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Background. A critical care unit admits on a daily basis patients who are critically ill or injured. The condition of these patients’ may deteriorate to a point where the medical practitioner may prescribe or decide on a ‘do not resuscitate’ (DNR) order which must be executed by a professional nurse, leading to moral distress which may manifest as poor teamwork, depression or absenteeism.
Objective. To explore and describe factors contributing to moral distress of critical care nurses executing DNR orders.
Design. The explorative descriptive qualitative design was selected to answer the research questions posed.
Methods. Critical care nurses of a selected public hospital in Gauteng Province were selected via purposive sampling to participate in the study, and data were collected through semi-structured interviews.
Participants. A shift leader assisted with selection of participants who met the eligibility criteria. The mean age of the participants was 36 years; most of them had more than five years’ critical care nursing experience. Twelve critical care nurses were interviewed when data saturation was reached. Thereafter two more interviews were conducted to confirm data saturation. A total of 14 interviews were conducted.
Results. Tesch’s eight-step method was utilised for data analysis. The findings were classified under three main themes: moral distress, communication of DNR orders and unavailability of psychological support for nurses.
Conclusion. The findings revealed that execution of DNR orders is a contributory factor for moral distress in critical care nurses. National guidelines and/or legal frameworks are required to regulate processes pertaining to the execution of DNR orders. The study further demonstrated the need for unit-based ethical platforms and debriefing sessions for critical care nurses.
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How to Cite
Vincent H. Relationships of moral distress among interprofessional ICU teams (2018). UT SON Dissertations (Open Access). 25.
Vanderspank-Wright B, Efstathiou N, Vandyk AD. Critical care nurses’ experiences of withdrawal of treatment: A systematic review of qualitative evidence. Int J Nurs Stud 2018;77:15-26.
Velarde-García JF, Luengo-González R, González-Hervías R, et al. Limitation of therapeutic effort experienced by intensive care nurses. Nurs Ethics 2018;25(7):867-879.
Chen Y-S, Chen Y, Chu T-S, Lin KH, Wu CC. Further deliberating the relationship between do-not-resuscitate and the increased risk of death. Sci Rep 2016;6:23182.
Nankudwa E, Brysiewics P. Lived experiences of Rwandan ICU nurses caring for patients with do-not-resuscitate order. South Afr J Crit Care 2017;33(1):19-21.
Hassan CP, Ali AM. Do-not-resuscitate orders: Islamic viewpoint. Int J Human Health Sci 2018;2(1):8-12.
Viljoen C. Pre-hospital care and do not attempt to resuscitate orders: The legal and ethical consequences [doctoral dissertation, University of the Free State]. 2017.
Voget U. Professional nurses’ lived experiences of moral distress at a district hospital [doctoral dissertation, Stellenbosch University]. 2017.
Allen R. Addressing moral distress in critical care nurses: A pilot study. Int J Crit Care Emerg Med 2016;2(2):2474-3674.
Hunter D, McCallum J, Howes D. Defining exploratory-descriptive qualitative (EDQ) research and considering its application to healthcare. J Nurs Health Care 2019;4(1).
Brink H, Van der Walt C, Van Rensburg G. Fundamentals of Research Methodology for Healthcare Professionals. 4th ed. Cape Town: Juta; 2018.
Polit FD, Beck TC. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 10th ed. Wolters Kluwer: Philadelphia; 2021.
Bordignon SS, Lunardi VL, Barlem ELD, Dalmolin GdL, da Silveira RS, Ramos FRS, Barlem JGT. Moral distress in undergraduate nursing students. Nursing Ethics 2019;26(7-8):2325-2339.
Creswell JW. Research design: Qualitative, quantitative and mixed method approaches. 4th ed. Thousand Oaks: Sage; 2014.
Guba EG. Criteria for assessing the trustworthiness of naturalistic inquiries. Ed Com Technol J1981;29:75-91.
Campbell S M, Ulrich C, Grady C. A broader understanding of moral distress. In: Ulrich CM, Cady C, editors. Moral distress in the health professions. New York: Springer, 2018; 59-77.
Pettersson M, Hedström M, Höglund AT. The ethics of DNR decisions in oncology and hematology care: A qualitative study. BMC Med Ethics 2020;21(1):1-9.
Akdeniz M, Yardımcı B, Kavukcu E. Ethical considerations at the end-of-life care. SAGE Open Med 2021;9:20503121211000918.
Vu B. Ethical considerations of DNR orders from nursing perspective/DNR-päätöksen eettiset näkökohdat hoitotyön näkökulmasta. 2019. https://urn.fi/URN:NBN:fi:amk-201903153191 (accessed 15 August 2022).
Dzeng E, Curtis JR. Understanding ethical climate, moral distress, and burnout: A novel tool and a conceptual framework. BMJ Quality Safety 2018;27(10):766-770.
Azab S, Abdul-Rahman SA, Esmat IM. Survey of end-of-life care in intensive care units in Ain Shams University Hospitals, Cairo, Egypt. HEC Forum 2020:1-15.
Kelly PA, Baker KA, Hodges KM, Vuong EY, Lee JC, Lockwood SW. Nurses’ perspectives on caring for patients with do-not-resuscitate orders. Am J Nurs 2021;121(1):26-36.
Jensen HI, Halvorsen K, Jerpseth H, Fridh I, Lind R. Practice recommendations for end-of-life care in the intensive care unit. Crit Care Nurse 2020;40(3):14-22.
Turale S, Meechamnan C, Kunaviktikul W. Challenging times: Ethics, nursing and the COVID-19 pandemic. Int Nurs Review 2020;67(2):164-167.