, Research Paper
Nurse?s Attitudes TowardDo Not Resuscitate Orders
In Partial Fulfillment of the Requirementsfor Nursing 4522Nursing Research II
Presented toAllen Nottingham, R.N., B.S.
ByMeggin BeanJessica BrownellShannon GenzerLeslie LoomanShanna McIntosh
April 20, 1998
TABLE OF CONTENTS
I. INTRODUCTION?????????????????????1 Background??????????????????????1 Theoretical Framework?????????????????. 4 Problem Statement??????????????????? 5 Statement of Purpose??????????????????..5 Research Question???????????????????..6 Theoretical Definitions?????????????????.. 6 Operational Definitions?????????????????..7
II. REVIEW OF LITERATURE?????????????????9 Introductory Statement??????????????????9 Conceptual Framework?????????????????..101. Pre-Conventional Level?????????????112. Conventional Level??????????????.. 173. Post-Conventional Level????????????.. 21 Summary???????????????????????.24
III. METHODOLOGY????????????????????.. 26 Introductory Statement?????????????????.. 26 Research Setting????????????????????. 27 Subjects???????????????????????.. 27 Procedure??????????????????????? 28 Instrumentation????????????????????.. 29 Assumptions related to Methodology????????????. 31
IV. REFERENCES??????????????????????. 32
V. APPENDICES??????????????????????. 36 Appendix A?????????????????????? 36 Appendix B?????????????????????? 41 Appendix C?????????????????????? 42 Appendix D?????????????????????? 43 Appendix E?????????????????????? 45
Background Many influences such as cultural background, values, morals, and beliefs bring great force to bear upon almost every decision a person must make throughout an average day whether it be a choice, idea , or action. These influences are used in the formation of attitudes about one?s self in general, and about right or wrong. All people have these childhood influences to credit for our attitudes, choices, ideas, and even beliefs that are held dear. Attitudes developed during childhood and throughout life play a key role in the way people interact with one another, handle crises, or even deal with day-to-day problems that occur in their lives. These beliefs are central to every human whether they be carpenter, politician, or registered nurse. So enmeshed in our daily lives are these values, that very often their role in the decision process goes unnoticed. In fact, one can live their entire life and never have awareness as to what triggers certain emotions, feelings toward the other sex, or even what drives the direction of thought. Yet, they are passed on to every generation often blindly, with every gesture, every arched eyebrow, and every fairy tale. The awareness of their presence is secondary to the need to have them. They are the thread that stitches communities together, brings people to a common ground, and gives many a purpose for living. Attitudes about death and dying are derived from a lifelong process of experiencing life and the beliefs about death that one accepts as their own. In many cultures beliefs and issues surrounding death are the ones held dearest and closest to oneself. Many, if not all, cultures accept that death is but another step in the process of life. However, differences in how one may choose to welcome or elude death are varied and many. How one chooses to face death, what instrumentation, and even where to die (when one has the choice) are all matters of personal preference. Use of Do Not Resuscitate (DNR) orders or exhaustive measures are also matters of preference ( when there is a living will and these decisions are made ahead of time), and these preferences affect many lives ranging from friend to caregiver. As a caregiver, the nurse must deal with death and those that are dying on an almost daily basis. As a nurse, one must be aware of his or her own personal feelings and beliefs regarding death and be prepared to respect the wishes of the patient regarding this issue. More often, the nurse will be the very person to carry out a DNR order. This means that the nurse may have to stand and watch or take the hand of a patient while he or she dies. The decision that a nurse will make will be based on attitudes toward death and dying, as well as the very notion of the DNR order. Some nurses may perceive a DNR order as an easy way out of expensive medical bills and a direct hand in the death of the patient, while others may see it as a merciful end to a painful and tormented existence. When confronted with the legality of DNR orders and the humanity of caring and wanting to preserve life, the nurse is often confronted with a dilemma. The nurse?s decision can be one that can affect her career as well as the wishes of the patient. Whatever the nurse?s feelings are, they must be addressed in order to better serve the patient and to ensure that the patient?s rights and best interests are at the center of the concern. By addressing the nurse?s issues with DNR orders or just death itself, the patient benefits from the knowledge that the nurse has an understanding of why he or she may feel a certain way about a particular topic. Understanding of where our values, beliefs, and perception originate can only serve to, help us become stronger, more compassionate, and wiser.Researchers of this study believe that results will contribute to the already vast body of nursing knowledge by delivering an article that when read, may aid the readers to look within oneself and determine what beliefs, or lack of, are governing their actions. In addressing this issue, the researchers feel that a nurse will gain valuable insight which may help him or her to better cope with the issues surrounding a patient that is near death and has a DNR order attached to his or her chart. The researchers will also present information on the process whereby formation of these attitudes or beliefs occurs and in doing so will provide source from whence changes and or understanding of what we believe can be achieved. Furthermore, the researchers believe that the extent to which these findings can be generalized are not just limited only to certain floors or departments within a hospital setting but, are available to everyone with the desire to understand what makes them care about certain issues. Still, these findings can be useful in areas of oncology, pediatrics, geriatrics, and or any area where DNR orders are in place. Also, these findings can be useful in palliative, as well as curative settings, within the home health community, and the retirement community. In general, the researchers hope that this information which may aid anyone in their search for understanding of who and what they are, will also serve as a tool to affect a change in how those that read this study treat one another as well as what one says and does.
Theoretical FrameworkKohlberg?s Theory of Moral Development will be used as a conceptual framework for this study (Wong, 1995). Kohlberg?s theory consist of three levels. Within each level are two distinct stages of moral development. Within level one, the Pre-moral level, are the stages one and two which state that a person obeys rules to prevent punishment or to bring about reward respectively. Within Kohlberg?s level one is Piaget?s stage one of moral reasoning called Moral Realism from which attitude formation, and attitudes about death and dying are formulated ( Coffey & March, 1983).The second Kohlberg level is known as the Pre-Conventional level. Within this level are stages three and four . Stage three addresses the method whereby individuals pursue the approval of others by portraying themselves as good. Stage four states that people have respect for authority and social order and that people are oriented toward duty and respect for authority. Also within this level is Piaget?s second stage of moral reasoning called Morality of Cooperation which deals with the way cooperation is achieved in moral development and its implications on developing morals and attitudes.The last level of Kohlberg?s model is the Post-Conventional level. Within this level are the fifth and sixth stages. Stage five addresses that people are receptive to obeying democratically accepted laws and rules of behavior, while stage six implies that morality is individual conscience. Within this section studies will be presented that state that nurses function at this level of Kohlberg?s Theory of Moral Development. It is because of this level that one can be in touch with the emotions and attitudes that are responsible for how people feel and act regarding a specific subject. These actions and the attitudes behind them are the foundations for what makes something right or wrong (at least in the mind of the person or persons involved). Kohlberg?s model will be used to explain the actions of individuals based on the level of development previously stated by the many levels of Kohlberg?s model. It has been stated that nurses function at the stage 6 level that states morality is individual conscience. With all the stages having been laid out quite specifically, a researcher should be very capable of assigning a specific subject to a specific stage of development and also be able to determine with some degree of accuracy the attitudes held by that person by the way a set of questions are answered (Kohlberg, 1969).Problem StatementWhat factors, moral and ethical, influence nurses? attitudes and decisions regarding patient care of a client with DNR orders?Statement of PurposeThe researchers believe that independent variables such as patient demographics, as well as physiological aspects ranging from age and sex to acuity and nature of disease will have an affect on the dependent variable, the nurses? attitude on death and dying. This study will explore the nurses? attitudes about death and dying as well as specific issues about DNR orders which may have deep rooted origins and may be affected by various factors such as familial wishes and cultural issues that are out of the control of the nurse. In this descriptive study, the researchers will attempt to add to the vast body of nursing knowledge by exploring the attitudes that nurses have toward death and dying as well as their attitude toward the DNR order itself. The researchers believe that by investigating the origins of one?s values and beliefs the nurse will become a better nurse and a better person .This insight into oneself will allow the nurse to deliver better patient care and develop a sense of who they are and where they come from.Research QuestionWhat factors that affect nurses? attitudes toward death, the dying, and the DNR order can be discovered and identified in a descriptive study by the use of a subject specific questionnaire such as a DNR questionnaire?Definition of TermsTheoretical DefinitionsDNR Order: “A note written in the patient record and signed by a qualified, usually senior or attending physician, instructing the staff of the institution not to attempt to resuscitate a particular patient in the event of cardiac or respiratory failure. This instruction is usually only given when a person is so gravely ill that death is imminent and inevitable” (Mosby?s Medical & Nursing Dictionary, 1996).Attitude: “State of mind, behavior, or conduct regarding some matter, as indicating opinion or purpose” (Britannica World Language Dictionary, 1995).Nurse: “A person educated and licensed in the practice of nursing; one who is concerned with “the diagnosis and treatment of human responses to actual or potential health problems” (American Nurses? Association). The practice of the nurse includes data collection, diagnosis, planning, treatment, and evaluation with men in framework of the nurse?s singular concern with the person?s response to the problem rather than to the problem itself. The concerns of the nurse or thus broader and less discrete and circumscribed than the traditional concerns of medicine. In a cooperative participatory relationship with the client or patient, the nurse acts to promote, maintain, or restore the health of the person; wellness is the goal. A collegial collaborative of relationship with other health professionals who share a mission and a common data base furthers the practice of nursing. Guided by a humanitarian, ethical principles, the nurse practices in a personal, nurturing, and protective manner that promotes health in all ways. The nurse may be a generalist or a specialist and, as a professional, is ethnically and legally accountable for the nursing activities performed and for the actions of others to whom the nurse has delegated responsibility” (Mosby?s Medical & Nursing Dictionary, 1996).Questionnaire: A written or printed form comprising a series of questions submitted to a number of persons in order to obtain data for a survey or report ” (Britannica World Language Dictionary, 1995).
Operational DefinitionsDNR order: An order made by a physician (of one of the three hospitals involved in the UCO DNR study) after consultation with family members which entails the lack of effort to revive a patient that has naturally ceased to breath or has experienced cardiopulmonary arrest.Attitude: An inner personal feeling toward a certain subject, person, or philosophy that could be positive or negative held by one or more nurses involved in the UCO descriptive DNR study.Nurse: A graduate of a one (Licensed Practical Nurse), two, or a four year, accredited nursing program, or a graduate of a certificate program and licensed by any state to practice as a nurse and currently employed at any one of three metropolitan hospitals in the Southwestern United States which are currently assisting with the UCO DNR research project.Questionnaire: The tool used to ascertain attitudes and acquire information about DNR orders from participating nurses employed at one of the three Southwestern United States Hospitals involved in the UCO DNR study.
Review of Literature
The Review of Literature has been organized into Kohlberg’s Theory of Moral
Development. Kohlberg’s theory was used in this study because it directly addresses
moral development in children and adults, and focuses on the reasons an individual
makes a decision; rather than the actual morality of their decision. Kohlberg’s Moral
Development Theory progresses through three levels and six stages.
The first level, the Pre-Moral or Pre-Conventional, consists of two
stages. Stage one involves punishment and obedience orientation. Stage two involves
instrumental-relativist orientation in which action is taken to satisfy one’s needs.
Incorporated into this level is Piaget’s stage one of moral reasoning, which consists of
Moral Realism and attitude formation (Coffey and March, 1983). At this level, nurses
attitudes begin to formulate in relation to deep rooted origins of beliefs and values.
Furthermore, these beliefs and values often influence nurses attitudes towards Do- not -
The second level, The Conventional Level, includes stages three and four.
Stage three involves interpersonal concordance, which focuses on individuals adhering to
a good boy/nice girl morality. Stage four involving law and order orientation states that
right behavior is obeying the law and following the rules. This level includes Piaget’s
second stage of moral reasoning called Morality of Cooperation. As previously stated
nurses formulate attitudes, however at this level ethical consideration takes precedence
over the DNR order.
The last level of Kohlberg’s theory is called The Post-Conventional, Autonomous,
or Principled Level. This level consists of stages five and six. Stage five involves social
contract and legalistic orientation, and focuses on adhering to laws
that protect the welfare and rights of others. Stage six involves universal/ethical
principles. This focuses on the fact that universal moral principles are internalized.
Nurses are often confronted with ethical dilemmas due to oppositions between their own
conscience of what is right and wrong and ethical considerations.
In retrospect, our Review of Literature has focused on Kohlberg’s Theory of
Moral Development which may be the basis for a nurses moral reasoning.
Moral development is a continuous process in which a person learns to
consciously accept right and wrong, according to their own beliefs and values.
An individual learns throughout childhood a sense of what is right and what is wrong.
Through this, a sense of morality is formed by their behavior as “good” or “bad”. This is
established through rewards and punishments.
An individual must understand how morality is formed throughout
childhood (Kozier & Erb, 1995). A child?s moral development is highly influenced by
the parent or guardian. A child is rewarded for what a parent or guardian considers good
behavior and punished for what a parent or guardian considers a bad or negative
behavior. Therefore, a child’s belief of what is right or wrong is developed by their
parent’s disciplinary actions.
PRE- CONVENTIONAL LEVEL. Kohlberg developed a structure to form a
theory of moral development. Moral development is a complex process, which involves
learning what ought to be and what ought not to be done (Kozier and Erb, 1995).
According to Kohlberg, moral development progresses through each stage of each level.
Levels and stages are not always linked to a particular developmental stage, because
some persons progress to a higher level of moral development that others (Kozier &
The first stage of the Pre-conventional level is the Right of literal obedience to
rules and authority, avoiding punishment, and not doing physical harm (Kohlberg,1927).
This stage takes an egocentric point of view. A person at this stage does not recognize
the interests of others. They do not relate two points of view. Instead, they value their
own beliefs. Actions are judged in terms of physical consequences rather than in terms
of psychological interests of others (Kohlberg, 1927). For instance, a nurse follows a
physician’s orders so as not to be fired, although many nurses may have
conflicting beliefs it is their duty to carry out DNR orders. Many statutes provide
immunity to health care providers who do. Failing to honor an DNR order could lead to
a battery suit by the patient or his family, and disciplinary action by the Board of
Nursing (Sloan, 1996). Individuals function in order to avoid punishment. Rules are
sacred and unchangeable, and those who violate rules must be punished according to the
magnitude of their offenses (Shultz, 1997).
Health care as a profession involves far more ethical principles than perhaps any
other profession. Nurses, as well as other health care professionals with a principle-
centered life and practice, create an internal structure that will help them consistently
meet ethical obligations to themselves, patients, families, and communities. Developing
a central set of Principles, encourages nurses to apply the same set of ethics to
themselves as well as to their patient (Moss, 1995).
Jezewski (1994) conducted a study to describe the conflict that occurs during the
process of consenting to do-not-resuscitate status and the strategies used by critical
care nurses to attempt and prevent, minimize, and/or resolve these conflicts. His study
consisted of a grounded theory design. Twenty-two critical care nurses practicing in
upstate New York in urban and rural, profit and nonprofit hospitals were involved in the
study. Of the 22 participants, 21 were female and 1 was a male. The age range was 26-53
years old, with a mean of 34 (+ or – 6 years). Years in practice ranged from 4-31 years.
Semi-structured, in-depth interviews were used to collect data. The interview schedule
consisted of open-ended questions and were formulated to elicit nurses’ experiences in
the context of interacting with patients and family members during the process of their
deciding whether to consent to a DNR status. The data was analyzed with the continuous
comparative method of grounded theory. The results show that conflict occurred during
the process of consenting to DNR status. Two major categories of conflict were
intrapersonal (inner conflict in coming to terms with DNR-status decision) and
interpersonal (conflict that took place between individuals involved in consenting to a
DNR status). Intrapersonal conflict, for the nurses occurred while determining the
appropriateness of DNR order for their patients and coming to terms with the meaning
of DNR status. Nurses had to come to terms that a DNR order was appropriate or
inappropriate for the patient. To do this, the nurse assessed the patient’s physical status
in conjunction with quality of life issues, conferred with other health care professionals,
and talked with the patient and/or family. It was important for the nurses to personally
resolve any conflict about the appropriateness before they could optimally assist patients
and families with the decision to consent to DNR status. Interpersonal conflict occurred
between family members, patients, and staff. Nurses descriptions of their role were
reflective of a culture broker framework incorporating advocacy, negotiation, meditation,
and sensitivity to patient?s and family?s needs. They would talk with family members to
try to understand their feelings about consenting to a DNR status. The nurses
emphasized the importance of allowing time for family members to come to terms with
the patient’s status and the meaning of DNR for themselves individually and as a group
Attitudes, values, and ethics set the stage for managed care nursing (Salladay,
1997). Ajzen and Fishbein(1980) theorized that human beings base their actions on
rational, systematic use of information; persons consider the implications of their actions
before they decide to engage in a given behavior. Attitudes are defined as the persons
evaluation of the positive or negative effects of the outcomes of specific behaviors or
actions taken. Whereas, Behavioral intention is the reported degree of likelihood that the
nurse will perform a certain action (Ajzen & Fishbein, 1980).
Nurses must decide what their own moral actions ought to be in a situation
concerning a DNR order. Because of the special nature of the nurse-client relationship,
they must support and sustain clients and families who are facing difficult moral
decisions. On the other hand, nurses must also support clients and families who are
living out the decisions made for and about them by others, or themselves. Nurses can
make better moral decisions and have a positive attitude to any given situation by
thinking in advance about their beliefs and values (Moss, 1995).
Schaefer and Tittle (1994) conducted a study to explore the attitudes and
perceptions of registered nurses (RNs) and physicians (MDs) regarding the care of
patients with do-not-resuscitate (DNR) orders in the intensive care units (ICU).
Structured interviews were conducted with twenty RNs and MDs from the ICUs of
twenty-five Veterans Administration Hospitals. The questionnaire included four
hypothetical cases which tested a statement as to who would best support the autonomy
of the patient in making a DNR decision: (a) when the patient is incompetent, (b) when
the patient is not competent and a close relationship exists with the family, (c) when the
patient is not competent, has no close relationship with family but a therapeutic
relationship exists between the physician and the patient, and (d) when the patient is not
competent, has no close relationship with the family but a therapeutic relationship exists
between the nurse and the patient. A total of 226 (45.2%) questionnaires were received;
160 (70.8%) from the RNs and 66 (29.2%) from MDs. The mean age of RNs was 38.4
with a range of 22-58. The mean age of the MDs was 42.4 with a range of 27-76. The
RNs and MDs did not agree who would best support patient autonomy in any of the four