Nurses' and physicians' approaches to delirium management in the intensive care unit: A focus group investigation

BackgroundDelirium in the intensive care unit (ICU) is common, but reliable evidence-based recommendations are still limited.ObjectivesThe aim of our study was to explore nurses' and physicians' experiences and approaches to ICU delirium management.MethodOur study had a qualitative multicentre design using interdisciplinary focus groups and framework analysis. Participants were strategically selected to include nurses and physicians with experience in delirium management at five ICUs in four out of five regions in Denmark.ResultsWe conducted eight focus group interviews with 24 nurses and 15 physicians; median ICU experience was 9 years (range 1–35). The main issues identified were (1) the decision to treat or not to treat ICU delirium based on delirium phenotype, (2) the decision to act based on experience or evidence, and (3) the decision to intervene using nursing care or medications. ICU delirium was treated with pharmacological interventions in patients with signs of agitation, hallucinations, and sleep deprivation. The first choice of agent was haloperidol or olanzapine. Agitated and combative patients received benzodiazepines, propofol, or dexmedetomidine. Calm delirious patients were managed with non-pharmacological solutions. Physicians recommended pro re nata (PRN) orders to prevent over medication, whereas nurses opposed PRN orders with the fear that it would increase their responsibilities.ConclusionOur study described an algorithm of contemporary delirium management in Danish ICUs based on qualitative inquiry. When evidence-based solutions are unclear, nurses and physicians rely on personal experience, collective experience, and best available evidence to determine which patients to treat and what methods to use to treat ICU delirium. Delirium management still needs clear objectives and guidelines with evidence-based recommendations for first-line treatment and subsequent treatment options.     

Spiritual needs during COVID 19 pandemic in the perceptions of Spanish emergency critical care health professionals

ObjectivesTo investigate the perceptions and attitudes of health professionals working in emergency services and critical care units in Spain about spiritual care provided during the COVID-19 pandemic.MethodsA qualitative investigation was carried out using in-depth interviews.SettingEmergency and emergency and ICU health professionals from different regions of Spain.FindingsThe sample consisted of 47 nursing and one nursing assistant. The qualitative analysis yielded four main themes that reflect the following categories: “the experience with spirituality in clinical practice”; “resources and barriers to provide spiritual care”; “the COVID pandemic and spiritual care” and “training in spiritual care”. In addition, two subdeliveries were also obtained: “ethical dilemma” and “rituals of death”.ConclusionsThe majority of emergency and critical care nurses believe spiritual care is important to their clinical practice, but there are still several barriers to address patients’ spiritual needs. During the COVID-19 pandemic in Spain, professionals felt that spiritual beliefs have emerged as important needs of patients and the restrictions imposed by the pandemic made health professionals more exposed to ethical dilemmas and end-of-life religious issues. The general impression of health professionals is that more training and resources are needed on this topic.Implications for clinical practiceHealth professionals in emergency intensive care must provide nursing care that meets the spiritual needs of their patients to improve care in crisis situations such as the one suffered by the COVID-19 pandemic. For this, emergency services professionals must work and participate in the development of measures to overcome certain barriers present in emergency services, such as lack of time, lack of training and misconceptions that make it difficult to approach emergency services these needs.     

Dealing with a troublesome body: A qualitative interview study of men’s experiences living with prostate cancer treated with endocrine therapy

PurposeEndocrine therapy for prostate cancer causes substantial side effects, and previous studies have focused on the impacts on sexuality and masculinity. Little is known about how men experience bodily alterations in everyday life through the course of the prostate cancer and treatment. The aim of this study was to show how men with prostate cancer experience bodily changes and how these alterations influence daily life.MethodThe study was conducted via qualitative interviews with a phenomenological hermeneutic approach. We interviewed ten men (aged 58–83) with prostate cancer who received endocrine therapy as the primary treatment method.ResultsThe results showed that five themes were important for the men’s experiences of their bodily alterations throughout the course of the illness: “something is ‘wrong’”, “when the body becomes troublesome”, “to be well or to be ill”, “dealing with the alterations” and “to talk about cancer and the intimate details”. Initially, the shock of receiving a cancer diagnosis and the physical changes in their bodies were at the forefront of many patients’ minds. Eventually, the impact of the side effects became more evident, which caused problems in everyday life. Yet, the men were able to reflect on the impact of treatment on their everyday lives.ConclusionThis study showed that hormone treatment has a significant influence, both directly and indirectly, on the bodies of prostate cancer patients. The experiences of men with prostate cancer may lead to feelings of loss of identity on an existential level.     

Workplace aggression as cause and effect: Emergency nurses’ experiences of working fatigued

IntroductionEmergency nursing requires acute attention to detail to provide safe and effective care to potentially unstable or critically ill patients; this requirement may be significantly impaired by physical and mental fatigue. There is a lack of evidence regarding the effects of fatigue caused by factors other than a sleep deficit (e.g., emotional exhaustion). Fatigue affects nurses’ ability to work safely in the emergency care setting and potentially impacts their health and quality of life outside of work.MethodsThis was the qualitative arm of a mixed methods study; we used a qualitative exploratory design with focus group data from a sample of 16 emergency nurses. Themes were identified using an inductive approach to content analysis.Results/discussionThe following themes were identified: “It’s a weight on your back;” “Competitive nursing;” “It’s never enough;” “You have to get away;” and “Engagement as a solution.”ConclusionsOur participants reported high levels of fatigue, which compromised patient care, had a negative effect on their personal lives, and created a toxic unit environment. They reported lateral violence as both the cause and effect of mental and emotional fatigue, suggesting that unit culture affects nurses and the patients they care for.     

Nursing Students' Experiences Related to Operating Room Practice: A Qualitative Study

PurposeThe purpose of this study was to examine the experiences of nursing students concerning operating room (OR) practice.DesignA qualitative design was used in this study.MethodsData were collected from second-year nursing students using the semistructured interview form including open-ended questions about their OR experiences. Perspectives of phenomenological approach including existentials of lived body, lived relations, lived space, and lived time were used in data analysis.FindingsThe study data regarding experiences of nursing students concerning OR practice were organized under three themes, namely, “OR environment,” “emotions,” and “career plans after graduation.” Nine subthemes emerged: educational experience, teamwork, and communication, excitement, enjoyment, anxiety, fear, different emotions, working as a surgical nurse, and working in departments other than OR.ConclusionsIn clinical environments, student nurses should be supported by staff and instructors to facilitate learning and create meaningful learning experiences.     

El significado del lenguaje estandarizado NANDA-NIC-NOC en las enfermeras de cuidados intensivos madrileñas: abordaje fenomenológico

Nursing standardized language is a tool that makes it possible to integrate a theoretical framework of problem identification, interventions and outcomes in care. Its use in the difference care settings is varied. In the case of intensive care units, it is necessary to study the implications that integration of this language would have in nursing area.ObjectiveTo describe the meaning of standardized NANDA-NIC-NOC language for the nurses working in Intensive Care Units in Madrid.MethodA phenomenological qualitative study was conducted. Inclusion criteria: ICU in Madrid of nurses with one year or more experience at the time of the study who were working in the ICU.SamplePurposive and Snowball sampling technique.Data collectionUnstructured interviews, personal documents (letters, diaries). Interviews were recorded and transcribed verbatim for later analysis.AnalysisGiorgi proposal. Identifying meaning units, groups of common senses and themes.ResultsThree themes made up the meaning of standardized language in intensive care nursing. “Living integrating 2 sides of the same coin”, “living a conceptual imposition”, and “living a development opportunity and professional autonomy”.ConclusionsThere is a gap in the theory of language and its clinical application. Nurses report feeling imposition of a specific conceptual language. This creates the construction of a hierarchy between nurses based on the use of NANDA-NIC-NOC. Even so, the standardized language is experienced as a professional development opportunity.     

Family functioning of families experiencing intensive care and the specific impact of the COVID-19 pandemic: A grounded theory study

ObjectivesIn order to provide a deeper understanding of family functioning, the aim of this study was to identify, describe and conceptualise the family functioning of families where a formerly critically ill family member had stayed at the intensive care unit, with the impact of a pandemic.Research methodology/designThe study has a grounded theory design including interviews with eight families.SettingFormer adult intensive care patients cared for Covid-19 infection and their family. Eight patients and twelve family members from three different intensive care units.Main outcome measuresThe results presented are grounded in data and identified in the core category “Existential issues” and the categories “Value considerateness; Anxiety and insecurity in life; Insight into the unpredictability of life.”FindingsThe core category could be found in all data and its relationship and impact on the categories and each other. The core is a theoretical construction, whereas the family functioning of families where a formerly critically ill family member had stayed at the intensive care unit was identified, described, and conceptualised. Being able to talk repeatedly about existential issues and the anxiety and insecurity in life, with people that have similar experiences helps the patient and their family to consider and gain insight into the unpredictability of life, and thereby better cope with changes in life.ConclusionThere is awareness about the love that exists within the family. A willing to supporting each other in the family even if the critical illness made the family anxious and afraid.Implications for clinical practiceEven if the pandemic Covid-19 led to restrictions inhibiting family focused nursing, it is important to confirm the family as a part of the caring of the ICU patient. The patients are not alone, their family are fighting together for the future.     

Learning and knowing bodies: Norwegian psychomotor physiotherapists’ reflections on embodied knowledge

Background: The lived experience is irreducible, and can give access to pre-reflective and implicit, embodied knowledge. There is a lack of research concerning how specialists in Norwegian Psychomotor physiotherapy (NPMP) utilize their patients’ embodied knowledge. Aim: The aim of this study was to explore if the NPMP therapists experience the phenomenon “listening to the body” as a useful source of personal knowledge and motivation in the patient’s process of’ recovery, and if there could be too much “listening to the body”? Design and methods: A qualitative study based on empirical data from the interviews with 12 specialists in NPMP. The research data were analyzed using systematic text condensation as analyzing method. Results: Four themes emerged: (1) “The negative imperative of the body”; (2) “The embodied traumatic experiences”; (3) “The process of creating meaning”; and (4) “The embodied person emerges—who am I and what choice do I have?” The results revealed the importance of becoming aware of embodied experiences, which might represent different aspects of the patients’ lives. Conclusion: Embodied knowledge can support the physiotherapists in their clinical practice. The learning and knowing body represents resources of empowerment for the patients.     

Medidas no farmacológicas para el tratamiento del síndrome confusional agudo en la unidad de cuidados intensivos

The incidence of delirium in intensive care units is high and it has been under-diagnosed and under-treated.ObjectiveTo describe the experiences of ICU nurses in the identification and application of non-pharmacological treatments.MethodA qualitative phenomenological research study was performed, based on focus groups. Inclusion criteria: ICU nurses with one year of more of experience were included.Sample Purpose and snowball technique. Data collection: Data from the focus groups were transcribed for analysis and a thematic analysis of the texts was performed.ResultsFour themes were identified: a) the physical and social structure of the ICU b) family involvement, c) need for training of health professionals, and d) encouraging the sleep-wake cycle.ConclusionsIt is necessary to control the ICU environment to make it more friendly, to change the routine work to promote relaxation, implement training activities and to make visiting hours flexible.     

‘Who will do it if I don’t?’ Nurse anaesthetists’ experiences of working in the intensive care unit during the COVID-19 pandemic

BackgroundDuring the COVID-19 pandemic, the workload on the intensive care unit (ICU) increased nationally in Sweden as well as globally. Certified registered nurse anaesthetists (CRNAs) in Sweden were transferred at short notice to work with seriously ill patients with COVID-19 in the ICU, which is not part of the CRNAs' specialist area. However, limited research has shed light on healthcare professionals’ experiences of the pandemic.ObjectivesThis study illuminates CRNAs’ experiences of working in the ICU during the COVID-19 pandemic.MethodsThis study used a qualitative method with an inductive approach to interview nurse anaesthetists who worked in the ICU during the COVID-19 pandemic.FindingsThe participants experienced ambivalent feelings towards their work in the ICU. They also lacked information, which created feelings of uncertainty and resulted in expectations that did not correspond to the reality. They described that owing to an inadequate introduction, they could only provide “sufficient” care, which in many cases caused ethical stress. Not being able to get to know their new colleagues well enough to create effective cooperation created frustration. Even though the participants experienced the work in the ICU as demanding and challenging, overall, they enjoyed their time in the ICU and were treated well by their colleagues.ConclusionsAlthough CRNAs cannot replace intensive care nurses, they are a useful resource in the ICU in the care of patients with COVID-19. Healthcare workers who are allocated from their ordinary units to the ICU need adequate information and support from their work managers to be able to provide the best possible care and to stay healthy themselves.     

Hermeneutic phenomenological interpretations of patients with head and neck neoplasm experiences living with radiation-induced xerostomia: The price to pay?

PurposePatients with head and neck neoplasms often experience a number of persistent treatment related symptoms including xerostomia. The impact of xerostomia can be profound and wearing on the patients, hence negatively influencing their quality of life. The purpose of this study was to explore the in-depth experiences of the patients living with radiation-induced xerostomia.Methods and sampleThis was a hermeneutic phenomenological study inspired by the Philosophy of Paul Ricoeur. Research data were retrieved with individual narratives from 15 patients diagnosed with head and neck neoplasm that underwent radiotherapy.Interpretation proceeded through three phases: naïve reading, structural analysis and comprehensive understanding.ResultsFive themes consisting of ten sub-themes emerged from the narratives reflecting on the patients' lived experiences. The themes were “suffering of the body”, “suffering of the person's world”, “being helpless against xerostomia”, “suffering of the mind” and “being alone”. The comprehensive understanding disclosed new possibilities for being-in-the world in relation to living with xerostomia.ConclusionThe precedent consideration of xerostomia mainly as a physical side-effect of radiotherapy was outweighed by the social and psychological effects revealed by this study. These xerostomia's effects are inflicted on the patients with an obvious reflection on their perceived quality of life. The findings call upon a shift towards acknowledging the severity of xerostomia and the need to care for these patients holistically.     

Combination of delirium and coma predicts psychiatric symptoms at twelve months in critically ill patients: A longitudinal cohort study

PurposeWe aimed to determine any associations between delirium and comas during intensive care unit (ICU) stay, and long-term psychiatric symptoms and disability affecting activity of daily living (ADL).Materials and methodsIn this prospective observational study, we enrolled critically ill adult patients that were emergently admitted to an ICU. We assessed psychiatric symptoms and disability affecting ADL at three and twelve months after ICU discharge.ResultsAmong the 81 and the 47 patients that responded to the questionnaires at three and twelve months, 22 (27%) and 13 (28%) patients experienced delirium, respectively. During their ICU stay, 28 (35%) and 21 (45%) had been in comas, respectively. At three and twelve months, 51 (63%) and 23 (49%) of patients experienced composite psychiatric symptoms or disability affecting ADL, respectively. After adjusting predefined confounders, the combination of delirium and comas was an independent risk factor for the presence of composite psychiatric symptoms or disability affecting ADL (adjusted odds ratio [aOR] 3.38; 1.10–10.38 at three months; aOR 8.28; 1.48–46.46 at twelve months).ConclusionsIn critically ill adults, combination of delirium and comas during ICU stay is a predictor of psychiatric symptoms or ADL disability.Trial registration: UMIN Clinical Trial Registry no. UMIN000023743, September 1, 2016.     

Incidence and short-term consequences of delirium in critically ill patients: A prospective observational cohort study

BackgroundDelirium is a serious and frequent psycho-organic disorder in critically ill patients. Reported incidence rates vary to a large extent and there is a paucity of data concerning delirium incidence rates for the different subgroups of intensive care unit (ICU) patients and their short-term health consequences.ObjectivesTo determine the overall incidence and duration of delirium, per delirium subtype and per ICU admission diagnosis. Furthermore, we determined the short-term consequences of delirium.DesignProspective observational study.Participants and settingAll adult consecutive patients admitted in one year to the ICU of a university medical centre.MethodsDelirium was assessed using the Confusion Assessment Method-ICU three times a day. Delirium was divided in three subtypes: hyperactive, hypoactive and mixed subtype. As measures for short-term consequences we registered duration of mechanical ventilation, re-intubations, incidence of unplanned removal of tubes, length of (ICU) stay and in-hospital mortality.Results1613 patients were included of which 411 (26%) developed delirium. The incidence rate in the neurosurgical (10%) and cardiac surgery group (12%) was the lowest, incidence was intermediate in medical patients (40%), while patients with a neurological diagnosis had the highest incidence (64%). The mixed subtype occurred the most (53%), while the hyperactive subtype the least (10%). The median delirium duration was two days [IQR 1–7], but significantly longer (P < 0.0001) for the mixed subtype. More delirious patients were mechanically ventilated and for a longer period of time, were more likely to remove their tube and catheters, stayed in the ICU and hospital for a longer time, and had a six times higher chance of dying compared to non-delirium ICU patients, even after adjusting for their severity of illness score. Delirium was associated with an extended duration of mechanical ventilation, length of stay in the ICU and in-hospital, as well as with in-hospital mortality.ConclusionsThe delirium incidence in a mixed ICU population is high and differs importantly between ICU admission diagnoses and the subtypes of delirium. Patients with delirium had a significantly higher incidence of short-term health problems, independent from their severity of illness and this was most pronounced in the mixed subtype of delirium. Delirium is significantly associated with worse short-term outcome.     

Hematopoietic Stem Cell Transplantation Patients Are Skilled at Adapting to “Out of the Ordinary” Situations: A Qualitative Study

ObjectiveBlood cancers can potentially be cured by hematopoietic stem cell transplantation (HCT), but HCT recipients can remain immunocompromised for extended periods of time and require caregiver support. Though the COVID-19 pandemic has globally affected the livelihood and well-being of all individuals, it has affected certain populations in unique ways, HCT recipients being one of them. This study intends to understand the lived experience of HCT recipients and HCT-eligible patients during the COVID-19 pandemic.Data SourcesThis qualitative study enrolled participants (N=25) from a parent study that recruited transplant patients (HCT eligible or HCT recipients) between May and October 2020. Participants were invited to participate on a one-on-one interview via an electronic platform. A phenomenologic qualitative approach was used to identify emerging themes and subthemes.ConclusionThree themes were developed: a) the pandemic experience was influenced by the transplant journey; b) participants found ways to thrive despite the odds and access support in unique ways; and c) participants described challenges during the pandemic regarding non-transplant care, vaccine considerations, and distrust in media.Implications for Nursing PracticeResults from this study highlighted that HCT recipients were uniquely prepared for “out of the ordinary” situations during the pandemic and underscored challenges faced by them during this time, identifying areas for improvement in the health care system. Nurses in their unique role can initiate and lead process changes to address barriers such as lack of access to reliable information, poor communication, and inadequate resources for accessing non-transplant care especially during uncertain times.