A qualitative analysis of the process of developing and implementing do not resuscitate and degrees of intervention policy in long term care settings in British Columbia
Date
1993
Authors
Laughlin, Diane Gail
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Abstract
This descriptive qualitative study examines the process of developing and implementing policies on two types of advance directives, Do Not Resuscitate (DNR) and Degrees of Intervention (DI), in Long Term Care (LTC) facilities in British Columbia.
Thirty-three participants from twenty-three LTC facilities engaged in face to face or telephone interviews. The facilities were randomly selected to represent four regions of the province. The semi-structured in-depth interview format was comprised of questions pertaining to the policy process particularly in relation to the impact of the 1989 provincial guideline documents "Death and Dying in Long Term Care Facilities".
A thematic analysis of the qualitative data illuminated several findings. Respondents identified feelings of uncertainty, fear of legal sanctions, concern for resident rights to self-determination and the desire for residents to die in place as problems related to DNR and DI prior to the release of the 1989 guidelines.
Consequently, the respondents described a process of first clarifying these problematic situations and then defining specific procedural and moral circumstances that required action. The definitive problems which emerged involve not only unwritten agency policy, but unclear doctor's orders, absent and existing legislation, divergent value perspectives on resident autonomy and the meaning of death in LTC facilities.
For all the facilities in the study, the process of developing and implementing agency policy on DNR and DI was enhanced by the information provided in the 1989 provincial government guideline documents. Additionally, individual attitudes, group perspectives both internal and external to LTC facilities, and structural and functional components of the LTC organization were identified as influences on the policy development process. Five distinct types of policy paths that led to development of DNR and DI policy were evident. Eventual approval of a DNR or DI policy in a LTC facility resulted from a process of consensus encompassing many different perspectives.
The respondents described a number of unique factors which influenced implementation of DNR and DI. These include individual styles of communicating the policy issue, the amount of time available to discuss the policy, and the degree education (basic and inservice) of care staff and doctors around issues related to DNR and DI.
This study underscores the significance of public policy-making in local units and the importance of practitioners as policy-makers in the policy development process. Future research directed toward illuminating policy networks between nurses practicing in LTC settings would be beneficial. Finally, studying the impact of implementing DNR and DI policies on care staff, residents and families would provide insight into the realities of resident choice, informed consent and discretionary decision-making.
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UN SDG 16: Peace, Justice, and Strong Institutions