Grief, Physical Symptoms, and Decision-Making in Mothers of Newborns Who Die

The purpose of this study was to describe predictors of level of grief and physical symptoms in mothers during the year after a newborn death. This was undertaken to fmd better ways to help these mothers during this crisis. Following appropriate approvals, volunteer subjects were contacted through hospitals, the Internet, and a health department. Of the 75 who responded, 77% were White and married, 64% were Christian. 51 % had other living children, 72% had had no prior pregnancy losses, 87% had support with decision-making about newborn care, and their mean age was 30 yrs. Once subjects had agreed to take Par4 the survey and consent form were sent to them. Study outcome variables were: Total scores on the Perinatal Grief Scale, Short Version (level of grief; T oedter, Lasker, & Alhadeff. 1988) and Sickness Impact Profile 68 (level of physical symptoms; de Bruin, Buys, de Witte, & Diederiks, 1994). Predictor variables were total scores on the Personal Resources Questionnaire 85, Part U (perceived support; Brandt & Weinert, 1981); Relationship Satisfaction Questionnaire (relationship satisfaction; Olson & McCubbin, 1983); Emotion-Focused. Problem-Focused, and Mixed Coping Subscales (emotion-focused, problem-focused, and mixed coping; Lazarus & Folkman, 1988); interval since death, ethnicity, religion, socioeconomic status, gestational age, and presence of living children. Coefficient alphas for scales were all over .75. In two stepwise-hierarchical multiple regressions, perceived support and emotion- focused coping combined to predict 43% of the variance in level of grief, and level of grief alone predicted 50% of the variance in level of physical symptoms. In written comments, mothers said they valued their role in decision-making about newborn care even with death as the result. and felt supported in that process. Findings may be used to design intervention programs to help bereaved mothers following a newborn death. Specifically, programs can help increase perceived support for bereaved mothers, and teach new ways of coping. Both strategies may result in lower levels of grief and physical symptoms in this group of bereaved mothers.

Referral to rehabilitation following traumatic brain injury: practitioners and the process of decision-making

The study aimed to examine the factors influencing referral to rehabilitation following traumatic brain injury (TBI) by using social problems theory as a conceptual model to focus on practitioners and the process of decision-making in two Australian hospitals. The research design involved semi-structured interviews with 18 practitioners and observations of 10 team meetings, and was part of a larger study on factors influencing referral to rehabilitation in the same settings. Analysis revealed that referral decisions were influenced primarily by practitioners' selection and their interpretation of clinical and non-clinical patient factors. Further, practitioners generally considered patient factors concurrently during an ongoing process of decision-making, with the combinations and interactions of these factors forming the basis for interpretations of problems and referral justifications. Key patient factors considered in referral decisions included functional and tracheostomy status, time since injury, age, family, place of residence and Indigenous status. However, rate and extent of progress, recovery potential, safety and burden of care, potential for independence and capacity to cope were five interpretative themes, which emerged as the justifications for referral decisions. The subsequent negotiation of referral based on patient factors was in turn shaped by the involvement of practitioners. While multi-disciplinary processes of decision-making were the norm, allied health professionals occupied a central role in referral to rehabilitation, and involvement of medical, nursing and allied health practitioners varied. Finally, the organizational pressures and resource constraints, combined with practitioners' assimilation of the broader efficiency agenda were central factors shaping referral. (C) 2004 Elsevier Ltd. All rights reserved.

Factors influencing Hong Kong Chinese patients' decision-making in seeking early treatment for acute myocardial infarction

The purpose of this study was to identify, through in-depth interview, factors that influenced 27 Hong Kong Chinese patients' decision-making in seeking early treatment for acute myocardial infarction (AMI). The median delay time from the onset of symptoms to arrival at the hospital was 15.6 hours for men and 53.7 hours for women. Three major categories emerged from the data: (a) becoming aware of the threat, (b) maintaining a sense of normality, and (c) struggling to mobilize resources. A variety of decisions were made by patients from the onset of chest Pain to seeking help. These decisions were heavily influenced by healthcare factors (access to emergency medical service (EMS) and treatment), personal factors (cognitive interpretations of symptoms), sociocultural factors (family situation, cultural beliefs, and practices), and coping strategies. (c) 2006 Wiley Periodicals, Inc.

Study of management decision making by ward sisters in a hospital and the effects on decision making after the implementation of a decision support sytem

This thesis considers management decision making at the ward level in hospitals especially by ward sisters, and the effectiveness of the intervention of a decision support system. Nursing practice theories were related to organisation and management theories in order to conceptualise a decision making framework for nurse manpower planning and deployment at the ward level. Decision and systems theories were explored to understand the concepts of decision making and the realities of power in an organisation. In essence, the hypothesis was concerned with changes in patterns of decision making that could occur with the intervention of a decision support system and that the degree of change would be governed by a set of `difficulty' factors within wards in a hospital. During the course of the study, a classification of ward management decision making was created, together with the development and validation of measuring instruments to test the research hypothesis. The decision support system used was rigorously evaluated to test whether benefits did accrue from its implementation. Quantitative results from sample wards together with qualitative information collected, were used to test this hypothesis and the outcomes postulated were supported by these findings. The main conclusion from this research is that a more rational approach to management decision making is feasible, using information from a decision support system. However, wards and ward sisters that need the most assistance, where the `difficulty' factors in the organisation are highest, benefit the least from this type of system. Organisational reviews are needed on these identified wards, involving managers and doctors, to reduce the levels of un-coordinated activities and disruption.

Classifying clinical decision making:a unifying approach

This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism.

Protocol: Quality of Life, Decision Making, Costs and Impact on Carers in People Managed without Dialysis - The PACKS Study

Using an end-of-life care pathway in acute stroke: a mixed methods study of decision-making and care experiences

Background: The evidence base on end-of-life care in acute stroke is limited, particularly with regard to recognising dying and related decision-making. There is also limited evidence to support the use of end-of-life care pathways (standardised care plans) for patients who are dying after stroke. Aim: This study aimed to explore the clinical decision-making involved in placing patients on an end-of-life care pathway, evaluate predictors of care pathway use, and investigate the role of families in decision-making. The study also aimed to examine experiences of end-of-life care pathway use for stroke patients, their relatives and the multi-disciplinary health care team. Methods: A mixed methods design was adopted. Data were collected in four Scottish acute stroke units. Case-notes were identified prospectively from 100 consecutive stroke deaths and reviewed. Multivariate analysis was performed on case-note data. Semi-structured interviews were conducted with 17 relatives of stroke decedents and 23 healthcare professionals, using a modified grounded theory approach to collect and analyse data. The VOICES survey tool was also administered to the bereaved relatives and data were analysed using descriptive statistics and thematic analysis of free-text responses. Results: Relatives often played an important role in influencing aspects of end-of-life care, including decisions to use an end-of-life care pathway. Some relatives experienced enduring distress with their perceived responsibility for care decisions. Relatives felt unprepared for and were distressed by prolonged dying processes, which were often associated with severe dysphagia. Pro-active information-giving by staff was reported as supportive by relatives. Healthcare professionals generally avoided discussing place of care with families. Decisions to use an end-of-life care pathway were not predicted by patients’ demographic characteristics; decisions were generally made in consultation with families and the extended health care team, and were made within regular working hours. Conclusion: Distressing stroke-related issues were more prominent in participants’ accounts than concerns with the end-of-life care pathway used. Relatives sometimes perceived themselves as responsible for important clinical decisions. Witnessing prolonged dying processes was difficult for healthcare professionals and families, particularly in relation to the management of persistent major swallowing difficulties.

"I’ll call you when we are ready" (One family’s experience of critical care and end of life decision making)

The purpose of this paper is to explore through narrative accounts one family's expérience of critical care, after the admission of a family member to an Intensive Care Unit (ICU) and their subséquent death five weeks later. Numerous studies support the need for effective communication and clear information to be given to the family. In this instance it was évident from their stories that there were numerous barriers to communication, including language and a lack of insight into the needs of the family. Many families do not understand the complexities of nursing care in an ICU so lack of communication by nursing staff was identified as uncaring behavior and encounters. Facilitating a family's proximity to a dying patient and encouraging them to participate in care helps to maintain some sensé of personal control. Despite a commitment to involving family members in care, which was enshrined in the Unit Philosophy, relatives were banished to the waiting room for hours. They experienced feelings of powerlessness and helplessness as they waited with other relatives for news following investigations or until 'the doctor had completed his rounds'. Explanations of "we must make 'the patient' comfortable" was no consolation for those who wished to be involved in care. The words "I'il call you when we are ready" became a mantra to the forgotten families who waited patiently for those with power to admit them to the ICU. Implications are this family felt they were left alone to cope with the traumatic expériences leading up to and surrounding the death. They felt mainly supported by the priest, who not only administered the last rites but provided spiritual support to the family and dealt sensitively with many issues. Paternalism in décision making when there is a moral obligation to ensure that discussions on end of life dilemmas are an inclusive process with families, doctors, nurses was not understood, therefore it caused conflict within the family over EOL décision making. The family felt that the opportunity to share expériences through telling and retelling their stories would enable them to reconfigure the past and create purpose in the future.

Research Monograph: Constructing online collaborative environmental decision making systems

The use of computing to support environmental planning and the development of land use models dates back to the late 1950s. The main thrust of computing applications, which by the early 1980s increasingly included the use of geospatial technologies, is their contribution to better planning and decision making. The computing tools and technologies are designed to enhance the planners’ capability to deal with complex environments and to plan for prosperous and livable communities. This paper examines the role of Information Technologies (IT) and particularly Internet Based Geographic Information Systems (Internet GIS) as spatial decision support systems to aid community based local decision making. The paper also covers the advantages and challenges of these internet based mapping applications and tools for collaborative decision making on the environment.

Research monograph : emergence of smart urban ecosystems : application of ICT for capacity building in environmental decision making

Since the industrial revolution, our world has experienced rapid and unplanned industrialization and urbanization. As a result, we have had to cope with serious environmental challenges. In this context, explanation of how smart urban ecosystems can emerge, gains a crucial importance. Capacity building and community involvement have always been the key issues in achieving sustainable development and enhancing urban ecosystems. By considering these, this paper looks at new approaches to increase public awareness of environmental decision making. This paper will discuss the role of Information and Communication Technologies (ICT), particularly Web-based Geographic Information Systems (Web-based GIS) as spatial decision support systems to aid public participatory environmental decision making. The paper also explores the potential and constraints of these web-based tools for collaborative decision making.