Exploring the quality of dying of patients with chronic obstructive pulmonary disease in the intensive care unit: a mixed methods study

Rationale for the study:  Improving the quality of end-of-life (EOL) care in critical care settings is a high priority. Patients with advanced chronic obstructive pulmonary disease (COPD) are frequently admitted to and die in critical care units. To date, there has been little research examining the quality of EOL care for this unique subpopulation of critical care patients.
Aims:  The aims of this study were (a) to examine critical care clinician perspectives on the quality of dying of patients with COPD and (b) to compare nurse ratings of the quality of dying and death between patients with COPD with those who died from other illnesses in critical care settings.
Design and sample:  A sequential mixed method design was used. Three focus groups provided data describing the EOL care provided to patients with COPD dying in the intensive care unit (ICU). Nurses caring for patients who died in the ICU completed a previously validated, cross-sectional survey (Quality of Dying and Death) rating the quality of dying for 103 patients.
Data analysis:  Thematic analysis was used to analyse the focus group data. Total and item scores for 34 patients who had died in the ICU with COPD were compared with those for 69 patients who died from other causes.
Results:  Three primary themes emerged from the qualitative data are as follows: managing difficult symptoms, questioning the appropriateness of care and establishing care priorities. Ratings for the quality of dying were significantly lower for patients with COPD than for those who died from other causes on several survey items, including dyspnoea, anxiety and the belief that the patient had been kept alive too long. The qualitative data allowed for in-depth explication of the survey results.
Conclusions:  Attention to the management of dyspnoea, anxiety and treatment decision-making are priority concerns when providing EOL care in the ICU to patients with COPD.     

Dying and bereavement: The role of the critical care nurse

The critical care units of today are environments totally dedicated to implementing life saving and life supporting measures. The development of the critical care unit is such that now many critical care units offer specific specialised disease/surgical management e.g. the cardiothoracic unit, transplant centres. As the ability of the critical care units to offer extensive life supportive measures continually improves, the fact is that there is still an increased potential for death to occur in the critical care unit, more than in other acute areas.While the prime function of the critical care staff will always be to support and sustain the life of their patients for whom they care, they also have a responsibility to offer a caring and compassionate level of care to the dying critically ill patient and to ensure that they support the dying patients' relatives in every way that they can.The prospect of death (for the patient), and the actual loss of the patient (for the relatives/medical and nursing staff) can present a number of difficulties for all those involved. These difficulties, which will be identified in the course of the article, may if unresolved predispose to a poor and traumatic bereavement process for the relatives, while the critical care staff may experience possible feelings of frustration, helplessness and low morale. (Caughill, 1976). It is therefore the aim of this article to examine the role of the critical care nurse in caring for the dying patient in the intensive care areas. It will aim to offer some insight into the nature of grief, the process that may follow, and to relate this to the possible difficulties that the bereaved relatives may experience following the loss of their family member in the critical care setting. It will also identify those measures that can be implemented to promote a caring approach to meeting the needs of the dying critically ill patient, the bereaved relatives, and in which the health care professionals can take support and comfort during this difficult time.     

Dwelling with stories that haunt us: building a meaningful nursing practice

The purpose of this article is to reflect on pediatric critical care nurses' experience of grief by focusing on the meaning of the stories that haunt them. It is suggested that these stories are the nurses' attempt to find ways to journey through their grief and to live with the mystery of life and death. It is also the task of these stories to throw light on their experiences, a task that is never entirely finished. Dwelling with the stories that haunt them helps to provide nurses with a moral structure of critical care nursing practice. Their reflections upon the meaning of their experiences of grief can lead to a view of death that is not always perceived as an evil to flee, but is upheld as a source of value and revelation as critical care nurses strive to build who they are and how they practice the art of nursing.     

Care of patients with chronic obstructive pulmonary disease in primary health care

Aim.  This paper is a report of a study of nurses' perceptions of caring for patients with chronic obstructive pulmonary disease.
Background.  Chronic obstructive pulmonary disease is a global health problem and the number of patients being treated with this disease in primary healthcare settings is increasing. This places new demands on the nurses involved.
Method.  A phenomenographic approach was adopted, using a purposive sample. Data were generated between February and May 2003 from 20 interviews with district nurses and general nurses who cared for patients in primary healthcare settings with chronic obstructive pulmonary disease.
Findings.  In most cases, nurses cared for older people with moderate to severe chronic obstructive pulmonary disease. They described this care from two overall orientations: task and individual. The nurses' perceptions of the care of these patients were described as creating commitment and participation by establishing a good relationship with patients and supporting them in their personal care, educating patients by supplying information and knowledge in various ways, co-operation by co-operating with or referring to other caregivers, and arranging and implementing clinical examinations and treatments.
Conclusion.  The type of care depended on who the patient met: either a task-oriented nurse or an individual-oriented nurse. Therefore, nursing programmes should pay special attention to the support and guidance of new and inexperienced and task-oriented nurses. Healthcare planners should take into consideration the need for individualized care when organizing care and allocating resources for chronically ill people.     

The role of technology in critical care nursing

Title.  The role of technology in critical care nursing.
Aim.  This paper is a report of a study to identify the meaning for critical care nurses of technology related to weaning from mechanical ventilation and to explore how that technology was used in practice.
Background.  The literature concerned with the development of critical care (intensive care and high dependency units) focuses mainly on innovative medical technology. Although this use of technology in critical care is portrayed as new, it actually represents a transfer of technology from operating theatres.
Method.  An ethnographic study was conducted and data were collected on one critical care unit in a large teaching hospital over a 6-month period in 2004. The methods included participant observation, interviews and the collection of field notes.
Findings.  The overall theme 'The nursing–technology relation' was identified. This comprised three sub-themes: definition of technology, technology transferred and technology transformed. Novice nurses took a task-focussed approach to weaning, treating it as a 'medical' technology transferred to them from doctors. Expert nurses used technology differently and saw its potential to become a 'nursing technology'.
Conclusion.  Nurses need to examine how they can adapt and to 'reconfigure' technology so that it can be transformed into a nursing technology. Those technologies that do not fit with nursing may have no place there. Rather than simply extending and expanding their roles through technology transfer, nurses should transform those technologies that preserve the essence of nursing and can contribute to a positive outcome for patients.     

Mental health community liaison in aged care: a service of value to all

Aim.  This paper describes an effective community nursing role in which mental health care is brought to long-term care in a way that restores and promotes mental health wellbeing in the older person, builds understanding between clinicians, and develops staff confidence in attending to the whole needs of residents of nursing homes.
Background.  Mental health is a significant issue in the ageing population and there is much that mental health nurses as well as staff in long-term care can do to promote early detection of problems, facilitate effective treatment and build coping in the older person and family so that they recover from grief or depression issues and go on to make this stage of life satisfying and rewarding.
Conclusions.  The mental health nurse liaison role is a useful contribution to comprehensive aged care in the community. The role provides support to clinicians enabling them to develop skills and expand their area of practice, whilst creating an environment in which the needs of the client may also be better understood and thereby met.     

Acute care teaching in the undergraduate nursing curriculum

Aim:  To incorporate basic aspects of acute care into the undergraduate nursing programme by providing an opportunity for the development of knowledge and skills in the early recognition and assessment of deteriorating patients on general hospital wards.
Background:  Acute care initiatives implemented in the hospital setting to improve the identification and management of 'at risk' patients have focused on the provision of education for trained or qualified staff. However, to ensure student nurses are 'fit to practice' at the point of registration, it has been recommended that acute care theory and skills are incorporated into the undergraduate nursing curriculum.
Practice development initiative:  An 'Integrated Nursing Care' module was incorporated into year 3 of the undergraduate nursing programme to introduce students to acute care theory and practice. Module content focuses on the early detection and management of acute deterioration in patients with respiratory, cardiac, neurological or renal insufficiencies. We used a competency-based framework to ensure the application of theory to practice through the use of group seminars. High-fidelity patient-simulated clinical scenarios were a key feature. The United Kingdom Resuscitation Council Intermediate Life Support course is also an important component of the module.
Conclusions:  Incorporating the Integrated Nursing Care module into the undergraduate nursing curriculum provides pre-registration students the opportunity to develop their knowledge and skills in acute care.
Relevance to clinical practice:  The provision of undergraduate education in care of the acutely ill patient in hospital is essential to improve nurses' competence and confidence in assessing and managing deteriorating patients in general wards at the point of registration.     

Palliative care in nursing homes: exploring care assistants' knowledge

Aim.  To explore the level of palliative care knowledge and to identify educational needs of care assistants (CAs) working within a nursing home context.
Background.  In the United Kingdom (UK) many patients at the end-of-life are admitted to (or reside in) nursing homes, where they receive care from unqualified CAs who have little formal training. Mandatory training in specific skills to meet palliative care needs are absent.
Method.  Questionnaire to CAs in 48 of 91 private nursing homes in one UK region.
Findings.  A population of 1135 CAs were targeted with a response rate of 45% ( n  = 508). A high proportion of CAs in this sample required information about the philosophy and principles of palliative care. Results support the need for an educational initiative to improve palliative care in nursing homes.
Conclusion.  Although recognized as a common place of death for older people, CAs are often unprepared to provide end-of-life care to nursing home residents. It is recommended that attention be given towards developing the skills and knowledge of this staff group.     

Nurses' attitudes and perceptions of pain assessment in neonatal intensive care

Scand J Caring Sci; 2010; 24; 49–55
Nurses' attitudes and perceptions of pain assessment in neonatal intensive care
Background:  Pain assessment of premature infants continue to be ineffective. The problem may be partly because of misconceptions or lack of knowledge in the assessment of pain in children.
Aims:  This paper reports a study to describe nurses' attitudes towards and perceptions of pain assessment in neonatal intensive care and the demographic factors related to these attitudes and perceptions of pain.
Methods:  The participants consisted of 257 Finnish nurses who were recruited from all five of the country's university hospitals caring for the premature infants receiving intensive care or monitoring. We collected data by using a Likert-type questionnaire in spring 2006. The response rate was 71% from the represented population.
Findings:  Almost all (97%) of the nurses agreed that pain assessment in premature infants is important. However, over half (60%) of the respondents agreed that they could assess the premature infants pain reliably without pain scores. The respondents' perceptions of the premature infants' ability to sense and express pain indicated rather good knowledge of the topic. Nevertheless, one-fourth of the participants was unaware that a premature infant could be more sensitive in sensing pain than a full term counterpart. Education, work experience and the working unit were the demographic factors that were significantly related to the respondents' attitudes and perceptions.
Conclusions:  On average nurses' attitudes were positive towards the pain assessment in neonatal intensive care. However, there were some gaps in the knowledge concerning the respondents' perceptions of the items, which is a challenge to nursing and nursing education.     

Research in intensive care nursing

• • The results of a questionnaire study about intensive care nursing in Finland indicate that the chief problems in intensive care nursing are concerned with staff coping resources, quality development and patient experiences.
• • Questions on staff stress and coping have been researched quite extensively. Earlier studies have described intensive care nursing as highly stressful and pointed to numerous problems related to coping.
• • It is clear that intensive care nursing warrants closer attention in research.

     

Memory making in end-of-life care in the adult intensive care unit: A scoping review of the research literature

ObjectiveThe objective of this review is to describe the practice of memory making as part of end-of-life care within an adult intensive care setting and determine reported outcomes.MethodsA scoping review of the literature was performed. Data were collected from sources such as ProQuest, CINAHL, Medline, Embase, PsycINFO, and PubMed using combinations of the keywords: including adult, critical care, intensive care, ICU, death, dying, grief, bereavement, end?of?life, memento*, memor*, keepsak*, and transitional object. Peer-reviewed studies reporting on the use of memory making within an adult intensive care setting and its outcomes for family members were included.ResultsFour activities facilitating memory making as part of end-of-life care for adults are reported in the literature, all in the intensive care setting. Use of a computer-generated word cloud image received by families in the intensive care was reported as a meaningful keepsake and sometimes displayed in places such as the patient's funeral memorial. Offering a printed copy of the patient's electrocardiogram as a memento was considered by some to be extremely or very helpful during their bereavement experience and was reported by nursing staff to be well received by family members. The use of patient diaries during bereavement has been reported with the potential to promote better understanding of the events leading to the death, and photography was also included in some patient diaries as a visual memento.ConclusionAlthough limited evidence is available concerning memory making in the adult intensive care environment, from studies to date, surviving family members of deceased patients in the intensive care unit mostly report valuing memory-making opportunities when offered. However, further research is required to evaluate both healthcare staff's competence and confidence in offering memory making and determine if such offerings promote the family's adjustment to the loss of their loved one after a death in the intensive care area.     

Heteronormative communication with lesbian families in antenatal care, childbirth and postnatal care

Title.  Heteronormative communication with lesbian families in antenatal care, childbirth and postnatal care.
Aim.  This paper is a report of a study of lesbian parents' experience of antenatal care, childbirth and postnatal care.
Background.  In a strictly heteronormative-based care system, 'parents' naturally implies a man and a woman, and all communication and routines are based on heterosexual couples.
Method.  A qualitative interview study was carried out in 2008. Ten mothers, eight of whom were in a relationship with another woman, participated. The participants had experience from several care facilities from three different cities in central Sweden.
Findings.  Most participants had positive experiences but also complained that the focus was not always on the pregnancy and that no parenthood education had been offered. Heteronormativity was communicated by midwives and nursing staff throughout the process – from antenatal care to postnatal care, via forms, journals, verbal communication and orientation visits. This was experienced as embarrassing for the participant parents, and they also described encountering what they interpreted as embarrassment on the part of care providers. Participants called for increased knowledge about lesbian parenting, since they believed this would influence and facilitate communication, not least with midwives in antenatal care.
Conclusion.  Midwives educated in lesbian issues could ask questions and communicate in a more neutral way at the first meeting, and thereby make prospective parents feel less insecure. Special parenthood education groups for lesbians are recommended so that lesbian couple can meet others with similar experiences and so that the focus will be on prospective parenthood and not on their sexual orientation.     

Communication with dying patients--perception of intensive care units nurses in Brazil

Aims and objectives. This study aimed to assess whether nurses working in intensive care units view the establishment of communication with patients beyond therapeutic possibilities as an effective palliative therapeutic resource, and which aspects of this communication they valued most. Method. Data were collected in November 2002, by semi‐structured interviews with 10 nurses of both clinical and surgical intensive care unit at a school hospital in Sao Paulo city, Brazil. Interviews were recorded and transcribed to be further analysed according to the qualitative methodology of content analysis. Results. Four categories of thematic order raised from the collected statements, which clarify (i) the value of communication with terminal patients; (ii) the obstacles found during this process; (iii) the need to identify the individual demands of each patient, (iv) be able to use communication as a tool in the palliative care of the dying patient. Conclusion. In conclusion, we found that the nurses working at the intensive care unit do consider communication with dying patients an effective therapeutic resource, in spite of their own difficulties in communicating with dying patients, viewing themselves as ill prepared to the task, and often, distancing themselves from the dying patients because of their inability to deal with their own feelings, which were brought forth by the confrontation with the imminence of death. Relevance to clinical practice. Although the number of interviewed nurses in our study was small, the results corroborated the findings of other studies and revealed an educational aspect in nursing training that deserves serious consideration.     

Pressure ulcer prevalence in intensive care patients: a cross-sectional study

Background  Pressure ulcers are a potential complication for intensive care patients and their prevention is a major issue in nursing care. Therefore, this study aims to assess pressure ulcer prevalence in intensive care patients, patients' characteristics and preventive measures related to pressure ulcer prevalence in intensive care patients and to determine the most common body sites of pressure ulcers.
Method  The research design was a cross-sectional study. The sample consisted of 1760 patients (298 in 2002, 408 in 2003, 453 in 2004, 368 in 2005 and 233 participants in 2006) from surgical, medical and interdisciplinary intensive care.
Results  The results revealed a mean prevalence rate of ±30% from 2002 to 2005 while it considerably decreased down to 16.2% in 2006. Half of the pressure ulcers were of grade 1. Furthermore, a significant relation was found between the presence of pressure ulcers and age ( P  ≤ 0.022), Braden score ( P  ≤ 0.01) and bowel incontinence ( P  ≤ 0.01).
Conclusion  It is crucial to select appropriate and applicable preventive material/devices and nursing care measures. Moreover, factors related to the presence of pressure ulcers should be taken into consideration in order to prevent development of further pressure ulcers.     

Earplugs improve patients' subjective experience of sleep in critical care

Aims:  This study aimed to determine the effects of earplug use on the subjective experience of sleep for patients in critical care.
Background:  The negative effects of noise in critical care include sleep disturbances, increased stress response, and reduced patient satisfaction. The nature of critical care often precludes quiet time protocols. Previous studies indicated that earplugs can improve REM sleep and sleep efficiency. This study examined the effects of earplugs as a non-invasive method for improving the subjective sleep experience and increasing patient satisfaction.
Design:  Quasi-experimental intervention study with random assignment of subjects.
Method:  Subjects were non-ventilated, non-sedated adults admitted to critical care. The intervention group used earplugs during nighttime sleep hours allowing short term removal during patient care. Participants completed the Verran-Snyder-Halpern Sleep Scale, an 8-question visual analogue scale, to describe their subjective response to sleep. Two sample T-tests were used to detect differences between the group scores.
Results:  88 participants (49 intervention/39 control) completed the study. Mean age 63, 56% males, 93% Caucasian. Total sleep satisfaction scores were significantly better for the intervention group (p = .002). Seven of the subjective categories were independently significant (p = .005-.044). One category, satisfaction with the amount of time needed to fall asleep, was not significant (p = .111).
Conclusions:  Earplug use improved the subjective experience of sleep for un-medicated critical care patients without interfering with care delivery.
Relevance to Practice:  The negligible cost and low level of invasiveness of earplugs makes this preferable as a primary intervention to promote sleep while avoiding unnecessary sedating medications.