A retrospective study of patients' recall of respirator treatment (2): Nursing care factors and feelings of security/insecurity

Psychological consequences associated with intensive care treatment

Intensive Care Unit (ICU) treatment involves a range of physical and psychological stressors including serious illness, invasive medical procedures, and prolonged incapacity. In addition to physical health problems, those that survive ICU often experience long term psychological difficulties such as cognitive impairment, depression, anxiety, and post-traumatic stress disorder. This review will first consider the types of psychological problems that can occur both during ICU treatment and following discharge and some of the factors involved in their development. Second, consideration is given to medical and psychological intervention strategies that can be provided both during treatment and in follow-up.

The experience of communication difficulties in critically ill patients in and beyond intensive care: Findings from a larger phenomenological study

Communication difficulties in intensive care units (ICU) with critically ill patients have been well documented for more than three decades. However, there is only a paucity of literature that has explored communication difficulties beyond the ICU environment. This paper discusses the experience of communication difficulties in critically ill patients in ICU and beyond as part of findings from a larger study that explored the lived experiences of critically ill patients in ICU in the context of daily sedation interruption (DSI). The aim of the study was to describe the lived experience of people who experienced critical illness in ICU using a hermeneutic phenomenological approach in the DSI context. Twelve participants aged between 20 and 76 years with an ICU stay ranging from 3 to 36 days were recruited from a 16 bed ICU in a large regional referral hospital in New South Wales (NSW), Australia. Participants were intubated, mechanically ventilated and subjected to (DSI) during their critical illness in ICU. In-depth face to face interviews with participants were conducted at two weeks after discharge from ICU and at six to eleven months later. Interviews were audio taped and transcribed. Thematic analysis using van Manen's (1990) method was completed. The overarching theme; 'Being in limbo' and subthemes 'Being disrupted'; 'Being imprisoned' and 'Being trapped' depict the main elements of the experience. This paper discusses communication difficulties in critically ill patients as one of the main findings relating to the theme 'Being trapped'. Participants' reports of communication difficulties in ICU are similar to those reported by patients in other studies where DSI was not used. However, not many studies have reported ongoing communication difficulties after ICU hospitalisation. Recommendations are made for new models of care and support to mitigate critically ill patients' communication concerns in ICU and for further research into the causes and treatment to benefit this group of patients. Most importantly, extra care is recommended not to damage vocal cords during intubation and cuff inflation in the course of mechanical ventilation.

"The button": initiating the patient-nurse interaction

Patient-nurse interactions are foundational to care that is desired by patients. Evidence about patient-initiated interactions with nurses is scant and little focus has been placed on the meaning to patients of ways to call for help when needed. The purpose of this secondary analysis was to provide a more intensive focus on initiative, one of four categories identified in a grounded theory study related to the perception of feeling safe in intensive care. Of 10 participants, a subset of 9 participant interviews was included in this analysis. Participants perceived "the button" was a way to initiate interaction with a nurse and to get the help they might need "right now." This report emphasizes the importance of nurse call lights to patients and contributes to evidence focused on the meaning for patients of initiating interaction with nurses. Findings have important implications for care quality and nurse education.

Older adults' perceptions of feeling safe in an intensive care unit

AIM

This paper is a report of a study of older adults' perceptions of feeling safe in an intensive care unit.

BACKGROUND

Significant ageing of the world population is expected. Correspondingly, there is a growing global urgency for healthcare systems to prepare for the increased number of older adults who will require intensive care. Although patients have recounted situations in which feeling safe was essential to their experience, there is little empirical evidence about feeling safe for older adults in intensive care.

METHOD

In 2008, 10 older adults who suffered unexpected critical health events and who were admitted to intensive care units were recruited for this grounded theory study. Participants were interviewed after transferring to an intermediate care unit and again after discharge. They were asked to reflect upon and discuss their experiences of feeling safe in intensive care.

FINDINGS

Participants' actual and expected interaction with intensive care nurses was essential to their perceptions of feeling safe. Four main categories were identified as requisite to interaction with nurses: proximity, oversight, predictability and initiative. A substantive grounded theory of feeling safe for older adults in intensive care is presented.

CONCLUSION

Nurses must present themselves as accessible so patients perceive that they can initiate interaction with a qualified nurse. Patients must also see that nurses are monitoring them and believe that the nurses will help them if they experience a critical health event while in the intensive care unit.

Experiences of critically ill patients in the ICU

BACKGROUND

Experiences of critically ill patients are an important aspect of the quality of care in the intensive care (ICU).

OBJECTIVE

The aims of the study were firstly, to evaluate the perceptions of patients regarding nursing care in the ICU, and secondly, to explore patients' perceptions and experiences of ICU stay.

METHOD

A qualitative approach using a semi-structured focused interview in 11 patients was used (phase 1), followed by a quantitative approach using a self-reported questionnaire in 100 patients, 62 were returned and 50 could be evaluated (phase 2).

RESULTS

A number of themes emerged from the interviews (phase 1), although support dominated as an important key theme. This was experienced as a continuum from the feeling being supported by the nurse to not being supported. This key theme was central to each of the three categories emerging from the data pertaining to: (1) providing the seriously ill patient with information and explanation, (2) placing the patient in a central position and (3) personal approach by the nurse. The responders to the subsequent questionnaire (phase 2) predominantly experienced sleeping disorders (48%), mostly related to the presence of noise (54%). Psychological problems after ICU stay were reported by 11% of the patients, i.e. fear, inability to concentrate, complaints of depression and hallucinations.

CONCLUSIONS

Although the nurses' expertise and technical skills are considered important, caring behaviour, relieving the patient of fear and worries were experienced as most valuable in bedside critical care.

A qualitative study into the lived experience of post-CABG patients during mechanical ventilator weaning

AIM

Research into mechanical ventilator weaning has predominantly been devoted to analysis and evaluation of predictors of weaning success. Few studies have examined the patient experience of weaning. The aim of this study was to provide a contemporary description of the patient experience of weaning, in order to up-date this aspect of knowledge in the context of newer modalities of mechanical ventilation and sedation.

METHODOLOGY

The study had a descriptive qualitative design focusing on the lived experience of post-CABG (coronary artery bypass graft) patients ventilated > or = 24h (n=10). Data were generated using semi-structured depth interviews conducted 2-5 months after hospital discharge. A hermeneutic phenomenological approach was used to analyze the data.

RESULTS

The article presents selected themes that emerged during the process of analysis. The main findings relate to general phenomena such as discomfort and impaired communication, psychological phenomena such as loss of control and loneliness, and existential phenomena such as temporality and human interaction.

CONCLUSION

Newer modalities of sedation and mechanical ventilation have not entirely eliminated the discomforts of critical illness; the human aspects of suffering remain. In order to address some of the general, psychological, and existential patient experiences, care should be taken to acknowledge the patient and to respect the patient domain and individual time frames. In nurse-patient communication, it is recommended that caregivers give accurate and unambiguous information.

Silent, slow lifeworld: the communication experience of nonvocal ventilated patients

The author explored communication experience of nonvocal ventilated individuals in rehabilitation settings with an aim to understand the reality of being voiceless using interpersonal relations theory as the theoretical study framework. Nineteen participants of varied ages and with varied ventilator courses shared their experiences while they were still nonvocal. The author used an interpretive phenomenological approach and analyzed the data using thematic analysis. Participants described the meaning of their nonvocal experience as "Being trapped in a silent world makes me feel frustrated and incomplete," "Days pass in slow motion while the rest of the world speeds by," "Making and preserving connections is of paramount importance," and "The powerlessness of being nonvocal was ameliorated by developing coping strategies and by consistent and reliable nursing care." In the discussion, the author provides an expanded understanding of the complexities of living in a silent, slow world.

ICU patients' recall of emotional reactions in the trajectory from falling critically ill to hospital discharge: follow-ups after 3 and 12 months

Patients' memories of frightening ICU experiences may be a threat to later psychological recovery. The purpose of the study is to describe ICU patients' recall of their emotional reactions, from falling critically ill to hospital discharge; this at 3 and 12 months following discharge from the ICU. The study is qualitative and concerns eight ICU patients ventilated for more than 72h. The participants were interviewed twice and the data were subjected to qualitative content analysis. It emerged that the memories of emotions during the trajectory of critical illness were extensive, detailed and strong, and that unpleasant emotions were clearly stable over time. At 12 months as compared with 3 months, the unpleasant emotions were less intense and had less prominent; furthermore the ICU care was more greatly associated with a sense of security, and there was greater recall of caring doctors and nurses (though not of their names) as well as next of kin.

CONCLUSIONS

The study generated knowledge not previously described about how ICU patients' recollection of their emotions during the trajectory of critical illness changes over time. This has implications regarding future study of patients' ICU memories and regarding patients' need for support in coping with such memories.

Injured in traffic: experiences of care and rehabilitation

A traffic injury can be traumatic from both physical and emotional points of view. Nine people injured in a traffic environment were interviewed 6 months after the incident in a qualitative study about their experiences of pre-hospital and hospital care and subsequent rehabilitation. The transcribed data were analysed using qualitative content analysis. Four themes emerged: (i) facing commotion, (ii) experiencing trust and security, (iii) lacking security and support, and (iv) struggling to return to everyday life. The main findings in the study indicate that the quality in the interaction between people injured in traffic events and their care providers are of utmost importance. Interaction must be seen as a dialectic process in which caregivers are open to the injured person's needs. An open-minded caregiver makes recovery easier for the injured.

‘Fishing with the dead’—Recall of memories from the ICU

The purpose of this study was to explore the memories of patients who had a short-term admission to the ICU, with a particular focus on dreams, nightmares and confusion. Descriptive data were collected from a target sample of 50 participants, by means of a questionnaire. Following this, eight patients who had completed and returned the questionnaire and had reported hallucinations, dreams or confusion participated in open-ended, semi-structured interviews. Analysis of the data generated by the questionnaire revealed that the most common memories of ICU were anxiety, pain, thirst and nausea. Nightmares, hallucinations and confusion were also common and were reported to be highly distressing. The transcribed interviews were subjected to a thematic analysis. The themes that emerged were, reality and unreality, blackness and colour, powerlessness and purpose, and death. Participants described horrifying paranoid delusions. It is proposed that constant reassurance and explaining every day ICU happenings may assist patients to understand what they are experiencing and loved ones may provide an important link with reality.

Patients' reports of health care practitioner interventions that are related to communication during mechanical ventilation

BACKGROUND

The literature supports nursing interventions to maximize communication in mechanically ventilated patients, yet limited research exists on patients' perceptions of the helpfulness of health care practitioner interventions to enhance communication. In addition, the level of frustration experienced by these patients has not been reported. Thus, further research is necessary to examine patients' perspectives of the helpfulness of health care practitioner interventions that enhance communication of the mechanically ventilated patient.

OBJECTIVES

This study describes the level of frustration experienced by mechanically ventilated patients and ascertains the helpfulness of methods used by health care practitioners to meet the communication needs of the mechanically ventilated patient.

METHODS

A total of 29 critically ill patients, extubated within the last 72 hours, were included in this descriptive study using qualitative and quantitative methods. Subjects participated in an average 30-minute audiotaped interview session consisting of questions pertinent to their perceived level of frustration in communicating and the interventions practitioners used to meet their communication needs. Transcripts were analyzed by question and for overall themes.

RESULTS

It was found that 62% of patients (n = 18) reported a high level of frustration in communicating their needs while being mechanically ventilated. There was no significant difference between the duration of intubation and the level of frustration (Spearman r =.109, P =.573) or between the diagnosis and the level of frustration (P =.932). Patients who received anxiolytics (n = 23, 79% of the sample) had a lower level of frustration (mean 3.26) than those who did not receive anxiolytics (n = 6, 21% of the sample, mean 4.33). This difference trended toward significance (P =.084). Patients cited health care practitioner behaviors, characteristics, and attributes that both facilitated communication (kind, informative, and physically present at the bedside) and impeded their ability to communicate (mechanical, inattentive, and "absent" from the bedside). Patients reported problems and stresses associated with communication difficulties that can be alleviated by the health care practitioner.

CONCLUSIONS

Mechanically ventilated patients experience a high level of frustration when communicating their needs, and health care providers have a significant impact on the mechanically ventilated patient's experience. Further research is needed to explore and measure methods of facilitating communication that increase patient satisfaction, reduce patient anxiety, and obtain optimal pain management.

The lived experience of survivors of prolonged mechanical ventilation: a phenomenological study

BACKGROUND

Successful liberation from prolonged mechanical ventilation (PMV) is a challenging phenomenon. Whereas many physiological factors have been linked to successful PMV liberation, the psychosocial components are not well delineated.

OBJECTIVES

This article serves to describe the experience of patients who survived PMV and to identify salient factors that contributed to successful liberation.

METHODS

A phenomenological approach was used to explore the lived experience of seven PMV survivors.

RESULTS

Six mutually exclusive themes emerged from the participants' descriptions to create a structural description of the lived experience.

CONCLUSIONS

Survivors credited their own self-determination and the expertise and care of health care professionals with their ability to be successfully liberated from prolonged mechanical ventilation. Although surviving PMV was described as frightening and traumatic, comfort and resolve were derived from family members, religion, prayer, and angelic encounters. These findings are useful in providing direction for critical care clinical practice and future research.

Psycho-affective disorder in intensive care units: a review

This paper reviews the literature related to the Intensive Care Unit (ICU) Syndrome. The intention of the paper is to explore the range of psychotic and affective phenomena that may be observed in practice, together with the management of contributory stressors. Patients experience a range of psycho-affective disturbances that may be triggered by drugs, the environment, dehumanizing practices and sleep deprivation. Symptoms do not always disappear following discharge and further research is required to determine the long-term psychological effects of an ICU. Comprehensive assessment of the patient's psychological state, using an appropriate tool, is necessary and should form an integral part of ongoing care. Interventions identified include eradication of dehumanizing behaviour, modification of environmental stimuli, effective communication and therapeutic touch. Where possible, communication needs should be addressed prior to admission, and patients and their families prepared for the unfamiliar world of the ICU.

Suctioning: a review of current research recommendations

Effective suctioning is an essential aspect of airway management in the critically ill. However, there are many associated risks and complications. These range from trauma and hypoxaemia to cardiac dysrhythmias and, in extreme cases, cardiac arrest and death. This paper identifies the current research recommendations for safer suctioning practices. The literature is reviewed in three parts: prior to suctioning; during suctioning; and post-suctioning. The recommendations prior to suctioning include patient assessment, patient preparation and hyperoxygenation. The recommendations during suctioning include appropriate catheter selection, depth of insertion, negative pressure, duration of procedure and number of suction passes. Measures for maintenance of asepsis, such as hand-washing, wearing gloves, goggles and aprons are other essential considerations, which must not be overlooked. The recommendations post-suctioning include reconnection of oxygen, patient assessment, reduction of oxygen to baseline level, and providing patient reassurance. In order to improve standards of care, it is imperative that nurses are aware of current research recommendations. This will enable nurses to make informed decisions about their own suctioning practices, based on the individual needs of the patient.

Vulnerability and security in seriously ill patients in intensive care

The purpose of this research was to gain an understanding of the experience of being a seriously ill patient in an intensive care unit (ICU). Fourteen former patients, aged 17-71 years old, who had been in ICU 3-53 days, participated in focus group interviews 3-6 months after discharge. The focus groups met 3 times each for 1.5 hours, resulting in 13-14 hours of audiotaped discussions. The transcribed data were qualitatively analysed to identify themes representing participants' experiences. Vulnerability emerged as a central concept that captured the identified themes. The data reveal that patient vulnerability while in ICU was related to extreme physical and emotional dependency. Lack of information and depersonalizing care were associated with fear, anxiety and increased vulnerability. Lack of sleep and rest also contributed to patient fear and anxiety. Vulnerability decreased when patients were kept informed of what was occurring while in ICU, received care that was personalized to their individual needs, and when their families were present. The results of this study suggest that ICU patients' vulnerability may be decreased by the security that they experience when they are adequately informed about what is happening, and when nursing and medical care is personalized to their individual needs.

Maintaining patient dignity in intensive care settings

Maintenance of the dignity of intensive care unit (ICU) patients, particularly minimizing exposure of genitalia, may be problematic. The aim of the study was to develop strategies to maximize the dignity of ICU patients using an action research methodology. The first stage assessed current practice through 62 hours of non-participant observation of patient care. Patient dignity was maintained in almost one-third of observed cases. However, more intimate areas such as bosom and genitalia were exposed in over 40% of the incidents. Whilst screens were fully used in over one-third of exposure incidents, full screening did not occur for all or part of the remaining incidents. Significant factors (P < 0.05) influencing exposure included gender and age. Female and younger (< 60 years) patients were more likely to be exposed; older patients (> 70 years) were less likely to be screened when exposed. The next stage involved identification of solutions to the problem of inappropriate patient exposure through the medium of a multi-disciplinary focus group. The focus group recommended raising staff awareness and documentation of situations that may compromise maintenance of dignity. The final stage of the study involved an audit of these recommendations. The main audit findings were more adequate clothing of patients plus a high level of staff awareness of patients' dignity needs.

Communication between nurse and patient during ventilator treatment: patient reports and RN evaluations

BACKGROUND

The current treatment preference for patients requiring artificial ventilation is to have them non-sedated whenever feasible. To be aware but unable to communicate is a novel experience for patients and produces problems in nursing. A review of the literature shows that few studies have focused on this significant issue in intensive care nursing.

AIM

To study patient experiences of communication problems during ventilator treatment.

SUBJECTS AND METHODS

Twenty-two consecutive patients treated in an intensive care unit (ICU) were interviewed three times over a 2-month period about their experiences of changes to their communication during ventilator treatment. Structured questionnaires, including open-ended questions were used on each occasion. The registered nurse (RN) in charge of each patient evaluated the extent of communication during the ventilator treatment in a nurse protocol.

RESULTS

Thirteen of the twenty-two patients reported that the RNs were able to understand their needs and wishes during the ventilator treatment. The RNs, however, reported functional communication in nineteen patients. A functional communication was typically related to the use of effective communication methods, while a lack of communication was associated with compromised medical status of the patients.

DISCUSSION

The results suggest the need for detailed examination of patients' potential for effective communication, evaluation of the communication skills of the RNs, and further investigation of devices that can help facilitate communication between RNs and patients during ventilator treatment.

The nearest and dearest: a lifeline for ICU patients

This study was designed to examine, describe and elucidate patients' experiences of the presence and visits of the nearest and their participation in the care process during their stay in the ICU. Five patients, three men and two women, were interviewed for about one hour each. A hermeneutic approach was used when the texts from the interviews were interpreted and analysed. The theoretical frame of interpretation was based on Tillich's theory concerning 'The courage to be' and Eriksson's theory on 'Suffering'. It was found that suffering from severe disease or injury results in not only a threat against the person as an individual, but also against the individual as a part in the world, with consequent feelings of estrangement and the fear of meaninglessness. The threat can, however, be neutralized by the nearests' presence and visits. These represent fellowship, togetherness and participation and thus can help to maintain the patient's identity and individuality. By experiencing this, patients as individuals may be able to affirm themselves and their 'courage to be' will be given strength and support.

Ventilated patients' self-esteem during intubation and after extubation

The primary purpose of this study was to determine if there was a difference in patients' self-esteem during intubation and after extubation, when differences in acuity were controlled. A secondary purpose was to examine and compare the self-esteem of subjects intubated for medical or surgical reasons. A descriptive longitudinal design compared the self-esteem of 29 subjects during intubation and after extubation. A repeated measures analysis of covariance found self-esteem to be significantly higher after extubation in subjects as a whole, when acuity at extubation was controlled. A repeated measures multivariate analysis of variance revealed a significant interaction effect for reason of intubation. Only medical patients experienced an increase in self-esteem over time. Their self-esteem was also lower when they were intubated. The findings support the dynamic nature of self-esteem in hospitalized patients. The implications of the study for research and practice are discussed.

Patients' experience of being critically ill or severely injured and cared for in an intensive care unit in relation to the ICU syndrome. Part I

The intensive care unit (ICU) syndrome is regarded principally as a complex interaction of several contributory factors, all of which can be seen as partly responsible for the development of the syndrome. The purpose of this study was to describe and give a deeper insight into patients' experiences and memory recall, both during and after their stay in the ICU. Nineteen patients who had been respirator treated (ventilated), and had stayed at least 36 hours in the ICU, were interviewed about one week after discharge, and again 4-8 weeks after their discharge from the ICU. Patients' experiences are interpreted and related to previous views held concerning the syndrome, together with an awareness of other important and significant phenomena, i.e. a hermeneutic approach. This study partly confirms the findings of earlier studies concerning the ICU syndrome, but also reveals some new aspects, which have not previously been considered. The patients described themselves as experiencing some sort of state of chaos following the onset of their sickness, injury or accident, which resulted in feelings of extreme instability, vulnerability and fear, often experienced as prolonged inner tension. It was reported that even the most trivial events in circumstances or routines could trigger changes-either an increase or decrease-in patients' feelings of fear or inner tension. The caring relationship was perceived as providing an important degree of security and comfort. Nursing care actions can therefore be seen as vital factors in patients overcoming the accompanying horrific experiences to which they can be subjected. This state of chaotic feeling, and how it is combated and treated, appear to be one critical factor in the development and progression of the ICU syndrome.

Factors related to the emotional responses of intubated patients to being unable to speak

OBJECTIVES

The purpose of the study was to examine the relationships among the intensity of intubated patients' negative emotional responses to being unable to speak and selected personal and situational variables.

DESIGN

Prospective correlational.

SETTING

Four intensive care units in a midwestern, university-affiliated medical center.

PATIENTS

A convenience sample of 48 patients intubated for 24 or more hours, alert and oriented to person, place, and situation.

OUTCOME MEASURES

Emotional responses (anger and worry/fear) to being unable to speak.

RESULTS

Multiple regression showed that self-esteem, severity of illness, difficulty with communication, and the number of days intubated at data collection were significantly associated with patients' emotional responses.

CONCLUSIONS

Results from this study extend prior research and support the need for nurses to facilitate communication and to support self-esteem in patients receiving ventilatory assistance, particularly in the early days of intubation. Implications for future research are discussed.

Sensoristrain: an exploration of nursing interventions in the context of the Neuman systems theory

Defining what nurses do and why has been the endeavour of many researchers, both academic and clinical. Nursing interventions are a fundamental component of nursing practice and a focus on accountability means that nurses must be able to justify their actions. The sensoristrain experience of intensive care patients is widely acknowledged in nursing literature, though without the use of the word 'sensoristrain'. The aim in this paper is to place patients, their experience and the role of nurses within the practical framework of a suitable nursing theory which will elucidate and guide everyday practice in preventing and alleviating the causes (stressors), symptoms (reactions) and emotional aftermatch. Nursing interventions appropriate for the three modalities of intervention elucidated by the Neuman systems theory have been outlined, paralleled by a discussion of how these could relate to the three dimensions of nursing care: comfort care; knowing the patient; and the therapeutic presence of the nurse. Nurses must use each opportunity to advance practice through emphasizing the value of nursing in today's cost-conscious health care climate. In order to do this, and to ensure nurses' continued presence at the bedside, clear articulation of the contribution of nursing interventions to improved patient outcomes is essential.

A comparison of patients' communication-related responses during intubation and after extubation

OBJECTIVE

The purpose of this exploratory pilot study was to examine patients' communication-related responses during intubation and after extubation, and to determine whether differences in patients' report of responses at these two points in time, if present, were associated with demographic and situational variables.

DESIGN

Descriptive comparative.

SETTING

Four intensive care units in a midwestern, university-affiliated medical center.

PATIENTS

Convenience sample of 29 patients intubated for 24 or more hours, alert and oriented to person, place, and setting during intubation and after extubation.

OUTCOME MEASURES

Emotional responses (anger and worry/fear) to being unable to speak, perceived difficulty with communication.

RESULTS

Paired t tests showed no significant differences over time in the mean scores of the Emotion subscales and Ease of Communication scale. However, more than 30% of subjects reported postextubation responses that were different from their earlier responses by 20% or more. Significant differences in subjects' worry/fear at being unable to speak and difficulty with communication were found in relation to history of prior intubation and total number of days intubated. Subjects varied in the number of days that they were intubated, and the number of days intubated when they first participated in the study.

CONCLUSIONS

Results provide direction for larger longitudinal prospective and retrospective studies with larger samples that examine patients' recall of their responses during intubation, especially related to communication.

A concept analysis of the sensoristrain experienced by intensive care patients

Psychological disturbances that patients may experience during admission to intensive care units (ICUs) can have distressing implications for their emotional and physical integrity, progress and subsequent recovery. It is widely believed by practitioners and reflected in professional literature that these disturbances are precipitated by sensory deprivation or overload in the physical environment of intensive care units. In this paper the sources and mechanism of the sensory imbalances experienced by these patients are examined. A new concept--sensoristrain--has been developed in an attempt to promote awareness and improve understanding of the phenomenon among nurses. Once this has been achieved, assessment and identification of patients at risk are optimized and appropriate interventions can be formulated. Using an eclectic approach to analyse sensoristrain, both causes and effects of the phenomenon have been identified from the literature. This information has been combined with practical examples in the development of a model of the concept sensoristrain. The paper concludes by outlining the resulting implications for nursing practice, which may be used to guide future research both in concept development and identification of effective prevention of the phenomenon conceptualized and interventions if it occurs.

Qualitative analysis of patients' work during mechanical ventilation and weaning

OBJECTIVE

To describe patients' recollections of their experiences during mechanical ventilation and weaning and to extend an evolving nursing theory of weaning.

DESIGN

A qualitative approach that used grounded theory techniques.

PATIENTS AND METHODS

We surveyed 20 hospitalized patients who had recently undergone mechanical ventilation and weaning from the ventilator in a critical care unit. Included in the analysis were any thoughts, feelings, or actions recalled by the patients that were related to the weaning experience.

RESULTS

During ventilation and weaning, patients were engaged to various degrees in what they called "work," which consisted of their efforts to assist in their adjustment and recovery. This work had four themes: sense making, enduring, preserving self, and controlling responses. These themes represented activities by which patients dealt with their personal concerns and cooperated with the therapeutic plan.

CONCLUSIONS

Despite good care during the process, mechanical ventilation and weaning are stressful experiences that require active participation by patients. Patients' work needs to be understood and supported by clinicians to facilitate recovery from mechanical ventilation and weaning.

Caring and comfort metaphors used by patients in critical care

OBJECTIVE

To examine the meaning of metaphors used by critical care patients about their ventilator weaning experience.

DESIGN

Grounded theory.

POPULATION, SAMPLE, SETTING

In 1992-1993, from a population of mechanically ventilated patients, a convenience sample of 20 adult patients was recruited from one 14-bed multispecialty ICU in a 740-bed teaching hospital in eastern Canada.

METHODS

Transcripts of interviews were reviewed from the 20 original study transcripts, of which 18 included one or more metaphors for a total of 70. All were coded and classified with sub-themes analyzed for implicit meanings.

FINDINGS

Four categories of metaphors were Physical Discomfort, Nurse Caring, Altered Self, and Patient Work. Data provide the elements for a mid-range theory of caring.

CONCLUSIONS

Metaphors provide vivid images of significant patient concerns and are a way for people to express meaning and feeling.

CLINICAL IMPLICATIONS

People communicate about their inner world through language. Examining patients' metaphors is a valuable approach to understanding the experiential world of patients in critical care so that nursing actions can be directed toward personal needs which may not be expressed openly. Providing interventions aimed at these personal needs will help patients find suitable levels of physical and emotional comfort.

A concept analysis of panic

Minimal attention has been focused on the concept of panic in the discipline of nursing. Hindering a greater understanding of panic is its lack of explication and development in nursing. To help remedy this situation, a concept analysis of panic was performed. The hybrid model of concept development was used, which consists of an initial theoretical phase, a fieldwork phase, and a final analytical phase. In the theoretical phase, after a cross-disciplinary literature search was done, existing definitions and measurement of the concept of panic were analyzed, and a working definition of panic was formulated. In the fieldwork phase, women experiencing postpartum panic disorder were interviewed to collect qualitative data for further analysis of panic. The final phase focused on comparing and contrasting the findings from the theoretical phase with the insights discovered from the fieldwork. Applicability of panic across nursing is addressed along with implications for nursing theory, practice, and research.

Patient's experiences of communication during the respirator treatment period

This paper reports a study of the patients' experiences of communication during the respirator treatment period (RT period) in the intensive care unit (ICU). This descriptive and exploratory study was designed to answer the question. How do respirator treated patients experience communication? Eight individuals who had experienced being treated with a respirator in two ICUs in Iceland, took part in audiotape-recorded, open interviews. They described their subjective experiences of communication during the RT period. The descriptions were analysed phenomenologically, using Colaizzi's method, described by Hycner (1985). The results revealed 57 themes within four categories, namely 'the patients' experiences of communication during the RT period', 'problems of communication experienced', 'additional problems of communication experienced' and 'nursing interventions experienced'. In this paper the themes within the categories of the patients' experiences of communication and problems of communication will be reported. The participants remembered their experience of communication clearly. The patients' experiences of communication were generally described as negative; they experienced communication as impaired, which evoked various negative emotions, and sometimes they had the feeling of giving up. Participants generally described being tired or exhausted during the intubation period. They emphasised the importance of the information and explanation provided by the nurses. The presence and support provided by family members was also valuable to them. The results add to the cumulative knowledge base of communication between nurses and patients by generating new meanings of the nature and essences of communication during the RT period from the patients' perspectives. In this article, the findings of the study are described and discussed in relation to earlier published research and clinical literature on the subject.

Intensive care syndrome: a literature review

The aim in this literature review is to describe the definitions, denominations, clinical signs and symptoms, explanations, causative factors and interrelationships of the intensive care syndrome discussed since 1950. It was found that there is no agreement about which symptoms should be included in the syndrome, when the syndrome may appear and how many patients may be affected. Furthermore, it is unclear what causes the development of the syndrome; most authors conclude that there are many reasons for it. The syndrome has generally been examined by using a medical or psychological approach, but during the last few years it has also been described and analysed from a nursing care perspective. From this nursing perspective the syndrome may be seen as an individual pattern developed by patients during their stay in an intensive care unit (ICU) and sometimes this pattern of clinical signs and symptoms lasts for a shorter or longer period even after discharge from the unit. From a wider viewpoint the development of the syndrome can be seen as an increase by degrees or as a vicious circle. finally, most authors agree that the ICU syndrome consists of, and is caused by, a complex interaction between many factors.

The communication process with ventilator patients in the ICU as perceived by the nursing staff

Intensive care unit (ICU) nurses (n = 27) were interviewed about their experiences and opinions of the communication process with ventilator treated patients. Nurses with limited ICU experience considered the initial contact with a new critically ill ventilated patient more frustrating than experienced nurses. The nurses thought that the content of the communication commonly requested by a patient was dominated by factors related to the clinical condition, prognosis and reassurance that the situation was under control. Factors considered to limit the communication and to create feelings of uncertainty and stress for nurses with an ICU experience of less than 5 years were: work overload, unstable condition of the patient, impaired communication with the patient, and their own personal problems or worries. For nurses with an ICU experience of more than 5 years stress was more commonly evoked by the presence of worried and anxious spouses/relatives, and by the feeling that something was wrong with the patient but they were unable to identify the problem. Failure to understand a ventilated patient could induce feelings of incompetence, stress and sometimes even despair. The present small scale study shows that there are many factors, in addition to ICU experience, that may influence the ability of an ICU nurse to establish and maintain a well functioning communication with ventilated patients and the likelihood of doing so.

Towards basic nursing information in patient records

Four key concepts for good nursing care and a list of key words for nursing documentation in patient records were established and to some extent tried in clinical practice in Sweden. The method consisted of the following steps: extensive literature review, review of nursing records, development of a list of key words on two levels, a first level corresponding to the nursing process, and a second level consisting of subdivisions for possible use in practice, use and assessment in clinical practice by nurses and students, expert panel judgement and refinement of the key words including an examination of semantic accuracy of the Swedish key words by an expert in Nordic languages. The proposed key words are presented both in English and Swedish and explanations, comments and references are given. The version of key words presented here is subject to further testing for possible modifications.

Patients' experiences of postoperative respirator treatment--influence of anaesthetic and pain treatment regimens

The influences of premedication, anaesthetic agents, and postoperative sedation and pain treatment regimens on the experiences of postoperative respirator treatment of surgical patients (n = 107) have been assessed. Of the patients, 55% recalled the respirator treatment. Administration of anticholinergic drugs and halogenated anaesthetic agents was found to impair the memory process and reduce the number of recallers, and sedation in the ICU with benzodiazepines was found to decrease the number of discomforts experienced by the recalling patients. Most of the patients who received treatment postoperatively for pain, mainly by epidural administration of local anaesthetic agents and/or morphine, recalled the respirator treatment period (85%), as compared to only 50% of the patients receiving intravenous opioids. The number and type of complaints experienced by patients receiving epidural pain treatment did not, however, differ from those reported by intravenously treated patients, and no significant adverse psychological reactions seemed to occur. It is concluded that the use of mainly regional techniques, when appropriate, for pain treatment of surgical patients needing postoperative ventilatory support seems advantageous. The primary aim of relieving pain from the wound area is achieved, allowing such light intravenous sedation and pain treatment that the possibility of communication and giving comforting reassurance is maintained. Such nursing care may be more efficient in helping the patient to cope with the stressful respirator treatment situation then heavy intravenous sedation and pain treatment regimens.