Long-term mechanical ventilation in a critical care unit: existing in an uneveryday world

Patients' lived body experiences in the intensive care unit and beyond - a meta-ethnographic synthesis

INTRODUCTION

Physical therapists supporting patients in intensive care unit (ICU) rehabilitation can improve their clinical practice with insight in patients' lived body experiences.

OBJECTIVE

To gain insight in patients' lived body experiences during ICU stay and in recovery from critical illness.

METHODS

Through a comprehensive systematic literature search, 45 empirical phenomenological studies were identified. Patients' lived body experiences were extracted from these studies and synthesized following the seven-phase interpretative approach as described by Noblit and Hare.

RESULTS

Three lines of argument were illuminated: 1) "recovery from critical illness starts from a situation in which patients experience the lived body as unable;" 2) "patients experience progress in recovery from critical illness when the lived body is empowered;" and 3) "recovery from critical illness results in a lived body changed for life." Eleven third-order constructs were formulated as different kinds of bodies: 1) "an intolerable body;" 2) "an alienated body;" 3) "a powerless body;" 4) "a dependent body;" 5) "a restricted body;" 6) "a muted body;" 7) "a touched body;" 8) "a transforming body;" 9) "a re-discovering body;" 10) "an unhomelike body;" and 11) "a remembering body."

CONCLUSION

Patients' lived body experiences during ICU stay and in recovery from critical illness have richly been described in phenomenological studies and were synthesized in this meta-ethnography.

Determinants of Communication Failure in Intubated Critically Ill Patients: A Qualitative Phenomenological Study from the Perspective of Critical Care Nurses

AIM

To explore what factors determine communication with awake intubated critically ill patients from the point of view of critical care nursing professionals.

BACKGROUND

Impaired communication frequently affects mechanically ventilated patients with artificial airways in the intensive care unit. Consequences of communication breaches comprise emotional and ethical aspects as well as clinical safety, affecting both patients and their conversation partners. Identification of determining factors in communication with awake intubated patients is needed to design effective action strategies.

DESIGN

A qualitative phenomenological approach was used.

METHODS

Semi-structured interviews were used as the data collection method. A total of 11 participants from three intensive care units of three Majorcan public hospitals, selected by purposive sampling, were interviewed.

FINDINGS

Three major themes regarding the communication determinants of the awake intubated critically ill patients were identified from the interviewees' statements: factors related to the patient (physical and cognitive functionality to communicate, their relational and communicative style and their personal circumstances), to the context (family presence, ICU characteristics, workload, availability/adequacy of communication aids, features of the messages and communication situations) and, finally, those related to the professionals themselves (professional experience and person-centredness).

CONCLUSIONS

The present study reveals determinants that influence communication with the awake intubated patient, as there are attitudes and professional beliefs.

RELEVANCE TO CLINICAL PRACTICE

The discovery of relations between different kinds of determinants (of patient, context or professionals) provides a multi-factor perspective on the communicative problem which should be considered in the design of new approaches to improve communicative effectiveness. This study is reported according to the COREQ checklist.

Usability Testing of an iPad Communication Application for Mechanically Ventilated Patients

BACKGROUND

Patient communication challenges during mechanical ventilation can negatively impact symptom management and psychological recovery. Alternative communication (AC) aids have the potential to improve mechanically ventilated (MV) patient experiences.

OBJECTIVES

This study evaluated the feasibility and usability of a communication application on a tablet (iPad).

METHOD

A single-group pilot study was guided by the augmentative and alternative communication acceptance model. We recruited patients from 1 medical intensive care unit. Existing communication application software (Proloquo2Go) was tailored to MV patients' needs. Usability testing included patient communication of 5 messages with data collected on success, message completion time, and patient feedback.

RESULTS

Ten patients with a mean age of 50 years (SD, 16.7) were enrolled. Of the 7 patients able to complete usability testing, 85.7% found the device easy to use, and 100% wanted the iPad available for their use when on the ventilator. Three patients were extubated immediately after usability testing. Two patients preferred other modes of communication (writing). Two patients used the iPad as their primary mode of communication during the remainder of their time on the ventilator. Nurse feedback on the communication application was positive.

DISCUSSION

Tablet-based communication applications can be successfully used by MV patients and should be considered as 1 tool to support effective patient communication during mechanical ventilation. Future research is needed to identify which patients may be most likely to benefit from the availability of these devices.

Psychological Recovery after Critical Illness and Stay in Hospital ICU

Abstract The effects of critical illness and hospitalization in intensive care units (ICU) have been associated with the presence of negative psychological consequences. This study explores the experiences of sick people who were admitted to an ICU, seeking to know its repercussions on the self. In-depth qualitative interviews and participant observations were carried out with two people since their ICU admission until at least six months after discharge from the unit. Data was analyzed following an adaptation of the clinical qualitative method within a longitudinal frame and interpreted with Winnicott’s psychoanalytic perspective. This research managed to describe participants’ lived experiences and the ways they affected their psychic organization. To the interviewed, these experiences configured threshold situations which promoted a process of psychic disintegration. Psychological recovery, then, depends on the articulation of lived experiences, and is supported by facilitating intersubjective relationships that promote the expression of personal potentialities.

Consequences and Solutions for the Impact of Communication Impairment on Noninvasive Ventilation Therapy for Acute Respiratory Failure: A Focused Review

Objectives:

With over 2 million cases of acute respiratory failure in the United States per year, noninvasive ventilation has become a leading treatment modality, often supplanting invasive mechanical ventilation as the initial treatment of choice. Most acute respiratory failure patients use a full face (oronasal) mask with noninvasive ventilation, which is known to impair communication, but its popularity and benefit has led many providers to accept the communication impairment. Medical staff periodically remove masks to communicate with patients, but patients are often limited to short utterances and risk lung derecruitment upon removal of positive pressure. These problems can lead to noninvasive ventilation failure, which is often linked to worse outcomes than first initiating invasive mechanical ventilation and can lead to increased hospitalization costs.

Data Sources:

We searched MEDLINE and Google Scholar for “speech,” “communication,” “impairment,” “failure,” “complications,” “NIPPV,” “NIV,” and “noninvasive ventilation.”

Study Selection:

We included articles with patients in acute respiratory failure. We excluded articles for patients using noninvasive ventilation therapy for obstructive sleep apnea.

Data Synthesis:

Communication impairment has been associated with increasing noninvasive ventilation anxiety (odds ratio, 1.25). Of patients using noninvasive ventilation, 48% require early discontinuation, 22% refuse noninvasive ventilation, and 9% are ultimately intubated. Improvements to communication have been shown to reduce fear and anxiety in invasive mechanical ventilation patients. Analogous communication problems exist with effective solutions in other fields, such as fighter pilot masks, that can be easily implemented to enhance noninvasive ventilation patient care, increase adherence to noninvasive ventilation treatment, and improve patient outcomes.

Conclusions:

Communication impairment is an underappreciated cause of noninvasive ventilation complications and failure and requires further characterization. Analogous solutions—such as throat microphones and mask-based microphones—that can be easily implemented show potential as cost-effective methods to reduce noninvasive ventilation failure.

Heideggerian hermeneutic phenomenology as method: modelling analysis through a meta-synthesis of articles on Being-towards-death

While the richness of Heideggerian philosophy is attractive as a healthcare research framework, its density means authors rarely utilise its fullest possibilities as an hermeneutic analytic structure. This article aims to clarify Heideggerian hermeneutic analysis by taking one discrete element of Heideggerian philosophy (Being-towards-death), and using it's clearly defined structure to conduct a meta-synthesis of Heideggerian phenomenological studies on the experience of living with a potentially life-limiting illness. The findings richly illustrate Heidegger's philosophy that there is either an inauthentic positioning towards death, or an authentic positioning towards death with a proposition that (1) death is certain; (2) death is indefinite; (3) death is non-relational; and (4) death is not-to-be-outstripped. None of the 29 included studies on the experience of a confrontation with death fully utilised this framework, despite claiming a grounding in Heideggerian thought. This demonstrates the value in modelling how Heideggerian existential structures can be used proactively as analytical 'hooks' for data in research claiming a basis in this philosophy and/or method. By modelling the potential application of an important Heideggerian philosophical construct to published qualitative data, this meta-synthesis has revealed new domains and more nuanced understandings of the temporal structure of Being-towards-death. Such an approach helps to more fully unveil the existential concerns of people at the core of interpretative phenomenological enquiry and may provide a blueprint to map either primary or synthesised data to other key ontological existentials.

Patients' experiences of acute deterioration: A scoping review

BACKGROUND

Patient experience is recognised as a means of assessing healthcare delivery with organisations in many countries now gathering patient experience or satisfaction data. It is well documented that the benefits of improving a patients' experience include increased satisfaction, reduced length of stay, improved patient outcomes and reduction of costs. The experience of acute clinical deterioration is unique, extensive and complex as well as being a difficult experience for all involved. However, little is known about this experience from the patient's perspective.

AIM

To explore what is known about the experiences of acute deterioration from the perspective of the patient.

DESIGN

A scoping review of international, peer-reviewed research studies and grey literature published between the years of 2000 and 2018. This review was guided by the three-step search strategy recommended by the Joanna Briggs Institute (JBI).

DATA SOURCES

A range of databases were searched, including CINAHL, Medline, Health Source, Joanna Briggs Institute, PsycINFO, Embase via Ovid, Cochrane library, Ovid Emcare, Scopus as well as grey literature, reference lists and the search engine Google Scholar.

REVIEW METHODS

Joanna Briggs Institute (JBI) scoping review framework was utilised to identify patients' experiences of acute deterioration. Ten databases were searched, and 249 articles were retrieved. After screening the titles and abstracts, 102 articles were assessed in full text for eligibility, and finally 23 articles were further analysed and synthesised using inductive thematic analysis.

RESULTS

19 qualitative studies, three quantitative and one mixed methods study met the inclusion criteria. Seven key themes emerged related to patients' experience of acute deterioration: (1) transformation of perception: memories of factual events; (2) psychological transformation: emotional distress and well-being; (3) physiological transformation: physical distress; (4) facing death; (5) the severity of acute deterioration: from the perspective of the patient; (6) relationship with healthcare professionals and the clinical environment; and (7) the value of relationships: the support of family and friends.

CONCLUSIONS

Participants had considerable recall of their experiences and hospital admissions. The themes highlight the important issues patients face during their own acute physiological deterioration. This review has highlighted that further research is needed to specifically explore the patients' experience of acute deterioration and the emergency management they receive, for example from a hospital's rapid response team (RRT) or medical emergency team (MET).

Early and late-recorded predictors of health-related quality of life of burn patients on long-term follow-up

BACKGROUND

Unintentional and intentional burn injuries vary across age groups, gender, income, and global region. In high-income countries, the trend over the last several years has been a reduction in burn incidence, burn severity, length of hospital stay, and mortality rate. However, there is a lack of data on predictors of the health-related quality of life (HRQoL) of major burn survivors extending beyond a follow-up period of 10 years.

PATIENTS AND METHODS

This single-center cross-sectional study is considering 42 long-term severe burn survivors with deep partial thickness burns and an affected total body surface area (TBSA) of ≥20%. For study eligibility design a minimum follow-up of 10 years was obligatory. Entitled individuals were asked to fill in the generic Short Form 36 (SF-36) questionnaire. The physical (PCS) and mental (MCS) component scores of the SF-36 were used as the primary outcome variables. Putative predictor variables were drawn from medical records. Burn-specific functionality and scar tissue quality were assessed using the Burn Specific Health Scale-Brief (BSHS-B) questionnaire and the Patient and Observer Scar Assessment Scale (POSAS), respectively. Correlation between putative predictor variables and SF-36 norm scores were evaluated by Pearson- and Point-Biserial correlation as well as multivariate linear regression. The SF-36 norm scores were compared to the general German population.

RESULTS

Mean follow-up was 14 (±3) years with a minimum and maximum of 10 and 28 years, respectively. Mean age at the time of the incident was 37 (±17) years. The majority of individuals were male (74%). The mean burn size was 39 (±17) % (TBSA) with 76% of the individuals showing a full thickness burn. SF-36 norm scores were not statistically different from the general population. Statistically significant independent predictor variables of the physical summary score were: age at the time of the injury (-0.381), time since injury (-0.466), length of hospital stay (-0.356), limb amputation (-0.318), unemployment (-0.433), work (0.593), hand function (0.601), body image (0.518), affect (0.355), simple abilities (0.602), burns involving the hands (-0.339) and back (-0.343), POSAS patient- (-0.521) and observer scores (-0.483). In multivariate analysis, work (4.315), the POSAS Score (-2.082) and the age at the time of the incident (-0.242) were statistically significant predictors. Statistically significant independent predictor variables of the mental summary score were: duration of mechanical ventilation (-0.459), hand function (0.415), body image (0.502), sexual activity (0.625), social support (0.542), burns involving the back (-0.315) and affect (0.692). In multivariate analysis, affect (13.844) and the length of mechanical ventilation (-0.115) were statistically significant independent predictor variables.

CONCLUSION

Ten years after the burn incident, the quality of life was on average comparable to the one in the general population. Multiple variables seem to influence the physical and mental long-term outcome. Herein presented data may support in adapting and designing follow-up strategies tailored to a patient's burn-specific circumstances.

Patient and Family Centered Actionable Processes of Care and Performance Measures for Persistent and Chronic Critical Illness: A Systematic Review

Supplemental Digital Content is available in the text.

To identify actionable processes of care, quality indicators, or performance measures and their evidence base relevant to patients with persistent or chronic critical illness and their family members including themes relating to patient/family experience.

The impact of a prolonged stay in the ICU on patients' fundamental care needs

AIMS AND OBJECTIVES

To explore patients', families' and health professionals' experiences of a long-stay patient in an intensive care unit.

BACKGROUND

The fast-paced technologically driven intensive care unit environment, designed for a short patient stay, supports the provision of complex physiologically focused care for those with life-threatening illnesses. Long-stay patients with pronounced fundamental care needs fall outside predicted patient pathways, and nurses can find caring for these patients challenging.

DESIGN AND METHODS

A longitudinal, qualitative, multicase study of six cases from four New Zealand units. Case participants were patients, family members, nurses and other health professionals. Data collection methods included observation, conversations, interviews and document review. Data were analysed using thematic analysis, vignette development and trajectory mapping.

RESULTS

Challenges and successes of providing fundamental care for long-stay ICU patients are attributed to two interlinked factors. First, the biomedical model influences ICU nursing practices, resulting in prioritising tasks and technology for patient survival while simultaneously devaluing relational and comfort work. Fundamental psychosocial needs such as family presence, comfort, relationships and communication may be unmet. Second, the unit environment and culture have a significant impact on long-stay patients' ICU experiences and form physical and psychological barriers to families being present and involved. Some nurses negotiated these challenges to provide fundamental, patient- and family-centred care by adopting an approach of knowing the patient and these nurses reported satisfaction when seeing patients' positive responses.

CONCLUSION

The care environment and culture provide challenges to the provision of patient- and family-centred care for long-stay patients; however, when nurses prioritise knowing their patient these challenges can be overcome and patient and family distress reduced with the potential to improve patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

Recognition that patients have fundamental care needs irrespective of the setting where they receive care. Intensive care environments and cultures create challenges for nurses when there is such a heavy burden of physiological needs to be met and technological tasks to be undertaken, with a focus on acuity; however, improving provision fundamental care can result in positive patient outcomes.

Prolonged Ventilator Dependence

The purpose of this qualitative inquiry was to examine the meaning of prolonged mechanical ventilation from the perspective of the patient with a diagnosis of chronic obstructive pulmonary disease (COPD). Interviews were conducted with four individuals with a diagnosis of COPD who had experienced long-term ventilator dependence. Participants were asked to reflect on their experiences while they were ventilator dependent, and their narratives were utilized as text for hermeneutical analysis. The study's findings describe three distinct phases experienced by the participants, beginning with intubation and lasting until well after discharge from the hospital. The support of nurses was an important aspect of maintaining hope for the participants. The study revealed that prolonged mechanical ventilation had a profound impact on COPD patients and their sense of self. Postdischarge psychological support and follow-up with survivors of this experience is warranted.

Dependency in Critically Ill Patients: A Meta-Synthesis

By necessity, critically ill patients admitted to intensive care units (ICUs) have a high level of dependency, which is linked to a variety of negative feelings, such as powerlessness. However, the term dependency is not well defined in the critically ill patients. The concept of “dependency” in critically ill patients was analyzed using a meta-synthesis approach. An inductive process described by Deborah Finfgeld-Connett was used to analyze the data. Overarching themes emerged that reflected critically ill patients’ experience and meaning of being in dependency were (a) antecedents: dependency in critically ill patients was a powerless and vulnerable state, triggered by a life-threatening crisis; (b) attributes: the characteristic of losing “self” was featured by dehumanization and disembodiment, which can be alleviated by a “self”-restoring process; and (c) outcomes: living with dependency and coping with dependency. The conceptual model explicated here may provide a framework for understanding dependency in critically ill patients.

The intensive care unit psychosocial care scale: Development and initial validation

The main objective of the current study was to construct a new self-report scale - ICU-PC Scale - to measure the psychosocial care (PC) of patients in Intensive Care Unit (ICU) and examine different psychometric issues in the development and initial validation of this scale. The findings indicate that the ICU-PC Scale has established high internal consistency. A three-factor structure - protection of human dignity and rights, transparency for decision making and care continuity and sustained patient, family orientation - has been identified with a substantial number of subjects (N=250) in hospital settings. The three oblique factor solutions are found to be interrelated and interdependent with good indices of internal consistency and content validity. This new instrument is the first of its kind to measure the psychosocial care to be provided to patients in the ICU. The present findings indicate that the ICU-PC scale, with additional factor analytic research, could become an established and clinical tool.

Follow-up visit in an ICU: receiving a sense of coherence

AIM

To describe patients' experiences of a follow-up visit to an intensive care unit (ICU) after being critically ill and nursed there.

BACKGROUND

Knowledge about the follow-up visit needs to be developed, with the previously critically ill patient in focus.

DESIGN

Qualitative descriptive.

METHOD

Semi-structured interviews were conducted with nine patients and analysed using qualitative content analysis. The data collection occurred during spring 2014.

FINDINGS

During the follow-up visits in ICU, the relatives, the patient diary, and those who took part in the care contribute to fill memory gaps to create a picture and an explanation of the care period.

CONCLUSION

The follow-up visit is an important tool in the patients' struggle to create a context and coherence from a missing or unreal time. The patient diary is essential to subsequently be able to relate to the period of care.

RELEVANCE TO CLINICAL PRACTICE

The follow-up visit, together with a personal diary, after an ICU stay could be seen as significant for strengthening the patients' feeling of coherence and better health.

"Not being able to talk was horrid": A descriptive, correlational study of communication during mechanical ventilation

OBJECTIVES

The purpose of this study was to describe the patient experience of communication during mechanical ventilation.

RESEARCH METHODOLOGY

This descriptive study is a secondary analysis of data collected to study the relationship between sedation and the MV patients' recall of the ICU. Interviews, conducted after extubation, included the Intensive Care Experience Questionnaire. Data were analysed with Spearman correlation coefficients (rs) and content analysis.

SETTING

Participants were recruited from a medical-surgical intensive care unit in the Midwest United States.

RESULTS

Participants (n = 31) with a mean age of 65 ± 11.9 were on the ventilator a median of 5 days. Inability to communicate needs was associated with helplessness (rs = .43). While perceived lack of information received was associated with not feeling in control (rs = 41) and helplessness (rs = 41). Ineffective communication impacted negatively on satisfaction with care. Participants expressed frustration with failed communication and a lack of information received. They believed receipt of information helped them cope and desired a better system of communication during mechanical ventilation.

CONCLUSION

Communication effectiveness impacts patients' sense of safety and well-being during mechanical ventilation. Greater emphasis needs to be placed on the development and integration of communication strategies into critical care nursing practice.

[Tolerance of endotracheal tubes in patients on mechanical ventilation]

BACKGROUND

Modern concepts for sedation and analgesia and guidelines recommend light analgesia and sedation, so that patients on mechanically ventilation are more awake, compared to previous concepts. Hence, these patients are more alert and able to experience their situation on the ventilator and their endotracheal tube (ETT).

PROBLEM

There is currently no convincing evidence of how patients tolerate the tube under present conditions, which interventions could help them, or whether they want to be sedated deeper because of the tube. Based upon our own observations, a broad range of reactions are possible.

PURPOSE

The tolerance of the ETT in intensive care patients was explored.

METHOD

A systematic literature research without time constraints in the databases PubMed and CINAHL was performed. Included were quantitative and qualitative studies written in German or English that investigated tolerance of the ETT in adult intensive care patients. Excluded were anesthetic studies including in- and extubation immediately before and after operations.

RESULTS

Of the 2348 hits, 14 studies were included, including 4 qualitative studies about the experience of intensive care, 8 quantitative studies including 2 randomized controlled studies, and 2 studies with a mixed approach. Within the studies different aspects could be identified, which may in- or decrease the tolerance of an ETT. Aspects like breathlessness, pain during endotracheal suctioning and inability to speak decrease the tolerance. Information, the presence of relatives and early mobilization appear to increase the tolerance.

CONCLUSION

Tolerance of the ETT is a complex phenomenon. A reflected and critical evaluation of the behavior of the patient with an ETT is recommended. Interventions that increase the tolerance of the ETT should be adapted to the situation of the patient and should be evaluated daily.

Metabolic monitoring in the intensive care unit: a comparison of the Medgraphics Ultima, Deltatrac II, and Douglas bag collection methods

BACKGROUND

The accuracy of oxygen consumption measurement by indirect calorimeters is poorly validated in mechanically ventilated intensive care patients where multiple confounders exist. This study sought to compare the Medgraphics Ultima (MGU) and Deltatrac II (DTII) devices, and the Douglas bag (DB) technique in mechanically ventilated patients at rest.

METHODS

Prospective comparison of oxygen consumption measurement using three indirect calorimetry techniques in stable, resting mechanically ventilated patients at rest. Oxygen consumption (VO2), carbon dioxide production (VCO2), resting energy expenditure (REE), and respiratory quotient (RQ) were recorded breath-by-breath by the MGU over a 30-75 min period. During this time, simultaneous measurements were taken using the DTII, the DB, or both.

RESULTS

While there was no systematic error (bias) between measurements made by the three techniques (VO2: MGU vs DTII 3.6%, MGU vs DB 3.3%), the limits of agreement were wide (VO2: MGU vs DTII 33%, MGU vs DB 54%).

CONCLUSIONS

Resting oxygen consumption values in stable mechanically ventilated patients measured by the three techniques showed acceptable bias but poor precision. There is an important clinical and research need to develop new indirect calorimeters specifically tailored to measure oxygen consumption during mechanical ventilation.

Communication between the Nursing Team and Patients on Invasive Mechanical Ventilation in an Intensive Care Unit

La comunicación se basa en la utilización de herramientas e involucra la interacción recíproca de dos interlocutores. En las Unidades de Cuidados Intensivo (UCI), la aplicación de ventilación mecánica invasiva (VMI), genera condiciones especiales en el paciente que dificultan su comunicación. La ausencia de comunicación entre el equipo de enfermería (EE) y los pacientes con VMI es atribuida a múltiples barreras y produce efectos negativos que afectan la recuperación y el bienestar. Objetivo: conocer las características de la comunicación con pacientes con VMI que aplica elementos de la Teoría Fundada para el proceso de análisis y que utilizó como técnica de recolección de datos grupos focales de enfermeras y técnicos de enfermería que realizan cuidado directo a pacientes con VMI en una UCI. Método: Investigación de diseño cualitativo, orientada por la Teoría Fundada, para el análisis y la asociación de conceptos, que utilizó grupos focales como técnica de recolección de la información. Resultados: si bien los hallazgos permiten describir las principales características de la comunicación con estos pacientes identificando los medios y las formas utilizados por el EE para hacerlo, los momentos en que ocurre la comunicación, los beneficios y las barreras percibidas por el grupo de participantes, no se llega a establecer una categoría central con las estructuras y definiciones del proceso dentro de la misma, para lo que se requerirían nuevas investigaciones. Conclusión: a partir de estos hallazgos se espera contribuir al cuerpo de conocimientos de la disciplina de enfermería y fortalecer la gestión del cuidado que realiza el EE en las UCI.

"Releasing a lot of poisons from my mind": patients' delusional memories of intensive care

OBJECTIVES

To describe intensive care unit (ICU) patients' delusional memories and interpretations of those memories.

BACKGROUND

Delusional memories of the ICU are distressing for patients and may impact psychological recovery.

METHODS

This is a secondary analysis from a study of mechanically ventilated patients' recall in relation to sedation. Subjects, recruited from one medical-surgical ICU, participated in structured interviews after extubation.

RESULTS

Subjects (n = 35) with a mean age of 66 (SD 12.9) and on the ventilator a median of 4.5 days provided detailed descriptions of delusional memories of being shackled, caged, strangled, or being in a foreign country. Delusions were very real and frightening in the moment. Subjects had difficulty connecting to reality to allow processing of the delusions.

CONCLUSIONS

Patients' delusional memories of ICU share common distressing themes. Assisting patients' to connect to real ICU events and process delusional memories may help with psychological recovery after critical illness.

Impact of tracheostomy placement on anxiety in mechanically ventilated adult ICU patients

OBJECTIVE

To determine if self-reported anxiety levels decreased after tracheostomy placement in a sample of mechanically ventilated intensive care unit patients.

BACKGROUND

There is limited research regarding the impact of a tracheostomy on patients' anxiety. Elevated anxiety delays healing and contributes to long-term mental health complications.

METHODS

This was a secondary analysis of data from a large clinical trial conducted in urban Minnesota. Fifty-one of 116 patients received a tracheostomy. Anxiety scores were obtained daily using the Visual Analog Scale-Anxiety. Mixed model analysis was used to compare anxiety ratings pre- and post-tracheostomy.

RESULTS

There was no significant decrease in anxiety following tracheostomy after controlling for time and gender (all p > .16). Age was the only variable to impact anxiety levels: anxiety scores increased as age increased (p = .02).

CONCLUSIONS

Prospective studies are needed to more accurately assess the impact of tracheostomy placement on patient anxiety and salient outcomes.

Lived experience of patients being cared for in ICUs in Southern Thailand

BACKGROUND

Technologies in ICUs are increasingly saving human lives. The challenge for nursing in ICUs is to use technologies competently in order to know patients more fully within the harmonized view of technology, nursing and human care.

PURPOSE

The purpose of this study was to describe the meaning of the experiences of patients who were dependent on technologies while being cared for in ICUs.

METHOD

A hermeneutic phenomenological approach was used to describe the experiences of 10 participants who were discharged from adult ICU units in Southern Thailand. Lincoln and Guba's criteria for trustworthiness was used to establish the rigour of the study.

FINDINGS

Four thematic categories structured the meaning of the participants' experiences: Living suffering; Harmonizing living; Being in trust and security; and Transitioning to a better life. These thematic categories were reflective of the four lived worlds of corporeality, relationality, spatiality and temporality.

CONCLUSION

The description of being cared for was based on the narratives of patients who were discharged from ICUs in Southern Thailand. In conclusion, the lived experience of being cared for with technologies in ICU was described as living suffering within trust and security, and harmonizing living while transitioning to a better life.

RELEVANCE TO CLINICAL PRACTICE

The findings of the study could be used to design innovative nursing strategies and interventions to enhance understanding of human health and well-being while maintaining and advancing competencies in the use of technologies for human care.

Nurses' perceptions of unpleasant symptoms and signs in ventilated and sedated patients

AIMS AND OBJECTIVES

To describe intensive care nurses' perceptions and assessments of unpleasant symptoms and signs in mechanically ventilated and sedated adult intensive care patients.

BACKGROUND

Mechanically ventilated patients are unable to express themselves verbally and depend upon nurses to control their symptoms by understanding their unpleasant experiences, such as pain, anxiety or delirium and interpret the relevant signs. Nurses must have enough knowledge to adjust their analgesics and sedatives appropriately and to avoid under- or oversedation.

DESIGN

A cross-sectional survey design.

METHODS

A study with a self-administrated questionnaire was undertaken in October 2007 to February 2008, with a convenience sample of 183 intensive care nurses in Norway.

RESULTS

The questionnaire was completed by 86 (47%) nurses. Most perceived that critical illness polyneuropathy/myopathy occurred frequently. Half the nurses underestimated pain, anxiety and delirium. Signs such as a response to contact, cough reflex, wakefulness and muscle tone were considered most important in assessing oversedation. Agitation, facial grimacing, tube intolerance and wakefulness were considered most important in assessing undersedation. The Comfort Scale and Adoption of the Intensive Care Environment corresponded best to the signs identified by the nurses.

CONCLUSION

The nurses underestimated unpleasant symptoms other than critical illness polyneuropathy/myopathy. A further mapping of patients' experiences should be conducted, with an emphasis on the more 'silent' distressing symptoms. Further tools to facilitate the communication of consciousness levels and the intolerance of unpleasant symptoms must be developed and implemented.

RELEVANCE TO CLINICAL PRACTICE

A deeper understanding of unpleasant symptoms and signs focused in learning activities may help nurses to recognize patients' early problems and allow targeted interventions. A more active stimulus-response assessment of ICU patients is required to detect oversedation, critical illness polyneuropathy/myopathy and hypoactive delirium. Assessment tools should reflect both the patient's tolerance of various unpleasant symptoms and the level of consciousness.

Memories from intensive care unit persist for several years--a longitudinal prospective multi-centre study

INTRODUCTION

In connection with the care received in the intensive care unit (ICU), the patient can experience discomfort and frustration. Earlier studies have shown mechanical ventilation (MV) to be a factor that increases patients' delusional memories in the ICU. The patients who need MV after a physical trauma constitute a vulnerable group who so far has attracted little attention from a long-term perspective.

AIM

The aim for this study is to describe mechanically ventilated trauma patients over time regarding their memories, psychological recovery and health related quality of life (HRQoL).

METHODS

In a multicentre study, 41 patients who had received MV, answered a questionnaire with the SF-36, HAD and ICUM tool on two occasions about one and five years after the injury and care in the ICU.

RESULTS

The patients' memories were stable over time and significantly more patients remembered panic and anxiety. 37% remembered pain one year after the trauma and 46% five years thereafter. The majority of the patients remembered the family's presence from their ICU stay. Half of the patients had thoughts regarding why they had so few recollections. One fourth of the patients experienced clear symptoms of anxiety and the same amount had symptoms of depression one year after the injury. In seven of the patients the symptoms of probable anxiety persisted after five years. In six of the patients the symptoms of probable depression persisted after five years. Two of eight dimensions in HRQoL, the physical and emotional role functions, had improved significantly five years after the injury.

CONCLUSIONS

Five years after the trauma, the memories from the ICU were still the same and the HRQoL improved in only two out of eight dimensions. A smaller group of patients had remaining symptoms of psychological ill-health. MV in connection with trauma may result in continued reduced health in the long term.

Patients' interactions in an intensive care unit and their memories of intensive care: a mixed method study

AIM

The aim of this study was to describe the interaction between intensive care patients and the intensive care unit (ICU) environment from the perspective of the hospital bed and patients' memories of the ICU.

METHODS

Four adult patients in an intensive care unit were each recorded on DVD over a 24 hour period. The patients were also interviewed three months and six months after discharge from hospital. The data generated regarding their interactions with the ICU environment were then analysed using qualitative and quantitative content analysis.

RESULTS

The ICU patient has short, direct and indirect contacts during treatment. In addition, the patient reacts to events in the ICU environment that do not include contact. Patients' memories were divided into two main categories: internal and external. Internal memories included physical and mental memories, which were experienced as surreal, unpleasant feelings or physical symptoms such as pain or the experience of being cold or thirsty. External experiences included events that the patient experienced through participation or observation, for example during nursing routines, or through hearing or observing other people, communication and the surroundings.

CONCLUSION

The patient's day in ICU is occupied with episodes of brief contact with nursing staff in an environment that the patient experiences as confusing or incomprehensible. The day and night rhythm is disturbed while the patient's opportunities for rest or concentration are limited. Most interactions affect the patient and it is important for staff to be aware of the impact of potentially unsettling events.

People's experiences of being mechanically ventilated in an ICU: a qualitative study

OBJECTIVES

In previous studies people receiving mechanical ventilation treatment have described experiencing distress over their inability to speak and feelings such as anxiety. More research is needed to improve their experience in the intensive care unit and promote recovery. The aim of this study was to describe the intensive care unit experiences of people undergoing mechanical ventilation.

METHOD

Qualitative, personal interviews were conducted during 2011 with eight people who were mechanically ventilated in an intensive care unit in the northern part of Sweden. Interview transcripts were analysed using qualitative content analysis.

FINDINGS

Two themes emerged, with four and three categories, respectively. Being dependent for survival on other people and technical medical equipment created a sense of being vulnerable in an anxious situation and a feeling of uncertainty about one's own capacity to breathe. Having lines and tubes in one's body was stressful. Being given a diary and follow-up visit to the intensive care unit after the stay were important tools for filling in the missing time, but there was also one participant who did not want to remember his stay in the intensive care unit.

CONCLUSION

To be dependent on other people and technical medical equipment for survival creates a sense of being delivered into the hands of others, as the people being mechanically ventilated could not trust their body to function.

Critical care nurses' experiences of follow-up visits to an ICU

AIM

The aim of this study was to describe critical care nurses' experiences of follow-up visits for formerly critically ill people discharged from an intensive care unit and their close relatives.

BACKGROUND

The critical illness experience affects the ill person and their close relatives not only during the stay in an intensive care unit, but also for a long time afterwards. Follow-up visits were introduced to offer people the opportunity to talk about their experiences. This activity has not been studied earlier from the perspective of critical care nurses.

DESIGN

The design of this study was qualitative.

METHOD

Eight critical care nurses narrated their experiences of follow-up visits by formerly critically ill people and their close relatives to an intensive care unit. Data were collected during 2007-2008. Qualitative thematic content analysis was applied to the interview texts.

RESULTS

The findings show that to feel they were doing a good job it was vital for the critical care nurses to be well prepared for the follow-up visits. It was difficult, in a positive way, to recognise formerly critically ill people when they returned looking healthy. The critical care nurses were disappointed that their former patients remembered so few real events. The follow-up visits gave the critical care nurses a new picture of how the critically illness experience influenced the former patient's everyday life during and after their stay in the intensive care unit and how it affected the lives of their close relatives.

CONCLUSIONS

Through sharing the experiences of formerly critically ill peoples' and their close relatives' critical care nurses receive valuable feedback about their work.

RELEVANCE TO CLINICAL PRACTICE

Receiving feedback about one's work from follow-up visits gives critical care nurses the possibility for to evaluate given care. Follow-up visits to intensive care units can provide them with valuable knowledge that might lead to improved nursing care.

Revisiting caring science: some integrative ideas for the 'head, hand and heart' of critical care nursing practice

AIM

This paper introduces the notion of 'Caring science' as a way to delineate and develop particular kinds of knowledge relevant to caring practices in critical care.

RELEVANCE FOR PRACTICE

Firstly, one particular development of person centred care, lifeworld led care is offered. Its relevance for critical care nursing is analysed by pointing to examples of studies which describe temporality, spatiality, intersubjectivity and embodiment and how they may manifest with reference to the person as 'body object/body subject' and the matter of technology in critical care environments. Secondly, by use of an imagined practice scenario, the challenge of expanding our traditional notions of evidence to encompass ways of knowing that are more intimately embodied and practice related is discussed. Such knowledge, referred to as 'embodied relational understanding' is particularly relevant to a conception of caring for persons' in a holistic way.

CONCLUSION

The paper concludes by pointing to the potential for caring science, grounded in lifeworld led care, to offer some integrating ideas that legitimate the full range of resources, 'head', 'hand' and 'heart', that nurses can draw upon in everyday holistic critical care practice.

Muslim women's experiences of suffering in Jordanian intensive care units: a narrative study

This paper explores Muslim women's experiences of suffering in Jordanian intensive care units. A narrative approach was employed to access women's stories of their critical illness. Sixteen women who had spent at least 48 hours in intensive care were recruited from two hospitals in a Jordanian city and took part in between one and three interviews over a six-month period. Women's accounts of suffering were pervaded with physical, social, spiritual and technological themes. Pain was a central strand in the women's accounts and was experienced often as severe, overwhelming and disturbing to their sleep. The sudden onset of illness, the unfamiliar ICU environment and feeling of uncertainty made it difficult for the women to interpret their experiences. Religious beliefs and cultural norms helped the women make sense of their suffering. Social support, especially from the family, was reported by the women to be essential: a lack of social support was seen as a symbol of death. This study emphasises the importance of looking at a patient who is critically ill as a whole person within the context of their cultural, spiritual and biographical milieu.

A systematic review of the experiences of adult ventilator-dependent patients

OBJECTIVES

The objective of this meta-synthesis study was to describe the nature of the experience of adult ventilator-dependent patients.

INCLUSION CRITERIA

This review considered studies utilized qualitative methods to examine the experience of adult with ventilator. The phenomena of interest were experiences of patients who were treated with ventilator for both short term and long term in ICU settings or home settings. The research was limited to studies published in Chinese or in English language.

SEARCH STRATEGY

The searching strategy sought to find both published and unpublished studies. The CINAHL, PubMed, MEDLINE, Cochrane Library, Chinese Periodicals Index and JIB website were used to search the articles. The preliminary keywords were drawn from the natural language terms of the topic, in the title, abstract and subject descriptors.

METHODOLOGICAL QUALITY

Each paper was assessed independently by two reviewers for methodological quality. The Joanna Briggs Institute's Qualitative Assessment and Review Instrument were used to appraisal the methodological quality of the articles. Any disagreements that arose between the reviewers were resolved through discussion with a third reviewer.

DATA SYNTHESIS

Qualitative research findings were pooled and the data analysis process involved synthesizing findings to generate a set of statements that represent the nature of the experiences of ventilator-dependent adult patients. The categories and themes/meta-syntheses were emerged from the analysis process.

RESULTS

A total of 997 papers were identified from various database and hand searches. Nineteen papers were critically appraised and 15 met inclusion criteria. Four papers were excluded because they did not meet the inclusion criteria. Five themes/meta-syntheses emerged from the analysis: 1). The feelings of fear due to being dependent on ventilator and the loss of control of life, 2). Disconnection with reality, 3). Impaired embodiment (body image and body boundary), 4). Construction of coping patterns, 5). Trust and caring relationship.

CONCLUSION

The five themes/meta-syntheses derived from the review represent the patients' experiences in regarding the threatening of the integrity of self, self-other and self-environment relationships, the coping patterns and resilient resources to maintain their self-identify and the meaning of life. These findings also illustrate the resiliency factors for those patients to cope with this stressful situation.The implications to practice include enhancing the trust relationship with health professionals, as well as the nursing actions prior to suction, during the suction procedure and post suction in related to release their psychological distress and empower their resilience factors was suggested.Furthermore, the further research could focus on the development and implementation of support programs for the patients, families, and health professionals, as well as the research regarding the reduction of psychological distress and empower the coping patterns.

More than nothing: the lived experience of tracheostomy while acutely ill

While the physical sensations surrounding tracheostomy tube insertion have been reported within nursing and allied healthcare literature, the lived experience of these sensations is poorly described. This appears relevant given the imminent results of the Tracman study (2008). A purposive sample of three participants who had tracheostomy tubes previously within a critical care area or still in situ were recruited. They described their experiences in a face-to-face semi-structured interview that were audio taped. The interviews were transcribed verbatim and analysed using Giorgi's 5 concrete steps of the human scientific phenomenological method (1997). Findings revealed themes that drew attention to the fundamental aspects of the experience. These were: Practical recommendations draw attention to the organisational support required for staff expected to care for these patients in the ward environment. This involves the introduction of evidence based guidelines and competency based care to promote the acquisition of skills required to perform those essential tasks such as suction and stoma care to a high standard. Protected, formalised skills based teaching is seen as fundamental in this process. Patients' felt confident in nursing staff that were able to demonstrate proficiency with such tasks and this is seen as crucial when one considers that the tracheostomy tube is a new experience for patients.

Qualitative analysis of patients' intensive care experience during mechanical ventilation

AIM

To understand patients' intensive care experience while receiving mechanical ventilation in intensive care units.

BACKGROUND

The mechanically ventilated patient's experience in the intensive care unit is unique. Notably lacking are international studies on patients' experience, particularly those living in Asia. A better understanding of patients' experience is needed for nurses to develop approaches to take care of these patients.

DESIGN

A phenomenological approach formed by the ideas of Heidegger was used.

METHODS

Eleven participants surviving from mechanical ventilation were interviewed in-depth. Patients were asked to describe their experience by responding to the question 'what is it like to experience mechanical ventilation treatment at an ICU?'. Giorgi's phenomenological analysis procedure was used to analyse the data.

RESULTS

Five mutually exclusive themes emerged, which were: 'being in an unconventional environment', 'physical suffering', 'psychological suffering', 'self-encouragement' and 'self-reflection'. 'Self-encouragement' and 'self-reflection' enhanced patients' self-confidence, which was beneficial to recovering.

CONCLUSION

Patient's experiences while receiving mechanical ventilation in the intensive unit were poignant and frightening.

RELEVANCE TO CLINICAL PRACTICE

Critical care nurses should place the highest priority on recognising and meeting the needs of ventilated patients in intensive care units. An intensive care unit should be a place for the patient to live as a human being; not just a place to survive.

Validity of the Faces Anxiety Scale for the assessment of state anxiety in intensive care patients not receiving mechanical ventilation

OBJECTIVES

Anxiety is a commonly reported discomfort in critically ill patients in the intensive care unit (ICU) but is rarely assessed routinely in a systematic manner. The main aim of this study was to assess criterion validity of the Faces Anxiety Scale in relation to the State-Anxiety Inventory (SAI) in intensive care patients able to respond verbally to the items in the SAI of the Spielberger State-Trait Anxiety Inventory. It also reports on the severity of anxiety in intensive care patients not receiving mechanical ventilation.

METHODS

Nonventilated intensive care patients (n=100) self-reported anxiety levels on the Faces Anxiety Scale and on the SAI, administered in random order. Validity was examined using Spearman's rho.

RESULTS

Patients had a mean age of 59.8 years and 65% were male; were in ICU for mainly cardiovascular, respiratory, and neurological diagnoses; and had median length of stay of 2.1 days. The correlation between the two scales was .70 (P<.0005), indicating good criterion validity. Patients reported low to moderate levels of anxiety on both the Faces Anxiety Scale and the Spielberger SAI.

CONCLUSION

The Faces Anxiety Scale is a valid single-item, self-report measure of state anxiety in intensive care patients that is easy to administer and imposes minimal respondent burden. It has the potential to be a useful instrument for the assessment of state anxiety by clinicians and for research into the reduction of anxiety in this vulnerable population.

Re-visiting the ICU Experiences of follow-up visits to an ICU after discharge: a qualitative study

The aim of this study is to describe how people who have been critically ill, and their close relatives experience a post-discharge, follow-up visit to the intensive care unit (ICU) that provided the care. There is a lack of studies from such a standpoint. The study design is qualitative. A total of 18 adults participated; nine had been critically ill and nine were close relatives, all made a post-discharge follow-up visit to an ICU in the northern part of Sweden. The study data was collected through personal interviews, conducted after the follow-up visit, using a narrative approach. The data were then subjected to qualitative thematic content analysis which resulted in four themes: receiving strength from returning together; making sense of the critical-illness experience; feeling grateful to have survived and the possibility of improving the care. People who had been critically ill and close relatives felt that returning together was valuable. Meeting the staff, with whom participants felt they had developed a relationship, made it possible for them to express their gratitude for the treatment and nursing care received, and to suggest improvements. The interviews revealed that the follow-up visit was seen as an important way of learning what had happened and why during the period of critical illness.

A journey in quest of meaning: a hermeneutic-phenomenological study on living with memories from intensive care

BACKGROUND

In a short-term perspective, a high incidence of psychological problems linked to memories from intensive care has been found in survivors of critical illness. Little is known about what kinds of memories patients might carry with them and what it is like to live with memories from intensive care as years go by.

AIM

The aim of this study was to explore the meaning of living with memories from intensive care.

METHODS

A hermeneutic-phenomenological approach. In-depth interviews with ten former intensive care patients 10 years after their admission.

FINDINGS

Memories of bodily sensations and memories containing strong emotions were surprisingly well kept. Memories residing in the body at a prereflective level and that could be awakened without being triggered by will or conscious thought comprised an important segment of the memory spectrum. Complaints such as panic attacks and anxiety were strongly linked to these kinds of memories and experienced as flashbacks of frightening experiences that entailed strong emotions. Some informants still strove to understand experiences and reactions. Living with these memories and flashbacks was interpreted as a journey in quest of meaning. Having someone and something to live for implied strength on the journey. The presence of close relatives at the bedside provided strength to go on and someone with whom to share experiences afterwards.

CONCLUSION

A period of critical illness and intensive care stay for treatment may leave durable traces in the patient's life. Finding meaning of existential and ontological nature seems to be of decisive significance for how people fare in their lives after having lived through intensive care treatment. The identified journey in quest of meaning points to the need for follow-up programmes, and we must acknowledge close relatives as important resources for the patient both at the bedside and in the subsequent process of discovering meaning in lived experience.

Caring for critically ill patients with advanced COPD at the end of life: a qualitative study

Providing expert critical care for the high acuity patient with a diagnosis of COPD at the end of life is both complex and challenging. The purpose of this descriptive study was to examine intensive care unit (ICU) clinicians' perspectives on the obstacles to providing quality care for individuals with COPD who die within the critical care environment. Transcripts of three focus groups of ICU clinicians were analyzed using thematic analysis. The three themes of "managing difficult symptoms", "questioning the appropriateness of life-sustaining care" and "conflicting care priorities" were noted to be significant challenges in providing high quality end of life care to this population. Difficulties in palliating dyspnea and anxiety were associated with caregiver feelings of helplessness, empathy and fears about "killing the patient". A sense of futility, concerns about "torturing the patient" and questions about the patient/family's understanding of treatment pervaded much of the discourse about caring for people with advanced COPD in the ICU. The need to prioritize care to the most unstable ICU patients meant that patients with COPD did not always receive the attention clinicians felt they should ideally have. Organizational support must be made available for critical care clinicians to effectively deal with these issues.

Depressive und Angststörungen bei somatischen Krankheiten

Depressiv-ängstliche Störungen sind bei den unterschiedlichen somatischen Erkrankungen häufig. Sie sind nicht nur als Reaktion auf die Situation der Erkrankung zu verstehen, sondern in ein komplexes Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen, die das Zentralnervensystem oder endokrine Regulationssysteme direkt betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich.

Do ventilated neonates require pain management?

Mechanical ventilation is a stressful experience in neonates resulting in changes in neuroendocrine parameters, pain scores, and physiologic responses. Assisted ventilation in neonates is presumed to be associated with chronic repetitive pain, which in turn is associated with adverse long-term sequelae. Reasons to routinely sedate ventilated neonates include improved ventilator synchrony, improved pulmonary function, and decreased neuroendocrine responses, including cortisol, beta-endorphine, and catecholamines. Reasons not to treat include the well-known adverse side effects of pain medication, especially the opiates, including hypotension from morphine, chest wall rigidity from fentanyl, and tolerance, dependence, and withdrawal from both opiates and benzodiazepines. Additionally, adverse effects such as death and IVH are not improved with preemptive treatment. Chronic pain assessment is poorly validated and difficult to assess in this population, and most studies have evaluated only acute pain scores. If patients are treated, opiates are the most common class of drugs, with morphine the most well studied. Fentanyl may be advantageous in hypotensive, younger neonates because it has fewer cardiovascular effects. The benzodiazepines, midazolam and lorazepam, have been used in ventilated neonates, but midazolam has been associated with adverse effects in one small study so concern remains regarding its use. Significant gaps in our knowledge exist, especially in regard to long-term effects of treatment, or lack thereof, and in the assessment of the chronic pain associated with assisted ventilation.

Receiving power through confirmation: the meaning of close relatives for people who have been critically ill

AIM

This paper is a report of a study to elucidate the meaning of close relatives for people who have been critically ill and received care in an intensive care unit.

BACKGROUND

Falling critically ill can bring about a difficult change in life. In previous reports such events are described as frightening experiences, and close relatives are described as an important source of support in this difficult situation.

METHOD

A purposive sample of 10 adults, eight men and two women, narrated how they experienced their close relatives during and after the time they were critically ill. The data were collected in 2004. The interview texts were transcribed and interpreted using a phenomenological hermeneutic approach influenced by the philosophy of Ricoeur.

FINDINGS

One major theme was identified, experiencing confirmation, with six sub-themes: receiving explanations; a feeling of being understood; a feeling of safety; gaining strength and will-power; having possibilities and realizing their value. Close relatives served as tools for the person who was ill, facilitating better communication and an increased ability to do various things. Simultaneously, feelings of dependence on the close relatives were expressed. There were descriptions of loneliness and fear in the absence of close relatives and, in order to feel safe, the participants wanted their close relatives to stay near them.

CONCLUSION

Close relatives are vital, as they are the ill person's motivation to stay alive and to continue the struggle. Their presence is of great importance for the ill person and must be facilitated by staff.

Nursing care of the mechanically ventilated patient: what does the evidence say? Part two

The care of the mechanically ventilated patient is a fundamental component of a nurse's clinical practice in the intensive care unit (ICU). Published work relating to the numerous nursing issues of the care of the mechanically ventilated patient in the ICU is growing significantly, yet is fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated patient. In part one of this two-part paper, the evidence on nursing care of the mechanically ventilated patient was explored with specific focus on patient safety: particularly patient and equipment assessment. This article, part two, examines the evidence related to the mechanically ventilated patient's comfort: patient position, hygiene, management of stressors (such as communication, sleep disturbance and isolation), pain management and sedation.