How do intensive care nurses assess patients’ pain?

Identification and evaluation of pain in critical care patients may be difficult because of communication problems. Moreover, at present there are very few nursing studies that examine the attitudes of critical care nurses towards the assessment of patients' pain. This study was designed to determine the approach of critical care nurses towards assessing patients' pain levels, and to evaluate the problems in nursing diagnosis of those having difficulty in articulating their pain symptoms. We used a questionnaire to assess nurses attitudes to patients' pain. The study sample consisted of 91 critical care nurses who were recruited between January and February 2002. The results suggest that patient pain was considered undesirable by 44% of nurses. About 70-3% of the nurses reported resorting to administering analgesics to relieve their patients' pain. Some 57.1 % of nurses stated that they would have investigated whether the patients had really been experiencing pain, prior to administering the prescribed analgesics to patients. Some 85.7% of the sample indicated that the patients themselves would make the most accurate evaluation of their pain. The data suggested that 39.6% of nurses did not know how to evaluate pain symptoms in critical care patients suffering from complicated problems, and that 37.4% evaluated pain by monitoring the patients' behaviours. The study demonstrated that most of the critical care nurses did not know how to evaluate pain in patients having communication problems. The paper concludes by suggesting that there is a clear need to address nursing education and training with regard to evaluation and management of patients' pain whilst in critical care environment.     

Palliative care volunteers: why do they do it?

Two studies were conducted to examine people's motives for joining a palliative care volunteer program. To generate a pool of reasons for becoming a palliative care volunteer, previous studies of motivations relevant to palliative care were reviewed and interviews were conducted with 15 palliative care volunteers (Study 1). Combining the literature review and interviews, a total of 22 distinct reasons for volunteering were identified and used to create an Inventory of Motivations for Palliative Care Voluntarism (IMPCV). In Study 2, 113 palliative care volunteers responded to the IMPCV. "To help ease the pain of those living with a life-threatening illness" was rated as the most influential reason for becoming a palliative care volunteer. A principal components factor analysis was conducted on the IMPCV. It was decided that four factors adequately represented the items: Leisure, Personal Gain, Altruism, and Civic Responsibility.     

Can regulation improve safety in critical care?

This article examines national and state safety practice initiatives, including the Centers for Medicare and Medicaid Services quality focus, federal and state outcomes reporting, and consumer access to outcomes data. The efforts of national and regional legislators and health care institutions to create regulations for staffing and technology to reduce medical errors is reviewed. The potential of a unified cooperative effort from all stakeholders to implement the above initiatives to improve intensive care unit safety practices is discussed.     

Humiliation or care? A qualitative study of patients’ and health professionals’ experiences with tuberculosis treatment in Norway

Scand J Caring Sci; 2012; 26; 313–323 Humiliation or care? A qualitative study of patients’ and health professionals’ experiences with tuberculosis treatment in Norway Aim: Directly observed treatment (DOT) has been implemented globally as a strategy in treatment of tuberculosis. Studies from high‐endemic settings show that DOT involves social and economical burdens for patients, but little is known about experiences with practicing DOT in low‐endemic settings. The present study explores patients’ and health professionals’ views and experiences with DOT in Norway. Method: In‐depth interviews were conducted with 22 patients originating from Somalia and Ethiopia and with 20 health professionals. Data from the interviews were analysed using systematic text condensation. Findings: We found that there was little room for patients to negotiate whether or not to consent to the organization of treatment (DOT). Patients told that it was difficult to question the way treatment was organized, as they got the impression that there was no other way of gaining access to medication. Both patients and health professionals reported that persuasion based on authority and subtle threats was used as means to facilitate patients’ acceptance of DOT. A majority of patients experienced DOT as humiliating and discriminating, while some had the experience of being cared for. Patients who attended school or had occupational obligations reported high social costs related to the treatment. Patients with positive experiences told that they had been given an opportunity to negotiate flexible treatment schedules and emphasized the importance of continuity among health professionals. Health professionals had divergent views and practices. Some argued that patients should be treated equally, while others argued for an individualized and flexible approach. Conclusion: The practice of DOT reflects societal power structures that influence the clinical interactions between health professionals and patients. To avoid experiences of disempowerment and humiliation among patients, treatment and care should be organized in a way that safeguards patients’ right to consent to treatment and that allows patients to negotiate an individualized treatment schedule.     

Palliative care network and the elderly: what autonomy do they have?

Several Swiss institutions of a socio-sanitary region have put together a network with the view of assuring efficient palliative care. A research was conducted in partnership with four health-care establishments in order to verify if the concept of autonomy conceived by professionals corresponded to the patients' needs. Semi-directive interviews were conducted, along with questionnaires. The analysis showed a considerable disparity between palliative philosophy and the real needs of elderly patients. The aging process experienced by the people interviewed was synonymous with illness, loss, suffering and quality of life are associated with youth. The dimension of the projects and partnerships is difficult for them to imagine.     

Assessing patients’ needs: does the same information guide expert and novice nurses?

The difficulties experienced by nurses in assessing patients before providing care have been the subject of enquiry for many years. Much has been written about the nursing process and, in particular, the data-collection component, where the nurse gathers information before deciding on a diagnosis and nursing intervention. There is, however, very little published on the differences between expert and novice nurses, in either the way they gather information or the emphasis placed on the different data sources accessed when preparing to carry out a nursing procedure. Communication between nurses is essential in the provision of safe, competent care, and yet we have minimal understanding of how experts use data sources to plan procedural care giving. This article reports on the findings of one component (the differences between expert and novice nurses in accessing data before implementing a nursing procedure) of a larger study into the identification of problem-solving strategies adopted by nurses during procedural care giving. The study was conducted in clinical settings and used a qualitative research methodology of observation followed by an in-depth semistructured interview. The study results indicate that expert and novice nurses accessed four similar information sources before meeting a patient. However, there were differences noted between the two groups in the amount of information accessed, as well as in the interpretation and use of that information. This is an important issue for nurse educators.     

Treating individuals according to evidence: why do primary care practitioners do what they do?

Research evidence does not necessarily translate into changed management for individual patients, but that may not mean that the evidence has been ignored. Drawing on accounts from general practitioners, we use a study of non-rheumatic atrial fibrillation (NRAF) to illuminate the processes by which practitioners became aware of and assimilated research evidence. We follow that with an account of how the evidence was incorporated into practice protocols for anticoagulation and then applied to a review of individual patients' records. Practitioners used a range of sources of evidence. They reported difficulties arising from their own skills and circumstances and from the perceived quality of the evidence. Creating a protocol involved overcoming problems of scheduling, resources and managing judgements about the value of the review process. In applying the protocol practitioners drew on their knowledge of the patients' preferences, circumstances and previous specialist consultations. As a result, practitioners made judgements that evidence, combined with prior experience, did not support the initiation of anticoagulation in 52% of an unselected primary care population with NRAF. Our findings have implications for evidence-based practice and for practitioner education.     

Effect of oral melatonin and wearing earplugs and eye masks on nocturnal sleep in healthy subjects in a simulated intensive care unit environment: which might be a more promising strategy for ICU sleep deprivation?

IntroductionSleep deprivation is common in critically ill patients in the intensive care unit (ICU). Noise and light in the ICU and the reduction in plasma melatonin play the essential roles. The aim of this study was to determine the effect of simulated ICU noise and light on nocturnal sleep quality, and compare the effectiveness of melatonin and earplugs and eye masks on sleep quality in these conditions in healthy subjects.MethodsThis study was conducted in two parts. In part one, 40 healthy subjects slept under baseline night and simulated ICU noise and light (NL) by a cross-over design. In part two, 40 subjects were randomly assigned to four groups: NL, NL plus placebo (NLP), NL plus use of earplugs and eye masks (NLEE) and NL plus melatonin (NLM). 1 mg of oral melatonin or placebo was administered at 21:00 on four consecutive days in NLM and NLP. Earplugs and eye masks were made available in NLEE. The objective sleep quality was measured by polysomnography. Serum was analyzed for melatonin levels. Subjects rated their perceived sleep quality and anxiety levels.ResultsSubjects had shorter total sleep time (TST) and rapid eye movement (REM) sleep, longer sleep onset latency, more light sleep and awakening, poorer subjective sleep quality, higher anxiety level and lower serum melatonin level in NL night (P <0.05). NLEE had less awakenings and shorter sleep onset latency (P <0.05). NLM had longer TST and REM and shorter sleep onset latency (P <0.05). Compared with NLEE, NLM had fewer awakenings (P = 0.004). Both NLM and NLEE improved perceived sleep quality and anxiety level (P = 0.000), and NLM showed better than NLEE in perceived sleep quality (P = 0.01). Compared to baseline night, the serum melatonin levels were lower in NL night at every time point, and the average maximal serum melatonin concentration in NLM group was significantly greater than other groups (P <0.001).ConclusionsCompared with earplugs and eye masks, melatonin improves sleep quality and serum melatonin levels better in healthy subjects exposed to simulated ICU noise and light.

Trial registration

Chinese Clinical Trial Registry ChiCTR-IPR-14005458. Registered 10 November 2014.     

Measurements in the intensive care unit: what do they mean?

Intensivists depend upon a large number of measurements to make daily decisions in the ICU. However, the reliability of these measures may be jeopardized by the effects of therapy. Moreover, in critical illness, what is normal is not necessarily optimal. Procalcitonin, a putative marker of occult infection, is emerging as a valuable diagnostic marker in the ICU. Although questions remain regarding its specificity, an increasing body of work suggests that it is reliably elevated in the setting of infection. As demonstrated by Level and colleagues in this issue of Critical Care, its utility as a diagnostic marker is not affected by concomitant hemodialysis.     

How do we know when patients sleep properly or why they do not?

The importance of adequate sleep for good health and immune system function is well documented as is reduced sleep quality experienced by ICU patients. In the previous issue of Critical Care, Elliot and co-workers present a well done, largest of its kind, single-center study on sleep patterns in critically ill patients. They base their study on the ''gold standard'', the polysomnography technique, which is resource demanding to perform and often difficult to evaluate. The results are especially interesting as the authors not only used polysomnography in a large sample but also, in contrast to others, excluded patients with prior sleep problems. They also recorded patients'' subjective sleep experiences in the ICU and thereafter in the ward (validated questionnaires) with simultaneous data collection of factors known to affect sleep in the ICU (mainly treatment interventions, light and sound disturbances). Interestingly, but not surprisingly, sleep was both quantitatively and qualitatively poor. Furthermore, there seemed to be little or no improvement over time when compared to earlier studies. This study stresses the magnitude of the sleep problem despite interventions such as earplugs and/or eyeshades. Sound disturbance was found to be the most significant but improvable factor. The study highlights the challenge and the importance of evaluating sleep in the critical care setting and the present need for alternative methods to measure it. All that in conjunction can be used to solve an important problem for this patient group.The role of sleep in general health is well known. Poor sleep predicts cardiovascular disease [1], and increases oxidative stress [2]. It also increases pro-inflammatory cytokines and worsens subjective health [3]. Furthermore, which may be especially important in ICU patients, short sleep duration increases the susceptibility to infections [4]. It is also well known that many critically ill patients experience sleep disruptions, which is assumed to have health implications [5]. Important also is the fact that the ICU population as such is a heterogeneous group burdened with increased rates of co-morbidities [6]. Pre-existing diseases - that is, poor health - comprise a well-known factor that affects sleep during ''normal'' conditions and sleep patterns may be thought to further deteriorate during periods of critical illness and affect health-related quality of life [7]. The effect of such induced poor sleep may therefore result in further health difficulties. Such complicating background factors may have implications for investigations, such as that by Elliot and co-workers in the previous issue of Critical Care [8], as it is difficult to know the ''normal'' sleep pattern of any patient and, consequently, in sleep research examining hospital populations, the choice of control group is a challenge.Significant efforts are continuously being directed to assess and combat organ dysfunction and failure in critical illness. Among these has been a recent focus on the brain supported by results from the anesthesia perspective where cognitive dysfunction has been registered after general anesthesia and surgery or heart surgery. Concomitantly, a hot topic in critical care has been the issue of delirium, possibly caused by central nervous system failure and/or as a consequence of sedation techniques, other drugs or even exhaustion due to sleep deprivation, possibly caused by direct practical care-related issues [9,10]. A significant portion of critically ill patients are furthermore sedated, not uncommonly as a substitute for not being able to sleep otherwise. This underlines the importance of sleep scoring as a part of overall brain function monitoring and to assess when there is need for supportive measures. Still, brain function assessment and surveillance in the ICU setting, both for clinical and scientific purposes, is difficult due to a shortage of relevant and practical methods to use [11]. For clinical use practical techniques are sought that are validated and that are specific for the scientific counterparts. Neither of these are available today, as exemplified by, for example, the low sensitivity of the best recommended assessment tool for delirium [12]. Furthermore, besides the strictly practical difficulties seen in the ICU setting, there is also a lack of knowledge and consensus on how to assess cognitive functions in this patient group, who often in parallel are also affected by pharmacological agents.Elliot and colleagues [8] contribute significantly to an important aspect of brain function monitoring by examining sleep patterns. These we know have very significant health implications. The authors are to be congratulated on their high level of ambition to gain knowledge regarding sleep patterns in the ICU by performing a large study using good methodology including the use of polysomnography (the ''gold standard'') combined with adequate, validated patient questionnaires and simultaneous data collection of data depicting factors known to affect sleep in the ICU.Furthermore, previous studies have rarely collected data on the patient perception of sleep quality and the potential causes of sleep disturbing factors, important factors that have also been included in the present study. The study shows clearly, as may be expected, that the patients included in the study experience poor sleep and that this issue should be further examined and improvement interventions developed. Another and possibly even more important issue that the authors stress in their article is the demanding nature and practical difficulties known for this methodology. It needs then to be appreciated that although 656 patients satisfied inclusion criteria, only 53 patients (less than 10%) were in the end included and examined. Many drop outs are due to different methodological issues, that is, difficulties in evaluating sleep in situations where, for example, sleep patterns prior to ICU are already poor or patients are neurologically impaired. This unfortunately reduces the generalizability of the results. In delirium or cognitive dysfunction, electroencephalography frequencies are often slow already in wakefulness, which makes assessment of sleep stages difficult. Many pharmacological agents (for example, benzodiazepines, morphine) in themselves also change the electroencephalogram and/or sleep patterns. Absence of information concerning medication and presence of pain (also very important when it comes to degree of sleep disturbance) are minor flaws in the present report. An obvious practical shortcoming complicating sleep evaluations - compared to, for example, diagnosing delirium or cognitive dysfunction - is that many examining procedures for this purpose may in themselves affect sleep if not done in specialized laboratories.