A study into the views of intesive care nurses on the psychological needs of their patients

of i A study into the vi o-n tha ptychatogieal nu patients Christopher Turnock

This small scale study examined the way in which ICU nurses perceived the psychological needs of their patients. Data was collected through the use of semistructured interviews, and was then analysed using a modified grounded theory approach. Two overall themes were developed from the data, one being the way in which ICU nurses make choices about the organisation of their work and the other nurse-project relationship . Secondly the theme of the nurse-patient relationship was developed, in which ICU nurses experience difficulty in communicating with their patients. Paradoxically it would appear that the quality of this communication becomes poorer when the patient is more able to participate in the communication process. This problem in communication is substantiated by research into other areas of nurse-patient communication

INTRODUCTION The development of Intensive Care Units (ICU) over the last 30 years has resulted in nurses working in these areas to develop specialised clinical skills. These skills are multi-faceted, relating not only to the physical, psychological, and social needs of the patients and their families, but also to the ever expanding technical needs of the patient in terms of the safe functioning of the ‘machinery supporting the patients life. A number of studies Ashworth (1980), Asbury (1985, suggest that there is an inability to meet these needs. Therefore I decided to undertake an Christephor fumock RGN, DPSN, DANS, MSc Nurse Tutor, Continuing Nwm Education and fbeaarch Unit, Newcwtb School of Nursing, 16/l 7 Framlington Place, Nwwxstkupon-Tyns.

(Roqwsta far offprinta and wrmqw&wce to: 10 Quaens Drive, Whkley Bay, Tyne and Wear, NE26 2JU) Acceptsd for publication 11 September lB3

examination of the way in which ICU nurses perceived their role and the needs of their patients. The study would attempt to examine how ICU nurses perceived the psychological needs of their patients, what Strategies were used to meet these needs, and the factors which interfered with this process.

DATA COLLECTION I decided to select a qualitative approach in undertaking the process of data collection. Swanson and Chenitz (1982) believe that the world in which nursing takes place is too complex, containing too many variables and interactions for the researcher to control. Therefore the choice of a qualitative approach is particularly appropriate when trying to gain an understanding of a social phenomenon (Trigg, 1985). One approach to qualitative research is based upon grounded theory (Glaser & Strauss, 1967)) 159

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where research does not aim to verify theory, but instead focuses on the generation of theory that results from the analysis of the collected data. This is thought by Melia (1982) to be a theoretical approach which outlines informality with a flexibility that enables the researcher to successively elicit the views and perspectives held by a group of nurses. In undertaking research with no pre-selected or controlled variables, or a hypothesis, Pearsall (1965) advocates the use of the interview for collecting data. This is thought to maximise the possibility of obtaining material that will enable the researcher to interpret the actors behaviour. I decided to use a semi-structured interview, as this enables the researchers to focus on collecting the certain types of information from each subject, whilst redefining the phrasing and ordering of questions for each subject (Denzin, 1978). Thus the researcher is more able to study the feelings and perceptions of the subject, though still ensuring that analysis of the interviews is not too difficult or time consuming.

POPULATION The population that was to be studied was drawn from two Intensive Care Units in separate hospitals within the same city. One of the units was a IO-bedded Cardiothoracic ICU that provided care for adults following cardiac surgery, including organ transplantation. The other unit was a seven-bedded ICU, in which patients were admitted for a variety of reasons, including postoperative care, trauma, and medical disorders. The amount of time available within which to undertake the study was limited, therefore the researcher decided to randomly select a sample of staff from both day and night duty. To obtain a cross-section of clinical and educational backgrounds, the researcher approached a sister, a staff nurse, and an enrolled nurse from day and night duty from both the units. Unfortunately, the researcher was only able to gain the consent of two enrolled nurses, resulting in a total of 10 subjects being interviewed. However the sample that was used provided a more typical distribution of grades within the units, in so far as few enrolled nurses were employed in the units. The

main reason for the reluctance of certain individuals to participate in the study appeared to have resulted from the use of a tape recorder to record the interviews. Interviewing took place within the home of each subject, for as Schatzman and Strauss (1973) point out the choice of an appropriate setting for data collection is essential. This allowed the subjects to be in familiar surroundings that detached them from their work situations, enabling them to analyse their clinical practice without the risk of interruption, or the subject feeling guilty about leaving the workplace for a period of time. Each interview was structured on a series of themes, allowing the researcher to cover common areas for discussion and also explore points raised in individual interviews in greater detail. The themes used were ones that were identified as being pertinent to the psychological needs of the ICU patient, and so the themes were: Previous clinical experience Previous educational experience Psychological needs of an ICU patient Sensory deprivation Talking to patients Touching patients Understanding patients Maintaining the patients privacy Sleep needs of ICU patients Sedation and the ICU patient ICU Psychosis Allocation of workload to physical, logical, and technical tasks Good and bad ICU nursing ICU environment Boredom for ICU patients

psycho-

The last three themes were included in the interviews after analysis of the initial two interviews, in which the researcher was already able to develop certain ideas about the collected data.

DATA ANALYSIS As part search, of the analysis.

of the grounded theory approach to reGlaser and Strauss (1967) outline the use constant comparative method for data This approach has four stages, firstly the

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comparison of incidents applicable to each category; then the integration of categories and their properties; thirdly the delimitation of theory; and finally, writing the theory. Therefore this approach combines an explicit coding of the data with the generation of properties and hypotheses. However the use of a small sample is likely to result in a limited amount of data being collected. Therefore this data cannot be considered as being theoretically saturated, making it impossible to generate theory from the data. To overcome these problems a modified constant comparative method was used. This involved a series of themes to be identified. These themes are based upon similar incidents mentioned by the subjects that show a certain feature of that theme. The next step involves the comparison of the identified themes to see if any areas of similarity exist, thus enabling the researcher to generate new themes. By developing these new themes, the researcher is able to produce ideas about the data and the features of it. Two themes were identified from the initial data analysis: Organidon of Work Within this theme the emphasis in organising work involves the ICU nurses performing physical and technical tasks before tasks that relate to the patients psychological needs. Therefore the main priority for the ICU nurse is in meeting the physical needs of the patient, and ensuring that machinery is functioning safely. For example: ‘I would say it was observation of the patient and machines. . . . Coming a very close second is the physical tasks, such as mouth care, the eye care and all that sort of thing. Psychological things are probably the last thing you would think of.’ It should be noted that this hierarchy of priorities may vary according to patient dependency. When the patient is acutely ill, i.e. ventilated and sedated, physical and technical needs have greatest priority. However, once the patient enters the post-acutely ill phase i.e. conscious and extubated, then psychological needs have a greater priority than when actually ill, e.g.

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‘It varies with the type of patient you’ve got. If you have somebody who has just been admitted then obviously you’re going to spend a lot of time on technical things. If it’s just a long term patient . . . who is stable and just weaning off the ventilator then you would spend more time on rehabilitating them.’ Another feature of this theme is that many ICU patients are nursed naked, especially if they are acutely ill. The reason for this being that the patients have so many drips or lines, that it is more convenient for the ICU nurse to nurse the patient naked. There is a strong likelihood that once the patient enters the post-acute phase they will then be clothed in some way, e.g. ‘Because of their lines, you’d have to disconnect them all to put anything on them.’ ‘. . . but after a week they have fewer drips, so it’s easier to dress them.’ The ICU nurses also describe how they use screens to protect the privacy of patients when they are being exposed. Incidents are given when the screens inadequately protect the patient from external view, or that nurses forget to use them at the appropriate time. This would imply that the need to protect the patient from exposure and to maintain their dignity is given low priority by the ICU nurses, e.g. ‘We do it on ward rounds with the doctors and nurses standing around the patient and the covers are of@n taken off without an explanation and screens aren’t pulled round.’ ‘. . . but even when they’re brought round they don’t hide everything, so they are exposed. Nurses don’t always bring the screens around, because they think there’s nobody around.’ In citing the reasons why they thought many ICU patients did not get sufficient sleep, the nurses interviewed blamed the noise levels on the ICU, as well as the need to continually disturb the patient for physical procedures. Thus the physical and technical needs of the patient, particularly when acutely ill, plus the communication needs of the staff take priority over the sleep needs of the patient, for example: ‘I think an ITU is one of the noisiest places for

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people to sleep through the night, because of the activity of the staff.’ ‘They receive 2 hourly care. Even the ventilated patients who are getting better will still be disturbed every 2 hours, for suction. They might not get the whole hog, such as turned, but there are certain things such as suction, which must be done. Nurse-Patient Relationship The second theme has a number offeatures relating to the way in which both patient and nurse behave within the ICU environment. Firstly the ICU nurses acknowledge that many of their patients may become confused or aggressive. Once the ICU nurse seeks an explanation for this behaviour, then the commonest, or first thought of reason is that their behaviour is due to some physiological factor, such as hypoxia or electrolyte disturbance, e.g. ‘Nearly always first, that they’re hypoxic that their U’s and E’s are a problem.’

or

Another feature of this theme reflects the main reason why ICU nurses choose to work within that environment. The one-to-one relationship that the ICU nurse has with their patient is seen as being special, and unique to ICU nursing in that the nurse is able to provide all the necessary care to one patient, e.g. ‘Because I like the one to one basis of nursing, and I like the total patient care.’ The ICU nurses also perceived 1 he aim of their care was to treat the patient as a person, that they should avoid treating the patient merely as a condition, nor should they concentrate more on the surrounding machinery to the detriment of the patient. The ICU nurses also describe how the involvement of the patients’ relatives played a significant part in this process, thus: ‘. . . and to treat them as a patient and not worry too much about the machines or the bleeps that go off around them.’ ‘I think it’s just as important to encourage the relatives to talk to them.’ When considering nurse-patient communication the ICU nurses outline two key areas of com-

munication. Firstly they tried to provide the patient with information to help orientate them to time, place, their condition and progress, as well as waqning the patient about procedures and providing explanations about the procedure. In trying to comfort patients, the ICU nurses employed two strategies, either verbally or by touching the patient, to aim to reduce the amount of distress the patient was experiencing. ‘I would explain what I was doing to the patient. I would talk about general things such as the news, or weather, about their family, just general conversation.’ ‘Obviously, if they were showing signs of agitation I would sit down and talk to them and try to orientate them to where they are, why they’re there, point out why they need to have all these things.’ ‘Just people you can tell are upset, then you can try and calm them down by holding their hand, or stroking their head.’ Occasions would occur when the ICU nurses would experience difficulty in understanding their patient, particularly ones who were intubated with an endotracheal tube or a tracheostomy tube. To overcome these problems, a variety of aids would be used, for example lipreading, patient writing words, using key words, or electronic aids. If the nurse was still unable to understand the patient then the help of another nurse would be sought to see if they could understand the patient, e.g. ‘If they are able to, we give them a pen and get them to write down the main word and what they are trying to say, not the whole sentence. Or we make out an alphabet and we get them to point out what they want. We also have a keyboard which they press to print out a message.’ ‘Sometimes I think some nurses are better at lip-reading than others, and if I feel there is somebody better than me at lip-reading, then I’ll ask them to come over and help.’ The acutely ill patient who is intubated and unable to participate in nurse-patient communication will affect the nature of this communication e.g.

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‘It’s very difficult if somebody is intubated but awake, and they’re trying desperately to tell you that there’s something wrong.’ Thus the lack of a response as creating difficulties for means that they will talk than they would talk to a example:

by the patient is seen the ICU nurse, and to these patients less conscious patient, for

‘I dislike the lack of communication sometimes back from the patients. You don’t get very much, it’s just talking to the patients and it’s just a one-way communication.’ Several subjects describe how some nurses forgot to talk to patients e.g. ‘. . . she switched the suction on, took the end off his tube and was busy talking to somebody else, and the tube was halfway down before she said “I’m just going to suck you out”.’ This was particularly so when ventilated patients would he undergoing procedures, as if the patient was no longer being considered as a person. Once the patient becomes post-acutely ill then the ICU nurse spends less time with the patient. It would appear that as the patients’ physical dependency reduces, so there is reduced patient contact. The environment of the ICU is thought to be very boring for the patients, in that it is almost completely windowless with drab walls. This is particularly so for the patient who is in ICU for several days. To overcome the problems of patients becoming bored, the ICU nurses outline their attempts to stimulate the patients by using television, radio, or newspapers. However many patients, particularly those who are conscious and extubated, appear to become withdrawn and switch off from the activity going on around them, e.g. ‘Ask them if they want to watch T.V., read a newspaper or a magazine, because it’s amazing how quickly they switch off and are not interested in reading newspapers or magazines. They’re not interested in what’s going on around them, but they’ll sit and stare and watch T.V. all day.’ Finally I.C.N.-

B

a number

of subjects

describe

how

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contact time with the patient reduces as they enter the post-acutely ill phase. It would appear that physical dependency is an important factor in determining the amount of time the ICU nurse spends with the patient, for example: ‘I think just leaving the patient to sit all day. I think that if your patient is well enough to get up and sit in the chair, then people tend to think he’s O.K. or doesn’t need to be in ITU, and they wander to help other people who might need assistance and leave the patient to sit all day, which is not good stimulation for anybody.’ The next stage in the data analysis involves the comparison of these themes and to develop new themes.

Making choices This first new theme involves the comparison of the properties of the first two themes. It seems that ICU nurses make choices about their actions, based upon a hierarchy of priorities. Thus, within this hierarchy, the physical needs of the patient and the needs of the staff take precedence over the psychological needs of the patient. However, once the patient is recovering, then under certain circumstances the order of the hierarchy may be reversed. Ways in which these features are demonstrated can be seen in the way the ICU nurses practice. For example, the need to nurse the patient naked shows how the convenience needs of the staff take priority over the needs of the patient for dignity and self respect. Also the need of the ICU nurses to communicate was described as taking priority over the needs of the patient to sleep in a quiet environment. When the patient is acutely ill, then their physical needs are viewed as taking priority over their need for undisturbed periods for resting. However, reversal of the hierarchy may occur when the patient enters the post-acute phase. Thus, as the patient becomes less physically dependent, so they are less likely to be disturbed.

Nurse-patient relationship Development

of this new theme

recognises

that

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ICU nurses are aware of the special communication needs of their patients, particularly when they are acutely ill. The subjects were able to describe the special one to one relationship they have with their patient, the need to treat him as an individual, and a variety of strategies for communicating with the patient, in particular the acutely ill patient. The subjects are also able to describe situations when they experience difficulty in communicating with their patients. In relation to the acutely ill patient, the presence of the endotracheal tube and the lack of patient response can cause communication problems. A number of problems relate to the post-acutely ill patient. The lack of environmental stimulation and the resulting boredom for the patients leads to them becoming detached from their surroundings and switching off. So it would appear that ICU nurses experience communication difficulties with both acute and post-acutely ill patients. Also, as the subjects identify the communication needs of the acutely ill patient and the reduced contact time with the post-acutely ill patient it is possible to conclude that the amount and quality of communication between the ICU nurse and patient may depend upon the patients physical condition, and may actually deteriorate as physical condition improves.

DISCUSSION Previous literature reviews by a number of authors have described the various effects that the ICU environment may hold for its patients (Ashworth, 1980; Asbury, 1985). This situation is exacerbated by the difficulties patients have in interpreting the environment stimuli as it cannot be understood in their normal cognitive context (Ballard, 198 I), together with the effects of medical intervention and drugs upon their ability to interpret this strange new world (Thomssen, 1981). In relation to this piece of work, many studies and anecdotal pieces of work outline these effects on the patients’ recollections of their stay in ICU. Badger ( 1974) cites the lack of privacy as a main problem of his spell as an ICU patient, however

Ballard ( 1981) found in a study that many patients felt too ill to be concerned about their own privacy, yet were more concerned at being able to observe nursing interventions on other patients. Clearly, the need to protect privacy has implications for not only the patient involved in a procedure, but also the surrounding patients. The experimental work of Chew (1986) and Hewitt (1970) both bear out the personal account of Badger (1974) that the ICU environment can be terrifying for patients, especially when procedures such as tracheal suction are performed. These authors also cite patients finding the ICU environment as being noisy, this is supported by Woods (1974) who found that noise levels never fall below 50 decibels, a level which Theissen ( 1970) found has a 50% chance of wakening a sleeping patient. Thus as Asbury (1985) found, this constant activity and noise, together with the need to continually disturb patients, are the main factors why ICU patients fail to receive adequate opportunity to sleep. A result of these effects of the ICU environment on the individual may often lead to ‘ICU ( 1981) describes this conPsychosis’. Ballard dition as involving a clouding of the consciousness, a decreased ability to think, perceive and remember. Thus, ICU patients may become disorientated to person, time and place. A situation which may well be exacerbated by being deprived of sleep (Helton, 1980). In relation to this study, the nurses interviewed tended to seek a physiological, rather than environmental explanation for this patient behaviour, ignoring the conclusions reached in the literature. Various authors have prescribed ways in which ICU nurses can attempt to protect their patients from the harmful effects of the ICU environment. For example, Wallington-Smith (1986) believes that amongst other things the ICU nurse should try to reduce noise levels within the unit, whilst Asbury (1985) states they should maintain the privacy of the patient wherever possible. Emphasis is put on the need for good nurseAshworth ( 1980)) patient communication Asbury (1985) effective communication. Yet as both Ashworth (1979) and this study demonstrate, it is very difficult for ICU nurses to hold

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conversations with unresponsive lengthy patients. It could however be expected that once communication returns to being a two way process again, that is when the patient enters the postacutely ill phase, then communication should improve. However there is evidence to suggest this is not so, both this study and one cited by Ashworth (1984) idend@ problems in nurse-patient communication for post-acutely ill patients. What is the explanation for this poor communication? Is there something unique about ICU nurses, or do they behave in the same way as all nurses. One explanation lies with the ICU environment, which Michaels (1971) believes is very stressful for both patients and staff, which means that the staff are struggling to cope with this environment and this is exacerbated by the high threat of death associated with many ICU patients (Shudham, 1986). These problems of communicating with patients threatened by death are widespread. Kubler-Ross (1981) found that nurses avoided discussing problems with dying patients, yet for the post-acutely ill ICU patient the threat of dying is diminished. One explanation then could be that most nurse-patient communication is nurse centred, relating to tasks and procedures. Thus as the patient becomes less dependent, so there is less interaction. The work of Stockwell (1972) found that 75% of nurse-patient interaction related to performance of a task, whilst Crotty (1985) found 69% of interactions were very short, often merely a few words spoken by either nurse or patient. It may be just part of a nurses role to communicate poorly with patients. Fielding and Lleweis a lyn ( 1987) believe that communication demanding and difficult aspect of the nurses role that is often done badly. The work of Nievaard (1987) suggest that despite improved training in communication, nurses continue to fail to open their feelings to patients, or to make their interaction patient centred. Yet MacLeod-Clark (1985) argues that often the research on nurse-patient communication focuses on the quantity of the interaction. This study would suggest that the ICU nurse is aware of the need to communicate with the acutely ill

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patient, yet paradoxically seems to have difficulty in communicating with post-acutely ill patients who are more able to participate in the interaction. ICU nurses may be making a choice to prioritise meeting the physical needs of other acutely ill patients over those of post-acutely ill patients. It could therefore be argued that ICU nurses have been able to develop excellent communication skills, it is the quality of this interaction that is poor.

CONCLUSION It is important to note that this is only a small scale study. With more time and resources, the researcher would have sampled a larger population, and considered using additional method(s) of data collection to promote understanding of the nature of ICU nursing and help permit the generation of theory. This study has however provided a useful examination of the area, providing insight into the perceptions of ICU nurses of their patients needs, particularly with regard to prioritising care and communication with different groups of patients. Clearly there are a number of areas that require greater exploration through future research.

References Asbury A J 1985 Patient memories and reactions to intensive care. Care of the Critically Ill l(2): 12-13 Ashworth P 1979 The Acutely Ill. Nursing Times 75(7): 290294 Ashworth P 1980 Care to Communicate. RCN London Ashworth P 1984 Staff patient communication in Coronary Care Units. Journal ofAdvanced Nursing 9( 1): 35-42 Badger T L 1974 The physician-patient in the Recovery & Intensive Care Units. Archives of Surgery 109: 359-360 Ballard K S 1981 Identification of Environmental Stresses for Patients in a Surgical Care Unit. Issues in Mental Health Nursing 3(1-2): 89-108 Chenitz W C, Swanson J M 1982 Why Qualitative Research in Nursing? Nursing Outlook 30(4): 241-245 Chew S L 1986 Psychological Reactions of Intensive Care Patients. Care ofthe Critically Ill 2(2): 62-65 Crotty M (1985) Communication between Nurses and their Patients. Nurse Education Today 5(3): 130-134 Denzin N K (1978) The Research Act. McGraw-Hill, New York Fielding R G, Llewelyn S P (1987) Communication Training in Nursing May Damage Health and Enthusiasm: some warnings. Journal ofAdvanced Nursing 12(3): 281-290

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Glaser B, Strauss A 1967 The Discovery of Grounded Theory. Aldine, New York Helton M C 1980 The correlation between Sleep and Sleep Deprivation and the ICU syndrome. Heart and Lung g(3): 464468 Hewitt P B 1970 Subjective Follow-up of Patients from a Surgical Intensive Therapy Ward. British Medical Journal 1970(4): 669673 Kubler-Ross E 1981 Living with Death & Dying. Trinity Press: Worcester MacLeod-Clark J 1985 Communication-why it can go wrong. Nursing 2(38): 1119-l120 Melia K 1982 ‘Tell it as it is’-Qualitative Methodology Nursing Research. Understanding the Student Nurses World. Journal ofAdvanced Nursing 7(4): 327-335 Michaels D R 1971 Too much in need ofsupport to give any? American Journal ofNursing 71(10): 1932-1935 Nievaard AC 1987 Communication Climate & Patient Care: causes and effects ofnurses attitudes to patients. Social Science & Medicine 24(9): 777-784

Pearsall M 1965 Participant Observation as a Role & Method in Behavioural Research. Nursing Research 14(I): 37-42 Schatzman L, Strauss A 1973 Field Research: Strategies for a Natural Sociology. Englewood Cliffs, New Jersey Shurdham C 1986 The Nurse on the Intensive Care Unit. Intensive Care Nursing l(4): 181-186 Stockwell F 1972 The Unpopular Patient. RCN London Theissen C 1970 Cited in: Physiological Effects of Noise During Sleep. Welch B L & Welch A S. Plenum Press, New York Thomssen R 1981 Psychological Aspects of Intensive Care Units. New Zealand Nursing Journal 74(9): 2627,34 Trigg R 1985 Understanding Social Science. Blackwell, Oxford Wallington-Smith S A 1986 Care of the multi-ignored patient: a nursing perspective. Care of the Critically Ill 2(l): 28-29 Woods N G 1974 Noise Stimuli in the Acute Care Area. Nursing Research 23(2): 144-150