- Eli Haugen Bunch, Ph.D.
Institute of Nursing Science, University of Oslo,
POB 1120, 0317 Oslo, Norway
This critical care unit admits all types of multi trauma patients except neurosurgical injuries. The patients are defined as critically ill and practically all are on respirators and unable to communicate verbally. To the untrained eye the drama of the unit is hidden behind quiet voices and the hissing of the respirators, the blipping of the suction bottles and monitor alarms needing adjustment.
A qualitative comparative design with participant field observations and interviews explored the clinical discussions providers engage in terms of continuing or terminating treatment .The interpretive method, grounded theory, as described by Glaser and Strauss 7 and Glaser 8, 9 was used. Blumers 10 symbolic interactionism is the theoretical framework for this way of analyzing observational data. Grounded theory is well suited for studies that explore the symbolic negotiations among actors within a defined context. In this study the context was a critical care trauma unit and the actors were nurses and doctors and the study focus was ethical dilemmas.
Observational data were collected from October of 1997 through August of 1999; a total of 50 days yielded about 80 hours of field observations. All weekdays, weekends and holidays were observed on day- and evening shifts at this Norwegian University hospital. A semi-structured interview guide with twelve questions was used for formal interviews with the nurses. The interview guide had questions like: what are the most difficult ethical problems, how do you feel about terminating treatment, are the patients autonomy respected, are you ever afraid the machinery might malfunction, etc. A total of twelve formal interviews were made with nurses. In addition to the interviews, fifteen of the more experienced nurses served as informants throughout the data collection period. Notes were written while in the field and later transcribed to a word processor and then analyzed. The majority of the nurses had critical care education and trauma training along with many years' clinical experience. The nurses were in their late twenties to early fifties and about 20% were male nurses.
Ethical permission to the study was obtained from the Director of nursing services, the chief surgeons, nursing supervisor and head nurse. The staff nurses gave individual consent. Several staff meetings were attended to explain the study and a copy of the research protocol was put in the unit information book. Doctors, patients and families were excluded.
After transcribing the field observations to my personal computer they were analyzed according to Glaser's 8, 9 scheme of open coding, selective coding, writing of memos, theoretical coding and analyses. The purpose of this qualitative comparative analyses is to generate a theoretical understanding of the social processes in the chosen field that is grounded in the empirical reality of the nurses and doctors.
Data analyses generated a central theme of hidden and emerging drama in the context of ambiguity. A subprocess to the above was the emulation of composure while routinizing the handling of complex technology.
When walking on to a high technology unit like the one where the observations were made, one expects open drama in terms of activity- and noise level. On this unit the drama was hidden behind quiet voices and staff that never ran. Patients were lying very still in their beds, most of them unconscious and with a respirator breathing for them. The open drama and noise came from the ticking of the machines, the blip, blip of the respirators and suction bottles and an occasional alarm from a machine that needed attention.
The emerging drama became evident after many months of observations when I learned to identify the signs that initially were hidden to my untrained eye. The drama became evident when I was able to identify the number and qualifications of the nurses assigned to the patient, the intensity and urgency of the nursing care and by the number of machines and intravenous tubes attached to the patient. To the untrained eye one is unable to see the drama as the nurses emulate composure and have routinized the handling of complex technical equipment.
The drama behind the clinical status of each patient was very complex and most difficult to interpret, partly because it was hidden, and only emerged when one learned how to interpret the signs and symptoms. The drama was played out in a context of clinical ambiguity, as much of the clinical data was uncertain and difficult to predict in terms of patient trajectories. The extent and complications of the injuries of multi trauma patients develops over days and weeks along with respiratory complications and infections11.
The providers need years of education and clinical experience to be able to identify, recognize and plan interventions for trauma patients. The subprocess of routinizing the handling of the technology was something the nurses developed over years. Experienced nurses learned to pay selective attention to the technology while they read and interpreted the data. When a nurse was able to routinize the handling of the technology they also touched the patient more than the less experienced nurses. They touched the patients for comfort and checking for signs and symptoms. To the nurses the technology became tools. A statement often made when I talked with them was: "We provide professional nursing care to human beings, not machines".
The nurses continuously assessed the patient and collected clinical data while they planned and predicted patients' trajectories in a context of clinical ambiguity. A subprocess to planning and predicting patient developments was the degree of patient complexity, intensity and urgency. The primary nurse assigned to the patient collected data and assessed the patient status while deliberating what interventions must be made and struggling to get a clearer picture of ambiguous data. The primary nurse must also decide when to call the primary doctor, as s/her were not on the unit every minute. Thus the primary nurse in charge of a patient had much professional autonomy and also decided when to call the physician.
Findings from this study show that the nurses and physicians displayed much collegial interaction and mutual respect. Each group depended on the other for giving professional nursing care and medical treatment, and providing information about clinical data in order to mutually discuss treatment options. The importance of well-educated nurses along with collegial interactions constituted a large part of the hidden drama.
Within the hidden and emerging drama played out in this context of ambiguity on a critical care unit, nurses identified many ethical dilemmas. The nurses have a clear nursing goal based on their ideology that guide them and permeate the unit. Their nursing ideology was to provide quality-nursing care to human persons and to use the technology as tools. The nurses felt each patient must be given a chance to survive and thus never gave up hoping since some did survive. Within this context they identified several problematic ethical dilemmas: patients lingering on, transferring patients too soon, asking the question if there ought to be an age limit to certain surgical operations and limited resources in terms of more and better qualified nurses.
Lingering on was problematic when a patient remained critically ill for weeks and months with a unclear clinical picture. Sometimes the patient status would improve to some extent but then become worse and in the end die. The nurses would become attached to the patient and complex issues of the individual versus the common good led many nurses to say: "The patient must be given a chance, who am I to determine what quality of life means"(Nurses). Patients lingering on was emotionally draining for the family members as well as the nurses and doctors.
Transferring patients too soon is a thorny dilemma, as this university hospital must admit all emergency trauma patients. Patients were transferred to central or local hospitals as soon as they could be safely transported. The timing of the transfer became problematic because of professional pride in the nursing care given and the staffs belief that other hospitals do not have the same qualifications, sophisticated equipment and clinical experienced staff as this hospital had.
A frequent dilemma occurred when older patients were offered coronary surgery even when the documented evidence for recovery was not obvious. All patients receive detailed explanations about the upcoming surgery including possible adverse outcomes. Older peoples physiology is brittle and complications occur more frequently than in younger people but many elderly patients said: "I would rather have the surgery and risk dying on the operating table. I might survive and have many good months with my family". Offering coronary surgery to all patients needing this is linked to the fact there is no age limit for surgical procedures in Norway. Family members find it extremely difficult to decline surgery when it is offered despite the questionable outcomes. When the patients did have complications, it was very stressful for the family and staff to watch the pain and agony the patient was suffering.
Perhaps the most profound ethical dilemma, resource allocations, occurred around staffing issues. But the staff nurses never mentioned this dilemma. However, the nurses in leadership positions constantly brought up the issue of resource allocations. If they said yes to admit one patient, they might have to say no to the next patient who required critical care. The charge nurse had to distribute the limited resources as best she could. The unit was built for as many as eighteen patients and only had safe staffing for six to eight patients.
For the patients that lingered on or had roller coaster trajectories the nurses and doctors would have team discussion. The unit had organized the staff in 5 teams with one doctor and four to five nurses per team. During team discussions they talked about the treatment options, possible outcomes, and what to do in case the patient might require rescucitation. The team conferences not only helped clarify clinical values, they distributed the work load, responsibilities, and decision making among the providers. The legal obligation of the physician to order medical interventions and sign orders were never questioned. The cost of treating patients was never an issue in the team conferences and was not used as an argument to terminate treatment. There seemed to be a mutual trust between the nurses and doctors where the nurses had to navigate the patient beyond standard treatment protocols. To my knowledge the issue of whether the nurses went beyond their qualifications or not, was never discussed.
Staff held team discussions with family members and sometimes the patient was included. Treatment options and possible outcomes were openly discussed with them. A decision to terminate treatment was never reached without the providers and family reaching a type of consensus.
The nurses had developed a helpful strategy of making an appointment to call the family after a patient died. The primary nurse usually waited two weeks before calling and a conversation never lasted much beyond 30 minutes. Talking with the family provided closure for the nurse and if they found the family was not coping adequately they referred them to appropriate services outside the hospital.
To the untrained
eye, this unit presents a picture of calm competence. While professional
competence best describes the nurses there, underlying this surface
one finds a drama hidden in a context full of difficult interacting
and ethical problems. The actors in this hidden and emerging
drama face ethical issues surrounding end of life including ambiguous
clinical data on which to base decisions to what the ethically
right action is in a specific situation. Along with this issue
and compounding it, questions of distributive justice arise asking
who should get what resources and whether age should be a variable
in these discussions. The importance of shared deliberations makes
the nurses and doctors able to undertake actions that they think
are right and yet shared with each other and family. The bedside
discussions were based on mutual respect and understanding. How
representative the findings from this study unit are for other
critical care units in Norway need to be researched in future
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