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APA CitationEXAMPLE:Hunt, R. R., Smith, R. E., & Dunlap, K. R. (2011). How does distinctive processing reduce false recall? Journal of Memory and Language, 65, 378-389.(APA format is very specific. I recommend picking up an APA manual 7th edition. They’re pretty cheap and an amazing resource. Otherwise, you can find APA format info by googling “Owl Purdue APA format.”)NOTE: Different types of sources require different methods of citation. So, the citation format for a journal article will differ from that of a book chapter or an internet source.
Research QuestionWhat is the underlying question the researchers were aiming to answer?EXAMPLES:Does masturbation frequency change as a function of age?Is there a meaningful relationship between sexual preferences and religious background?What is the prevalence of HIV in a given population?Do oysters act as an aphrodisiac?
Importance (why would other researchers be interested in this study?)What can be gained from the information provided in this study? How might this inform future research?
HypothesesHypotheses are specific predictions about the general research question. For example, if the research question is, “Does masturbation frequency change as a function of age,” then a hypothesis might be, “As age increases, masturbation frequency decreases.”
Design & VariablesDesign: Descriptive, correlational, meta-analytic, or experimental?Independent variable(s): This is “manipulated” variable. Only experimental designs involve independent variables. If the research question is, “Do oysters act as an aphrodisiac?” then the independent variable would be the administration of oysters. For example, you might have one group of participants who consume a half-dozen of oysters, another group who consumes a dozen oysters, and a third group who consumes no oysters (i.e., a control group).Dependent variable(s): This is the “variable of interest.” In other words, this is the thing that the researchers are trying to acquire information about. While only experimental designs include independent variables, all research designs will include at least one (and sometimes many more) dependent variable. In the above example, the researchers are wanting to know if the consumption of oysters increases sexual desire. In order to determine this, they might measure self-reported sexual desire levels and/or physiological signs of sexual desire, like blood flow, perspiration, and pupillary dilation. Sexual desire would be the dependent variable, and these things would be used to measure it.
Number of participants (n = ____)This is just the number of individuals who acted as participants in the study.
Materials & MeasuresIn psychology, we often have to use indirect measures to acquire information about a dependent variable. In the above example involving oysters and sexual desire, the way one might go about measuring sexual desire could include self-reports, questionnaires, tools that measure blood flow, eye trackers that measure pupil dilation, etc. Any materials that were used to gather data should be listed/briefly described here.NOTE: Type of materials used will often differ depending on the research design. For example, descriptive research often employs behavioral observations, questionnaires, and/or surveys.
Brief Description of ProcedureHere, you should provide a brief chronological account of what participants actually did in the study.EXAMPLE:Participants completed informed consents and were randomly assigned to one of three conditions. Measures of sexual desire were gathered prior to oyster exposure in order to get baseline measures for each participant. Depending on condition, participants then consumed either a half-dozen oysters, a dozen oysters, or zero oysters. Next, participants again completed the sexual desire measures so that any change in desire due to oyster consumption could be inferred.NOTE: Procedures can differ greatly depending on the research design. For example, a meta-analytic design would involve analyzing several experimental studies on a particular subject and then summarizing the collective results.
ResultsWhat did the researchers find? Was there a significant correlation or experimental effect? If the design was descriptive, what kind of frequency data did they find?
Limitations (Is there anything about this research that might affect the generalizability of the results?)There are always limitations to every research design. More specifically, there are some limitations that will apply to all studies employing a given design (e.g., all descriptive research), and there will be limitations that apply to a particular study. For example, descriptive and correlational research can be said to have low internal validity because it is difficult (or impossible) to control for extraneous variables. Experimental designs, on the other hand, can be said to have lower external validity because it often involves a great degree of variable control. Another common limitation is sample size. Results from a small sample may be less generalizable than those from a larger sample. If the researchers utilized a sample of convenience (i.e., one that was convenient but might not be representative of the entire population of interest), this this could also be considered a limitation.NOTE: I want you to come up with something to put here. This might take some critical thought!
How does this inform your group project?Why is this study relevant to your own project topic?
https://doi.org/10.1177/0269216319888986

Palliative Medicine 2020, Vol. 34(3) 430 –434 © The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0269216319888986 journals.sagepub.com/home/pmj

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What is already known about the topic?

•• Neonatologists and nurses who take care of dying neonates in a neonatal intensive care unit are prone to develop com- passion fatigue or burnout, which could have an influence not only on their personal life but also on their ability to care for patients and parents.

Psychological support in end-of-life decision-making in neonatal intensive care units: Full population survey among neonatologists and neonatal nurses

Laure Dombrecht1,2 , Joachim Cohen1, Filip Cools3, Luc Deliens1,2, Linde Goossens4, Gunnar Naulaers5, Kim Beernaert1,2* and Kenneth Chambaere1,2*; on behalf of the NICU consortium6

Abstract Background: Moral distress and burnout related to end-of-life decisions in neonates is common in neonatologists and nurses working in neonatal intensive care units. Attention to their emotional burden and psychological support in research is lacking. Aim: To evaluate perceived psychological support in relation to end-of-life decisions of neonatologists and nurses working in Flemish neonatal intensive care units and to analyse whether or not this support is sufficient. Design/participants: A self-administered questionnaire was sent to all neonatologists and neonatal nurses of all eight Flemish neonatal intensive care units (Belgium) in May 2017. The response rate was 63% (52/83) for neonatologists and 46% (250/527) for nurses. Respondents indicated their level of agreement (5-point Likert-type scale) with seven statements regarding psychological support. Results: About 70% of neonatologists and nurses reported experiencing more stress than normal when confronted with an end-of-life decision; 86% of neonatologists feel supported by their colleagues when they make end-of-life decisions, 45% of nurses feel that the treating physician listens to their opinion when end-of-life decisions are made. About 60% of both neonatologists and nurses would like more psychological support offered by their department when confronted with end-of-life decisions, and 41% of neonatologists and 50% of nurses stated they did not have enough psychological support from their department when a patient died. Demographic groups did not differ in terms of perceived lack of sufficient support. Conclusion: Even though neonatal intensive care unit colleagues generally support each other in difficult end-of-life decisions, the psychological support provided by their department is currently not sufficient. Professional ad hoc counselling or standard debriefings could substantially improve this perceived lack of support.

Keywords Perinatal death, end-of-life care, decision-making, questionnaire design, psychological support system, intensive care units, neonatal

1 End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Ghent, Belgium

2 Department of Public Health and Primary Care, Ghent University, Ghent, Belgium

3 Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium

4 Department of Neonatology, Ghent University Hospital, Ghent, Belgium

5 Department of Development and Regeneration, KU Leuven, Leuven, Belgium

888986PMJ0010.1177/0269216319888986Palliative MedicineDombrecht et al. research-article2019

Short Report

6 Ghent University Hospital, Brussels University Hospital, Leuven University Hospital, Antwerp University Hospital, Hospital Oost-Limburg Genk, Hospital GZA St Augustinus, AZ St Jan Brugge, ZNA Middelheim

*Contributed equally

Corresponding author: Laure Dombrecht, Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, K3, 6th Floor, Room 007, 9000 Ghent, Belgium. Email: [email protected]https://uk.sagepub.com/en-gb/journals-permissionshttp://journals.sagepub.com/home/pmjmailto:[email protected]http://crossmark.crossref.org/dialog/?doi=10.1177%2F0269216319888986&domain=pdf&date_stamp=2019-11-19

Dombrecht et al. 431

What this paper adds?

•• Flemish neonatal intensive care unit staff members perceived more stress than usual when dealing with end-of-life deci- sions, and even though almost all respondents felt supported by their colleagues, only about half felt that the psycho- logical support they received at their neonatal intensive care unit was sufficient.

•• Only 45% of nurses felt that the treating physicians listen to their opinion regarding end-of-life decisions and only 32% felt they can express any objections they might have about end-of-life decisions, indicating that nurses are often excluded from the decision-making process.

Implications for practice, theory or policy

•• Existing guidelines indicate appropriate solutions to insufficient staff support in neonatal intensive care units should be considered in Flemish and other neonatal intensive care units.

•• These solutions include regular debriefings and counselling sessions in order to prevent and counteract the negative consequences of stress.

•• Including nurses in the neonatal end-of-life decision-making process could both increase the quality of these decisions and benefit nurses themselves by reducing moral distress caused by being excluded from this decision-making.

Introduction Neonatologists and nurses working in neonatal intensive care units often experience moral distress,1,2 especially when an infant in their care can no longer benefit from treatment and a life-shortening end-of-life decision is made.1,3 The emotional impact on parents of losing a child and the support needed from both neonatal intensive care units and psychological support staff have previously been studied,4,5 and guidelines on supporting them have been developed by several organisations.3,6,7 However, research on professional support for neonatal intensive care unit staff and their coping and emotional burden has been lacking.

Healthcare professionals often experience suffering and grief as well as moral distress and emotional exhaus- tion.8,9 Because of this, intensive care units healthcare professionals in general are prone to developing compas- sion fatigue and burnout.10,11 In neonatal intensive care units, survey studies estimate the prevalence of burnout to be 30% in neonatologists12 and 7.5%–54.4% in nurses.13 Developing burnout and compassion fatigue does not only have an impact on their personal life but also affects their ability to care for patients and to have empathy for grieving parents6,11,12 which could reduce the quality of care overall. Despite these known risks, only one study, after reviewing neonatal end-of-life protocols, recom- mended colleague and professional psychological support around end-of-life care for neonatal intensive care unit staff members.3 Actual research on perceived psychologi- cal support by and for neonatal intensive care unit profes- sionals is lacking.

Our study evaluates stress in relation to end-of-life decisions, perceived colleague and professional psycho- logical support and whether or not this support is suffi- cient in neonatologists and nurses working in neonatal intensive care units and examines whether psychological

support differs between socio-demographic or profes- sional groups.

Methods

Design and participants We performed a full-population mail survey of all neona- tologists and neonatal nurses in all eight Flemish neonatal intensive care units, with full cooperation from all units. A total of 83 neonatologists and 527 nurses were identified by means of personnel files.

Data collection A representative working at each neonatal intensive care unit handed out the questionnaire to every neonatologist and nurse in their unit in May 2017 (gatekeeper method), inviting them to fill it out anonymously and send it back in a prepaid envelope within 1 month. This method was pre- ferred to sending a questionnaire directly to every neona- tologist and nurse in order to maximise their motivation to participate. Sending back a filled-out questionnaire was seen as informed consent. We obtained ethical approval from the ethical review board of Ghent University Hospital (registration number: B670201731709).

Questionnaire The questionnaire items used in this report consisted of seven socio-demographic questions (see Table 1) and seven questions concerning colleague and professional psychological support, developed by a multidisciplinary team consisting of sociologists, psychologists, neonatolo- gists and a gynaecologist. The questionnaire was cogni- tively tested with five neonatologists (from four separate hospitals), three neonatal nurses (from two separate

432 Palliative Medicine 34(3)

hospitals) and one gynaecologist, leading to only minor adjustments in wording.

Measures The questionnaire included statements about perceived stress, professional psychological support provided by the neonatal intensive care units and psychological support provided by colleagues. We included a statement on the option of expressing protest concerning an end-of-life decision which could be an additional source of distress when this is discouraged. The statements were scored on a 5-point Likert-type scale. Three of the seven questions differed between neonatologists and nurses because in the Flemish healthcare setting, physicians are the main decision-makers when it comes to making end-of-life decisions for their patients, mostly during physician team meetings. Thus while nurses are often not involved in this decision-making process, they are however involved in the implementation of the medical decisions.

Statistical analysis (SPSS 24.0) Percentages of disagreement (‘totally disagree’ and ‘disa- gree’), neutrality and agreement (‘agree’ and ‘totally agree’) were calculated for neonatologists and nurses separately.

Results Across all eight neonatal intensive care units, the response rate was 63% (52/83) for neonatologists and 46% (250/527) for nurses. In our sample, 71% of neonatolo- gists and 95% of nurses were female (Table 1).

Most neonatologists and nurses agreed that making an end-of-life decision (neonatologists) or being confronted by one (nurses) in neonates causes more stress than usual (72.5% and 70.2%, respectively, Table 2). During the deci- sion-making process, most neonatologists (86.3%) agreed that they feel supported by their colleagues. Fewer than half the neonatal nurses (44.6%) agreed that physicians lis- ten to their opinions in making an end-of-life decision. While most neonatologists (88.2%) agreed that their neo- natal intensive care unit provides sufficient opportunity to express protest about certain end-of-life decisions, only 31.6% of nurses agreed with this statement. Almost all neonatologists and nurses agreed that they can talk to their colleagues when something is bothering them about an end-of-life decision (neonatologists, 94.1%, nurses, 92.4%). When they do not agree with an end-of-life deci- sion that has been made, half of neonatologists (52.9%) and 65% of nurses agreed that they can opt to no longer be involved in that case; 57% of neonatologists and 60% of neonatal nurses agreed that they would prefer their neo- natal intensive care unit to provide more psychological

support for staff members when they are being confronted with end-of-life decisions. About 40% of neonatologists and half of neonatal nurses agreed that they receive suffi- cient psychological support from their neonatal intensive care unit after a patient dies.

For both groups sex, age (<40 years and ⩾40 years), years of experience (⩽10 years and >10 years), whether or not they are religious and whether they believe their religion has an impact on their attitudes towards end-of- life decisions were added. In addition, we included func- tion for neonatologists (resident or in training) and diploma for nurses (bachelor, masters or graduate degree). None of the demographic variables had a signifi- cant influence (not in table).

Discussion In this survey study concerning stress and perceived psy- chological support by colleagues or professionals during the neonatal end-of-life decision-making process, we found

Table 1. Demographics of neonatologists and neonatal nurses.

Neonatologists N = 52 (%)

Neonatal nurses N = 250 (%)

Sex Female 37 (71.2) 237 (95.2) Male 15 (28.8) 12 (4.8) Age <30 12 (23.1) 75 (30.2) 30–39 15 (28.8) 65 (26.2) 40–49 11 (21.2) 53 (21.4) ⩾50 14 (26.9) 55 (22.2) Years of experience working in a NICU <5 years 22 (42.3) 58 (23.3) 5–10 years 8 (15.4) 34 (13.7) 11–20 years 9 (17.3) 77 (30.9) >20 years 13 (25) 80 (32.1) Function of physicians N/A Neonatologist 39 (75) Specialist in training 13 (25) Degree nurses N/A Graduate 3 (1.2) Bachelor 229 (92.3) Master 16 (6.5) Religion or beliefs Religious 28 (53.8) 164 (66.1) Not religious 24 (46.2) 84 (33.9) Belief that their religion or belief has impact on their attitudes towards end-of-life decisions Yes 13 (25.5) 45 (18.4) No 38 (74.5) 200 (81.6)

Missing values: varied from 0% for sex, age, years of experience, func- tion and to 1.9% in the impact of religion in neonatologists (n = 52) and from 0.4% in sex and years of experience to 2% in the impact of religion in neonatal nurses (n = 250).

Dombrecht et al. 433

that both neonatologists and neonatal nurses working in a Flemish neonatal intensive care unit experience more stress than usual when dealing with end-of-life decisions. Even though almost all feel supported by colleagues, only about half feel that the psychological support they receive is sufficient. Finally, we could not identify a subgroup based on demographic characteristics that had a higher need for psychological support within our population.

Most neonatologists and nurses reported having more stress than usual when they make or are confronted with an end-of-life decision. They generally felt that they can talk to their peers when something is bothering them regarding an end-of-life decision. However, this support from colleagues does not seem sufficient. Our findings show that other, pro- fessional, support is often lacking, since about 60% of neona- tologists and nurses would like their department to provide more psychological support when they are confronted with an end-of-life decision, and only two out of five neonatolo- gists and half of nurses feel that they receive sufficient psy- chological support from their department when one of their patients dies. As we did not specify which psychological sup- port the participants would like to receive or which support they are currently lacking, we consulted available studies and

recommendations on varying types of psychological support in a neonatal intensive care unit such as debriefings and counselling sessions. However, future studies should inquire about the specific nature and content of the psychological support that is currently lacking for Flemish neonatologists and neonatal nurses. Existing guidelines on neonatal end-of- life and palliative care already provide suggestions for staff support, namely regular debriefings and counselling sessions in order to prevent and counteract the negative conse- quences of stress.3 This could not only benefit the personal and professional lives of staff by preventing burnout and compassion fatigue6 but might also improve their ability to care for, and show empathy towards, both neonates and par- ents,12 thus improving the care and support they provide.13

Since only 45% of nurses felt that the treating physicians listen to their opinion regarding end-of-life decisions and only 32% felt they can express any objections they might have, our study indicates that nurses are often excluded from the decision-making process. We believe that includ- ing nurses could increase the quality of these decisions because they often have more interaction with the infant and family than physicians do and are therefore more familiar with their wishes regarding the care and death of

Table 2. Proportion of neonatologists and neonatal nurses agreeing with psychological support items.

Item Group Disagree (%) Neutral (%) Agree (%)

Stress Taking decisions about the end of life causes me more stress than

usual Neonatologist 6 (11.8) 8 (15.7) 37 (72.5) Neonatal nurse N/A N/A N/A

Being confronted with an end-of-life decision for a newborn baby in my department causes me more stress than usuala

Neonatologist N/A N/A N/A Neonatal nurse 44 (17.7) 30 (12.1) 174 (70.2)

Psychological support by colleagues I feel that I am being supported by my colleagues in the decisions I

make about my patients’ end of life Neonatologist 0 (0) 7 (13.7) 44 (86.3) Neonatal nurse N/A N/A N/A

I have the feeling that the treating physician(s) listen to my opinion when an end-of-life decision is taken about a newborn baby with a serious conditionb

Neonatologist N/A N/A N/A Neonatal nurse 68 (27.3) 70 (28.1) 111 (44.6)

There are adequate possibilities offered by the department to express any protests I might have about end-of-life decisionsc

Neonatologist 2 (3.9) 4 (7.8) 45 (88.2) Neonatal nurse 95 (38.5) 74 (30) 78 (31.6)

If something is bothering me about taking an end-of-life decision, I can talk to my colleagues about it

Neonatologist 0 (0) 3 (5.9) 48 (94.1) Neonatal nurse N/A N/A N/A

If something is bothering me about a decision made about a patient’s end of life, I can talk to my colleagues about itd

Neonatologist N/A N/A N/A Neonatal nurse 8 (3.2) 11 (4.4) 231 (92.4)

If I don’t agree with the outcome of a certain decision about a patient’s end of life, I can opt to no longer be involved in that cased

Neonatologist 10 (19.6) 14 (27.5) 27 (52.9) Neonatal nurse 23 (9.2) 65 (26) 162 (64.8)

Professional psychological support I would like my department to offer more psychological help to

staff when they are confronted with end-of-life decisionsa Neonatologist 6 (11.8) 16 (31.4) 29 (56.9) Neonatal nurse 38 (15.3) 61 (24.6) 149 (60.1)

I receive sufficient psychological support from my department after a patient has died in our departmentd

Neonatologist 13 (25.5) 17 (33.3) 21 (41.2) Neonatal nurse 85 (34) 40 (16) 125 (50)

All items were translated by a language editor. One neonatologist had missings on all psychological support items and was thus excluded from analysis. a0.8% missing values in nurses. b0.4% missing values in nurses. c1.2% missing values in nurses. dNo missing values in nurses.

434 Palliative Medicine 34(3)

the child.1,14 Another study indicated that higher levels of stress in nurses compared with physicians could possibly be due to them having less impact on end-of-life decisions.15 We thus hypothesise that including nurses in interdiscipli- nary end-of-life decisions team meetings could possibly benefit the nurses themselves by reducing moral distress caused by being excluded from the decision-making.

Limitations of the study Our study contacted all neonatologists and neonatal nurses working in all Flemish neonatal intensive care units, which is a strength. However, only about 50% com- pleted our questionnaire, and we do not have demo- graphic information about those who did not participate, or their reasons for not doing so. Due to ethical considera- tions, we were unable to identify the neonatal intensive care units in which the respondents worked and are thus not able to identify which do or do not provide adequate support to their staff. Finally, we did not examine whether different types of end-of-life decisions such as non-treat- ment decisions or drug administration with or without an explicit life-shortening intention are associated with dif- ferent perceived stress levels or needs of psychological support. We therefore recommend future research to examine whether different types of end-of-life decisions bring forth differences in stress levels and whether or not they warrant different means of psychological support.

Acknowledgements The authors would like to thank all neonatologists, nurses and neonatal intensive care unit wards that participated in this study, as well as the neonatologists and nurses who aided in testing and validating the questionnaire. Furthermore, they would like to thank Saskia Baes for her help in developing the questionnaire and collecting the data. Finally, they would like to thank Roos Colman for her statistical expertise, Helen White for translating the items used in their questionnaire and Jane Ruthven for her language editing. Collaborators in the consor- tium: Sabrina Laroche, Claire Theyskens, Christine Vandeputte, Luc Cornette and Hilde Van de Broek.

Availability of data and material Questionnaires and detailed research protocols (in Dutch) are available upon written request to the corresponding author ([email protected]).

Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study is funded by the Research Foundation Flanders (FWO; grant no. G041716N to J.C.) and the special research fund of

Ghent University (BOF; grant no. 01J06915 to L.De.). K.B. is a postdoctoral fellow of the Research Foundation Flanders (FWO). The study sponsors had no role in study design, the collection, analysis and interpretation of data, the writing of the report and the decision to submit the manuscript for publication.

ORCID iD Laure Dombrecht https://orcid.org/0000-0002-7174-4678

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