Craig Dale

Critical Care Nurses’ Pain Assessment and Management Practices: A Survey in Canada

BACKGROUND Regular pain assessment can lead to decreased incidence of pain and shorter durations of mechanical ventilation and stays in the intensive care unit. OBJECTIVES To document knowledge and perceptions of pain assessment and management practices among Canadian intensive care unit nurses. METHODS A self-administered questionnaire was mailed to 3753 intensive care unit nurses identified through the 12 Canadian provincial/territorial nursing associations responsible for professional regulation. RESULTS A total of 842 nurses (24%) responded, and 802 surveys could be evaluated. Nurses were significantly less likely (P < .001) to use a pain assessment tool for patients unable to communicate (267 nurses, 33%) than for patients able to self-report (712 nurses, 89%). Significantly fewer respondents (P < .001) rated behavioral pain assessment tools as moderately to extremely important (595 nurses, 74%) compared with self-report tools (703 nurses, 88%). Routine (>50% of the time) discussion of pain scores during nursing handover was reported by 492 nurses (61%), and targeting of analgesia to a pain score or other assessment parameters by physicians by 333 nurses (42%). Few nurses (n = 235; 29%) were aware of professional society guidelines for pain assessment and management. Routine use of a behavioral pain tool was associated with awareness of published guidelines (odds ratio, 2.5; 95% CI, 1.7-3.7) and clinical availability of the tool (odds ratio, 2.6; 95% CI, 1.6-4.3). CONCLUSIONS A substantial proportion of intensive care unit nurses did not use pain assessment tools for patients unable to communicate and were unaware of pain management guidelines published by professional societies.

Behavioral Pain Assessment Tool for Critically Ill Adults Unable to Self-Report Pain

BACKGROUND Critically ill adults often cannot self-report pain. OBJECTIVE To determine the effect of the Critical-Care Pain Observation Tool on frequency of documentation of pain assessment and administration of analgesics and sedatives in critically ill patients unable to self-report pain. METHODS Data on patients in 2 intensive care units of a university-affiliated hospital were collected before and after implementation of the tool. Patients were prospectively screened for eligibility; data were extracted retrospectively. RESULTS Data were recorded for a maximum of 72 hours before and after implementation of the tool in the cardiovascular intensive care unit (130 patients before and 132 after) and in the medical/surgical/trauma unit (59 patients before and 52 after). Proportion of pain assessment intervals with pain assessment documented increased from 15% to 64% (P < .001) in the cardiovascular unit and from 22% to 80% (P < .001) in the other unit. Median total dose of opioid analgesics decreased from 5 mg to 4 mg in the cardiovascular unit (P = .02) and increased from 27 mg to 75 mg (P = .002) in the other unit. Median total dose of benzodiazepines decreased from 12 mg to 2 mg (P < .001) in the cardiovascular unit and remained unchanged in the other unit. Increased documentation of pain assessment was associated with increased age in the cardiovascular unit and with decreased maximum scores on the Sequential Organ Failure Assessment in the other unit. CONCLUSION Implementation of the tool increased frequency of pain assessment and appeared to influence administration of analgesics in both units.

The relationship between organizational culture and family satisfaction in critical care.

Objectives: Family satisfaction with critical care is influenced by a variety of factors. We investigated the relationship between measures of organizational and safety culture, and family satisfaction in critical care. We further explored differences in this relationship depending on intensive care unit survival status and length of intensive care unit stay of the patient. Design: Cross-sectional surveys. Setting: Twenty-three tertiary and community intensive care units within three provinces in Canada. Subjects: One thousand two-hundred eighty-five respondents from 2374 intensive care unit clinical staff, and 880 respondents from 1381 family members of intensive care unit patients. Interventions: None. Measurements and Main Results: Intensive care unit staff completed the Organization and Management of Intensive Care Units survey and the Hospital Survey on Patient Safety Culture. Family members completed the Family Satisfaction in the Intensive Care Unit 24, a validated survey of family satisfaction. A priori, we analyzed adjusted relationships between each domain score from the culture surveys and either satisfaction with care or satisfaction with decision-making for each of four subgroups of family members according to patient descriptors: intensive care unit survivors who had length of intensive care unit stay <14 days or >14 days, and intensive care unit nonsurvivors who had length of stay <14 days or ≥14 days. We found strong positive relationships between most domains of organizational and safety culture, and satisfaction with care or decision-making for family members of intensive care unit nonsurvivors who spent at least 14 days in the intensive care unit. For the other three groups, there were only a few weak relationships between domains of organizational and safety culture and family satisfaction. Conclusions: Our findings suggest that the effect of organizational culture on care delivery is most easily detectable by family members of the most seriously ill patients who interact frequently with intensive care unit staff, who are intensive care unit nonsurvivors, and who spend a longer time in the intensive care unit. Positive relationships between measures of organizational and safety culture and family satisfaction suggest that by improving organizational culture, we may also improve family satisfaction.

Pain descriptors for critically ill patients unable to self‐report

AIM   To examine descriptors used by nurses in two Canadian intensive care units to document pain presence for critically ill patients unable to self-report. BACKGROUND   Systematic documentation of pain assessment is essential for communication and continuity of pain management, thereby enabling better pain control, maximizing recovery and reducing physical and psychological sequelae. METHOD   A retrospective, mixed method, having observational design in two Level-III intensive care units of a quaternary academic centre in Toronto, Canada. During 2008-2009, data were abstracted via chart review guided by a reference compendium of potential behavioural descriptors compiled from existing behavioural pain assessment tools. RESULTS   A total of 679 narrative descriptions were extracted. Behavioural descriptors (232, 34%), physiological descriptors (93, 14%), and descriptors indicating the patient was pain free (117, 17%) were used to describe pain presence or absence. Narratives also described analgesia administered without descriptors of pain assessment (117, 17%) and assessment and analgesic administration prior to a known painful procedure (30, 4%). Emerging themes included life-threatening treatment interference, decisional uncertainty and a wakefulness continuum. CONCLUSION   Inconsistent or ambiguous documentation was problematic in this sample. This may reflect confounding behaviours and concomitant safety priorities. Developing a lexicon of pain assessment descriptors of critically ill patients unable to self-report for use in combination with valid and reliable measures may improve documentation facilitating appropriate analgesic management. Protocols or unit guidelines that prioritize a trial of analgesia before administration of sedatives may decrease decisional uncertainty when patients exhibit ambiguous behaviours such as agitation or restlessness.

Mouth care for orally intubated patients: A critical ethnographic review of the nursing literature

OBJECTIVES The aim of this critical ethnographic literature review was to explore the evolution of nursing discourse in oral hygiene for intubated and mechanically ventilated patients. METHODS The online databases CINAHL and MEDLINE were searched for nurse-authored English language articles published between 1960 and 2011 in peer-reviewed journals. Articles that did not discuss oral problems or related care for intubated adult patients were excluded. Articles that met the inclusion criteria were chronologically reviewed to trace changes in language and focus over time. RESULTS A total of 469 articles were identified, and 84 papers met all of the inclusion criteria. These articles presented an increasingly scientific and evaluative nursing discourse. Oral care originally focused on patient comfort within the literature; now it is emphasized as an infection control practice for the prevention of ventilator-associated pneumonia (VAP). Despite concern for its neglected application, the literature does not sufficiently address mouth cares practical accomplishment. CONCLUSIONS Mouth care for orally intubated patients is both a science and practice. However, the nursing literature now emphasises a scientific discourse of infection prevention. Inattention to the social and technical complexities of practice may inhibit how nurses learn, discuss and effectively perform this critical aspect of patient care.

A qualitative study of the variable effects of audit and feedback in the ICU

Background Audit and feedback is integral to performance improvement and behaviour change in the intensive care unit (ICU). However, there remain large gaps in our understanding of the social experience of audit and feedback and the mechanisms whereby it can be optimised as a quality improvement strategy in the ICU setting. Methods We conducted a modified grounded theory qualitative study. Seventy-two clinicians from five academic and five community ICUs in Ontario, Canada, were interviewed. Team members reviewed interview transcripts independently. Data analysis used constant comparative methods. Results Clinicians interviewed experienced audit and feedback as fragmented and variable in its effectiveness. Moreover, clinicians felt disconnected from the process. The audit process was perceived as being insufficiently transparent. Feedback was often untimely, incomplete and not actionable. Specific groups such as respiratory therapists and night-shift clinicians felt marginalised. Suggestions for improvement included improving information sharing about the rationale for change and the audit process, tools and metrics; implementing peer-to-peer quality discussions to avoid a top-down approach (eg, incorporating feedback into discussions at daily rounds); providing effective feedback which contains specific, transparent and actionable information; delivering timely feedback (ie, balancing feedback proximate to events with trends over time) and increasing engagement by senior management. Conclusions ICU clinicians experience audit and feedback as fragmented communication with feedback being especially problematic. Attention to improving communication, integration of the process into daily clinical activities and making feedback timely, specific and actionable may increase the effectiveness of audit and feedback to affect desired change.

Organizational and safety culture in Canadian intensive care units: Relationship to size of intensive care unit and physician management model

PURPOSE The objectives of this study are to describe organizational and safety culture in Canadian intensive care units (ICUs), to correlate culture with the number of beds and physician management model in each ICU, and to correlate organizational culture and safety culture. MATERIALS AND METHODS In this cross-sectional study, surveys of organizational and safety culture were administered to 2374 clinical staff in 23 Canadian tertiary care and community ICUs. For the 1285 completed surveys, scores were calculated for each of 34 domains. Average domain scores for each ICU were correlated with number of ICU beds and with intensivist vs nonintensivist management model. Domain scores for organizational culture were correlated with domain scores for safety culture. RESULTS Culture domain scores were generally favorable in all ICUs. There were moderately strong positive correlations between number of ICU beds and perceived effectiveness at recruiting/retaining physicians (r = 0.58; P < .01), relative technical quality of care (r = 0.66; P < .01), and medical director budgeting authority (r = 0.46; P = .03), and moderately strong negative correlations with frequency of events reported (r = -0.46; P = .03), and teamwork across hospital units (r = -0.51; P = .01). There were similar patterns for relationships with intensivist management. For most pairs of domains, there were weak correlations between organizational and safety culture. CONCLUSION Differences in perceptions between staff in larger and smaller ICUs highlight the importance of teamwork across units in larger ICUs.

Nurse Research Experiences and Attitudes Toward the Conduct of Intensive Care Research: A Questionnaire Study.

Objective:To characterize ICU nurses’ research experience, work environments, and attitudes toward clinical research in critically ill adults and children. Design:Cross-sectional survey. Setting:Eight (seven adult and one pediatric) academic ICUs affiliated with the Canadian Critical Care Trials Group. Participants:Four hundred eighty-two ICU nurses. Interventions:None. Measurements and Main Results:Response rate was 56%. Most participants had over 6 years of ICU experience (61%) and held a baccalaureate nursing degree (57%). Most participants (63%) had provided care for patients receiving research study procedures more than five times in the past 12 months and agreed that research leads to improved care for the critically ill (78%) and eligible patients should be approached for research participation (78%). Few perceived practicalities of nursing care are considered in study design (20%); 41% agreed that research studies increases nursing workload. Few participants reported receiving adequate information about study progress (24%) or findings (26%). Principal factor analysis identified three factors each in the environmental and attitudinal domains. Linear regression models demonstrated that positive relationships between researchers and clinicians were associated with favorable perceptions of research impact on nursing care (p < 0.001), ICU research acceptability (p < 0.001), and nursing engagement in research (p < 0.05). Nurses with more formal education reported more favorable attitudes toward nursing engagement in research (p < 0.01) and research acceptability (p < 0.01). Lack of experience in study protocol development and/or data analysis was associated with less favorable attitudes about nursing engagement in research (p < 0.01) and impact of research on nursing care (p < 0.01). Conclusion:In these research-intensive ICUs, nurses frequently care for research participants and believe ICU research is important. Inclusion of nurses in study protocol development, improved communication of study progress and findings, and investigation of research-related nursing workload are warranted. Such interventions will support intervention fidelity and data reliability during study conduct and translation of evidence into practice on study completion.

Implementation of a research awareness program in the critical care unit: effects on families and clinicians☆

BACKGROUND Successful conduct of research studies in the critically ill requires communication with families, substitute decision-makers and clinicians. OBJECTIVE To assess the effect of a communication package on attitude, knowledge and research awareness among family members and clinicians. METHODS We conducted a prospective, single centre, before and after study. We distributed a validated questionnaire to family members and clinicians assessing the three domains of research attitude, knowledge and awareness before and after implementation of a research communication package consisting of an informational pamphlet and display poster. RESULTS Response rates for the family member survey were 22% (baseline) and 15% (post-intervention). No differences were found in the attitude, knowledge and awareness of family members following implementation of the research communication package. The global awareness score (calculated by summing the domain responses) rose 4.0 points (P=0.056). Response rates for clinicians were 36% (baseline) and 33% (post-intervention). No differences were found in attitude, knowledge and awareness and global awareness score. CONCLUSION Passive dissemination of research materials was not sufficient to generate an increased awareness, knowledge, or perceived utility of research.

A mixed-methods systematic review protocol to examine the use of physical restraint with critically ill adults and strategies for minimizing their use

BackgroundCritically ill patients frequently experience severe agitation placing them at risk of harm. Physical restraint is common in intensive care units (ICUs) for clinician concerns about safety. However, physical restraint may not prevent medical device removal and has been associated with negative physical and psychological consequences. While professional society guidelines, legislation, and accreditation standards recommend physical restraint minimization, guidelines for critically ill patients are over a decade old, with recommendations that are non-specific. Our systematic review will synthesize evidence on physical restraint in critically ill adults with the primary objective of identifying effective minimization strategies.MethodsTwo authors will independently search from inception to July 2016 the following: Ovid MEDLINE, CINAHL, Embase, Web of Science, Cochrane Library, PROSPERO, Joanna Briggs Institute, grey literature, professional society websites, and the International Clinical Trials Registry Platform. We will include quantitative and qualitative study designs, clinical practice guidelines, policy documents, and professional society recommendations relevant to physical restraint of critically ill adults. Authors will independently perform data extraction in duplicate and complete risk of bias and quality assessment using recommended tools. We will assess evidence quality for quantitative studies using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and for qualitative studies using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) guidelines. Outcomes of interest include (1) efficacy/effectiveness of physical restraint minimization strategies; (2) adverse events (unintentional device removal, psychological impact, physical injury) and associated benefits including harm prevention; (3) ICU outcomes (ventilation duration, length of stay, and mortality); (4) prevalence, incidence, patterns of use including patient and treatment characteristics and chemical restraint; (5) barriers and facilitators to minimization; (6) patient, family, and healthcare professional perspectives; (7) professional society-endorsed recommendations; and (8) evidence gaps and research priorities.DiscussionWe will use our systematic review findings to produce updated guidelines on physical restraint use for critically ill adults and to develop a professional society-endorsed position statement. This will foster patient and clinician safety by providing clinicians, administrators, and policy makers with a tool to promote minimal and safe use of physical restraint for critically ill adults.Systematic review registrationPROSPERO CRD42015027860