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Preventing the ITU syndrome or how not to torture an ITU patient! Part 2
Preventing the ITU syndrome or how not to torture an ITU patient! Part 2 lan Dyer
lan Dyer RGN, Dip N, MSc, PhD, Senior Nurse/Clinical Nurse Specialist, Cardiothoracic Intensive Therapy Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, BI5 2TH, UK (Requests for offprints to ID) Manuscript accepted 8 April 1995 Part I of this article, bythe same author, was published inVol. II (3): 130-139 of this journal
Admission to an intensive therapy unit (ITU) has been described as a 'necessary evil' (Barrie-Shevlin 1987), and some of the 'tortures' described in Part I of this article (Dyer 1995) may be an inevitable result of ITU care. This does not mean that the development of the ITU syndrome should be regarded as inevitable. Many potential causes of the syndrome can be avoided or at least ameliorated. Some suggested means of preventing the syndrome include designing ITUs with windows (Keep et al 1980), use of noise reducing materials when building ITUs (Hopkinson 1994, Topf & Davis 1993), using noise level as a criterion when purchasing equipment (Dracup 1988) or using remote telemetry for monitoring (Fisher & Moxham 1984). These would undoubtedly be beneficial but they are not practical propositions for nurses who wish to improve psychological care in the short term. For this reason, this article, concentrates mainly on immediately applicable, relatively cost-free interventions. Methods of preventing the syndrome should begin, whenever possible, before admission and should continue throughout the patients' stay. The main emphasis should be placed on prevention, but early detection and treatment of problems should also be given high priority. If a patient exhibits symptoms of psychological disturbance physical causes should be considered, but at the same time the ITU syndrome should be suspected and attempts made to alleviate possible causes of this. Nurses play a vital role in any attempts to
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alleviate problems and in 'humanising' the technical ITU environment (Ashworth 1987, Mackellaig 1990). Hopkinson & Freeman (I 988) suggest that: The greatest asset is...caring nursing staff who will talk and explain to the patient continually and provide an essential human interface with the high technology medical care. All staff interacting with patients should be aware that they have a role to play in prevention, but nurses, as those most closely involved in patient care, play a leading role and should receive a thorough education in all aspects of the syndrome and its prevention (Hansell 1984). Important nursing interventions include reducing patient isolation, facilitating meaningful perception, reducing debility and exhaustion, and auditing the ITU environment to identify potential problems.
R E D U C T I O N OF ISOLATION Reduction of isolation entails several complementary approaches: patients should be familiarised with the environment; adequate two-way communication should be ensured and depersonalisation avoided. Familiarisation with the environment should begin (whenever possible) before admission with pre-admission visits to the patient (Adams et al 1978, Shovelton 1979). Information should be provided on the reasons for admission and the expected events and interventions during the I T U stay. If possible, prospective patients should be invited to visit the ITU. These visits should be timed so that visitors are also seen and prepared for postoperative visiting (Dyer 1991). Information provision at this time has been reported to reduce anxiety and enhance recovery (Derham 1991, Stanton 1991). These visits may also be used to gain information about the patient: preferred name; hearing; sight or mobility difficulties (and any aids used); potential sources of discomfort or pain (e.g. arthritis) and any specific anxieties and personal details which may influence the delivery of subsequent care. The information should be recorded so that it is available to all hospital staff (Ashworth 1980). If the patient may be physically isolated (e.g. due to immunosuppression) giving information about the reasons for this may help to reduce anxiety (Genvert et al 1979). When unplanned and emergency admissions occur information
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from family and friends should be obtained after admission so that care may be individualised. Communication
An I T U environment includes the physical surroundings and the staffcaring for the patient, and a key role of I T U staff, particularly nurses, is communicating with patients. C o m m u n i cation should not only involve explanation about care activities or about the patients' condition, though both of these are essential and should occur frequently (Johnson & Sexton 1990). Communication should extend beyond this. It should be personalised by addressing patients by their preferred name and should include 'normal' conversation to provide a link with the outside world (Norrie 1992). The specifics of conversation are less important than the fact that it takes place, but some of the information given should provide orientation, e.g. date, weather, current events. It is essential to use words which the patient understands (Albarren 1991) and information should be repeated frequently since patients may not retain this (Gries & Fernsler 1988). In addition, staff should avoid discussing patients within the hearing of any patient (Wood 1993). The use of unfamiliar medical terms or talking over a patient can convey the impression that he or she is an object whose feelings are not worth considering. This may increase feelings of isolation. Orientation can be assisted by clocks and calendars visible to the patient, by use of radio and television (Finley 1991) and by reducing light and noise at night to maintain a normal day-night cycle (see also below). Hospital staff should remember that much communication is on the non-verbal level, e.g. eye contact and the tone of voice used can indicate a caring attitude. Gries & Fernsler (1988) found that reassuring words and a caring manner reduced stress in ventilated patients. Touch, e.g. hand-holding, is also a very valuable means of showing concern and caring, and nurses should develop the habit of using this, but should also bear in mind that this may invade the patient's personal space and may not always be welcomed. This said, in most cases the use of non-verbal means of communication is supportive and informs patients that they are cared about as well as cared for. Visitors may provide valuable support to patients (Gaglione 1984, Stanton 1991), They can play a direct role in talking to and touching the patient (Ashworth 1979) which will help to maintain orientation, reduce isolation (Stanley 1991), alleviate emotional deprivation and help to prevent the occurrence of the I T U syndrome (Heater 1985). Nurses should demonstrate this
by example in order to encourage visitors to interact with patients. Visitors to long-term patients can be asked to provide photos of family members or pets which may help to keep patients in touch with normal life (Heath 1989). Visitors can provide information which helps nurses to individualise care (Ashworth 1984, Hughes 1982) and to get to know a patient better (Dunkel & Eisendrath 1983). This may make care and communication easier for nurses since, though they may not receive feedback from the patient, they are no longer attempting to talk to a total stranger. Involving visitors in care will also help them and reduce the feelings of helplessness which many visitors experience (Dyer 1991). To achieve this involvement visitors will require a great deal of support from nurses, particularly if the patient is confused. Since communication is ideally a two-way process it should involve both imparting information to patients and enhancing the ability of patients to communicate with staffand visitors. Just as patients may 'read' non-verbal cues from a nurse, nurses should also be aware of nonverbal communication from patients (Stratton 1991), e.g. movement and facial expression, which may indicate signs of pain, distress or anxiety. The best method of communication is speech. This is denied to many I T U patients as a result ofintubation or tracheostomy. In some cases it is possible to use tracheostomy speaking tubes (Benzer et al 1983). Alternatively, electronic or mechanical communication aids may be used (Jones 1986). These require a degree of physical and mental ability but when a patient can use them they are ideal, since they allow the communication of complex ideas. In many cases cheaper and more readily available alternatives can be used, e.g. a writing pad and pen, but these simple devices have drawbacks. For example Johnson & Sexton's (1990) study revealed that attempts to write may fail as a result of fatigue, poor vision, hand tremors due to weakness and difficulty in writing whilst reclined, and this failure may be a source of frustration for patients. An alternative which is easier to use is the alphabet board, where the patient points to single letters of the alphabet and spells out words one letter at a time. If necessary the nurse may point to letters whilst the patient indicates the correct choice by nodding or blinking. An equally 'low tech' option is the picture chart depicting basic and commonly expressed needs such as toilet, drink, bed or pain. Such charts have the added advantage that they overcome language barriers and do not require a great deal of effort, coordination and concentration to use. Maintaining communication with unresponsive patients can be very difficult. It is all
Preventing the ITU syndrome or how not to torture an ITU patient! Part 2
too easy to assume that it is unnecessary to communicate with patients who show no signs of awareness, but lack of response does not necessarily mean lack o f awareness. Hudak et al (1990) suggest that it is important to refer to patients as 'unresponsive' rather than 'unconscious' since 'unconscious' denotes a lack o f sensory awareness.., whereas 'unresponsive' means that motor- and sensory-coordinated responses cannot be elicited'. In order to avoid this problem Asworth (1980) suggests that all patients should be treated as if they are conscious and able to understand. Keep et al (1980) concur with this view since they found that a high proportion of patients in the I T U were conscious and aware of their surroundings and that they retained some long-term memory o f their stay. Schroeder (1971) suggests that 'Nurses must learn.., to carry out a one-sided conversation or commentary'. As Stratton (1987) notes 'There is nothing sophisticated about.., just talking to the patient'. This is within the grasp of every I T U nurse and should be regarded as a basic aspect o f nursing care. Prevention of isolation by communication is the crucial means o f avoiding the development o f the I T U syndrome. N o t only is adequate communication important in its own right, it also allows many of the other potential problems to be 'discussed' by the patient and nurse and thus avoided or alleviated. For example, one o f the 'tortures' mentioned in Part 1 of this article (Dyer 1995) was 'threats' which mainly relate to fear of the unknown. Adequate communication reduces these unknowns, and appropriate explanation in clear language helps patients to understand why treatments and interventions are necessary, so that these are not perceived as trivial or based on whim.
Avoidance of depersonalisation Depersonalised care treats patients as objects which are simply the recipients o f care. This is the antithesis o f holistic and personalised care which treats patients as autonomous individuals. Failure to consider the needs of patients for privacy (the 'torture' o f degradation) is an aspect o f depersonalisation. W h e n screens round the bed are ignored and when the patient is handled or uncovered without permission or explanation then the patient is being treated as an object. All staffshould be educated to respect each patient's privacy. Curtains round the bed should mean 'do not enter unless absolutely necessary'. Wherever possible the patient should be provided with nightclothes. If standard hospital nightclothes cannot be used due to the presence o f lines or drains, they can be modified by the addition o f ties and vents to allow access when required but at the same time
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keep the patient covered (Ward and Hurst 1991). If nurses know the patient as a person individualised care is far easier. This may be achieved to some extent by preoperative visits and by sohciting information about the patient from visitors. This helps hospital staff to get to know the patient. This is necessary for personalised care but is not sufficient. Personalised care is a two-way process and patients need help to get to know hospital staff. This is facilitated by ensuring continuity of care with the same few staff caring for the patient, allowing nurses and patients to get to know each other (Albarran 1991, Heath 1989, Johnson & Sexton 1990). It is important to remember that patients may not have perfect recall o f the hospital staff they encounter and staff should reintroduce themselves whenever they meet a patient (Stanley 1991). It is also important to maximise patients' autonomy. It is often necessary to carry out procedures which patients may find unpleasant or to deny requests. Patients should always receive a thorough explanation of the reasons for this. It is not sufficient simply to inform the patient that 'treatment X is necessary', the reasons for this should be described, and whenever possible, permission of the patient should be sought. The goal is to assist patients to become active participants in care rather than passive recipients. This approach has been found to reduce feehngs o f powerlessness (Wright 1985) and wherever possible the patient should be involved in decisionmaking and take an active role in treatment decisions (Bolin 1974). For complex medical interventions this may not be feasible, but for more basic care there is no reason why a patient should not be consulted, for example, 'do you want a wash now?' All too often patients are simply told; T i n going to wash you now'. The general aim should be to modify the routine to meet each patient's needs rather than adjust the patient's care to the routine. A final, and seldom considered aspect of autonomy is how patients should be addressed. Patients are frequently addressed by their first name or by a family nickname, and it has been suggested that this is appreciated since it makes the I T U seem less clinical (Smith 1987). However, this should not be assumed, and older patients may prefer to be addressed more formally as Mr, Mrs, etc. Ideally the patient or visitor should be consulted and permission sought before using any first name or nickname.
FACILITATING MEANINGFUL PERCEPTION The aims of interventions in this area are two-
226 Intensiveand CriticalCare Nursing fold, firstly to reduce meaningless sensory inputs, and secondly to increase meaningful inputs.
Sight As far as possible sights which have no meaning or may cause distress should be reduced. For example, equipment should, if possible, not be placed in view o f the patient and screens should be used when carrying out procedures on other patients. Additionally, meaningful visual inputs should be maximised, where appropriate, by the use o f television, magazines and photos provided by visitors. The possibility of making the I T U more visually stimulating should be considered, for example, pictures could be placed on the walls (remembering that patients' perceptions may be distorted). W h e n redecoration takes place this could involve a more imaginative colour scheme than 'standard hospital white'. It is of course, necessary to ensure that patients can see. If the patient normally wears spectacles these could be utilised, and where possible the patient should not be nursed flat but should be assisted to sit up in bed or a chair. This will reduce the tedium of staring at a visually monotonous ceiling (Bassett 1993).
Hearing Meaningless noise can be reduced by moving equipment from patients' immediate environment, turning off equipment when not in use (e.g. suction), setting alarm limits carefully, muting non-essential alarms, answering the telephone promptly and reducing the volume of telephone rings at night (Green 1992, Johnson & Sexton 1990, Snyder-Halpern 1985). Even when these measures are applied a limited amount o f noise from equipment may be inevitable, I T U care requires the use of equipment with alarms and other noise. What is not inevitable and can always be reduced is much o f the human generated noise. For example, conversations can be carried out quietly (particularly at night), equipment can be carried rather than dragged, and wherever possible noisy activities should be carried out during the day rather than at night. Reduction o f meaningless noise should not be taken to mean total silence. This would be equally disorientating. The 'hole' left by the reduction on meaningless noise should be filled by meaningful stimulation. An important measure here is staff conversation with patients (as discussed above). However, maintaining consistent conversation to an unresponsive patient may be very difficult and TV and radio can be very helpful if properly used. Ideally these should be under the control of patients by
use of remote devices. W h e n these are not available or patients cannot use them it is important to consult patients or visitors o f unresponsive patients about the choice of station. Headphones may be useful if the alternative would be several radio stations competing with each other and adding to the background noise. A 'Walkman' may be particularly helpful. These are cheap, block out extraneous noise and can be used to provide orientating and stimulating information, for example, favourite radio programmes, talking books, music and home produced recordings o f family conversations and messages (Green 1992). It is important that these devices are used with thought otherwise patients may receive unwanted noise (Bassett 1993). Furthermore, these should be used in addition to, not instead of, communication from staff. Simply putting earphones on a patient for 12 h per day is not a solution to the problem o f isolation. Finally, many older I T U patients may have hearing deficits therefore their hearing aids should be utilised, and if the patient has a 'good' ear speech should be directed to this side.
Taste This will be difficult to stimulate in patients who are unable to receive oral fluids. For these patients the main aim is comfort rather than stimulation, and oral toilet may be required hourly to maintain moistness of the oral mucosa (Maurer 1977). Artificial saliva may help to achieve this (Levine et al 1987). Patients who can receive oral fluids may appreciate 'sharp' acid tastes (e.g. lemon or lime) and iced water or slivers of ice may be preferred over tap water (Heath 1989). These or flavoured mouth care sticks (e.g. lemon and glycerine) may be useful for patients who are allowed 'nil by mouth'. It has been suggested that glycerine may actually produce dryness of the mouth. There is little convincing evidence for this, but it is known that frequent use o f acid solutions may cause erosion o f tooth enamel, so these should be used with care in dentate patients (Roth & Creason 1986).
Touch It was noted earlier that'touch is a valuable means of communication but may. be underused. Visitors often take their cue from nurses with regard to talking to the patient and patient contact. If visitors see that staffdo not touch the patient except for procedures they are likely to emulate this, and conversely if visitors see nurses using touch to communicate with patients they are more likely to maintain physi-
Preventing the ITU syndrome or how not to torture an ITU patient! Part 2
cal contact which may benefit both the patient and the visitor. Like other methods o f c o m m u nication touch is not a one-way process. Touch and movement are also used by patients to explore their environment. Monitoring and infusion lines should be attached securely and 'slack' provided so that the patient can move without risk of disrupting them. Finally, consideration should be given to more general stimulation. The assistance of physiotherapists or occupational therapists may be extremely helpful in providing both physical and mental stimulation. Board games may be useful for some patients, newspapers or books should be considered and in rare cases 'trips' away from the I T U may be an option. This is obviously not feasible for acutely ill patients but may be possible for longer-term patients whose condition is stable. Even an artificially ventilated patient can be taken away from the I T U with a portable ventilator or hand ventilation.
REDUCTION OF DEBILITY A N D EXHAUSTION Most I T U patients are at risk from pain or discomfort, which if unrelieved may contribute to exhaustion and debility. The main cause of these is usually the illness or operation which has resulted in I T U admission, but in addition many of the interventions which are a normal part of I T U care may result in distress and discomfort, and the patient may have pre-existing problems which also cause pain or discomfort. It is important that each I T U has a formal means of assessing pain, that this is utilised regularly and that if it is found that a patient is experiencing pain this information is acted on. However, even when formal assessment tools are used it may be difficult to assess the pain of I T U patients. Patients may be unresponsive or sedated and unable to communicate pain or discomfort. In these circumstances the nurse may be able to assess this by the recognition of physical expressions of pain and distress, e.g. grimacing, sweating, restlessness and increases in heart rate or blood pressure (Clark 1989). It should be remembered that these are not always reliable, and as a general rule pain should be assumed to be present unless the opposite is confirmed (Ashbury 1985). To treat pain successfully it is helpful to have some knowledge of pain and pain-relieving drugs. Nurses do not necessarily need to be familiar with the detailed theories of the physiology o f pain, though this would be ideal (for information in this area see, for example, Lonsdale 1991, Puntillo 1988, Wall 1978, Wallace 1992), but all nurses should have a
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basic knowledge of pain mechanisms and pain relief methods (see Bullingham 1985, Freeman & Hopkinson 1988, Glynn 1992, Hopkinson & Freeman 1988, Russell 1992). In most cases pain relief will require drugs given intramuscularly or more usually intravenously. In this latter case patient controlled analgesia (PCA) may play a useful role, particularly in high dependency areas (Clark 1992, Jenkins 1992, Smith & R e n n i e 1991). Not only does this deliver effective pain relief in the majority of patients, but it also gives them some control and autonomy It is important to remember that pain relief does not necessarily require pharmacological intervention. Reassurance may be helpful and drugs are not a substitute for sympathetic handling or for identification o f the causes o f distress (Bion 1988). Alternative methods o f pain relief such as relaxation, massage, pressure, heat, cold, distraction (e.g. music, humour) and transcutaneous nerve stimulation (TENS) may also be useful (McCaffery 1990, Puntillo 1990). It is also important to remember that pain and discomfort may have sources other than the site of any operation. Pain may come from preexisting conditions and patients may suffer discomfort from a variety o f sources, for example immobility, uncomfortable positioning, restraint, constipation and endotracheal suction. These may be alleviated by skilled nursing care such as careful positioning and suction technique (Johnson & Sexton 1990). It is these little details which will make the patient feel cared for and cared about. Much I T U care is invisible to the patient, e.g. monitoring, drug titration, laboratory tests and so on. The I T U care that is o f most immediate concern to each patient is the care that he or she directly experiences, and reduction o f discomfort is a direct expression o f care which may be o f far greater importance to the patient than its apparent contribution to patient recovery would indicate.
Sleep Sleep is essential to human well-being though
its specific functions are still far from clear (Finlay 1991). The assessment of sleep is often very difficult. Most I T U nurses will be familiar with patients who have apparently slept all night but claim not to have slept. As with pain, the simple rule should be - believe the patient. If he/she claims not to have slept then he/she has not slept sufficiently. Nurses should aim to provide the conditions which enhance the ability to sleep. This entails ensuring that light and noise are reduced, that the patient is comfortable, warm and pain-free. It is particularly important to treat pain at night when it may
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Intensiveand Critical Care Nursing disturb sleep and seem worse as a result o f the reduction o f outside distractions which occur during the day. There are times in most ITUs (e.g. when an admission occurs at night) when it is not possible to reduce light and noise to very low levels. In these circumstances patients could be supplied with eye shades or ear plugs which may reduce external distractions sufficiently to allow sleep. Equally important in encouraging sleep is the planning o f care activities (Stanton 1991). Sleep is reported to occur in 90 min cycles. ' R o u t i n e ' care should be organised to allow gaps o f at least 90 min between interventions and the needs o f each patient should be assessed (Dracup 1988, Stanley 1991). Consideration should be given to omitting non-essential care (e.g. does the patient really need 2-hourly m o u t h care?) and wherever possible essential care should be timed so that all interventions are carried out at the same time to maximise the amount o f time for sleep between interventions (Closs 1988, Lazarus & Hagens 1968, Schroeder 1971). If appropriate, sedative drugs should be administered but these should be used as an addition not as an alternative to encouraging normal sleep. Many I T U patients have a disrupted sleepwake cycle. T h e y may be awake at night and sleep during the day. Nurses should aim to correct this by waking patients if they sleep in the day and should, at the same time, ensure that sleep is assisted at night. Czeizler et al (1986) have shown that exposure to bright light can reset the human circadian pacemaker by about 6 hours. N o record has been found that this intervention has been utilised therapeutically but this could be attempted in patients with disturbed sleep patterns, for example by use o f a bright portable lamp during the day (ensuring that this is not directed into the patient's eyes) and ensuring very low light levels at night. The keys to reducing the causative factors o f the I T U syndrome are understanding and empathy. Understanding will deal with the general risk factors. Nursing staffshould think themselves into the situation o f each patient and ask themselves 'what would my needs be ifI was in this position?' (recognising that individual needs may differ). Empathic care will help nurses to meet individual needs and deal with the specific problems and difficulties which each patient may have. Neither o f these require technical skills, they may be described as basic caring qualities and activities, and any nurse, regardless o f his/her technical knowledge should be able to meet these basic requirements.
USING AUDIT TO ASSESS THE ITU ENVIRONMENT Methods o f reducing the incidence o f the I T U syndrome have been described. In order to ensure that these are put into practice it may be helpful to conduct a 'unit audit' of staff awareness, practices and equipment availability. Some of these factors need only be audited once since they will affect every patient, others will require assessment for every patient. Given the constraints which operate it is unrealistic to suggest that walls are knocked through to provide windows, that new, quieter equipment is purchased or other such changes. Thus, the emphasis here will be on low cost or cost free modifications o f practice. The audit consists o f a series o f questions (Box). If the answer to any of these is no, then this highlights an area where action should be considered. If the answer is believed to be yes then in each case, consideration should be given to how this is assessed and monitored.
CONCLUSION Any patient who is in an I T U for any length o f time is at risk o f developing the I T U syndrome, but with many patients it is possible (and we should always try) to prevent the development o f the syndrome by the use of basic nursing skills. The essentials are firstly, awareness that the syndrome should be taken seriously; secondly, identification o f potential stressors; and thirdly, planning o f specific strategies to reduce or remove these stressors. These are not 'extras' which I T U patients may receive if nurses are not too busy. It is the basic right o f all I T U patients to be treated with humanity, to have their suffering minimised, to have their autonomy maximised and to have their individual needs met, and it is within the ability of every skilled nurse to meet these needs. Even the most perfect physical care is not sufficient alone for I T U care to be of a high standard. However technically skilled nurses are in providing physical care, I T U patients need and deserve more than this. If all I T U staff do is to provide physical care then many I T U nurses could be replaced by untrained staff and by machines. The role o f I T U nurses is to give care to people, not to sets o f deranged physiological parameters and failed organ systems; and people need the 'human touch'. In describing the possible causes of the syndrome as analogues to psychological torture no criticism o f I T U staff is intended. The aim is to emphasise the potential seriousness o f the
Preventing the ITU s y n d r o m e o r h o w not to t o r t u r e an ITU patient! Part 2
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Education and staff awareness • Are all staff involved in patient care aware of the causes, effects and prevention of the ITU syndrome? • Do orientation programmes for new staff include information on the area? Information provision to patients and visitors • Do pre-admission visits take place where possible? Are patients and visitors provided with adequate information? Are the personal details of the patient recorded. Are they available to all relevant ITU staff?. • Are patients familiarised with their surroundings and carets? Is the language used appropriate? Is the understanding of the patient assessed? How? • Does the care plan assist planning to meet needs for information and emotional support? • Are patients regularly provided with information about their condition and about plans for care? Orientation and stimulation • Are clocks and calendars available? Are they visible to the patient? • Are day and night differentiated, e.g. by reducing light and noise at night? • Are visitors to longer term patients requested to provide photos and personal possessions? Are these and 'get well cards' displayed where the patient can see them? • Are walls and ceillings bare? Could posters or paintings be obtained? • Are the needs of the patient for mental stimulation met? e.g. newspaper, 'Walkman', games, 'occupational therapy'? • Is the patient consulted about -IV and radio programmes? If this is not possible are the patient's likely tastes considered? Could these be placed under the control of the patient? Are headphones available for "IV and radio? • Are other senses stimulated wherever possible, e.g. flavoured mouth care solutions and drinks? Is nutrition considered early in the patients stay? • Is the advice of all relevant hospital personnel sought, e.g. occupational therapist, physiotherapist, dietician? Communication • Do all staff talk to the patient? Does this include 'conversation' and 'passing the time of day' or simply involve activities/interventions? • Is the ability of the patients to communicate and receive communication assessed?, e.g. hearing, sight, touch, writing. Are prostheses always utilised? • Are communication aids available, e.g. alphabet or picture boards? Are these regularly used? • Are communication aids available for non-English speakers, e.g. picture board, bilingual word sheets? Does the unit have a list of local translators, and the hours that these are available? • Are tracheostomy speaking tubes available, and used where possible? • Are staff aware of, and do they use, non-verbal methods of communication and reassurance, e.g. touch, eye contact? • Do visitors receive regular and comprehensive information? Is this recorded? Are visitors encouraged to interact with the patient and to assist with care? Privacy • Are curtains always used? Are they perceived as a barrier by staff or are sometimes these ignored? Could nightdresses or pyjamas (modified if necessary) be worn by patients? • Is the patient consulted about planned care, washing, movement, etc? Are the patient's options respected where possible? Is the patient given a choice about radio and -I-V? Could these be placed under the control of the patient? Personalised care • Do all staff introduce themselves whenever they interact with the patients? • Is the patient addressed by his/her preferred name? • Is there continuity of care, i.e. is the number of nurses caring for the patient limited? • Is the orientation of the patient regularly assessed? If problems are detected are these acted on? • Does the care plan/nursing process assist the planning and assessment of individual needs, personal details, etc? Pain • Is this regularly assessed? Is the assessment tool reliable? Are assessments acted on? Is PCA an option? Are alternative means of pain relief available and used e.g. heat, cold, TENS, massage, distraction? Sleep • Is sleep assessed? Is the routine given priority or are nursing interventions individually assessed and planned to minimise interruptions to sleep? Could pressure relief mattresses be obtained so that the need for interventions is reduced? Should sedation be considered? • Is it possible to dim lights at night? Are these dimmed? Could eye shades be used to assist sleep? • Can noisy equipment be removed from the vicinity of the bed areas? Can extraneous noise be reduced e.g. by closing doors to noisy areas? Can the volume of any of these (e.g. 'phones, alarms) be reduced without affecting patient safety? V~hen equipment is purchased is noise considered? Could ear plugs be used to encourage sleep? Mobility • Do staff facilitate patient movement, e.g. by ensuring that 'lines' are fixed securely and by providing 'slack' in these? Are passive movements carried out? Is patient comfort considered when the patient is positioned? • Are longer term patients 'mobilised', e.g. by sitting out of bed, by trips away from the unit? This may require portable monitoring and ventilation - are these available? Is it possible to move the patient's bed in order to vary the sights seen?
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s y n d r o m e a n d to e n c o u r a g e staff to take a c t i o n to r e d u c e its i n c i d e n c e . A l t h o u g h t h e e m p h a s i s in this p a p e r is o n adults i n I T U s
a recent report by Hughes
(1994) suggests that c h i l d r e n m a y also b e at risk of developing the syndrome, and many ward a n d h i g h d e p e n d e n c y u n i t ( H D U ) p a t i e n t s also e x p e r i e n c e t h e stressors discussed (albeit at a l o w e r level). T h o u g h t h e s e p a t i e n t s m a y n o t b e at risk o f d e v e l o p i n g t h e I T U s y n d r o m e t h e y h a v e e v e r y r i g h t to e x p e c t to b e able to sleep, to h a v e t h e i r p a i n r e l i e v e d , to r e c e i v e a d e q u a t e information comments
and
communication.
made
Thus
the
are r e l e v a n t to all h o s p i t a l
areas, a n d m a y b e m o r e so in t h e f u t u r e since t h e p r o p o r t i o n o f v e r y ill p a t i e n t s in h o s p i t a l is likely t o increase. It is h o p e d that as w e l l as e n c o u r a g i n g I T U nurses to act this p a p e r will also
encourage
develop
HDU
strategies
to
and
ward
reduce
the
nurses
to
stressors
discussed herein.
REFERENCES Adams M, Hanson R, Norkool D, Beaulieu A, Bellville E, Morss K 1978 The confused patient: psychological responses to critical care units. American Journal of Nursing 78 (9): 1504-1512 Adomat 1K, Killing@orth A 1994 Care of the critically ill patient: the impact of stress on the use of touch in intensive therapy units. Journal of Advanced Nursing 19 (5): 912-922 Albarran JW 1991 A review of communication methods with ventilated patients and those with tracheostomies in an intensive care environment. Intensive Care Nursing 7 (3): 179-186 Amnesty International 1973 Report on torture. Duckworth, London Amnesty International Medical Commission 1984 Doctors and torture. Bellew, London, pp 61-71 Ashbury AJ 1985 Patients memories and reactions to intensive care. Care of the Critically Ill I (2): 12-13 Ashworth P 1979 Sensory deprivation - 2. The acutely ill. Nursing Times 75 (7): 290-294 Ashworth P 1980 Care to communicate. 1KCN, London Ashworth P 1984 Communicating in an intensive care unit. In: Fanlkner A (ed) Communication. Churchill Livingstone, Edinburgh, pp 94-112 Ashworth P 1987 The needs of the critically ill patient. Intensive Care Nursing 3 (4): 182-190 Baker CF 1984 Sensory overload and noise in the ICU: sources of environmental stress. Critical Care Quarterly 6 (March): 66-69 Baker CF 1992 Discomfort to environmental noise: Heart rate responses of SICU patients. Critical Care Nursing Quarterly 15 (2): 75-90 Barrie-Shevlin P 1987 Monitoring sensory balance for the critically ill patient. Nursing 3 (16): 597--601 Bassett CC 1993 Communication with the critically ill. Care of the Critically Ill 9 (5): 216-219 Bentley S, Murphy F, Dudley H 1977 Perceived noise in surgical wards and an intensive care area: an objective analysis. British Medical Journal 10 December: 1503-1508 Benzer H, Mutz N, Pauser G 1983 Psychological sequelae of intensive care. International Anaesthesiology Clinics 21 (2): 169-180 Bergbom-Engherg I 1991 Giving up and withdrawal by
ventilator treated patients: nurses experience. Intensive Care Nursing 7 (4): 200-205 Bergbom-Engherg I, Haljamae H 1989 Assessment of patient's experience of discomfort during respiratory therapy. Critical Care Medicine 17 (1): 1068-1072 Bergbom-Engberg I, Haljamae H 1993 The communication process with ventilator patients in the ICU as perceived by the nursing staff. Intensive and Critical Care Nursing 9 (I): 40-47 Biley FC, Mlllar BJ, Wilson AM 1993 Issues in intensive care visiting. Intensive and Critical Care Nursing 9 (2): 75-81 Bion JF 1988 Sedation and analgesia in the Intensive Care Unit. Hospital Update March: 1272-1286 Bolin HB 1974 Sensory deprivation: an overview. Nursing Forum XIII (3): 240-258 Borsig A, Steinacker I 1982 Communication with patients in the intensive care unit. Nursing Times Supplement 78 (12): 1-11 Briggs D 1991 Preventing ICU psychosis. Nursing Times 87 (19): 30-31 Bullingham I ~ S 1985 Optimum management of postoperative pain. Drags 29 (4): 376-386 Campbell IT, Minors DS, Waterhouse JM 1986 Are circadian rhythms important in intensive care? Intensive Care Nursing 1 (3): 144-150 Chen Y-c 1990 Psychological and social support systems in intensive and critical care. Intensive Care Nursing 6 (2): 59-66 Chew SL 1986 Psychological reactions of intensive care patients. Care of the Critically Ill 2 (2): 62-65 Chilver WLC 1978 On being a patient in an intensive therapy unit. Nursing Mirror 146 (14): 33-35 Clark EC 1989 Pain relief in intensive care. Care of the Critically Ill 5 (3): 94-95 Clark EC 1992 Postoperative patient controlled analgesia. Surgical Nurse 5 (3): 20-21 Clifford C 1986 Patients, relatives and nurses in a technological environment. Intensive Care Nursing 2 (2): 67-72 ClossJ 1988 Patients sleep-wake rhythms in hospital. Part 2. Nursing Times 84 (2): 54-55 Coles EM 1982 Clinical psychology: an introduction. Roufledge and Kegan Paul, London, pp 205-228 Czeizler CA, Allan JS, Strogatz SH et al 1986 Bright light resets the human circadian pacemaker independent of the timing of the sleep-wake cycle. Science 233 (4764): 667-671 Davison K 1989 Adverse psychiatric reactions to drugs used in the ITU. Care of the Critically Ill 5 (1): 9-12 Dement WC 1969 Studies on the function of rapid eye movement (paradoxical) sleep in human subjects. In: Pribram KH (ed) Brain and behaviour 1. Mood, states and mind. Penguin, Harmon&worth, pp 138-181 Dement WC, Henry P, Cohen H, FergusonJ 1969 Studies of the effects of sleep deprivation in humans and animals. In: Pribram KH (ed) Brain and behaviour 1. Mood, states and mind. Penguin, Harmondsworth, pp. 115-129 Derham C 1991 An evaluation of the pre-operative information given by intensive care nurses. Intensive Care Nursing 7 (2): 80-85 Dootson S 1990 Sensory imbalance and sleep loss. Nursing Times 86 (35): 26-29 Dracup K 1988 Are critical care units hazardous to health? Applied Nursing Research 1 (1): 14-21 DunkelJ, Eisendrath S 1983 Families in the intensive care unit: their effect on staff. Heart and Lung 12 (3): 258-261 Dyer I 1991 Meeting the needs of visitors - a practical approach. Intensive Care Nursing 7 (3): 135-147 Dyer I 1995 Preventing the ITU syndrome or how not to torture an ITU patient. Part 1. Intensive and Critical Care Nursing 11 (2): 130-139
Preventing the ITU syndrome or how not to torture an ITU patient! Part 2
Egerton N, KayJH 1964 Psychological disturbances associated with open heart surgery. British Journal of Psychiatry 110 (May): 433-439 Estabrooks CA 1989 Touch: a nursing strategy in the intensive care unit. Heart and Lung 18 (4): 392-401 Finlay G 1991 Sleep and intensive care. Intensive Care Nursing 7 (1): 61-68 Fisher ME, Moxham PA 1984 ICU Syndrome.Critical Care Nurse May/June: 39-44 Fitter M 1986 The Impact of New Technology on Workers and Patients in the Health Services: Physical and Psychological Stress. Consolidated Report, European Foundation for the Improvement of Living and Working Conditions, Dublin FreemanJW, Hopkinson Pal3 1988 Therapeutic progress in intensive care, sedation and analgesia Part II - Drug selection. Journal of Clinical Pharmacy and Therapeutics 13 (1): 41-50 Gaglione KM 1984 Assessing and intervening with families of C C U patients. Nursing Clinics of North America 19 (3): 427-432 Genvert G, Theil J, Levy-Gombek E, Topf-Olstein B, Drusin L 1979 Isolation information booklet stimulates dialog, allays fears. Hospitals (US) 53 (3): 72-75 Glynn C 1992 Pain control in intensive care nursing. British Journal of Intensive Care 2 (4): 172-177 Green A 1992 How nurses can ensure that the sounds patients hear have a positive rather than a negative effect upon recovery and quality of life. Intensive and Critical Care Nursing 8 (4): 245-248 Cries ML, FemslerJ 1988 Patient perceptions of the mechanical ventilation experience. Focus on Critical Care 15 (2): 52-59 Hansell H N 1984 The behavioural effects of noise on man: The patient with 'intensive care unit psychosis'. Heart and Lung 13 (1): 59-65 HeathJV 1989 What the patients say. Intensive Care Nursing 5 (3): 101-108 Heater BS 1985 Nursing responsibilities in changing visiting restrictions in the intensive care unit. Heart and Lung 14 (2): 181-186 HenryJA 199i Poisoning by psychoactive drugs. Care of the Critically Ill 7 (3): 100-105 Hill CF 1993 Is massage beneficial to critically ill patients in intensive care units? A critical review. Intensive and Critical Care Nursing 9 (2): 116-121 Hopklnsoin R_B 1994 How to plan an ICU. Care of the Critically II1 10 (2): 57--62 Hopklnsoni RB, FreemanJW 1988 Therapeutic progress in intensive care, sedation and analgesia Part I Principles. Journal of Clinical Pharmacy and Therapeutics 13 (1): 33-40 Hudak CM, Galo BM, BenzJ 1990 Critical care nursing, 5th edn. Lippincott, Philadelphia, p 29 HughesJ 1982 Helplessness and frustration: The relatives dilemma. Nursing Times 78 (23): 960-961 Hughes J 1994 Hallucinations following cardiac surgery in a paediatric intensive care unit. Intensive and Critical Care Nursing 10 (3): 209-211 Ingham A 1989 A review of the literature relating to touch its use in intensive care. Intensive Care Nursing 5 (2): 65-75 Jenkins BJ 1992 Patient controlled infusion of drags in intensive and high dependency care. Intensive Care Britain, Greycoat, London, pp 62-65 Johnson MM, Sexton DE 1990 Distress during mechanical ventilation: patients perceptions. Critical Care Nurse 10 (7): 48-57 Jones E 1986 Communication aids for the critically ill. Care of the Critically Ill 2 (3): 117-122 -
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Jones J, Hoggart B, Withey J, Donaghue K, Ellis BW 1979 What the patients say: a study of reactions to an intensive care unit. Intensive Care Medicine 5 (2): 89-92 Keep PJ, James J, Inman M 1980 Windows in the intensive therapy unit. Anaesthesia 35 (3): 257-262 Komfeld DS 1977 Psychiatric considerations in the intensive care unit. In: Kinney JM, Bendixon HH, Powers SR (eds) Manual of surgical intensive care. W.B. Saunders, Philadelphia, pp 177-190 Lazarus H R , HagensJH 1968 Prevention of psychosis following open heart surgery. American Journal of Psychiatry 124 (9): 1190-1195 Levine MJ, Aguirre A, Hutton MN, Tubak LA 1987 Artificial salivas: present and future. Journal of Dental Research 66 (February): 693-698 Lonsdale M 1991 Pain relief in the intensive care unit. Part 1. Intensive Therapy and Clinical Monitoring 12 (1): 10-13 MaurerJ 1977 Providing optimal oral health. Nursing Clinics of North America 12 (4): 671-685 McCaffery M 1990 Nursing approaches to nonpharmacological pain control. International Journal of Nursing Studies 27 (1): 1-5 McCorkle R 1974 Effects of touch on seriously ill patients. Nursing Research 23 (2): 125-132 McGonnigal KS 1986 The importance of sleep and the sensory environment to critically ill patients. Intensive Care Nursing 2 (2): 73-83 McKegney FP 1966 The intensive care syndrome. Connecticut Medicine 30: 633. Quoted in Kornfeld 1977, op cit MackellaigJM 1987 A study of the psychological effects of intensive care with particular reference to patients in isolation. Intensive Care Nursing 2 (4): 176-185 MackellaigJM 1990 A review of the psychological effects of intensive care on the isolated patient and his family. Care of the Critically Ill 6 (3): 100-102 Mackinnon C 1987 The nursing care of patients receiving paralysing agents. Intensive Care Nursing 2(3): 135-138 Norrie P 1992 The inteisve care experience. Nursing Times 88 (46): 40-42 North N 1988 Psychosocial effects of coronary artery bypass surgery. Nursing Times 84 (I): 26-29 Pennock BE, Cranshaw L, Maher T, Price T, Kaplan PD 1994 Distressful events in the ICU as perceived by patients recovering from coronary artery bypass surgery. Heart and Lung 23 (4): 323-327 Puntillo KA 1988 The phenomenon of pain and critical care nursing. Heart and Lung 17 (3): 262-271 Puntillo KA 1990 Pain experience of intensive care unit patients. Heart and Lung 19 (5): 526-533 Robinson JS 1974 The psychological effects of intensive care. Unpublished paper given at the First World Congress of Intensive Care, London Roth PT, Creason NS 1986 Nurse administered oral hygiene: is there a scientific basis? Journal of Advanced Nursing 11 (3): 323-331 Russell K 1992 Pharmacology of pain. Surgical Nurse 5 (6): 18-22 Schefl]in AW, Opton EM 1978 The mind manipulators. Paddington, New York Schoenhofer SO 1989 Affectional touch in critical care nursing: a descriptive study. Heart and Lung 18 (2): 146-154 Schroeder HG 1971 Psycho-reactive problems of intensive care. Anaesthesia 26 (1): 28-35 Seers K, Goodman C 1987 Perceptions of pain. Nursing Times 83 (48): 37-39 Shovelton DS 1979 Reflections on an intensive therapy unit. British Medical Journal Part 1:737-738
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Intensiveand Critical Care Nursing Smith C 1987 In need of intensive care - a personal perspective. Intensive Care Nursing 2 (3): 116-122 Smith KM, Rennie MJ 1991 Pain control in critical care. A rote for patient controlled analgesia? British Journal oflntensive Care I (1): 11-15 Snyder-Haipem R 1985 The effect of critical care unit noise on patient sleep cycles. Critical Care Quarterly 7 (4): 41-51 Stanley M 1991 Ensuring a safe ICU stay for your confused elderly patient. Dimensions of Critical Care Nursing 10 (2): 62-67 Stanton DJ 1991 The psychological impact of intensive therapy: the role of nurses. Intensive Care Nursing 7 (4): 230-235 Stratton H 1987 Keeping the patient in touch with reality. Care of the Critically Ill 3 (1): 22 Stratton H 1988 Its all in the mind. Care of the Critically Ill 4 (3): 23-25 Teske K, Dent RL, Cleeland CS 1983 Relationships between nurse's observations and patient's self reports of pain. Pain 16 (3): 289-296 TopfM, Davis JE 1993 Critical care unit noise and rapid eye movement (REM) sleep. Heart and Lung 22 (3): 252-258 Tucker LA 1993 Post-pump delerium. Intensive and Critical Care Nursing 9 (4): 269-273 Wall PD 1978 The gate control theory of pain mechanisms. Brain 101 (1): 1-18 Wallace KG 1992 The pathophysiology of pain. Critical Care Nursing Quarterly 15 (2): 1-13
Ward L, Hurst K 1991 Modesty in ICUs. Nursing Times 87 (28): 40-41 Weber RJ, Oszko MA, Bolander BJ, Grysiak DL 1985 The intensive care unit syndrome: causes, treatment and prevention. Drug Intelligence and Clinical Pharmacy 19 (1): 13-19 Weiss SJ 1990 Effects of differential touch on nervous system arousal of patients recovering from cardiac disease. Heart and Lung 19 (5): 474-480 Wilson V S 1987 Identification ofstressors related to patients psychologic responses to the surgical intensive care unit. Heart and Lung 16 (3): 267-273 Winn D 1983 The manipulated mind. Brainwashing, conditioning and indoctrination. Octagon Press, London Wood AM 1993 A review ofhterature relating to sleep in hospital with emphasis on the sleep of the ICU patient. Intensive and Critical Care Nursing 9 (2): 129-136 Wright JH 1985 Encouraging hope in the ventilator patient. Journal of Practical Nursing 35 (3): 37-39 Zainal G 1994 Nutrition in critically ill people. Intensive and Critical Care Nursing 10 (3): 165-170 ZubekJP, Bayer L, Mistein S, ShepardJM 1969 Behavioral and physiological changes during prolonged immobilisation plus perceptual deprivation. Journal of Abnormal Psychology 74 (April): 230-236 ZubekJP 1973 Behavioral and physiological effects of prolonged sensory and perceptual deprivation: a review. In: Rasmussen JE (ed) Man in isolation and confinement. Aldine, Chicago, pp 9-83
lan Dyer RGN, Dip N, MSc, PhD, Senior Nurse/Clinical Nurse Specialist, Cardiothoracic Intensive Therapy Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, BI5 2TH, UK (Requests for offprints to ID) Manuscript accepted 8 April 1995 Part I of this article, bythe same author, was published inVol. II (3): 130-139 of this journal
Admission to an intensive therapy unit (ITU) has been described as a 'necessary evil' (Barrie-Shevlin 1987), and some of the 'tortures' described in Part I of this article (Dyer 1995) may be an inevitable result of ITU care. This does not mean that the development of the ITU syndrome should be regarded as inevitable. Many potential causes of the syndrome can be avoided or at least ameliorated. Some suggested means of preventing the syndrome include designing ITUs with windows (Keep et al 1980), use of noise reducing materials when building ITUs (Hopkinson 1994, Topf & Davis 1993), using noise level as a criterion when purchasing equipment (Dracup 1988) or using remote telemetry for monitoring (Fisher & Moxham 1984). These would undoubtedly be beneficial but they are not practical propositions for nurses who wish to improve psychological care in the short term. For this reason, this article, concentrates mainly on immediately applicable, relatively cost-free interventions. Methods of preventing the syndrome should begin, whenever possible, before admission and should continue throughout the patients' stay. The main emphasis should be placed on prevention, but early detection and treatment of problems should also be given high priority. If a patient exhibits symptoms of psychological disturbance physical causes should be considered, but at the same time the ITU syndrome should be suspected and attempts made to alleviate possible causes of this. Nurses play a vital role in any attempts to
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alleviate problems and in 'humanising' the technical ITU environment (Ashworth 1987, Mackellaig 1990). Hopkinson & Freeman (I 988) suggest that: The greatest asset is...caring nursing staff who will talk and explain to the patient continually and provide an essential human interface with the high technology medical care. All staff interacting with patients should be aware that they have a role to play in prevention, but nurses, as those most closely involved in patient care, play a leading role and should receive a thorough education in all aspects of the syndrome and its prevention (Hansell 1984). Important nursing interventions include reducing patient isolation, facilitating meaningful perception, reducing debility and exhaustion, and auditing the ITU environment to identify potential problems.
R E D U C T I O N OF ISOLATION Reduction of isolation entails several complementary approaches: patients should be familiarised with the environment; adequate two-way communication should be ensured and depersonalisation avoided. Familiarisation with the environment should begin (whenever possible) before admission with pre-admission visits to the patient (Adams et al 1978, Shovelton 1979). Information should be provided on the reasons for admission and the expected events and interventions during the I T U stay. If possible, prospective patients should be invited to visit the ITU. These visits should be timed so that visitors are also seen and prepared for postoperative visiting (Dyer 1991). Information provision at this time has been reported to reduce anxiety and enhance recovery (Derham 1991, Stanton 1991). These visits may also be used to gain information about the patient: preferred name; hearing; sight or mobility difficulties (and any aids used); potential sources of discomfort or pain (e.g. arthritis) and any specific anxieties and personal details which may influence the delivery of subsequent care. The information should be recorded so that it is available to all hospital staff (Ashworth 1980). If the patient may be physically isolated (e.g. due to immunosuppression) giving information about the reasons for this may help to reduce anxiety (Genvert et al 1979). When unplanned and emergency admissions occur information
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from family and friends should be obtained after admission so that care may be individualised. Communication
An I T U environment includes the physical surroundings and the staffcaring for the patient, and a key role of I T U staff, particularly nurses, is communicating with patients. C o m m u n i cation should not only involve explanation about care activities or about the patients' condition, though both of these are essential and should occur frequently (Johnson & Sexton 1990). Communication should extend beyond this. It should be personalised by addressing patients by their preferred name and should include 'normal' conversation to provide a link with the outside world (Norrie 1992). The specifics of conversation are less important than the fact that it takes place, but some of the information given should provide orientation, e.g. date, weather, current events. It is essential to use words which the patient understands (Albarren 1991) and information should be repeated frequently since patients may not retain this (Gries & Fernsler 1988). In addition, staff should avoid discussing patients within the hearing of any patient (Wood 1993). The use of unfamiliar medical terms or talking over a patient can convey the impression that he or she is an object whose feelings are not worth considering. This may increase feelings of isolation. Orientation can be assisted by clocks and calendars visible to the patient, by use of radio and television (Finley 1991) and by reducing light and noise at night to maintain a normal day-night cycle (see also below). Hospital staff should remember that much communication is on the non-verbal level, e.g. eye contact and the tone of voice used can indicate a caring attitude. Gries & Fernsler (1988) found that reassuring words and a caring manner reduced stress in ventilated patients. Touch, e.g. hand-holding, is also a very valuable means of showing concern and caring, and nurses should develop the habit of using this, but should also bear in mind that this may invade the patient's personal space and may not always be welcomed. This said, in most cases the use of non-verbal means of communication is supportive and informs patients that they are cared about as well as cared for. Visitors may provide valuable support to patients (Gaglione 1984, Stanton 1991), They can play a direct role in talking to and touching the patient (Ashworth 1979) which will help to maintain orientation, reduce isolation (Stanley 1991), alleviate emotional deprivation and help to prevent the occurrence of the I T U syndrome (Heater 1985). Nurses should demonstrate this
by example in order to encourage visitors to interact with patients. Visitors to long-term patients can be asked to provide photos of family members or pets which may help to keep patients in touch with normal life (Heath 1989). Visitors can provide information which helps nurses to individualise care (Ashworth 1984, Hughes 1982) and to get to know a patient better (Dunkel & Eisendrath 1983). This may make care and communication easier for nurses since, though they may not receive feedback from the patient, they are no longer attempting to talk to a total stranger. Involving visitors in care will also help them and reduce the feelings of helplessness which many visitors experience (Dyer 1991). To achieve this involvement visitors will require a great deal of support from nurses, particularly if the patient is confused. Since communication is ideally a two-way process it should involve both imparting information to patients and enhancing the ability of patients to communicate with staffand visitors. Just as patients may 'read' non-verbal cues from a nurse, nurses should also be aware of nonverbal communication from patients (Stratton 1991), e.g. movement and facial expression, which may indicate signs of pain, distress or anxiety. The best method of communication is speech. This is denied to many I T U patients as a result ofintubation or tracheostomy. In some cases it is possible to use tracheostomy speaking tubes (Benzer et al 1983). Alternatively, electronic or mechanical communication aids may be used (Jones 1986). These require a degree of physical and mental ability but when a patient can use them they are ideal, since they allow the communication of complex ideas. In many cases cheaper and more readily available alternatives can be used, e.g. a writing pad and pen, but these simple devices have drawbacks. For example Johnson & Sexton's (1990) study revealed that attempts to write may fail as a result of fatigue, poor vision, hand tremors due to weakness and difficulty in writing whilst reclined, and this failure may be a source of frustration for patients. An alternative which is easier to use is the alphabet board, where the patient points to single letters of the alphabet and spells out words one letter at a time. If necessary the nurse may point to letters whilst the patient indicates the correct choice by nodding or blinking. An equally 'low tech' option is the picture chart depicting basic and commonly expressed needs such as toilet, drink, bed or pain. Such charts have the added advantage that they overcome language barriers and do not require a great deal of effort, coordination and concentration to use. Maintaining communication with unresponsive patients can be very difficult. It is all
Preventing the ITU syndrome or how not to torture an ITU patient! Part 2
too easy to assume that it is unnecessary to communicate with patients who show no signs of awareness, but lack of response does not necessarily mean lack o f awareness. Hudak et al (1990) suggest that it is important to refer to patients as 'unresponsive' rather than 'unconscious' since 'unconscious' denotes a lack o f sensory awareness.., whereas 'unresponsive' means that motor- and sensory-coordinated responses cannot be elicited'. In order to avoid this problem Asworth (1980) suggests that all patients should be treated as if they are conscious and able to understand. Keep et al (1980) concur with this view since they found that a high proportion of patients in the I T U were conscious and aware of their surroundings and that they retained some long-term memory o f their stay. Schroeder (1971) suggests that 'Nurses must learn.., to carry out a one-sided conversation or commentary'. As Stratton (1987) notes 'There is nothing sophisticated about.., just talking to the patient'. This is within the grasp of every I T U nurse and should be regarded as a basic aspect o f nursing care. Prevention of isolation by communication is the crucial means o f avoiding the development o f the I T U syndrome. N o t only is adequate communication important in its own right, it also allows many of the other potential problems to be 'discussed' by the patient and nurse and thus avoided or alleviated. For example, one o f the 'tortures' mentioned in Part 1 of this article (Dyer 1995) was 'threats' which mainly relate to fear of the unknown. Adequate communication reduces these unknowns, and appropriate explanation in clear language helps patients to understand why treatments and interventions are necessary, so that these are not perceived as trivial or based on whim.
Avoidance of depersonalisation Depersonalised care treats patients as objects which are simply the recipients o f care. This is the antithesis o f holistic and personalised care which treats patients as autonomous individuals. Failure to consider the needs of patients for privacy (the 'torture' o f degradation) is an aspect o f depersonalisation. W h e n screens round the bed are ignored and when the patient is handled or uncovered without permission or explanation then the patient is being treated as an object. All staffshould be educated to respect each patient's privacy. Curtains round the bed should mean 'do not enter unless absolutely necessary'. Wherever possible the patient should be provided with nightclothes. If standard hospital nightclothes cannot be used due to the presence o f lines or drains, they can be modified by the addition o f ties and vents to allow access when required but at the same time
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keep the patient covered (Ward and Hurst 1991). If nurses know the patient as a person individualised care is far easier. This may be achieved to some extent by preoperative visits and by sohciting information about the patient from visitors. This helps hospital staff to get to know the patient. This is necessary for personalised care but is not sufficient. Personalised care is a two-way process and patients need help to get to know hospital staff. This is facilitated by ensuring continuity of care with the same few staff caring for the patient, allowing nurses and patients to get to know each other (Albarran 1991, Heath 1989, Johnson & Sexton 1990). It is important to remember that patients may not have perfect recall o f the hospital staff they encounter and staff should reintroduce themselves whenever they meet a patient (Stanley 1991). It is also important to maximise patients' autonomy. It is often necessary to carry out procedures which patients may find unpleasant or to deny requests. Patients should always receive a thorough explanation of the reasons for this. It is not sufficient simply to inform the patient that 'treatment X is necessary', the reasons for this should be described, and whenever possible, permission of the patient should be sought. The goal is to assist patients to become active participants in care rather than passive recipients. This approach has been found to reduce feehngs o f powerlessness (Wright 1985) and wherever possible the patient should be involved in decisionmaking and take an active role in treatment decisions (Bolin 1974). For complex medical interventions this may not be feasible, but for more basic care there is no reason why a patient should not be consulted, for example, 'do you want a wash now?' All too often patients are simply told; T i n going to wash you now'. The general aim should be to modify the routine to meet each patient's needs rather than adjust the patient's care to the routine. A final, and seldom considered aspect of autonomy is how patients should be addressed. Patients are frequently addressed by their first name or by a family nickname, and it has been suggested that this is appreciated since it makes the I T U seem less clinical (Smith 1987). However, this should not be assumed, and older patients may prefer to be addressed more formally as Mr, Mrs, etc. Ideally the patient or visitor should be consulted and permission sought before using any first name or nickname.
FACILITATING MEANINGFUL PERCEPTION The aims of interventions in this area are two-
226 Intensiveand CriticalCare Nursing fold, firstly to reduce meaningless sensory inputs, and secondly to increase meaningful inputs.
Sight As far as possible sights which have no meaning or may cause distress should be reduced. For example, equipment should, if possible, not be placed in view o f the patient and screens should be used when carrying out procedures on other patients. Additionally, meaningful visual inputs should be maximised, where appropriate, by the use o f television, magazines and photos provided by visitors. The possibility of making the I T U more visually stimulating should be considered, for example, pictures could be placed on the walls (remembering that patients' perceptions may be distorted). W h e n redecoration takes place this could involve a more imaginative colour scheme than 'standard hospital white'. It is of course, necessary to ensure that patients can see. If the patient normally wears spectacles these could be utilised, and where possible the patient should not be nursed flat but should be assisted to sit up in bed or a chair. This will reduce the tedium of staring at a visually monotonous ceiling (Bassett 1993).
Hearing Meaningless noise can be reduced by moving equipment from patients' immediate environment, turning off equipment when not in use (e.g. suction), setting alarm limits carefully, muting non-essential alarms, answering the telephone promptly and reducing the volume of telephone rings at night (Green 1992, Johnson & Sexton 1990, Snyder-Halpern 1985). Even when these measures are applied a limited amount o f noise from equipment may be inevitable, I T U care requires the use of equipment with alarms and other noise. What is not inevitable and can always be reduced is much o f the human generated noise. For example, conversations can be carried out quietly (particularly at night), equipment can be carried rather than dragged, and wherever possible noisy activities should be carried out during the day rather than at night. Reduction o f meaningless noise should not be taken to mean total silence. This would be equally disorientating. The 'hole' left by the reduction on meaningless noise should be filled by meaningful stimulation. An important measure here is staff conversation with patients (as discussed above). However, maintaining consistent conversation to an unresponsive patient may be very difficult and TV and radio can be very helpful if properly used. Ideally these should be under the control of patients by
use of remote devices. W h e n these are not available or patients cannot use them it is important to consult patients or visitors o f unresponsive patients about the choice of station. Headphones may be useful if the alternative would be several radio stations competing with each other and adding to the background noise. A 'Walkman' may be particularly helpful. These are cheap, block out extraneous noise and can be used to provide orientating and stimulating information, for example, favourite radio programmes, talking books, music and home produced recordings o f family conversations and messages (Green 1992). It is important that these devices are used with thought otherwise patients may receive unwanted noise (Bassett 1993). Furthermore, these should be used in addition to, not instead of, communication from staff. Simply putting earphones on a patient for 12 h per day is not a solution to the problem o f isolation. Finally, many older I T U patients may have hearing deficits therefore their hearing aids should be utilised, and if the patient has a 'good' ear speech should be directed to this side.
Taste This will be difficult to stimulate in patients who are unable to receive oral fluids. For these patients the main aim is comfort rather than stimulation, and oral toilet may be required hourly to maintain moistness of the oral mucosa (Maurer 1977). Artificial saliva may help to achieve this (Levine et al 1987). Patients who can receive oral fluids may appreciate 'sharp' acid tastes (e.g. lemon or lime) and iced water or slivers of ice may be preferred over tap water (Heath 1989). These or flavoured mouth care sticks (e.g. lemon and glycerine) may be useful for patients who are allowed 'nil by mouth'. It has been suggested that glycerine may actually produce dryness of the mouth. There is little convincing evidence for this, but it is known that frequent use o f acid solutions may cause erosion o f tooth enamel, so these should be used with care in dentate patients (Roth & Creason 1986).
Touch It was noted earlier that'touch is a valuable means of communication but may. be underused. Visitors often take their cue from nurses with regard to talking to the patient and patient contact. If visitors see that staffdo not touch the patient except for procedures they are likely to emulate this, and conversely if visitors see nurses using touch to communicate with patients they are more likely to maintain physi-
Preventing the ITU syndrome or how not to torture an ITU patient! Part 2
cal contact which may benefit both the patient and the visitor. Like other methods o f c o m m u nication touch is not a one-way process. Touch and movement are also used by patients to explore their environment. Monitoring and infusion lines should be attached securely and 'slack' provided so that the patient can move without risk of disrupting them. Finally, consideration should be given to more general stimulation. The assistance of physiotherapists or occupational therapists may be extremely helpful in providing both physical and mental stimulation. Board games may be useful for some patients, newspapers or books should be considered and in rare cases 'trips' away from the I T U may be an option. This is obviously not feasible for acutely ill patients but may be possible for longer-term patients whose condition is stable. Even an artificially ventilated patient can be taken away from the I T U with a portable ventilator or hand ventilation.
REDUCTION OF DEBILITY A N D EXHAUSTION Most I T U patients are at risk from pain or discomfort, which if unrelieved may contribute to exhaustion and debility. The main cause of these is usually the illness or operation which has resulted in I T U admission, but in addition many of the interventions which are a normal part of I T U care may result in distress and discomfort, and the patient may have pre-existing problems which also cause pain or discomfort. It is important that each I T U has a formal means of assessing pain, that this is utilised regularly and that if it is found that a patient is experiencing pain this information is acted on. However, even when formal assessment tools are used it may be difficult to assess the pain of I T U patients. Patients may be unresponsive or sedated and unable to communicate pain or discomfort. In these circumstances the nurse may be able to assess this by the recognition of physical expressions of pain and distress, e.g. grimacing, sweating, restlessness and increases in heart rate or blood pressure (Clark 1989). It should be remembered that these are not always reliable, and as a general rule pain should be assumed to be present unless the opposite is confirmed (Ashbury 1985). To treat pain successfully it is helpful to have some knowledge of pain and pain-relieving drugs. Nurses do not necessarily need to be familiar with the detailed theories of the physiology o f pain, though this would be ideal (for information in this area see, for example, Lonsdale 1991, Puntillo 1988, Wall 1978, Wallace 1992), but all nurses should have a
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basic knowledge of pain mechanisms and pain relief methods (see Bullingham 1985, Freeman & Hopkinson 1988, Glynn 1992, Hopkinson & Freeman 1988, Russell 1992). In most cases pain relief will require drugs given intramuscularly or more usually intravenously. In this latter case patient controlled analgesia (PCA) may play a useful role, particularly in high dependency areas (Clark 1992, Jenkins 1992, Smith & R e n n i e 1991). Not only does this deliver effective pain relief in the majority of patients, but it also gives them some control and autonomy It is important to remember that pain relief does not necessarily require pharmacological intervention. Reassurance may be helpful and drugs are not a substitute for sympathetic handling or for identification o f the causes o f distress (Bion 1988). Alternative methods o f pain relief such as relaxation, massage, pressure, heat, cold, distraction (e.g. music, humour) and transcutaneous nerve stimulation (TENS) may also be useful (McCaffery 1990, Puntillo 1990). It is also important to remember that pain and discomfort may have sources other than the site of any operation. Pain may come from preexisting conditions and patients may suffer discomfort from a variety o f sources, for example immobility, uncomfortable positioning, restraint, constipation and endotracheal suction. These may be alleviated by skilled nursing care such as careful positioning and suction technique (Johnson & Sexton 1990). It is these little details which will make the patient feel cared for and cared about. Much I T U care is invisible to the patient, e.g. monitoring, drug titration, laboratory tests and so on. The I T U care that is o f most immediate concern to each patient is the care that he or she directly experiences, and reduction o f discomfort is a direct expression o f care which may be o f far greater importance to the patient than its apparent contribution to patient recovery would indicate.
Sleep Sleep is essential to human well-being though
its specific functions are still far from clear (Finlay 1991). The assessment of sleep is often very difficult. Most I T U nurses will be familiar with patients who have apparently slept all night but claim not to have slept. As with pain, the simple rule should be - believe the patient. If he/she claims not to have slept then he/she has not slept sufficiently. Nurses should aim to provide the conditions which enhance the ability to sleep. This entails ensuring that light and noise are reduced, that the patient is comfortable, warm and pain-free. It is particularly important to treat pain at night when it may
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Intensiveand Critical Care Nursing disturb sleep and seem worse as a result o f the reduction o f outside distractions which occur during the day. There are times in most ITUs (e.g. when an admission occurs at night) when it is not possible to reduce light and noise to very low levels. In these circumstances patients could be supplied with eye shades or ear plugs which may reduce external distractions sufficiently to allow sleep. Equally important in encouraging sleep is the planning o f care activities (Stanton 1991). Sleep is reported to occur in 90 min cycles. ' R o u t i n e ' care should be organised to allow gaps o f at least 90 min between interventions and the needs o f each patient should be assessed (Dracup 1988, Stanley 1991). Consideration should be given to omitting non-essential care (e.g. does the patient really need 2-hourly m o u t h care?) and wherever possible essential care should be timed so that all interventions are carried out at the same time to maximise the amount o f time for sleep between interventions (Closs 1988, Lazarus & Hagens 1968, Schroeder 1971). If appropriate, sedative drugs should be administered but these should be used as an addition not as an alternative to encouraging normal sleep. Many I T U patients have a disrupted sleepwake cycle. T h e y may be awake at night and sleep during the day. Nurses should aim to correct this by waking patients if they sleep in the day and should, at the same time, ensure that sleep is assisted at night. Czeizler et al (1986) have shown that exposure to bright light can reset the human circadian pacemaker by about 6 hours. N o record has been found that this intervention has been utilised therapeutically but this could be attempted in patients with disturbed sleep patterns, for example by use o f a bright portable lamp during the day (ensuring that this is not directed into the patient's eyes) and ensuring very low light levels at night. The keys to reducing the causative factors o f the I T U syndrome are understanding and empathy. Understanding will deal with the general risk factors. Nursing staffshould think themselves into the situation o f each patient and ask themselves 'what would my needs be ifI was in this position?' (recognising that individual needs may differ). Empathic care will help nurses to meet individual needs and deal with the specific problems and difficulties which each patient may have. Neither o f these require technical skills, they may be described as basic caring qualities and activities, and any nurse, regardless o f his/her technical knowledge should be able to meet these basic requirements.
USING AUDIT TO ASSESS THE ITU ENVIRONMENT Methods o f reducing the incidence o f the I T U syndrome have been described. In order to ensure that these are put into practice it may be helpful to conduct a 'unit audit' of staff awareness, practices and equipment availability. Some of these factors need only be audited once since they will affect every patient, others will require assessment for every patient. Given the constraints which operate it is unrealistic to suggest that walls are knocked through to provide windows, that new, quieter equipment is purchased or other such changes. Thus, the emphasis here will be on low cost or cost free modifications o f practice. The audit consists o f a series o f questions (Box). If the answer to any of these is no, then this highlights an area where action should be considered. If the answer is believed to be yes then in each case, consideration should be given to how this is assessed and monitored.
CONCLUSION Any patient who is in an I T U for any length o f time is at risk o f developing the I T U syndrome, but with many patients it is possible (and we should always try) to prevent the development o f the syndrome by the use of basic nursing skills. The essentials are firstly, awareness that the syndrome should be taken seriously; secondly, identification o f potential stressors; and thirdly, planning o f specific strategies to reduce or remove these stressors. These are not 'extras' which I T U patients may receive if nurses are not too busy. It is the basic right o f all I T U patients to be treated with humanity, to have their suffering minimised, to have their autonomy maximised and to have their individual needs met, and it is within the ability of every skilled nurse to meet these needs. Even the most perfect physical care is not sufficient alone for I T U care to be of a high standard. However technically skilled nurses are in providing physical care, I T U patients need and deserve more than this. If all I T U staff do is to provide physical care then many I T U nurses could be replaced by untrained staff and by machines. The role o f I T U nurses is to give care to people, not to sets o f deranged physiological parameters and failed organ systems; and people need the 'human touch'. In describing the possible causes of the syndrome as analogues to psychological torture no criticism o f I T U staff is intended. The aim is to emphasise the potential seriousness o f the
Preventing the ITU s y n d r o m e o r h o w not to t o r t u r e an ITU patient! Part 2
229
Education and staff awareness • Are all staff involved in patient care aware of the causes, effects and prevention of the ITU syndrome? • Do orientation programmes for new staff include information on the area? Information provision to patients and visitors • Do pre-admission visits take place where possible? Are patients and visitors provided with adequate information? Are the personal details of the patient recorded. Are they available to all relevant ITU staff?. • Are patients familiarised with their surroundings and carets? Is the language used appropriate? Is the understanding of the patient assessed? How? • Does the care plan assist planning to meet needs for information and emotional support? • Are patients regularly provided with information about their condition and about plans for care? Orientation and stimulation • Are clocks and calendars available? Are they visible to the patient? • Are day and night differentiated, e.g. by reducing light and noise at night? • Are visitors to longer term patients requested to provide photos and personal possessions? Are these and 'get well cards' displayed where the patient can see them? • Are walls and ceillings bare? Could posters or paintings be obtained? • Are the needs of the patient for mental stimulation met? e.g. newspaper, 'Walkman', games, 'occupational therapy'? • Is the patient consulted about -IV and radio programmes? If this is not possible are the patient's likely tastes considered? Could these be placed under the control of the patient? Are headphones available for "IV and radio? • Are other senses stimulated wherever possible, e.g. flavoured mouth care solutions and drinks? Is nutrition considered early in the patients stay? • Is the advice of all relevant hospital personnel sought, e.g. occupational therapist, physiotherapist, dietician? Communication • Do all staff talk to the patient? Does this include 'conversation' and 'passing the time of day' or simply involve activities/interventions? • Is the ability of the patients to communicate and receive communication assessed?, e.g. hearing, sight, touch, writing. Are prostheses always utilised? • Are communication aids available, e.g. alphabet or picture boards? Are these regularly used? • Are communication aids available for non-English speakers, e.g. picture board, bilingual word sheets? Does the unit have a list of local translators, and the hours that these are available? • Are tracheostomy speaking tubes available, and used where possible? • Are staff aware of, and do they use, non-verbal methods of communication and reassurance, e.g. touch, eye contact? • Do visitors receive regular and comprehensive information? Is this recorded? Are visitors encouraged to interact with the patient and to assist with care? Privacy • Are curtains always used? Are they perceived as a barrier by staff or are sometimes these ignored? Could nightdresses or pyjamas (modified if necessary) be worn by patients? • Is the patient consulted about planned care, washing, movement, etc? Are the patient's options respected where possible? Is the patient given a choice about radio and -I-V? Could these be placed under the control of the patient? Personalised care • Do all staff introduce themselves whenever they interact with the patients? • Is the patient addressed by his/her preferred name? • Is there continuity of care, i.e. is the number of nurses caring for the patient limited? • Is the orientation of the patient regularly assessed? If problems are detected are these acted on? • Does the care plan/nursing process assist the planning and assessment of individual needs, personal details, etc? Pain • Is this regularly assessed? Is the assessment tool reliable? Are assessments acted on? Is PCA an option? Are alternative means of pain relief available and used e.g. heat, cold, TENS, massage, distraction? Sleep • Is sleep assessed? Is the routine given priority or are nursing interventions individually assessed and planned to minimise interruptions to sleep? Could pressure relief mattresses be obtained so that the need for interventions is reduced? Should sedation be considered? • Is it possible to dim lights at night? Are these dimmed? Could eye shades be used to assist sleep? • Can noisy equipment be removed from the vicinity of the bed areas? Can extraneous noise be reduced e.g. by closing doors to noisy areas? Can the volume of any of these (e.g. 'phones, alarms) be reduced without affecting patient safety? V~hen equipment is purchased is noise considered? Could ear plugs be used to encourage sleep? Mobility • Do staff facilitate patient movement, e.g. by ensuring that 'lines' are fixed securely and by providing 'slack' in these? Are passive movements carried out? Is patient comfort considered when the patient is positioned? • Are longer term patients 'mobilised', e.g. by sitting out of bed, by trips away from the unit? This may require portable monitoring and ventilation - are these available? Is it possible to move the patient's bed in order to vary the sights seen?
230
Intensive and Critical Care Nursing
s y n d r o m e a n d to e n c o u r a g e staff to take a c t i o n to r e d u c e its i n c i d e n c e . A l t h o u g h t h e e m p h a s i s in this p a p e r is o n adults i n I T U s
a recent report by Hughes
(1994) suggests that c h i l d r e n m a y also b e at risk of developing the syndrome, and many ward a n d h i g h d e p e n d e n c y u n i t ( H D U ) p a t i e n t s also e x p e r i e n c e t h e stressors discussed (albeit at a l o w e r level). T h o u g h t h e s e p a t i e n t s m a y n o t b e at risk o f d e v e l o p i n g t h e I T U s y n d r o m e t h e y h a v e e v e r y r i g h t to e x p e c t to b e able to sleep, to h a v e t h e i r p a i n r e l i e v e d , to r e c e i v e a d e q u a t e information comments
and
communication.
made
Thus
the
are r e l e v a n t to all h o s p i t a l
areas, a n d m a y b e m o r e so in t h e f u t u r e since t h e p r o p o r t i o n o f v e r y ill p a t i e n t s in h o s p i t a l is likely t o increase. It is h o p e d that as w e l l as e n c o u r a g i n g I T U nurses to act this p a p e r will also
encourage
develop
HDU
strategies
to
and
ward
reduce
the
nurses
to
stressors
discussed herein.
REFERENCES Adams M, Hanson R, Norkool D, Beaulieu A, Bellville E, Morss K 1978 The confused patient: psychological responses to critical care units. American Journal of Nursing 78 (9): 1504-1512 Adomat 1K, Killing@orth A 1994 Care of the critically ill patient: the impact of stress on the use of touch in intensive therapy units. Journal of Advanced Nursing 19 (5): 912-922 Albarran JW 1991 A review of communication methods with ventilated patients and those with tracheostomies in an intensive care environment. Intensive Care Nursing 7 (3): 179-186 Amnesty International 1973 Report on torture. Duckworth, London Amnesty International Medical Commission 1984 Doctors and torture. Bellew, London, pp 61-71 Ashbury AJ 1985 Patients memories and reactions to intensive care. Care of the Critically Ill I (2): 12-13 Ashworth P 1979 Sensory deprivation - 2. The acutely ill. Nursing Times 75 (7): 290-294 Ashworth P 1980 Care to communicate. 1KCN, London Ashworth P 1984 Communicating in an intensive care unit. In: Fanlkner A (ed) Communication. Churchill Livingstone, Edinburgh, pp 94-112 Ashworth P 1987 The needs of the critically ill patient. Intensive Care Nursing 3 (4): 182-190 Baker CF 1984 Sensory overload and noise in the ICU: sources of environmental stress. Critical Care Quarterly 6 (March): 66-69 Baker CF 1992 Discomfort to environmental noise: Heart rate responses of SICU patients. Critical Care Nursing Quarterly 15 (2): 75-90 Barrie-Shevlin P 1987 Monitoring sensory balance for the critically ill patient. Nursing 3 (16): 597--601 Bassett CC 1993 Communication with the critically ill. Care of the Critically Ill 9 (5): 216-219 Bentley S, Murphy F, Dudley H 1977 Perceived noise in surgical wards and an intensive care area: an objective analysis. British Medical Journal 10 December: 1503-1508 Benzer H, Mutz N, Pauser G 1983 Psychological sequelae of intensive care. International Anaesthesiology Clinics 21 (2): 169-180 Bergbom-Engherg I 1991 Giving up and withdrawal by
ventilator treated patients: nurses experience. Intensive Care Nursing 7 (4): 200-205 Bergbom-Engherg I, Haljamae H 1989 Assessment of patient's experience of discomfort during respiratory therapy. Critical Care Medicine 17 (1): 1068-1072 Bergbom-Engberg I, Haljamae H 1993 The communication process with ventilator patients in the ICU as perceived by the nursing staff. Intensive and Critical Care Nursing 9 (I): 40-47 Biley FC, Mlllar BJ, Wilson AM 1993 Issues in intensive care visiting. Intensive and Critical Care Nursing 9 (2): 75-81 Bion JF 1988 Sedation and analgesia in the Intensive Care Unit. Hospital Update March: 1272-1286 Bolin HB 1974 Sensory deprivation: an overview. Nursing Forum XIII (3): 240-258 Borsig A, Steinacker I 1982 Communication with patients in the intensive care unit. Nursing Times Supplement 78 (12): 1-11 Briggs D 1991 Preventing ICU psychosis. Nursing Times 87 (19): 30-31 Bullingham I ~ S 1985 Optimum management of postoperative pain. Drags 29 (4): 376-386 Campbell IT, Minors DS, Waterhouse JM 1986 Are circadian rhythms important in intensive care? Intensive Care Nursing 1 (3): 144-150 Chen Y-c 1990 Psychological and social support systems in intensive and critical care. Intensive Care Nursing 6 (2): 59-66 Chew SL 1986 Psychological reactions of intensive care patients. Care of the Critically Ill 2 (2): 62-65 Chilver WLC 1978 On being a patient in an intensive therapy unit. Nursing Mirror 146 (14): 33-35 Clark EC 1989 Pain relief in intensive care. Care of the Critically Ill 5 (3): 94-95 Clark EC 1992 Postoperative patient controlled analgesia. Surgical Nurse 5 (3): 20-21 Clifford C 1986 Patients, relatives and nurses in a technological environment. Intensive Care Nursing 2 (2): 67-72 ClossJ 1988 Patients sleep-wake rhythms in hospital. Part 2. Nursing Times 84 (2): 54-55 Coles EM 1982 Clinical psychology: an introduction. Roufledge and Kegan Paul, London, pp 205-228 Czeizler CA, Allan JS, Strogatz SH et al 1986 Bright light resets the human circadian pacemaker independent of the timing of the sleep-wake cycle. Science 233 (4764): 667-671 Davison K 1989 Adverse psychiatric reactions to drugs used in the ITU. Care of the Critically Ill 5 (1): 9-12 Dement WC 1969 Studies on the function of rapid eye movement (paradoxical) sleep in human subjects. In: Pribram KH (ed) Brain and behaviour 1. Mood, states and mind. Penguin, Harmon&worth, pp 138-181 Dement WC, Henry P, Cohen H, FergusonJ 1969 Studies of the effects of sleep deprivation in humans and animals. In: Pribram KH (ed) Brain and behaviour 1. Mood, states and mind. Penguin, Harmondsworth, pp. 115-129 Derham C 1991 An evaluation of the pre-operative information given by intensive care nurses. Intensive Care Nursing 7 (2): 80-85 Dootson S 1990 Sensory imbalance and sleep loss. Nursing Times 86 (35): 26-29 Dracup K 1988 Are critical care units hazardous to health? Applied Nursing Research 1 (1): 14-21 DunkelJ, Eisendrath S 1983 Families in the intensive care unit: their effect on staff. Heart and Lung 12 (3): 258-261 Dyer I 1991 Meeting the needs of visitors - a practical approach. Intensive Care Nursing 7 (3): 135-147 Dyer I 1995 Preventing the ITU syndrome or how not to torture an ITU patient. Part 1. Intensive and Critical Care Nursing 11 (2): 130-139
Preventing the ITU syndrome or how not to torture an ITU patient! Part 2
Egerton N, KayJH 1964 Psychological disturbances associated with open heart surgery. British Journal of Psychiatry 110 (May): 433-439 Estabrooks CA 1989 Touch: a nursing strategy in the intensive care unit. Heart and Lung 18 (4): 392-401 Finlay G 1991 Sleep and intensive care. Intensive Care Nursing 7 (1): 61-68 Fisher ME, Moxham PA 1984 ICU Syndrome.Critical Care Nurse May/June: 39-44 Fitter M 1986 The Impact of New Technology on Workers and Patients in the Health Services: Physical and Psychological Stress. Consolidated Report, European Foundation for the Improvement of Living and Working Conditions, Dublin FreemanJW, Hopkinson Pal3 1988 Therapeutic progress in intensive care, sedation and analgesia Part II - Drug selection. Journal of Clinical Pharmacy and Therapeutics 13 (1): 41-50 Gaglione KM 1984 Assessing and intervening with families of C C U patients. Nursing Clinics of North America 19 (3): 427-432 Genvert G, Theil J, Levy-Gombek E, Topf-Olstein B, Drusin L 1979 Isolation information booklet stimulates dialog, allays fears. Hospitals (US) 53 (3): 72-75 Glynn C 1992 Pain control in intensive care nursing. British Journal of Intensive Care 2 (4): 172-177 Green A 1992 How nurses can ensure that the sounds patients hear have a positive rather than a negative effect upon recovery and quality of life. Intensive and Critical Care Nursing 8 (4): 245-248 Cries ML, FemslerJ 1988 Patient perceptions of the mechanical ventilation experience. Focus on Critical Care 15 (2): 52-59 Hansell H N 1984 The behavioural effects of noise on man: The patient with 'intensive care unit psychosis'. Heart and Lung 13 (1): 59-65 HeathJV 1989 What the patients say. Intensive Care Nursing 5 (3): 101-108 Heater BS 1985 Nursing responsibilities in changing visiting restrictions in the intensive care unit. Heart and Lung 14 (2): 181-186 HenryJA 199i Poisoning by psychoactive drugs. Care of the Critically Ill 7 (3): 100-105 Hill CF 1993 Is massage beneficial to critically ill patients in intensive care units? A critical review. Intensive and Critical Care Nursing 9 (2): 116-121 Hopklnsoin R_B 1994 How to plan an ICU. Care of the Critically II1 10 (2): 57--62 Hopklnsoni RB, FreemanJW 1988 Therapeutic progress in intensive care, sedation and analgesia Part I Principles. Journal of Clinical Pharmacy and Therapeutics 13 (1): 33-40 Hudak CM, Galo BM, BenzJ 1990 Critical care nursing, 5th edn. Lippincott, Philadelphia, p 29 HughesJ 1982 Helplessness and frustration: The relatives dilemma. Nursing Times 78 (23): 960-961 Hughes J 1994 Hallucinations following cardiac surgery in a paediatric intensive care unit. Intensive and Critical Care Nursing 10 (3): 209-211 Ingham A 1989 A review of the literature relating to touch its use in intensive care. Intensive Care Nursing 5 (2): 65-75 Jenkins BJ 1992 Patient controlled infusion of drags in intensive and high dependency care. Intensive Care Britain, Greycoat, London, pp 62-65 Johnson MM, Sexton DE 1990 Distress during mechanical ventilation: patients perceptions. Critical Care Nurse 10 (7): 48-57 Jones E 1986 Communication aids for the critically ill. Care of the Critically Ill 2 (3): 117-122 -
2:} I
Jones J, Hoggart B, Withey J, Donaghue K, Ellis BW 1979 What the patients say: a study of reactions to an intensive care unit. Intensive Care Medicine 5 (2): 89-92 Keep PJ, James J, Inman M 1980 Windows in the intensive therapy unit. Anaesthesia 35 (3): 257-262 Komfeld DS 1977 Psychiatric considerations in the intensive care unit. In: Kinney JM, Bendixon HH, Powers SR (eds) Manual of surgical intensive care. W.B. Saunders, Philadelphia, pp 177-190 Lazarus H R , HagensJH 1968 Prevention of psychosis following open heart surgery. American Journal of Psychiatry 124 (9): 1190-1195 Levine MJ, Aguirre A, Hutton MN, Tubak LA 1987 Artificial salivas: present and future. Journal of Dental Research 66 (February): 693-698 Lonsdale M 1991 Pain relief in the intensive care unit. Part 1. Intensive Therapy and Clinical Monitoring 12 (1): 10-13 MaurerJ 1977 Providing optimal oral health. Nursing Clinics of North America 12 (4): 671-685 McCaffery M 1990 Nursing approaches to nonpharmacological pain control. International Journal of Nursing Studies 27 (1): 1-5 McCorkle R 1974 Effects of touch on seriously ill patients. Nursing Research 23 (2): 125-132 McGonnigal KS 1986 The importance of sleep and the sensory environment to critically ill patients. Intensive Care Nursing 2 (2): 73-83 McKegney FP 1966 The intensive care syndrome. Connecticut Medicine 30: 633. Quoted in Kornfeld 1977, op cit MackellaigJM 1987 A study of the psychological effects of intensive care with particular reference to patients in isolation. Intensive Care Nursing 2 (4): 176-185 MackellaigJM 1990 A review of the psychological effects of intensive care on the isolated patient and his family. Care of the Critically Ill 6 (3): 100-102 Mackinnon C 1987 The nursing care of patients receiving paralysing agents. Intensive Care Nursing 2(3): 135-138 Norrie P 1992 The inteisve care experience. Nursing Times 88 (46): 40-42 North N 1988 Psychosocial effects of coronary artery bypass surgery. Nursing Times 84 (I): 26-29 Pennock BE, Cranshaw L, Maher T, Price T, Kaplan PD 1994 Distressful events in the ICU as perceived by patients recovering from coronary artery bypass surgery. Heart and Lung 23 (4): 323-327 Puntillo KA 1988 The phenomenon of pain and critical care nursing. Heart and Lung 17 (3): 262-271 Puntillo KA 1990 Pain experience of intensive care unit patients. Heart and Lung 19 (5): 526-533 Robinson JS 1974 The psychological effects of intensive care. Unpublished paper given at the First World Congress of Intensive Care, London Roth PT, Creason NS 1986 Nurse administered oral hygiene: is there a scientific basis? Journal of Advanced Nursing 11 (3): 323-331 Russell K 1992 Pharmacology of pain. Surgical Nurse 5 (6): 18-22 Schefl]in AW, Opton EM 1978 The mind manipulators. Paddington, New York Schoenhofer SO 1989 Affectional touch in critical care nursing: a descriptive study. Heart and Lung 18 (2): 146-154 Schroeder HG 1971 Psycho-reactive problems of intensive care. Anaesthesia 26 (1): 28-35 Seers K, Goodman C 1987 Perceptions of pain. Nursing Times 83 (48): 37-39 Shovelton DS 1979 Reflections on an intensive therapy unit. British Medical Journal Part 1:737-738
232
Intensiveand Critical Care Nursing Smith C 1987 In need of intensive care - a personal perspective. Intensive Care Nursing 2 (3): 116-122 Smith KM, Rennie MJ 1991 Pain control in critical care. A rote for patient controlled analgesia? British Journal oflntensive Care I (1): 11-15 Snyder-Haipem R 1985 The effect of critical care unit noise on patient sleep cycles. Critical Care Quarterly 7 (4): 41-51 Stanley M 1991 Ensuring a safe ICU stay for your confused elderly patient. Dimensions of Critical Care Nursing 10 (2): 62-67 Stanton DJ 1991 The psychological impact of intensive therapy: the role of nurses. Intensive Care Nursing 7 (4): 230-235 Stratton H 1987 Keeping the patient in touch with reality. Care of the Critically Ill 3 (1): 22 Stratton H 1988 Its all in the mind. Care of the Critically Ill 4 (3): 23-25 Teske K, Dent RL, Cleeland CS 1983 Relationships between nurse's observations and patient's self reports of pain. Pain 16 (3): 289-296 TopfM, Davis JE 1993 Critical care unit noise and rapid eye movement (REM) sleep. Heart and Lung 22 (3): 252-258 Tucker LA 1993 Post-pump delerium. Intensive and Critical Care Nursing 9 (4): 269-273 Wall PD 1978 The gate control theory of pain mechanisms. Brain 101 (1): 1-18 Wallace KG 1992 The pathophysiology of pain. Critical Care Nursing Quarterly 15 (2): 1-13
Ward L, Hurst K 1991 Modesty in ICUs. Nursing Times 87 (28): 40-41 Weber RJ, Oszko MA, Bolander BJ, Grysiak DL 1985 The intensive care unit syndrome: causes, treatment and prevention. Drug Intelligence and Clinical Pharmacy 19 (1): 13-19 Weiss SJ 1990 Effects of differential touch on nervous system arousal of patients recovering from cardiac disease. Heart and Lung 19 (5): 474-480 Wilson V S 1987 Identification ofstressors related to patients psychologic responses to the surgical intensive care unit. Heart and Lung 16 (3): 267-273 Winn D 1983 The manipulated mind. Brainwashing, conditioning and indoctrination. Octagon Press, London Wood AM 1993 A review ofhterature relating to sleep in hospital with emphasis on the sleep of the ICU patient. Intensive and Critical Care Nursing 9 (2): 129-136 Wright JH 1985 Encouraging hope in the ventilator patient. Journal of Practical Nursing 35 (3): 37-39 Zainal G 1994 Nutrition in critically ill people. Intensive and Critical Care Nursing 10 (3): 165-170 ZubekJP, Bayer L, Mistein S, ShepardJM 1969 Behavioral and physiological changes during prolonged immobilisation plus perceptual deprivation. Journal of Abnormal Psychology 74 (April): 230-236 ZubekJP 1973 Behavioral and physiological effects of prolonged sensory and perceptual deprivation: a review. In: Rasmussen JE (ed) Man in isolation and confinement. Aldine, Chicago, pp 9-83