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Nursing patients suffering from trauma: Critical care nurses narrate their experiences
International Journal of Orthopaedic and Trauma Nursing (2012) 16, 21–29
www.elsevier.com/locate/ijotn
Nursing patients suffering from trauma: Critical care nurses narrate their experiences ¨m RN, CCN, MSc a, Klara Magnusson RN, CCN, MSc b, Madelene Bostro ˚sa Engstro ¨m RN, CCN, MSc, PhD (Senior Lecturer) c,* A a
˚ Hospital, Sweden ICU, Skelleftea ¨ lvsborgs County Hospital, Sweden ICU, Northen A c ˚ University of Technology, Division of Nursing, Department of Health Care Science, Lulea ˚, Sweden SE-971 87 Lulea b
KEYWORDS
Summary The aim of this study was to describe critical care nurses’ experiences of nursing patients suffering from trauma. Eight critical care nurses were interviewed. Qualitative thematic content analysis was applied to the data and resulted in one theme; ‘Needing to feel in control and part of a team’, with six categories; ‘different ways of dealing with uncertainty’, ‘feelings of responsibility and security’, ‘wanting to relieve the pain’, ‘supporting the relatives’, ‘suppressing one’s own feelings’, and ‘reflecting over one’s work’. The findings show the importance of preparation for caring for a patient suffering from trauma. Standardized care of the patient according to Advanced Trauma Life Support was described as a good basis, but for the quality of care to be good this always had to be complemented with personal nursing care for the patient and care for their relatives. This study contributes knowledge about meeting critically ill patients suffering from trauma and suggestions about how to cope with thoughts that might arise after a serious situation in nursing care. c 2011 Elsevier Ltd. All rights reserved.
Qualitative thematic content analyze; Qualitative interview; Critical care nurses; Nursing care; Trauma; Experience; Communication; Support; Reflection
Editor’s comments The critically ill trauma patient represents significant challenges for those providing their care during this difficult phase of recovery. This piece of qualitative research clearly shows the impact of this on those caring for severely injured patients at this stage. Feeling well-prepared to cope with the physical and psychological needs of patients with severe trauma is central to providing care that is conducive to recovery. JS-T
* Corresponding author. Tel.: +46 920 49 38 75; fax: +46 920 49 38 50. ˚. Engstro E-mail address: [email protected] (A ¨m).
1878-1241/$ - see front matter c 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2011.06.002
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Background When a patient is suffering from trauma urgent nursing care and treatment begin immediately (O’Mahoney, 2005). The initial goal when nursing such patients is to treat failing vital functions (Lennquist, 2007) and all work should be done according to a standardized schedule. In Sweden, and more than 40 others countries (Lennquist, 2007), this work is guided by the Advanced Trauma Life Support (ATLS) (O’Mahoney, 2005). The method is described under a series of letters, A–E, that stand for Airway with c-spine control, Breathing, Circulation, Disability and Exposure, which are worked through in order with the life-threatening injuries taking prioritory. Trauma resuscitation focuses on optimizing oxygenation, ventilation and circulation (Curtis, 2001; Laskowski-Jones, 2006). The patient is constantly re-evaluated, the goal being one step ahead with observations and evaluation in order to prevent complications and meet the patient’s needs (Curtis, 2001). The application of the ATLS concept has improved the outcome for patients afflicted by trauma (Arman and Bja ¨lke, 2006). One weakness with ATLS is the principle of doing one thing at the time as a lot of the work is done parallely; and it can be hard to follow ATLS when there are several injured and limited resources (Lennquist, 2007). To have suffered trauma may give the patient a feeling that their lives have been turned upside– down (Arman and Bja ¨lke, 2006). From perhaps being completely healthy the patient receives injuries which might mean that initially he or she cannot, nor is allowed to, move (Tutton et al., 2007). Patients who are suddenly badly injured through trauma have described a feeling of fear and even though there are initially a large number of people around the patient, sometimes a feeling of loneliness and isolation (Arman and Bja ¨lke, 2006; O’Brien and Forthergill-Bourbonnais, 2004). When a patient suffers from trauma and is admitted to an intensive care unit (ICU), the life situation of the relatives also changes dramatically. They may experience shock and find it difficult to accept what has happened (Morse and Pooler, 2002). There are probably feelings of anxiety arising from thoughts about whether or not the patient will survive, be functionally limited and/or suffer other complications (Johansson et al., 2005). The relatives need information, support and the possibility of being close to their loved ones in such a situation. By supporting the relatives, the critical care nurses (CCNs) can ease the difficult situation and make it possible for them to regain a feeling of self-control (Engstro ¨m, 2008).
M. Bostro ¨m et al. Communication is an important part of the CCNs efforts to create a relationship with the patient and their relatives (Tan et al., 2008), but there are obstacles to effective communication with a trauma patient, for example the patient’s head may be fixed when the neck is stabilized. It is the CCNs’ duty to find creative ways around these obstacles (O’Mahoney, 2005). Physical contact in combination with verbal communication can play an important part in helping the patient to reduce their suffering during trauma resuscitation (Chang, 2001). Beyond the high technology surveillance and monitoring, which is integral to the CCN’s role, lies the art of caring for the injured patient. The art of nursing is dependent on the individual nurse’s competence and background experience; it is not confined to one particular part of the trauma continuum (O’Shea, 2005). A patient’s experience of nursing care can be seen as conveying a message about a problem, a need and a wish addressed to the nurse. Nursing care needs are about whether the patient can feel trust in the nurse, that he or she is competent, can communicate and knows how to improve the wellbeing of the patient. The patient’s need for nursing care should be understood in terms of the patient’s apprehension of suffering, but also as related to the well-being experience (Fagerstro ¨m et al., 1998). To summarize, a review of the literature shows that suffering from trauma brings about a sudden and difficult change in life for both the patient and their relatives. It also reveals that there is a lack of research about CCNs’ experiences of nursing patients suffering from trauma.
Aim The aim with this study was to describe CCNs’ experience of nursing patients suffering from trauma.
Methods This study has an inductive descriptive qualitative design, anchored within the naturalistic paradigm (cf. Polit and Beck, 2008). It was performed with personal interviews and analyzed with qualitative thematic content analysis, in order to describe and understand CCNs’ experiences of nursing patients afflicted by trauma.
Participants and procedure The managers of two general ICUs in Sweden were informed about the study and gave their permission for
Nursing patients suffering from trauma: Critical care nurses narrate their experiences it to be carried out by signing a consent form. The nurse managers of the ICUs contacted a total of eight CCNs who were experienced in nursing patients suffering from trauma. The eight CCNs were sent an information letter about the study together with a request that they participate; all of them were interested in participating and answered the letter by signing a consent form. The first and second authors contacted them by telephone and made appointments for the interviews in accordance with their wishes. All eight CCNs had experiences they wanted to talk about that were related to the aim of the study as they regularly nursed patients suffering from trauma. The CCNs who participated were aged between 33 and 50 years, and all were women. They had worked as CCNs for between 2 and 29 years.
Data collection The data were collected during 2010 by means of qualitative, personal interviews. The CCNs were asked to describe their experiences of nursing patients suffering from trauma; about their experiences of meeting the relatives of such patients; and about their thoughts and feelings after they had nursed such a patient. Follow-up questions were asked such as; Please, give an example; How did you feel then? The interviews lasted for 26–67 min each (median = 48 min) and took place in a quiet room in the ICU that the CCNs worked in, in accordance with their wishes. The interviews were digitally recorded and transcribed verbatim; the authors reviewed the transcripts to ensure accuracy (cf. Kvale and Brinkmann, 2009). To guarantee the quality of the interviews a pilot interview was conducted, which was transcribed into text, read by all three authors several times and then discussed to discover whether there was any need to refine the questions. This was not found to be necessary and, therefore, the pilot interview was also included in the study.
Data analysis The interview text was analyzed by the authors using qualitative content analysis as described by DowneWamboldt (1992). Each interview was read through several times in order to gain a sense of the content as a whole. The entire text was then read in order to identify text units, guided by the aim of the study. The text units were condensed and sorted into categories related by content, thus constituting an expression of the manifest content of the text. All categories were then compared and a theme, i.e. threads of meaning that appeared in category after category, were identified (cf. Baxter, 1991).
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Ethical considerations The University Ethics Committee approved the study and the managers of the ICUs gave their permission for it to be carried out. Information about the study was repeated orally to the CCNs prior to starting the interviews. Assurances were given that all data would remain confidential, that participation was voluntary and that the CCNs had the right to withdraw at any time without prejudice. The CCNs who participated were given opportunities to talk about feelings evoked by the interview situation.
Rigor Every interview was subsequently evaluated by the authors providing the opportunity to make improvements at an early stage. The authors were all involved in every step of the analysis and, moving back and forth between the text and the product of the analysis, progressively refined the findings. The findings are illustrated with quotations from the interview transcripts allowing the reader to trace data to their original sources (Holloway and Wheeler, 2010).
Findings Needing to feel in control and part of a team Different ways of dealing with uncertainty When the CCNs knew that a patient afflicted by trauma was coming to the ICU they wanted to know about the patient, what had happened, what kind of trauma the patient had suffered and what conceivable injuries the patient might have. The CCNs said they asked about various parameters such as breathing, circulation status, consciousness, age and information about the patient as a person, e.g. whether the relatives had been informed. Before the patient arrived at the ICU the CCNs described that they usually felt they experienced an adrenalin rush which increased their vigilance. They thought they derived an advantage from knowing in advance that a patient was coming, which meant that they could remain calm and could usually prepare themselves mentally by picturing what the situation would be like. If you know where to start it’s easier. . . I always have the worst scenario in my mind, I might hear a little about what has happened, traffic accident with five injured, then I think
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M. Bostro ¨m et al. all of them are severely injured, but it’s seldom like that. I expect the worst and then it’s not that bad. . .
Now I feel more secure in what I’m doing, I’ve got more self-confidence. I felt completely at first, unsafe. . . I felt like a newly qualified registered nurse, but I’ve grown into the role.
Feelings of responsibility and security The CCNs described their overall task as being responsible for the supervision of such patients afflicted by trauma and they tried constantly to be one step ahead in the nursing care of the patient. When the patient arrived at the ICU the CCNs usually started to talk to them calmly. If the patient was unconscious the CCNs judged the level of consciousness. The CCNs connected ECG monitors and constantly measured the patient’s blood pressure, pulse, saturation and breathing frequence. If the patient had arterial cannulation blood gases could be helpful in judging their circulation and respiration. The CCNs described the importance of working calmly and methodically to reduce the risk of making mistakes.
The CCNs described how they worked systematically following the ATLS concept. It felt secure having routines and a common concept that the team followed, with everyone knowing what to do. The CCNs described how they took care of patients with different injuries that they might have had no previous experience of. They worked together and helped each other when a patient suffering from trauma arrived in the ICU. If the team was to work properly a clear leader and good communication were prerequisites, according to the CCNs. It was important to report back what was done so that the whole team was informed. They felt a security in knowing that there was always someone working who could handle the situations that might arise in the care of trauma patients.
I choose to be at the bedside continually so I’ve control over what’s being done for the patient. It was important to grasp what medication would be given and in what doses the CCNs should administer it to the patient. In stressful situations the CCNs described how they used schedules about how to mix various medicines, and if they felt unsure they double checked with some colleagues that the mixture and dilution were correct. The CCNs described the importance of knowing what were reasonable doses of different medicines. The communication between the CCNs and the physicians was central to ensuring that they were all talking about the same medicine and treatment. You have to think fast and understand what you are told, but before I give any medicines I check with the physician; now I give so much of that, I always double check to make sure I’ve got it right. Working as a CCN with no experience of nursing patients afflicted by trauma required help and support from colleagues, especially when transporting patients outside the ICU. With more experience, the CCNs said they acquired a better overview of the patient’s needs. After some years in the work the CCNs said that, while they could never be prepared for every situation, their experiences made it easier for them to handle the uncertainty.
Wanting to relieve the pain The CCNs met patients with severe injuries who sometimes had a really bad prognosis. Many patients afflicted by trauma expressed anxiety about the future. The CCNs then tried to help the patient to focus on what was happening at that moment and getting through the traumatic situation. It was important for the CCNs to explain what they were doing so the patient would feel safe and trust them. The CCNs wanted to have someone from the staff close to the patients suffering from trauma to answer their questions and listen to their wishes. If you think when there has been a big accident and there is a patient who is awake. . . concentration is first and foremost on the vital functions but you communicate continually with the patient. . .they need to feel safe and sure that we know what we are doing. The CCNs said they used their imagination to reduce the suffering of the patient. If the patient was unconscious the CCNs tried to feel what it would be like to be in that situation and how the best care could be given. They always tried to screen the patients and cover them to guard their integrity. It was important for the CCNs to show the patients that they cared and that they wanted to give them personal care. The patients suffering from trauma could not always tell by themselves if anything felt wrong; if a patient became restless and seemed anxious the CCNs saw it as their task to find out
Nursing patients suffering from trauma: Critical care nurses narrate their experiences what was bothering the patient and to try to alleviate the suffering. It’s not just medically, it’s about that this patient is feeling well. . .Having the best possible comfort.
Supporting the relatives Supporting the patients’ relatives when the patients were critically injured and unstable was sometimes experienced as hard, due to lack of time. The CCNs tried to tell relatives what they were doing with the patient and why, and tried to give them some comfort in the alien environment in the ICU. They [relatives] will feel calm and know that we’re doing all we can, I try to mediate that feeling. The CCNs felt that they could never replace the relatives’ presence and therefore encouraged relatives to stay close to the patient. The CCNs said that relatives’ anxiety could be relieved by their being involved in and close by during nursing care, and the patients were usually calmer if they could see and hear their relatives. Suppressing one’s own feelings The CCNs described the importance of being professional in encounters with patients and their relatives. That could mean that the CCNs tried to suppress their own feelings in order to give support. I can think and feel different things but that’s maybe not the place to show them, my job as a CCN is to be calm, safe and to do my work. Not all patients suffering from trauma survived, which was demanding for the CCNs. Sometimes they worked for a long time with a patient who then died and in those circumstances they felt tiredness combined with sorrow. The CCNs said they would console the relatives first and only afterwards begin their own reflection. I try to keep calm even if I’m boiling inside. Keep my face calm even if I feel stressed and want to hurry on. Feelings of stress connected to working with patients suffering from trauma was not always negative. The stress experienced could sharpen the
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CCNs’ awareness in emergency situations and it felt positive as long as they were in control of the patient’s situation. If the CCNs had too many tasks to do at the same time it could lead them to lose focus and their overview of the patient’s situation. The CCNs described how they tried to work calmly and methodically in order to deal with the stress. I try to be calm towards patients and relatives, not yelling and screaming and gesticulating. I try to hide my inner stress. . .
Reflecting over one’s work The CCNs felt it was good to reflect over their work, both by themselves and with others, they thought that it improved the care the next time a similar situation arose. I go through it all with myself; Did I do the right things? Did we do it in the right order? If the initial work with the patient suffering from trauma went well and everyone in the team knew what to do the CCNs felt they had done a good and satisfying job with the patient. If the teamwork did not function well the CCNs were irritated and felt that the work was hard and took a lot of energy, and they had problems communicating calmness to the patient and relatives. The CCNs believed that they had done a good job if they felt that they had made the right interventions, even if the patient’s prognosis was poor. It’s ambiguous in a way when it doesn’t end well for the patient, but sometimes anyhow we have to be pleased with what we have done. Continuing to think about patients and relatives and situations was something the CCNs said was a part of being a CCN. They described how they talked with each other within the team that had cared for the patient and the importance of having open communication and listening to each other. It cannot change things and events but having someone to listen, the fact that it is possible to do that and care for each other, that is important. After acute situations involving several of the staff they tried to come together and talk about the work done and their feelings. The CCNs said that during this kind of debriefing they realized what others thought and they received a coherent
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picture of the care given. The CCNs appreciated the possibility of having a debriefing; how effective it felt depended on who was in charge of it. It sometimes took the CCNs a long time to work through their feelings and reactions after severe trauma. One CCN described how she used to end her day at work by thinking a positive thought. Sometimes when I get such thoughts I think; what has been positive about today? If you try to see something positive, you will find it, you do that.
Discussion The aim of this study was to describe CCNs’ experience of nursing patients suffering from trauma. The CCNs strove to satisfy primarily the needs of the patient, but also of the patient’s relatives and the needs within the team. The difficulties experienced in the work place related to the feelings aroused, while practical tasks were mentioned less often. The findings show that the CCNs wanted to prepare themselves for the nursing of patients suffering from trauma. Cook (1998) describes how the CCNs prepare themselves by creating an image of what the trauma resuscitation will be like. It is essential for the staff to know where everything is and that all the equipment that might be necessary is available, because this creates efficiency in trauma resuscitation (Turner and Kenward, 2002). In trauma care high demands are made on CCNs’ ability to focus and prioritize their work assignments (Sinclair, 2006). The findings show that the CCNs considered it their responsibility to check the supervision of the patient suffering from trauma. According to O’Neill and Le Grove (2003) it is important to link up the patient to the monitoring equipment quickly so as to be able to follow and identify the patient’s physiological responses to gain an idea of how effective the treatment given is. The CCNs need to know about the monitoring equipment and how to correctly interpret the data; however, monitors cannot replace a human observation of the patient’s clinical status. In the findings, CCNs also emphasized the importance of listening to what the patient said, since only the patient can tell how it they feel. According to Wiman and Wikblad (2003) patients suffering from trauma suddenly lose control over their life situation. The CCNs in this study described how they met patients with difficult injuries and sometimes poor prognoses. Hawley (2000) shows that a patient suffering from trauma
is the subject of extreme stress. In the findings the CCNs described how such patients felt afraid about their future. According to Hawley (2000), this is strengthened by painful treatments in unknown environments with unknown people. The CCNs described how they tried to help the patient to focus on the present and just get through the traumatic situation. Morse and Proctor (1998) show that the CCNs can support the stressed patient in trauma resuscitation by being next to the patient at all times. From this position the CCNs can answer questions and focus on the patient. According to Hawley (2000) a well-informed patient is less troubled, less shocked and feels safer. Not being informed leads to increased anxiety in the patient (Hawley, 2000). The results show that the CCNs used their imagination to ease the discomfort of the patient afflicted by trauma. Morse and Proctor (1998) argue that the small actions CCNs perform in the nursing care, for example making things more comfortable for the patient, lead to the patient feeling calmer. Hawley (2000) shows that both conversation and physical contact are important elements that contribute to comfort and helps the patient to endure the situation when suffering from trauma. Comfort often means being at the right temperature, dry and clean, with clothing that fits. Comfort conjures up feelings of being safe and protected, of calmness and being relaxed and is in contrast of suffering which is always a uniquely individual experience (SantyTomlinsson, 2011). The findings show that handling medicines was an assignment that was sometimes perceived as stressful by the CCNs and they usually double checked with the physician before they administered an ordered dose. Harkins (2009) shows that that some kind of reporting system is important in ensuring effective teamwork. However, in the findings the CCNs also said that stress did not have to be negative as in the account where the CCNs increased their sharpness and stayed alert. This is confirmed by Caine and Ter-Bagdasarian (2003) who show that stressfull situations, when the demands are extremely high, lead to greater capacity in the CCNs. But stressful situations can also be experienced negatively, and according to Moola et al. (2008) effective communication systems should be established between managers and CCNs to address inconsistencies as they arise, like critical shortages of staff or equipment. In the findings the CCNs stated that the relatives should have the opportunity to be present and involved in the nursing care. Engstro ¨m and So ¨derberg (2004) show that it is of great importance for the relatives to be close to the patient and to know
Nursing patients suffering from trauma: Critical care nurses narrate their experiences what is happening. Engstro ¨m et al. (2011) emphasizes the importance of preparing the relatives for what they will see, by explaining about the environment and the equipment around the patient, before they enter the patient’s room. It is important that the relatives receive honest information in a way that they can understand. ˚ ga According to A ˚rd and Terkildsen Maindal (2009) the more comfortable the relatives are in the ICU, the more support they can give to the patient. Even when the patient cannot remember everything from their stay in the ICU, Ringdal et al. (2006) show that the visits by relatives are remembered by most patients suffering from trauma. Empathy is an important part of the care and can be a cornerstone in the relationship between the CCNs and the patients and their relatives (Stayt, 2008). When the CCNs carry out their work with a feeling of compassion, the patients and their relatives feel that the CCNs care about them (O’Brien and Forthergill-Bourbonnais, 2004). The CCNs felt they did a good job when the teamwork functioned well and everyone was focused and knew what to do. Twedell and Pfrimmer (2009) show that effective teamwork and good communication are necessary in order to give the patient safe and reliable care, as it helps to prevent mistakes from occurring. However, Harkins (2009) shows that too often the team is in a chaotic and stressful situation where a lack of communication develops constituting a source of frustration when the goals for the patient are not achieved (Pryzby, 2004) and according to Beeby (2000) this frustration may cause a loss of energy. In the findings the CCNs wondered what could have been done better and how they themselves influenced what happened. Morrisey (2005) shows that this reflection over the work makes it possible for the CCNs to examine how they can handle and process similar, difficult care situations. The CCNs said that their work meant that they thought about events even after work. Martins and Robazzi (2009) show that CCNs know that it is wrong to take difficult care situations home with you, but they find it hard to let it go. Working with suffering people and witnessing death can cause the CCNs to develop work-related stress; sometimes CCNs work so intensely with patients suffering from trauma that they do not have time to process their own feelings (Martins and Robazzi, 2009). According to Cook (1998) this can cause delayed reactions in the form of feeling emotionally drained afterwards. Reactions after taking care of a patient suffering from trauma, according to Morrisey (2005), can include troublesome thoughts, irritation, disrupted sleep or feelings of guilt and shame. The findings show
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how the CCNs talked to each other in order to process thoughts and reactions after nursing patients afflicted by trauma. Morrisey (2005) shows that CCNs have traditionally used personal conversations as a mean of unloading their feelings after difficult care situations. Such personal conversation are an effective way of processing feelings, but on occasions the CCNs are often interrupted during their conversation and therefore go onto other topics before everyone has had a chance to talk about their feelings. However, according to Cook (1998) both personal and more formal conversations help in the processing of difficult care situations. According to Vouzavali et al. (2011) CCNs need to be aware of and prepared for the nature and effects of their engagement with the critically ill, and to be clear that bonding and interpersonal relationships with patients develop, including unconscious patients, and that this may have an enormous effect on themselves. The findings show that the staff sometimes gathered in a more structured way, in the form of a debriefing to discuss feelings and reactions after a difficult care situation, where many of the staff had reacted to what had happened. Regel (2010) describes debriefing as psychological, structured crisis intervention, where the team reflects over difficult care situations. Twedell and Pfrimmer (2009) argue that debriefing can be a complicated process; including discussions of what went well, what has been learned, and what can be done differently next time. Harkins (2009) show that debriefing and feedback leads to continued improvement and learning since they give the staff an opportunity to learn from their experiences. According to Regel (2010) debriefing aims to support, by giving the incident a context and helping to ease the emotional process. Through debriefing the staff can see each other’s needs and help each other to seek adequate help in time, but it has to respect that not everyone might want to express their feelings in front of their co-workers (Morrisey, 2005). Therefore all encouragement, support and help have to be based on what needs there are in the group (Regel, 2010).
Study limitations This study has limitations; it was based on a sample of only eight participants. When determining the sample size we judged the quality of the data collected against the specific aim. Variation was required to allow deep analysis of the data (Sandelowski, 1995) and the participants did provide rich descriptions of their experiences
28 concerning the topic under study. In qualitative research the goal is not to generalized the findings, instead the findings can be transferred to similar situations if they are recontextualized (Lincoln and Guba, 1985).
Conclusion Being well prepared, knowing the patient and having the knowledge to nurse him or her are prerequisites for the CCNs do a good job when nursing patients suffering from trauma. The CCNs want to do well for, and reduce the suffering of, the patients and their relatives. The importance of working structurally, following the ATLS concept is highlighted throughout this study, given that it is complemented with personal nursing care, which supports existing knowledge and previous studies. The work of nursing patients suffering from trauma in ICUs is an important and common task for CCNs and knowledge in the field is essential if patients are to receive optimal nursing care and treatment. A dynamic combination of efficiency and caring by trauma team members creates an environment where patients can feel safe (O’Brien and Forthergill-Bourbonnais, 2004). This is something that the CCNs in this study were aware of, but the CCNs also need to feel safe with their own feelings, reactions and thoughts when nursing patients suffering from trauma.
Conflict of Interest Statement The authors declare there are no conflicts of interest.
Funding Source This research received grants for the English language revision from the Division of Nursing, Department of Health Science, Lulea ˚ University of Technology, Sweden, where it also was carried out.
Ethical Approval The protocol for the research project has been approved by an Ethics Committee of the institution within which the work was undertaken and this conforms to the provision of the Declaration of Helsinki in 1995 (as revised in Edinburgh 2000).
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Acknowledgements We would like to thank the CCNs for sharing their experiences and Pat Shrimpton for revising the English language.
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Ringdal, M., Johansson, L., Lundberg, Bergbom, I., 2006. Delusional memories from the intensive care unit – experienced by patients with physical trauma. Intensive and Critical Care Nursing 22, 346–354. Sandelowski, M., 1995. Focus on qualitative method. Sample size in qualitative research. Research in Nursing & Health 18 (2), 179–183. Santy-Tomlinsson, J., 2011. Comfort-more than just the absence of pain. International Journal of Orthopaedic and Trauma Nursing 15 (2), 55–56. Sinclair, T.D., 2006. The role of the rapid response nurse: hospitalwide and in trauma resuscitations. Journal of Trauma Nursing 13 (4), 175–177. Stayt, L.C., 2008. Death, empathy and self preservation: the emotional labor of caring for families of the critically ill in adult intensive care. Journal of Clinical Nursing 18 (9), 1267– 1275. Tan, K.L., Lim, L.M., Chiu, L.H., 2008. Orthopedic patients’ experience of motor vehicle accident in Singapore. International Nursing Review 55 (1), 110–116. Turner, L., Kenward, G., 2002. Preparing to receive patients with trauma. Nursing Times 98 (37), 34–38. Tutton, E., Seers, K., Langstaff, D., 2007. Professional nursing culture on a trauma unit: experiences of patients and staff. Journal of Advanced Nursing 61 (2), 145–153. Twedell, D., Pfrimmer, D., 2009. Teamwork and communication. The Journal of Continuing Education in Nursing 40 (7), 294–295. Vouzavali, F., Papathanassoglou, E., Karanikola, M., Koutroubas, A., Patiraki, E., Papadatou, D., 2011. ’The patient is my space’: hermeneutic investigation of the nurse–patient relationship in critical care. Nursing in Critical Care 16 (3), 140–151. Wiman, E., Wikblad, K., 2003. Caring and uncaring encounters in nursing in an emergency department. Journal of Clinical Nursing 13 (4), 422–429.
www.elsevier.com/locate/ijotn
Nursing patients suffering from trauma: Critical care nurses narrate their experiences ¨m RN, CCN, MSc a, Klara Magnusson RN, CCN, MSc b, Madelene Bostro ˚sa Engstro ¨m RN, CCN, MSc, PhD (Senior Lecturer) c,* A a
˚ Hospital, Sweden ICU, Skelleftea ¨ lvsborgs County Hospital, Sweden ICU, Northen A c ˚ University of Technology, Division of Nursing, Department of Health Care Science, Lulea ˚, Sweden SE-971 87 Lulea b
KEYWORDS
Summary The aim of this study was to describe critical care nurses’ experiences of nursing patients suffering from trauma. Eight critical care nurses were interviewed. Qualitative thematic content analysis was applied to the data and resulted in one theme; ‘Needing to feel in control and part of a team’, with six categories; ‘different ways of dealing with uncertainty’, ‘feelings of responsibility and security’, ‘wanting to relieve the pain’, ‘supporting the relatives’, ‘suppressing one’s own feelings’, and ‘reflecting over one’s work’. The findings show the importance of preparation for caring for a patient suffering from trauma. Standardized care of the patient according to Advanced Trauma Life Support was described as a good basis, but for the quality of care to be good this always had to be complemented with personal nursing care for the patient and care for their relatives. This study contributes knowledge about meeting critically ill patients suffering from trauma and suggestions about how to cope with thoughts that might arise after a serious situation in nursing care. c 2011 Elsevier Ltd. All rights reserved.
Qualitative thematic content analyze; Qualitative interview; Critical care nurses; Nursing care; Trauma; Experience; Communication; Support; Reflection
Editor’s comments The critically ill trauma patient represents significant challenges for those providing their care during this difficult phase of recovery. This piece of qualitative research clearly shows the impact of this on those caring for severely injured patients at this stage. Feeling well-prepared to cope with the physical and psychological needs of patients with severe trauma is central to providing care that is conducive to recovery. JS-T
* Corresponding author. Tel.: +46 920 49 38 75; fax: +46 920 49 38 50. ˚. Engstro E-mail address: [email protected] (A ¨m).
1878-1241/$ - see front matter c 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2011.06.002
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Background When a patient is suffering from trauma urgent nursing care and treatment begin immediately (O’Mahoney, 2005). The initial goal when nursing such patients is to treat failing vital functions (Lennquist, 2007) and all work should be done according to a standardized schedule. In Sweden, and more than 40 others countries (Lennquist, 2007), this work is guided by the Advanced Trauma Life Support (ATLS) (O’Mahoney, 2005). The method is described under a series of letters, A–E, that stand for Airway with c-spine control, Breathing, Circulation, Disability and Exposure, which are worked through in order with the life-threatening injuries taking prioritory. Trauma resuscitation focuses on optimizing oxygenation, ventilation and circulation (Curtis, 2001; Laskowski-Jones, 2006). The patient is constantly re-evaluated, the goal being one step ahead with observations and evaluation in order to prevent complications and meet the patient’s needs (Curtis, 2001). The application of the ATLS concept has improved the outcome for patients afflicted by trauma (Arman and Bja ¨lke, 2006). One weakness with ATLS is the principle of doing one thing at the time as a lot of the work is done parallely; and it can be hard to follow ATLS when there are several injured and limited resources (Lennquist, 2007). To have suffered trauma may give the patient a feeling that their lives have been turned upside– down (Arman and Bja ¨lke, 2006). From perhaps being completely healthy the patient receives injuries which might mean that initially he or she cannot, nor is allowed to, move (Tutton et al., 2007). Patients who are suddenly badly injured through trauma have described a feeling of fear and even though there are initially a large number of people around the patient, sometimes a feeling of loneliness and isolation (Arman and Bja ¨lke, 2006; O’Brien and Forthergill-Bourbonnais, 2004). When a patient suffers from trauma and is admitted to an intensive care unit (ICU), the life situation of the relatives also changes dramatically. They may experience shock and find it difficult to accept what has happened (Morse and Pooler, 2002). There are probably feelings of anxiety arising from thoughts about whether or not the patient will survive, be functionally limited and/or suffer other complications (Johansson et al., 2005). The relatives need information, support and the possibility of being close to their loved ones in such a situation. By supporting the relatives, the critical care nurses (CCNs) can ease the difficult situation and make it possible for them to regain a feeling of self-control (Engstro ¨m, 2008).
M. Bostro ¨m et al. Communication is an important part of the CCNs efforts to create a relationship with the patient and their relatives (Tan et al., 2008), but there are obstacles to effective communication with a trauma patient, for example the patient’s head may be fixed when the neck is stabilized. It is the CCNs’ duty to find creative ways around these obstacles (O’Mahoney, 2005). Physical contact in combination with verbal communication can play an important part in helping the patient to reduce their suffering during trauma resuscitation (Chang, 2001). Beyond the high technology surveillance and monitoring, which is integral to the CCN’s role, lies the art of caring for the injured patient. The art of nursing is dependent on the individual nurse’s competence and background experience; it is not confined to one particular part of the trauma continuum (O’Shea, 2005). A patient’s experience of nursing care can be seen as conveying a message about a problem, a need and a wish addressed to the nurse. Nursing care needs are about whether the patient can feel trust in the nurse, that he or she is competent, can communicate and knows how to improve the wellbeing of the patient. The patient’s need for nursing care should be understood in terms of the patient’s apprehension of suffering, but also as related to the well-being experience (Fagerstro ¨m et al., 1998). To summarize, a review of the literature shows that suffering from trauma brings about a sudden and difficult change in life for both the patient and their relatives. It also reveals that there is a lack of research about CCNs’ experiences of nursing patients suffering from trauma.
Aim The aim with this study was to describe CCNs’ experience of nursing patients suffering from trauma.
Methods This study has an inductive descriptive qualitative design, anchored within the naturalistic paradigm (cf. Polit and Beck, 2008). It was performed with personal interviews and analyzed with qualitative thematic content analysis, in order to describe and understand CCNs’ experiences of nursing patients afflicted by trauma.
Participants and procedure The managers of two general ICUs in Sweden were informed about the study and gave their permission for
Nursing patients suffering from trauma: Critical care nurses narrate their experiences it to be carried out by signing a consent form. The nurse managers of the ICUs contacted a total of eight CCNs who were experienced in nursing patients suffering from trauma. The eight CCNs were sent an information letter about the study together with a request that they participate; all of them were interested in participating and answered the letter by signing a consent form. The first and second authors contacted them by telephone and made appointments for the interviews in accordance with their wishes. All eight CCNs had experiences they wanted to talk about that were related to the aim of the study as they regularly nursed patients suffering from trauma. The CCNs who participated were aged between 33 and 50 years, and all were women. They had worked as CCNs for between 2 and 29 years.
Data collection The data were collected during 2010 by means of qualitative, personal interviews. The CCNs were asked to describe their experiences of nursing patients suffering from trauma; about their experiences of meeting the relatives of such patients; and about their thoughts and feelings after they had nursed such a patient. Follow-up questions were asked such as; Please, give an example; How did you feel then? The interviews lasted for 26–67 min each (median = 48 min) and took place in a quiet room in the ICU that the CCNs worked in, in accordance with their wishes. The interviews were digitally recorded and transcribed verbatim; the authors reviewed the transcripts to ensure accuracy (cf. Kvale and Brinkmann, 2009). To guarantee the quality of the interviews a pilot interview was conducted, which was transcribed into text, read by all three authors several times and then discussed to discover whether there was any need to refine the questions. This was not found to be necessary and, therefore, the pilot interview was also included in the study.
Data analysis The interview text was analyzed by the authors using qualitative content analysis as described by DowneWamboldt (1992). Each interview was read through several times in order to gain a sense of the content as a whole. The entire text was then read in order to identify text units, guided by the aim of the study. The text units were condensed and sorted into categories related by content, thus constituting an expression of the manifest content of the text. All categories were then compared and a theme, i.e. threads of meaning that appeared in category after category, were identified (cf. Baxter, 1991).
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Ethical considerations The University Ethics Committee approved the study and the managers of the ICUs gave their permission for it to be carried out. Information about the study was repeated orally to the CCNs prior to starting the interviews. Assurances were given that all data would remain confidential, that participation was voluntary and that the CCNs had the right to withdraw at any time without prejudice. The CCNs who participated were given opportunities to talk about feelings evoked by the interview situation.
Rigor Every interview was subsequently evaluated by the authors providing the opportunity to make improvements at an early stage. The authors were all involved in every step of the analysis and, moving back and forth between the text and the product of the analysis, progressively refined the findings. The findings are illustrated with quotations from the interview transcripts allowing the reader to trace data to their original sources (Holloway and Wheeler, 2010).
Findings Needing to feel in control and part of a team Different ways of dealing with uncertainty When the CCNs knew that a patient afflicted by trauma was coming to the ICU they wanted to know about the patient, what had happened, what kind of trauma the patient had suffered and what conceivable injuries the patient might have. The CCNs said they asked about various parameters such as breathing, circulation status, consciousness, age and information about the patient as a person, e.g. whether the relatives had been informed. Before the patient arrived at the ICU the CCNs described that they usually felt they experienced an adrenalin rush which increased their vigilance. They thought they derived an advantage from knowing in advance that a patient was coming, which meant that they could remain calm and could usually prepare themselves mentally by picturing what the situation would be like. If you know where to start it’s easier. . . I always have the worst scenario in my mind, I might hear a little about what has happened, traffic accident with five injured, then I think
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M. Bostro ¨m et al. all of them are severely injured, but it’s seldom like that. I expect the worst and then it’s not that bad. . .
Now I feel more secure in what I’m doing, I’ve got more self-confidence. I felt completely at first, unsafe. . . I felt like a newly qualified registered nurse, but I’ve grown into the role.
Feelings of responsibility and security The CCNs described their overall task as being responsible for the supervision of such patients afflicted by trauma and they tried constantly to be one step ahead in the nursing care of the patient. When the patient arrived at the ICU the CCNs usually started to talk to them calmly. If the patient was unconscious the CCNs judged the level of consciousness. The CCNs connected ECG monitors and constantly measured the patient’s blood pressure, pulse, saturation and breathing frequence. If the patient had arterial cannulation blood gases could be helpful in judging their circulation and respiration. The CCNs described the importance of working calmly and methodically to reduce the risk of making mistakes.
The CCNs described how they worked systematically following the ATLS concept. It felt secure having routines and a common concept that the team followed, with everyone knowing what to do. The CCNs described how they took care of patients with different injuries that they might have had no previous experience of. They worked together and helped each other when a patient suffering from trauma arrived in the ICU. If the team was to work properly a clear leader and good communication were prerequisites, according to the CCNs. It was important to report back what was done so that the whole team was informed. They felt a security in knowing that there was always someone working who could handle the situations that might arise in the care of trauma patients.
I choose to be at the bedside continually so I’ve control over what’s being done for the patient. It was important to grasp what medication would be given and in what doses the CCNs should administer it to the patient. In stressful situations the CCNs described how they used schedules about how to mix various medicines, and if they felt unsure they double checked with some colleagues that the mixture and dilution were correct. The CCNs described the importance of knowing what were reasonable doses of different medicines. The communication between the CCNs and the physicians was central to ensuring that they were all talking about the same medicine and treatment. You have to think fast and understand what you are told, but before I give any medicines I check with the physician; now I give so much of that, I always double check to make sure I’ve got it right. Working as a CCN with no experience of nursing patients afflicted by trauma required help and support from colleagues, especially when transporting patients outside the ICU. With more experience, the CCNs said they acquired a better overview of the patient’s needs. After some years in the work the CCNs said that, while they could never be prepared for every situation, their experiences made it easier for them to handle the uncertainty.
Wanting to relieve the pain The CCNs met patients with severe injuries who sometimes had a really bad prognosis. Many patients afflicted by trauma expressed anxiety about the future. The CCNs then tried to help the patient to focus on what was happening at that moment and getting through the traumatic situation. It was important for the CCNs to explain what they were doing so the patient would feel safe and trust them. The CCNs wanted to have someone from the staff close to the patients suffering from trauma to answer their questions and listen to their wishes. If you think when there has been a big accident and there is a patient who is awake. . . concentration is first and foremost on the vital functions but you communicate continually with the patient. . .they need to feel safe and sure that we know what we are doing. The CCNs said they used their imagination to reduce the suffering of the patient. If the patient was unconscious the CCNs tried to feel what it would be like to be in that situation and how the best care could be given. They always tried to screen the patients and cover them to guard their integrity. It was important for the CCNs to show the patients that they cared and that they wanted to give them personal care. The patients suffering from trauma could not always tell by themselves if anything felt wrong; if a patient became restless and seemed anxious the CCNs saw it as their task to find out
Nursing patients suffering from trauma: Critical care nurses narrate their experiences what was bothering the patient and to try to alleviate the suffering. It’s not just medically, it’s about that this patient is feeling well. . .Having the best possible comfort.
Supporting the relatives Supporting the patients’ relatives when the patients were critically injured and unstable was sometimes experienced as hard, due to lack of time. The CCNs tried to tell relatives what they were doing with the patient and why, and tried to give them some comfort in the alien environment in the ICU. They [relatives] will feel calm and know that we’re doing all we can, I try to mediate that feeling. The CCNs felt that they could never replace the relatives’ presence and therefore encouraged relatives to stay close to the patient. The CCNs said that relatives’ anxiety could be relieved by their being involved in and close by during nursing care, and the patients were usually calmer if they could see and hear their relatives. Suppressing one’s own feelings The CCNs described the importance of being professional in encounters with patients and their relatives. That could mean that the CCNs tried to suppress their own feelings in order to give support. I can think and feel different things but that’s maybe not the place to show them, my job as a CCN is to be calm, safe and to do my work. Not all patients suffering from trauma survived, which was demanding for the CCNs. Sometimes they worked for a long time with a patient who then died and in those circumstances they felt tiredness combined with sorrow. The CCNs said they would console the relatives first and only afterwards begin their own reflection. I try to keep calm even if I’m boiling inside. Keep my face calm even if I feel stressed and want to hurry on. Feelings of stress connected to working with patients suffering from trauma was not always negative. The stress experienced could sharpen the
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CCNs’ awareness in emergency situations and it felt positive as long as they were in control of the patient’s situation. If the CCNs had too many tasks to do at the same time it could lead them to lose focus and their overview of the patient’s situation. The CCNs described how they tried to work calmly and methodically in order to deal with the stress. I try to be calm towards patients and relatives, not yelling and screaming and gesticulating. I try to hide my inner stress. . .
Reflecting over one’s work The CCNs felt it was good to reflect over their work, both by themselves and with others, they thought that it improved the care the next time a similar situation arose. I go through it all with myself; Did I do the right things? Did we do it in the right order? If the initial work with the patient suffering from trauma went well and everyone in the team knew what to do the CCNs felt they had done a good and satisfying job with the patient. If the teamwork did not function well the CCNs were irritated and felt that the work was hard and took a lot of energy, and they had problems communicating calmness to the patient and relatives. The CCNs believed that they had done a good job if they felt that they had made the right interventions, even if the patient’s prognosis was poor. It’s ambiguous in a way when it doesn’t end well for the patient, but sometimes anyhow we have to be pleased with what we have done. Continuing to think about patients and relatives and situations was something the CCNs said was a part of being a CCN. They described how they talked with each other within the team that had cared for the patient and the importance of having open communication and listening to each other. It cannot change things and events but having someone to listen, the fact that it is possible to do that and care for each other, that is important. After acute situations involving several of the staff they tried to come together and talk about the work done and their feelings. The CCNs said that during this kind of debriefing they realized what others thought and they received a coherent
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M. Bostro ¨m et al.
picture of the care given. The CCNs appreciated the possibility of having a debriefing; how effective it felt depended on who was in charge of it. It sometimes took the CCNs a long time to work through their feelings and reactions after severe trauma. One CCN described how she used to end her day at work by thinking a positive thought. Sometimes when I get such thoughts I think; what has been positive about today? If you try to see something positive, you will find it, you do that.
Discussion The aim of this study was to describe CCNs’ experience of nursing patients suffering from trauma. The CCNs strove to satisfy primarily the needs of the patient, but also of the patient’s relatives and the needs within the team. The difficulties experienced in the work place related to the feelings aroused, while practical tasks were mentioned less often. The findings show that the CCNs wanted to prepare themselves for the nursing of patients suffering from trauma. Cook (1998) describes how the CCNs prepare themselves by creating an image of what the trauma resuscitation will be like. It is essential for the staff to know where everything is and that all the equipment that might be necessary is available, because this creates efficiency in trauma resuscitation (Turner and Kenward, 2002). In trauma care high demands are made on CCNs’ ability to focus and prioritize their work assignments (Sinclair, 2006). The findings show that the CCNs considered it their responsibility to check the supervision of the patient suffering from trauma. According to O’Neill and Le Grove (2003) it is important to link up the patient to the monitoring equipment quickly so as to be able to follow and identify the patient’s physiological responses to gain an idea of how effective the treatment given is. The CCNs need to know about the monitoring equipment and how to correctly interpret the data; however, monitors cannot replace a human observation of the patient’s clinical status. In the findings, CCNs also emphasized the importance of listening to what the patient said, since only the patient can tell how it they feel. According to Wiman and Wikblad (2003) patients suffering from trauma suddenly lose control over their life situation. The CCNs in this study described how they met patients with difficult injuries and sometimes poor prognoses. Hawley (2000) shows that a patient suffering from trauma
is the subject of extreme stress. In the findings the CCNs described how such patients felt afraid about their future. According to Hawley (2000), this is strengthened by painful treatments in unknown environments with unknown people. The CCNs described how they tried to help the patient to focus on the present and just get through the traumatic situation. Morse and Proctor (1998) show that the CCNs can support the stressed patient in trauma resuscitation by being next to the patient at all times. From this position the CCNs can answer questions and focus on the patient. According to Hawley (2000) a well-informed patient is less troubled, less shocked and feels safer. Not being informed leads to increased anxiety in the patient (Hawley, 2000). The results show that the CCNs used their imagination to ease the discomfort of the patient afflicted by trauma. Morse and Proctor (1998) argue that the small actions CCNs perform in the nursing care, for example making things more comfortable for the patient, lead to the patient feeling calmer. Hawley (2000) shows that both conversation and physical contact are important elements that contribute to comfort and helps the patient to endure the situation when suffering from trauma. Comfort often means being at the right temperature, dry and clean, with clothing that fits. Comfort conjures up feelings of being safe and protected, of calmness and being relaxed and is in contrast of suffering which is always a uniquely individual experience (SantyTomlinsson, 2011). The findings show that handling medicines was an assignment that was sometimes perceived as stressful by the CCNs and they usually double checked with the physician before they administered an ordered dose. Harkins (2009) shows that that some kind of reporting system is important in ensuring effective teamwork. However, in the findings the CCNs also said that stress did not have to be negative as in the account where the CCNs increased their sharpness and stayed alert. This is confirmed by Caine and Ter-Bagdasarian (2003) who show that stressfull situations, when the demands are extremely high, lead to greater capacity in the CCNs. But stressful situations can also be experienced negatively, and according to Moola et al. (2008) effective communication systems should be established between managers and CCNs to address inconsistencies as they arise, like critical shortages of staff or equipment. In the findings the CCNs stated that the relatives should have the opportunity to be present and involved in the nursing care. Engstro ¨m and So ¨derberg (2004) show that it is of great importance for the relatives to be close to the patient and to know
Nursing patients suffering from trauma: Critical care nurses narrate their experiences what is happening. Engstro ¨m et al. (2011) emphasizes the importance of preparing the relatives for what they will see, by explaining about the environment and the equipment around the patient, before they enter the patient’s room. It is important that the relatives receive honest information in a way that they can understand. ˚ ga According to A ˚rd and Terkildsen Maindal (2009) the more comfortable the relatives are in the ICU, the more support they can give to the patient. Even when the patient cannot remember everything from their stay in the ICU, Ringdal et al. (2006) show that the visits by relatives are remembered by most patients suffering from trauma. Empathy is an important part of the care and can be a cornerstone in the relationship between the CCNs and the patients and their relatives (Stayt, 2008). When the CCNs carry out their work with a feeling of compassion, the patients and their relatives feel that the CCNs care about them (O’Brien and Forthergill-Bourbonnais, 2004). The CCNs felt they did a good job when the teamwork functioned well and everyone was focused and knew what to do. Twedell and Pfrimmer (2009) show that effective teamwork and good communication are necessary in order to give the patient safe and reliable care, as it helps to prevent mistakes from occurring. However, Harkins (2009) shows that too often the team is in a chaotic and stressful situation where a lack of communication develops constituting a source of frustration when the goals for the patient are not achieved (Pryzby, 2004) and according to Beeby (2000) this frustration may cause a loss of energy. In the findings the CCNs wondered what could have been done better and how they themselves influenced what happened. Morrisey (2005) shows that this reflection over the work makes it possible for the CCNs to examine how they can handle and process similar, difficult care situations. The CCNs said that their work meant that they thought about events even after work. Martins and Robazzi (2009) show that CCNs know that it is wrong to take difficult care situations home with you, but they find it hard to let it go. Working with suffering people and witnessing death can cause the CCNs to develop work-related stress; sometimes CCNs work so intensely with patients suffering from trauma that they do not have time to process their own feelings (Martins and Robazzi, 2009). According to Cook (1998) this can cause delayed reactions in the form of feeling emotionally drained afterwards. Reactions after taking care of a patient suffering from trauma, according to Morrisey (2005), can include troublesome thoughts, irritation, disrupted sleep or feelings of guilt and shame. The findings show
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how the CCNs talked to each other in order to process thoughts and reactions after nursing patients afflicted by trauma. Morrisey (2005) shows that CCNs have traditionally used personal conversations as a mean of unloading their feelings after difficult care situations. Such personal conversation are an effective way of processing feelings, but on occasions the CCNs are often interrupted during their conversation and therefore go onto other topics before everyone has had a chance to talk about their feelings. However, according to Cook (1998) both personal and more formal conversations help in the processing of difficult care situations. According to Vouzavali et al. (2011) CCNs need to be aware of and prepared for the nature and effects of their engagement with the critically ill, and to be clear that bonding and interpersonal relationships with patients develop, including unconscious patients, and that this may have an enormous effect on themselves. The findings show that the staff sometimes gathered in a more structured way, in the form of a debriefing to discuss feelings and reactions after a difficult care situation, where many of the staff had reacted to what had happened. Regel (2010) describes debriefing as psychological, structured crisis intervention, where the team reflects over difficult care situations. Twedell and Pfrimmer (2009) argue that debriefing can be a complicated process; including discussions of what went well, what has been learned, and what can be done differently next time. Harkins (2009) show that debriefing and feedback leads to continued improvement and learning since they give the staff an opportunity to learn from their experiences. According to Regel (2010) debriefing aims to support, by giving the incident a context and helping to ease the emotional process. Through debriefing the staff can see each other’s needs and help each other to seek adequate help in time, but it has to respect that not everyone might want to express their feelings in front of their co-workers (Morrisey, 2005). Therefore all encouragement, support and help have to be based on what needs there are in the group (Regel, 2010).
Study limitations This study has limitations; it was based on a sample of only eight participants. When determining the sample size we judged the quality of the data collected against the specific aim. Variation was required to allow deep analysis of the data (Sandelowski, 1995) and the participants did provide rich descriptions of their experiences
28 concerning the topic under study. In qualitative research the goal is not to generalized the findings, instead the findings can be transferred to similar situations if they are recontextualized (Lincoln and Guba, 1985).
Conclusion Being well prepared, knowing the patient and having the knowledge to nurse him or her are prerequisites for the CCNs do a good job when nursing patients suffering from trauma. The CCNs want to do well for, and reduce the suffering of, the patients and their relatives. The importance of working structurally, following the ATLS concept is highlighted throughout this study, given that it is complemented with personal nursing care, which supports existing knowledge and previous studies. The work of nursing patients suffering from trauma in ICUs is an important and common task for CCNs and knowledge in the field is essential if patients are to receive optimal nursing care and treatment. A dynamic combination of efficiency and caring by trauma team members creates an environment where patients can feel safe (O’Brien and Forthergill-Bourbonnais, 2004). This is something that the CCNs in this study were aware of, but the CCNs also need to feel safe with their own feelings, reactions and thoughts when nursing patients suffering from trauma.
Conflict of Interest Statement The authors declare there are no conflicts of interest.
Funding Source This research received grants for the English language revision from the Division of Nursing, Department of Health Science, Lulea ˚ University of Technology, Sweden, where it also was carried out.
Ethical Approval The protocol for the research project has been approved by an Ethics Committee of the institution within which the work was undertaken and this conforms to the provision of the Declaration of Helsinki in 1995 (as revised in Edinburgh 2000).
M. Bostro ¨m et al.
Acknowledgements We would like to thank the CCNs for sharing their experiences and Pat Shrimpton for revising the English language.
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