Natalie S. McAndrew

A Balancing Act Experiences of Nurses and Physicians When Making End-of-Life Decisions in Intensive Care Units

The purpose of this qualitative, descriptive study was to describe end-of-life decision-making experiences as understood by critical care nurses and physicians in intensive care units (ICUs). A purposive sample of seven nurses and four physicians from a large teaching hospital were interviewed. Grounded theory analysis revealed the core category of “end-of-life decision making as a balancing act.” Three interacting subthemes were identified: emotional responsiveness, professional roles and responsibilities, and intentional communication and collaboration. Balancing factors included a team approach, shared goals, understanding the perspectives of those involved, and knowing your own beliefs. In contrast, feeling powerless, difficult family dynamics, and recognition of suffering caused an imbalance. When balance was achieved during end-of-life decision making, nurses and physicians described positive end-of-life experiences. The consequence of an imbalance during an end-of-life decision-making experience was moral distress. Practice recommendations include development of support interventions for nurses and physicians involved in end-of-life decision making and further research to test interventions aimed at improving communication and collaboration.

Experiences of Families When Present During Resuscitation in the Emergency Department After Trauma

Several organizations have published national guidelines on providing the option of family presence during resuscitation (FPDR). Although FPDR is being offered in clinical practice, there is limited description of family experiences after FPDR. The aim of this study was to describe family experiences of the FPDR option after trauma from motor vehicle crashes and gunshot wounds. A descriptive, qualitative design based on content analysis was used to describe family experiences of the FPDR option. Family members (N = 28) were recruited from a major level 1 adult trauma center in the Midwest. Participants in this study were 1 family member per patient who were 18 years or older, visited the patient in the surgical intensive care unit, spoke and understood English, and had only one critically injured patient in the family. Family interview data on experiences during FPDR after trauma were used to identify themes. Two main categories were found. Families view the role of health care professionals (HCPs) to “fix” the patient, whereas they as family members have an important role to protect and support the patient. Subcategories related to the role of the HCP include the following: multiple people treating the patient, completion of many tasks with “assessment of the damages,” and professionalism/teamwork. Important subcategories related to the family member role include the following: providing information to the HCP, ensuring that the medical team is doing its job, and remaining close to provide physical and emotional comfort to the patient. Health care professionals are viewed positively by the family, and the role of the family is viewed as important. Families wanted to be present and would recommend the choice to other family members. The findings of this study support that the FPDR option is an intervention that helps family members build trust in HCPs, fulfills informational needs, allows family members to gain close proximity to the patient, and support their family member emotionally.

Process-Related Barriers to Optimizing Enteral Nutrition in a Tertiary Medical Intensive Care Unit

PURPOSE Enteral nutrition (EN) is the preferred route of nutrient delivery in critically ill patients. Research has consistently described an incomplete delivery of EN in critically ill patients. The purpose of this study was to investigate barriers to reach and maintain >90% prescribed EN among critically ill medical intensive care unit (ICU) patients. METHODS We performed a retrospective cohort quality improvement study of patients ≥ 18 years of age admitted to a tertiary medical ICU and referred for EN from October 1-December 31, 2013. We excluded patients who received intermittent or bolus feeding. Demographic, clinical, and nutrition data were collected. Potential barriers to EN were categorized a priori. RESULTS Seventy-eight patients receiving 344 days of EN were included in the study. EN was initiated at a median of 32 hours (interquartile range, 18.5-75 hours) after ICU admission. Initiation and advancement of EN was identified as the most common reason for <90% prescribed intake. The top 5 interruption reasons were extubation, fasting for bedside procedure, loss of enteral access, gastric residual volume (0-499 mL), and radiology suite procedure. CONCLUSIONS Suboptimal EN volume delivery continues to be an issue in critically ill patients. Our study identified initiation and advancement of EN as the most common reason for suboptimal EN volume delivery. Variation in practice was noted within several categories, and multiple reversible barriers to optimal EN delivery were identified. These data can serve as the impetus to modify practice models and workflow to optimize EN delivery among critically ill patients.

Moral distress in critical care nursing: The state of the science.

Background: Moral distress is a complex phenomenon frequently experienced by critical care nurses. Ethical conflicts in this practice area are related to technological advancement, high intensity work environments, and end-of-life decisions. Objectives: An exploration of contemporary moral distress literature was undertaken to determine measurement, contributing factors, impact, and interventions. Review Methods: This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015, and included 12 qualitative, 24 quantitative, and 6 mixed methods studies. Results: Synthesis of the scientific literature revealed inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions. Conclusion: Providing compassionate care is a professional nursing value and an inability to meet this goal due to moral distress may have devastating effects on care quality. Further study of patient and family outcomes related to nurse moral distress is recommended.

Factors Influencing Active Family Engagement in Care Among Critical Care Nurses

ABSTRACT Critical care nurses are vital to promoting family engagement in the intensive care unit. However, nurses have varying perceptions about how much family members should be involved. The Questionnaire on Factors That Influence Family Engagement was given to a national sample of 433 critical care nurses. This correlational study explored the impact of nurse and organizational characteristics on barriers and facilitators to family engagement. Study results indicate that (1) nurses were most likely to invite family caregivers to provide simple daily care; (2) age, degree earned, critical care experience, hospital location, unit type, and staffing ratios influenced the scores; and (3) nursing work‐flow partially mediated the relationships between the intensive care unit environment and nurses’ attitudes and between patient acuity and nurses’ attitudes. These results help inform nursing leaders on ways to promote nurse support of active family engagement in the intensive care unit.

Challenges in Conducting Research After Family Presence During Resuscitation

Family presence during resuscitation (FPDR) is an option occurring in clinical practice. National clinical guidelines on providing the option of FPDR are available from the American Association of Critical-Care Nurses, American Heart Association, Emergency Nurses Association, and Society of Critical Care Medicine. The FPDR option currently remains controversial, underutilized, and not the usual practice with trauma patients. This article is based on the methodological and practical research challenges associated with an ongoing study to examine the effects of the FPDR option on family outcomes in patients experiencing critical injury after motor vehicle crashes and gunshot wounds. The primary aim of this study was to examine the effects of the FPDR option on family outcomes of anxiety, stress, well-being, and satisfaction and compare those outcomes in families who participate in FPDR to those families who do not participate in FPDR. Examples of real clinical challenges faced by the researchers are described throughout this article. Research challenges include design, sampling, inclusion/exclusion criteria, human subjects, and procedures. Recruitment of family members who participated in the FPDR option is a complex process, especially after admission to the critical care unit.

Noise in the ICU: sound levels can be harmful

September l Nursing2014CriticalCare l 29 TThe crescendo of triple-beat alarms, staff conversations, the drone of noise coming from bedside dialysis machines, and a myriad of other sounds feel normal to most experienced ICU nurses and providers. The critical care environment may not allow caregivers to stop and consider the way sound impacts patients. However, it’s well documented that noise has an adverse influence on patients’ sleep1-4 and may contribute to hospital-acquired delirium.5 Additionally, high sound levels are a source of nursing stress.1 According to the World Health Organization, the maximum level of noise at night in hospitals shouldn’t be greater than 40 decibels (dB) A-weighted equivalent continuous sound level (LAeq) or dB(A), and no more than 30 dB during the day and evening hours.6 LAeq or dB(A) is a measurement that provides an average of continuous and varying sound levels over time. The majority of patients in the hospital already have a compromised ability to tolerate additional stress caused by noise; thus, sound levels in patient rooms shouldn’t exceed 35 dB LAeq.6 Despite these recommendations, ICU peak sound levels may resister as high as 90 dB(A)7 to 101 dB(A).5 Average Noise in the ICU: sound levels can be harmful

Quiet time for mechanically ventilated patients in the medical intensive care unit

OBJECTIVE Sleep disruption occurs frequently in critically ill patients. The primary aim of this study was to examine the effect of quiet time (QT) on patient sedation frequency, sedation and delirium scores; and to determine if consecutive QTs influenced physiologic measures (heart rate, mean arterial blood pressure and respiratory rate). METHOD A prospective study of a quiet time protocol was conducted with 72 adult patients on mechanical ventilation. SETTING A Medical Intensive Care Unit (MICU) in the Midwest region of the United States. RESULTS Sedation was given less frequently after QT (p=0.045). Those who were agitated prior to QT were more likely to be at goal sedation after QT (p<0.001). Although not statistically significant, the majority of patients who were negative on the Confusion Assessment Method (CAM-ICU) prior to QT remained delirium free after QT. Repeated measures analysis of variance (ANOVA) for three consecutive QTs showed a significant difference for respiratory rate (p=0.035). CONCLUSION QT may influence sedation administration and promote patient rest. Future studies are required to further understand the influence of QT on mechanically ventilated patients in the intensive care unit.

Bridges and Barriers: Patients' Perceptions of the Discharge Process Including Multidisciplinary Rounds on a Trauma Unit

Discharge planning is a complex process and ideally begins early in the patient stay. Despite evidence about the importance of discharge readiness, there is limited literature about the patients view during this transition. The goal of this study was to explore patient perspectives about the discharge process, including multidisciplinary rounds. Multidisciplinary rounding is a process where care providers from various specialties meet to communicate, coordinate patient care, make decisions, and manage responsibilities. The theme found was “bridges and barriers to discharge.” Participants identified timelines and tasks, communication, social support, and motivation as helpful and medical setbacks, insurance limitations, and infrequent communication as hindrances to the discharge. Future research is recommended examining efficacy of various discharge models and examination of communication and support throughout hospitalization.

Quiet Time for Mechanically Ventilated Patients in a Medical Intensive Care Unit

Sleep disruption occurs frequently in critically ill patients. The purpose of this study was to (a) determine if a quiet time (QT) affected patient sedation frequency and sedation and delirium scores, and (b) measure the patient’s physiological responses (heart rate, mean arterial blood pressure, and respiratory rate) to consecutive QTs. Topf’s Environmental Stress Model (ESM) guided the design and selection of variables. Noise in the critical care environment creates stressors that induce adverse physiological and psychological responses in patients. QT, by reducing noise and patient interruptions, may (a) improve the quality and quantity of patient sleep, (b) decrease sedative medication administration, and (c) prevent or reduce delirium. This was a prospective study of a QT protocol with 72 mechanically ventilated patients. Patients were recruited over a year from one medical intensive care unit (ICU) at an academic medical center. The QT protocol involved a reduction of light and sound within the patient’s room, and minimizing interruptions. The QT occurred daily from 2:00 p.m. to 4:00 p.m. for those enrolled in the study. Sedation was given less frequently after QT (p = .045), and those who were agitated prior to QT were more likely to be at the goal sedation score after QT (p < .001). Although not statistically significant, the majority of patients who were negative on the Confusion Assessment Method (CAM-ICU) prior to QT remained delirium free after QT. Repeatedmeasures ANOVA for 3 consecutive QTs showed a significant difference for respiratory rate (p = .035). Our findings suggest that the QT protocol may influence sedation administration; however, future research is needed to understand the effect of QT on the use of sedative medications. While the impact of QT on delirium was inconclusive in this study, it warrants further investigation. It is recommended that future studies implement experimental study designs that incorporate objective measures of sleep to further explicate the effects of QT on mechanically ventilated patients in the ICU.