Iranian Nurses and Do Not Resuscitate Orders: Knowledge, Skills, and Behaviors Must Be Addressed

Sir,

Mogadasian et al. have reported a fascinating paper on the attitudes of nurses with regard to ‘do not resuscitate’ orders.[1] Clearly there is room for improvement and so it is likely to be worthwhile giving some thought as to how this improvement might be achieved. However, before developing a plan for improvement, a clear assessment of the problems must be made. Mogadasian's paper purports to address the attitudes of nurses, but close examination of the questionnaire suggests that there might be problems with more than just the attitudes. One of the items in the questionnaire states that ‘it is difficult for me to talk to my patients about death’. A difficulty in this regard may result from an attitudinal problem but may equally mean that the nurses do not have the necessary skills to talk to their patients – more specifically the communication skills. The statement ‘I feel I must conform to my peers’ wishes regarding DNR orders’ once again might suggest a problem with attitude but might equal be reflective of a problem with behavior. Lastly, a positive response to the statement ‘I wish I had a better understanding of the legal ramifications of DNR’ is clearly indicative of a knowledge deficit.

The lesson is clear. Deficit in nursing competence and confidence with regard to DNR orders suggests underlying problems with knowledge, skills and behaviors, as well as attitudes. Specifically improvements need to be made in applied knowledge, communication skills, and team-working behaviors. And so the educational intervention required to redress the deficit will equally need to be multifactorial. Nurses might need online learning content to improve knowledge, communication skills workshops to improve communication skills, and perhaps role play or simulation sessions to improve actual behaviors and performance. With such a strategy it is likely that all areas of competence will improve.