n t s to a deterioration i n the patient's status, although the cardinal signs of deterioration were not . present. The partic i p a n t s admitted that often they knew that something was wrong with the patient before they knew what was wrong. I think that scared me (referri n g to the patient's confusion and d i s t r e s s immediately before an arrest) because i t set up a l l kinds of alarms about what was happening to him. See, l o g i c a l l y , you know even though I maybe didn't pinpoint i t or a r t i c u l a t e i t at the time. I mean his blood pressure was dropping because hi s a o r t i c aneurysm was worsening. In many paradigm cases, the CCN's s e n s i t i v i t y to, and understanding of the person's usual and a t y p i c a l responses assisted the nurse to assess the person's l e v e l of anxiety, fear, and t h e i r r e s i l i e n c e . Knowing the person f a c i l i t a t e d the CCN to recognize and understand the meaning of the experience to the i n d i v i d u a l . I mean at one point he, i t was, i t was sort of, things ju s t didn't, because he was t r y i n g to sort of bargain. Well, he was doing I, "I want to have t h i s shortness of breath taken away but I don't want to be on a v e n t i l a t o r . Can't we just do t h i s instead?" He had a VT (ventricular tachycardia) arrest i n ICU and survived that. And then he came to us and, the day I had him he had, he went into VT and, he was j u s t d e f i b r i H a t e d out of i t and survived that and then I believe he had another small arrest and went into VT and then he came out of that again. And then, the next night I had him, well, a c t u a l l y I didn't r e a l l y have him but I was helping out and, then he went into a f u l l 84 arrest and didn't survive that one. Knowing what the person had been through and what they were going through ( i . e . , anxiety, fear) produced feelings of anxiety, helpless, suffering, and d i s t r e s s for CCNs when they were unable to a l l e v i a t e the cause of the behaviour (e.g., pain). The part i c i p a n t s used t h e i r knowledge of the person's unique c h a r a c t e r i s t i c s and responses to determine the s p e c i f i c needs of the person for care and intervention. Because the CCN knew the person, and not ju s t the patient or the case, she was often able to i d e n t i f y that the patient's primary need was other than what was t y p i c a l i n these s i t u a t i o n s . For example, one pa r t i c i p a n t recognized that a patient had a greater need to see h i s s i g n i f i c a n t other than to have pain r e l i e f . Another pa r t i c i p a n t described her int e r a c t i o n with a man i n h i s eighties who had a large myocardial i n f a r c t i o n , two days p r i o r to her caring f o r him. The nurse's knowledge of him as a person assisted her to understand that t h i s person had l i v e d a f u l l and complete l i f e and that he would not want heroic measures to sustain his l i f e . Because of t h i s , the nurse advocated a f t e r he arrested that no heroic measures be used i n r e s u s c i t a t i o n . Knowing the person established a connection between the CCN and the person. The CCNs were able to empathize with the person's d i s t r e s s , suffering, and responses more c l o s e l y because they knew the patient as a unique i n d i v i d u a l . The 85 pa r t i c i p a n t s concurred that being connected to the person influences the CCN's g r i e f response i n unsuccessful patient r e s u s c i t a t i o n s . Although the loss of a patient, to whom the CCN had become connected, was p a i n f u l , the connection of the c CCN to the patient as a person enabled the nurse to advocate for the person's needs and wishes, as well as to enhance the meaning of the experience for the nurse. The CCNs* knowledge of the person's desires and needs often resulted i n moral and e t h i c a l c o n f l i c t s f o r the CCN. In one paradigm case, the CCN believed that, i f the person had been apprised of the severity of h i s condition, he would not have wanted re s u s c i t a t i v e e f f o r t s . The p a r t i c i p a n t involved i n caring for t h i s man expressed moral d i s t r e s s over what she perceived as the " v i o l a t i o n " of the person. I t would have s t i l l been upsetting i f he had died and to follow him through that death would have been upsetting - but the fact that he was "viol a t e d " l i k e that, by a l l these people coming i n and, you know, doing the compressions and s t i c k i n g him with these needles and t r y i n g to get a blood gas o f f and a l l those kinds of things. I t was so unnecessary because the outcome was not going to be any d i f f e r e n t . How does Knowing the Person Do What i t Does? Knowing the person gives a d i f f e r e n t meaning to the CCNs' experience of unsuccessful patient r e s u s c i t a t i o n . In knowing the person, the patient becomes not someone who receives care but someone who i s cared for. Such a d i s t i n c t i o n e n t a i l s the involvement of the CCN i n the world of the person. Knowing the person r e s u l t s i n the CCN experiencing concern for the patient. Concern for the 86 person creates an involvement of the CCN i n which she must engage with the person i n such a way as to acknowledge his/her i n d i v i d u a l needs, desires, and c h a r a c t e r i s t i c s . Knowing the person creates a re l a t i o n s h i p between the CCN and the person. The person i s no longer a "patient" or a "case". The t r a n s i t i o n from patient to person i s d i s t i n c t i n that there exists a strong connection, characterized by compassion and empathy, experienced by the CCN fo r the i n d i v i d u a l . The nature of t h i s connection and the -pa r t i c i p a n t s 1 i d e n t i f i c a t i o n with the person i n an unsuccessful r e s u s c i t a t i o n influences the nurse's personal loss and g r i e f . Detachment i s not possible when the CCN knows the person; therefore, the CCN i s unable to protect h e r s e l f from the loss and g r i e f she experiences when the patient i s unsuccessfully resuscitated. Because the g r i e f response i s so p a i n f u l , the CCNs attempted i n a v a r i e t y of ways to negate or minimize the impact of the person's death. Knowing the person creates a strong connection and i d e n t i f i c a t i o n with the person. The CCN i d e n t i f i e s with the anxiety, fear, and suff e r i n g experienced by the patient. The implications of t h i s r e l a t i o n s h i p become apparent i n the pa r t i c i p a n t s ' desire to protect the person from s u f f e r i n g and in d i g n i t y . Significance of Knowing the Person Suffering i s a s i g n i f i c a n t dimension of the experience of CCNs when they know the person who i s unsuccessfully 87 resuscitated. Because the CCN knows the patient as a person, the nurse i s vulnerable to the issues, concerns, and emotions associated with observing the s u f f e r i n g of the patient and his/her s i g n i f i c a n t others. Knowing the person i n t e n s i f i e d the sense of the CCN's loss when the patient died, thus r e s u l t i n g i n the nurse's s u f f e r i n g . Meaning i s another central aspect of the experience of CCNs when they know the person who i s unsuccessfully resuscitated. Because the CCN knows the person, the experience of caring for the patient before, during, and a f t e r the re s u s c i t a t i o n i s meaningful, causing the CCN to r e f l e c t , rethink, and to create new options ( i . e . , new ways to think, f e e l , and relate) i n h i s or her nursing p r a c t i c e . Although knowing the person who i s unsuccessfully resuscitated i s connected with both stress and loss, i t i s the meaning of these experiences which caused the part i c i p a n t s to characterize them as paradigmatic i n t h e i r c r i t i c a l care career. R e l i a b i l i t y and V a l i d i t y In q u a l i t a t i v e research, the issues of r e l i a b i l i t y and v a l i d i t y pose s p e c i f i c problems. Benner (1994) proposes two c r i t e r i a f or judging the r e l i a b i l i t y and v a l i d i t y of q u a l i t a t i v e research: ensuring that the researcher has heard the voice of the par t i c i p a n t ; and accurately presented the voice of the pa r t i c i p a n t . 88 Hearing the Voice of the Participant A phenomenological approach to research "requires dialogue and l i s t e n i n g that allow the voice of the other to be heard" (Benner, 1994, p. 100). Hearing the voice of the p a r t i c i p a n t i s enhanced by several mechanisms. According to Benner "the researcher's own background p r a c t i c a l knowledge i s considered as part of the perceptual lens, enabling s k i l l s and l i m i t s for conducting the study" (p. 103). The researcher attempted to i d e n t i f y her perceptions and biases i n a va r i e t y of ways. The l i t e r a t u r e related to unsuccessful patient r e s u s c i t a t i o n was reviewed p r i o r to i n i t i a t i n g data c o l l e c t i o n . This provided the researcher with an understanding of other descriptions and empirical findings associated with the phenomenon. As a c r i t i c a l care nurse with eight years of c l i n i c a l experience, the researcher r e f l e c t e d on her own experiences with unsuccessful patient r e s u s c i t a t i o n to i d e n t i f y pre-existing biases and b l i n d spots. The researcher has acknowledged and recorded her assumptions regarding the influence of unsuccessful patient r e s u s c i t a t i o n on the CCN (see Assumptions). The interview process i s central to hearing and understanding the voice of the pa r t i c i p a n t . Open l i s t e n i n g , or allowing the interviewee to shape the narrative account and focus on the key aspects of the s i t u a t i o n , i s e s s e n t i a l to hearing the voice of the p a r t i c i p a n t (Benner, 1994). The 89 researcher endeavoured to a c t i v e l y l i s t e n and r e f l e c t on the narrative accounts without interrupting the p a r t i c i p a n t . Benner (1994) recommends that the researcher use open ended questions to c l a r i f y and probe unclear areas. In an e f f o r t to obtain the best description of the paradigm case s i t u a t i o n , the researcher asked open ended questions to c l a r i f y the meaning of participant's statements and to explore areas i n greater d e t a i l . The researcher's understanding of c r i t i c a l care nursing and unsuccessful patient r e s u s c i t a t i o n may have hindered her a b i l i t y to recognize some aspects of the participants* experience as common or d i f f e r e n t . Consequently, the researcher may not have c l a r i f i e d or questioned some aspects of CCNs* experience with unsuccessful patient r e s u s c i t a t i o n that seemed obvious to the researcher. For example, although the p a r t i c i p a n t s stated that unsuccessful resuscitations caused them a great deal of emotional stress, i t i s s t r i k i n g that t h e i r accounts of unsuccessful resuscitations are characterized by an objective, unemotional, recounting. Because of the investigator's experience as a CCN, she did not f i n d t h i s to be unusual. The researcher knew from personal experience that a CCN learns to distance oneself from such emotionally-laden sit u a t i o n s i n order to cope with the assault of such experiences. The researcher did not question i t . When a member of the thesis committee asked why such a d i s p a r i t y 90 existed i n the par t i c i p a n t s ' accounts of unsuccessful r e s u s c i t a t i o n , the investigator considered two possible explanations: (1) the participants practised emotional distancing as a protective mechanism and, therefore, recounted t h e i r narratives i n a decidedly unemotional manner; and (2) the researcher i s an inexperienced interviewer who may have lacked the s k i l l to encourage the part i c i p a n t s to move beyond an objective stance to a more personal and emotional one. The researcher maintained a r e f l e c t i v e journal of the data c o l l e c t i o n and analysis process. Benner (1994) suggests that researchers remain c r i t i c a l l y r e f l e c t i v e about what t h e i r biases and b l i n d spots might be and why they think the questions that they are asking are pertinent. The researcher c a r e f u l l y maintained s e l f - r e f l e x i v i t y i n the research process by using the Reactivity Analysis framework (Paterson, 1994) during data analysis. The Reactivity Analysis framework a s s i s t s the researcher to analyze data for reactive e f f e c t s i n a r e f l e x i v e manner (Paterson, 1994). In q u a l i t a t i v e research, r e a c t i v i t y consists of the partici p a n t ' s response to the presence of the researcher, and the researcher's reaction to the research process ( P o l i t & Hungler, 1991). The Reac t i v i t y Analysis framework employs f i v e themes to a s s i s t the researcher i n s e l f - r e f l e c t i o n . The f i v e themes of the framework are the common sources of r e a c t i v i t y : emotional 91 valence, d i s t r i b u t i o n of power, importance of the inte r a c t i o n , goal of the int e r a c t i o n , and the e f f e c t of normative or c u l t u r a l c r i t e r i a . "The framework i s p a r t i c u l a r l y e f f e c t i v e i n a s s i s t i n g the researcher to i d e n t i f y how the participants affected the way i n which the researcher constructed and reported the data" (Paterson, p. 12) . Following the i n i t i a l i d e n t i f i c a t i o n of c l u s t e r s and themes within the t r a n s c r i p t s , the researcher l i s t e n e d to a research presentation by Fonteyn and Fisher (1994) on the phenomenon of "knowing" i n c r i t i c a l care p r a c t i c e . The researcher i s uncertain how much hearing t h i s presentation influenced the i d e n t i f i c a t i o n of the unifying themes of t h i s study. The participants repeatedly expressed the themes of "knowing the patient" and "knowing the person" i n t h e i r narrative accounts, however, the investigator may have clustered these themes d i f f e r e n t l y i f she had not been exposed to the research findings of Fisher and Fonteyn. The investigator attempted to reduce researcher bias by sharing and v a l i d a t i n g emerging themes with the pa r t i c i p a n t s of the study, and by c r i t i q u i n g and reviewing the inte r p r e t a t i o n of the data analysis with members of the thesis committee. Both the participants and members of the thesis committee validated the themes and theme c l u s t e r s . Accurately Presenting the Participant's Voice Accurately presenting the partici p a n t • s voice i s a 92 rigorous and challenging component of phenomenological research. There are a number of strategies that promote accurate presentation of the partic i p a n t ' s voice. Benner (1994) contends that "the guiding ethos i s to be true to the text" (p. 101). The researcher attempted to be f a i t h f u l to the text by staying as close to the pa r t i c i p a n t ' s words as possible. A d d i t i o n a l l y , a t h i r d interview was conducted to c l a r i f y and v a l i d a t e interpretations to ensure that the researcher understood the participant's meaning. The investigator attempted to vali d a t e interpretations i n a tentative manner, f a c i l i t a t i n g the pa r t i c i p a n t ' s a b i l i t y to disagree (Benner, 1994). Accurately presenting the voice of the p a r t i c i p a n t i s enhanced by examining the text from a v a r i e t y of perspectives (Benner, 1994). The researcher used both the framework developed by C o l l a i z i (1978) and an adaptation of the method of thematic inquiry developed by van Manen (1990). Each of these methods assisted the researcher to r e f l e c t on the text from d i f f e r e n t perspectives. This analysis and r e f l e c t i o n increased the investigator's understanding of the participant's voice. The researcher tracked changes i n perspective and understanding i n f i e l d notes and a researcher's journal. The process of wr i t i n g and rewriting the findings assisted the investigator to r e f i n e her understanding and accurately portray the voice of the p a r t i c i p a n t . 93 The r i g o r of research that uses a phenomenological approach l i e s i n the a b i l i t y to apply the c r i t e r i a described by Benner (1994). In examining the research findings the reader must take into account that the method and the researcher's lack of experience influenced the findings of the study. The study o f f e r s a beginning understanding of aspects of the CCN's experience of unsuccessful patient r e s u s c i t a t i o n . The c r i t e r i a of ensuring that the researcher has heard the voice of the participant, and accurately presented the voice of the p a r t i c i p a n t provided the investigator with a guide to ensure r i g o r i n the research process. Summary The CCNs who p a r t i c i p a t e d i n t h i s research study recounted paradigm case s t o r i e s of unsuccessful patient r e s u s c i t a t i o n . The analysis of the findings revealed that the experience of CCNs must account for the context of t h e i r experience of unsuccessful patient r e s u s c i t a t i o n . The central theme of "knowing" was i d e n t i f i e d from the research data. Knowing involves three themes: knowing the case, knowing the patient, and knowing the person. The p a r t i c i p a n t s ' accounts of unsuccessful r e s u s c i t a t i o n i l l u s t r a t e that these themes are often i n d i s t i n c t and overlapping. The way i n which the CCN i s engaged i n the patient care s i t u a t i o n ( i . e . , how much she knows and i s connected with 94 the person) was found to create d i f f e r e n t p o s s i b i l i t i e s i n regard to the nurse•s emotional involvement with and commitment to the patient. The degree of involvement was discovered to a f f e c t d i f f e r e n t management issues for the CCN. The CCN's a b i l i t y to use detachment as a means of protecting h e r s e l f from the emotional assault of watching the person s u f f e r and die was decreased as the CCN became increasingly involved with the personhood of the patient. 95 CHAPTER FIVE DISCUSSION . The findings of the investigation are analyzed and discussed within t h i s chapter. The discussion of the findings begins with an exhaustive description of CCNs' knowing as i t relates to unsuccessful patient r e s u s c i t a t i o n . The themes of knowing the case, patient, and person are discussed i n the context of unsuccessful patient r e s u s c i t a t i o n . Implications of the findings for nursing practice, education, and research conclude t h i s chapter. Exhaustive Description of Knowing as i t Relates to Unsuccessful Patient Resuscitation A CCN comes to "know" the in d i v i d u a l who eventually i s unsuccessfully resuscitated through the dynamic process of uncovering the layers of an i n d i v i d u a l . This process occurs as the CCN becomes increasingly connected to the i n d i v i d u a l . Knowing the case, patient, and person influences CCNs1 expectations regarding the outcome of the r e s u s c i t a t i o n e f f o r t s and t h e i r a b i l i t y to manage the emotional aftermath of unsuccessful patient r e s u s c i t a t i o n . P r i o r to establishing a connection with the i n d i v i d u a l , the CCN u t i l i z e s her/his knowledge of the case to d i r e c t the nursing care of the i n d i v i d u a l . CCNs gain an understanding of the case by applying t h e o r e t i c a l knowledge and experience with the patient population i n c r i t i c a l care settings to the s i t u a t i o n . CCNs' knowledge and experience of c r i t i c a l care 96 cases a s s i s t s them to provide competent and confident care to the i n d i v i d u a l , as well as to anticipate a cardiac and/or respiratory arrest. A n t i c i p a t i n g the r e s u s c i t a t i o n enables the CCN to provide competent technical care p r i o r to and during the re s u s c i t a t i o n e f f o r t , and to f o r t i f y her/himself for the emotional consequences of unsuccessful patient r e s u s c i t a t i o n . As CCNs care for individuals over time, and develop a rel a t i o n s h i p with the individuals and t h e i r s i g n i f i c a n t others, they begin to uncover unique facets of the patient and the person. Understanding the patient and the person i s heightened by the i n s t a b i l i t y of the ind i v i d u a l ' s status and the degree of d i s t r e s s and su f f e r i n g experienced by the ind i v i d u a l p r i o r to the unsuccessful r e s u s c i t a t i o n . The patient's responses to pain and su f f e r i n g illuminate aspects of the person that f a c i l i t a t e the CCN's understanding of the person. Knowing the patient involves a rel a t i o n s h i p , characterized by a sense of professional o b l i g a t i o n and r e s p o n s i b i l i t y , between the CCN, the patient and the patient's s i g n i f i c a n t others. This r e l a t i o n s h i p i s manifested i n the physiological, psychological, and r e l a t i o n a l care that the CCN gives to both the patient and his/her s i g n i f i c a n t others. The nurse's understanding of the patient's responses allows her to i d e n t i f y and predict, with greater accuracy than knowing the case, the patient's 97 i n s t a b i l i t y and the unsuccessful r e s u s c i t a t i o n . At times, CCNs use emotional detachment or professional distancing to manage the emotions associated with the pote n t i a l death of a patient by cardiopulmonary arrest. Despite the use of professional distancing, CCNs are forced to shed t h e i r emotional detachment, reaching inside themselves to locate t h e i r emotional response, i n order to be able to t e l l the d e t a i l s of the r e s u s c i t a t i o n e f f o r t and support the s i g n i f i c a n t others following unsuccessful patient r e s u s c i t a t i o n . Knowing the patient who i s unsuccessfully resuscitated r e s u l t s i n feelings of hope and hopelessness, pessimism, loss and g r i e f . Knowing the person that i s unsuccessfully resuscitated i s both rewarding and painful for CCNs. The rewards come from a strong connection between the patient and nurse that i s translated into an intimate knowledge of the person and an emotional attachment to the patient and s i g n i f i c a n t others. The benefits of knowing the person are evident i n the CCN's a b i l i t y to provide i n d i v i d u a l i z e d care to the person and t h e i r s i g n i f i c a n t others. A d d i t i o n a l l y , knowing the person r e s u l t s i n the CCN being able to judge the severity of a s i t u a t i o n and predict a cardiac and/or respiratory arrest based on very subtle p h y s i o l o g i c a l and behavioral cues. The CCN1s involvement with the person and h i s or her s i g n i f i c a n t others i s frequently p a i n f u l because nurses 98 experience the threat of loss of the person whom they have come to know and care for at the onset of the cardiac and/or respiratory arrest. Knowing the person who i s unsuccessfully resuscitated frequently p r e c i p i t a t e s the CCN's feelings of hopelessness, powerlessness, moral d i s t r e s s , los s , and g r i e f . Knowing the Case The parti c i p a n t s commenced knowing the layers of the person through "knowing the case". The pa r t i c i p a n t s used t h e i r knowledge of the case, i n combination with both t h e o r e t i c a l knowledge and previous experience with s i m i l a r patient populations, to provide competent patient care. Knowing the case provided an important foundation that assisted the CCN to make competent c l i n i c a l decisions based on t h e i r knowledge and experience. Using t h e i r knowledge of-the case as a template, CCNs were able to assess patients and judge what was *normal' or x t y p i c a l ' i n the case to make c l i n i c a l decisions based on t h i s knowledge. The CCNs were also able to plan, implement, and evaluate care based on t h e i r knowledge of s i m i l a r cases. The CCN's knowledge of the case incorporates s c i e n t i f i c knowledge of the diagnosis, physiology, p h y s i o l o g i c a l responses, and the interventions associated with the cardiopulmonary arrest and nurses' personal experience with s i m i l a r patient populations. Carper (1978) describes four patterns of knowing i n nursing practice: empirics, 99 esthetics, personal, and moral knowing. Knowing the case encompasses both the empirical pattern of knowing and the nurse's personal knowledge of s i m i l a r cases. According to Carper (1978), empirics i s "knowledge that i s systematically organized into general laws and theories for the purpose of describing, explaining, and predicting phenomena of spe c i a l concern to the d i s c i p l i n e of nursing" (p. 13). Personal knowledge has been described as "subjective, concrete and e x i s t e n t i a l " (Carper, p. 17). Empirical knowledge allows the CCN to predict basic physiological responses and behaviours associated with s p e c i f i c events, whereas, personal knowledge allows the nurse to understand how the in d i v i d u a l patient i s d i f f e r e n t from s i m i l a r cases. Knowing the case was s i g n i f i c a n t as i t allowed CCNs to care competently and confidently for the patient as they developed a rel a t i o n s h i p with the patient/person. The CCN's knowledge of the case i s key to caring for patients confidently, despite a lim i t e d knowledge of the patient. This knowledge heightens p r e d i c t a b i l i t y of concerns, interventions, and patient outcomes by uncovering the differences between t h i s case and other cases. Ad d i t i o n a l l y , the CCN i s able to draw on her previous experience with cardiac and/or respiratory arrests to judge a patient's i n s t a b i l i t y and predict a cardiopulmonary arrest. The a b i l i t y to predict i n s t a b i l i t y and a po t e n t i a l unsuccessful patient r e s u s c i t a t i o n allows the CCN to prepare 100 h e r s e l f mentally for the r e s u s c i t a t i o n e f f o r t . The nurses i n t h i s study described a personal sense of "control" when they could anticipate the r e s u s c i t a t i o n e f f o r t and employ previously learned theory and s k i l l s associated with a r e s u s c i t a t i o n e f f o r t . A n t i c i p a t i o n of an impending r e s u s c i t a t i o n enabled the CCNs to plan and implement strategies that reduced the stress associated with the r e s u s c i t a t i o n event. In contrast, experience with s i m i l a r cases decreases the CCN's poten t i a l for emotional d i s t r e s s as i t influences her a b i l i t y to anticipate a r e s u s c i t a t i o n e f f o r t . "Knowing the case" was useful to the p a r t i c i p a n t s of t h i s research study because CCNs were able to care for unstable patients both p r i o r to and during a r e s u s c i t a t i o n e f f o r t i n a competent and confident manner, despite l i m i t e d understanding of the patient's unique responses. Recently, researchers determined that knowing the case was e s s e n t i a l to CCNs for meeting the primary goal of caring for unstable post-operative patients (Fonteyn & Fisher, 1994). In both t h i s study and that conducted by Fonteyn and Fisher, CCNs who cared for unstable patients valued knowing the case as a mechanism for providing care despite l i m i t e d information. There are l i m i t a t i o n s to knowing the case without knowing the patient and/or the person. Knowing the case forces the nurse to make assumptions about what i s xnormal' or ^ t y p i c a l 1 for the average patient. When one i s forced to 101 make assumptions about xnormal' responses of unique human beings i n the context of c r i t i c a l i l l n e s s , there i s a great deal of po t e n t i a l for error i n c l i n i c a l decision-making. Jenny and Logan (1992) studied "knowing the patient" i n the context of expert nursing practice during v e n t i l a t o r weaning of adult patients. These researchers found that "without the p a r t i c u l a r i s t i c patient knowledge, the nurses were aware that they were operating only on generalized knowledge, and often f e l t that t h i s was i n s u f f i c i e n t " (p. 257). Knowing the case may l i m i t the CCN's a b i l i t y to make appropriate c l i n i c a l decisions and predict a range of patient outcomes. Add i t i o n a l l y , knowing only the case l i m i t s the CCN's focus to the physiological concerns associated with the case and does not incorporate the patient's or the patient's s i g n i f i c a n t others' behavioral concerns into the plan of care. Knowing the Patient "Knowing the patient" was the CCNs' second layer of knowing. The partic i p a n t s of t h i s study developed knowledge of the patient by building on t h e i r understanding of the case. The CCNs gained knowledge of the patient through the patient's record> assessment, i n t e r a c t i n g with the patient and h i s or her s i g n i f i c a n t others, and providing nursing care. The CCNs accumulated additional knowledge of the patient's roles and h i s or her t y p i c a l patterns or responses through the process of developing a r e l a t i o n s h i p with the 102 patient and the s i g n i f i c a n t others. The CCN's involvement i n the re l a t i o n s h i p with the patient and h i s or her s i g n i f i c a n t others was central to knowing the patient. The nurse-patient r e l a t i o n s h i p at t h i s l e v e l of knowing i s characterized by a l e v e l of involvement and concern for the patient and the s i g n i f i c a n t others. The l e v e l of involvement was dependent on the q u a l i t y of the rel a t i o n s h i p and the a b i l i t y of the nurse to connect with the patient. The nurse-patient r e l a t i o n s h i p was i n t e g r a l to knowing the patient. The CCN's knowledge of the patient encompassed both the empirical knowledge of the case and the nurse's personal knowledge of the patient. Personal knowledge has been depicted as an interpersonal process between the nurse and patient that a s s i s t s the nurse to understand the patient's meaning of health i n terms of i n d i v i d u a l w e l l -being (Carper, 1978, p. 16). The CCN uses personal knowledge of the patient to recognize t y p i c a l and a t y p i c a l responses or patterns to predict i n s t a b i l i t y and unsuccessful patient r e s u s c i t a t i o n . The phenomenon of "knowing the patient" has been described i n four recent studies of nurses i n practice (Benner, 1991; Fonteyn, & Fisher, 1994; Jenks, 1993; Tanner, Benner, Chesla, & Gordon, 1993). Each of these studies describes knowing the patient i n a manner s i m i l a r to the descriptions of knowing the patient i n t h i s study. A l l of 103 these studies underscore the knowledge gained from a personal r e l a t i o n s h i p with the patient and the influence of that knowledge on c l i n i c a l decision-making. .Knowing the patient was important to c l i n i c a l d ecision-making as i t allowed the p a r t i c i p a n t s to perceive the patient's t y p i c a l and a t y p i c a l responses or patterns. The p a r t i c i p a n t s recognized patterns of responses and responses to interventions and care through constant observation, repeated assessments, and the provision of nursing care. The CCNs were able to anticipate and provide p h y s i o l o g i c a l and psychological care to the patient i n a s k i l l e d manner, based on p a r t i c u l a r knowledge of the patient's needs. This p a r t i c u l a r i z e d knowledge assisted CCNs to a r r i v e at appropriate conclusions and to make accurate c l i n i c a l judgements i n the provision of nursing care. Because they knew the patient, the CCNs were able to predict i n s t a b i l i t y and unsuccessful patient r e s u s c i t a t i o n with greater accuracy because of t h e i r a b i l i t y to perceive and d i f f e r e n t i a t e s a l i e n t physiological and behavioral changes i n the patient's status.. When they were able to predict an unsuccessful patient r e s u s c i t a t i o n , the pa r t i c i p a n t s were able to emotionally prepare both the patient's s i g n i f i c a n t others and themselves for the patient's death. The CCN helped to prepare the patient's s i g n i f i c a n t others for the patient's death by providing information, emotional support, and by accessing resources. 104 The CCN prepared herself for the patient's death by pro f e s s i o n a l l y distancing or detaching he r s e l f emotionally from the patient. In a study of nurses verbal and nonverbal behaviors with cancer patients, Bottorff and Morse (1994) found four types of attending: doing more, doing with, doing for, and doing tasks. xDoing for' and *doing tasks' were s i m i l a r to the way the CCNs described caring for patients they knew who were eventually unsuccessfully resuscitated. xDoing f o r ' was characterized by a personalized approach to patient requests and needs involving working and connecting touch, and i n some instances, comforting and orienting touch (Bottorff & Morse, p. 57). Connecting touch involved two types of touch: " . . . one involved stationary contact of the palmer surface of a nurse's fingers and hand and the other type involved l i g h t carressing of the palmer surface of the nurse's fingers" (p. 55). Bottorff and Morse described *doing tasks' as: "... at times a focus on tasks was c r i t i c a l , i t seemed to distance the nurse from the patient; consequently, nurses were less s e n s i t i v e to patient's concerns or d i s t r e s s " (Bottorff & Morse, 1994). These patterns of attending were evidenced i n the nurse's paradigm cases of knowing the patient who was unsuccessfully resuscitated. xDoing for' was manifested i n the CCN's personalized and focused approach to providing care to unstable patients who were i n d i s t r e s s ; whereas, *doing 105 tasks' was apparent when the nurse blocked out the patient's responses and focused on completing tasks both p r i o r to and during the r e s u s c i t a t i o n e f f o r t . The complex care provided to unstable c r i t i c a l l y i l l patients required the CCN to be able to s h i f t her focus of attention between the patient's needs and the tasks that are required to s t a b i l i z e the patient. The nature of the interpersonal r e l a t i o n s h i p between the CCN and the patient and his or her s i g n i f i c a n t others created a sense of concern and r e s p o n s i b i l i t y for the nursing care of the patient. The CCN's involvement with the patient established the nurse's sense of r e l a t i o n a l care and professional r e s p o n s i b i l i t y . In t h i s study, CCNs' r e l a t i o n a l care included moral concern for the patient and hi s or her s i g n i f i c a n t others. Knowing the patient created an opportunity for the CCN to be able to advocate for the patient, based on her understanding of the patient s i t u a t i o n . The nurse's r o l e as patient advocate ranged from attempting to obtain adequate care for the patient to discontinuing the r e s u s c i t a t i o n attempt. The nurses 1s r o l e as a patient advocate has the potential to be s a t i s f y i n g and d i s t r e s s i n g . The findings revealed that CCNs who perceived a f i t between the s i t u a t i o n and her moral values were s a t i s f i e d with the care experience. In contrast, CCNs who perceived a lack of moral agency, experienced feelings associated with moral d i s t r e s s ( i . e . , resentment, 106 f r u s t r a t i o n , abandonment, sorrow). Relational care entailed the CCN's desire to protect the patient and his or her s i g n i f i c a n t others from xpoor outcomes*. This moral concern was contextually determined. Protecting the patient from poor outcomes varied from rigorous attempts to save the patient's l i f e to not wanting the patient to l i v e , based on the anticipated q u a l i t y of l i f e for the patient. According to Parker (1990), "Experiences of intense pain, abandonment, and fear of l i v i n g and dying are shared i n an e f f o r t to coconstruct the meaning of seemingly meaningless experiences" (p.38). Parker defines the coconstruction of meaning as ". . . a dynamic process that necessitates engaged l i s t e n i n g , authentic responsiveness, mutual disclosure, and negotiation" (p. 38). The coconstruction of meaning enhances the nurse's s e n s i t i v i t y to subtle changes i n the nature of the s i t u a t i o n that "may necessitate a reevaluation of moral options" (Parker, p. 38). The CCNs' involvement and concern for the patient and the s i g n i f i c a n t others influenced how the participants perceived the s i t u a t i o n . The p a r t i c i p a n t s ' compassion and moral concern f o r the patient within the context of t h e i r s i t u a t i o n has been described as an ethic of care (Fry, 1989; Parker, 1990). Participants of t h i s research study commonly used detachment or professional distancing when they anticipated an unsuccessful r e s u s c i t a t i o n of a patient they knew. 107 Tanner, et a l . (1993) describe knowing the patient as "... an involved, rather than detached understanding of the patient's s i t u a t i o n and the patient's responses ..." (p. 275). Detachment seems a paradox to the CCNs' involvement i n the nurse-patient rel a t i o n s h i p . This finding was not mentioned i n other studies associated with knowing the patient. This finding may be related to the context of unsuccessful patient r e s u s c i t a t i o n . The emotional consequences of knowing patients who are unsuccessfully resuscitated may have taught CCNs to distance themselves from patients whom they know are medically unstable and have the p o t e n t i a l to be unsuccessfully resuscitated to protect the nurses' emotional well-being. ' What are the costs of detachment? According to Kadner (1994), "Perceptions gathered through verbal and non-verbal communication i n a t r u s t i n g r e l a t i o n s h i p should be more accurate than those obtained when the par t i c i p a n t s are distanced from each other" (p. 217). This comment suggests that assessment data may be more complete and accurate when the nurse and patient are not distanced from one another. Consequently, a CCN's c l i n i c a l decision-making may be hindered when she employs detachment. The par t i c i p a n t s i n t h i s research study used detachment predominately to protect themselves from the p o s s i b i l i t y of loss of a patient, however, the use of t h i s protective mechanism may have influenced CCNs' a b i l i t y to respond to moral issues. Parker 108 (1990) contends that "the strength of nursing i s linked to nurses* r e f u s a l to adopt an impartial, detached posture i n response to moral c o n f l i c t " (p. 39). Detachment may negatively a f f e c t the CCN's commitment to respond to moral concerns and to advocate for the patient. Furthermore, Benner and Wrubel (1988) contend that emotional distance does not a s s i s t nurses to manage s t r e s s f u l nursing sit u a t i o n s , but emotionally numbs the nurse and separates her from the humanity of both the c l i e n t and the nurse. These findings ra i s e the question: how much detachment i s constructive and healthy i n situations of unsuccessful patient resuscitation? Although detachment may have s i g n i f i c a n t implications for patient care, i t i s important to remember that t h i s process was used to protect nurses 1 emotional well-being. In unsuccessful patient resuscitation, detachment may a s s i s t the nurse to focus on getting the job done. CCNs must be cautious not to be judgemental of colleagues who use detachment, but to recognize the reason for i t s use. Knowing the patient was described by the pa r t i c i p a n t s as a means of involvement. In a study of nurses i n acute medical and sur g i c a l wards i n Scotland, May (1991) i d e n t i f i e d three central features of nurses' involvement with patients: "knowledge, r e c i p r o c i t y , and investment" (p. 552). The context i n which the par t i c i p a n t s of May's research described * involvement' ranges across three moral 109 imperatives. Two of these three imperatives are very s i m i l a r to CCNs1 involvement with t h e i r patients. May described these imperatives as: involvement as a general q u a l i t y of nursing work, characterized by a nonproblematic i n t e r e s t , and a f a m i l i a r i t y with the patient, and as an investment of nursing s k i l l s characterized by *professional distance*. Although May's description of involvement and professional distance p a r a l l e l s the CCNs' experience, the par t i c i p a n t s of t h i s study did not describe t h e i r involvement with patients and s i g n i f i c a n t others as nonproblematic. CCNs were often unable to maintain t h e i r professional distance i n supporting family members a f t e r an unsuccessful patient r e s u s c i t a t i o n . The nurses* concern for the patient's s i g n i f i c a n t others compelled them to reach inside themselves and to "get i n touch" with t h e i r emotions i n order to t e l l the news of unsuccessful r e s u s c i t a t i o n and to support the s i g n i f i c a n t others i n an empathetic and compassionate manner. The partic i p a n t s described the experience of t e l l i n g and supporting the patient's s i g n i f i c a n t others of the unsuccessful r e s u s c i t a t i o n as s t r e s s f u l and emotionally draining. The p a r t i c i p a n t s of t h i s study described mechanisms that allowed CCNs to maintain t h e i r a f f e c t i v e n e u t r a l i t y following unsuccessful r e s u s c i t a t i o n . One practice, imbedded i n the c r i t i c a l care unit's structure, included having the assistant head/charge nurse and physician t e l l 110 the s i g n i f i c a n t others the news of the patient's unsuccessful r e s u s c i t a t i o n . This practice allowed CCNs to maintain t h e i r emotional detachment and protected them from the emotional aftermath of having to get i n touch with t h e i r feelings to intera c t with the patient's s i g n i f i c a n t others. Another method of maintaining a f f e c t i v e n e u t r a l i t y involved the CCN transforming a s i g n i f i c a n t unsuccessful r e s u s c i t a t i o n into a routine event that was viewed as a routine element of the nurse's r o l e . Knowing the Person The f i n a l and most intimate l e v e l of knowing was knowing the person. The nurse's involvement i n the rel a t i o n s h i p went beyond the professional and e t h i c a l commitment evident i n knowing the patient. Knowing the person involved a connection between the nurse and patient. This knowledge was associated with an indepth understanding of the person's character, unique responses, and primary needs. The nurses' i n t e r a c t i o n with the person p r i o r to and during the re s u s c i t a t i o n attempt, and t h e i r i n t e r a c t i o n with s i g n i f i c a n t others during and following the unsuccessful r e s u s c i t a t i o n provided an opportunity for t h i s knowing to develop. Jacono's (1993) description of caring as loving i s very s i m i l a r to the CCN's experience of knowing the person. Caring i s loving i s defined as "the willingness to provide support for others i n times of need" (Jacono, p. 193). The I l l CCNs' i d e n t i f i e d the person by observing and t r y i n g to understand the patient's i n s t a b i l i t y and s u f f e r i n g and by engaging with the patient and/or the s i g n i f i c a n t others i n meaningful dialogue. The only study located that explicates knowing the person was the study by Fonteyn and Fisher (1994). Although t h i s study describes s p e c i f i c components of knowing the person, i t does not discuss how the nurse comes to know the person. The study by Tanner, et a l . (1993) i d e n t i f i e s knowing the person as a subcategory of knowing the patient. These authors discuss nurses coming to know the person through putting away of preconceptions and through engagement with the person and t h e i r family. Knowing the patient as a person established a connection that went beyond r a t i o n a l understanding. In many situ a t i o n s , the CCN who knows the person i s able to i n t u i t i v e l y sense that there i s a problem with few or no d e f i n i t e clues as to the nature of the problem. The term i n t u i t i v e l y i s defined within the context of t h i s study as "immediate awareness of past, present, or future events without the conscious use of l i n e a r reasoning" ( M i l l e r & Rew, 1989, p. 85). The CCN's openness to the v u l n e r a b i l i t y , s u f f e r i n g , and needs of the person and/or the s i g n i f i c a n t others provided the foundation for knowing the person. Knowing the person i s very s i m i l a r to the concept of therapeutic intimacy as described by Kadner (1994). Kadner 112 defines therapeutic intimacy as an openness to the exchange of shared meaningful information between c l i e n t and nurse. This author describes the constructs of attachment, empathy, compassion, t r u s t , and transference i n r e l a t i o n to the concept of intimacy. "Intimacy would include each of these f e e l i n g states, the degree dependent on the psychosocial h i s t o r y and readiness of each i n d i v i d u a l involved i n the i n t e r a c t i o n " (p. 216). The rewards and pain associated with the CCN's experience of knowing the person who was unsuccessfully resuscitated w i l l be explored within each of these constructs. The construct of attachment i s s i m i l a r to how the pa r t i c i p a n t s described connection i n t h i s study. Attachment may be defined as "the f e e l i n g that binds one to a person" (Kadner, 1994, p. 216). The i n t e n s i t y of the s i t u a t i o n and the openness of the CCN, allowed a deeper l e v e l of involvement, a connection. Knowing the person i n an attached or connected way allowed the CCN to recognize subtle changes i n the person's responses, anticipate the person's responses to interventions, and perceive the primary need of the person. This knowledge allowed the CCN to provide i n d i v i d u a l i z e d care to the person, judge the severity of the s i t u a t i o n for the i n d i v i d u a l , and to predict the outcome of a r e s u s c i t a t i o n attempt with even greater accuracy than merely knowing the patient. Despite early knowledge of the person's i n s t a b i l i t y and the severity of 113 the s i t u a t i o n , the CCN's feelings of hopelessness, powerlessness, and loss were s i g n i f i c a n t l y increased when c l i n i c a l interventions could not provide the desired outcome of successful r e s u s c i t a t i o n . The constructs of empathy and compassion are c l o s e l y related and w i l l be discussed together. Empathy i s defined as, " i d e n t i f i c a t i o n with the experiences of another. Compassion i s sorrow for someone accompanied by a desire to a l l e v i a t e the s u f f e r i n g " (Kadner, 1994, p.216). In each of the paradigm cases i n which the nurse knew the patient, the CCN was able to empathize with how i t would f e e l to be i n the s i t u a t i o n of either or both the patient or s i g n i f i c a n t others. The CCN's i d e n t i f i c a t i o n with the experiences of the person and/or s i g n i f i c a n t others produced feelings of hope and hopelessness, and sorrow. Compassion was evident i n the CCN's desire to connect with the person to a l l e v i a t e t h e i r s u f f e r i n g . The CCN's powerlessness to reduce the person's s u f f e r i n g often created feelings of anxiety and d i s t r e s s for the nurse. The nurse suffered emotional d i s t r e s s i n watching the person s u f f e r and by being unable to meet the person's primary need. Botto r f f and Morse (1994), found a p a r a l l e l pattern of attending they c a l l e d %doing more' i n a study of nurses' caring f o r patients with cancer. xDoing more' i s a type of attending i n which the nurse i s making contact or t r y i n g to xreach out' to the patient i n a manner that i s beyond what 114 i s required to complete care (p. 55). An example of doing more i s when the CCNs attempted to prepare the person's s i g n i f i c a n t others for the person's unsuccessful r e s u s c i t a t i o n i n an e f f o r t to reduce t h e i r anguish. The CCN's compassion encompassed respecting the humanity of the person p r i o r to, during, and following the unsuccessful r e s u s c i t a t i o n . The desire to respect the dig n i t y of the person generated unique challenges and tensions i n the context of unsuccessful r e s u s c i t a t i o n . The nurses portrayed respect for the person i n the way that they communicated with the person and through t h e i r provision of intimate and private care. The person's d i g n i t y was maintained during the re s u s c i t a t i o n procedure and i n "tid y i n g up" the person following the r e s u s c i t a t i o n e f f o r t . In a study of how Australian nurses' manage the patient's body, Lawler (1991) found that nurses treated the body *with respect' when they prepared the body for the morgue, and handled i t c a r e f u l l y . Furthermore, Lawler found that one of the c r i t i c a l elements i n how nurses treated the body was whether or not they had an ex i s t i n g r e l a t i o n s h i p with the person who died. At times, the CCNs perceived the person's boundaries had been v i o l a t e d during the re s u s c i t a t i o n attempt. Though the CCNs f e l t the person's dignity had been v i o l a t e d , they had d i f f i c u l t y advocating for the person during the res u s c i t a t i o n e f f o r t . The participants expressed moral 115 d i s t r e s s when they r e f l e c t e d on these experiences. r Trust i s a hallmark of a therapeutic r e l a t i o n s h i p and i s e s s e n t i a l to the notion of attachment. Trust i s defined by Kadner as, "reliance on the i n t e g r i t y of another" (p. 216). Trust was i m p l i c i t i n the connection that was established between the CCN and the person and/or s i g n i f i c a n t others i n these paradigm cases. Transference i s the f i n a l construct of therapeutic intimacy (Kadner, 1994). "Transference i s a s h i f t of emotions from e a r l i e r relationships to a present r e l a t i o n s h i p " (p. 216). The participants frequently personalized the experience when the knew the person (e.g., the CCNs r e f l e c t e d on what i t would f e e l l i k e to lose t h e i r mother). The concept of therapeutic intimacy lends understanding to CCNs experience of knowing the person that i s unsuccessfully resuscitated. The intimate nature of the rel a t i o n s h i p between the CCN and the person, and the nurse's investment i n t h i s r e l a t i o n s h i p places the nurse i n a vulnerable p o s i t i o n . The stronger the connection between the CCN and the person, the more intense the feelings of pain and loss when the person i s unsuccessfully resuscitated. May (1991) described t h i s type of involvement as "a s p e c i f i c attachment to p a r t i c u l a r patients, characterized by intense stresses on the nurse" (p. 550). CCNs must manage the threat of and actual loss when 116 they know the person who i s unsuccessfully resuscitated. The CCNs attempted to manage the loss of a person through several practices. The partic i p a n t s focused on the actions associated with the re s u s c i t a t i o n e f f o r t , rather than the feelings associated the loss of a person. The a b i l i t y to do for the person was valued by the par t i c i p a n t s of t h i s study. The CCNs consistently described t h e i r s a t i s f a c t i o n with the provision of t e c h n i c a l l y competent care to the person during the r e s u s c i t a t i o n . Following the re s u s c i t a t i o n e f f o r t , the CCNs concentrated on ordering and normalizing the environment. These actions appeared to a s s i s t the CCN to achieve a f f e c t i v e n e u t r a l i t y and manage the loss of the person without dealing with the emotions associated with the loss of a person that was connected to the nurse. Future Imperatives The findings of t h i s study have implications f o r nursing i n the areas of practice, education, and research. Nursing Practice The findings of t h i s study lead to a number of implications for nursing practice. These are important, not only for c r i t i c a l care nurses who provide care to the unsuccessfully resuscitated patient, but also to nursing and hosp i t a l administrators. Caring for c r i t i c a l l y i l l patients and t h e i r s i g n i f i c a n t others poses unique challenges f o r the CCN.. The acuity of the patients and the uncertain or tenuous nature 117 of t h e i r outcomes create tension for the patients,-s i g n i f i c a n t others, and the CCN. The po t e n t i a l for unsuccessful patient r e s u s c i t a t i o n i s a constant r e a l i t y i n the c r i t i c a l care s e t t i n g . According to Beaudoin (1990), "Working with dying patients may make death more f a m i l i a r , but t h i s does not take away death's s t i n g for caregivers" (p. 19) . The need to care for the CCN i s evident i n the findings of t h i s study. CCNs must recognize that knowing the patient or person that i s unsuccessfully resuscitated places the CCN in an emotionally vulnerable p o s i t i o n . The need for CCNs to explore and express feelings associated with unsuccessful patient r e s u s c i t a t i o n i s an important finding of t h i s study. Expressing feelings of personal loss and moral d i s t r e s s requires compassionate l i s t e n e r s and a safe environment. Sharing s t o r i e s of unsuccessful patient resuscitations would provide CCNs with an opportunity to a l l e v i a t e the emotional burden of unsuccessful resuscitations. P a r t i c i p a t i n g i n t e l l i n g and l i s t e n i n g to s t o r i e s of unsuccessful patient r e s u s c i t a t i o n would give CCNs an opportunity to understand t h e i r colleagues and t h e i r own l i v e d experiences. Furthermore, CCNs would r e a l i z e that they are not experiencing these feelings i n i s o l a t i o n . CCNs need to be involved i n the development of practices that support nurses during and following unsuccessful patient resuscitations. For instance, 118 assistance during the re s u s c i t a t i o n procedure from colleagues may provide a sense of support i n the chaotic environment of a re s u s c i t a t i o n . Colleagues and/or administrators could take d i r e c t i o n from the CCN involved i n the unsuccessful patient r e s u s c i t a t i o n about the nature of support that she requires. For example, the CCN may require help with the physical care of the patient, assistance with supporting the patient's s i g n i f i c a n t others, the opportunity to mourn the loss of a patient and/or person, choice of workload following the resuscitation, and the opportunity and time to t a l k about the s i t u a t i o n and feelings the unsuccessful patient r e s u s c i t a t i o n evoked. CCNs who experience emotional turmoil associated with knowing the in d i v i d u a l who i s unsuccessfully resuscitated require adequate resources to deal with these experiences. Examples of resources may include peer support groups, c l i n i c a l nurse s p e c i a l i s t s , expert counsellors, and c r i t i c a l incident debriefing teams. Unsuccessful patient r e s u s c i t a t i o n occurs twenty-four hours a day; therefore, support must be consistently available to CCNs. The indi v i d u a l s involved i n providing support would require an understanding of CCNs' experience of knowing the case, patient and/or person, loss and g r i e f , arid communication and counselling s k i l l s . The CCN's work demands must allow an opportunity and time to analyze and r e f l e c t on the unsuccessful resuscitation, and to express the feelings 119 associated with unsuccessful patient r e s u s c i t a t i o n . Formal programs that address death, loss, and caregiver s u f f e r i n g may a s s i s t CCNs to support and care for one another. A systematic process to mourn i n si t u a t i o n s of unsuccessful patient resuscitations may give CCNs permission to grieve. Neonatal and p e d i a t r i c CCNs have developed bereavement strategies such as follow-up with bereaved families i n the months following death, and unit based memorials to a s s i s t nurses with the loss of a patient (Sheard, 1990; Small, Engler, & Rushton, 1991). These strategies could be adopted i n adult c r i t i c a l care settings i f CCNs determined that these strategies would be h e l p f u l . Several p a r t i c i p a n t s of t h i s study discussed the need to know the cause of death. Although post mortems are frequently performed on patients who are unsuccessfully resuscitated, CCNs are ra r e l y informed of the r e s u l t s . Communicating the cause of death to the CCNs d i r e c t l y involved i n unsuccessful patient r e s u s c i t a t i o n may diminish feelings of negligence and g u i l t . Another implication of the study's findings i s the need to reduce CCNs* moral and e t h i c a l d i s t r e s s . I n t e r d i s c i p l i n a r y forums that provide dialogue surrounding e t h i c a l issues associated with cardiac and/or respiratory arrest may help to challenge standards of care during and following unsuccessful patient r e s u s c i t a t i o n . Workshops directed at a s s i s t i n g CCNs to express t h e i r moral and 120 e t h i c a l concerns i n the context of tense s i t u a t i o n s may a s s i s t s t a f f nurses to advocate for patients and t h e i r s i g n i f i c a n t others. The moral and e t h i c a l issues surrounding cardiac and/or respiratory arrest (e.g., prolonging l i f e , q u a l i t y of l i f e ) are e t h i c a l minefields for CCNs. Acute care hospitals should include CCNs on t h e i r e t h i c a l committees to increase the understanding of committee members regarding the implications of these issues i n c r i t i c a l care practice. Nursing administrators and inservice educators should be aware that CCNs1 experience anxiety and turmoil when they are confronted with death. They should encourage a l l CCNs to p a r t i c i p a t e i n seminars that are focused on issues related to death and dying (e.g., biomedical, e t h i c a l , r e l i g i o u s ) , counselling, and supporting bereaved family members. Nursing Education The unique demands of the c r i t i c a l care nursing challenge beginning CCNs1 a b i l i t i e s i n si t u a t i o n s such as unsuccessful patient r e s u s c i t a t i o n . C r i t i c a l care s p e c i a l t y education draws on and develops nurses 1 t h e o r e t i c a l knowledge i n basic nursing education and t h e i r experience as p r a c t i c i n g nurses. The study's findings indicate that CCNs experienced discomfort with death and some turmoil surrounding the conceptualization of death and the body care associated with the dead. Consequently, an implication of 121 the findings i s the i d e n t i f i c a t i o n of the need for educational preparation i n the meaning and sig n i f i c a n c e s of death for nurses. Nursing students may benefit from examining various perspectives of death ( i . e . , p h ilosophical, r e l i g i o u s , e t h i c a l , biomedical) and exploring t h e i r own b e l i e f s surrounding death. Educating nurses i n theory associated with death and dying, loss and g r i e f , as well as care of the body following death w i l l help nurses understand t h e i r personal b e l i e f s surrounding death. Furthermore, increased understanding of the issues involved i n death and dying, and loss and g r i e f w i l l a s s i s t nurses to support patients' s i g n i f i c a n t others. The r e l a t i o n s h i p between the CCN and the patient i s central to CCNs' knowing. Beginning CCNs need to know the various dimensions of knowing and both the rewards and challenges of t h i s knowing. The s i g n i f i c a n t challenges for CCNs include performing complex s k i l l s during the re s u s c i t a t i o n despite a relat i o n s h i p with the patient and/or person, p o t e n t i a l moral and e t h i c a l c o n f l i c t s , and the emotional implications of unsuccessful patient r e s u s c i t a t i o n . Each of these challenges have implications for education i n the c r i t i c a l care spec i a l t y . C r i t i c a l care spe c i a l t y education should include ensuring that beginning CCNs are able to function safe l y and competently i n a cardiopulmonary r e s u s c i t a t i o n . C r i t i c a l care educators need to teach beginning CCNs that the 122 "adrenalin rush" associated with p a r t i c i p a t i o n i n a cardiac and/or respiratory arrest a s s i s t s CCNs to focus on the re s u s c i t a t i o n procedure. Ad d i t i o n a l l y , compartmentalizing segments of the cardiac and/or respiratory arrest decreases the stress associated with arrest procedure and allows the CCN to focus on her ro l e and tasks during the r e s u s c i t a t i o n . The CCN•s moral and e t h i c a l d i s t r e s s i s an important finding of t h i s study. Building on students' understanding of e t h i c a l issues i n nursing, the spe c i a l t y c u r r i c u l a should focus on the moral dilemmas associated with unsuccessful patient r e s u s c i t a t i o n . The nature of unsuccessful patient r e s u s c i t a t i o n creates c o n f l i c t with the goals of the c r i t i c a l care se t t i n g ( i . e . , patient s t a b i l i t y , saving l i v e s ) . Students must be aware that the goals of the c r i t i c a l care se t t i n g are not always achievable. CCNs often f e l t unable to advocate for t h e i r patients before or during the r e s u s c i t a t i o n procedure. Beginning CCNs need to prac t i c e and develop the s k i l l of advocacy i n simulated si t u a t i o n s that are r e a l i s t i c i n nature. The emotional implications of "knowing" the case, patient, or person who i s unsuccessfully resuscitated i s a central finding within t h i s study. CCNs must be prepared for feelings of hope and hopelessness, powerlessness, pessimism, sorrow, suffering, g r i e f and loss both during and following unsuccessful r e s u s c i t a t i o n of patients who they know as a patient and/or person. Although CCNs commonly use 123 detachment to manage the emotions associated with unsuccessful patient resuscitation, they must understand the l i m i t a t i o n s and concerns i d e n t i f i e d with t h i s means of management. C r i t i c a l care educators must teach a l t e r n a t i v e strategies to manage the emotions related to unsuccessful patient r e s u s c i t a t i o n . C r i t i c a l care educators need to use teaching techniques (e.g., narratives or story t e l l i n g ) that w i l l help beginning CCNs understand the meanings of unsuccessful patient r e s u s c i t a t i o n to nurses. This type of teaching technique w i l l underscore the r e a l i t y of t h i s experience and prepare beginning CCNs for practice s i t u a t i o n s . Hospital orientation and c r i t i c a l care inservice education program coordinators need to examine issues surrounding unsuccessful patient r e s u s c i t a t i o n . These programs need to encompass issues related to death and dying, e t h i c a l issues of patient r e s u s c i t a t i o n , loss and g r i e f , emotional responses associated with "knowing" the unsuccessfully resuscitated patient, and strategies to support and care for CCNs. Encouraging experienced CCNs to share t h e i r s t o r i e s of unsuccessful patient r e s u s c i t a t i o n may a s s i s t both experienced and beginning nurses to understand the issues associated with unsuccessful patient r e s u s c i t a t i o n . 124 Nursing Research Several implications for nursing research originate from the l i m i t a t i o n s of t h i s study. CCNs who pa r t i c i p a t e d i n t h i s research were experienced i n c r i t i c a l care nursing. I t would be useful to conduct t h i s type of research with beginning CCNs to compare the l i v e d experience of beginning and experienced CCNs. CCNs often p a r t i c i p a t e i n a cardiac arrest team i n a medical or sur g i c a l ward res u s c i t a t i o n . They seldom have a p r i o r r e l a t i o n s h i p with a patient that i s unsuccessfully resuscitated on a ward. I t may be useful to study the experiences of CCNs i n unsuccessful resuscitations on hosp i t a l wards, comparing the findings to that of t h i s study. The context of nursing may influence the nurses* experience of unsuccessful patient r e s u s c i t a t i o n . Further research on nurses i n other spec i a l t y contexts (e.g., ob s t e t r i c s , emergency) may illuminate the unique aspects of patients• deaths and nurses 1 r e s u s c i t a t i o n experiences within the subculture of the specialty. A d d i t i o n a l l y , nurses who "know" and care for patients on wards but are unable to p a r t i c i p a t e i n the arrest procedure of a patient may have a completely d i f f e r e n t experience of unsuccessful patient r e s u s c i t a t i o n . The cumulative e f f e c t on CCNs of caring for patients who are unsuccessfully resuscitated i s unknown. Research 125 r e l a t e d to the repeated exposure to unsuccessful patient r e s u s c i t a t i o n and the long term e f f e c t s of t h i s phenomenon on nurses may provide insight into the experiences of burnout and a t t r i t i o n among nurses. This study described CCNs knowing i n the context of unsuccessful patient r e s u s c i t a t i o n . The study d i d not prescribe the length of time a nurse had to care for the patient p r i o r to the res u s c i t a t i o n . I t was su r p r i s i n g to the investigator that the length of time that the nurse cared for the patient did not always a f f e c t the depth of the nurses knowledge of the patient. Further research should investigate how length of association a f f e c t s the dimensions of nurses knowing and the care provided to patients. CCNs frequently employed professional distancing and detachment to manage the emotions associated with unsuccessful patient r e s u s c i t a t i o n . The findings of t h i s study suggest that detachment influences CCNs' rela t i o n s h i p s and involvement with patients and t h e i r s i g n i f i c a n t others. Further research i s required to understand the implications of detachment on CCNs1 decision making and provision of patient care. F i n a l l y , the need to implement strategies to support and care for CCNs who experience unsuccessful patient r e s u s c i t a t i o n i s evident. As strategies to support CCNs are implemented i t i s imperative that evaluative research be conducted to ascertain the effectiveness of these 126 strategies. This research study was useful i n understanding the experiences of a s p e c i f i c sample of CCNs who experienced unsuccessful patient r e s u s c i t a t i o n . As the research on nurses 1 experience with unsuccessful patient r e s u s c i t a t i o n i s i n i t s infancy, i t i s esse n t i a l that other studies be conducted to increase our understanding of t h i s phenomenon. 127 CHAPTER SIX SUMMARY AND CONCLUSIONS This chapter includes a summary of the study and conclusions based on the findings and future imperatives. Summary Although there have been numerous studies that investigated stress i n c r i t i c a l care nursing, there were no studies located that related to CCNs1 experience of unsuccessful patient r e s u s c i t a t i o n . The research related to stress i n c r i t i c a l care nursing focused on determining stressors for CCNs and understanding t h e i r coping strategies. These researchers determined that the death of a patient was consistently ranked by CCNs among the top three stressors. Despite t h i s finding, there were no studies located that focused on CCNs1 experience with the death of patients. The purpose of t h i s study was to explore and describe the experience of CCNs who p a r t i c i p a t e i n unsuccessful patient r e s u s c i t a t i o n . The study was guided by the philosophical perspective of phenomenology i n the t r a d i t i o n of Benner (1984, 1994) and Benner and Wrubel (1989). The goal of t h i s approach to i n t e r p r e t i v e phenomenology i s to illuminate the commonalities and differences of the phenomenon when one i s involved i n the s i t u a t i o n (Benner, 1994). The investigator used paradigm case interviews to explicate issues, concerns, meanings, and understandings from the p a r t i c i p a n t ' s 128 perspective. Paradigm cases are narrative accounts of s i g n i f i c a n t c l i n i c a l s i tuations which reveal the p r a c t i c e of nursing (Benner, 1984; Benner & Wrubel, 1989). Data were c o l l e c t e d from each of the nine p a r t i c i p a n t s by means of a pre-interview, paradigm case interview, and a f i n a l interview. In the pre-interview, the researcher described the study, answered questions related to the research interview and introduced the interview plan to the p a r t i c i p a n t . During the paradigm case interview, the researcher sought to understand the CCN's experience by the method of paradigm case interview described extensively by Benner (1984). The f i n a l interview was used to c l a r i f y aspects of the paradigm case interview, to provide an opportunity for participants to ask the researcher questions, and for participants to respond to i n i t i a l themes and theme cl u s t e r s i d e n t i f i e d i n the paradigm interview. The p a r t i c i p a n t s had between 8 and 19 years of experience as a Registered Nurse, and between 3 and 14 years of experience as a CCN. The participants included one male and eight females. The majority of the paradigm case s t o r i e s were from the p a r t i c i p a n t s ' recent experience. One story occurred early i n the nurse's c r i t i c a l care nursing experience and was contrasted with her current response to s i m i l a r s i t u a t i o n s . The central theme of "knowing" emerged from the narrative accounts of CCNs' experiences with unsuccessful 129 patient r e s u s c i t a t i o n . The context of knowing was i d e n t i f i e d by the participants as influencing how knowing was enacted i n t h e i r role i n unsuccessful patient r e s u s c i t a t i o n . Knowing involved three themes: knowing the case; knowing the patient; and knowing the person. The contextual factors which are unique to c r i t i c a l care were perceived by the participants as a f f e c t i n g the nature of t h e i r experience i n situations of unsuccessful patient r e s u s c i t a t i o n . The goals of both the medical and nursing s t a f f of c r i t i c a l care units i s to s t a b i l i z e and care for c r i t i c a l l y i l l patients. The events p r i o r to and during cardiopulmonary arrest are directed toward l i f e saving. Consequently, CCNs1 knowing was influenced by the acuity of the patients, the pace and goals of care. The lack of time and competing roles and r e s p o n s i b i l i t i e s were i d e n t i f i e d as common constraints to CCNs1 knowing. The r e l a t i o n s h i p between the CCN and the other health care workers involved i n the r e s u s c i t a t i o n e f f o r t influenced the CCN's s a t i s f a c t i o n with the r e s u s c i t a t i o n procedure. The "adrenalin rush" associated with p a r t i c i p a t i n g i n an arrest s i t u a t i o n was seen as h e l p f u l to CCNs as i t allowed them to think c l e a r l y and focus on t h e i r tasks and r o l e within the r e s u s c i t a t i o n team. Additionally, the p a r t i c i p a n t s ' perceived that "tidying up" the patient and normalizing the environment following the unsuccessful patient r e s u s c i t a t i o n assisted them to manage the inner turmoil they experienced. 130 The CCNs experienced knowing through the process of uncovering aspects of the case, patient, and person. The part i c i p a n t s commenced knowing the in d i v i d u a l through "knowing the case". The CCN's knowledge of the case incorporated s c i e n t i f i c knowledge of the diagnosis, physiology, physiological responses, and the interventions associated with cardiopulmonary arrest and the nurse's experiences with s i m i l a r patient populations. Knowing the case was s i g n i f i c a n t as i t allowed the par t i c i p a n t s to care competently and confidently for the patient as they developed a relat i o n s h i p with the patient. In addition, the CCN's knowledge of the case increased the p r e d i c t a b i l i t y of the concerns, interventions, and the range of patient outcomes by uncovering the differences between t h i s case and other cases. The CCN's a b i l i t y to anticipate an impending arrest allowed the nurse to plan and implement strategies that decreased the stress associated with the r e s u s c i t a t i o n e f f o r t . Participants that lacked experience with the case were unprepared for the turn of events and the patient's death. Whenever a CCN was not able to accurately predict the unsuccessful patient resuscitation, she experienced anxiety and g r i e f . As the CCNs' developed a rel a t i o n s h i p with the patient and/or s i g n i f i c a n t others, they began to know the patient. Knowing the patient involved understanding the patient's age, gender, roles, past medical history, current 131 p h y s i o l o g i c a l status, and s i g n i f i c a n t others. The CCN's rel a t i o n s h i p with the patient was characterized by a sense of professional o b l i g a t i o n and r e s p o n s i b i l i t y . The par t i c i p a n t s who knew the patient provided care that focused on the patient and the s i g n i f i c a n t others. The CCN's understanding of the patient's responses allowed her to i d e n t i f y and predict, with greater accuracy than knowing the case, the patient's i n s t a b i l i t y and eventuality of the unsuccessful r e s u s c i t a t i o n . The a b i l i t y to anticipate an arrest assisted the CCN to better perform her r o l e i n the re s u s c i t a t i o n e f f o r t . The CCNs• valued knowing the patient as a mechanism for preparing them selves to be competent, and emotionally stable during and a f t e r an unsuccessful patient r e s u s c i t a t i o n . The participants described the use of emotional detachment or professional distancing to manage the emotions associated with unsuccessful patient r e s u s c i t a t i o n . The CCNs were unable to maintain a detached stance when int e r a c t i n g and supporting the patient's s i g n i f i c a n t others. The i n a b i l i t y to maintain t h e i r detached stance pre c i p i t a t e d feelings of hope and hopelessness, pessimism, moral d i s t r e s s , loss and g r i e f . Aspects of knowing the person included knowing the indi v i d u a l ' s character, unique responses to the s i t u a t i o n , and t h e i r primary need. Knowing the person was a double edged sword for the CCN. Knowing the person established a 132 connection between the CCN and person. The strong connection between the CCN and the person resulted i n the nurse's investment i n the person's well-being. The par t i c i p a n t ' s connection with the person provided intimate knowledge of the person and emotional attachment to the person and t h e i r s i g n i f i c a n t others. The rewards of t h i s connection between the CCN and person were evidenced i n the in d i v i d u a l i z e d care provided to the person and t h e i r s i g n i f i c a n t others. Additionally, the CCN was able to predict a cardiac and/or respiratory arrest based on very subtle physiologic and behavioral cues. A disadvantage to knowing the person was that the connection between patient and nurse caused the CCN to be vulnerable to feelings of loss and g r i e f when the patient was unsuccessfully resuscitated. The CCN's involvement with the person and t h e i r s i g n i f i c a n t others was painful because nurses experienced the threat of loss of the person who they have come to know and care f o r . Knowing the person who was unsuccessfully resuscitated was associated with feelings of hope and hopelessness, powerlessness, moral d i s t r e s s , sorrow, suffe r i n g , loss and g r i e f for the CCN. The dimensions of CCNs' "knowing" influence the nurse's ro l e within the re s u s c i t a t i o n e f f o r t and t h e i r sense of s a t i s f a c t i o n with the res u s c i t a t i o n procedure. The CCN's rel a t i o n s h i p with the patient and s i g n i f i c a n t others i s 133 central to the feelings that are generated from the loss of a patient and/or person who i s unsuccessfully resuscitated. Conclusion The analysis of nine CCNs1 paradigm case experiences with unsuccessful patient r e s u s c i t a t i o n has been presented i n t h i s report. The paradigm s t o r i e s revealed the complex and dynamic nature of CCNs• experience with unsuccessful patient r e s u s c i t a t i o n . The study uncovered aspects of c r i t i c a l care nursing practice that have not been previously described. For example, the process of detachment as a s e l f - p r o t e c t i v e measure has not previously been illuminated i n c r i t i c a l care nursing. As a r e s u l t , the study w i l l contribute to the understanding of c r i t i c a l care nursing pr a c t i c e . This study has contributed to the paucity of research i n the area of CCNs' l i v e d experience of unsuccessful patient r e s u s c i t a t i o n . Further research i n the area of unsuccessful patient r e s u s c i t a t i o n w i l l contribute to a broader understanding of nurses 1 experience with unsuccessful patient r e s u s c i t a t i o n . 134 References American Heart Association. (1987). Textbook of advanced cardiac l i f e support. Dallas, TX: Author. Anderson, C.A., & Basteyns, M. (1981). Stress and the c r i t i c a l care nurse reaffirmed. Journal of Nursing Administration, 11, 31-34. 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C r i t i c a l Care Nurse. 6(1), 64-69. 141 Appendix A Research Pertaining to Causes of CCNs * Stress RESEARCHERS SAMPLE METHODOLOGY KEY FINDINGS Huckabay & 46 CCNs Survey: Five most Jagla (1979) questionnaire s t r e s s f u l s i t u a t i o n s : •workload •death of a patient •communica-t i o n ( s t a f f & nursing o f f i c e ) i •communica-t i o n ( s t a f f & physicians) •needs of family Anderson & Basteyns (1981) 182 CCNs Survey: questionnaire Five most s t r e s s f u l s i t u a t i o n s : •death of a young adult • short s t a f f e d •physician unavailable i n an emergency •medication errors • inadequate help to properly care for patients 142 Spoth & 241 CCNs ICU Stressor Three Konewko Survey primary (1987) stressors: •work overload •issues of death & dying •physical & environment stressors Vincent & •22 ICU Survey: Three top Coleman nurses • Professional ranking (1986) •19 non-ICU p r o f i l e t o o l stressors nurses * •Stressors for nurses form (not s i g n i f . d i f f e r e n t ) : •unit management • interper-sonal c o n f l i c t s •nature of d i r e c t pt. care (inc. death of a patient) Vachon 600 health Phenomeno- Five top (1987) care workers l o g i c a l occupational i n c r i t i c a l & interviews stressors: p a l l i a t i v e •team com-care munication problems •pt/family coping problems •nature of the unit •role ambiguity •role c o n f l i c t 143 Foxa l l , •35 ICU Survey: •No Zimmerman, nurses Nursing s i g n i f i c a n t Standley, & •30 hospice Stress Scale differences Captain nurses i n frequency (1990) •73 medical- and sources s u r g i c a l of stress i n nurses the 3 groups of nurses •ICU & hospice nurses experienced more stress related to death & dying Lewis & •577 CCNs Survey: Work Five main Robinson Related work-related (1992) Stressor stressors: Questionnaire • interper-•Response to sonal Stressor r e l a t i o n s Questionnaire • environment • Coping •pt. care Measures (inc. death Questionnaire of a patient) •profession-alism •knowledge 144 Appendix B Research Related to CCNs1 Coping Strategies RESEARCHERS SAMPLE METHODOLOGY KEY FINDINGS Oskins 79 CCNs Survey: Four coping (1979) •Narrative methods used questionnaire over 50% of •Coping scale the time: •talking i t out with others •taking d e f i n i t i v e action •drawing on past experiences • anxiety Stone, 7 6 CCNs Survey: •Nurses with Jebsen, •Maslach burnout Walk, & Burnout were Belsham Inventory d i s s a t i s f i e d (1984) • Coping and viewed Methods s t r e s s f u l Survey events as •Work threatening Environment •Using a Scale number of •L i f e coping Experience s k i l l s Survey increased CCNs1 sense of personal accomplish-ment 145 Lewis & 30 CCNs Survey: Five most Robinson Questionnaire frequently (1986) developed by use coping researchers strategies: •discussing problems with coworkers •problem-solving •watching TV/reading • caffeine •taking a vacation Dewe (1987) 1801 nurses •Stage 1: I d e n t i f i e d content s i x coping analysis of strategies 312 used by interviews nurses i n •Stage 2: s t r e s s f u l questionnaire s i t u a t i o n s : developed •problem-from data i n oriented Stage 1 behaviour •try to unwind & gain perspective • express feelings •keep the problem to yourself •accept the job as i t i s and t r y not to l e t i t get to you 146 Schaeffer & 2 09 CCNs & Survey: •No Peterson non-CCNs Jaloweic difference (1992) Coping Scale between the 2 groups i n coping strategies used or e f f e c t i v e -ness •Most e f f e c t i v e coping strategies were: -confront-a t i o n a l - o p t i m i s t i c - s e l f -r e l i a n t • Least e f f e c t i v e strategies were: -evasive - p a l l i a t i v e 147 Appendix C Participant Information Letter UBC Department Letterhead Letter of Information for Research Study: Unsuccessful Patient Resuscitation: The Lived Experiences of C r i t i c a l Care Nurses I am a registered nurse working towards a Master's degree i n nursing at the University of B r i t i s h Columbia. For my thesis, I am conducting a study to gain an understanding of the experience of c r i t i c a l care nurses who p a r t i c i p a t e i n unsuccessful patient r e s u s c i t a t i o n . I hope the findings of the study w i l l be valuable for nursing by increasing awareness of nurses' experiences with unsuccessful patient r e s u s c i t a t i o n . This l e t t e r i s to i n v i t e you to p a r t i c i p a t e i n my study. The c r i t e r i a for p a r t i c i p a t i o n i n the study are that you are a registered nurse employed i n the cardiac, cardiac s u r g i c a l , or intensive care unit and that you p a r t i c i p a t e d i n an unsuccessful r e s u s c i t a t i o n of a patient you cared for p r i o r to the r e s u s c i t a t i o n attempt. The study w i l l involve a telephone or personal pre-interview to discuss your i n t e r e s t and answer questions related to volunteering for t h i s study. I f you agree to p a r t i c i p a t e , the study w i l l consist of a two hour interview i n which you w i l l be asked to share a s i t u a t i o n from your experience with unsuccessful patient r e s u s c i t a t i o n , and a f i n a l interview of approximately two hours to review content and c l a r i f y statements from the f i r s t interview. I f you agree to p a r t i c i p a t e I w i l l be asking you for some demographic information (years of c l i n i c a l experience, years of c r i t i c a l care experience, educational background, and age) . The interviews w i l l be scheduled at a mutually convenient time and place. The interviews w i l l be audiotaped to ensure accuracy i n data c o l l e c t i o n . However, complete c o n f i d e n t i a l i t y w i l l be ensured throughout the study by the use of a code number on audiotapes and t r a n s c r i p t s . A s e c r e t a r i a l transcriber w i l l transcribe the audiotape, however, t h i s person w i l l not have access to the i d e n t i t y of the p a r t i c i p a n t s . The l i s t i d e n t i f y i n g the pa r t i c i p a n t s with the assigned code numbers w i l l be kept i n a locked drawer available only to the researcher. The persons mentioned i n the interviews w i l l be referred to by a code number or l e t t e r . 149 Appendix D Demographic Data YEARS OF EXPERIENCE AS AN R.N. YEARS OF EXPERIENCE AS A CRITICAL CARE NURSE CURRENT AREA OF EMPLOYMENT: Cardiac Care Cardiac Surgical Care Intensive Care EDUCATIONAL LEVEL: (check a l l that apply) Diploma i n Nursing Specialty C e r t i f i c a t e B.S.N. Other (please specify) GENDER: Male Female AGE IN YEARS: 151 My c o n f i d e n t i a l i t y w i l l be maintained i n t h i s study by the following procedures: 1. I w i l l be i d e n t i f i e d by a code number on the tape, t r a n s c r i p t s , t h esis, and presentation or publ i c a t i o n of the study. 2. The sole person to know my i d e n t i t y i s the researcher, Cheryl Isaak. The l i s t i d e n t i f y i n g p a r t i c i p a n t s i n the study w i l l be kept i n a locked drawer, avail a b l e only to the researcher. 3. The i d e n t i t y of myself, patients, and family members w i l l not be revealed i n the tra n s c r i p t i o n s of the research interviews, thesis, or presentation or publ i c a t i o n of the research findings. The participants and persons mentioned i n the interview w i l l be referred to by a code number or l e t t e r . 4. The s e c r e t a r i a l transcriber w i l l have access to the audiotape but my anonymity w i l l be maintained by a code number i d e n t i f y i n g the audiotape. The audiotapes and tr a n s c r i p t s w i l l be destroyed a f t e r seven years. 5. Transcripts of interviews which indicate only my code number, w i l l be shared only with the researcher's thesis committee members. The thesis committee members w i l l not be informed of my i d e n t i t y . The r i s k s of p a r t i c i p a t i n g i n t h i s study could involve psychological discomfort that may a r i s e from r e l a t i n g my story. I am free to withdraw from the study at any time. I also have the r i g h t to refuse to answer any question. My employment w i l l not by affected by taking part or not taking part i n the study. There may be no d i r e c t benefits to myself i n taking part i n t h i s study. However, increased awareness of nurse's experience with unsuccessful patient r e s u s c i t a t i o n may be valuable. My questions have been answered. I understand the nature of the study and consent to p a r t i c i p a t e . I also acknowledge receiving a copy of t h i s consent form. Signature of Participant: Signature of Witness :^  Date Signed: Please indicate i f you would l i k e a summary of the research findings p r i o r to presentation or publication. 152 Appendix F Participant Letter to Accompany Transcripts Date Dear Participant: Thank you for volunteering your time to be interviewed for my the s i s , " Unsuccessful Patient Resuscitation: The Lived Experience of C r i t i c a l Care Nurses." Please f i n d a copy of the t r a n s c r i p t of our interview enclosed. Please keep i n mind that the way we t a l k may not make for good reading, so do not l e t that concern you. Your ideas are the important aspect of t h i s interview. I am sending you the t r a n s c r i p t to allow you to review i t p r i o r to our f i n a l interview together. The purposes of t h i s interview are to: 1. give you an opportunity to c l a r i f y any aspect of the t r a n s c r i p t ; 2. give me an opportunity to c l a r i f y any aspect of the t r a n s c r i p t ; 3. give you an opportunity to respond to my beginning interpretations of the interview. I w i l l c a l l you to set up an appointment for our f i n a l interview within the next week. I f you have any questions or concerns that you would l i k e addressed p r i o r to our next meeting, please f e e l free to contact me at XXX-XXXX. Sincerely, Cheryl Isaak 153 Appendix G Examples of S i g n i f i c a n t Statements and Their Formulated Meanings S i g n i f i c a n t Statements Formulated Meanings 1. You have some ... r e a l l y well run arrests. And even i f the person doesn't make i t , you s t i l l f e e l good about i t ; that everything was done and everything was done properly. (8)* 2. I think you have to turn yourself o f f during the r e s u s c i t a t i o n as to who they are j u s t to get through i t because you're thinking and you're going through your next algorithms. (8) * 3. I had a cry for awhile and then, I might have had a break I j u s t remember taking him down to the morgue, I don't remember that much afterwards. (5)* 4. I began to get to know her j u s t from her husband and her son what they said about her, what health she had, her f i g h t through her breast cancer. (12)* 5. I f i n d myself p r a c t i s i n g that more professional distance and t r y i n g to not be emotional. (16)* 1. Smoothness and e f f i c i e n c y of r e s u s c i t a t i o n procedures influence s a t i s f a c t i o n with re s u s c i t a t i o n . 2. The CCN must detach herself during the re s u s c i t a t i o n to focus on the procedure. 3. The CCN experienced sadness and a sense of loss following an unsuccessful patient r e s u s c i t a t i o n . 4. Knowing the person can occur through s i g n i f i c a n t others. 5. Detachment protects the CCN. * Numbers s i g n i f y the number of s i m i l a r s i g n i f i c a n t statements from which formulated meanings were derived. 

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