What are critical care nurses' perceptions of the long-term

What are critical care nurses’ perceptions of the long-term mechanically ventilated patient in the ICU setting?

Lisa Mace

MSc, BSc (Hons), RGN

Cardiac Nurse Specialist

Background

Working in critical care is challenging and demanding

Majority of patients recovery is quick

Small but increasing number patients ICU stay is complicated and prolonged (Carasa & Nepoli, 2002)

Long-term ICU patients have complex needs

Consequently they maybe perceived as ‘difficult’ or ‘unpopular’ to care for

The ‘Unpopular’ or ‘difficult’ patient phenomenon

Concept of ‘unpopular’ or ‘difficult’ patient is not new to nursing

Application of the label is not straightforward

Numerous factors may come into play:

Behavioural characteristics (Stockwell, 1972)

Challenging nurses competency/control (Breeze & Repper, 1998; Strandberg & Jansson, 2003)

Personal characteristics which conflict with nurses belief/value system (Albarran & Salmon, 2000)

Within the context of ICU it has received minimal consideration

Consideration of the phenomenon in the ICU

settingThe demanding nature of care

Overwhelming work load (Lally & Pearce, 1996)Patient behaviours – ‘ICU syndrome’ (Dyer, 1995; Todres et al, 2000)

Challenging nurse’s skill set

‘Curing’ vs ‘CaringEvoking negative feelings of incompetence, frustration and despair in nurses (Bergbom-Engberg & Haljamae, 1993, Sevick et al, 1994)

Personality conflict

Personal characteristics – obese, alcohol misusers, eldery, sexual orientation (Albarran & Salmon, 2000, MacDonald, 2003)

Aims of the Study

To explore ICU nurses’ experiences and attitudes of caring for long-term critically ill patients.

The purpose, to generate a detailed account of how nurses engaged and coped when dealing with patients who required a prolonged period of care, including artificial ventilation, in ICU.

Methodology

Qualitative design used to unravel ICU nurses perceptions

1. Purposive sample 2. 23 critical care nurse recruited from general ICU

or cardiac ICU3. Focus group interviews 4. 4 focus groups: recruited to junior/senior group

from respective work area5. Interview schedule

Data generated - thematic content analysis (Burnard, 1991 )

Findings

Three Main Themes Emerged

Clinical challenges

Rewarding aspects

Organisational challenges

Themes and CategoriesCore Theme -

Clinical ChallengesCore Theme -

Rewarding Aspects

Core Theme -Organisational

Challenges

1. Physical Challenges 1. Connecting and forming a bond with patients

(a) Patient Personality(b) Patient responsiveness(c) Young patients

1. Appropriate patient allocation

2.Psychological challenges

(a) Supporting the patient emotionally/psychological dependency

(b) Facingmanipulative/intimidating

patient behaviours

2. Feeling you have made a difference

2.Supporting/protecting the nursing team(a) Physical and

psychological support(b) Need for a break

3. Dealing with behaviour of family members

3. Striking a balance between technology and caring

4. Not genuine acutely ill patients

4. Refocusing nursing care(a) Thinking outside the

boundaries(b) Creating a supportive

environment

Clinical challenges of caring for the long-term intensive care patient

Physical challenges

Physically demanding to care for:

‘I remember one day…with a long-term patient with diarrhoea and I must have had to roll and turn them 25 times and I was nearly crying by the end of the morning’ (F1,U)

‘…if they [long-term patient] are unable to do anything and they have diarrhoea all the time, that’s when it is really hard to manage…. if that is what is happening… I won’t go with a spring in my step, I will think oh no…!’ (F3,J)


Physical challenges

Participants stated how, on occasions, they felt ‘a bit overwhelmed by all the things you have do to do’ (F1, U) when caring for a long-term patient.

Physical exhaustion – 14 hour shifts


Physical challenges

Maintaining constant state of hyper-vigilance

‘you just don’t take your eyes of them otherwise infusion lines and tubes become dislodged (F4, F)’


However…

Maintaining constant patient surveillance to ensure patient safety made caring for these individuals demanding:

‘He [long-term patient] had not been orientated, pulling… ventilator alarms every five minutes, so I am running around the bed space, like every five minutes… I don’t want to go to that situation every day’ (F3, K)


Physical challenges - physical characteristics could also complicate care delivery

‘struggled to care for long-term patient patients who were obese’ (F4, C)


Psychological Challenges:

Supporting the patient emotionally/dealing with psychological dependency

‘…he used to be like wean, wean, wean…we would say do half an hour weaning and he will say, I will do an hour, but now it’s no, I don’t want to do anything! That’s hard!’ (F2, L)

‘…Mr A has been really depressed, he is really frustrated and doesn’t want to do anything and… you think, what am I going to do’ (F3, H)



Trying to keep long-term patients upbeat and interested appeared to take it’s toll on

nurses

‘…if you have been there [with long-term patient] for a quite a while, like 3-4 days it’s mentally knackering’ (F3, H)

‘… sometimes it’s just so hard [caring for long-term patient] you are just exhausted, physically and emotionally (F4, A)



Supporting the patient emotionally

‘…if there was someone in a role who could actually focus on the psychological care of the long-term patients as I find it very difficult sometimes’ (F4, C)



Facing manipulative and intimidating behaviours

‘…you will go in there thinking what else is he [long-term patient] watching, what else is he going to say, because then you are not as free as you would always be…, it takes you a while to build up your confidence to work with that patient’ (F4, B)

‘ …long-term patients can be very manipulative…difficult to manage, playing people off against each other…there will be a lot of she does it this way… (F2, L)



Manipulative and intimidating behaviours

Emotionally scarred by threats from a long-term patient

‘…a particular long-term patient I am recalling, threw a bowl of water over me and told me he would kill me when he got out of hospital and I really believed he might do it. I never wanted to go near that man again, I was really frightened’ (F2, O)


Dealing with difficult behaviour not isolated to patient

Relatives’ anger and hostility:

‘ The wife of the gentleman that we have at the moment is lovely if everything goes her way, but there are certain members of staff that she doesn’t really like looking after J… and she can be quite rude…’ (F2, L)

‘…if she is having a bad day, she becomes confrontational… she is like a pressure cooker and unfortunately it is the person stood in front of her gets the brunt of it’ (F2, O)


Long-term ICU patients not seen as part of ‘typical’ ICU population

Often perceived as less exciting and stimulating to care for:

‘…with the acute patient…dealing with all the pumps all the filters…to look after a long-term patient…isn’t quite so rewarding and challenging’ (F2, P)

‘…if I had may choice, I would want the sickest patient there basically…that would be the most acute patient…the most stimulating’ (F1, T)

‘ …it’s just so monotonous; you know what is going to happen, with that patient [long-term patient] same thing, same story’ (F4, A)

Core Theme: rewarding aspects of caring for long-term patients in

ICU

Connecting and forming bonds

‘…it feels so good to look after those patients [long-term patients] if you have been looking after them for quite some time and you really get a chance to bond with them… you feel like you are one of the family’ (F3, H)

Rewarding aspects of caring for long-term patients in ICU


It just depends on their personality:

‘…she [long-term patient] was a lovely person…she had a lovely smile, she made contact with you’ (F1, T)

Patient responsiveness

Positive attributes ‘ humorous’ ‘chatty’

‘…you could talk to her, she never got particularly pissed off and she had a lucid sense of humour’ (F1, T)



Young patients

‘…she [young patient] should not have been stuck in that bed with that god awful disease’ (F2, M)

‘…we had that young woman who died…she got a long way and she was a character, she was a lovely woman and her husband and the children…that was really sad’ (F1, T)


Feeling you have made a difference

‘… sitting them out in the chair and wash their hair and someone comes in and goes wow…and that is like your reward…and they say I feel great’ (F2, L)

‘… hair washing and shaving, that sort of thing gives you a sense of satisfaction, relatives think you have cared for them, the patient, they look so much better … they maybe haven’t advanced in terms of weaning, but they just look so much better’ (F1, T)


Striking the balance between technology and caring

‘it is quite rewarding when you are giving really nice care… you can make the long-term patient feel relaxed and you don’t have to worry about all the other things… where you think of changing a pump every 5 seconds… with the acute patients that is often the case that those really nice things that we all like to do are the last things you get a chance to do, because all the other things are so much more life-threatening and have to be maintained (F1, U)

Staff allocation – finding the ‘right person for the right patient’ (F1, S)

‘the problem I find, is often that with the long-term patients that’s when you actually need the less technically skilled nurses.…when it comes to allocation you think, well that’s a really sick patient, but in the next bed-space is a really, really sick patient …you then start to run out of people who ideally you would like to look after the long-termers’ (F1, T)

Core Theme: Organisational challenges associated with long-term ICU patients

Organisational challenges associated with long-term ICU

patientsStaff allocation – safest option for all patients

however…

Recognition that junior staff did not always have relevant skills


patients

Supporting and protecting the nursing team

Senior nurses emphasised need to support junior nurses:

‘What I try to do if it is a junior nurse with a long-term patient…I will go and briefly discuss what we are going to do. It is just about getting a vague structure and them knowing that they get your support to do it’ (F1, T)


patientsSupporting and protecting the nursing team

Likewise, junior nurses described the need to feel supported and the opportunity to talk things through.

That said, not always readily available:

‘…many people are in and out…they will say everything OK? And without waiting for the answer they will walk off’ (F3, K)

‘ …the long-term patient in bed 3 is very big, lack of staff and most of the nurses are busy, that day we just couldn’t cope’ (F4, J)


patients

Supporting and protecting the nursing team

‘…if I have been there for a few days…I really need a change if I want to carry on with my positivity and energy. I need a couple of days out’ (F3, G)

‘…I have had a couple of people who have said, I need a break, I had had J [long-term patient] for so many days…I think it is probably the psychological care, for people to give it is really wearing’ (F2, N)

Implications and Recommendations

Providing adequate support:

Regular breaks Senior staff visibly on hand De-briefing meetings Formal support mechanisms – Action Learning Sets

Equipping ICU nurses with relevant skills/knowledge to meet needs of long-term patients more effectively

Equipping ICU nurses with necessary practical skills to deal with difficult patient or relative behaviours

Conclusions

This small study identified that the idea of the unpopular patient still pervades and exists in a modern ICU setting

Evidence to suggest that caring for long-term critically ill patients can be difficult and demanding

Equally, such patients were viewed as producing rewarding and satisfying experiences of caring

Adequate formal and informal support mechanisms would help ICU nurses to meet the very complex set of needs of long-term critically ill patients.

This will do much to maximise the quality of care long-term patients receive while minimising the stress ICU nurses experience during care delivery

Questions?

Lisa Mace

[email protected]

MSc, BSc (Hons), RGN

Cardiac Nurse Specialist

Health & Medicine

What are critical care nurses' perceptions of the long-term