Skills retention for insertion of the Combitube and laryngeal mask airway

OBJECTIVE

To determine if the skills to successfully ventilate using the laryngeal mask (The Laryngeal Mask Company Limited, Henley on Thames, United Kingdom) and Combitube (The Kendall Company, Mansfield, USA) can be retained after seven months.

METHODS

Nursing, medical and theatre staff from Dunedin Hospital were recruited in a prospective study. Subjects were taught to insert and ventilate an Ambuman manikin using both devices. Subjects were tested on their ability to ventilate the manikin with both devices within one month then following a six-month period.

RESULTS

A total of 101 subjects were recruited with 86 subjects retested at least six months later. Initial testing resulted in subjects successfully ventilating the manikin in 90% (laryngeal mask) and 92% (Combitube) of attempts. At retesting, successful ventilation was achieved in 85% (laryngeal mask) and 77% (Combitube) of attempts. The decline in skills level was significant for the Combitube only (95% CI 4% to 26%).

CONCLUSION

The ability to successfully ventilate is better maintained with the laryngeal mask than the Combitube after seven months.

Family carers of ICU survivors: a survey of the burden they experience

Intensive care unit (ICU) survivors may experience deterioration in their quality of life for months following their return home, with families assuming a caregiving role. The aim of this study was to measure the burden associated with caring for a family member who had been critically ill. The study also sought to describe the relationship between three factors (filial obligation, social support, self-efficacy) and caregiver burden. Seventy-one family carers, 51 females (72%) and 20 (28%) males of long-term intensive care patients completed a mailed survey, after signing an informed consent form. Although the vast majority of the caregivers were providing substantial number of hours of care each week, they scored lower than the midpoint on all caregiver burden inventory subscales. Filial obligation was found to be positively associated with caregiver burden; however, there was no association between social support, self-efficacy and caregiver burden. Male caregivers experienced significantly more burden than female caregivers. The findings suggest that an understanding of the factors that impact on caregiver burden of families of ICU survivors is only beginning to emerge.

Family-focused interventions

CATs are interventions that should be considered by critical care nurses when planning interventions for meeting the needs of families of critically ill patients. More research is needed on the effect of family members providing CAT to critically ill patients and what forms of CAT are most effective. Comparison studies of CAT being provided by certified providers versus family members are needed. Using CAT for family members may be useful in reducing their levels of stress and anxiety and therefore reducing negative physiologic and psychologic responses to stress.

Using complementary and alternative therapies to promote comfort at end of life

Dying is a journey for all involved. We have been fortunate to work in a hospital with both an ICU and a palliative care/hospice unit. We have transferred patients for whom care was withdrawn and who were still alive on the next day to the palliative care unit and have found the transfer to work to maximize comfort in dying. For many patients and families who have developed relationships with the staff in their ICU, the combination of established relationships, traditional therapies, and CAT maximizes the comfort during the dying process.

TheraPulse ATP for preventing and treating pressure ulcers

In the modern healthcare environment where evidence-based best practice is key in seeking quality improvements for patient care, using treatment and therapies that have evidence of clinical efficacy is paramount. The current evidence bases supporting pulsating air suspension therapy is excellent and the improved lymphatic flow and enhanced microcirculation along with reduction of pressure ulcer potential (El-Habbal and Smith, 1996; Gunther and Brofeldt, 1996) ensures a firm place for TheraPulse ATP (KCI Medical) in reduction of oedema and pressure ulcers in the critically ill patient.

"Realising the potential of critical care nurses": an exploratory study of the factors that affect and comprise the nursing contribution to the recovery of critically ill patients

BACKGROUND

This study seeks to make evident the complexity of issues associated with the delivery of care by nurses to the critically ill. Emphasis had been placed on the results and implications of these for nursing practice. For a more in-depth account, the full report can be accessed on www.lscn.co.uk.

METHOD

Following multi-centre research ethics committee approval, 10 critical care units participated in the 3-month study. Data collection comprised 231 nurse interviews and 51 relative interviews during 33 observation participation periods.

RESULTS

Analysis demonstrated that the context of the critical care unit, in terms of geographical layout, unit activity, case mix and skill mix of nurses, had a major effect on the ability of nurses to contribute to the recovery of the critically ill. The effectiveness of the nursing resource appeared to be a function of knowledge (theoretical and patient related), experience and exposure. Nurses who were unused to a particular environment were not seen to be as effective as those who were. A model was constructed that identified the central tenets upon which nursing care can be optimised or compromised. When nursing care was optimised the difference nurses made potentially decreased risk to patients, enabled timely patient progression and increased the potential for patient recovery.

CONCLUSIONS

The results confirm that nurses have a significant contribution to make in the recovery of patients who have experienced critical illness. Recommendations are far reaching and include the need to develop a valid and reliable tool which addresses patients' need for nursing in terms of nurses' knowledge and experience, patient dependency and decreasing clinical risk across the continuum of care. Current nursing workload tools and patient:nurse ratios were seen to lack validity because they do not appraise the context in which care is delivered, define all nurses as equal and concentrate on activity rather than the effect nurses can have on the outcome of the critically ill.

End-of-life decisions in Swedish ICUs. How do physicians from the admitting department reason?

OBJECTIVE

To study how physicians from the admitting department reason during the decision-making process to forego life-sustaining treatment of patients in intensive care units (ICUs).

DESIGN

Qualitative interview that applies a phenomenological approach.

SETTING

Two ICUs at one secondary and one tertiary referral hospital in Sweden.

PARTICIPANTS

Seventeen admitting-department physicians who have participated in decisions to forego life-sustaining treatment.

RESULTS

The decision-making process as it appeared from the physicians' experiences was complex, and different approaches to the process were observed. A pattern of five phases in the process emerged in the interviews. The physicians described the process principally as a medical one, with few ethical reflections. Decision-making was mostly done in collaboration with other physicians. Patients, family and nurses did not seem to play a significant role in the process.

CONCLUSION

This study describes how physicians reasoned when confronted with real patient situations in which decisions to forego life-sustaining treatment were mainly based on medical--not ethical--considerations.

Following the path of ICU survivors: a quality-improvement activity

Recent interest in continuity of care has meant that the illness trajectory experienced by intensive care unit (ICU) patients has received more attention. Using continuous quality improvement as a framework, this paper describes information obtained during a 3-year period relating to ICU patients' long-term experiences after being discharged from hospital. This information identified that most participants had been discharged home but that many experienced problems with mobility, disability and fatigue. Changes in employment status and the need for financial assistance were noted. As a result of the information provided by this activity, clinical practice has changed and a number of formal research studies have been undertaken.

"It's like an explosion in your life...": lay perspectives on stress and myocardial infarction

Psychological difficulties are common after myocardial infarction (MI). These difficulties are most often represented to patients through cardiac rehabilitation services and the literature offered to patients after MI as being related to "stress" and its management. However, no research has examined what MI patients understand by the term "stress" or how congruent lay views of stress are with those evident in the professional literature. The aim of the study reported here was to examine post-MI patients' views of stress, its functioning and relationship to their MI. As patients' views of stress were sought, qualitative interviews were used. A philosophical approach was taken (critical realism) that recognizes the legitimacy of both professional and lay perspectives. Data were generated in 44 semistructured interviews with 14 MI patients who were interviewed 48 hours, 1 week, 1 month and 3 months after hospital admission. While participants described their experiences after MI as being difficult, to convey this they used everyday terms such as fear, fright and worry. Rather than viewing stress as being a consequence of their MI, they perceived it to be a common cause of heart problems. Many considered stress as having a more influential role than other risk factors, such as smoking and diet. They expressed a wide variety of sophisticated and diverse views of stress and its functioning. Each of these views placed different weighting on the roles of social, personal and situational factors in contributing to the stressful reaction. Parallels were apparent between these lay accounts and theories of stress developed in the professional literature.

Nosocomial infections in adult intensive-care units

Nosocomial infections affect about 30% of patients in intensive-care units and are associated with substantial morbidity and mortality. Several risk factors have been identified, including the use of catheters and other invasive equipment, and certain groups of patients-eg, those with trauma or burns-are recognised as being more susceptible to nosocomial infection than others. Awareness of these factors and adherence to simple preventive measures, such as adequate hand hygiene, can limit the burden of disease. Management of nosocomial infection relies on adequate and appropriate antibiotic therapy, which should be selected after discussion with infectious-disease specialists and adapted as microbiological data become available.

Respiratory care in spinal cord injury with associated traumatic brain injury: bridging the gap in critical care nursing interventions

Spinal cord injury (SCI) is a devastating and challenging condition. The events that lead to SCI, such as road traffic accidents, falls, sports and violence [Top. Spinal Cord Inj. Rehabil. 5 (1999) 83], are also the common aetiologies of traumatic brain injury (TBI). It's not surprising then, that 20-50% of those with cervical SCI have TBI [J. Trauma 46 (1999) 450]. The literature pertaining to the management of either injury in isolation is vast, but lacking where the two conditions are experienced together and require distinct adaptations to interventions. Consequently, a gap in the literature exists. This paper focuses on those patients with SCI of the cervical spine with associated head injury, and pay particular attention to respiratory difficulties, and presents interventions required to minimise and treat the effects of such pulmonary compromise.

Developing a competency framework for critical care to match patient need

The competency framework developed by the critical care education group of the London Standing Conference aims to serve every grade and level of practitioner. It is neither time specific nor static. The patient is the central focus of the framework and the elements of competence reflect patient need at any critical care level [Comprehensive Critical Care: A Review of Adult Critical Care Services, The Stationary Office, London]. A group of expert nurses have developed the competency framework, with widespread consultation and collaboration. This approach intended to develop consistency for critical care education and practice. It is envisaged that this will reduce pockets of repeated activity, which places huge demands on limited resources. The critical care competency framework was developed using the method of functional analysis. A plan for the future has been identified, including continued collaboration and consultation with Trusts and Higher Educational Institutions and the development of an online manual to support the competency framework.

KEY POINTS

1. Critical care delivery has been under close scrutiny and a number of key contemporary drivers have led to the development of this competency framework. 2. The development of a consistent pan-London approach to critical care education has been identified. 3. The patient is the focus of critical care delivery and therefore patient need is central to the critical care competency framework. 4. Wider collaboration is needed with other agencies and groups to prevent the repetition of work already carried out.

Improving the utilization of medical crisis teams (Condition C) at an urban tertiary care hospital

PURPOSE

Serious clinical deterioration precedes most cardiopulmonary arrests, and there is evidence that organized responses to this deterioration may prevent a substantial proportion of in-hospital deaths. We aimed to increase the utilization of our medical crisis response team (Condition C) to impact this source of mortality.

METHODS

We have examined the change in numbers of Condition Cs and the main alternative response strategy (sequential stat pages) after the implementation of 4 strategies to increase Condition C utilization: (1) immediate reviews of all sequential STAT pages, (2) feedback to caregivers responsible for delays in Condition C activation, (3) creation of objective criteria for invoking a crisis response, and (4) dissemination of objective criteria through posting in units, e-mail, and in-service oral presentations.

RESULTS

Over a 3-year period, interventions were followed by increased use of organized responses to medical crises (Condition Cs) and decreased numbers of disorganized responses (sequential STAT pages). The interventions that involved objective definition and dissemination of criteria for initiating the Condition C response were followed by 19.2 more Condition Cs monthly (95% confidence interval [CI], 12.1-26.3; P<0001) and 5.7 fewer sequential STAT pages monthly (95% CI, 3.2-8.2). The interventions that involved giving feedback to medical personnel based on review of their care were not associated with changes in the measures.

CONCLUSION

Utilization of an important patient safety measure may be increased by focused interventions at an urban tertiary care hospital.

Developing best practice in critical care nursing: knowledge, evidence and practice

Because the current drive towards evidence-based critical care nursing practice is based firmly within the positivist paradigm, experimentally derived research tends to be regarded as 'high level' evidence, whereas other forms of evidence, for example qualitative research or personal knowing, carry less weight. This poses something of a problem for nursing, as the type of knowledge nurses use most in their practice is often at the so-called 'soft' end of science. Thus, the 'Catch 22' situation is that the evidence base for nursing practice is considered to be weak. Furthermore, it is argued in this paper that there are several forms of nursing knowledge, which critical care nurses employ, that are difficult to articulate. The way forward requires a pragmatic approach to evidence, in which all forms of knowledge are considered equal in abstract but are assigned value according to the context of a particular situation. It is proposed that this can be achieved by adopting an approach to nursing in which practice development is the driving force for change.

Nursing care of the acute head injury: a review of the evidence

This article aims to review the current evidence in relation to acute head injury care. Head injuries are a frequent cause of death and disability in western society with the first 72 h being an important period for prevention of further brain damage. The underlying physiology behind head injury and intracranial pressure will be discussed. The monitoring of intracranial pressure and implications for practice will be addressed. The specialized nursing care and drug therapy management that is necessary for acute head injury patients will be highlighted. Recommendations for practice will be given.

Sedation in neurointensive care: advances in understanding and practice

PURPOSE OF REVIEW

To evaluate the rationale and the pharmacologic options for sedating neurointensive care patients.

RECENT FINDINGS

Sedation is a fundamental element in the neurointensive care unit. Even if the sedative strategy in the neurointensive care unit shares the same general aims with intensive care, the characteristics of the patients in the neurointensive care unit pose other unique challenges and some specific indications. The primary aim of neurointensive care is to maintain adequate cerebral perfusion pressure, to control intracranial pressure, and to maintain an adequate mean arterial pressure. Reducing the brain's metabolic demand is an important treatment strategy, and analgesic and sedative agents are used to prevent undesirable increases in intracranial pressure. There are many different pharmacologic agents available, each with distinct advantages and disadvantages.

SUMMARY

The pharmacokinetic and pharmacologic effects of the available sedatives used in neurointensive care patients are reviewed.

Predictors of backrest elevation in critical care

Low backrest and supine positions are associated with increased mortality and ventilator associated pneumonia (VAP). Data are not available across ICU settings about the level of backrest position used and its relationship to enteral feeding and hemodynamic status. The purpose of this descriptive study was to document the level of backrest elevation and position and identify factors associated with and predict positioning in a medical, surgical and neuroscience intensive care unit. Data were collected randomly in each unit over a 6-week period, resulting in 506 observations for170 patients. Backrest elevation was determined by electronic bed read-out or bed frame elevation gauge. BP, HR and enteral feeding status were retrieved from the medical record. Results showed that mean backrest elevation was 19.2 degrees and 70% of subjects were supine. No difference in backrest elevation among units was found. Significant correlations between backrest elevation and systolic BP (r=0.15, P=0.006); and backrest and diastolic BP (r=0.13, P=0.02) were found. There was no difference in backrest elevation between patients being fed and not being fed. Differences in backrest elevation for intubated versus nonintubated patients approached significance (P=0.07) with intubated patients at lower backrest elevations. In summary, use of higher backrest elevations (>30 degrees ) is minimal, is not related to feeding and minimally related to hemodynamic status. Strategies to meet published recommendations for backrest elevation (30-45 degrees ) must include repeated feedback about nurse's use of backrest elevation and estimates of elevation.

Health-related quality of life of patients with multiple organ dysfunction: individual changes and comparison with normative population

OBJECTIVE

To determine health-related quality of life in medical intensive care patients with multiple organ dysfunction.

DESIGN

Prospective, observational study.

SETTING

A 12-bed, noncoronary, medical intensive care unit of a university hospital.

PATIENTS

Between June 1998 and May 1999, 318 consecutively admitted adult patients with an intensive care unit stay of >24 hrs were studied.

MEASUREMENTS AND MAIN RESULTS

Health-related quality of life was assessed using a generic instrument, the Medical Outcomes Study Short Form-36 Health Survey, at admission and at 6-month follow-up. Patients who developed multiple organ dysfunction (n = 170) consumed 85% of the therapeutic activity provided in the intensive care unit. Compared with age- and sex-adjusted general population controls, multiple organ dysfunction patients had a worse preadmission health-related quality of life than other intensive care unit patients, predominantly due to a higher burden of comorbid disease. In a multivariate analysis, multiple organ dysfunction was the only variable independently associated with deteriorated physical health domains at follow-up (odds ratio, 4.4; 95% confidence interval, 1.3-14.6; p =.015), but it had no impact on dimensions of mental health. Analyzing the impact of different organ system failures, respiratory failure (odds ratio, 4.1; 95% confidence interval, 1.6-10.3; p =.002) and acute renal failure (odds ratio, 3.3; 95% confidence interval, 1.0-11.5; p =.05) increased the risk of deteriorated physical health at follow-up. No impact of the various organ system failures on mental health was noted. At 6-month follow-up, 83-90% of survivors had regained their previous health-related quality of life, and 94% were living at home with their families.

CONCLUSIONS

This study has shown that preadmission health-related quality of life of our medical, noncoronary patients was substantially reduced compared with a matched general population. This demonstrates the need to take prehospitalization health-related quality of life into account when examining the outcomes of intensive care unit survivors. Multiple organ dysfunction was the major determinant of poor physical health at follow-up, but it had no impact on mental health domains.

The effects of preparatory sensory information on ICU patients

Preparatory sensory information (PSI) has been found to have significant effects in reducing distress, tension, restlessness, negative moods, and anxiety, and also in reducing length of postoperative hospitalization during various threatening medical events, but no evidence has demonstrated the effect of PSI on a patient during ICU hospitalization. On the basis of Lazarus' theory, a structural equation model was developed to examine the role of the nursing intervention, PSI, as a significant factor influencing patients' processes of cognitive appraisals and coping, adaptational responses, and patient care outcomes during ICU hospitalization. The analytical model examined the net effect of PSI on outcomes, controlling for the effects of mastery, interpersonal trust, social support, socioeconomic status, severity of illness, age, and gender. A quasi-experiment was executed in four large acute care hospitals. Data were collected from 41 subjects in the control group and from 42 in the treatment group receiving PSI before ICU admission. Structural equation modeling was employed to test the proposed analytic model. The initial tests of model fit indicate that the original model did not fit the data well with GFI = 0.85, AGFI = 0.76, RMSEA = 0.059, p_close = 0.28, and critical N = 78. A revised model was developed, and the fit indices suggested an adequate fit with GFI = 0.90, AGFI = 0.84, RMSEA = 0.00, p_close = 0.89, and critical N = 109. These findings provide empirical support for Lazarus' theory on stress, appraisal, and coping. The findings also verify the beneficial effects of the nursing intervention of PSI on ICU patients.

Snake bite in Australia: first aid and envenomation management

Australia is inhabited by a large variety of snakes, including some of the most poisonous in the world. Sightings are regular, and the incidence of snake bite is estimated to be several thousand a year. A bite does not necessarily result in envenomation occurring, however there are at least 300 snakebites a year requiring treatment of envenomation, with between 1 and 4 fatalities every year. The incidence of fatalities from snake bite has increased over recent years. The explanation for this is unclear, but possible reasons include the urban sprawl, and a delay in application of appropriate first aid and definitive treatment for envenomation. Emergency nurses in particular should be aware of the first aid techniques appropriate for Australian snake bite, as well as the recognition and management of envenomation. This article will outline the steps required and rationale for applying first aid techniques considered to be effective in retarding spread and circulation of snake venom. It will also discuss the manifestations that indicate systemic envenomation, and management considered to be responsible for reducing the incidence of death from snake envenomation in Australia.

[In-hospital cardiac arrest resuscitation: medical and paramedical theory skill assessment in an university hospital]

OBJECTIVES

Theory knowledge and attitude assessment about in-hospital cardiac arrest (CA) basic life support by hospital staff.

METHODS

We tested medical and paramedical working staff in a 450 beds university hospital with anonymous questionnaire based on training for basic life support. Questions were about presence of a formation before, clinical signs reached in front of unconscious patient, attitude in front of cardiac-arrest, practical experience with basic life support and ward emergency trolley.

RESULTS

Five hundred and seventy one on 996 people answered to handed out questionnaires (57%): 158 from medical staff (Med group) and 413 from nurses "Pmed". Seventy one percent people from "Med" group and 64% from "Pmed" received one time at least training about cardiac-arrest. Front of unconscious patient, no spontaneous breath was reached explicitly by 55% people from Med group and 19% from "Pmed" group and central pulse was reached explicitly by 70% people from "Med" group and 18% from "Pmed" group. Front of CA, 50% people from "Med" group released airway, 75% began ventilation and 86%, External Heart Compression (EHC) and 42% called for rescue. There were respectively 29, 47, 64 and 60% people from "Pmed" group. Eighty-one percent people from "Med" group thought they knew to do ventilation and 82% did it one time at least. Eighty-eight thought they knew to do EHC and 85% did it one time at least. They were respectively 67, 76, 73 and 78% people from Pmed group. Sixty-four per cent of Med group people know that there is emergency trolley in there department versus 89% for "Pmed" group.

CONCLUSION

This study showed that theoretical knowledge of hospital staff about cardiac arrest diagnostic and management are insufficient from the point of view of national and international guidelines. Analysis is difficult because of weak response number and knowledge people overestimation.

Predictor of core hypothermia and the surgical intensive care unit

Inadvertent postoperative core hypothermia is associated with multiple physiological effects, especially in patients admitted to the intensive care unit (ICU). Despite previous reports of the relationship between patient, surgical, and anesthetic factors and immediate postoperative core hypothermia, this information might need to be reconsidered in the light of progress in surgery, anesthetic, and warming techniques. We designed this prospective study of 194 postgeneral surgical patients to assess the incidence, predictive factors, and outcome of core hypothermia (tympanic membrane core temperature [Tc] <36.0 degrees C) at the time of admission to the general ICU in a large tertiary university medical center from December 2000 to March 2001. The following variables were studied: age, sex, body weight, body surface area, preoperative body temperature, ASA physical status, history of diabetic neuropathy, emergency surgery, surgical subspecialty performing surgery, type of surgery, type of anesthesia (general, regional, or combined epidural and general), temperature monitoring, use of a forced air warming technique, amount of fluid and blood replacement, duration of anesthesia, duration of surgery, and the ambient operating room temperature. Other outcomes, i.e., length of ICU stay and mortality, were also assessed. The incidence of core hypothermia was 57.1%, 41.3%, and 28.3% according to the definition of Tc <36.0 degrees C, <35.5 degrees C, and <35.0 degrees C, respectively. Multiple logistic regression showed the following risk factors for core hypothermia: high ASA physical status (odds ratio, 2.87; 95% confidence interval [CI], 0.82-10.03 for ASA II; odds ratio, 8.35; 95% CI, 1.67-41.88 for ASA >II), magnitude of surgical procedure (odds ratio, 6.60; 95% CI, 1.66-26.19 for medium surgery; odds ratio, 22.23; 95% CI, 5.41-91.36 for major surgery), use of combined epidural and general anesthesia (odds ratio, 3.39; 95% CI, 1.05-10.88), and duration of surgery >2 h (odds ratio, 4.50; 95% CI, 1.48-13.68). Not using temperature monitoring seems to be a risk factor as well (odds ratio, 3.00; 95% CI, 0.87-10.12). Significant protective factors against core hypothermia were heavier body weight (odds ratio, 0.94; 95% CI, 0.89-0.98), higher preoperative body temperature (odds ratio, 0.31; 95% CI, 0.15-0.65), and warmer ambient operating room temperature (odds ratio, 0.67; 95% CI, 0.51-0.88). In conclusion, the incidence of core hypothermia (Tc <36.0 degrees C) at the time of admission to the general ICU is still frequent. To reduce the incidence, more efforts and concern should be taken to prevent core hypothermia, especially in the patient with high ASA physical status, undergoing more intensive and lengthy surgery, and using combined epidural and general anesthesia.

IMPLICATIONS

In an effort to decrease the frequent incidence of core hypothermia at the time of admission to the general surgical intensive care unit, this prospective study showed that high ASA physical status, the use of a combined epidural and general anesthesia, surgery lasting longer than 2 h, and extensive surgery were the important risk factors, whereas heavier body weight, higher preoperative body temperature, and warmer ambient operating room temperature were important protective factors.

Intensive care nurses' and physicians' experiences with demands for treatment: some implications for clinical practice

OBJECTIVE

This study was conducted to develop an empiric description of intensive care unit (ICU) physicians' and nurses' (participants) experiences providing life-sustaining treatments at the insistence of family members, treatments that they believed should have been withheld or withdrawn. From this description, steps to minimize or prevent their sources of distress in such situations are suggested.

DESIGN

Semistructured, open-ended interviews. Participants were asked to describe cases in which treatment had been provided primarily in response to demands from family members.

PARTICIPANTS

Six physicians and 6 nurses from 6 university-affiliated ICUs in Canada. All were members of a task force developing a multicenter policy to address demands for treatment, and physician members were heads of their ICUs.

OUTCOME MEASURES

Systematic analysis of interview transcripts and synthesis of findings.

RESULTS

Participants recalled 28 cases in which treatment had been provided at the insistence of family members. Many cases described were very distressing for both medical staff and family members. Consistently problematic areas included: (1) suffering of dying patients, (2) the marked distress of family members, and (3) a breakdown in the relationship between care providers and families.

CONCLUSIONS

Conflict with family members about decisions to limit life-sustaining treatment can be very stressful for health care providers. Three important areas that give rise to distress were identified in this study. These key sources of distress should be looked for. They could be addressed by: (1) identifying to family members the importance of minimizing suffering and ongoing bodily injury of patients at risk for dying, (2) by doing so addressing directly the distress of family members by the provision of emotional support, and when appropriate directed toward helping them accept that the patient is dying, and (3) pursuing efforts to maintain or create a good relationship with family members despite disagreement about the appropriateness of continuing life-sustaining treatment.

Achieving collaborative workplace learning in a university critical care course

The purpose of this paper is to describe the development, implementation and evaluation of a new critical care curriculum based on the tenets of collaborative workplace learning. It also examines lecturers' and clinical educators' issues, and explores students' evaluations of the old curriculum compared with those of the new curriculum. Three data collection methods were used for this study. Comprehensive notes were maintained of the meetings conducted with lecturers, clinical educators and representative students during the development and implementation of the course. Three focus group interviews were conducted with students before the introduction of the new curriculum and three focus group interviews were conducted during first semester following implementation of the new curriculum. Quality-of-teaching surveys were also completed by two groups of critical care course students: one group before and one group following the introduction of the new curriculum. Major findings in this study included: developing a sense of ownership of the curriculum for clinical educators, clinical educators' difficulties with addressing their responsibilities, amalgamating theoretical learning with clinical practice, and tackling students' workload. This paper demonstrates the value of using the collaborative workplace learning approach in strategically addressing the challenges of developing and conducting a university critical care course.

Cardiorespiratory Nurses’ Perceptions of Palliative Care in Nonmalignant Disease: Data for the Development of Clinical Practice

Nurses lack a comprehensive body of scientific knowledge to guide the palliative care of patients with nonmalignant conditions. Current knowledge and practice reveal that nurses in many instances are not well prepared to deal with death and dying. Focus groups were used in an exploratory study to examine the perceptions of palliative care among cardiorespiratory nurses (n = 35). Content analysis was used to reveal themes in the data. Four major themes were found: (1) searching for structure and meaning in the dying experience of patients with chronic disease, (2) lack of a treatment plan and a lack of planning and negotiation, (3) discomfort in dealing with death and dying, and (4) lack of awareness of palliative care philosophies and resources. The information derived from this sample of cardiorespiratory nurses represents a complex interplay between personal, professional, and organizational perspectives on the role of palliative care in cardiorespiratory disease. The results of the study suggest a need for nurses to be equipped on both an intellectual and a practical level about the concept of palliative care in nonmalignant disease.

Comparing Basic Knowledge in Critical Care Nursing Between Nurses From the United States and Nurses From Other Countries

• Background No previous research was found that compared basic knowledge in critical care nursing among nurses from different nations. Nurses from outside the United States were invited to participate during reliability testing of the Basic Knowledge Assessment Tool, Version 5.

• Purpose To compare basic knowledge in critical care between nurses from the United States and nurses from other countries and to measure the reliability of the Basic Knowledge Assessment Tool, Version 5.

• Sample Data were collected for 16 months from 682 critical care nurses: 528 from the United States and 154 from other countries.

• Results The Basic Knowledge Assessment Tool, Version 5, was a reliable test for all nurses studied, regardless of country of origin. The level of knowledge of nurses from English-speaking countries other than the United States did not differ from that of nurses from the United States. Scores for nurses from non–English-speaking nations were lower than scores for nurses from the United States. The largest source of variance in scores among all subjects was the length of experience in critical care nursing.

• Conclusions The Basic Knowledge Assessment Tool, Version 5, is a valid and reliable tool for assessing critical care nurses from the United States and the other countries studied. Critical care nurses from English-speaking countries scored higher than nurses from countries where the primary language is not English.

Utility of a weight-based heparin nomogram for patients with acute coronary syndromes

BACKGROUND

Unfractionated heparin has been pivotal in the management of acute coronary syndromes (ACS), and continues to be used widely despite the emerging role of low molecular weight heparins (LMWH). The apparent superiority of LMWH over unfractionated heparin may, at least partially, reside in its more predictable achievement of therapeutic effect, with high rates of non-therapeutic activated partial thromboplastin time (APTT) results being observed in the intravenous heparin treatment groups.

AIM

To evaluate the impact of introduction of a weight-based heparin nomogram developed for use in patients with ACS on frequency of 'therapeutic' APTT results.

METHODS

The effectiveness of an existing non-weight-based heparin nomogram in achieving a therapeutic APTT was compared sequentially with that of a weight-based heparin nomogram in 89 and 84 consecutive patients admitted with a diagnosis of ACS.

RESULTS

Patients in whom heparin dosage adjustment was weight based rapidly achieved therapeutic APTT. The median time to achieve an APTT within the target range was 8.75 h in the weight-based group versus >24 h in the non-weight-based group. Utilization of a weight-based nomogram was associated with markedly increased proportions of readings within the therapeutic APTT range at 6 h and at 24 h (51%vs. 26% and 72%vs. 36%, respectively).

CONCLUSIONS

The current study confirms the marked superiority of the weight-based heparin regimen for treatment of patients with ACS. The nomogram dramatically facilitated the attainment of therapeutic APTT, and may represent the optimal method for titration of heparin dosage to individual heparin requirements in patients with ACS.

Cooling strategies for patients with severe cerebral insult in ICU (Part 2)

Critically ill patients who have sustained a severe cerebral insult will be actively cooled should they develop an elevated body core temperature. Patients who require therapeutic hypothermia for neuroprotection may require the same cooling strategies. A literature review suggested limited evidence to support cooling strategies currently used within one intensive care unit. An experimental approach was used to examine the effects of paracetamol and four external cooling strategies on patients with severe cerebral insult It is suggested that paracetamol is effective in reducing body core temperature and that fans may not. However, data obtained from the study of the four external cooling strategies were inconclusive.

Critical care obstetrics and gynecology

The critical care aspects of obstetrics and pregnancy are varied and demand that critical care practitioners have a thorough knowledge of fetal and maternal changes in physiology as pregnancy progresses. Pregnancy can affect every organ system; and organ-specific conditions as well as syndromes that span multiple organ systems were described. Care of the critically ill, pregnant patient requires a true multidisciplinary approach for optimal outcomes. A review of the current concepts and suggestions for therapy were presented.

Certificate Programs in Continuing Professional Education

BACKGROUND

Career-long learning is a concept at the heart of professional disciplines such as nursing. Nursing shortages, especially in some areas of practice, have stimulated the need for in-depth education and training in specific knowledge content areas. One approach to career-long learning is certificate programs.

METHOD

Factors, trends, and strategies to consider in creating certificate programs are reviewed, and guidelines for developing certificate programs are presented.

FINDINGS

Certificate programs are increasingly in demand by both employers and nurses. Certificate programs provide individuals with a chance to refresh their study skills and raise their abilities and levels of confidence for mastering new learning. Certificate programs also serve as a recruitment and retention strategy for hospitals and agencies.

CONCLUSION

Certificate programs are a viable continuing professional education activity and offer opportunities for nurses to develop specific skill sets and in-depth knowledge in specialized areas of nursing practice.

Non-invasive BiPAP--implementation of a new service

Non-invasive ventilation has been shown to be an effective treatment for acute hypercapnic respiratory failure. It is now increasingly used in the treatment of acute hypoxemic respiratory failure. National guidelines published by the British Thoracic Society state that facilities for NIV should be available 24 hours per day in all hospitals likely to admit such patients. If an acute NIV service is not provided, the shortage of Intensive Care beds means that some patients will die because facilities to invasively ventilate are not available. Conversely, results of a survey performed by the indicate that at the time of data collection, only 48% of United Kingdom hospitals provided an acute NIV service. The BiPAP Vision (Respironics Inc.) offers Continuous Positive Airway Pressure (CPAP), Bi-level Spontaneous/Timed and Proportional Assist Ventilation/Timed modes and is ideal for use in a critical care environment. This article presents some of the issues surrounding NIV, the impact of a new service, and the process of implementing NIV within a critical care setting.

The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients

Sedative medications are widely used in intensive care unit (ICU) patients. Structured assessment of sedation and agitation is useful to titrate sedative medications and to evaluate agitated behavior, yet existing sedation scales have limitations. We measured inter-rater reliability and validity of a new 10-level (+4 "combative" to -5 "unarousable") scale, the Richmond Agitation-Sedation Scale (RASS), in two phases. In phase 1, we demonstrated excellent (r = 0.956, lower 90% confidence limit = 0.948; kappa = 0.73, 95% confidence interval = 0.71, 0.75) inter-rater reliability among five investigators (two physicians, two nurses, and one pharmacist) in adult ICU patient encounters (n = 192). Robust inter-rater reliability (r = 0.922-0.983) (kappa = 0.64-0.82) was demonstrated for patients from medical, surgical, cardiac surgery, coronary, and neuroscience ICUs, patients with and without mechanical ventilation, and patients with and without sedative medications. In validity testing, RASS correlated highly (r = 0.93) with a visual analog scale anchored by "combative" and "unresponsive," including all patient subgroups (r = 0.84-0.98). In the second phase, after implementation of RASS in our medical ICU, inter-rater reliability between a nurse educator and 27 RASS-trained bedside nurses in 101 patient encounters was high (r = 0.964, lower 90% confidence limit = 0.950; kappa = 0.80, 95% confidence interval = 0.69, 0.90) and very good for all subgroups (r = 0.773-0.970, kappa = 0.66-0.89). Correlations between RASS and the Ramsay sedation scale (r = -0.78) and the Sedation Agitation Scale (r = 0.78) confirmed validity. Our nurses described RASS as logical, easy to administer, and readily recalled. RASS has high reliability and validity in medical and surgical, ventilated and nonventilated, and sedated and nonsedated adult ICU patients.

The expanded role of the critical care nurse: a review of the current position

The advanced practice role of the registered nurse is a topic that is currently being debated both nationally and internationally. This paper examines the literature as it relates to role expansion within nursing in general and more specifically to critical care nurses. The role of the critical care nurse is changing and this has occurred as a result of historical evolution, the use of increasing technology, the blurring of medical and nursing roles and current workforce shortages. The literature reviewed identifies some of the factors that have propelled this process and examines the use of terminology as it relates to advanced practice roles and their titles. Finally, the attributes and educational preparation required to perform at an increased level are examined.

The need for a new advanced nursing practice role for Australian adult critical care settings

The current deficit of knowledge related to advanced nursing practice in Australian adult critical care settings presents a barrier to future role development. This paper reports the findings of one theme identified by a research study that explored issues related to the potential for a new advanced nursing practice role for these settings. The qualitative approach of focus group methodology was used to collect data from a purposive sample of regional Queensland critical care nurses (n = 26). Thematic content analysis of the data identified concepts that progressively contributed to five major themes. This paper will report the findings related to the theme that there is a need for a new advanced nursing practice role for adult critical care settings. Participants perceived that nurses are already practising at advanced levels that may predetermine a new role. There was believed to be a need for recognition of and legal sanction for critical care nurses' present practices that extend beyond the current scope of nursing practice. Participants proposed that critical care nurses may be more competent than inexperienced medical personnel in this environment and participants wanted consistent levels of autonomy for advanced practices. The current career structure was seen to be a failure and many participants perceived the lack of opportunities for critical care nurses to advance up the clinical career pathway as problematic in recruitment and retention issues. The findings of this study provide new information that makes an important contribution to further exploration of advanced nursing practice role development for Australian adult critical care settings.

[Job stress perceived by hospital medical staff]

OBJECTIVE

To identify the psychosocial risk factors related to psychological demands perceived by specialist physicians from six public hospitals in the province of Valencia in Spain.

METHODS

A qualitative study was carried out. The population studied comprised the hospitals' specialist medical staff (Oncology, Internal Medicine, Traumatology, Radiology and Intensive Care). A trained interviewer performed 47 individual, face-to-face, semi-structured interviews. To select the participants, the following structural variables were taken into account: gender, age, family responsibilities, medical specialty, professional standing, length of service, and type of contract. Interviews were tape recorded and subsequently transcribed. Finally, the content of the interviews was analyzed.

RESULTS

The main psychosocial risk factors mentioned by the participants were workload and lack of staff, mainly due to the characteristics of work organization in the hospital. Another job stressor was daily contact with suffering and death, and feeling responsible for human life. Other significant job stressors were interpersonal relations in the work environment, in the case of patients' relatives, uncertainty about diagnosis and treatment, the possibility of being sued for malpractice, and communicating bad news.

CONCLUSIONS

Hospital physicians report a large number of psychosocial risk factors. Some involve the characteristics of the medical profession (contact with suffering and death, responsibility for human life, uncertainty about diagnosis and treatment) and others concern work organization (workload and staffing shortages).

Observation of pain assessment and management--the complexities of clinical practice

Pain assessment and management are complex issues that embrace physiological, emotional, cognitive, and social dimensions. This observational study sought to investigate nurse-patient interactions associated with pain assessment and management in hospitalized postsurgical patients in clinical practice settings. Twelve field observations were carried out on Registered Nurses' activities relating to pain with their assigned patients. All nurses were involved in direct patient care in one surgical unit of a metropolitan teaching hospital in Melbourne, Australia. Six observation times were identified as key periods for activities relating to pain, which included change of shift and high activity periods. Each observation period lasted 2 hours and was examined on two occasions. Four major themes were identified as barriers to effective pain management: nurses' responses to interruptions of activities relating to pain, nurses' attentiveness to patient cues of pain, nurses' varying interpretations of pain, and nurses' attempts to address competing demands of nurses, doctors and patients. These findings provide some understanding of the complexities impacting on nurses' assessment and management of postoperative pain. Further research using this observational methodology is indicated to examine these influences in more depth. This knowledge may form the basis for developing and evaluating strategic intervention programmes that analyse nurses' management of postoperative pain and, in particular, their administration of opioid analgesics.

Mechanisms of action of midazolam on expression of contextual fear in rats

BACKGROUND

Midazolam may suppress conditioned fear after an aversive event by disrupting the memory trace formed during conditioning, by altering the emotional part of the aversive event, or by the combination of both effects. The purpose of the present study was to determine whether affective-related processes contribute to the amnesic-like effects of midazolam on aversive events.

METHODS

The effects of acute administration of low doses of midazolam (0.37-3 mg kg(-1)) on fear conditioning (association between a neutral context and an aversive stimulus) and on innate anxiety in fearful surroundings were examined in rats. The effect of midazolam on the deleterious consequences of pre-exposure to the context (a non-aversive event) for subsequent fear conditioning was then compared with its effect on fear conditioning. The role of midazolam as an affective context was assessed by performing the testing phase under midazolam. Possible locomotor impairment or long-term effects of midazolam were controlled in additional experiments.

RESULTS

Midazolam reduced both contextual fear conditioning and spontaneous fear. The deleterious effect of midazolam on pre-exposure to the context was of the same magnitude as its effect on the acquisition phase of fear conditioning. The effects of midazolam on both pre-exposure to the context and fear conditioning were unchanged when rats received a second injection of midazolam before the retention phase.

CONCLUSIONS

Low doses of midazolam that do not impair locomotion suppress conditioned fear to the context by acting on memory processes rather than on affective or anxiolytic processes.

Are postoperative pain instruments useful for specific groups of vulnerable infants?

Based on the authors' review of the literature on pediatric postoperative pain assessment with special attention to groups of vulnerable infants, this article (1) reports on type of surgery and its relationship to postoperative pain intensity; (2) reviews the characteristics of existing postoperative pain instruments for neonates, infants, and toddlers; (3) discusses timing, duration, and who should assess postoperative pain; (4) reviews the specific literature on pain assessment in critically ill infants, including the extremely low birth weight and the cognitively and/or neurologically impaired infant, and (5) discusses the role of parents in postoperative pain assessment. Postoperative pain instruments are useful for specific groups of vulnerable infants, but it is important that in addition to the valuable scoring of pain, common sense is used and factors such as developmental stage, temperament and personality, number of previous painful experiences, anxiety, and environmental factors are taken into account.

Registered nurses' lived experience of advocacy within a critical care unit: a phenomenological study

Anecdotally, it has often been expressed by registered nurses (RNs) working within critical care environments that they are patient advocates. However, to date, little systematic research has been undertaken to validate this assertion. Thus this project, which explored the lived experience of RNs working within a critical care unit in a country area of Australia, was conceived. The five participants of this study were all Division 1 RNs possessing a critical care certificate and a minimum of 4 years' nursing experience. Through their participation in an in-depth audiotaped interview they revealed a wealth of experiences and ideas about their involvement as patient advocates. The results of this research indicate that the phenomenon of nurse advocacy is a multi-faceted process and embraces many kinds of activities that nurses engage in on behalf of their clients. The findings of this study indicate that some of the participants' experiences are congruent with elements of advocacy contained within the nursing literature and statements of professional nursing bodies. However, there are some findings in this study that are not consistent with available literature. For instance, these participants markedly reject the notion that advocacy is an inappropriate concept for nurses, despite suggestions in the literature that this is an inappropriate role. Instead they wholeheartedly embrace this role, asserting it as central to their practice. Further, although the literature identifies potential controversies regarding enactment of the role of advocacy, the participants of this study are silent on these matters. It is not known what this silence implies and, in light of the study findings, it is recommended that nursing organisations, theorists and clinicians consider whether it is worthwhile to more clearly confirm the nature and role of advocacy within Australian nursing.