Verbal communication: what do critical care nurses say to their unconscious or sedated patients?

[Person-Centered Relational Care Experienced by Critical Care Nurses: An Interpretative Phenomenological Analysis Study]

PURPOSE

The aim of the study was to explore nurses' experience of person-centered relational care in the context of critical care.

METHODS

Key interview questions were developed based on the human-to-human relationship model suggested by Travelbee. Data were collected through in-depth interviews with a purposive sample of 11 nurses having more than 2 years of working experience in intensive care units. An interpretative phenomenological analysis was conducted to analyze the data.

RESULTS

Four super-ordinate and nine sub-ordinate themes were identified. Emerged super-ordinate themes were as follows: (1) encountering a live person via patient monitoring systems; (2) deep empathic connection; (3) humanistic and compassionate care, and (4) accompanying the journey to the end. Study findings revealed that nurses in intensive care units experienced 'balancing emotions' and 'authenticity' in caring when entering human-to-human relationships with dying patients. The phenomenon of person-centered relational care in intensive care units was found to subsume intrinsic attributes of empathy, compassion, and trust, similar to the central concepts of Travelbee's theory.

CONCLUSION

The interpretative findings in this study provide deeper understanding of Travelbee's human-to-human relationship model. The technological environment in intensive care units did not hinder experienced nurses from forming human-to-human relationships. These themes need to be emphasized in critical care nursing education as well as in nursing management. The results of this study will contribute to understanding nurse-patient caring relationships in depth, and help improve the quality of nursing care in intensive care units.

Effect of Auditory Stimulation on the Level of Consciousness in Comatose Patients Admitted to the Intensive Care Unit: A Randomized Controlled Trial

BACKGROUND

Comatose patients are exposed to sensory deprivation in the intensive care units. Auditory stimulation of patients who are unconscious is a nonmedical procedure. This study examines the effect of organized voice, performed by a nurse, on the state of consciousness of comatose patients in intensive care units.

METHOD

This randomized controlled trial study of 60 patients was conducted fitting between August 2017 and February 2018. For 10 days, patients received the voice of a male nurse twice a day in the morning and night shifts, recorded on MP3 and repeated at least 3 to 4 times. Glasgow Coma Scale (GCS) scores were recorded by the researcher before and after auditory stimulation.

RESULTS

Patient mean age was 69.2 years; 56.7% of the experimental group and 53.3% of the control group were male. On the first day in the morning and evening after auditory stimulation, the mean GCS was 4.8 in the experimental group and 4.7 in the control group. Before and after the intervention on the 10th day after auditory stimulation, the mean GCS of patients was 9.5 in the experimental group and 7.1 in the control group in the morning and 9.6 and 7.2, respectively, in the evening. No significant differences in mean GCS by group were observed for the first 3 days (P > .05). However, the difference in mean GCS scores of the 2 groups was statistically significant after the third day (P < .05).

CONCLUSIONS

Auditory stimulation is associated with higher GCS in comatose patients.

Delirium prevention in critically ill adults through an automated reorientation intervention - A pilot randomized controlled trial

OBJECTIVES

Explore the effect of an automated reorientation intervention on ICU delirium in a prospective randomized controlled trial.

BACKGROUND

Delirium is common in ICU patients, and negatively affects outcomes. Few prevention strategies have been tested.

METHODS

Thirty ICU patients were randomized to 3 groups. Ten received hourly recorded messages in a family member's voice during waking hours over 3 ICU days, 10 received the same messages in a non-family voice, and 10 (control) did not receive any automated reorientation messages. The primary outcome was delirium free days during the intervention period (evaluated by CAM-ICU). Groups were compared by Fisher's Exact Test.

RESULTS

The family voice group had more delirium free days than the non-family voice group, and significantly more delirium free days (p = 0.0437) than the control group.

CONCLUSIONS

Reorientation through automated, scripted messages reduced incidence of delirium. Using identical scripted messages, family voice was more effective than non-family voice.

Challenges of collecting data in the clinical setting

Undertaking a piece of research in the clinical setting is often far more difficult than it appears from descriptions in textbooks. This paper describes some of the challenges faced in the course of completing a non-participant observational study that examined how health promotion practice was carried out by hospital-based nurses in an acute setting. The challenges included deciding which observational role to adopt, whether to use structured or unstructured observations, which observational position to adopt, how long observation sessions should be and how to deal with ethical issues when the researcher is also a nurse. It is concluded that the answers to some dilemmas and challenges are not always found in the literature and that decisions taken often depend on the researcher's morality and pure common sense.

Comunicação verbal com pacientes inconscientes

OBJETIVO: A comunicação com pacientes críticos nas unidades de cuidados intensivos gera desafios para a equipe de enfermagem e demanda habilidades específicas. MÉTODOS: Trata-se de um estudo desenvolvido em duas etapas, por meio de métodos qualitativos, para caracterização e padronização da comunicaçao verbal utilizada com pacientes inconscientes. A primeira etapa consistiu de revisão sistemática e de análise de conteúdo da literatura disponível sobre comunicação e estimulação verbal em pacientes inconscientes. RESULTADOS: Os resultados da análise de conteúdo foram utilizados na segunda etapa do estudo e forneceram a base para a construção de uma mensagem padronizada de estímulo. Quatro áreas problemáticas foram identificadas: dificuldades básicas na comunicação com pacientes que não são capazes de responder, pressões do ambiente de trabalho, conhecimento limitado sobre as necessidades de pacientes insconscientes, e conhecimento detalhado limitado do porquê e de como se comunicar com pacientes insconscientes. CONCLUSÃO: A mensagem estímulo desenvolvida pode facilitar a comunicação com pacientes inconscientes.

Practical wisdom: a qualitative study of the care and management of non-invasive ventilation patients by experienced intensive care nurses

OBJECTIVES

To describe the reasoning and actions of experienced nurses caring for patients with non-invasive ventilation due to acute respiratory failure from chronic obstructive pulmonary disease.

INTRODUCTION

Treatment success for patients requiring non-invasive ventilation remains challenging. Understanding the reasoning and actions of experienced nurses that care for patients with non-invasive ventilation can identify how nurses contribute to treatment success, and this information can be used to train less experienced nurses to provide excellent care.

DESIGN

Qualitative descriptive study. A secondary analysis on data of qualitative participant observations during non-invasive ventilation treatment and additional six interviews with experienced ICU nurses was carried out in 2012.

RESULTS

The experienced nurses exhibited 'practical wisdom'. Each nurse could stay alert to the patient's condition and respond to NIV. Conceptualisation of the complexities in nurses' reasoning and actions illustrated their tendency to separate problematic situations into three interrelated components: (1) achieving non-invasive adaptation, (2) ensuring effective ventilation and (3) responding attentively to patients' perceptions of non-invasive ventilation. Each component comprises a set of nursing reasoning and actions that experienced nurses use to achieve treatment success.

CONCLUSIONS

Understanding how experienced nurses think and act during non-invasive ventilation care may help to optimise continuing professional development and help educate junior nurses.

'The patient is my space': hermeneutic investigation of the nurse-patient relationship in critical care

BACKGROUND

The nurse-patient relationship has been postulated to lie at the core of nursing care. However, it is unclear how this concept applies in critical care, as a great majority of critically ill patients are unable to communicate.

AIMS

Through a phenomenological hermeneutical perspective, we aimed to explore intensive care nurses' perceptions and meanings regarding their interpersonal relationship with critically ill individuals.

METHODS

A Heideggerian hermeneutical approach was used to design the study and analyse the data, which were collected through repetitive interviews with 12 intensive care nurses.

RESULTS

Critical care nurses report to experience deep relationships with patients, which seem to be mediated by the ongoing contact with patients' bodies. These relationships evoke intense feelings of love, empathy and care and affect how nurses perceive and make sense of their role and their world. The identified core theme of their experience is entitled 'syncytium', which describes a network of closely connected cells. According to participants' perceptions, nurse and patient affect each other reciprocally and are mutually dependent upon each other. In Heideggerian terms patients provide nurses with opportunities to experience 'authentic care' and they participate in their 'being-in-the-world', thus they are central in nurses' meanings about their role and existence. Other elicited themes that account for the perceived nurse-patient relationship include the spatiality/temporality of the relationship, nurses' perceptions and meanings attributed to their role and nurses' perceptions of death.

CONCLUSIONS

Critical care nurses appear to experience their relationships with patients intensely. These relationships are invested with meanings and elicit powerful feelings over a shared course with patients. Patients are central in nurses' meaning-making process and role perception.

RELEVANCE TO CLINICAL PRACTICE

These findings have implications for the educational preparation of critical care nurses and their psychological support.

Assessment of comatose patients: a Portuguese instrument based on the Coma Recovery Scale - revised and using nursing standard terminology

AIMS

To translate and adapt the Coma Recovery Scale - Revised to Portuguese using the ICNP® (International Classification of Nursing Practice) terminology and to determine if it can be administered reliably across examiners.

BACKGROUND

Assessment tools for the person in a coma can contribute to the planning, implementation and evaluation of care. It also strengthens the autonomy and responsibility of nurses, contributing to the safety, quality and satisfaction of those who deliver and receive care. This allows the sharing of information amongst healthcare professionals and supports decision-making within a multidisciplinary team.

METHODS

A convenience sample of 20 patients admitted to an intensive care unit constituted the study participants. The data were collected during 2009. The instrument was administered by the same two raters in all the patients on two consecutive days. The total and subscale score agreement was then examined, using inter-rater and test-retest analyses. The intercorrelation dependencies between the subscales were also analysed.

RESULTS

The results of the analyses suggest that the instrument can be used reliably, even when there are some patient fluctuations. The correlation of the subscale scores was high and better than the results presented for the original Coma Recovery Scale - Revised, indicating that this scale is a homogeneous measure of neurobehavioural function.

CONCLUSION

The new instrument can be administered reliably by trained examiners and produces a high degree of reproducibility in scores between raters over repeated assessments. We believe that assessment tools that can assess the communication ability of patients will be relevant to evaluating the continuity of care, and promote the effectiveness of care.

Ventilatory weaning: a case study of protracted weaning

BACKGROUND

Dysfunctional ventilatory weaning response (DVWR) is characterized by interrupted and prolonged weaning. This reflective analysis presents how using nursing diagnoses in critical care can raise awareness of, and provide strategies for, managing problems related to ventilatory weaning.

AIM

To examine and reflect upon why one patient took so long to wean from the ventilator using the structured approach of instrumental case study and nursing diagnosis to explain aspects of the weaning process.

ANALYSIS

This case study examines one patient's experiences around ventilatory weaning using selected nursing diagnoses, exploring the implications that physiological, social, emotional and psychological factors have on both weaning and healing processes in critical care. By using dialogue, an explicit texture is presented of how one patient felt, with particular resonance to the relationships she had and the impact they made. Various nursing diagnoses proved useful in determining why this patient had an extended weaning trajectory and included DVWR, ineffective breathing pattern, impaired spontaneous ventilation, anxiety and impaired verbal communication. There were specific points of interest, in particular her anxiety, which proved a major factor, and her significantly improved functional status after the critical care episode. A DVWR may be minimized by nursing presence, reassurance and respect for patient autonomy. Complex anatomy and physiology contributes to protracted weaning and a DVWR and is compounded by anxiety. Furthermore, there is a significant element of nursing care, timely reassurance and presence, which can have a positive impact on patient well-being.

CONCLUSIONS

This reflective analysis highlights the benefits and importance of the nurse-patient relationship during what was a very protracted ventilatory wean. This shared trajectory enabled significant patient empowerment, and this case study gives the patient the voice she temporarily lost.

Effects of intensive care unit noise on patients: a study on coronary artery bypass graft surgery patients

AIMS AND OBJECTIVES

The aim of this study was to measure the noise levels in specific locations of an intensive care unit and determine the disturbance levels of patients owing to noise.

BACKGROUND

Studies have shown that hospital noise is a potential stressor for patients. Noise levels measured in the intensive care unit are mostly far beyond the recommended standards for hospitals, and generally measured around 60-70 dB (A). Although there are a few studies on noise levels in the intensive care unit, no study could be found that compares 24-hour intensive care unit noise measurement data at several locations of intensive care unit.

METHODS

The study was conducted with 35 coronary artery bypass graft surgery patients. The intensive care unit noise level was measured by using Bruel & Kjaer 2144 Model Frequency Analyzer next to the bed of each patient. A patient's disturbance owing to the intensive care unit noise was questioned.

RESULTS

Noise levels ranged between 49 and 89 dB (A) with a mean of 65 dB (A). Peak noise levels were measured as high as 89 dB (A). The noise levels measured at different locations in the intensive care unit did not differ significantly. Noises created by other patients, those who were admitted from emergency room and operating room into intensive care unit, monitor alarms, conversations among staff were the most disturbing noise sources for patients.

CONCLUSION

The patients who were located in the bed which was closer to the nurses' station were more affected by the intensive care unit noise than other patients. Having a previous intensive care unit experience also affected the patients' disturbance levels owing to noise.

RELEVANCE TO CLINICAL PRACTICE

Nurses are in key positions where they can identify physical, psychological and social stressors that affect patients during their hospital stay. Staff education, planned nursing activities and proper design of intensive care unit may help combat this overlooked problem.

Good nursing care to ICU patients on the edge of life

Critically ill patients are admitted to intensive care units (ICUs) to receive advanced technological and medical treatment. Some patients seem not to benefit from the treatment, and sometimes questions are raised as to whether treatment should be withheld or withdrawn. This study was conducted using ICU nurses' experiences with the aim of acquiring a deepened understanding of what good nursing care is for these patients. The study was performed at an adult ICU in Norway, where 14 ICU female nurses were included as participants. The research design was based on interpretative phenomenology and data was collected by group interviews inspired by focus-group methodology. The participants were divided into two groups and each group was interviewed four times. Colaizzi's model was used in the process of analysis. The results show that good nursing care depended on several basic conditions: continuity, knowledge, competence and cooperation, and included clear goals to give appropriate life-saving -- or end-of-life treatment and care. Cornerstones in good nursing care were nurses' verbal communication and nurses' use of their hands. The study emphasises several consequences for future ICU nursing practice and education to enhance good nursing care to patients on the edge of life.

Understanding distress in people with severe communication difficulties: developing and assessing the Disability Distress Assessment Tool (DisDAT)

BACKGROUND

Meaningful communication with people with profound communication difficulties depends on the ability of carers to recognize and translate many different verbal cues. Carers appear to be intuitively skilled at identifying distress cues, but have little confidence in their observations. To help in this process, a number of pain tools have been developed, but this sits uncomfortably with the lack of evidence that pain has any specific signs or behaviours. A palliative care team working with people with intellectual disabilities developed the Disability Distress Assessment Tool (DisDAT) to document a wide range of signs and behaviours of distress and when an individual is content.

METHOD

The tool was piloted with 16 carers and 8 patients. It was then assessed using quantitative and qualitative methods, employing 56 carers in routine clinical situations with 25 patients, most with severe communication difficulties. Carers of 10 patients participated in semi-structured interviews exploring the signs and behaviours demonstrated by patients when distressed and when content. These same 10 patients were observed for distress cues during different activities.

RESULTS

It became clear that distress did not have a common meaning among carers, but there was a clear understanding that distress did not just cover physical pain. The range of distress cues was wide, with no evidence that any cues were specific to particular causes. Although some distress cues were common between patients, each patient had a distinct pattern of distress cues. In addition, different carers identified a different range of distress cues, while the length of the relationship did not influence the number of cues identified. Most distress cues were a change from the norm, but some patients demonstrated distress as an absence of content cues. Carers found the DisDAT simple to use and useful, and several felt that DisDAT would have helped advocate for the patients in previous conflicts with clinical teams.

CONCLUSIONS

There was no evidence that pain has any specific signs or behaviours. The preliminary and assessment phases showed that distress was a useful clinical construct in providing care. The DisDAT reflected patients' distress communication identified by a range of carers, and provided carers with evidence for their intuitive observations of distress.

Caring for patients of Islamic denomination: Critical care nurses' experiences in Saudi Arabia

AIM

To describe the critical care nurses' experiences in caring for patients of Muslim denomination in Saudi Arabia.

BACKGROUND

Caring is known to be the essence of nursing but many health-care settings have become more culturally diverse. Caring has been examined mainly in the context of Western cultures. Muslims form one of the largest ethnic minority communities in Britain but to date, empirical studies relating to caring from an Islamic perspective is not well documented. Research conducted within the home of Islam would provide essential truths about the reality of caring for Muslim patients.

DESIGN

Phenomenological descriptive. Methods. Six critical care nurses were interviewed from a hospital in Saudi Arabia. The narratives were analysed using Colaizzi's framework.

RESULTS

The meaning of the nurses' experiences emerged as three themes: family and kinship ties, cultural and religious influences and nurse-patient relationship. The results indicated the importance of the role of the family and religion in providing care. In the process of caring, the participants felt stressed and frustrated and they all experienced emotional labour. Communicating with the patients and the families was a constant battle and this acted as a further stressor in meeting the needs of their patients.

CONCLUSIONS

The concept of the family and the importance and meaning of religion and culture were central in the provision of caring. The beliefs and practices of patients who follow Islam, as perceived by expatriate nurses, may have an effect on the patient's health care in ways that are not apparent to many health-care professionals and policy makers internationally.

RELEVANCE TO CLINICAL PRACTICE

Readers should be prompted to reflect on their clinical practice and to understand the impact of religious and cultural differences in their encounters with patients of Islam denomination. Policy and all actions, decisions and judgments should be culturally derived.

Communication with critically ill patients

AIM

This paper reports a study that investigated the experiences of a group of critical care Jordanian nurses concerning verbal communication with critically ill patients.

BACKGROUND

There is evidence that communication in critical care settings is not sufficiently implemented in practice. Inadequate nurse-patient communication results in increased levels of stress and anxiety. Verbal communication can help patients preserve their self-identity and self-esteem, which in turn will enhance their well-being and optimism.

METHOD

The study was guided by the phenomenological hermeneutics of Heidegger. Data were generated in 2002 from in-depth interviews and overt participant observation, and analysed qualitatively.

FINDINGS

Unconscious patients received less verbal communication and interaction than verbally responsive patients.

CONCLUSION

Communication with sedated or unconscious patients in intensive care units should not be viewed as only an interactive process. Rather, it should be perceived as the means to give the information and support that such patients need.

Observation of nurse-patient interaction in oncology: review of assessment instruments

The aim of this review is to identify assessment instruments that can be used for analyzing sequences and can be applied to research into nurse-patient communication in cancer care. A systematic search of the literature revealed a variety of methods and instruments applicable to studies recording nurse-patient interaction. The studies that were qualitative in nature offered valuable information on observational research in general, on procedures relating to informed consent and observational arrangements in nursing practice. The quantitative studies provided an insight into the content and structure of the interaction by describing communication concepts or by frequency counts of previously determined behaviours. Systematic research into interaction sequences was not found. However, some of the quantitative instruments identified could be adapted for this purpose. The complexity and time-consuming nature of observational research highlight the need for efficiency. For instance a combination of quantitative and qualitative instruments could be considered.

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.