ABOUT US

This is the official blog of Group D students of UPOU-MAN N-207 class of Prof. Sheila Bonito.

Who are we?

We are nurses in different parts of the world. We did not share time zones. We work on a rotation basis – work in the morning for a few days and then revert to working in the evening for a week and then a few days of night shifts before getting our most-awaited day off. But we were able to work as ONE.

Welcome!

CONTRIBUTORS:

Maria Elena Feliciano

Christopher John Fernandez

Marie Dominique Jewel Fortuna

Lea Gabriel

Elyn Gambet

Prinisel Gonato

Edmond Gonzales

Jill Iris Guerrero
Jessebel Ibañez

Katrina Igsoc

Jayson Caezar Javier

Iris Kay Jimenez

Michael Lagarde

Ana Liza Huet

MEMBERS:
Ralph Angelo Kapirig
Stephen Hernandez
Raymelia Feliciano
Kristine Gaye Fabi
Arianne Anne Gloria
Vanessa Michelle Khu
Eugene Lapatar
Mary Noemilyn Julian
Charmaine Lagasca
Sherilou Lagman
Andrea Katipunan
Helen Fernandez
Sherry Belle Galeno
Alexis Lamsen

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MEET THE THEORIST

Cornelia Ruland received her Ph.D. in nursing in 1998 from Case Western Reserve University in Cleveland, Ohio. She is an adjunct assistant professor in the Department of Medical Informatics at Columbia University in New York, in the Department of Community and Family Medicine at Dartmouth Medical School in Hanover, New Hampshire, and in the College of Nursing at University of Iowa in Iowa City. She is also the Director of the Center for Shared Decision Making and Nursing Research at Rikshospitalet National Hospital in Oslo, Norway (Columbia University, 2013).

Ruland’s research interests are patient preferences and shared decision making, decision support system (DSS) to support preference- and evidence-based patient care, consumer health informatics, evidence-based practice, quality improvement, DSS for nursing resource management, web-based education, and issues in knowledge presentation (Columbia University, 2013).

She has authored and co-authored several papers and published her own book entitled Introduction to Nursing and Medical Informatics in 2000. Her papers were recognized in the American Medical Informatics Association Fall Symposia in 1998 and in 2000 on application of medical informatics in healthcare or biomedical research. In 2000, she received the Sigma Theta Tau International’s Education Technology Award, along with Drs. Delaney, Ehnfors, and Thoroddsen, for an “international collaboration on the first Web-based Scandinavian Master-Course in Nursing Informatics (Columbia University, 2013).”

Shirley Moore is an Associate Dean for Research and Professor in the Frances Payne Bolton School of Nursing at Case Western Reserve University, where she also finished her MS in 1991 and Ph.D in nursing in 1993. She received her BS in nursing from Kent State University in Kent, Ohio. Her educational interests are epistemology and theory in nursing, interdisciplinary team models of care, and continuous quality improvement. She also heads the Frances Payne Bolton’s Center for Research and Scholarship as well as the Center for Excellence for Self-Management Advancement Through Research and Translation (SMART). She had previous leadership roles in professional organizations such as the American Heart Association and Sigma Theta Tau International Honor Society of Nursing (France Payne Bolton, 2013).

She has published several researches as a principal investigator and as a co-investigator. Her research interests are on the recovery following cardiac events, health behavior change, exercise following cardiac events, obesity, and quality and safety (France Payne Bolton, 2013).

Nurse theorists Joyce Fitzpatrick, Jean Johnson, and Elizabeth Lenz influenced her to develop her own theory. According to Moore, one of the important skills of a doctoral student is theory construction (Alligood, 2014).

References:

Department of Biomedical Informatics, Columbia University (2013). Cornelia M. Ruland profile. Retrieved from http://people.dbmi.columbia.edu/~cmr7001/

Frances Payne Bolton School of Nursing, Case Western Reserve University (2013). Shirley M. Mooreprofile. Retrieved from http://fpb.case.edu/faculty/moore.shtm

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PEACEFUL END OF LIFE (PEOL) THEORY: IN A NUTSHELL

The Peaceful End-of-Life Theory is a relatively young, mid-range nursing theory developed by Cornelia M. Ruland and Shirley M. Moore published in 1998. Its nursing goal is to enhance the quality of life and to achieve a peaceful end-of-life on a terminally-ill patient and relates nursing interventions and outcomes specific to this patient group.

I.          Major Concepts and Definitions

The theory is based on the standard of the peaceful end of life for terminally ill patients. Standard development concentrates on serene and meaningful quality of life in the time that remained patients and their significant others. This standard consists of sixteen outcome criteria (Table 1):

Table 1. Outcome Criteria of the Standard of Peaceful End of Life

The patient: Is not having pain Does not experience nausea Does not experience thirst Experiences optimal comfort Is at peace Does not die alone The patient and significant other(s): Have confidence that they are receiving the best possible care Maintain hope and meaningfulness Participate in decision making regarding patient’s care Experience being treated with dignity and respect as a human being Get assistance in clarifying practical and economical issues related to the patient’s coming to an end of life Experience a pleasant environment Significant others: ·         Are taking part in caring for the patient as they wish ·         Can say farewell with the patient in compliance with their beliefs, cultural rites, and wishes ·         Are informed about different funeral procedures and possibilities ·         Are offered a follow-up visit after the patient’s death

It can be discerned that the outcome criteria in the standard were concrete; thus, similar concepts were reduced into summary concepts (Table 2):

Table 2. Reduction of outcome criteria from the standard to outcome indicators
Standard	Theory
The patient is not having pain.	Not being in pain
The patient does not experience nausea. The patient does not experience thirst. The patient does experience optimal comfort. The patient and significant others experience a pleasant environment.	Experience of comfort
The patient and significant others participate in decision making regarding the patient’s care. The patient and significant others experience being treated with dignity and respect as human beings.	Experience of dignity/respect
The patient and significant others maintain hope and meaningfulness. The patient and significant others get assistance in clarifying practical and economical issues related to the patient’s coming to an end of life. The patient does not die alone. The patient is at peace.	Being at peace
Significant others: Are taking part in caring for the patient as they wish Can say farewell with the patient in compliance with their beliefs, cultural rites, and wishes Are informed about different funeral procedures and possibilities	Closeness to significant others/persons who care

Five outcome indicators were derived from the sixteen standard outcome criteria that represent the key concepts in the theory:

A.            Not Being in Pain

This concept is defined as not having the experience of pain (Ruland & Moore, 1998). This is the central part of many patients’ end-of-life experience. Pain is considered an unpleasant sensory or emotional experience associated with actual or potential tissue damage (Alligood, 2014).

B.            Experience of Comfort

The experience of comfort is defined as relief from discomfort, the state of ease and peaceful contentment, and whatever makes life easy or pleasurable (Ruland & Moore, 1998).

C.            Experience of Dignity and Respect

Each terminally ill patient is “respected and valued as a human being”. This concept incorporates the idea of personal worth, as expressed by the ethical principle of autonomy or respect for persons, which states that individuals should be treated as autonomous agents, and persons with diminished autonomy are entitled to protection (Alligood, 2014).

D.            Being at Peace

Being at peace involves the feeling of calmness, harmony, and contentment (Ruland & Moore, 1998). According to Aaron & Cooksey, the patient is free of anxiety and fear, and possess feelings of calmness and peace.

E.            Closeness to Significant Others

A connection, physical or emotional, to the caring individuals important to and involved in patient care (Aaron & Cooksey, 2013).

II.          Major Assumptions

Nursing, Person, Health and Environment

                                                                                                          

Two assumptions of Ruland and Moore’s theory are identified as follows:

A.            According to Ruland & Moore, the person’s approach to end-of-life is a highly personal experience. The occurrences and feelings of end-of-life experience are personal and individualized

B.            Nursing care is crucial for creating a peaceful end-of-life experience. Nurses assess and interpret cues that reflect the person's end-of-life experience and intervene appropriately to attain and maintain a peaceful experience, even when the dying person cannot communicate verbally (Alligood, 2014).

The following are two additional, implicit assumptions:

A.            Family a term that includes all significant others, is an important part of end-of-life care.

B.            The goal of end-of-life care is care is to maximize treatment. The best possible care will be provided through the judicious use of technology and comfort measures, in order to enhance quality of life and achieve a peaceful death (Alligood, 2014).

III.           Theoretical Assertions and Propositions

According to Ruland & Moore, six relational statements were identified as theoretical assertions for theory as follows:

A.            Monitoring and administering pain relief and applying pharmacological or non-pharmacological interventions contribute to the patient’s experiences of not being in pain.

B.            Preventing, monitoring and relieving physical discomfort, facilitating rest, relaxation and contentment, and preventing complications contribute to the patient’s experience of comfort.

C.            Including the patient and significant others in decision making regarding patient care, treating the patient with dignity, empathy and respect, and being attentive to the patient’s expressed needs, wishes, and preference contribute to the patient’s experience of dignity and respect.

D.            Providing emotional support, monitoring and meeting the patient’s expressed needs for anti anxiety medications, inspiring trust, providing the patient and significant others with guidance in practical issue, and providing physical preference of another caring person if desired contribute to the patient’s experience of being at peace.

E.            Facilitating participation of significant others’ grief, worries, and questions, and facilitating opportunities for family closeness contribute to the patient’s experience of closeness to significant others or person who care.

F.            The patient’s experience of not being in pain, comfort, dignity and respect, being at peace, closeness to significant others or person who contribute to peaceful end of life.

The five concepts comprised of outcome indicators are measurable in both qualitative and quantitative methodologies, while visualizing the direction of relationships (Figure 36-1):

FIGURE 36-1 Relationships among the concepts of the Peaceful End-of-Life Theory. From Ruland, C. M., & Moore, S. (1998]. Theory construction based on standards of care: A proposed theory of the peaceful end of life. Nursing Outlook, (46) 4, 174.

Reference:

Ruland, C.M., Moore, S. (1998). Theory Construction Based on Standards of Care: A Proposed Theory of the Peaceful End of Life. Nursing Outlook 1998 (46) 4: 169-175.

Alligood, M.R., (2014). Nursing Theorists and their Works (8^th ed.). USA: Mosby Elsevier.

Aaron, J.C. & Cooksey, C. (2013). Peaceful End-of-life Theory: A Mid-Range Nursing Theory [Video file]. Retrieved from https://www.youtube.com/watch?v=82016bO8Ku4

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THEORIST BACKGROUND STUDY OF PEACEFUL END OF LIFE THEORY

Cornelia Ruland graduated from the Case Western in Cleveland Ohio University in 1998. Shirly Moore recieved diploma in Nursing from Youngstown Hospital Association of Nursing in 1969 and her Bachelor degree in Nursing in 1974 from Kent University. She later returned to school in Case Western Reserve University and recieved a Master's degree in Psychiatric Nursing and Mental Health in 1990 and PhD in Nursing in 1998.

The Peaceful End of Life Theory originated in a Doctorial Theory course as an assignment to derived the middle range theory from a knowledgeable source of the student choice. Ruland was a student and Moore was a faculty. Ruland choose peaceful ending of life as her topic so she just completed a significant project in Norway with the group of nurses who had at least 5 years of experience in the surgical gastroenterologic unit, where half of thier subjects were cancer patients to develop a clinical practice standard of care and Moore resisted in redifining the theory. This theory is an example of the Middle Range Theory. It was develop using the standard of practice as a source in development by the doctorial nursing student was studying knowledge in ethics. The lack of clear directions for quality nursing care of terminally ill patients had been Ruland's drive to create such theory. She stated in her acticle that the main focus of her proposed theory does not lie on the process of dying itself but, as the title of the theory goes, relies more on "contributing to peaceful and meaningful livingin the time that remaind for the patients and thier significant others". Both Ruland and Moore not only focused on meeting physical comfort but also tackled on providing emotional social, emotional, psychological and financial relief. They have finally derived on 16 Outcome Criteria of the Standard of Peaceful End of Life, which has given birth to more than a hundred process criteria to meet the outcome.

Reference :
www.youtube.com/watch?V=XN6NX6_TVE Peacful EOL Kelly Kilcrease

Roland.C.M. & Moore S (1998 )Theory Construction Based on Standards of Care. A Proposed Theory of the Peaceful end of Life. Nursing Outlook 1998 (46 ) 4: 169-171

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PEOL THEORY IN NURSING EDUCATION

The Ruland-Moore theory serves as a good guide for establishment of standards of care appropriate for the terminally ill and significant others. Education should be rendered toward the limitations and scope of care for patients and their significant others. This theory should give us light as to the importance of nurse educators, patient coordinators, pain managers and support groups. It is a nurse's responsibility to be well-informed of an effective healthcare team. To what extent does our responsibility as nurse advocates to this group cover? With regards to nursing education, wherein one of the outcome criteria calls for a patient to be without pain, standard of care should be aimed toward finding specific means to know when a patient, whether responsive or unresponsive or paediatric, is in pain to meet this goal. The numeric pain scale (0-10 scoring of pain) has been created to assess a patient's tolerance to and severity of pain. In cases of unresponsive and/or paediatric clients, the FLACC scoring and the Wong-Baker's scale has been created to have a more objective way of assessment. Furthermore, a terminally ill patient should not be limited to his/her use of analgesics, for as long as analgesic dosages are appropriate for his/her age, weight and condition. The nurse should also be knowledgeable enough of the patient's and his/her family's religious beliefs and cultural practices. In the Middle East, it is considered unethical to commence or suggest a Do Not Resuscitate order. This is why a great number of ICU patients remain hospitalized long-term and are often "brain-dead" and on the ventilator. Even when sufficient information has been given by the medical physician regarding a patient's poor prognosis, the Do Not Resuscitate principle does not apply and is unlawful. (Roland, 1998)

This knowledge would allow for spreading expert nursing practices to all nurses in a systematic fashion, helping family members make decisions that are consistent with their values and goals for end-of-life care and reducing the amount of psychological distress of family members who make end-of-life decisions. It is also recommended that end-of-life education be broadened in nursing schools to give both undergraduate students and new nurses a better understanding about the concepts around end-of-life care and the dying process. (McMillen, 2008)

References:

Roland, C.M. & Moore, S. (1998). Theory Construction Based on Standards of Care: A Proposed Theory of the Peaceful End of Life. Nursing Outlook 1998 (46)4: 169-175.

R. E. McMillen, “End of life decisions: nurses perceptions, feelings and experiences,” Intensive and Critical Care Nursing, vol. 24, no. 4, 2008.

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PEOL THEORY IN NURSING PRACTICE

Nurses should be able to inform and encourage of the existence of options that patients and families can take such as the Sacrament of Annointment in the Philippines. Such rituals are not only done on the hour of death, but can also be encouraged earlier as this is believed to be part of a patient's process for healing, which now meets one of the outcome criteria of the standard for Peaceful End-of-Life -- "The patient is at peace" (Ruland and Moore, 1998)

Shimane, K. (2011, August). Image of the End-of-life Stage. Creating a Peaceful and Reliable End-of-life Stage. Retrieved from Ministry of Economy, Trade and Industry

In Nursing Practice, the Theory of Ruland and Moore has been laid down with great emphasis. Especially those working in established institutions, the set policies or guidelines that healthcare workers follow in dealing with near dying patients are connected to the said theory. However, these are not absolute and palliative care for the dying can be done with special considerations. (Thelen, 2005)

End-of-life care at home 007. (2012, January 18). People deserve to have their end-of-life care wishes met. Retreived from theguardian website http://www.theguardian.com/society/2012/jan/18/end-of-life-care-policy

As the patient’s disease worsen and the end is very near, healthcare providers should be dedicated in creating a peaceful end of life care to them. Together with the patient’s family, palliative care will be decided in which its goal is no longer for curative treatment. Rather, it will be focused on pain and symptoms management while giving attention to provision of comfort and dignity as he die, surrounded by people close to his heart. As the patient advocate, the nurse needs to cooperate and collaborate more between the interdisciplinary team and the patients’ family. Those who care for the dying patients need to be honest and straightforward in discussing death among the family members. They should be sensitive enough in delivering this unfortunate event and be able to empathize with them as they express their grief. In Middle Eastern countries, it is important for the family to be present with such situation. Nurses must allow opportunity for this and provide privacy as they recite the holy Qur’an precided by their Motawa (prayer leader for Muslims). One of their beliefs is to offer a prayer to Allah (their God) in behalf of their family member. For them, the patient will be at peace once they pray altogether. Muslims also believe that no matter what the effect of analgesia is, either worsening the patient’s condition or not, it is important to lessen the pain he is experiencing. They do not consider the “Do Not Resuscitate” order too as they count this as an immoral act. For them, it is necessary for a person to die whenever Allah will allow. Nurses should be aware of this and respect this decision. Another way of giving a sense of accomplishment for the dying Muslim patient is through contributing to a charity before he dies. In behalf of him, family members will donate money to any charity chosen by the patient. With this, he feels his life becomes more meaningful and he shows an act of being noble before his life will be taken.

References:

Roland, C.M. & Moore, S. (1998). Theory Construction Based on Standards of Care: A Proposed Theory of the Peaceful End of Life. Nursing Outlook 1998 (46) 4:169-175.

M. Thelen, “End-of-life decision making in intensive care,” Critical Care Nurse, vol. 25, no. 6, 2005.

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PEOL THEORY IN NURSING RESEARCH

Nurses need guidance in enacting their roles in end-of-life decision making so that they can help alleviate suffering and ensure that end-of-life needs and goals for their patients and family members are being met. These nursing strategies should be guided by empirical evidence – research study. Understanding how nurses engage in this process is essential to the development of interventions to improve the strategies that nurses use in end-of-life decision making. Case-oriented studies that identify how nurses engage in the end-of-life decision making process are needed. Such studies would provide a systematic understanding of the strategies that nurses use. Quantitative studies that are based in the existing literature to develop valid and reliable tools are needed to measure the extent to which nurses are enacting roles, the strategies they use, and the patient and family member outcomes. With the knowledge generated from these studies, interventions could be developed that target areas identified as important to the family members and most likely to improve their well-being. (Hanna, 2004)

The application of this theory has been seen in several research studies since its inception almost 15 years ago. It is a mid range theory that can be used by nurses to assist patients as well as their significant others in dealing with death. ¹

The studies include a doctoral dissertation in 2001 by Renea Lindstrom Beckstrand entitled National Survey of Critical Care Nurses’ (CCRN) Perceptions of End- of-Life Care and Effect of Incentives on Survey Response Rates.  Here she used this theory as a guide in formulating her questionnaire reflecting the aspects of all five of the adapted outcome indicators and all 14 of the nursing interventions. Knowledge on how to deal with deaths and assisting grieving families can help critical care nurses improve their job performance and avoid physical exhaustion in the process.

The study seeks to answer the following questions:

1. Which obstacles to providing end-of-life care to dying patients do critical-care nurses perceive as being the largest, most frequent, and most severe?

2. Which helpful behaviors (or helps) to providing end-of-life care to dying patients do critical-care nurses perceive as being the largest, most frequent, and most intense?

3. Which aspect of end-of-life care would critical-care nurses most like to see changed?

4. In what ways do critical-care nurses' perceptions of obstacles and helpful behaviors differ based upon length of I CU work experience?  

5. Do CCRN-certified critical-care nurses' perceptions of obstacles and helpful behaviors significantly differ from the perceptions of critical-care nurses who have never certified as a CCRN?

An experimental, posttest-only, control group design was used. A random sample of the American Association of Critical-Care Nurses (AACN) yielded 861 usable responses from 1,409 eligible respondents (61 %). The three most severe obstacles were frequent calls to the nurse, families not understanding the term "lifesaving measures," and physicians disagreeing about the direction of patient care. The three most intense helps were when nurse allowed the family adequate time alone (after death), provided a peaceful and dignified bedside scene and taught the family how to act around the dying patient.

Other results included nurses preferring that a patient experience a "good death," more time be provided to care for patients, communication to patients be more open and honest, and education in end-of-life care be provided to physicians and nurses. Nurses reporting more ICU work experience were older and also had cared for more dying patients (75 %) than did nurses reporting less experience (62 %). Certified critical-care registered nurses (CCRNs) perceive as larger obstacles physicians being overly optimistic about the patient surviving, families not accepting that the patient will die, visiting hours that are too restrictive, and patients who have pain that is difficult to alleviate or control. ²

Another related study in the role of critical nurses in ICU’s has been conducted back in 2009 by the group of Lee et al. in Taiwan. It is entitled Attaining Good End of Life Care in Intensive Care Units in Taiwan- The Dilemma and Strategy. ³ Here they used the five main components of this theory in providing good EOL (end-of-life) care to meet the dying patients’ need.

As with application on education, the theory was highlighted in the 2001 conference by the American Emergency Nurses Association regardingAssessment of EOL Practices with Patients with Multiple Trauma.⁴ Its purpose is to describe the documentation regarding end of life (EOL) care and test one relational statement from the middle range theory on a peaceful EOL. The theory focuses on ways nurses can contribute toward a peaceful and meaningful death for the patients. Medicals records back in 1998 of trauma patients upon arrival in the ER were reviewed.

Among the 88 deaths, 73 charts were available for review. The sample mean age was 41.67 years and patients are mostly male (72.9%). Three factors discussed in the theory were used in the methodology namely (1) being attentive to the patient's expressed wishes, needs, and preferences; (2) including the patient and family in patient care decision making; and (3) treating the patient with empathy, respect and dignity.

The following are outcome of the study, (1) Attention to spiritual needs was documented for 65.8% of patients/families; (2) 43.8% had documentation that death was the expected outcome, yet 60% of the patients died without being resuscitated. (3) An EOL conversation with health care providers was reported by 52% of families, with 6% of patients meeting with their physician. Over one-half (57%) of patients died while aggressive care was in progress and none of the records had any documentation of conflict between the family and a health care worker.

Nurses documented EOL care discussions by other health care providers more frequently than their own interactions. The study concluded that most were treated with respect and dignity through evidence of shared decision making and spiritual support consistent with the middle range theory.

References:

¹ http://ous-research.no/home/sps/Staff/8113

² http://content.lib.utah.edu/utils/getfile/collection/etd1/id/1635/filename/1593.pdf

³ http://www.sgecm.org.tw/db/Jour/2/200903/4.pdf

⁴ http://www.nursinglibrary.org/vhl/handle/10755/162714

D. R. Hanna, “Moral distress: the state of the science,” Research and Theory for Nursing Practice, vol. 18, no. 1, 2004.

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