Research ArticleCaring for non-sedated mechanically ventilated patients in ICU: A qualitative study comparing perspectives of expert and competent nurses
Introduction
In recent years, sedation practice in the intensive care unit (ICU) has undergone significant changes. Since year 2000 the strategy has evolved from deep to lighter or no sedation especially in the Scandinavians countries in mechanically ventilated ICU patients, unless deep sedation was specifically indicated (Strøm et al., 2010). This paradigm shift (Devabhakthuni et al., 2012, Kress, 2013) is the result of a ‘less is more’ strategy and increasing evidence that lighter sedation is beneficial to the patient by decreasing the duration of mechanical ventilation and ultimately the ICU stay (Brook et al., 1999, Kress et al., 2000).
Nurse-patient communication has always been a challenge in ICU where patients are restricted by intubation, sedation, and critical illness preventing verbal and nonverbal exchange (Albarran, 1991, Dithole et al., 2016). In the early 1990s less experienced nurses were more frustrated than experienced nurses by the initial contact with deeply sedated mechanically ventilated ICU patients (Bergbom-Engberg and Haljamăe, 1993). In 2001 lightly sedated ICU patients were less satisfied than nurses with nurse-patient communication (Wojnicki-Johansson, 2001). More recent studies describe a new complexity in the nurse-patient interaction with non-sedated patients (Everingham et al., 2014, Karlsson and Bergbom, 2014). Conscious patients that are aware of their pain and discomfort are described as more demanding than sedated patients (Laerkner et al., 2015). Non-sedated patients are described as requiring more attention than sedated patients, and studies suggest that ICU nurses are unprepared to meet the new challenges (Karlsson and Bergbom, 2014, Dithole et al., 2016, Laerkner et al., 2017).
More knowledge is needed regarding the nurse-patient interaction in conscious ICU patients. A qualitative approach is well suited to explore how nurses perceive caring for awake ICU patients and to help to uncover new skills required in this context. Also, to investigate how sedation practice affects the workload of ICU nurses. We assume that contemporary sedation practice potentially affects experienced (expert) and less experienced (competent) nurses differently as the scope of nursing education and intensive care specialisation have evolved in recent years.
The aim of our study was to compare the perspectives of expert and competent nurses regarding their interaction with non-sedated mechanically ventilated ICU patients.
Section snippets
Design
Our study had a qualitative comparative multicentre design using inductive latent content analysis and semi-structured dyadic interviews each with an expert and competent ICU nurse.
Setting
The study was conducted at five mixed medical-surgical ICUs at two university and three regional hospitals across Denmark. The ICUs varied from 6 to 12 beds and all units had sedation protocols in place recommending minimal sedation unless otherwise required in the individual case.
Participants
Expert and competent nurses were
Addressing distress
The psychological distress got to the nurses. It was difficult to care for hallucinated patients; it made nurses feel inadequate.
“The hallucinated awake patients are really difficult because I can see their suffering; yes, they really suffer”. (Expert nurse dyad 4)
Competent nurses were less concerned by the new sedation paradigm. They took it for granted, because they lacked experience with earlier sedation practice. But it was difficult to care for the delirious patients, who lived in another
Discussion
Our aim was to explore perspectives of expert and competent nurses regarding their interaction with non-sedated mechanical ventilated ICU patients. The main difference between the experiences of expert and competent nurses in our study was the degree of acceptance of the strategy of minimal sedation. Expert nurses showed more ambivalence toward minimal sedation because they had experienced the ease of caring for more sedated patients and questioned the comfort of being awake during mechanical
Strengths and limitations
The credibility of our study was achieved by adoption of well-established qualitative methodology, iterative questioning during the interviews and investigator triangulation during analysis. Dyadic interviews offer more than one perspective and enable participant triangulation. Our study was limited, however, by the pragmatic selection of expert and competent nurses. Transferability was increased by the multicentre approach and selection of nurses with varying experience. Dependability was
Conclusion
The study added to the knowledge of nurse-patient interaction by describing issues of frustration, ambivalence and insecurity in a contemporary context of minimal sedation. Nurses at different levels of experience were frustrated by communication problems in the patient-nurse interaction; they were unable to use their full potential and suffered feelings of inadequacy. Caring for awake mechanically ventilated patients requires knowledge and experience as well as adequate staffing and better
Acknowledgements
The authors would like to thank the involved nurses for participating in this study.
Funding
The authors have no sources of funding to declare.
Conflicts of interest
The authors have no conflict of interest to declare.
References (38)
A review of communication with intubated patients and those with tracheostomies within an intensive care environment
Intensive Care Nurs.
(1991)- et al.
The communication process with ventilator patients in the ICU as perceived by the nursing staff
Intensive Crit. Care Nurs.
(1993) Less sedation in intensive care: the pendulum swings back
Lancet Lond. Engl.
(2010)- et al.
Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness
Nurse Educ. Today
(2004) - et al.
Effect of a multi-level intervention on nurse–patient communication in the intensive care unit: results of the SPEACS trial
Heart Lung J. Acute Crit. Care
(2014) Sedation and mobility: changing the paradigm
Crit. Care Clin.
(2013)- et al.
Nurses’ experiences of caring for critically ill, non-sedated, mechanically ventilated patients in the Intensive Care Unit: a qualitative study
Intensive Crit. Care Nurs.
(2015) - et al.
A sense of agency: An ethnographic exploration of being awake during mechanical ventilation in the intensive care unit
Int. J. Nurs. Stud.
(2017) Adult intensive care patients’ perception of endotracheal tube-related discomforts: a prospective evaluation
Heart Lung J. Acute Crit. Care
(2011)The dyadic interview as a tool for nursing research
Appl. Nurs. Res.
(1995)
A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial
Lancet
Communication between nurse and patient during ventilator treatment: patient reports and RN evaluations
Intensive Crit. Care Nurs.
From novice to expert: excellence and power in clinical nursing practice
AJN Am. J. Nurs.
Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation
Crit. Care Med.
Unplanned extubations in Intensive Care Unit: evidences for risk factors. A literature review
Acta Biomed. Health Profess.
Doing Qualitative Research
Analgosedation: a paradigm shift in intensive care unit sedation practice
Ann. Pharmacother.
Exploring communication challenges between nurses and mechanically ventilated patients in the intensive care unit: a structured review
Worldviews Evid.-Based Nurs.
Approaches to and outcomes of dyadic interview analysis
Qual. Health Res.
Cited by (0)
- 1
Both first authors.