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Critical care nurses' decision making: Sedation assessment and management in intensive care
Abstract
This study was designed to examine the decision making processes that nurses use when assessing and managing sedation for a critically ill patient, specifically the attributes and concepts used to determine sedation needs and the influence of a sedation guideline on the decision making processes.
Sedation management forms an integral component of the care of critical care patients. Despite this, there is little understanding of how nurses make decisions regarding assessment and management of intensive care patients' sedation requirements. Appropriate nursing assessment and management of sedation therapy is essential to quality patient care.
Observational study.
Nurses providing sedation management for a critically ill patient were observed and asked to think aloud during two separate occasions for two hours of care. Follow-up interviews were conducted to collect data from five expert critical care nurses pre- and postimplementation of a sedation guideline. Data from all sources were integrated, with data analysis identifying the type and number of attributes and concepts used to form decisions.
Attributes and concepts most frequently used related to sedation and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; post, 9%) and treatment (pre, 31%; post, 26%) aspects of care.
Decision making in this setting is highly complex, incorporating a wide range of attributes that concentrate primarily on assessment aspects of care.
Clinical guidelines should provide support for strategies known to positively influence practice. Further, the education of nurses to use such guidelines optimally must take into account the highly complex iterative process and wide range of data sources used to make decisions.
... Following appraisal (AT), some limitations to the studies were identified. These included reduced generalisability due to singlecentre studies (Aitken, Marshall, Elliott, & McKinley, 2009;Choi & Song, 2003;Dolan & Looby, 2017;Fraser, Prato, Riker, Berthiaume, & Wilkins, 2000;Micek, Anand, Laible, Shannon, & Kollef, 2005;Pisani et al., 2013) and potential under-reporting of restraint use (Choi & Song, 2003;De Jonghe et al., 2013) due to the use of staff self-report. Secondary analysis was undertaken in one study (Luk et al., 2014), although the authors sought to cross-check data with the original participants. ...
... However, critical care nurses are able to titrate infusions according to need, and administer boluses of sedative drugs via existing infusions and pro re nata prescriptions. Perceived agitation or anxiety was cited as rationale for sedation boluses (Aitken et al., 2009). ...
... A need for formal nursing education regarding the use of physical restraints was expressed (Freeman et al., 2016;Palacios-Cena et al., 2016). Poor knowledge and lack of education was associated with neglecting to assess underlying causes of delirium and agitation (Aitken et al., 2009;Freeman et al., 2016), uncertainty regarding the correct interventions (Palacios-Cena et al., 2016) and unsafe practice (Suliman et al., 2017). Nurses who had received educational input demonstrated improved knowledge and safer restraint practice (Aitken et al., 2009;Suliman et al., 2017). ...
Aim:
To identify key determinants which lead to the decision to apply physical or chemical restraint on the critical care unit.
Background:
Psychomotor agitation and hyperactive delirium are frequently cited as clinical rationale for initiating chemical and physical restraint in critical care. Current restraint guidance is over a decade old and wide variations in nursing and prescribing practice are evident. It is unclear whether restraint use is grounded in evidence-based practice or custom and culture.
Study design:
Integrative review.
Method:
Seven health sciences databases were searched to identify published and grey literature (1995-2019), with additional hand-searching. The systematic deselection process followed PRISMA guidance. Studies were included if they identified physical or chemical restraint as a method of agitation management in adult critical care units. Quality appraisal was undertaken using Mixed Methods Appraisal Tool. Data was extracted, and thematic analysis undertaken.
Results:
23 studies were included. Four main themes were identified: The lack of standardised practice; patient characteristics associated with restraint use; the struggle in practice; the decision to apply restraint.
Conclusions:
There are wide variations in restraint use despite the presence of international guidance. Nurses are the primary decision-makers in applying restraint and report that caring for delirious patients is physically and psychologically challenging. The decision to restrain can be influenced by the working environment, patient behaviours and clinical acuity. Enhanced clinical support and guidance for nurses caring for delirious patients is indicated.
Relevance to clinical practice:
Delirium and agitation pose a potential threat to patient safety and the maintenance of life-preserving therapies. Restraint is viewed as one method of preserving patient safety. However, use appears to be influenced by previous adverse experiences and subjective patient descriptors, rather than robust evidence-based knowledge. The need for a precise language to describe restraint and quantify when it becomes necessary is indicated.
... The lack of sensitivity to recognize important cues and signs could lead to inaccurate judgment such as unnecessarily prolonged weaning, which not only could result in inefficient treatment cost and increase mortality rate (5) but also could rise respiratory tract infection incidence (6). Nurses require comprehensive knowledge with broad range attributes used during assessment and evaluation to support the decision-making process (7). ...
... Previous studies have shown that the complex factors encountered by critical care nurses may influence the type and method of their clinical decision-making and professional judgments (7)(8)(9). There is, however, limited information about the process of clinical decision-making in ICUs. ...
... Aitken et al. (7) state that contributing factors of decision-making for sedation management in ICUs include health history, current health status, anxiety, sedation level, patient' responses to therapies, family influences, and the outcomes of sedation management for each patient. They also point out that sedation assessment and management are greatly driven by the patient's neurological status; which is more influential in sedation assessment and management than pain and comfort. ...
Background Intensive Care Unit (ICU) is the hospital setting in which applied specific application of clinical decision making and judgement. The critical patient conditions in ICU may drive nurses to make decision and clinical judgement in short period of time. The approach of clinical decision making which appropriate to be applied in the critical circumstances is important to be identified, thus it could become a guidance for novice and expert critical nurses. Aim The aim of this study was to explain how clinical decision making is applied in Intensive Care Unit (ICU) Method A systematic review of 22 articles was carried out, articles were retrieved from CINAHL, MEDLINE, PUBMED and DISCOVERED databases. The articles were critically reviewed and analized to answer this study’s aim. Result The critically review of the articles were categorized in themes: 1) application of Tanner’s clinical judgment model in ICU, 2) Types of decisions in ICU, 3) Theoretical approach: implementation of decision-making in ICU, 4) Case illustration of decision-making scheme in ICU, 5) Influencing factors of decision-making in ICU, 6) Supporting tools for clinical decision-making in ICU, 7) Understanding of attributes and concepts may enhance the quality of the clinical decision-making process in ICU, 8) Implications for nursing education and practice of understanding clinical decision making in ICU. Conclusions Critical care nurses usually combine different techniques in making decisions; analytical methods including the hypothetic-deductive method, pattern recognition, intuition, narrative thinking, and decision analysis theory are potentially applied. Clinical decision activities in ICU appear in many clinical situations, such as intervention decisions, communication decisions, and evaluation decisions. There are several factors influencing clinical decision-making in intensive care units, including nurses’ experience, the patient’s situation, the layout of the ICU, shift work, inter-professional collaboration practice, physical and personnel resources. The application of clinical decision making could be supported by systematic tools, and the nurses’ knowledge about the concepts and attributes used in ICUs affect their clinical decision-making abilities. Keywords: clicinal decision making, critical care nurse, ICU
... Nurses' decision-making processes in the ICU are highly complex and incorporate multiple attributes. Aitken et al. (2009) found that the majority of attributes used by experienced critical care nurses when assessing and managing the sedation requirements of their patients were related to aspects of care, such as facial grimaces, responses to stimuli and discomfort. Nurses also use treatment and physiological attributes in their decision-making process. ...
... In addition, we reflect on the themes by using the French philosopher Maurice Merleau-Ponty (1945/2009 phenomenology of the body. For Merleau-Ponty the lived body takes on a central position and that we have access to the world through our bodies. ...
... For Merleau-Ponty (1945/2009), the lived body is central in being-to-the-world. The body is not considered an object ordered by the mind; instead, he emphasizes the body's exposure to the world as a central experience. ...
Aim:
To explore the phenomenon of assessing changes in patients' conditions in intensive care units from the perspectives of experienced intensive care nurses.
Background:
Providing safe care for patients in intensive care units requires an awareness and perception of the signs that indicate changes in a patient's condition. Nurses in intensive care units play an essential role in preventing the deterioration of a patient's condition and in improving patient outcomes.
Design and methods:
This hermeneutic phenomenological study conducted close observations and in-depth interviews with 11 intensive care nurses. The nurses' experience ranged from 7 to 28 years in the intensive care unit. Data were collected at two intensive care units in two Norwegian university hospitals. The analysis was performed using the reflective methods of van Manen.
Findings:
An overarching theme of 'sensitive situational attention' was identified, in which the nurses were sensitive in relation to a patient and understood the significance of a given situation. This theme was further unfolded in four subthemes: (1) being sensitive and emotionally present, (2) being systematic and concentrating, (3) being physically close to the bedside and (4) being trained and familiar with the routines.
Conclusions:
Nurses understand each patient's situation and foresee clinical eventualities through a sensitive and attentive way of thinking and working. This requires nurses to be present at the bedside with both their senses (sight, hearing, smell and touch) and emotions and to work in a concentrated and systematic manner. Knowledge about the unique patient exists in interplay with past experiences and medical knowledge, which are essential for nurses to understand the situation.
Relevance to clinical practice:
Clinical practice should develop routines that enable nurses to be present at the bedside and to work in a concentrated and systematic manner. Furthermore, providing safe care requires nurses to be sensitive and attentive to each patient's unique situation.
... More studies (41%) were carried out in the United States compared with other countries. [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] Five studies were conducted in the United Kingdom, [25][26][27][28][29] four studies in Australia, [30][31][32][33] three studies in Iran, [34][35][36] two studies in Canada, 37,38 two studies in Italy, 39,40 and one study in each of the following countries: Austria, 41 Bosnia and Herzegovina, 42 Turkey, 43 South Africa, 44 Korea, 45 Norway, 46 and China. 47 The studies were conducted during the period between the years 2007 and 2022. ...
... In nine studies, CDSS in ICU standardized nursing care aided evidence-based decisions about critical patient care and enabled nurses to make decisions more autonomously and effectively. 13,26,30,32,34,41,43,46 Two studies found that using CDSS in clinical simulations, education, and reflective interviewing augmented the critical-thinking skills of intensive care nurses and improved the level of correct decisionmaking. 37,42 Moreover, it was determined that ICU nurses mostly act intuitively in decision-making processes related to critical patient care, and the need for standardized and evidence-based protocols, algorithms, and guidelines and the use of CDSS were mentioned. ...
This study aimed to examine the impact of clinical decision support systems on patient outcomes, working environment outcomes, and decision-making processes in nursing. The authors conducted a systematic literature review to obtain evidence on studies about clinical decision support systems and the practices of ICU nurses. For this purpose, the authors searched 10 electronic databases, including PubMed, CINAHL, Web of Science, Scopus, Cochrane Library, Ovid MEDLINE, Science Direct, Tr-Dizin, Harman, and DergiPark. Search terms included “clinical decision support systems,” “decision making,” “intensive care,” “nurse/nursing,” “patient outcome,” and “working environment” to identify relevant studies published during the period from the year 2007 to October 2022. Our search yielded 619 articles, of which 39 met the inclusion criteria. A higher percentage of studies compared with others were descriptive (20%), conducted through a qualitative (18%), and carried out in the United States (41%). According to the results of the narrative analysis, the authors identified three main themes: “patient care outcomes,” “work environment outcomes,” and the “decision-making process in nursing.” Clinical decision support systems, which target practices of ICU nurses and patient care outcomes, have positive effects on outcomes and show promise in improving the quality of care; however, available studies are limited.
... Decision-making in the intensive care setting is complex and is impacted by the assessment component of nursing care ( Aitken et al., 2009 ;Wysong, 2014 ). Pain assessment in the sedated and ventilated patient is multifaceted: nurses need to analyse pain behaviour, interpret pain scores, make sound clinical decisions ( Gerber et al., 2015 ) and discriminate between situations needing analgesia and those requiring sedation ( Gerber et al., 2015 ). ...
... Pain assessment in the sedated and ventilated patient is multifaceted: nurses need to analyse pain behaviour, interpret pain scores, make sound clinical decisions ( Gerber et al., 2015 ) and discriminate between situations needing analgesia and those requiring sedation ( Gerber et al., 2015 ). Sedation management aimed at alleviating anxiety and promoting comfort is a fundamental element in the decision-making process and is dependant on a range of temporal, individual and contextual factors ( Aitken et al., 2009 ;Wikstrom et al., 2014 ). Critically ill patients may be provided analgesia and sedation to alleviate pain, optimise the outcomes of invasive procedures, reduce oxygen consumption and improve synchrony with the mechanical ventilator ( Hughes et al., 2012 ). ...
Background
Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment.
Objective
To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting.
Design
A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR).
Methods
The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were “pain”, “assessment”, “measurement”, “tools”, “instruments”, “practices”, “sedated”, “ventilated”, “adult”. A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting.
Results
The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency.
Conclusion
Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines.
The protocol of this review was registered with Open Science Framework (blinded for review)
Tweetable abstract:
Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.
... Clinical decision-making is a principal nursing skill and is highly complex in the context of critical care (Aitken, Marshall, Elliott, & McKinley, 2009). According to Bucknall (2000), nurses in intensive care units (ICU) face a decision or judgement every 30 s. Nurse decision-making in the ICU related to pain and other discomforts often relies on variables other than self-reporting. ...
... Decision-making by ICU nurses is complex because the patients are seriously ill and their health status changes rapidly (Bucknall, 2000(Bucknall, , 2003, often requiring nurses simultanously to deal with aspects of assessment, physiology and treatment (Aitken et al., 2009). Clinical decisions are influenced by the nurse's individual knowledge and experience (Bucknall, 2000(Bucknall, , 2003Shannon & Bucknall, 2003). ...
Aim
To explore the deliberation and enactment processes of nurses in relation to pain and other discomforts in the critically ill patients after the implementation of an analgosedation protocol.
Background
Nurses in intensive care units (ICU) face great challenges when managing pain and other discomforts and distinguishing between patients’ needs for analgesics and sedatives. An analgosedation protocol favouring pain management, light sedation and early mobilization was implemented in a university hospital ICU in Norway in 2014. Changing sedation paradigms resulting in an increasing number of awake patients during critical illness is expected to affect nursing practice.
Design
Exploratory, single‐unit study in a mixed adult ICU.
Methods
Data collection with participant observation and semi‐structured interviews in sixteen clinical situations in 2014 and 2015. Thirteen experienced certified critical care nurses were included. Thematic content analysis was conducted.
Results
An overall theme “Having the compass–drawing the map” emerged from the analysis. The protocol or strategy of analgosedation appeared to provide a direction for treatment and care, although requiring extensive interpretation of needs and individualization of care, often in challenging situations. The overall theme was abstracted from three themes: “Interpreting a complex whole,” “Balancing conflicting goals” and “Experiencing strain from acting across ideals.”
Conclusion
Nurses seem to attend adequately to patient pain, but the approach to discomforts other than pain appears unsystematic and haphazard. More explicit goals of care and strategies to handle discomfort as distinct from pain are needed. More research is needed to identify effective comfort measures for ICU patients.
... The characteristics of the stimuli in the simulated task environment and their relationship to performance have been clearly documented in the literature. [35][36][37] The results of the current study mirror those seen in studies of nurses with different levels of experience (e.g., novice versus expert), with the performance by the second-degree students reflecting the performance of more experienced practitioners. [35,38] Overall, the performance differences seen between the two groups are supportive of the notion that second-degree programs develop individuals with key advantages in decision-making capacity. ...
... [35][36][37] The results of the current study mirror those seen in studies of nurses with different levels of experience (e.g., novice versus expert), with the performance by the second-degree students reflecting the performance of more experienced practitioners. [35,38] Overall, the performance differences seen between the two groups are supportive of the notion that second-degree programs develop individuals with key advantages in decision-making capacity. [19] ...
Background: Students in accelerated second-degree programs are reported to be highly motivated, older, competitive, maintain higher grade point averages than their traditional counterparts, and score higher on standardized nursing achievement tests. However, studies that directly measure clinical performance parameters of students in accelerated second-degree programs in direct side-by-side comparison with traditional students under similarly controlled conditions have not been reported. Aim: The purpose of this study was to compare traditional and second-degree baccalaureate nursing students’ performance of key assessments and interventions in the management of deteriorating patients in a simulated task environment.
Methods: A convenience sample of 20 traditional and 20 accelerated undergraduate baccalaureate-nursing students participated. The four high-fidelity simulation exercises required the participants to detect early signs of patient deterioration and initiate treatment-based interventions. Two research personnel independently coded audio and videotaped data. The coders recorded the first time in which an assessment or intervention was performed. An independent samples t-test was performed to determine differences in nursing students’ performance of key assessments and interventions.
Results: Second-degree accelerated nursing students were in general more likely to recognize and respond to indicators of patient deterioration more promptly than their traditional counterparts.
Conclusions: Second-degree students appear to possess attributes that increase the likelihood that they will appreciate stimuli in the clinical environment, which is a precursor to effective intervention. Further research is required to substantiate the factors that account for performance differences between these traditional and second-degree baccalaureate nursing students.
... Previous research into clinical reasoning by critical care nurses has not been extensive. Recent studies have described factors that influence nurses' decisions, such as knowledge and experience (Anders-Ericsson et al. 2007), and how clinical decisions are made in everyday practice in relation to pain management (Mardegan 1997), recognising delirium (Souder & O'Sullivan 2000), pulmonary pressure monitoring (Aitken 2000), sedation management (Aitken et al. 2008) and management of postoperative patients (Hoffman et al. 2009). Investigators have used a variety of quantitative and qualitative methods, including observation, questionnaires, prospective or retrospective verbal protocols or mixed methods (Lundgren-Laine & Salantera 2010). ...
... There is limited evidence on the use of this theory to understand nurses' thinking process; mainly in assessing and managing pulmonary artery pressure monitoring (Aitken 2003), sedation (Aitken et al. 2008) and haemodynamic monitoring (Hoffman et al. 2009). These studies highlighted that the behaviour of the decision-maker depends on the definition of the nursing task, the depth of understanding the nurse seeks to achieve, the number and kinds of attributes attained and the order in which they are encountered when assessing the patient, the frequency and immediacy of validation of the hypotheses made and the anticipated outcomes of the decisions made. ...
Aim and objectives
To examine how nurses collect and use cues from respiratory assessment to inform their decisions as they wean patients from ventilatory support.
Background
Prompt and accurate identification of the patient's ability to sustain reduction of ventilatory support has the potential to increase the likelihood of successful weaning. Nurses' information processing during the weaning from mechanical ventilation has not been well‐described.
Design
A descriptive ethnographic study exploring critical care nurses' decision‐making processes when weaning mechanically ventilated patients from ventilatory support in the real setting.
Methods
Novice and expert Scottish and Greek nurses from two tertiary intensive care units were observed in real practice of weaning mechanical ventilation and were invited to participate in reflective interviews near the end of their shift. Data were analysed thematically using concept maps based on information processing theory. Ethics approval and informed consent were obtained.
Results
Scottish and Greek critical care nurses acquired patient‐centred objective physiological and subjective information from respiratory assessment and previous knowledge of the patient, which they clustered around seven concepts descriptive of the patient's ability to wean. Less experienced nurses required more encounters of cues to attain the concepts with certainty. Subjective criteria were intuitively derived from previous knowledge of patients' responses to changes of ventilatory support. All nurses used focusing decision‐making strategies to select and group cues in order to categorise information with certainty and reduce the mental strain of the decision task.
Conclusions
Nurses used patient‐centred information to make a judgment about the patients' ability to wean. Decision‐making strategies that involve categorisation of patient‐centred information can be taught in bespoke educational programmes for mechanical ventilation and weaning.
Relevance to clinical practice
Advanced clinical reasoning skills and accurate detection of cues in respiratory assessment by critical care nurses will ensure optimum patient management in weaning mechanical ventilation.
... This exemplar QSA was undertaken several years after the primary data were analyzed. (Aitken, Marshall, Elliott, & McKinley, 2009;Patel et al., 2009;Shehabi et al., 2008;Tanios, de Wit, Epstein, & Devlin, 2009;Weinert & Calvin, 2007). ...
... Similarly interaction has been reported as an important consideration for nurses when deciding when to sedate or restrain critically ill patients (Aitken, et al., 2009;Happ, 2000)). Li ((Li, Miaskowski, Burkhardt, & Puntillo, 2009) detected changes in vital signs and cortical arousal in deeply sedated patients when they underwent noxious stimuli (endotracheal suctioning or position changes). ...
Anxiety and agitation are experienced by critically ill patients frequently and produce management challenges for clinicians. The purpose of this study was to describe critically ill patients' behaviors classified as "anxious or agitated", clinician interpretation of these behavioral cues, and choice of interventions based on those interpretations. This qualitative secondary analysis used existing longitudinal data (observations, interviews, and medical records) from an ethnographic study of 30 critically ill patients who were weaning from prolonged mechanical ventilation, patient families and clinicians who cared for them. Each event of anxiety or agitation was analyzed using dimensional analysis techniques. Exploration of relationships of resulting themes and patterns using graphic displays led to development of the Anxiety -Agitation in Critical Illness Model which describes patient physiological, behavioral and psychological responses to stimuli of anxiety and agitation; clinician assessment of symptoms of anxiety and agitation, and management strategies chosen by clinicians. Interaction was identified as the core process in which patients appraised the threat of stimuli. Clinician assessment of patient interaction guided assessment and management of anxiety and agitation. Clinicians observed and interpreted patient responses to stimuli using "knowing the patient" and attributions about anxiety and agitation. Two opposing or dialectic attributions were revealed: discrimination vs. generalization and anxiety as an expected response vs. a character flaw. Interventions were designed to modify the stimulus of anxiety or agitation and included physical comfort measures, distraction, supportive verbal strategies, and music. Withholding presence and withholding information was described by clinicians as strategies used when patient anxiety was associated with ventilator weaning. These interventions were called "out of sight, out of mind" and "sneaking the wean". These were new and unexpected psychosocial interactions not described previously in the literature. Sedation was used to modify appraisal of or response to the stimulus. Sedation management was inconsistent and variable especially when anxiety was associated with ventilator weaning. This study provides a foundation for practice improvement by offering a comprehensive model and alternative considerations for interpretation and management of symptoms in the ICU. It suggests areas for additional study, specifically, social support, sedation and withholding information or presence.
... insertion of intravenous and urinary catheters, chest drains, endotracheal suctioning etc.) without jeopardising haemodynamic stability is a highly complex activity. Balancing sedation in tandem with patients' needs and physiological tolerances requires higher levels knowledge and skills beyond that obtained during preregistration nurse training (Aitken et al. 2009). Complications and adverse events have arisen from maintaining patients at deeper sedation levels than is necessary (Shehabi et al. 2013), and has been associated with higher levels of patient mortality ranging from 30-52% (Rodrigues & do Amaral 2004, Barr et al. 2013. ...
... Participants experiences captured in this study, similar to the observations of Aitken et al. (2009) of ICU nurses, demonstrated that the level of knowledge and skills needed to safely manage critically ill sedated intubated patients is highly complex. In this study, resuscitation nurse knowledge was conceptualised as knowing the location and use (i.e. ...
The aim of this study was to explore factors influencing practices in assessing, titrating and managing sedation for the critically ill intubated patients, from the perspective of emergency nurses.
The number of critically ill patients presenting to Australian public Emergency Departments has increased by over 30% since 1980. Emergency nurses are increasingly relied upon to manage sedation of critically ill intubated patients. There is little evidence within international literature relating to how emergency nurses accomplish this.
Descriptive qualitative study.
A purposive sample of 15 experienced emergency nurses participated in semi-structured face-to-face interviews. Transcribed data were analysed using thematic analysis.
The qualitative analysis yielded five themes: becoming the resuscitation nurse; becoming confident as the resuscitation nurse; communicating about sedation; visual cues and the vanishing act. The safety and quality of sedation experienced by critically ill intubated patients in ED was the responsibility of emergency nurses, yet uncertainties and barriers were evident.
Patient continuity of care, including optimisation of comfort relies upon the knowledge, skills and expertise of the emergency nurse allocated to the resuscitation area. For most nurses transitioning into the resuscitation nurse role, it represents the first time they will have had contact with patients with highly complex needs and sedation. The use of self-directed clinical workbooks and supervised clinical practice alone may be insufficient to adequately prepare nurses for the spectrum of critically ill sedated patients managed in the resuscitation area; a situation made worse in the presence of poor team communication.
The findings of this study should assist in the development of policy and formal education of emergency nurses transitioning into the resuscitation area and the management of continuous intravenous sedation to critically ill mechanically ventilated patients is required.
© 2015 John Wiley & Sons Ltd.
... The factors that were most strongly influential were the physical and clinical status of the patient and the experience of the nurse or midwife. Factors were identified in a variety of settings, including obstetric units (Cheyne et al., 2012;Oduro-Mensah et al., 2013;Wu et al., 2013), intensive care units (Aitken, Marshall, Elliott, & McKinley, 2008;Marshall et al., 2013;Tai, 2011), acute or critical care units (Bucknall, 2003;Cioffi, Conwyt, Everist, Scott, & Senior, 2009;Currey & Worrall-Carter, 2001;Currey, Browne, & Botti, 2006;Hancock & Easen, 2006;Hirsh et al., 2010;Hoffman, Donoghue, & Duffield, 2004;Lavellea & Dowling, 2011;McNett, Doheny, Sedlak, & Ludwick, 2010;Rattray et al., 2011;Thompson et al., 2008), coronary care units (Bakalisa et al., 2003;, emergency departments (Chung, 2005;Garbez, Carrieri-Kohlman, Stotts, Chan, & Neighbor, 2011;Gerdtz & Bucknall, 2001a, 2001b, psychiatric units (Dewar, Mullett, & Langdeau, 2009;Lindsey, 2009), medical/surgical wards (Harper, Ersser, & Gobbi, 2007;Hasegawa, Ogasawara, & Katz, 2007;Helmrich et al., 2001;King & Macleod, 2002;Ludwick et al., 2008;Pantazopoulos et al., 2012), and palliative and oncology wards (Searle & McInerney, 2008). ...
... Physical and clinical factors include the patient's history (Cheyne et al., 2012), clinical indicators such as temperature, respiratory rate, oxygen saturation level, blood glucose, systolic blood pressure, urine output, neurological status (Rattray et al., 2011), and even nonverbal behaviors and clinical observations (Harper et al., 2007). Psychosocial status includes the patient's ability to communicate and comprehend (Aitken et al., 2008), cultural and linguistic diversity, and impaired cognition (Cioffi et al., 2009). It can therefore be concluded that nurses' and midwives' sound decision making involves a holistic approach to patient care that includes physiological, psychosocial, and psychological factors. ...
To identify available literature concerning the factors that contribute to nurses and midwives making sound clinical decisions.
This is an integrative literature review.
Thirty-eight articles revealed four main domains that influence nurses' and midwives' clinical decision making-nurses and midwives' personal characteristics (n = 30), e.g., clinical experience; organizational factors (n = 26), e.g., colleagues; patient characteristics (n = 26), e.g., physical and clinical status; and environmental factors (n = 9), e.g., time. These four domains of factors combined influence sound clinical decision making in the context of nursing and midwifery.
Understanding the role of the factors influencing clinical decision making will help to improve patient and health outcomes.
Further understanding about the extent of the impact some factors have on clinical decision making is needed.
© 2015 NANDA International, Inc.
... Nurses' independent assessments and skills are vital because they are expected to notice changes in patients' sedation levels (Walker and Gillen, 2006) as they are at the patients' bedside constantly and are responsible for ensuring that patients are safely and optimally sedated. Therefore, nurses' knowledge, skills (Pun and Dunn, 2007;Patel and Kress, 2012), attitudes, experience, confidence (Walker and Gillen, 2006;Tanios et al., 2009) and clinical judgment (Aitken et al., 2009;Walker and Gillen, 2006) are important for safe sedative administration. ...
... One previous study showed that experienced nurses were more likely to provide higher sedation quality than junior nurses (Aitken et al., 2009). This current study, however, found that demographic characteristics did not affect nurses' abilities to assess and manage sedation, particularly at 9 months. ...
Background
Inappropriate sedation assessment can jeopardize patient comfort and safety. Therefore, nurses' abilities in assessing and managing sedation are vital for effective care of mechanically ventilated patients.Aims and objectivesThis study assessed nurses' sedation scoring and management abilities as primary outcomes following educational interventions. Nurses' perceived self-confidence and barriers to effective sedation management were assessed as secondary outcomes.DesignA post-test-only quasi-experimental design was used. Data were collected at 3 and 9 months post-intervention.MethodsA total of 66 nurses from a 14-bed intensive care unit of a Malaysian teaching hospital participated. The educational interventions included theoretical sessions, hands-on sedation assessment practice using the Richmond Agitation Sedation Scale, and a brief sedation assessment tool. Nurses' sedation scoring and management abilities and perceived self-confidence level were assessed at both time points using self-administered questionnaires with case scenarios. Sedation assessment and management barriers were assessed once at 9 months post-intervention.ResultsMedian scores for overall accurate sedation scoring (9 months: 4·00; 3 months: 2·00, p = 0·0001) and overall sedation management (9 months: 14·0; 3 months: 7·0, p = 0·0001) were significantly higher at 9 months compared to 3 months post-intervention. There were no significant differences in the perceived self-confidence level for rating sedation level. Overall perceived barrier scores were low (M = 27·78, SD = 6·26, possible range = 11·0–55·0). Patient conditions (M = 3·68, SD = 1·13) and nurses' workload (M = 3·54, SD = 0·95) were the greatest barriers to effective sedation assessment and management. Demographic variables did not affect sedation scoring or management abilities.Conclusions
Positive changes in nurses' sedation assessment and management abilities were observed, indicating that adequate hands-on clinical practice following educational interventions can improve nurses' knowledge and skills.Relevance to clinical practiceEducational initiatives are necessary to improve ICU practice, particularly in ICUs with inexperienced nurses.
... Undertaking sedation management demonstrates advanced skill and knowledge for understanding how physiological changes may reflect sedation and analgesic patient need. 50 Further, there is growing evidence to suggest that observational sedationscoring assessment tools may enhance nursing management of sedation of critically ill patients receiving continuous sedation. ...
... Our review of the literature reveals that the knowledge, skills and expertise required by emergency nurses 9 to safely balance time-sensitive procedures, medical therapies with pharmacological agents in the presence of patient haemodynamic instability and limited physiological reserves, is highly complex. 50 Continuity of care for the critically ill patient remains the responsibility of emergency nurses, and is therefore dependent upon the knowledge, skill and expertise of emergency nurses until the patient is transferred to an ICU. The specialised skills, abilities and knowledge necessary to safely care for critically ill or injured patients receiving continuous sedation in the resuscitation bay remain unclear. ...
Critically ill mechanically ventilated patients in ED have complex needs; chief among these is adequate sedation in addition to effective pain-relief. Emergency nurses are increasingly responsible sedation and analgesia for this complex cohort of patients. The aim of this review was to examine (1) the evidence around assessing, monitoring and managing continuous intravenous sedation for critically ill adult patients, and (2) the implications for emergency nursing practice.
Systematic review.
The review of literature extended from 1946 to 2013 and examined peer review journal articles, policy and guidelines to provide a more complex understanding of a phenomenon of concern. A total of 98 articles were incorporated and comprehensively examined.
Analysis of the literature identified several implications for emergency nursing practice and the management of continuous intravenous sedation: workload, education, monitoring and assessing sedation and policy.
Limited literature was found that directly addressed Australasian emergency nursing practices' in managing on-going intravenous sedation and analgesia for patients. Balancing patient sedation and analgesia requires highly complex knowledge, skills and expertise; the degree of education and training required is above that obtained during pre-registration nurse training. No state or national models of education or training were identified to support ED nurses' practices in managing sedation. Little research has addressed the safety of continuous sedation use in ED.
Copyright © 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
... Mechanically ventilated patients experience negative emotions such as anxiety, anger, fear and frustration during mechanical ventilation period because of the intensive care unit (ICU) environment, invasive monitoring devices, ventilator dyssynchrony, invasive procedures, communication difficulties, and dyspnea. [7,8]. ...
... del sonno, ansia e agitazione possono risultare incompatibili con le necessità terapeutiche. 4,5, 6 Le moderne tecniche di assistenza ventilatoria prevedono che il paziente sia sveglio e ben adattato al supporto meccanico; queste nuove strategie gestionali sottolineano l'importanza di un corretto uso della sedazione e dell'analgesia. 7 Diventa inoltre fondamentale l'ottimizzazione delle risorse atte a migliora-Introduzione I l paziente critico ricoverato in terapia intensiva subisce esperienze stressanti sia a causa della patologia che lo porta al ricovero, sia per le caratteristiche ambientali e sia per le manovre invasive a cui viene sottoposto. ...
Introduzione: la valutazione dello stato di coscienza e l’insorgenza di delirium andrebbero valutati nei pazienti ricoverati in terapia intensiva mediante strumenti standardizzati, semplici e di veloce utilizzo.Materiali e metodi: valutare l’applicazione della Richmond Agitation-Sedation Scale (RASS) e della Confusion Assessment Method for the ICU(CAM-ICU) nei pazienti ricoverati in una terapia intensiva polivalente. Studio osservazionale retrospettivo nel periodo gennaio 2007- dicembre 2011. La somministrazione della RASS è stata fatta almeno una volta per turno e ad ogni variazione dello stato di coscienza, mentre la CAM-ICU è stata somministrata quando l’infermiere sospettava la presenza di segni di delirium.Risultati: su una popolazione di 1523 pazienti sono state ottenute 25.813 misurazioni RASS con un punteggio medio di -1,05 (±1,22). Le rilevazioni totali di CAM-ICU sono state 678 e i pazienti che sono stati oggetto di valutazione di delirium (11,03%).Le rilevazioni positive sono state in totale 78 (11,50%). Il numero di pazienti con CAM-ICU positiva è stato pari a 45 (26,79%) rispetto a tutte le misurazioni effettuate e pari al 2,95% della popolazione totale.Conclusioni: al fine di migliorare l’assistenza infermieristica è importante valutare lo stato di coscienza e l’insorgenza di delirium e applicare tutte le strategie assistenziali atte a ridurne l’incidenza. La RASS e la CAM-ICU sono strumenti semplici, facilmente utilizzabili dagli infermieri di area critica.
... ICU nurses require insights and skills to discover nearly invisible signs among the patients, act and/or prevent actions in each situation (Benner, Hooper-Kyriakidis et al., 2011b). ICU nurses' decision-making process is highly complex and involves touching the patient's skin (Aitken et al., 2008). Caring touches such as stroking the patient's chin or holding his hand are important to preserve the patient's dignity and communicate safety and care (Bundgaard and Nielsen, 2011;Playfare, 2010;Hov et al., 2007). ...
Background
Historically, caring touch was integrated in targeted nursing acts as shoulder massage, calming patients or to check vital parameters by touching the patient`s skin. However, this phenomenon in intensive care nursing still lacks convincing descriptions. Caring touch is an important part of being an intensive care nurse and confirming the patient`s dignity. To touch the patient`s skin is a common nursing act, but not much spoken of. Caring touch on the patient`s chin, holding hands or giving a hug has earlier been called e.g., non-procedural touch.
Purpose
Explore the meaning of caring touch as it appeared for Norwegian intensive care nurses.
Methods
Secondary analysis of data from qualitative, individual semi-structured interviews. Eight experienced intensive care nurses at public Norwegian non-university hospitals. Registered by the Norwegian Center for Research data NSD December 2014. ID 41164.
Findings
Data analysis revealed one main-theme: The speaking body, with four sub-themes 1) Eyes and facial expressions, 2) Patients emotional expressions, 3) Closeness and distance, 4) ICU nurses’ emotional responses.
Conclusion
Caring touch is a silent way of showing culturally competent care and establish or continue nurse-patient relationships in intensive care units. Caring touch contributes to heighten ethical dimensions of dignity in intensive care nursing.
... Tipe ini, Peneliti tidak berusaha mengubah perilaku subjek dan memberi tahu mereka bahwa mereka sedang diamati. Penelitian oleh Aitken et al (2009) yang meneliti tentang faktor yang berkontribusi dalam pengambilan keputusan perawat saat menilai dan mengelola sedasi pada pasien sakit kritis. Perawat diamati saat memberikan sedasi (penenang) pada pasien sakit kritis dan diminta untuk "berpikir keras" selama 2 jam perawatan untuk meneliti proses pengambilan keputusan yang digunakan perawat ketika menilai dan mengelola kebutuhan sedasi pasien sakit kritis. ...
... Think Aloud has been previously used in studies based in critical care (Aitken et al., 2009;Han et al., 2007). The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed (Tong et al., 2007) (included in Data S1). ...
Aims & Objectives
This study aimed to explore the decision-making processes undertaken by critical care nurses when considering restraint to manage a patient with psychomotor agitation secondary to hyperactive delirium.
Background
Psychomotor agitation is frequently cited as clinical rationale for initiating chemical or physical restraint. Despite the presence of clinical guidance for restraint in critical care, wide variations in nursing and prescribing practice are evident. Nurses are the primary decision makers when initiating restraint, but little is known about this process and influencing factors.
Design
A pragmatic qualitative approach was used to explore critical care nurses’ decision-making processes.
Methods
A ‘think aloud’ approach was undertaken. Audio-visual vignettes featuring simulated patients were used as stimulus to elicit decision-making processes from thirty critical care nurses and practitioners. The COREQ checklist was followed.
Results
Five themes relating to restraint were identified: Intrinsic beliefs and aptitudes; Handover and labelling; Failure to maintain a consistent approach; Restraint might be used to replace vigilance; The tyranny of the now.
Conclusions
Restraint was more frequent when staffing ratios were reduced below 1:1 and opportunities for vigilance reduced. Participants described physical and psychological exhaustion when caring for a patient with delirium and how this might lead to restraint to create ‘space’ for respite. Variations in practice were evident and restraint use appears rooted in custom and culture rather than objective assessment.
Relevance to clinical practice
The lack of pre-emptive management for hyperactive delirium and reduced staffing ratios lead to the decision to restrain to preserve safety in acute agitation. The struggle to manage agitated behaviour is associated with nurse burnout and reduced engagement with therapeutic management methods, suggesting the need for psychological and educational support for clinical staff. Delirium is an important and debilitating form of organ dysfunction which should be collaboratively managed by the multi-disciplinary team.
... Data from the transcriptions were analysed using thematic analysis. The six phases of thematic analysis outlined by 27 were used as a framework to support the process, namely: comparisons was undertaken by all team members, supported by a mind-mapping tool. This allowed the team to make revisions and links across themes. ...
Background:
People who are experiencing a period of critical illness frequently experience severe agitation. The presence of agitation can pose risks to the patient, family, and clinical team.
Aims and objectives:
To capture the views and opinions of critical care multidisciplinary teams concerning the approaches in the management of agitation, and to understand and identify the perceived risks and benefits of current management strategies.
Design:
A descriptive qualitative design.
Methods:
Data were gathered using semi-structured interviews with multidisciplinary teams from adult critical care units from one region in the United Kingdom.
Findings:
A total of 19 participants participated between February to September 2017. There were two group interviews (GIs) (n = 12, GI 1 n = 8, GI 2 n = 4) and seven one-to-one interviews, across four hospital organisations with one participant working via an agency. The mean length (± SD) of each interview, one to one or group, was 58.86 minutes (5.81 minutes). Three major themes were generated about the complex clinical decision-making required to manage an agitated patient. These themes represented: the burden of care, continuity of clinical decision-making, and uncertainty and indecision experienced by participants.
Conclusion:
Participants described caring for an agitated patient as challenging and stressful. Staff sought clarification on what level of restrictive practice is allowed. Feelings of anxiety and stress generated by the decisions made may have an impact on staff, particularly those who are more inexperienced, which in the longer term could lead to fatigue or moral distress.
Relevance to clinical practice:
The study has emphasised the challenges faced by multidisciplinary teams and how decision-making may impact on individuals within the team.
... Nurses ID:p0095 are usually responsible for administering and manipulating sedation according to patient's condition, consciousness level, and treatment plan. Therefore, it is of utmost importance that nurses possess adequate knowledge and expertise to maintain sedation of MVP (Aitken et al., 2009). Literature supports that nurses with a good level of knowledge regarding sedation use in ICU can provide standard care to their patients and contribute to health promotion and maintenance (Varndell et al., 2015). ...
Background
Sedation assessment and management is an essential part of critical care nursing. The patients are at significant risks of undersedation and oversedation. Critical care nurses must possess sufficient knowledge about sedation assessment and its management.
Aim
This study aimed to determine critical care nurses’ knowledge of sedation and its management in mechanically ventilated patients in Pakistan.
Methodology
A cross-sectional descriptive study was conducted. The participants were recruited from three critical care units of a tertiary care hospital using a consecutive sampling technique. Data were collected using a self-administered questionnaire.
Findings
In total, 91 critical care nurses participated in this study. Most of them had less than 2 years of experience as registered nurses and as intensive care unit nurses. The majority of them had insufficient knowledge (poor knowledge 18.7% and fair knowledge 63.7%), whereas only 17.6% had good knowledge of sedation and its management. The average correct response rate for general knowledge of sedation management practices was 71.3%. Almost half of the participants (51.6%) had poor knowledge of assessing undersedation and oversedation. Overall, 67% of nurses had good knowledge of managing sedative drugs.
Conclusion
The majority of critical nurses lacked sufficient knowledge related to sedation and its management in mechanically ventilated patients. This poses risks to patients’ safety and quality of care.
... Tantangannya adalah memilih kombinasi obat untuk menghindari efek overdosis obat (Vazquez et al., 2011). Sementara jika tingkat sedasi tinggi dapat menyebabkan masalah seperti kecemasan, ekstubasi yang disengaja atau kerusakan fisik, serta dapat menyebabkan ketergantungan berkepanjangan pada penggunaan ventilasi mekanik (Aitken, Marshall, Elliott, & McKinley, 2009). Penelitian telah menunjukkan bahwa nyeri yang tidak dikelola dengan baik, terutama pada pasien tersedatif maka akan menimbulkan efek yang berbahaya meskipun telah dilakukan penilaian sedasi. ...
Background: Pain is experience of critically ill adult patient with ventilator. It is various among patient from moderate to severe. Factors that may affect pain in critical patients include gender, age, severity of the disease and type of sedative use. Objective: to determine the demographics of critically ill adult patients with ventilator who experience pain. Method: This is a non-experimental quantitative study with 66 ventilated adult patient in the ICUs of the 3 hospitals in Semarang. Results: The results showed that critically aged patients with 41-60 years old pain experienced 38.3%, over 60 years of 38.8%, the almost gender is man of 66.7% with the most medical diagnoses were respiratory disorders by 45% and no use sedation is 83.3%. Conclusions: The pain experienced in adult critical patients can be seen from the demographics of patients such as age, gender, medical diagnosis and sedation use.�Keywords : Pain assessment, criticall ill, adult, ventilator
... Kelly and Vincent (2011) found that nursing surveillance involves the purposeful and ongoing collection, interpretation and synthesis of data, including subtle changes in-and signs from-the patient. Aitken, Marshall, Elliott, and McKinley (2009) found that the majority of attributes used by expert nurses when assessing and managing their patients' sedation requirements were related to the assessment aspects of care, such as facial grimaces, responses to stimuli, and anxiety and discomfort. Randen and Bjørk (2010) reported that when assessing sedation needs, intensive care nurses consider personal experience and intuition as more important than research-based knowledge. ...
Providing safe care for patients in intensive care units (ICUs) requires both awareness and perception of the signs indicating changes in a patient’s condition at an early stage. In addition, ensuring high-quality health care and patient safety in the ICU requires an effective exchange of patient information among health professionals. The overall aims of this study were to explore the phenomenon of becoming aware of incipient changes in the clinical conditions of ICU patients. Furthermore, the study evaluated the dialogue between nurses and physicians regarding the clinical status of patients and the prerequisites for an effective and accurate exchange of information. A multimethod design included: Close observations and in-depth interviews with ICU nurses and focus group discussions with ICU nurses and physicians in two Norwegian ICUs were conducted. We found that identifying the incipient changes in a patient’s clinical condition requires understanding the ever-changing dynamics of the patient’s condition and images composed of signs that were sensory, measurable, and manifested as the mood of the nurse. Care situations and the following of patients through shifts are essential in enabling nurses to detect these signs. Nurses understand each patient’s situation and foresee clinical eventualities through a sensitive and attentive way of thinking and working. The information for each unique patient interacts with past experiences and medical knowledge, which are essential for nurses to understand the situation. Nurses should be aware of their essential role in conducting ongoing clinical observations of patients and their right to be included in decision-making processes regarding patient treatment and care. Accurate and effective dialogue between nurses and physicians on shift requires leadership that is able to organize routine interdisciplinary meetings. Furthermore, this type of dialogue requires physician willingness to listen to and include the nurses’ clinical observations and concerns regarding the patient in the decision-making process.
... The EOM II item that most directly assessed nurses' autonomy remained essentially Knowledge work theorists and researchers regard evidence based practice as a means to temper overreliance on subjective clinical judgment, and promote quality and clinical outcomes (Aitken, Marshall, Elliott, & McKinley, 2009;Antrobus, 1997;Benner et al., 1996;Lee, 2014;Snyder-Halpern et al., 2001). CDSSs are advanced by software vendors, hospital administrators, and nurse leaders as a way to deliver evidence to clinicians at the point-of-care. ...
Background: The HITECH act's financial incentives and meaningful use mandates have resulted in unprecedented rates of EHR and CDSS adoption. These systems are premised on evidenced-based guidelines, the standardization of care, and the reduction of subjective clinical decisions. They are designed to record clinical events, synchronize the efforts of care teams, facilitate the exchange of information, and improve the control and design of clinical processes. Knowledge workers are challenged to assimilate these changes into a deliberative and autonomous style of practice.^ Aims: The study examined the impact of a CDSS implementation on nurses' perceptions of their ability to perform aspects of knowledge work and on the nursing practice environment. Nurse and clinical unit characteristics were examined to identify those that predicted outcome variance.^ Methods: This study used The Impact of Health Information Technology (I-HIT) and The Essentials of Magnetism II (EOM II) instruments. Guided by the Quality Health Outcomes Model, this pre-post, quasi-experimental study includes t-tests, repeated measure and univariate general linear model regression analyses. Two groups comprised the convenience sample of 1,045 nurses: a paired (n=458) and independent (n=587).^ Results: The functionality of the CDSS was perceived to reduce nurses' ability to efficiently practice, communicate, share information, and interfered with workflow in ways that depersonalized care. Perceptions of the practice environment, interestingly, remained essentially unchanged, with slight improvements and no statistically significant declines. This included perceptions about autonomy, patient-centered values, professional satisfaction and quality care. Even though the CDSS's functionality interfered with practice, and may be poised to deemphasize subjective judgment and autonomy, nurses did not seem to reject the CDSS's ability to standardize aspects of care. This study also found that nurse and clinical unit characteristics such as clinical unit type, shift, expertise, race, and whether or not nurse education was obtained outside of the USA, explained more variance than years of experience, institutional tenure, and level of education.^ Conclusion: Results suggest that nursing science needs to investigate and advise the design of CDSSs, as well as, develop tactics to reap the benefits of processes and guidelines, while preserving knowledge works' emphasis on expertise, intuition, and holistic care.
... Nonverbal critically ill intubated patients require close observation and monitoring during treatment of their underlying condition, with titration of analgesia, sedation and ventilator settings (Aitken et al. 2009), now a role increasingly undertaken by emergency nurses (Varndell et al. 2015c). In the absence of communicating pain levels, observational assessment instruments with unidimensional measures with multiple domains or multidimensional measures are preferred to evaluate acute pain in nonverbal critically ill patients (Herr et al. 2011). ...
Aim and objective:
To examine the psychometric properties and suitability of the available observational pain instruments for potential use with nonverbal critically ill adult patients in the emergency department.
Background:
In the emergency department, assessing pain in critically ill patients is challenging, especially those unable to communicate the presence of pain. Critically ill patients are commonly unable to verbally communicate pain due to altered oral communication (e.g. endotracheal intubation) and/or diminished consciousness (e.g. sedation, delirium), placing them at great risk of inadequate pain management. Over half of intensive care critically ill intubated patients experience moderate-to-severe pain whilst intubated and mechanically ventilated.
Design:
Systematic review.
Data sources:
The CINAHL, EMBASE, MEDLINE, ProQuest databases, and the Cochrane Library and the National Institute of Clinical Excellence were also searched from their date of inception to April 2016, with no language restrictions applied.
Review method:
Studies were identified using predetermined inclusion criteria. Data were extracted and summarised and underwent evaluation using published classification of psychometric tests for consistency of interpretation.
Results:
Twenty-six studies evaluating five observational pain assessment instruments that had been used with critically ill intubated patients were identified. All five instruments included behavioural indicators, with two including physiologic indicators. All five instruments have undergone validity and reliability testing involving nonverbal critically ill intubated patients, three were examined for feasibility, and one instrument underwent sensitivity and specificity testing. None have been tested within the emergency department with nonverbal critically ill intubated adult patients.
Conclusion:
The use of an appropriate and valid observational pain assessment instrument is fundamental to detecting and optimising pain management in nonverbal critically ill intubated patients in the emergency department. Of the observational pain assessment instruments reviewed, the Critical-Care Pain Observation Tool was identified as most appropriate for testing in a prospective trial in an emergency department setting.
... Subramanian et al. 2011), end of life care(Carnevale et al. 2011, Piers et al. 2011, Festic et al. 2012) and treatment modality changes in general(Coombs & Ersser 2004). Conversely, recent Australian, Scandinavian, British and Irish studies reported a significant and highly influential role of nurses in decisions about sedation assessment and management(Aitken et al. 2008, Randen & Bjork 2010, Bjork & Hamilton 2011 and weaning from mechanical ventilation(Kydonaki 2010;Rose et al. 2011b, Lavelle & Dowling 2011, Haugdahl & Storil 2011, with experience, confidence, education and knowledge being particularly valuable in facilitating participation in treatment modality decisions. ...
Aim:
To explore critical care nurses' decisions to seek help from doctors.
Background:
Despite their well-documented role in improving critically ill patients' outcomes, research indicates that nurses rarely take decisions about patients' treatment modalities on their own and constantly need to seek advice or authorization for their clinical decisions, even for protocol-guided actions. However, research around the factors related to, and the actual process of, such referrals is limited.
Design:
A grounded theory study, underpinned by a symbolic interactionist perspective.
Methods:
Data collection took place in a general intensive care unit between 2010 - 2012 and involved: 20 hours of non-participant and 50 hours of participant observation; ten informal and ten formal interviews; and two focus groups with ten nurses, selected by purposive and theoretical sampling. Data analysis was guided by the dimensional analysis approach to generating grounded theory.
Findings:
Nurses' decisions to seek help from doctors involve weighing up several occasionally conflicting motivators. A central consideration is that of balancing their moral obligation to safeguard patients' interests with their duty to respect doctors' authority. Subsequently, nurses end up in a position of dual agency as they need to concurrently act as an agent to medical practitioners and patients.
Conclusion:
Nurses' dual agency relationship with patients and doctors may deter their moral obligation of keeping patients' interest as their utmost concern. Nurse leaders and educators should, therefore, enhance nurses' assertiveness, courage and skills to place patients' interest at the forefront of all their actions and interactions.
... Nurses in any organizational context are members of a team and cannot work independently. The team consists of nurses at different levels, physicians, other health care workers and administrators (Aitken, et al., 2009). Teamwork requires making decisions frequently and these decisions affect team performance on a day-to-day basis. ...
Background:
Nurses in any organizational context are members of a team and cannot work independently. Teamwork requires making decisions frequently, and these decisions affect team performance on a regular basis. Ultimately, the team shapes the quality of patient care.
Aim:
This study examines nurse decision-making related to patient care, self-management and the work environment.
Method:
Qualitative descriptive design was used to collect data. Eighteen staff nurses participated in semi-structured interviews to explore the perception of Jordanian staff nurses regarding their participation in decision-making.
Results:
Variation in decision-making involvement was found to exist across unit types and from hospital to hospital. In general, the participants were not satisfied with their level of decision-making involvement and believed that they could participate more.
Conclusion:
The results have implications for nurse managers in facilitating the engagement of staff nurses in decision-making and creating an organizational culture to facilitate this engagement.
Aim: The research was conducted to evaluate the effect of web-based education on the knowledge and practices of intensive care nurses about sedation management. Material and Method: In this study, which was carried out in a single group, pre-test-post-test design, the knowledge levels and practices of 62 intensive care nurses on sedation management were evaluated. The nurses were given web-based sedation management education, one month after the education, the knowledge levels and practices of the nurses participating in the study on sedation management in intensive care patients were re-evaluated, and the effectiveness of the education was evaluated by analyzing the data before and after the education. Results: After the web-based education, it was determined that there was a significant increase in the rate of correct answers to the statements about sedation management by nurses. It was determined that the rate of nurses applying nursing interventions to prevent agitation and reduce the sedation need of patients increased significantly after the education. Conclusion: It has been determined that web-based education is an approach that supports increasing the knowledge and practices of intensive care nurses on sedation management. It is recommended that web-based education programs be supported in order for intensive care nurses to perform effective agitation-sedation management.
ABSTRACT
This two-phase study focused on critical care nurses’ skills. The purpose was first to
describe and create a theoretical construction of patient observation skills in critical
care nursing, and second, to evaluate the current level of Finnish critical care nurses’
patient observation skills using subjective and objective assessment and investigate
the factors associated with the skills. The aim was to deepen the understanding of
critical care nurses’ skills, and ultimately to develop their skills to enhance quality
of care and patient safety in intensive care units.
In the first study phase, patient observation skills were described and a
preliminary theoretical construction was created based on the semi-structured
interviews among experienced critical care nurses (n=20). Thematic analysis was
used to analyse the data. The second phase utilized cross-sectional correlational
design to evaluate critical care nurses’ patient observation skills and to investigate
associated factors. An instrument, Patient Observation Skills in Critical Care
Nursing (POS-CCN) consisting of self-assessment and knowledge test, was
developed. Critical care nurses (n=372, response rate 49%) in Finnish intensive care
units in university hospitals answered the questionnaire. The methods of data
analysis included descriptive and inferential statistics and general linear model.
Patient observation skills in critical care nursing consist of information-gaining,
information-processing, decision-making and co-operation skills. The evaluation of
critical care nurses’ skills was limited to information-gaining and informationprocessing
skills. Critical care nurses assessed their information-gaining skills as
excellent, whereas knowledge test assessment suggested that information-processing
skills are suboptimal. Critical care nurses who were highly confident in their
competence and educated for special tasks in intensive care units had higher level of
patient observation skills.
There is a need for improving critical care nurses’ patient observation skills
especially in information processing. Systematic education and training in patient
observation is needed in intensive care units, and skills evaluation practices need to
be developed further.
Background: Critical Care Nursing is a specialized field of Nursing requiring focused knowledge and technical skills, compassionate care and skillful practice. This study was designed to develop and test Clinical Nursing Practice Guidelines (CNPG) for oral care of critically ill patients Methods: Clinical Nursing practice Guidelines were formed with evidence sources and consensus from relevant stakeholders. Quasi experimental pretest posttest research design was used to assess the effect of CNPG on oral care practice of Nursing personnel. Data was collected with non participant observation. Results: Implementation of Clinical Nursing practice Guideline showed a significant difference in the oral care practice of nursing personnel. Conclusion: The study highlights how evidence gathered from research studies can be translated into bedside care through Clinical Nursing Practice Guidelines. It also shows the effect of the CNPG on practice of nurses.
Background:
Vignettes are regularly used in nursing research and education to explore complex clinical situations. However, paper-based vignettes lack clinical realism and do not fully recreate the pressures, sights and sounds of clinical settings, limiting their usefulness when studying complex decision-making processes.
Aim:
To discuss the approach taken by the authors in developing and implementing audiovisual vignettes to collect data remotely in a qualitative study.
Discussion:
The authors describe how they created audiovisual vignettes for a qualitative 'Think Aloud' study exploring how critical care nurses decide whether to restrain agitated patients with varying degrees of psychomotor agitation. They discuss the practicalities of filming, editing and hosting, as well as the theoretical and clinical background that informed the creation of the vignettes.
Conclusion:
Audiovisual vignettes are a cost- and time-effective way of remotely exploring decision-making in challenging environments. This innovative method assists in studying decision-making under simulated clinical pressures and captures data about how people make complex decisions.
Implications for practice:
Audiovisual vignettes are an innovative tool for collecting data and could also be used in educational settings and offer the opportunity to explore complex clinical decision making remotely. Clinical accuracy is essential for immersing participants and simulating an environment and its pressures. The method could be further enhanced by making vignettes responsive to participants' decisions.
Nurses have a leading role in weaning patients from mechanical ventilation (WMV) given their constant presence and their continuous monitoring. To promote proper WMV, nurses must exercise autonomy and be involved in decision-making. However, in certain care contexts, there is little involvement of nurses. The purpose of this text is to establish the characteristics of the concept of autonomous decision-making applied to nursing during WMV. An analysis of this concept was carried out according to the evolutionary method of Rodgers. The identification of the attributes, antecedents, and consequences made it possible to note ambiguity in the definition of this concept. Nurses use autonomous decision-making for the execution of assigned tasks and when they make decisions according to a pre-prescribed decision-making algorithm. Significant foundations for the decision-making autonomy of critical care nurses during WMV emerged from this analysis : scope of practice, in-depth knowledge of the patient, and commitment to the success of WMV. Participation in interdependent decision-making allows nurses to bring the patient’s perspective into decisions. Avenues of reflection have also emerged, including decisions based on evidence to provide new avenues for autonomous decision-making.
Purpose: For this study an examination was done of relationships between intensive care unit (ICU) nurses' knowledge related to sedation and their clinical competencies in sedation practice. Methods: Ninety one ICU nurses were recruited from two tertiary hospitals in South Korea. A self-report questionnaire was used to examine the levels of knowledge related to sedation and nursing practice competence based on Ajzen's theory of planned behavior. Descriptive statistics, independent t-tests, one-way ANOVA, and Pearson correlations were performed using the IBM SPSS 21.0 Results: ICU nurses are more knowledgeable about general information on sedation rather than up-to-date information. Continuing education on sedation was related to difference in knowledge levels. However, the levels of knowledge were not related to competence in sedation practice. Instead, a positive attitude toward sedation practice was significantly related to the subjective norms; orders and goals, perceived behavioral control, practice of sedation, and intention to use. Conclusion: The results of this study provide fundamental information on levels of knowledge related to sedation practices of Korean ICU nurses. Continuing education should emphasize up-to-date information on sedation practice and need for positive attitudes which influence all other competencies towards sedation practices to achieve optical care of sedation in the ICU.
This chapter will describe clinical-nursing leadership and discuss how the collaboration between nurse leaders, nursing researchers, and clinical nurses can provide a foundation for a strong research culture in the clinical field. In particular, it will demonstrate the close connection between strategic leadership, quality development involving bedside clinicians, and focused clinical research in the intensive care unit (ICU) nursing service. Research ideas and topics originate from the clinical practices related to ICU patients’ daily challenges during treatment in the ICU as well as in the nursing interventions that address these patients’ needs. The focus has been on designing clinically relevant studies that respond to research questions in order to improve ICU patients’ survival and comfort, decrease their symptom burden, and minimise the length of their stay. A major emphasis has been placed on implementation strategies and on applying the research results in their original settings.
Qualitative secondary analysis (QSA) is the use of qualitative data that was collected by someone else or was collected to answer a different research question. Secondary analysis of qualitative data provides an opportunity to maximize data utility, particularly with difficult-to-reach patient populations. However, qualitative secondary analysis methods require careful consideration and explicit description to best understand, contextualize, and evaluate the research results. In this article, we describe methodologic considerations using a case exemplar to illustrate challenges specific to qualitative secondary analysis and strategies to overcome them.
Background:
Nursing Science presents surveillance as an indispensable component of patient safety. Although the literature defines surveillance fully, its implementation is not well understood.
Aim:
This research aims to formulate a theoretical explanation of the surveillance process that expert nurses employ in critical care.
Method:
To develop the theoretical explanation for the surveillance process of critical care nurses, Strauss and Corbin's (1998) grounded theory approach and Think Aloud Method (Fonteyn et al., 1993) were used with fifteen expert critical care nurses (n=15).
Results:
Surveillance in critical care is a continual process of collaborative vigilance that starts with the thought process and behavior related to data collection, analysis, and interpretation. The surveillance process comprises five key elements: 1) Managing the risk of complications; 2) Collecting data; 3) Detecting a problem; 4) Making a decision; and 5) Working in synergy.
Conclusion:
In developing a theoretical explanation, this research leads to an understanding of the surveillance process performed by expert nurses in a critical care context.
Background:
Pain and sedation protocols are suggested to improve the outcomes of patients within paediatric intensive care. However, it is not clear how protocols will influence practice within individual units.
Objectives:
Evaluate a nurse led pain and sedation protocols impact on pain scoring and analgesic and sedative administration for post-operative cardiac patients within a paediatric intensive care unit.
Methods:
A retrospective chart review was performed on 100 patients admitted to a tertiary paediatric intensive care unit pre and post introduction of an analgesic and sedative protocol. Stata12 was used to perform Chi 2 or student t tests to compare data between the groups.
Results:
Post protocol introduction documentation of pain assessments increased (pre protocol 3/24h vs post protocol 5/24h, p=0.006). Along with a reduction in administration of midazolam (57.6mcg/kg/min pre protocol vs 24.5mcg/kg/min post protocol, p=0.0001). Children's pain scores remained unchanged despite this change, with a trend towards more scores in the optimal range in the post protocol group (5 pre protocol vs 12 post protocol, p=0.06).
Conclusions:
Introducing a pain and sedation protocol changed bedside nurse practice in pain and sedation management. The protocol has enabled nurses to provide pain and sedation management in a consistent and timely manner and reduced the dose of midazolam required to maintain comfort according to the patients COMFORT B scores. Individual evaluation of practice change is recommended to units who implement nurse led analgesic and sedative protocols to monitor changes in practice.
Purpose:
The purpose of the study is to identify predictors of underuse of sedation scales and daily sedation interruption (DSI).
Methods:
We surveyed all physicians and seven nurses in every Belgian intensive care unit (ICU), addressing practices and perceptions on guideline recommendations. Underuse was defined for sedation scales as use less than 3× per day and for DSI as never using it. Classification trees and logistic regressions identified predictors of underuse.
Results:
Underuse of sedation scales and DSI was found for 16.6% and 32.5% of clinicians, respectively. Strongest predictors of underuse of sedation scales were agreeing that using them daily takes much time and being a physician (rather than a nurse). Further predictors were confidence in their ability to measure sedation levels without using scales, for physicians, and nurse/ICU bed ratios less than 1.98, for nurses. The strongest predictor of underuse of DSI among physicians was the perception that DSI impairs patients' comfort. Among nurses, lack of familiarity with DSI, region, and agreeing DSI should only be performed upon medical orders best predicted underuse.
Conclusions:
Workload considerations hamper utilization of sedation scales. Poor familiarity, for nurses, and negative perception of impact on patients' comfort, for physicians, both reduce DSI utilization. Targeting these obstacles is essential while designing quality improvement strategies to minimize sedative use.
Aim:
The aim of this study was to examine the decision-making of nursing students during team based simulations on patient deterioration to determine the sources of information, the types of decisions made and the influences underpinning their decisions.
Background:
Missed, misinterpreted or mismanaged physiological signs of deterioration in hospitalized patients lead to costly serious adverse events. Not surprisingly, an increased focus on clinical education and graduate nurse work readiness has resulted.
Design:
A descriptive exploratory design.
Methods:
Clinical simulation laboratories in three Australian universities were used to run team based simulations with a patient actor. A convenience sample of 97 final-year nursing students completed simulations, with three students forming a team. Four teams from each university were randomly selected for detailed analysis. Cued recall during video review of team based simulation exercises to elicit descriptions of individual and team based decision-making and reflections on performance were audio-recorded post simulation (2012) and transcribed.
Results:
Students recalled 11 types of decisions, including: information seeking; patient assessment; diagnostic; intervention/treatment; evaluation; escalation; prediction; planning; collaboration; communication and reflective. Patient distress, uncertainty and a lack of knowledge were frequently recalled influences on decisions.
Conclusions:
Incomplete information, premature diagnosis and a failure to consider alternatives when caring for patients is likely to lead to poor quality decisions. All health professionals have a responsibility in recognizing and responding to clinical deterioration within their scope of practice. A typology of nursing students' decision-making in teams, in this context, highlights the importance of individual knowledge, leadership and communication.
Aims and objectives:
This critical review considers the evidence since the Glasgow Coma Scale (GCS) was first launched, reflecting on how that evidence has shaped practice. It illustrates the lack of clarity and consensus about the use of the tool in practice and draws upon existing evidence in order to determine the route to clarity for an evidence-informed approach to practice.
Background:
The GCS has permeated and influenced practice for over 40 years, being well-established worldwide as the key tool for assessing level of consciousness. During this time, the tool has been scrutinised, evaluated, challenged and relaunched in a plethora of publications. This has led to an insight into the challenges, and to some extent the opportunities, in using the GCS in practice but has also resulted in a lack of clarity.
Design:
This is a discursive paper that invites readers to explore and arrive at a more comprehensive understanding of the GCS in practice and is based on searches of Scopus, Web of Knowledge, PubMed, Science Direct and CINAHL databases.
Results:
While the GCS has been rivalled by other tools in an attempt to improve upon it, a shift in practice to those tools has not occurred. The tool has withstood the test of time in this respect, indicating the need for further research into its use and a clear education strategy to standardise implementation in practice.
Conclusion:
Further exploration is needed into the application of painful stimuli in using the GCS to assess level of consciousness. Additionally, a robust educational strategy is necessary to maximise consistency in its use in practice.
Relevance to practice:
The evidence illustrates inconsistency and confusion in the use of the GCS in practice; this has the potential to compromise care and clarity around the issues is therefore necessary. This article is protected by copyright. All rights reserved.
There are a dearth of studies that quantitatively measure nurses' appreciation of stimuli and the subsequent generation of options in practice environments. The purpose of this paper was to provide an examination of nurses' ability to solve problems while quantifying the stimuli upon which they focus during patient care activities. The study used a quantitative descriptive method that gathered performance data from a simulated task environment using multi-angle video and audio. These videos were coded and transcripts of all of the actions that occurred in the scenario and the verbal reports of the participants were compiled. The results revealed a pattern of superiority of the experienced exemplar group. Novice actions were characterized by difficulty in following common protocols, inconsistencies in their evaluative approaches, and a pattern of omissions of key actions. The study provides support for the deliberate practice-based programs designed to facilitate higher-level performance in novices.
defi ne consciousness describe the AVPU assessment of consciousness discuss the use of the Glasgow Coma Scale describe pupillary assessment discuss the principles of intracranial pressure monitoring discuss the principles of jugular venous bulb oxygen saturation monitoring outline the monitoring of sedation outline the monitoring of pain and pain relief
The purpose of this study was to describe the life experience of conscious patients who were on light sedatives and mechanical ventilation in an ICU. The study used methods adapted from a phenomenological approach described by Giorgi, including observations and interviews regarding the intubation and mechanical ventilation of six male participants who were conscious and lightly sedated. The patients experienced various sensations, and nine major themes emerged from observations and interviews: "Being exposed in a defenseless state, surrounded by strange people in an unfamiliar environment"; "perceiving the situation by using the senses without explanation"; "being tied to a respiratory lifeline, there is indeterminate struggle and foreign bodily sensations"; "wanting to be awake rather than asleep under sedation"; "caring for surrounding people and being involved in personal care"; "being considered by care providers as being unable to speak and not being given an opportunity to speak"; "wanting to perform activities that is not left up to my own"; "intubated patients should seemingly not be moved without permission"; and "being treated in a way that feelings are not being recognized by the health care provider". The patients also stated that while they are maintaining a self-image, the proactive nature and existence of humanizing treatment has been threatened by the health care providers. These results suggest that health care providers must revise their perception of conscious patients on light sedatives that are intubated and mechanically ventilated. Moreover, there is a critical need to improve the patient-health care provider relationship, including communication.
SITUATION ASSESSMENT IN CRITICAL CARE: REPRESENTATIONS AND DATA PROCESSING Following Rasmussen (1986), numerous research studies have been carried out in cognitive activity diagnosis and decision making in dynamic situations. In this field of study, the object of our research is the clinical assessment undertaken by critical care nurses at the beginning of their task. Our study took place at the Geneva University Hospital (Switzerland). A real clinical assessment was filmed. Six expert nurses were shown the film, in accordance with work analysis methods (Leplat, 2000; Clot, 1999). The clinical assessment made by the nurse structures the organization of her daily tasks and contributes to her safety as well as that of the patient. Although precisely defined, the assessment procedure is adapted to each situation, depending on the patient's pathology, the stability of his vital functions and his specific equipment. Inspired by the methods developed by Hoc to analyze the work of blast furnace operators (1989, 1991), the objective of the confrontational interviews was to thoroughly study data collection processing by analyzing the information used by nurses in their reasoning and how this information is elaborated during bedside assessment. Our study offers an approach to nursing care which is complementary to current studies on decision making (Bucknall, 2000, 2003; Banning, 2006) and evidence-based practice. These models of best practice applied in different fields of nursing care, such as in acute care, are proposed by several authors (Aitken, 2000; Currey & Botti, 2006). Indeed, the analysis carried out in this study reverses the current perspective by highlighting the singularity of reasoning by nurses in real situations in the management of critical situations. This singularity is underlined by recognizing the specificity of each clinical situation, characterized by environmental evolution, as well as by constraints imposed during the activity. The thought process developed by the nurse during clinical assessment shows an ability to target pertinent entities with action plans and to mobilize deep knowledge to face dilemmas whilst in action.
Background: Fever is a common symptom in critically ill patients and may induce complications and increase mortality in intensive care unit (ICU) patients. Therefore, explorations of effective fever management and related cultural factors of influence are important. Purpose: This study explores the cultural context of the ICU-nurse fever management decision-making process. Methods: This qualitative study was undertaken using a grounded theory approach. We developed a semi-structured questionnaire for in-depth interviews conducted with 11 participants from 7 ICUs in 3 hospitals. Constant comparison, theoretical sampling, literature review, member checking and an expert panel were used to ensure research trustworthiness. Results: The "ICU's unit culture of fever management" category that emerged from study data comprised the two subcategories of "stubbornly persist in traditional fever management" and "ICUs have no standardized fever management guidelines." Unit culture was found to affect the fever management process of ICU nurses significantly. This study discovered that a prevalent lack of a standardized fever protocol led participants to manage patient fever symptoms using traditional ICU practices that were not based on published evidence. Participants thus expressed feeling uncertain about their treatments, which could negatively impact upon the quality of care given to critically ill patients. Conclusions / Implications for practice: Findings indicate ICU cultural mores are an important factor influencing the fever management process for nurses. Thus, we suggest that nursing education and medical institutions consider empirical evidence and unit culture when developing fever management guidelines in order to facilitate effective nurse decision-making.
The ICU is a place of frequent, high-stakes decision making. However, the number and types of decisions made by intensivists have not been well characterized. We sought to describe intensivist decision making and determine how the number and types of decisions are affected by patient, provider, and systems factors.
Direct observation of intensivist decision making during patient rounds.
Twenty-four-bed academic medical ICU.
Medical intensivists leading patient care rounds.
None.
During 920 observed patient rounds on 374 unique patients, intensivists made 8,174 critical care decisions (mean, 8.9 decisions per patient daily, 102.2 total decisions daily) over a mean of 3.7 hours. Patient factors associated with increased numbers of decisions included a shorter time since ICU admission and an earlier slot in rounding order (both p < 0.05). Intensivist identity explained the greatest proportion of variance in number of decisions per patient even when controlling for all other factors significant in bivariable regression. A given intensivist made more decisions per patient during days later in the 14-day rotation (p < 0.05). Female intensivists made significantly more decisions than male intensivists (p < 0.05).
Intensivists made over 100 daily critical care decisions during rounds. The number of decisions was influenced by a variety of patient- and system-related factors and was highly variable among intensivists. Future work is needed to explore effects of the decision-making burden on providers' choices and on patient outcomes.
Dans un contexte ou les institutions sanitaires ont une obligation de transparence tant vis-a-vis des autorites que de leurs patients, le management de la qualite et l’introduction de « bonnes pratiques » definies selon des standards scientifiques sont devenus une preoccupation majeure pour la gestion interne des etablissements. Or, si les protocoles et prescriptions sont indispensables a l’orientation du travail, ils ne s’appliquent pas tout seuls. Ces divers documents, du fait qu’ils presentent des descriptions standardisees et stabilisees du travail, contribuent a masquer ce que tout travailleur met effectivement en œuvre pour accomplir sa tâche dans des situations instables, variables, dans lesquelles il faut faire tenir ensemble une diversite d’elements parfois contradictoires. C’est ce que nous enseigne le courant d’ergonomie de langue francaise sur lequel nous nous appuyons, qui prend au serieux l’ecart irreductible entre le « travail prescrit » et le « travail reel ». La comprehension du travail issue de la recherche s’en trouve ainsi mieux ajustee aux realites professionnelles et devient une ressource pour la formation de futures professionnelles. Par le biais de trois etudes menees en analyse du travail par notre equipe en milieu hospitalier, nous approfondirons ces notions et leurs implications pour la pratique et la formation.
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).
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.
The tolerance of the ETT in intensive care patients was explored.
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.
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.
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.
Problem: Need for improved sedation strategy for adults receiving ventilator support. Design: Observational study of effect of introduction of guidelines to improve the doctors’ and nurses’ performance. The project was a prospective improvement and was part of a national quality improvement collaborative. Background and setting: A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours. Key measures for improvement: Reduction in patients’ mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes. Strategies for change: Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial. Effects of change: Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (−0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified. Lessons learnt: Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.
In August of 2002, a group of critical care experts met in Nashville, Tennessee, for a consensus conference on sedation assessment. The conference was made possible though a collaboration between the American Association of Critical-Care Nurses, Abbott Laboratories, and the Saint Thomas Health System (Nashville, TN) to address the critical need for a valid and reliable sedation assessment scale for use with critically ill patients. The collaboration was initially envisioned to be a three-phase process: Phase I, Convene a group of experts in sedation assessment to validate the state of the science surrounding sedation assessment and to recommend characteristics of an "ideal" sedation assessment scale; Phase II, Develop a new sedation assessment scale for critically ill adult patients; and Phase III, Conduct a multisite clinical research project to test the validity and reliability of the new scale. Conference participants were selected based on their expertise in a variety of critical care arenas and aspects of sedation to get a broad perspective on the sedation needs in critical care practice. In addition, members were selected for participation in the panel based on expertise specifically relevant to sedation assessment, including pain management, anxiety/fear, sleep problems, patient-ventilator synchrony, delirium, clinical pharmacology, and sedation scale development. This paper is a summary of the expert panel's perspectives on the current status of sedation assessment in critically ill patients and their recommendations for the development of a new sedation assessment scale. A series of questions were posed to the expert panel members; their responses to these questions during the 1-day conference are summarized in this paper. (4 tables, 2 figures, 16 refs.)
1. Uncovering the Knowledge Embedded in Clinical Nursing Practice. 2. The Dreyfus Model of Skill Acquisition Applied to Nursing. 3. An Interpretive Approach to Identifying and Describing Clinical Knowledge. 4. The Helping Role. 5. The Teaching-Coaching Function. 6. The Diagnostic and Monitoring Function. 7. Effective Management of Rapidly Changing Situations. 8. Administering and Monitoring Therapeutic Interventions and Regimens. 9. Monitoring and Ensuring the Quality of Health Care Practices. 10. Organizational and Work-Role Competencies. 11. Implications for Research and Clinical Practice. 12. Implications for Career Development and Education. 13. The Quest for a New Identity and New Entitlement in Nursing. 14. Excellence and Power in Clinical Nursing Practice. Epilogue: Practical Applications. References. Glossary. Appendix. Index.
Knowledge of how nurses make decisions is a desirable outcome of research. However, there currently exists an inadequacy in the techniques used to examine such decision making. In this article, the authors describe the techniques used in two studies incorporating "thinking aloud" to successfully examine the decision making of expert critical care practitioners in the natural setting. Both techniques of thinking aloud were found to provide useful information regarding decision making in the natural setting. No ethical implications were experienced in conducting these studies in the natural setting. In conclusion, the use of thinking aloud in the natural setting is an effective means of data collection.
Although many promising objective methods (measuring systems) are available, there are no truly validated instruments for monitoring intensive care unit (ICU) sedation. Auditory evoked potentials can be used only for research in patients with a deep level of sedation. Other measuring systems require further development and validation to be useful in the ICU. Continuing research will provide an objective system to improve the monitoring and controlling of this essential treatment for ICU patients. Subjective methods (scoring systems) that are based on clinical observation have proven their usefulness in guiding sedative therapy. The Glasgow Coma Score modified by Cook and Palma (GCSC) achieves good face validity and reliability, which assures its clinical utility for routine practice and research. Other scales, in particular the Ramsay Scale, can be recommended preferably for clinical use. An accurate use of available instruments can improve the sedative treatment that we deliver to our patients.
Need for improved sedation strategy for adults receiving ventilator support.
Observational study of effect of introduction of guidelines to improve the doctors' and nurses' performance. The project was a prospective improvement and was part of a national quality improvement collaborative.
A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours.
Reduction in patients' mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes.
Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial.
Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified.
Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.
Nurses have probably always known that their decisions have important implications for patient outcomes. Increasingly, however, they are being cast in the role of active decision makers in healthcare by policy makers and other members of the healthcare team. In the UK, for example, the Chief Nursing Officer recently outlined 10 key tasks for nurses as part of the National Health Service’s modernisation agenda and the breaking down of artificial boundaries between medicine and nursing.1 As well, nurses are expected to access, appraise, and incorporate research evidence into their professional judgment and clinical decision making.2 This active engagement with research evidence is the focus of this paper. We will explore why it is necessary to consider the clinical decision making context when examining the ways in which nurses engage with research based information. We will also consider the relation between the accessibility and usefulness of information from different sources and the decisions to which such information is applied. Finally, we will argue that if we are to encourage nurses to actively engage with research evidence during clinical decision making, we need to better understand the relation between the decisions that nurses make and the knowledge that informs them.
In this paper, we draw heavily on the findings of 2 major studies conducted at the University of York between 1997 and 2002.3–9 2 case studies were conducted in 3 geographical areas with different hospital types, population characteristics, and levels of health service provision. We purposively sampled participants according to a sampling frame constructed around variables deemed to be theoretically significant for clinical decision making.7 Data collection comprised 200 indepth interviews with nurses and managers; 400 hours of non-participant observation of “decision making and information use in action”; 4000 practice based documents audited for characteristics such as …
There is a lack of evidence regarding the kinds of decisions made by primary care nurses and the information sources they use in clinical decision making.
To describe the decisions made by nurses working in general practice and the sources of information they use to underpin those decisions.
Qualitative methods (interviews, observation, documentary analysis) were used to collect data on the clinical decision making and information seeking behaviour of a purposive sample of 29 practice nurses and four nurse practitioners from general practices in the North of England. Data were collected November 2001-September 2002.
A seven-fold typology captured the types of decisions the nurses made on a daily basis concerning assessment, diagnosis, intervention, referral, communication, service delivery and organization (SDO) and information seeking. Faced with clinical uncertainty, the majority of the nurses in the study relied on personal experience, or obtained advice and information from GP or other colleagues. These 'human sources' of information were overwhelmingly preferred to text or on-line resources. Despite encounters with evidence-based resources through continuing professional development, the nurses rarely used them to seek answers to routine clinical questions.
The decisions of the nurses in the study were mainly concerned with undifferentiated diagnosis and treatment, in the context of acute conditions and chronic disease management. 'Human sources' of information were preferred to any other; however, we do not know whether information obtained from colleagues is based on research.
The aim of the study was to explore trends and changes in sedation practices for mechanically ventilated patients in Danish intensive care units (ICUs) and to compare sedation practices in 1997 and 2003.
The study was a follow-up survey with a descriptive and comparative cross-sectional multicenter design.
Questionnaires were mailed in January 2003 to all Danish ICUs providing mechanical ventilation (n=48).
One head physician at each ICU in Denmark. INTERVENTIONS, MEASUREMENTS, AND RESULTS: Thirty-nine questionnaires were returned, yielding a response rate of 81%, representing 82% of Danish ICU beds. The main findings were a significant increase in the use of sedation scoring systems and a significant reduction of sedation and analgesia in relation to various modalities of mechanical ventilation and disease groups. Other important findings were a significant reduction in the use of benzodiazepines and opioids and a significant increase in the use of propofol in relation to all ventilator modes. The administration routes of sedative agents remained unchanged.
Sedatives and analgesics are still widely used in Danish ICUs. The trend is toward lighter sedation along with a shift from benzodiazepines toward propofol and from morphine toward fentanyl given by continuous infusion. More attention needs to be directed toward sedation standards and scoring systems in order to reduce the risk associated with sedation in mechanically ventilated patients.
To characterize the perceived utilization of sedative, analgesic, and neuromuscular blocking agents, the use of sedation scales, algorithms, and daily sedative interruption in mechanically ventilated adults, and to define clinical factors that influence these practices.
Cross-sectional mail survey.
Canadian critical care practitioners.
A total of 273 of 448 eligible physicians (60%) responded. Respondents were well distributed with regard to age, years of practice, specialist certification, size of intensive care unit and hospital, and location of practice. Twenty-nine percent responded that a protocol/care pathway/guideline for the use of sedatives or analgesics is currently in use in their intensive care unit. Daily interruption of continuous infusions of sedatives or analgesics is practiced by 40% of intensivists. A sedation scoring system is used by 49% of respondents. Of these, 67% use the Ramsay scale, 10% use the Sedation-Agitation Scale, 9% use the Glasgow Coma Scale, and 8% use the Motor Activity Assessment Scale. Only 3.7% of intensivists use a delirium scoring system in their intensive care units. Only 22% of respondents currently have a protocol for the use of neuromuscular blocking agents in their intensive care unit, and 84% of respondents use peripheral nerve stimulation for monitoring. In patients receiving neuromuscular blocking agents for >24 hrs, 63.7% of respondents discontinue the neuromuscular blocking agent daily. Intensivists working in university-affiliated hospitals are more likely to employ a sedation protocol and scale (p < .0001), as are intensivists working in larger intensive care units (>or=15 beds, p < .01). Intensivists with anesthesiology training (and no formal critical care training) are more likely to use a protocol and sedation scale, and critical care-trained intensivists are more likely to use daily interruption. Younger physicians (<40 yrs) are more likely to practice daily interruption (p = .0092).
There is significant variation in critical care sedation, analgesia, and neuromuscular blockade practice. Given the potential effect of practices regarding these medications on patient outcome, future research and educational efforts related to evidence-based protocols for the use of these agents in mechanically ventilated patients might be worthwhile.
To examine the effect of an algorithm-based sedation guideline developed in a North American intensive care unit (ICU) on the duration of mechanical ventilation of patients in an Australian ICU.
The intervention was tested in a pre-intervention, post-intervention comparative investigation in a 14-bed adult intensive care unit.
Adult mechanically ventilated patients were selected consecutively (n=322). The pre-intervention and post-intervention groups were similar except for a higher number of patients with a neurological diagnosis in the pre-intervention group.
An algorithm-based sedation guideline including a sedation scale was introduced using a multifaceted implementation strategy.
The median duration of ventilation was 5.6 days in the post-intervention group, compared with 4.8 days for the pre-intervention group (P=0.99). The length of stay was 8.2 days in the post-intervention group versus 7.1 days in the pre-intervention group (P=0.04). There were no statistically significant differences for the other secondary outcomes, including the score on the Experience of Treatment in ICU 7 item questionnaire, number of tracheostomies and number of self-extubations. Records of compliance to recording the sedation score during both phases revealed that patients were slightly more deeply sedated when the guideline was used.
The use of the algorithm-based sedation guideline did not reduce duration of mechanical ventilation in the setting of this study.
In the intensive care unit, sedation is essential to minimize discomfort and distress to the critically ill child and facilitate clinical care. It has no place in the management of children with acute respiratory failure prior to intubation and stabilization. The level of sedation required is influenced by many factors such as clinical state, diagnosis, length of time ventilated and the age of the patient. In addition the interaction between parent, child, nursing and medical staff affects the amount of sedation given.The adequately sedated patient is asleep but can easily be roused. However, in certain clinical conditions, a deeper level of sedation is appropriate. In other situations, after initial stabilization, no sedation is necessary. It is therefore useful to use a sedation scoring system with the desired level of sedation agreed between the medical and nursing staff. This should also be explained to the parents.
Reviews the origins, findings, and influence of the monograph
Medical problem solving:
An analysis of clinical reasoning by A. S. Elstein et al (1978). Methodological problems and scholarly issues in the field of cognition are discussed, including (1) sampling cases and Ss, (2) the definition of medical expertise, (3) the role of verbal report in analyzing thinking, (4) the level of clinical realism needed in research, and (5) the relation of information-processing approaches to more quantitative approaches such as behavioral decision theory and social judgment theory. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Increasing acuity of hospitalized persons with cardiac disease places great demands on nurses’ decision-making abilities. Yet nursing lags in knowledge-based system development because of limited understanding about how nurses use knowledge to make decisions. The two research questions for this study were: how do the lines of reasoning used by experienced coronary care nurses compare with those used by new coronary care nurses in a representative sample of hypothetical patient cases, and are the predominant lines of reasoning used by coronary care nurses in hypothetical situations similar to those used for comparable situations in clinical practice? Line of reasoning was defined as a set of arguments in which knowledge is embedded within decision-making processes that lead to a conclusion. Sixteen subjects (eight experienced and eight new nurses) from coronary care and coronary step-down units in a large, private, teaching hospital in Minnesota, USA, were asked to think aloud while making clinical decisions about six hypothetical cases and comparable actual case. One finding was that most subjects in both groups used multiple lines of reasoning per case; but they used only one predominantly. This finding highlighted the non-linear nature of clinical decision making. Subjects used 25 predominant lines of reasoning, with intergroup differences on six of them. Where there were differences, experienced nurses used lines of reasoning of lower quality than did new subjects. The type variability in lines of reasoning suggested that multiple pathways should be in-corporated into knowledge-system design. One implication of the variability in subjects’ line of reasoning quality is that nurses at all levels of expertise are fallible and could benefit from decision support. The finding that subjects tended to use similar lines of reasoning for comparable hypothetical and actual cases was modest validation of subjects’ performance on hypothetical cases as representing their decision making in practice. Consequently, there was support for using simulations and case studies in teaching and studying clinical decision making.
Under normal, unstressed conditions, the body maintains a dynamic equilibrium known as homeostasis--a complex interplay balancing the conflicting demands presented by many internal and external forces. In the face of threatened or actual disruptions (i.e., stress), molecular, cellular, physiologic, and behavioral responses act to restore homeostasis. These responses can be specific to a particular stressor and relatively circumscribed (e.g., secretion of insulin in response to an increase in blood glucose), or can be generalized and relatively nonspecific (e.g., behavioral manifestations of severe anxiety). Typically, more nonspecific and generalized responses occur in the setting of severe and threatening disruptions in homeostasis, and taken together, these responses are known as the "general adaptation or stress syndrome". We will describe the elements and organization of the generalized stress response with particular attention to the hypothalamic-pituitary-adrenal axis as it interacts with the immune system, and we will review what is known about this interactive network in the setting of critical illness.
Psychoneuroimmunology (PNI) is concerned with the mechanisms of bidirectional communication between the neuroendocrine and immune systems. Investigators in other disciplines have used this framework to guide the examination of possible relationships between behavioural factors and the progression of immunologically mediated illnesses and to evaluate the role of immune products in central nervous system disturbances. Nurse scientists have an opportunity to make unique contributions to the growing field of PNI. Unlike basic science research, which has as its goal the generation of fundamental knowledge concerning biological or behavioural processes, nursing research is driven by the need to promote excellence in nursing science as a guide for nursing practice. Although a few nurse scientists have conducted PNI research to date, additional studies are needed to generate new knowledge concerning mind-body interactions in health and illness and to develop strategies that promote mental and physical well-being in persons at risk for immune dysfunction. This paper highlights the few recently conducted nursing studies grounded in a PNI framework to illustrate the utility of PNI in advancing nursing science.
Cardiovascular function during cognitive stress using the Stroop Color Test (SCWT) was documented in 25 men with ischemic heart disease (IHD) before and after coronary artery bypass grafting (CABG). Impedance cardiography was used to measure changes from resting baseline in heart rate (HR), stroke volume (SV), cardiac output (CO), myocardial contractility, and total peripheral resistance (TPR). Cognitive stress was associated with significant increases in HR, blood pressure, SV, CO, and myocardial contractility. TPR did not change from resting baseline during cognitive stress before CABG. However, TPR decreased significantly from resting baseline during cognitive stress after CABG. These findings support the theory that cognitive stress is associated with a significant increase in myocardial oxygen demand.
A conceptual treadmill: the need for ‘middle ground’ in clinical decision making theory in nursing
This paper explores the two predominant theoretical approaches to the process of nurse decision making prevalent within the nursing research literature: systematic-positivistic approaches as exemplified by information processing theory, and the intuitive-humanistic approach of Patricia Benner. The two approaches’ strengths and weaknesses are explored and as a result a third theoretical stance is proffered: the idea of a cognitive continuum. According to this approach the systematic and intuitive theoretical camps occupy polar positions at either end of a continuum as opposed to separate theoretical planes. The methodological and professional benefits of adopting such a stance are also briefly outlined.
A total of 26 research studies on patients' experiences of being in an intensive care unit were reviewed. The studies were selected because they focused on experiences typical in intensive care units. Many patients recalled their time in the intensive care unit, sometimes in vivid detail. Patients recalled not only experiences that were negative but also ones that were neutral and even positive. Positive experiences included a sense of safety and security promoted especially by nurses. Negative experiences included impaired cognitive functioning and discomforts such as problems with sleeping, pain, and anxiety. The review indicates steps critical care staff can take to develop better ways to understand patients' experiences. Meeting such challenges can improve the quality of patients' experiences and reduce anxiety and may offset potential adverse effects of being a patient in an intensive care unit.
To describe the goals of sedative use in the intensive care unit and review the pharmacology of commonly used sedative drugs as well as to review pertinent publications in the literature concerning the comparative pharmacology of these drugs, with emphasis on outcomes related to sedation and comparative pharmacoeconomics.
Publications in the scientific literature.
Computer search of the literature with selection of representative articles.
Proper choice and use of sedative drugs is based on knowledge of the pharmacology of commonly used agents and is an essential component of caring for patients in the intensive care unit. The large variability in pharmacokinetics and pharmacodynamics in the critically ill make it difficult to directly compare agents. Midazolam provides rapid and reliable amnesia, even when administered for low levels of sedation. Propofol may be useful when deeper levels of sedation and more rapid awakening are required. Lorazepam can be used for long-term sedation in more stable patients if rapidity of effect is not required. Further investigation in assessment of depth of sedation in the critically ill is needed. Continued study of costs, side effects, and appropriate dosing strategies of all sedative agents is needed to answer questions not sufficiently addressed in the current literature.
An individualized approach to sedation based on knowledge of drug pharmacology is needed because of confounding variables including concurrent patient illness, depth of sedation, and concomitant use of analgesic agents. (Crit Care Med 2000; 28:854-866)
Clinical problem-solving in nursing: insights from the literature
This paper reviews the literature surrounding the research on how individuals solve problems. The purpose of the review is to heighten awareness amongst nurses in general, and nurse academics in particular about the theories developed, approaches taken and conclusions reached on how clinicians problem-solve. The nursing process, which is heavily used and frequently described as a problem-solving approach to nursing care, requires a deductive reasoning process which is not the problem-solving process in use during care-giving activities. More knowledge is required on what process is in place as we develop as a profession. The literature highlights the complexities involved in attempting to uncover thinking processes. The main research approaches to discovering problem-solving strategies in the past three decades have been from a cognitive perspective, with two main theories, decision-theory and information processing-theory, underpinning the majority of studies conducted. None of the research approaches used to date has resulted in the identification of a general model of problem-solving that is consistent across tasks or disciplines. However, early hypothesis activation with subsequent testing of the hypothesis seems to be consistent in clinicians across disciplines.
To systematically review instruments for measuring the level and effectiveness of sedation in adult and pediatric ICU patients. STUDY IDENTIFICATION: We searched MEDLINE, EMBASE, the Cochrane Library and reference lists of the relevant articles. We selected studies if the sedation instrument reported items related to consciousness and one or more additional items related to the effectiveness or side effects of sedation.
We extracted data on the description of the instrument and on their measurement properties (internal consistency, reliability, validity and responsiveness).
We identified 25 studies describing relevant sedation instruments. In addition to the level of consciousness, agitation and synchrony with the ventilator were the most frequently assessed aspects of sedation. Among the 25 instruments, one developed in pediatric ICU patients (the Comfort Scale), and 3 developed in adult ICU patients (the Ramsay scale, the Sedation-Agitation-Scale and the Motor Activity Assessment Scale), were tested for both reliability and validity. None of these instruments were tested for their ability to detect change in sedation status over time (responsiveness).
Many instruments have been used to measure sedation effectiveness in ICU patients. However, few of them exhibit satisfactory clinimetric properties. To help clinicians assess sedation at the bedside, to aid readers critically appraise the growing number of sedation studies in the ICU literature, and to inform the design of future investigations, additional information about the measurement properties of sedation effectiveness instruments is needed.
Platelets play an important role not only in hemostasis but also in the pathophysiology of coronary artery disease. The complex interactions among the vascular endothelium, platelets, and blood components are one of the most exciting research areas today. This review addresses some fundamentals of platelet physiology and examines why platelets are interesting probes for neurophysiology. Results of current studies suggest that platelets are affected by diverse stressors, including psychological ones, and that platelets offer an interesting vantage point for understanding the neurophysiology of various psychiatric disorders. We also describe how platelets have been used for various types of research, including studies of stress associated with cardiovascular disease and studies of platelets in psychopharmacological research. Finally, we examine some of the psychiatric literature related to platelets; these studies range from case studies from the 1920s to contemporary experimental studies.
Increasing acuity of hospitalized persons with cardiac disease places great demands on nurses' decision-making abilities. Yet nursing lags in knowledge-based system development because of limited understanding about how nurses use knowledge to make decisions. The two research questions for this study were: how do the lines of reasoning used by experienced coronary care nurses compare with those used by new coronary care nurses in a representative sample of hypothetical patient cases, and are the predominant lines of reasoning used by coronary care nurses in hypothetical situations similar to those used for comparable situations in clinical practice? Line of reasoning was defined as a set of arguments in which knowledge is embedded within decision-making processes that lead to a conclusion. Sixteen subjects (eight experienced and eight new nurses) from coronary care and coronary step-down units in a large, private, teaching hospital in Minnesota, USA, were asked to think aloud while making clinical decisions about six hypothetical cases and comparable actual case. One finding was that most subjects in both groups used multiple lines of reasoning per case; but they used only one predominantly. This finding highlighted the non-linear nature of clinical decision making. Subjects used 25 predominant lines of reasoning, with intergroup differences on six of them. Where there were differences, experienced nurses used lines of reasoning of lower quality than did new subjects. The type variability in lines of reasoning suggested that multiple pathways should be incorporated into knowledge-system design. One implication of the variability in subjects' line of reasoning quality is that nurses at all levels of expertise are fallible and could benefit from decision support. The finding that subjects tended to use similar lines of reasoning for comparable hypothetical and actual cases was modest validation of subjects' performance on hypothetical cases as representing their decision making in practice. Consequently, there was support for using simulations and case studies in teaching and studying clinical decision making.
Critical care nurses make numerous complex decisions during their day-to-day practice. General themes in previous decision-making studies have included the influence of knowledge and previous experience, the increasing complexity of decisions made and the change in decision-making processes used as the nurse progresses from a novice to an expert practitioner. This paper reports one component of a study which used a concept attainment framework to determine what data were used by eight expert critical care nurses in relation to haemodynamic monitoring. Results indicated that pulmonary artery pressure monitoring was used to attain the concepts of preload, cardiac output and blood pressure. In addition, participants used few clinical assessment attributes, but collected a large number of attributes which they arranged around three to five central concepts and took a broad view of haemodynamic assessment. One participant did not display many of the decision-making features normally associated with an expert practitioner. In conclusion, expert critical care nurses process an immense amount of data in a short space of time. However, they may not use all available data. Evidence suggests not all nurses who practise in the field for a lengthy period reach the level of an expert.
Critical care nurses often have wide discretion in managing the sedative therapy of patients receiving mechanical ventilation. Little is known about the factors and processes that influence sedative practice.
To determine if nurses' personal beliefs about and attitudes toward critical illness and their goals for sedation influence the nurses' sedative practice, to discover whether social factors influence sedative therapy, and to describe the processes that nurses use to assess patients' need for sedative therapy.
Audiotapes of focus group interviews with 5 groups of 34 experienced medical and surgical intensive care unit nurses from 2 hospitals were transcribed verbatim. Two investigators independently analyzed the verbatim text, and a sample of the participants validated the category summaries and interpretations.
Patients' family members can affect sedative practice directly or indirectly, and demands for efficient delivery of care can influence sedative therapy. Primary indications for sedation included patients' comfort and amnesia and prevention of patients' self-injurious behaviors. Conflicts between physicians and nurses arose when explicit and shared goals for sedation were lacking. Participants noted that numerous factors impede routine use of sedation protocols even though use of the protocols may improve communication and promote uniformity of sedative practice.
Social, personal, and professional factors influence sedative therapy. Future research should establish the relative importance of these factors and determine whether their impact is attenuated when sedation protocols are implemented.
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.
Although the administration of sedatives is a commonplace activity in the ICU, few guidelines are available to aid the clinician in this practice. The first principle of sedative administration is to define the specific problem requiring sedation and to rationally choose the drug and depth of sedation appropriate for the indication. Next, the clinician must recognize the diverse and often unpredictable effects of critical illness on drug pharmacokinetics and pharmacodynamics. Failure to recognize these effects may lead initially to inadequate sedation and subsequently to drug accumulation. Drug accumulation may result in prolonged encephalopathy and mechanical ventilation and may mask the development of neurologic or intra-abdominal complications. Daily interruption of continuous sedative infusions is a simple and effective way of addressing this problem. A glossary of sedative drugs commonly used in the ICU is included in this review.
? Sedation which is used for intubated patients may prolong mechanical ventilation by increasing the risk of complications. The aim of the study was to illuminate the specific terminology and unrecognized contextual factors which may influence nurses' and physicians' sedation practices.
? The main research questions were: How do nurses and physicians describe sedation? and How does the level of nursing skill relate to the level of sedation? The hypotheses were that sedation practices are inconsistent and that experienced nurses provide a better quality of sedation than less experienced nurses. The hypotheses were supported by the study.
? The research strategy was case study research with triangulation of sources and methods and a multicentre multiple-case design. Four university hospitals in Copenhagen, Denmark, and 14 cases were included in the study. The findings were based on secondary analysis of observation, interviews and chart review.
? The theoretical framework for the study was the problem-solving model, in which sedation was assumed to be provided according to indication (clinical problem), intervention (clinical decision) and expected outcome (clinical end-point). Indications could be patient-related, ventilator-related, or patient–ventilator related. Interventions could be related to the choice of agent, dose or administration method and the outcome was the level of sedation.
? Sedative therapy was prescribed by physicians and administered by nurses. The four sites in the study did not use guidelines for sedation and did not use sedation level assessment tools. The study shows that when the terminology is unclear, the indications, interventions and outcomes become unclear.
The aim of the study was to describe how nurses make decisions on measures in clinical practice.
• The data‐collection method consisted of audio‐taped interviews with six nurses. The interviews were then transcribed verbatim. The questions in the interviews were based on nursing situations observed earlier when the nurses initiated and implemented patient‐related measures and the focus was on the nurses' experience of decision making. A content analysis was performed.
• The results show that the nurses' decisions on measures were based on three themes: observation of cues related to the patient's situation, confirmation of information gathered and implementation of action strategies.
• The results are discussed in relation to earlier empirical research on decision‐making activities in the nurse's clinical practice and the nurse's utilization of knowledge during the decision‐making process.
• It is concluded that the nurse's awareness of the patient's situation, together with a well‐founded basis for decisions, can have positive effects on the nursing care provided by the nurse.
• Effective decision-making has the potential to facilitate improvements in health care. This paper reports several aspects of a study which used ‘thinking aloud’ within a concept attainment framework to examine the decision-making processes of expert critical care nurses in relation to haemodynamic monitoring.
• The purpose of this study was to examine whether hypotheses were used in the decision-making process and, if so, were hypotheses deactivated when no longer relevant. In addition, the strategies that were used during the decision-making process were examined.
• Eight expert critical care nurses consented to participate in the study after ethics clearance was obtained from both the University and Hospital ethics committees.
• The majority of expert critical care nurse participants in this study demonstrated extensive use of hypotheses to explain the relationship between attributes and concepts.
• There was no evidence of specific deactivation of hypotheses when they were no longer relevant.
• Participants demonstrated use of a range of decision-making strategies, with a Focus Gambling Strategy being the most common. The reason for using different decision-making strategies was not clear and may represent variation between decision-makers or between scenarios for each individual decision-maker.
• Recommendations are made to help improve critical care nurses' decision-making.
Many studies have tended to explore individual characteristics that impact on nurses' decision-making, despite significant acknowledgement that context is a major determinant in decision-making. The few studies that have examined environmental influences have tended not to study real decisions in the dynamic and complex clinical environment.
To investigate environmental influences on nurses' real decisions in the critical care setting.
Naturalistic observations and semi-structured interviews were conducted with 18 critical care nurses in private, public and rural hospitals. Observations and interviews were recorded, transcribed verbatim and coded for themes using content analysis.
All clinical decisions were strongly influenced by the context in which the decision was made. Three main environmental influences were identified: the patient situation, resource availability and interpersonal relationships. Time and risk guided all clinical decisions. Nurses established the state of the situation, the time constraints on decisions and the level of risk involved for both patient and nurse.
Decision-making is a manifestation of the landscape and although an increased understanding of the landscape is required, more important is the need to measure the impact of contextual variables on nurses' decision-making in order to improve health care outcomes.
The movement towards research and evidence-based practice in health care demands that the best available evidence is applied to practice. At the same time, changes to role boundaries mean that nurses are assuming increased responsibility, especially in relation to decision making. While increasing, there has been limited consideration about the application of best evidence and decision making by nurses in the context of their clinical work.
This study sought to explore the realities of research and evidence-based practice through an examination of the decision making of nurses when extubating patients following cardiac surgery.
The tradition of qualitative research and, more specifically, ethnography were used for the study.
Data were gathered over an 18-month period during 1998 and 1999 within a Cardiothoracic Intensive Care Unit (CICU).
The sample comprised 43 nursing, 16 medical and two managerial staff. A purposive sample of five nurses, a cardiac surgeon, intensivist, CICU manager and Deputy Divisional Manager were included in interviews.
All staff were included in participant observation. Semi-structured interviews were conducted with a purposive sample of nurses during the 6th and 14th months and with a purposive sample of other staff during the 16th month. Data were analysed using progressive focusing, data source triangulation and sensitising concepts to identify themes and categories.
The findings indicated that, despite the use of an unwritten physiologically based protocol for weaning and extubation, factors other than best evidence were significant in nurses' decision making. A range of personal, cultural and contextual factors including relationships, hierarchy, power, leadership, education, experience and responsibility influenced their decision making.
This study revealed, often disregarded, cultural, contextual and personal characteristics which combined to form a complex process of decision making. Providing new insight into research and evidence-based practice, the findings have implications for policy makers, educators, managers and clinicians and for the continued professional development of nursing.
A prolonged period of mechanical ventilation is costly for both the patient, in terms of the risk of complications such as ventilator-acquired pneumonia, and to the health service due to the high cost of maintaining a patient in intensive care. The recognition of the role nurses can play in the weaning process and the desire to try and reduce weaning times led to the introduction of nurse-managed weaning on the intensive care unit which is the focus of this study. This means that both doctors and nurses are now responsible for making decisions about weaning. Flexible guidelines for weaning were devised which still require a large element of individual, clinical decision-making during the process. At every stage in the weaning process clinicians are required to make judgments about patient responses, using these judgments as the basis for their decision-making. This study examined the ways doctors and nurses make these decisions. Semi-structured interviews were conducted with doctors and senior nurses. A grounded theory approach was used to analyse the results and the key themes of Treatment, Balance, Making Progress and The Individual were identified which were found to be linked with particular methods of decision-making.
The paper presents a study assessing the rate of adoption of a sedation scoring system and sedation guideline.
Clinical practice guidelines including sedation guidelines have been shown to improve patient outcomes by standardizing care. In particular sedation guidelines have been shown to be beneficial for intensive care patients by reducing the duration of ventilation. Despite the acceptance that clinical practice guidelines are beneficial, adoption rates are rarely measured. Adoption data may reveal other factors which contribute to improved outcomes. Therefore, the usefulness of the guideline may be more appropriately assessed by collecting adoption data.
A quasi-experimental pre-intervention and postintervention quality improvement design was used. Adoption was operationalized as documentation of sedation score every 4 hours and use of the sedation and analgesic medications suggested in the guideline. Adoption data were collected from patients' charts on a random day of the month; all patients in the intensive care unit on that day were assigned an adoption category. Sedation scoring system adoption data were collected before implementation of a sedation guideline, which was implemented using an intensive information-giving strategy, and guideline adoption data were fed back to bedside nurses. After implementation of the guideline, adoption data were collected for both the sedation scoring system and the guideline. The data were collected in the years 2002-2004.
The sedation scoring system was not used extensively in the pre-intervention phase of the study; however, this improved in the postintervention phase. The findings suggest that the sedation guideline was gradually adopted following implementation in the postintervention phase of the study. Field notes taken during the implementation of the sedation scoring system and the guideline reveal widespread acceptance of both.
Measurement of adoption is a complex process. Appropriate operationalization contributes to greater accuracy. Further investigation is warranted to establish the intensity and extent of implementation required to positively affect patient outcomes.
To discuss the approach to sedation of the mechanically ventilated patient.
Mechanically ventilated patients in the intensive care unit frequently require sedation and analgesia for anxiety and pain experienced during the time they are intubated. Multiple drugs are available for this purpose. Strategies that optimize comfort while minimizing the predilection for sedative and analgesic drug accumulation with prolongation of effect have been shown to improve outcomes. In particular, such strategies may decrease mechanical ventilation duration, intensive care unit length of stay, and complications associated with critical illness.
Sedation and analgesia are important in the management of patients who require mechanical ventilation. An evidence-based approach to administering sedatives and analgesics is necessary to optimize short- and long-term outcomes in mechanically ventilated patients.
To review the recent advances in providing analgesia and sedation to intensive care unit patients that can improve outcomes, and reduce resource utilization and adverse events.
Validated tools to assess patient sedation and analgesia are available, and have been shown to improve outcomes when used. A strategy providing analgesia-first and supplemented by sedation-as-needed appears to improve patient outcomes. The negative impact of deep sedation to the point of coma, even for brief periods, is again recognized. Additional data defining adverse events associated with propofol and lorazepam can help us develop strategies to avoid them.
Utilizing and incorporating these new advances can improve outcomes and result in a more comfortable patient.
Clinical Nurse Consultant, Intensive Care Unit Professor of Critical Care Nursing, Intensive Care Unit
- Authors Andrea
- Marshall
- Mn
- Sesqui Rn
- Lecturer Senior
- Sydney
- Nsw
- Rosalind Australia
- Elliott
- Bsc
- Mn
- Rn
Authors: Leanne M Aitken PhD, RN, Professor of Critical Care Nursing, Research Centre for Clinical and Community Practice Innovation, Griffith University and Princess Alexandra Hospital, Brisbane, Qld, Australia; Andrea P Marshall, MN, RN, Sesqui Senior Lecturer, Faculty of Nursing, Critical Care Nursing, University of Sydney, Sydney, NSW, Australia; Rosalind Elliott, BSc, MN, RN, Clinical Nurse Consultant, Intensive Care Unit, Royal North Shore Hospital, Sydney, NSW, Australia; Sharon McKinley, PhD, RN, Professor of Critical Care Nursing, Faculty of Nursing, Midwifery and Health, University of Technology Sydney and Northern Sydney Central Coast Health, Sydney, NSW, Australia Correspondence: Leanne M Aitken, Professor of Critical Care Nursing, Intensive Care Unit, Princess Alexandra Hospital, Ipswich Road, Woolloongabba Qld 4102, Australia. Telephone: +61 7 3240 7256. E-mail: l.aitken@griffith.edu.au References Abbott (2004) Consensus conference on sedation assessment. A collaborative venture by Abbott Laboratories, American Associa-tion of Critical-Care Nurses and Saint Thomas Health System. Critical Care Nurse 24, 33–41.
From Novice to Expert: Excellence and Power in Clinical Nursing Practice Menlo Park Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit
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- S Gjerde
- Plsek
Benner P (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park. Brattebo G, Hofoss D, Flaatten H, Muri AK, Gjerde S & Plsek PE (2002) Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit. British Medical Journal 324, 1386–1389.
Medical problem solving: an analysis of clinical reasoning
- Elstein
Consensus conference on sedation assessment. A collaborative venture by Abbott Laboratories, American Association of Critical‐Care Nurses and Saint Thomas Health System
- Abbott