Journal of Hayat

Training; a golden ring for removing nurses’ challenges in caring process of the brain death patients

Zahra Sadat Manzari

Statistics show that brain death constitutes 1-4% of hospital deaths and 10% of the deaths occurred at the intensive care units (1). In the United States, brain death accounts for less than 1% of all deaths (about 15000 to 20000) (2). According to Iranian statistics, more than 15000 brain deaths occur every year in Iran, and driving accidents are one of its main causes (3-6). Then, these patients are taken to the ICUs to be cared for by nurses (7).

Considering the great number of brain deaths in Iran, and also the great number of patients needing transplant who die due to lack of obtaining an appropriate transplant organ, the Ministry of Health has notified to the universities of medical sciences the regulation number 54/100 dated 23.01.1394. In the 4^th clause of this regulation, accurate and specialized medical care in accordance with the instructions, preserving the vital organs of brain death patient (maintaining electrolytes, kidneys, liver, heart, lungs, and stabilizing vital signs) are emphasized which shows the necessity and importance of accurate training for all staffs specially nurses involved in caring for the brain death patients.

Given the high rate of brain death, most patients that ICU nurses face are the brain death patients (8). The caring process of brain death patients has different challenging and undiscovered dimensions due to its difficult and complicated nature which has attracted attention of researchers from all over the world to study its different dimensions. Some of the most important challenges which ICU nurses referred to in the caring process of brain death patients in studies are as follows: understanding the concept of brain death by the ICU nurses is one of the most challenging dimensions of this process (9). Although the meaning of brain death and caring for these patients is one of the vital components of nursing practice at the ICUs (10), understanding the concept of brain death is very difficult for most nurses and challenges all their previous beliefs about death and dying (11) because the concepts and implications for understanding brain death are beyond the understanding of the normal death of a person. This phrase is translated as actual death which means there is no hope for improvement, while the physical appearance of brain death patients, the presence of family members and nurses’ caring activities at the bedside of patients give the impression that they are alive, and all of these contribute to this ambiguity. But this conflict is naturally emotional and experimental for nurses (12). Ronayne in their study found that despite the knowledge about the physiology of brain death, its experience is stressful for nurses even long after facing these patients (8).

One of the other challenges is the announcement of brain death to the patient’s family. Although this is one of the physician’s responsibilities, nurses are also involved in because of their constant presence at the hospital and easy access of patients’ family members to them. This announcement is very stressful and challenging for nurses and is one of the most important parts of caring process (13) because nursing care is not only limited to the patient but also includes facing the specific needs of patient’s family members who are in crisis and experiencing an acute, complex and stressful clinical situation (14). Other nurses’ challenges in the caring process of brain death patients are ethical and legal aspects especially in the field of brain death and organ donation (4). Studies in Iran show that only half of physicians and medical staffs have sufficient awareness about organ donation and its laws, but they do not attempt to encourage organ donation for the fear of increasing mental pressure on patient’s family members (4). However, training is considered an effective factor in facilitating organ donation process (15).

Caring for a brain death patient and possible potential members to donate is another nurses’ challenge in caring process. Caring for a brain dead patient has been always a big challenge for the ICU nurses (14). According to different studies, most nurses believe that they are not ready enough to care for a patient who is a candidate for organ donation (16). So, one of the most difficult responsibilities of ICU nurses is caring for a brain dead patient who is a candidate for organ donation after her/his family’s consent (12). Studies showed that nurses feel hopelessness, inadequacy and depression after caring for a brain dead patient. These feelings may interfere in the quality of patient care and lead the nurse to be burnout (17). Ronayne found that because of the stress of caring for the brain dead patients, some nurses experience cognitive dissonance (8). One of the most important and controversial aspects of caring process is to give the request form of organ donation to the patient’s family. Given that caring process at the ICU involves both the patient and her/his whole family (18), the attitude of staffs especially nurses towards organ donation is very important since their positive attitude leads them to try more to prepare families for organ donation consent (13).

Some research has shown that providing opportunities for training nurses in this area, promotes organ donation and transplant rates since potential donors are timely identified and introduced to the organ bank (19). Nurses found that they need training and support on all aspects of caring for a brain death patient, organ donation and supporting her/his family (15). So, accurate and comprehensive understanding of the caring process of brain death patients especially from the nurses’ perspectives is very important for high quality and comprehensive caring. Due to the shortage of organ donation and the importance of organ health for transplantation, accurate and high quality caring for patient is necessary to make sure that organs remain healthy. Therefore, it is necessary to consider the caring process of the brain dead patient in order to develop an appropriate caring program for these patients.

Thus, considering that nurses are responsible for one of the most stressful caring processes including both caring for a brain dead patient and facing her/his family members (who may not be able to accept their patient’s brain death), and given the necessity of increasing the organ donation rate, and as well as the lack of targeted education on caring for the brain dead patients and insufficient nurses’ knowledge in this area, there is a need for accurate training on this caring process more than before.

Pregnant mothers’ strategies for the management of pregnancy concerns

Ali Taghipour

Background & Aim: Mothers during pregnancy face many concerns. Identifying mothers’ strategies to manage those concerns can help healthcare providers to promote their mental health. The aim of this study was to explore pregnant mothers’ strategies for the management of their concerns during pregnancy.

Methods & Materials: This qualitative study was conducted in Gorgan city during 2014-2015. The study participants were 20 pregnant women and three of their husbands as well as three experienced midwives who were selected using purposive sampling and interviewed through semi-structured interview. Data were analyzed through conventional content analysis using the MAXQDA software.

Results: Data analysis led to the emergence of five main categories including the utilization of purposive knowledge acquisition, reliance on the leverage of spirituality, thinking management and stress control, the effort to maintain and improve familial interactions and emotional preparation for pregnancy.

Conclusion: The five strategies used by pregnant women to manage their concerns, were identified in this study. Midwives can play an important role in implementing these strategies and empowering pregnant women.

The impact of a group supportive training on caregiving burden in the mothers of children with thalassemia major

Nasrin Rezaee

Background & Aim: Improving the mental health of mothers of children with thalassemia major who experience great caregiving burden, requires an efficient supportive training to be developed and implemented. Therefore, this study aimed to determine the impact of a group supportive training on caregiving burden in the mothers of children with thalassemia major.

Methods & Materials: A quasi-experimental study (IRCT2016122731612N1) was conducted on 80 mothers of children with thalassemia, referred to Aliasghar hospital in Zahedan in summer 2016. The mothers were selected through convenience sampling method and divided into two intervention and control groups of 40 each. The intervention group received four sessions of supportive training during four weeks. Data were collected by the Caregiver Burden Inventory. SPSS version 21 and independent t test, paired t-test and the analysis of covariance were used to analyze the data.

Results: The mean score of caregiving burden before training in the intervention and control groups were respectively, 86.60±13.55 and 92.37±8.54 and declined to 59.62±9.90 and 89.57±5.83 after the intervention. Furthermore, The caregiving burden score in five dimensions including temporal, developmental, physical, social and emotional was significantly lower in the intervention group than in the control group (P<0.05).

Conclusion: The findings showed that collective supportive training leads to a decrease in caregiving burden in the mothers of children with thalassemia. Thus, this training could be an effective method in reducing the mothers’ caregiving burden. This program could be used in health centers in order to maintain and improve the mental health of mothers.

Intention to treat analysis in randomized clinical trials: A review

Leila Janani

Background & Aim: Randomized controlled trials often suffer from two major problems, i.e., noncompliance and missing outcomes. One potential solution to this problem is using the intention-to-treat (ITT) analysis approach. Therefore, the aim of this study was to review the concept of ITT and the most important issues related to it in practice since RCT researchers utilize it as a guide in order to improve the quality of RCT studies.

Methods & Materials: A review study was performed using available resources and comprehensive analysis. For this purpose, we searched the relevant articles in databases including Ovid/Medline, SCOPUS, Web of Science, Google scholar and Magiran. The key words that were used included randomized clinical trials, randomized controlled trials, intention-to-treat analysis, per-protocol analysis, ITT, as-treated.

Results: The advantages of ITT, the critique of ITT, the alternatives of ITT and their limitations, missing data and their management in clinical trial studies were discussed in this paper.

Conclusion: ITT approach, due to its adherence to the principles of randomization, protects clinical trials from confounding and bias and therefore leads to the generation of the highest quality scientific evidence in the clinical research field. ITT should be considered a strategy at all stages of research, including the design of study, implementation and data analysis, and it should not be considered only a statistical approach.

The relationship of depression and death anxiety to the quality of life among the elderly population

Reza Ghanei Gheshlagh

Background & Aim: Quality of life indicates the level of individual’s satisfaction or dissatisfaction with the different aspects of life and has specific characteristics at each stage of life. The quality of life in the elderly may be influenced by death anxiety and depression. The aim of this study was to evaluate the relationship of depression and death anxiety to the quality of life among the elderly population.

Methods & Materials: This study was a cross-sectional research conducted on 294 elderly living in Saghez in 2016. Samples were selected through convenience sampling. The 12-Item Short Form Health Survey (SF-12), Geriatric Depression Scale (GDS) and Death Anxiety Scale were used to gather the data. Data were analyzed using descriptive statistics, the Kolmogorov-Smirnov test, Pearson correlation coefficient and linear regression by Enter method. The level of significance was considered P<0.05.

Results: The mean (and standard deviation) scores for the quality of life, depression and death anxiety among the studied elderly were respectively 33.22±7.81, 4.92±3.82 and 33.63±7.40. There was a significant relationship between depression and the quality of life (P<0.0001) but there was no significant relationship between the quality of life and death anxiety.

Conclusion: Depression is a common problem among the elderly and related to their quality of life. When assessing the quality of life in the elderly, paying attention to their depression is necessary. Appropriate diagnosis and management of depression can improve the quality of life in the elderly.

The effect of Salvia aroma on labor anxiety among primigravida and multigravida women: a randomized clinical trial

Azam Bakhteh

Background & Aim: Mother’s intense fear of and anxiety about labor pain lead to muscle contractions. Intense muscle contractions especially uterine contractions interfere with the normal process of labor. So, this study aimed to investigate the effect of salvia aroma on reducing the women’s anxiety level during labor.

Methods & Materials: The present study was a two-group randomized clinical trial (IRCT2016042727633N1) conducted in 2015 on 160 pregnant women laboring in Motazedi Hospital in Kermanshah. The subjects were randomly assigned into two groups. Prior to the intervention, the Spielberger’s State-Trait Anxiety Inventory (STAI) was completed by both groups and the anxiety scores were determined. In the intervention group, immediately after the onset of the active phase of labor, a gauze impregnated with three drops of the salvia essence was attached to the samples’ collars and repeated every half an hour. In the control group, a placebo was administered in a similar way. After the intervention, anxiety was measured at a cervical dilation of 5-7 cm. The chi-square test, Fisher test, Kolmogorov-Smirnov test, Wilcoxon and Mann-Whitney tests were employed to analyze the data.

Results: The mean score for anxiety was similar in the two groups prior to the intervention (P=0.15). However, after the intervention the mean score for anxiety was lower in the aromatherapy group (39.86±10.39) than in the control group (64.25±7.41) (P<0.001).

Conclusion: The findings suggested that the level of labor anxiety was reduced using aromatherapy with salvia essence. Accordingly, the use of salvia essence aroma is recommended for reducing anxiety labor.

Effect of local heating on the success rate of venipuncture in the patients with overweight: a randomized clinical trial

Seyed Reza Mazloum

Background & Aim: Access to peripheral veins in more than 80% of hospitalized patients is necessary. This skill is more difficult in the patients with overweight. The study was conducted to determine the effect of local heating on the success rate of venipuncture in the patients with overweight.
Methods & Materials: An unblinded, randomized clinical trial (IRCT2017020832133N1) was done on 70 patients with overweight, hospitalized in the internal department of Imam Reza hospital in Mashhad in 2016. Subjects were randomly allocated to the two groups of experimental and control. For the experimental group, the 39.5 degree (Celsius) local dry heat was applied at the venipuncture site, 10 minutes before venipuncture. The control group had venipuncture in a similar condition but without local heating. In the two groups, the rate of visibility and palpability of peripheral veins was measured by the Lenhardt scale, the required time for venipuncture was determined by chronometer and the number of venipuncture attempt was measured by counting. Data were analyzed by descriptive statistics, independent t-test and Chi-square using the SPSS software version 16.
Results: For the intervention and control groups, the average number of venipuncture attempt were respectively 1.0±0.1 and 1.3±0.5 times, duration of venipuncture were 89.7±26.3 and 120±38.9 seconds and the rate of visibility and palpability of peripheral veins were 2.9±0.7 and 2.3±0.5, and all were statistically significant (P<0.05).
Conclusion: The use of local heating for the overweight patients can increase the visibility and palpability of peripheral veins and decrease the duration of venipuncture and venipuncture attempts.

The effect of Espresso coffee consumption through gastric tube on respiratory indicators among mechanically ventilated patients: A randomized clinical trial

Mohammad Sadegh Aboutalebi

Background & Aim: The role of caffeine as a cerebral stimulant for improving respiratory indicators in the mechanically ventilated patients is unclear. The purpose of this study was to evaluate the effect of coffee consumption on respiratory indicators among the mechanically ventilated patients in the Intensive Care Unit (ICU).
Methods & Materials: A double blind, randomized clinical trial (IRCT2013122915972N1) was performed on 80 patients who were selected by convenience sampling and randomly allocated into two groups (intervention and control). For the intervention group was administered 3.5 grams of espresso coffee powder dissolved in 80 cc water, then 20 cc water through gavage about an hour after breakfast. The control group received 100 cc distilled water. Respiratory parameters were recorded and compared in the two groups 2 minutes before the intervention and 30 minutes and 60 minutes after the intervention. Chi-square test, t-test and the repeated measures analysis of variance were used to analyze the data.
Results: There was no difference between the two groups in the baseline variables. After the intervention, the spontaneous respiratory rate, tidal volume, the minute ventilation rate and arterial O2 saturation increased in the intervention group compared to the control group, but the increase was statistically significant only for the spontaneous respiratory rate and tidal volume.
Conclusion: Espresso coffee consumption through gastric tube in the mechanically ventilated patients increases the spontaneous respiratory rate and tidal volume but does not significantly affect other respiratory indicators.