Assignment: Qualitative Research Article Analysis

Intensive and Critical Care Nursing (2016) 33, 21—29

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Nurses’ involvement in end-of-life care of patients after a do not resuscitate decision on general medical units in Saudi Arabia

Ibrahim K. Abu-Ghori a, Mustafa M.E. Bodrick b, Rafat Hussain c, G. Hussein Rassool d,∗

a Acute Medical Unit, Ministry of National Guard Health Affairs, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia b King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia c University of New England, Armidale, New South Wales, Australia d Faculty of Psychology, Islamic Online University, The Gambia

Received 11 March 2015; received in revised form 13 October 2015; accepted 14 October 2015

KEYWORDS Do-not-resuscitate; End-of-life care; Nurses’ involvement; Nurses’ lived experience; Reflective journaling technique

Summary Objectives: To describe the essence of the nurses’ lived experience and explore the meaning of their involvement in end-of-life care after a do-not-resuscitate decision has been made. Research methodology/design: The research design embraced qualitative, exploratory and descriptive approaches utilising aspects of phenomenology. Purposive sampling of twenty-six registered nurses was used. Data was collected using the reflective journaling technique and were analysed using an integrated approach. Field notes were also used as a mean to enrich the description of the findings contextually. Setting: Medical units in Saudi Arabia. Results: Three main themes emerged: exhausted medical treatment, continuity of nursing care and cultural considerations in nursing care. Related sub-themes were also identified as an extension to the description of the main themes. Conclusion: The findings affirm that nurses working on medical units continue to maintain a constant level of care for patients and families after the do-not-resuscitate decision. Nurses found that caring for dying patients was a rewarding and worthwhile experience, albeit a chal-

lenging and demanding one. The findings suggest that improvement in end-of-life care would

be best achieved by collaborativ members. © 2015 Elsevier Ltd. All rights re

∗ Corresponding author at: Sidi Bou Said, Avenue Bengali 3, Morcelleme E-mail addresses: ghorii@ngha.med.sa (I.K. Abu-Ghori), BodrickM@N

husseinrassool@gmail.com (G.H. Rassool).

http://dx.doi.org/10.1016/j.iccn.2015.10.002 0964-3397/© 2015 Elsevier Ltd. All rights reserved.

e and interdisciplinary practices amongst the health care team

served.

nt Raffray, Les Guibies, Pailles, Mauritius. Tel.: +230 2861734. GHA.MED.SA (M.M.E. Bodrick), rhussain@une.edu.au (R. Hussain),

22 I.K. Abu-Ghori et al.

Implications for Clinical Practice

• The findings should be used to strengthen the specific areas of interaction and cooperation between nurses and healthcare team members in the end-of-life care of patients who have a ‘do-not-resuscitate’ code on medical units.

• The educational preparation of nurse on the Islamic perspective of death and its related rituals. • The need for research to examine the role of nurses in addressing the spiritual and religious needs of dying Muslim

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patients and their families.

ntroduction

atients who suffer from chronic illnesses are admitted to edical units to receive medical treatment and nursing

are. In spite of the medical units’ primary emphasis on reatment and recovery from chronicity, many patients die uring the course of admission to these units. The ‘do not ttempt cardiopulmonary resuscitation’ (DNACPR) decision s initiated at a point when the curative treatment has been xhausted. A range of ‘end-of-life’ (EOL) care options is herefore provided on these units to such patients when eath is imminent. In recent years, the need to improve OL care has received growing recognition in the literature Bolmsjo, 2008; London and Lundstedt, 2007). Many authors ave highlighted that limited research attention has been iven to date on issues of EOL care on medical units despite he fact that such units are frequently the site of patient eaths when curative medical treatment plans have failed o sustain life (Borbasi et al., 2005; Rogers and Addington- all, 2005; Thompson et al., 2006). Concurrently, there is aucity of research studies from Saudi Arabia on EOL care egarding hospitalised patients after a DNACPR decision has een made.

EOL care relates to dying patients and is often used nterchangeably with terms such as palliative, terminal and omfort care (McCann et al., 2007). Comprehensive and uality EOL care not only involves provision of compassion- te care for dying patients, but also helping their families o cope with the imminence of death of their loved ones Allen, 2008). The cultural and spiritual needs of patients nd families at the EOL are considered nowadays as essen- ial determinants in providing quality EOL care, particularly n the acute hospital setting (Thomas et al., 2008). The most requently cited concern by patients at the EOL is that their ultural and spiritual needs are barely addressed in hos- itals and that there is a need to enhance the awareness nd knowledge of healthcare providers in these influential omains (Brown et al., 2006).

Nurses’ recognition of daily Muslim rituals at EOL care nd the subsequent delivery of respectful EOL nursing care o patient and family, is regarded as essential in the Saudi rabian context (Al-Shahri and Al-Khenaizan, 2005). Ross 2001) argues that nurses’ understanding of Muslim tradi- ional practices related to death would ensure provision of ulturally congruent EOL nursing care.

ackground

urses are the frontline caregivers for patients in the final hase of EOL on medical units. The literature depicts that lthough providing care for dying patients and their families

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n medical units is an essential component of nursing care, urses have experienced difficulties in meeting the unique eeds of these patients and their families, particularly fter the DNACPR decision has been made (Coombs et al., 012; Long-Sutehall et al., 2001). Although there are everal nursing studies that have investigated patient and amily experiences of EOL care, these have been conducted ainly on intensive care units (Badger, 2005; Heland, 2006; cGrath and Holewa, 2006). A review of literature on OL care has revealed that there is a limited literature xamining the role of nurses in EOL care on medical units Hopkinson et al., 2003; Graham et al., 2005; Thompson t al., 2006; Wallerstedt and Andershed, 2007).

Nurses perform a pivotal role in helping dying patients on edical units attain freedom from pain and other distressing

ymptoms. This unique experience therefore allows nurses o influence enormously the last moments of a person’s life nd the indelible memory of the death of a loved one for amily members (Smeltzer et al., 2010). The provision of OL care, nevertheless, can be one of the most demanding nd stressful experiences for nurses in their daily practice Weigel et al., 2007). Thompson et al. (2006) confirm the oint that there is a range of nursing issues which require onsideration, such as recognition in EOL care, provision f an EOL care plan and nursing support to family mem- ers. Furthermore, nurses must deal with their own personal oral, cultural and emotional responses alongside the dying rocess of the patient (Thompson et al., 2006).

Hopkinson et al. (2003), on the basis of a phenomenologi- al study of nurses’ experience of EOL care on medical units, eported that providing care for dying patients and their amilies tended to cause frustration and feeling of unease or nurses. The nurses were unable to answer questions from atients, which resulted in them subsequently, developing a ense of psychological isolation from other healthcare team embers. Clinical uncertainty and frequent deterioration

f these patients, however, can be difficult and unpre- ictable and quiet often create additional pressures and hallenges for healthcare professionals, specifically when eciding if patients have reached the terminal phase of their ife (Barnett, 2006; Bristowe et al., 2015).

Wallerstedt and Andershed (2007) study of nurses’ expe- ience in caring for terminally ill patients in hospital ettings, reported the expressions of dissatisfaction from urses, owing to perceptions of inadequate cooperation rom the other members of the healthcare team during the nal phase of a patient’s life. Using data from nurses’ reflec- ions of participation in EOL care, Graham et al. (2005) also

eport that nurses often develop a sense of failure when hey are unable to achieve the predetermined goals at the OL. The research studies outlined above emphasised the

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T u w that are applicable to qualitative methodologies, namely: credibility (truth value), transferability (applicability),

Nurses’ involvement in end-of-life care of patients after a do not

importance of nurses building a therapeutic relationship with patients and families, the establishment of efficacious and solid communication and interpersonal interactions and support for nurses in providing quality EOL care.

The cultural and religious differences between nurses and patients present as a challenge and concern in the care of EOL patients (Blais et al., 2006). There is a great need for sensitivity in EOL care delivery in relation to both cultural and religious beliefs of patients and families. In a country like Saudi Arabia, these issues are of consider- able significance, as the majority of patients are Muslims, whereas care providers, particularly nurses, are expatriates and predominantly non-Muslims. Within a hospital setting with a large multinational and multicultural expatriate nurs- ing workforce, nurses’ understanding of Islamic practices and considerations surrounding a patient’s death, the dying process and support for family members in coping with death all need further investigation since there is limited literature available on these issues (Touhy et al., 2005).

It was observed by the principal author that the multi- national nurses appear to become more involved in EOL care. These expatriate nurses, who are largely non-Muslims and non-Arabic speaking, have different religious, language and cultural backgrounds from the patients, who are Mus- lim, Arabic-speaking and live an Islamic way of life. Some nurses had raised the point that, contrary to expectations, the majority of physicians, who are Muslims and Arabic- speaking, appear to become less involved in EOL care after the DNACPR decision has been made. In the context of the research setting, this paradox of increased involvement by expatriate nurses after DNACPR and the lesser involvement of other healthcare members, particularly local physicians, is regarded as an unexplained phenomenon.

The study

Aim

The purpose of the study was to examine the nurses’ lived experience and the meaning of their involvement in EOL care after a DNACPR decision has been made on medical units in Saudi Arabia?

Design

This is a qualitative, exploratory and descriptive investi- gation that used related methods in a process of inquiry. It utilised aspects of phenomenology to study nurses’ reflective accounts of their lived experience and discover meanings in EOL care of DNACPR patients on medical units (Richards and Morse, 2007; Streubert and Carpenter, 2010). This methodology provides participants with an opportu- nity for introspection, disclosure and feedback (Ruth-Sahd, 2003), which matched the aim of the study that focused on the lived experiences of the nurses.

Setting

The study was conducted on eight medical units in a large tertiary-level teaching hospital in Riyadh, Saudi Arabia. A

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urposive sample of twenty-six registered nurses (RNs) were ecruited for participation. The intention was to recruit par- icipants who had experienced the phenomenon and who ould be able to articulate what it was like to have lived

hat experience. The eligibility of RNs invited to participate as based on the following exclusion criteria: employed at

he hospital for less than on year on medical units; last expe- ience in EOL care on medical units was more than two years go; and had experienced any level of emotional distress esulting from either a patient or a personal family mem- er’s death and/or who had undergone counselling related o EOL issues in nursing practice.

ata collection

ata were collected using a reflective journaling tech- ique. This technique was chosen because of its congruence ith the professional nursing practice context of the hos- ital setting and that it invokes depth of self-reporting y respondents (Taylor, 2006; Walker, 2006). The research nstrument was based on Johns’ original model of struc- ured reflection (1992) and informed by the modifications iven by Johns (2004) and Quinn and Hughes (2007). ractice for writing reflective journals was offered to the tudy participants through training sessions using their ost recent experiences related to non-EOL patient-care

Plack et al., 2005). In the present study, participants were iven four to six weeks to complete their reflective jour- al entries in a safe and private environment of their hoice.

ata analysis

uring data collection, the first author kept field notes o document his observations to contextualise and enrich he description of the findings and to ensure idiosyncratic escriptions or expressions heard or seen in the field had een recorded meticulously (Patton, 2002). The transcripts f the returned reflective journals were analysed using n integrated approach that included Coffey and Atkinson 1996), Johns’ model of structured reflection (Johns, 2004) nd Tesch (1990). The stepped approach (see Table 1 for etails) resulted in an emergence of main themes and sub- hemes. Concurrently, memos to the researcher were used s a method of recording significant aspects of findings dur- ng data analysis that added further depth and richness to he context of the findings.

rustworthiness

o maintain scientific integrity throughout the study, Guba’s pdated model of 1981, cited in Krefting (1991, 215) as used. It includes four aspects of trustworthiness

ependability (consistency) and confirmability (neutrality). able 2 presents these aspects, together with the strate- ies used to ensure the rigour and trustworthiness of this tudy.

24

Table 1 Modified data analysis process.

Steps Procedure

1. Read two to three reflective journals to obtain a sense of the whole experience and make notes as ideas occur relating to the coding process.

2. Select one section of the reflective journal and work on it to arrange categories related to the underlying meaning and experiences and continue making notes and/or write memos to self as ideas occur related to the context or phenomenon.

3. Select the next section in the reflective journal and repeat step 2 above but move to interpretation and linkages between segments of data. Continue to make notes on interpretation and/or write memos to self where aspects of data trigger thinking in relation to field notes, contextual data and/or content of other reflective journals.

4. After completion of four to five reflective journals, the analysis as undertaken in steps 1, 2 and 3 should be reviewed in combination with field notes and memos that have been generated. The review includes the coding process, naming of categories and arrangements thereof, emerging interpretations and any notes made.

5. The content is scrutinised to identify recurring and/or similar topics. These are assessed critically to identify depiction by words related to the essence of meaning. This identification represents emergent themes, which are then arranged into columns and the data from the four or five reflective journals that have been reviewed are arranged accordingly as the themes and content of categories are matched.

6. Repeat step 1 to step 5 above until all the reflective journals have been reviewed and analysed accordingly.

7. Devise a system of labelling for each theme with a symbol, as in coding and arrange the themes in separate columns to include the reflective journal code and related extract of narrative text.

8. Review the themes that do not conform to the recurrent topics in the emergent themes. Assess whether they are unique themes or redundant themes and make notes on the related justification.

9. After completion of all reflective journals following steps 6, 7 and 8 above, the themes in columns are reviewed for further assessment as major themes and their sub-themes, to portray the experiences of the RN participants in EOL care after DNACPR.

10. The major themes and sub-themes are finalised according to logical arrangement to reflect the

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thical considerations

pproval for the study was granted by the University of New ngland Human Research Ethics Committee and the Hospi- al’s Research and Ethics Committee where the study was arried out. Participation was voluntary and participants

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ere assured of their right to withdraw at any stage without reason. Written consent was obtained from all partici- ants prior to participate in the study. The confidentiality f data was assured by use of a specific numeric coding sys- em for reflective journal returns, which was known only to he researcher and the individual participant.

esults

list of the main themes and sub-themes that emerged rom the data analysis is presented in Table 2 and described n more detail in the relevant section below. Briefly, the nalyses of data lead to the development of three main hemes: ‘‘exhausted medical treatment’’; ‘‘continuity of ursing care’’; and ‘‘cultural considerations in nursing are’’. Within each of the three key themes, some distinct ub-themes were also identified (see Table 3 for details).

xhausted medical treatment

he first major theme focused on exhausted medical treat- ent. The thematic analysis also revealed the presence of

wo sub-themes embedded within the core theme: exclusion f on nursing staff from DNACPR decision-making process; nd varying physician involvement in patient care once a NACPR decision has been made. According to the partici- ants, exhausted medical treatment was an early indicator o recognise a dying patient. This posed a challenge for urses in managing patients on the medical units because f the opposing views of some doctors and a general lack f consensus on when the EOL stage had been reached. The ollowing reflective journal excerpt illustrates this situation:

‘‘End of life means when a pt [patient] is so gravely ill [and] that death is imminent and inevitable at any time. At this time the [patient] is considered in the terminal phase of a progressive, irreversible dying process. Having a pt [patient] in a terminal phase, is not easy at all.’’ (RJ 16)

In such a situation, if the patient is approaching death n the medical unit, then the nurses pay focused attention o the importance of the patient’s right to die, providing ignity and enabling accompanying family support. In the ollowing exemplar, a participant described honouring the atient’s dignity at death:

‘‘End-of-life care mean[s] to allow patient to die with considering his dignity and avoid[s] any inappropriate prolongation of dying.’’ (RJ 25)

A sense of exclusion from the DNACPR decision-making rocess was expressed by the participants who showed self- wareness regarding the cultural and religious differences hat possibly influence the non-participation of nursing in he DNACPR discussion. One participant raised the concern hat the majority of nurses who are working in the hospi- al are expatriates and non-Arabic speakers and as such are xcluded from the DNACPR decision-making process, stating

hat:

‘‘As nurse[s] we play a very minimal role in decision- making as a ‘No Code’ [DNACPR]. But nurses also can

Nurses’ involvement in end-of-life care of patients after a do not resuscitate decision on general medical units in Saudi Arabia 25

Table 2 Measures used to establish trustworthiness of the study.

Criteria Strategy Applicability

Credibility (truth value)

Prolonged engagement

The researcher was working as a full-time clinical nurse manager on an acute medical unit at the hospital. Trust and rapport with the participants was established through multiple information and training sessions that lasted about three months during data collection.

Field notes Field notes were kept by the researcher during data collection that added depth of context.

Transferability (applicability)

Authority of participants

The participants were selected by purposive sampling owing to their lived experience in EOL care after DNACPR on medical units.

Thick description The design of the reflective journal instrument with an open-ended question on each page and twenty (20) lines for expanded expressiveness contributes to rich and vivid descriptiveness. This provided Sufficient descriptive data on the context, the research methodology and the researcher’s epistemological stance.

Dependability (consistency)

Reflective journal training sessions

The reflective journal training sessions were conducted with participants prior to completion of their reflective journal entries. The established use of reflective practice and journaling by registered nurses at the hospital contributed to participants adapting easily to the reflective journal instrument for data collection.

Confirmability (neutrality)

Authority of the researcher and ongoing site co-supervisor

The research was supervised by an experienced qualitative researcher (co-supervisor) with expertise in reflective journaling and qualitative methodology who was available at the research site.

Reflexivity Field notes were used to preserve recorded information. Weekly sessions were held with the research site co-supervisor at which topics and field notes concerning data collection were discussed extensively and where appropriate bracketing was used to retain objectives curiosity in the research process.

Memos The memos were used during data analysis to identify and document the researcher’s own biases or perspectives, which preserved the authenticity of data collected.

Table 3 Emergent main themes and sub-themes in the study.

Main-themes Sub-themes

1. Exhausted medical treatment

1A. Nursing excluded from DNACPR decision-making 1B. Varying physician involvement after the DNACPR decision

2. Continuity of nursing care 2A. Compassionate and comfort nursing care 2B. Focused comprehensive nursing care 2C. Nurses coordinating care contributions

3. Cultural considerations in 3A. Recognition of Islamic aspects in nursing care B. In

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contribute factors like nutrition, family support, psycho- logical and physical condition, emotional condition of the patient when they discuss about ‘No Code’. But here in the hospital, no doctor will ask the nurse’s opinion before taking a decision. May [be] [because] lot of western and foreign nurses [are] working in this country, and language

is a barrier.’’ (RJ 03)

It is a noteworthy observation that the above participant, despite acknowledging the status of nurses as ‘foreign’, has

b

tegrating Islamic aspects into education on EOL nursing care

evertheless outlined that nurses could still be involved in OL care in ‘nutrition, family support, . . .’ related to the hysical and emotional needs of the patient. The nurses bserved that physicians and other member of the health- are team were seemingly not interested in being present ith the patient’s family when death occurred. The example

elow illustrates this view:

‘‘It is [a] very rare happen[ing] that the physician is present at [the] patient[’s] bedside upon [at] the moment

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of death of [the] DNACPR patient. They [physicians] are hesitant to provide emotional support for the family. . . . It [is] very seldom that the physician or any multidis- ciplinary team [members] are present [at] the time or moment of death of any DNACPR patient.’’ (RJ 01)

In the opinion of the respondents, the withdrawal of hysicians from active involvement with patients occurs ither because of reduced need for active medical inter- ention or because patients who are DNACPR are possibly onsidered as a low physician priority.

ontinuity of nursing care

he present study found that medical nurses render care in n ongoing manner so that patients’ and families’ needs are cknowledged, irrespective of the patients’ resuscitation ode status. The following empirical evidence confirmed hat nursing care is given on a continuum before and after he DNACPR decision:

‘‘The patients will be taken care of; support will be given to the family. For us [nurses] the end-of-life does not mean the end-of-care . . . My care was not different after the decision has been made.’’ (RJ 07)

Most participants acknowledged that the provision of ursing care for patients at the EOL after DNACPR should e based on the patient’s needs, rather than the medical iagnosis or the disease itself. This perspective in nursing ractice is epitomised in the following exemplar, in which a articipant explained how EOL nursing care on medical units as provided on the basis of patients’ needs, rather than the atient diagnosis or resuscitation code status:

‘‘We really try our best to provide them with excellent care and give them their remaining dignity and quality of life. In our unit, on nursing side we care [for] patients not base[d] on their code status, but providing equal right[s] as a patient.’’ (RJ 14)

In the following excerpt from the reflective journal, a articipant summed up the perceived understanding of con- inuity of nursing care in EOL, using various related terms hat illustrated the extent of the caring philosophy. It vividly aptured and encapsulated the full sense of the meaning n the term ‘continuity of nursing care’. The participant sed philosophically appropriate terms to convey the caring ttitude in EOL care such as ‘tender’, ‘loving’, ‘patiently’, devotedly’, ‘relieve him’, ‘very fragile’ and ‘best care’.

‘‘End-of-life care is a tender, loving, comprehensive and full of sympathy kind of care rendered to a very termi- nally ill and dying patient . . . So the nurse will have to patiently and devotedly turn him frequently, feed him as prescribed, give medications to relieve him from pain and discomfort. Wash him tenderly because the skin is already very fragile . . . We want the best care for them before they die.’’ (RJ 13)

ompassionate and comfort nursing care

he expressions ‘empathy’, ‘tender care’, ‘comfort care’ nd ‘compassionate care’ were used by the participants

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o describe the ‘compassionate and comfort nursing care’ or patients and families after a DNACPR decision has been ade. The following excerpt demonstrates how a par-

icipant, despite the deep level of understanding of the atient’s pain at EOL, was able to control the extent of motional involvement with the patient. Although it was a hallenge to remain calm and not to show concern openly, he participant was aware by reflective disclosure that this as an important contribution to caring for patients who ere dying:

‘‘However during his last admission I know it would be the last time though I prayed that he will still get well. I know this was the same prayer his parents had. I always try to provide the best care I can for my patients . . . as I gave my last nursing care [a] few days before he passed away, my heart was in pain too. I still wanted to save him or to prolong his life if I could, [.] [The] the day before he died, every time I entered the room, he was reaching out to me as he wanted to be held or carried out of bed.’’ (RJ 06)

In EOL care situations, the nurse-patient relationship is ntimate in nature and involves the provision of compas- ionate and comfort nursing care. The following reflective xemplar shows that compassionate nursing care was the ornerstone in provision of EOL care:

‘‘The most important [aspect] is — we are giving the most compassionate specialized care for the living. It is base[d] on comprehensive understanding of patient suffering and focuses on providing effective pain and symptoms management to seriously ill patients while inquiring [ensuring] quality of life. Providing appropriate end-of-life care became a primary concern of each and every one of us [as nurses].’’ (RJ 21)

urses coordinating care contributions

ursing staff use coordination as a skill to marshal avail- ble hospital resources effectively in response to patients’ nd families’ needs in EOL care. The following empirical vidence from the reflective journals explicates the commit- ent of a participant to coordinate EOL care for the dying atient:

‘‘Another role [for nurses in EOL care] is being the bridge between the doctor and family or patient, because some of them [patients or families] just consented [to DNACPR] without really understanding what is it. As a nurse [I] just tell the doctors to give some explanation to the fam- ily. For other team members, respiratory therapist for example using a nebulisation if patient is desaturating. For [the] dietician [I] can suggest diet of the patient. [Physicians] should visit patient from time to time, daily won’t [would not] hurt because if not it makes family more anxious.’’ (RJ 10)

There is also the revelation that other members of the ealthcare team were reluctant to intervene in situations

nvolving patients in EOL care after DNACPR. The respon- ent indicated a level of disappointment with experiences n which some team members appeared to ‘de-prioritise’ he care of EOL patients after DNACPR.

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Nurses’ involvement in end-of-life care of patients after a do not

‘‘Sad to say some members of the health team its [are] not fully active doing their responsibilities. I think they are considering, when working [with] this kind of patient [that] there’s [there is] no use or benefit on [of] it. That’s why when they will visit this kind of patient [,] they will not stay longer [than] even five minutes.’’ (RJ 21)

This profile draws attention to the different prioritisation applied in approaches to care between nurses and other healthcare team members. This variation in approach reaf- firms the role of nurses in coordinating care contributions by assuming an EOL advocacy and leadership role to ensure continuity of care for patient and family.

Cultural considerations in nursing care

The medical nurses acknowledge the Islamic and cultural aspects pertaining to the way of life in Saudi Arabia and that it must be taken into account during nursing interventions in EOL care. The extract that follows reveals how one partici- pant acknowledged the importance of cultural and religious practices, yet expressed concerns about the safety of the patient in relation to the medical care equipment.

‘‘When death is imminent, the family expects that the patient be dealt with differently e.g. [for example] [blessed] olive oil be applied all over the whole body. If the patient is on tube feeding, ordinary bottled water should not be used to flush the feed, instead ‘‘Zam-Zam’’ [obtained from the water well in the Holy Mosque in Saudi Arabia]. And again, the dying patient’s bed is positioned to face Mecca [the Muslim holy city in Saudi Arabia]. This [at] times creates a little bit of concern for the nursing staff as this position might be pulling the patient away from the necessary [medical] equipment i.e. oxygen and /or suction apparatus. Yes, nurses have to show respect for the culture and religion especially during this critical time.’’ (RJ 05)

The importance of respecting the patients’ and families’ beliefs, knowing the unique needs and responses of dying patients and families and trying to show respect for them is confirmed and characterised by the reflection on experience of one of the participants:

‘‘I have observed here that the family tries to use dif- ferent cultural and traditional way of treating the sick member of the family. They use prayers, . . ., putting oil to the whole body, applying herbal medicine..., apply- ing henna [herbal medicine] over the pt’s [patient’s] head. And for me, as a nurse, I respect what these peo- ple believe as long as it would not compromise the pt’s [patient’s] deteriorating condition and safety. I under- stood that it is not only the pt [patient] who suffers the pain from the disease but also the pain that’s in the heart of the family as they watch / see the near death of their loved ones. All I can offer is to give my support both to

the pt. [patient] and his family.’’ (RJ 16)

The depth of respect shown in the above excerpt further portrays the extent to which non-Muslim nurses demonstrate respect for Muslim traditional practices, even when they encounter them as new experiences.

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iscussion

he lived experience of nurses in this study illuminates spe- ific areas of interaction and cooperation between nurses nd healthcare team members that could be the focus or improvement in the EOL care of patients who have a NACPR code on medical units. In this study, a range of eelings were revealed by nurses regarding their role in the NACPR decision-making process: feelings of acceptance, atisfaction, emotional stress, powerlessness, unprepared- ess, dissatisfaction, frustration and anger. These emotions ccurred as a consequence of their exclusion from DNACPR ecisions. Several studies have reported that nurses in their aily practice may hold a range of views regarding their nvolvement in the EOL decision-making process (Calvin t al., 2007). However, the involvement of nurses in the NACPR decision-making process in the final stage of EOL emains debatable.

A noteworthy consideration with regard to continu- ty of nursing care is that nurses took the initiative to ead other healthcare members in responding appropri- tely to patients’ and families’ needs at the EOL. The urses observed how, without team work and support, their bility to coordinate effective care for DNACPR patients nd their families was a challenge. The strategies associ- ted with coordinating patient care for EOL after DNACPR ode appeared to be driven by the nurses’ belief in the mportance of their role as patient advocates. This is per- aps because nurses spend more time with patients and amilies in EOL care after DNACPR than any other health- are members. The withdrawal of physicians may indicate heir awkward feelings regarding death and dying, which is videnced by their avoidance of family near the moment f death. This could also be due to their lack of educa- ion on principles of EOL care. The findings of a study y Gibbins et al. (2011) on newly qualified physicians n the United Kingdom showed that the newly qualified hysicians felt unprepared to provide appropriate EOL are. The implication is that caring for patients in EOL hould be part of the undergraduate medical curriculum in audi Arabia.

The findings of the present study showed nurses’ ambi- ions to provide quality EOL care to DNACPR patients nd their families. This is reinforced by the findings from hompson et al. (2006) who found that nurses make great fforts to provide quality care for dying patients and their amilies despite their workload. Lack of sufficient time ded- cated to dying patients, owing to the increased acuity of ther patients or the complexity of tasks and clinical pro- edures on medical units, is an added challenge to the rovision of continuity of nursing care at the EOL after NACPR. Beckstrand et al. (2006) found that a lack of suf- cient time to care for dying patients and their families as a significant concern for nurses in the context of a omplex acute hospital setting. Wallerstedt and Andershed 2007) concluded that if nurses were to provide quality EOL are, then they needed sufficient time to allow them to espond promptly to the evolving needs of EOL patients and heir families. The implication of this study is that staffing

evels should be reviewed to meet the increased demands f patients and families who require EOL care on medical nits.

2

c t l a r o t l i e i g o 2

t t i h d J R a s a s d r o

L

T f h D e a w s r i m r i m t s o d

C

T m a h a r p

a s a a a m u a o

E

A E t c w a p o t t

C

N

F

T a

A

T t o e t

R

A

A

B

B

B

B

8

The findings of the present study highlight the need for ollaborative service development that is congruent with he International Council of Nurses (ICN) document on col- aborative practice in the twenty-first century (Schober nd McKay, 2004). The authors emphasise that collabo- ative service development denotes the contemporary need f modern times for interdisciplinary action in approaches o improving healthcare delivery. They assert that col- aborative service development is best positioned by an ntegrated approach where healthcare providers are consid- red equal in their roles and functions. In relation to this, the nterdisciplinary approach is grounded by common health oals, shared decision-making and ‘nourished by a climate f mutual respect, trust and support’ (Schober and McKay, 004:8).

Nurses in this study appeared to realise that meeting he cultural and religio-spiritual needs of dying patients and heir family members was as important as providing qual- ty physical nursing care. Although several research studies ave discussed nurses’ role in providing spiritual care for ying patients and their families, they are based on the udeo-Christian traditions and values (McCann et al., 2007; assool, 2000). In direct contrast, there has been scant ttention in the literature about nurses’ involvement in the piritual care of dying Muslim patients, particularly those in

conservative Muslim community. Thus, the findings of this tudy have the potential to provide researchers with evi- ence of the need for additional research to examine the ole of nurses in addressing the spiritual and religious needs f dying Muslim patients and their families.

imitations

he qualitative study was limited in approach because it ocused only on experiences within the context of one ospital in Saudi Arabia and limited in its transferability. espite this limitation, the knowledge of the meanings and ssences identified in the nurses’ lived experience provide n understanding of the experience of multinational nurses ith similar backgrounds. Another limitation is that this

tudy relied on each participant’s recall of the lived expe- ience in EOL care after DNACPR. The narratives included n the reflective journals cover a period of two years on edical units in the hospital. Therefore, the accuracy of

ecall may have been distorted as a result of the pass- ng of time, whereby previous experiences in EOL care ay have been diffused with other DNACPR experiences

o answer the reflective journal questions. It should be tated, however, that it was apparent that the experience f participants was both vividly recalled and thoroughly escribed.

onclusion

he findings of the study confirm that nurses working on edical units showed compassion towards DNACPR patients

nd their families. The essence of their lived experience is

aving the ability to identify with the suffering of patients nd families and their willingness to help and to provide elief and support at this time. Nurses found caring for dying atients to be a rewarding and worthwhile experience,

B

I.K. Abu-Ghori et al.

lbeit a challenging and demanding one. The findings uggest that improvement in EOL care would be best chieved by collaborative and interdisciplinary practices mongst the health care team members. Further research imed at understanding the perspectives of various team embers, in particular physicians would enhance our

nderstanding of provision of appropriate level of support nd optimal teamwork required to manage the phenomenon f EOL care after DNACPR on medical units in Saudi Arabia.

thical statement

pproval for the study was granted by the University of New ngland Human Research Ethics Committee and the Hospi- al’s Research and Ethics Committee where the study was arried out. Participation was voluntary and participants ere assured of their right to withdraw at any stage without

reason. Written consent was obtained from all partici- ants prior to participate in the study. The confidentiality f data was assured by use of a specific numeric coding sys- em for reflective journal returns, which was known only to he researcher and the individual participant

onflict of interest statement

o conflict of interest has been declared by the authors.

unding

his research received no specific grant from any funding gency in the public, commercial, or not-for-profit sectors.

cknowledgments

his research was conducted as part of the requirements for he degree of Master of Nursing (Honours) at the University f New England, Australia. We would like to thank the gen- ral medical unit nurses who participated in the study for heir valuable contribution.

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