What are critical care
nurses’ perceptions of the
long-term mechanically
ventilated patient in the ICU
setting?
Lisa Mace
...
Background
 Working in critical care is challenging and
demanding
 Majority of patients recovery is quick
 Small but in...
The ‘Unpopular’ or ‘difficult’ patient
phenomenon
Concept of ‘unpopular’ or ‘difficult’ patient is not new to nursing
Appl...
Consideration of the
phenomenon in the ICU
settingThe demanding nature of care
Overwhelming work load (Lally & Pearce, 199...
Aims of the Study
To explore ICU nurses’ experiences and
attitudes of caring for long-term critically ill
patients.
The pu...
Methodology
Qualitative design used to unravel ICU
nurses perceptions
1. Purposive sample
2. 23 critical care nurse recrui...
Findings
Three Main Themes Emerged
 Clinical challenges
 Rewarding aspects
 Organisational challenges
Themes and Categories
Core Theme -
Clinical Challenges
Core Theme -
Rewarding Aspects
Core Theme -
Organisational
Challeng...
Clinical challenges of caring for the
long-term intensive care patient
Physical challenges
Physically demanding to care fo...
Clinical challenges of caring for the
long-term intensive care patient
Physical challenges
Participants stated how, on occ...
Clinical challenges of caring for the long-term
intensive care patient
Physical challenges
Maintaining constant state of h...
Clinical challenges of caring for the
long-term intensive care patient
However…
Maintaining constant patient surveillance ...
Clinical challenges of caring for the long-term
intensive care patient
Physical challenges - physical characteristics
coul...
Clinical challenges of caring for the long-term
intensive care patient
Psychological Challenges:
Supporting the patient em...
Clinical challenges of caring for the long-term
intensive care patient
Psychological Challenges:
Trying to keep long-term ...
Clinical challenges of caring for the
long-term intensive care patient
Psychological Challenges:
Supporting the patient em...
Clinical challenges of caring for the
long-term intensive care patient
Psychological Challenges:
Facing manipulative and i...
Clinical challenges of caring for the
long-term intensive care patient
Psychological Challenges:
Manipulative and intimida...
Clinical challenges of caring for the
long-term intensive care patient
Dealing with difficult behaviour not
isolated to pa...
Clinical challenges of caring for the
long-term intensive care patient
Long-term ICU patients not seen as part
of ‘typical...
Core Theme: rewarding aspects of
caring for long-term patients in ICU
Connecting and forming bonds
‘…it feels so good to l...
Rewarding aspects of caring
for long-term patients in ICU
Connecting and forming bonds
It just depends on their personalit...
Rewarding aspects of caring
for long-term patients in ICU
Connecting and forming bonds
Young patients
‘…she [young patient...
Rewarding aspects of caring for
long-term patients in ICU
Feeling you have made a
difference
‘… sitting them out in the ch...
Rewarding aspects of caring for
long-term patients in ICU
Striking the balance between
technology and caring
‘it is quite ...
Staff allocation – finding the ‘right
person for the right patient’ (F1, S)
‘the problem I find, is often that with the lo...
Organisational challenges
associated with long-term ICU
patients
Staff allocation –
safest option for all patients
however...
Organisational challenges
associated with long-term ICU
patients
Supporting and protecting the
nursing team
Senior nurses ...
Organisational challenges
associated with long-term ICU
patients
Supporting and protecting the nursing team
Likewise, juni...
Organisational challenges
associated with long-term ICU
patients
Supporting and protecting the nursing
team
‘…if I have be...
Implications and
Recommendations
Providing adequate support:
 Regular breaks
 Senior staff visibly on hand
 De-briefing...
Conclusions
This small study identified that the idea of the unpopular patient
still pervades and exists in a modern ICU s...
Questions?
Lisa Mace
lisa.mace@uhbristol.nhs.uk
MSc, BSc (Hons), RGN
Cardiac Nurse Specialist
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  • For most recovery is quick and straightforward, but for some recovery may be complicated and prolonged by multiple organ failure or ventilator dependency (nierman, 2002; Stohr et al, 2002)
  • Attention to the concept has been sporadic over the years. In recent years it has been the focus of only a small no of studies, however it has been the feature of several editorial and non research papers suggesting it remains topical and relevant to current nursing practice (Mac Donald 2003)
    Common thread from early studies was description personality traits and behaviours of unpop or difficult patients. Eg aggressive violent, demanding labelled as difficult therefore unpopular with nurses.
    Simplistic view, more recent work explore phenomenon from range perspectives utilities variety research methods
  • Others factors which the literature has identified as coming into play in nurses preferences for caring for certain types of patients include – nurses in some cases viewing patients as less deserving of treatment.
    Viewed less favourably.
  • For instance dealing with the secondary complications of long-term critical illness and treatments meant that pts often suffered episodes of diarrhoea. Maintaining pt hygiene and comfort could be physically exhausting, especially if diarrhoea was uncontrolled/persistent as illustrated by the following experiences:
  • Administration of drugs, and other treatments whilst trying to find time to comfort and support patients and their relatives
  • Dealing with confused/disorientated
    long-term patients meant
  • Mainly because of the manpower needed to move them around
  • Evident that addressing psychological needs of LT patients very challenging and complex. Providing emotional support was described as difficult especially when patient’s become withdrawn or depressed,
  • In some instances nurses admitted that they did not have the skill or expertise to address the more serious pschyol symptoms patients exhibited. Indeed it was suggested that the these patients would benefit from having someone in s specialist role to focus solely on this aspect of care.
  • Tended to manifest in patients specifying only certain nurses should look after them
    Patients undermining nurses abilities
    Illustrated by the following:
  • Despite this, nurses tried to consider why long-term patients may exhibit manipulative tendencies and whether they were in some way responsbile
    Others tried to put themselves in the patients shoes and concluded they would be the same if in a similar situation.
    Nevertheless, when caring for a patients exhibiting these behaviours was difficult
  • Hostile behaviour placed demands on their time and was disruptive to patient care
    But, participants attributed such confrontational outburst to stress relatives were under
    Empathy
  • Not genuine acutely ill patients
    For many participants the attraction of working in ICU related to challenge and mental stimulation of caring for acutely ill who required intensive monitoring/treatment. Acute pts required high degree technical competence. In contrast to long-term who required less technically focused care
  • Positive experiences often linked with younger patients (teens early 40’s)
    Easy to relate to/Strong vocalisation of empathy:
  • It appeared that if patients looked and felt slightly better then the nurse did too
  • This population seemed to give nurses the chance to balance the technical aspect of their role while affording them the opportunity to focus on caring.
  • I need a break – acknowledging physical and mental energy required to care for long-term patient:
  • In house study days, teaching sessions, one-to-one teaching
    Post-graduate curriculum to give more attention to care of LTP
    Workshops – encouraging nurses to reflect on their feelings/reactions to particular LTP/family and how to deal with these in a constructive manner
  • What are critical care nurses' perceptions of the long-term ...

    1. 1. What are critical care nurses’ perceptions of the long-term mechanically ventilated patient in the ICU setting? Lisa Mace MSc, BSc (Hons), RGN Cardiac Nurse Specialist
    2. 2. Background  Working in critical care is challenging and demanding  Majority of patients recovery is quick  Small but increasing number patients ICU stay is complicated and prolonged (Carasa & Nepoli, 2002)  Long-term ICU patients have complex needs  Consequently they maybe perceived as ‘difficult’ or ‘unpopular’ to care for
    3. 3. The ‘Unpopular’ or ‘difficult’ patient phenomenon Concept of ‘unpopular’ or ‘difficult’ patient is not new to nursing Application of the label is not straightforward Numerous factors may come into play:  Behavioural characteristics (Stockwell, 1972)  Challenging nurses competency/control (Breeze & Repper, 1998; Strandberg & Jansson, 2003)  Personal characteristics which conflict with nurses belief/value system (Albarran & Salmon, 2000) Within the context of ICU it has received minimal consideration
    4. 4. Consideration of the phenomenon in the ICU settingThe demanding nature of care Overwhelming work load (Lally & Pearce, 1996) Patient behaviours – ‘ICU syndrome’ (Dyer, 1995; Todres et al, 2000) Challenging nurse’s skill set ‘Curing’ vs ‘Caring Evoking negative feelings of incompetence, frustration and despair in nurses (Bergbom-Engberg & Haljamae, 1993, Sevick et al, 1994) Personality conflict Personal characteristics – obese, alcohol misusers, eldery, sexual orientation (Albarran & Salmon, 2000, MacDonald, 2003)
    5. 5. Aims of the Study To explore ICU nurses’ experiences and attitudes of caring for long-term critically ill patients. The purpose, to generate a detailed account of how nurses engaged and coped when dealing with patients who required a prolonged period of care, including artificial ventilation, in ICU.
    6. 6. Methodology Qualitative design used to unravel ICU nurses perceptions 1. Purposive sample 2. 23 critical care nurse recruited from general ICU or cardiac ICU 3. Focus group interviews 4. 4 focus groups: recruited to junior/senior group from respective work area 5. Interview schedule Data generated - thematic content analysis (Burnard, 1991 )
    7. 7. Findings Three Main Themes Emerged  Clinical challenges  Rewarding aspects  Organisational challenges
    8. 8. Themes and Categories Core Theme - Clinical Challenges Core Theme - Rewarding Aspects Core Theme - Organisational Challenges 1. Physical Challenges 1. Connecting and forming a bond with patients (a) Patient Personality (b) Patient responsiveness (c) Young patients 1. Appropriate patient allocation 2.Psychological challenges (a) Supporting the patient emotionally/psycholog ical dependency (b) Facing manipulative/intimidating patient behaviours 2. Feeling you have made a difference 2.Supporting/protecting the nursing team (a) Physical and psychological support (b) Need for a break 3. Dealing with behaviour of family members 3. Striking a balance between technology and caring 4. Not genuine acutely ill patients 4. Refocusing nursing care (a) Thinking outside the boundaries (b) Creating a supportive environment
    9. 9. Clinical challenges of caring for the long-term intensive care patient Physical challenges Physically demanding to care for: ‘I remember one day…with a long-term patient with diarrhoea and I must have had to roll and turn them 25 times and I was nearly crying by the end of the morning’ (F1,U) ‘…if they [long-term patient] are unable to do anything and they have diarrhoea all the time, that’s when it is really hard to manage…. if that is what is happening… I won’t go with a spring in my step, I will think oh no…!’ (F3,J)
    10. 10. Clinical challenges of caring for the long-term intensive care patient Physical challenges Participants stated how, on occasions, they felt ‘a bit overwhelmed by all the things you have do to do’ (F1, U) when caring for a long-term patient. Physical exhaustion – 14 hour shifts
    11. 11. Clinical challenges of caring for the long-term intensive care patient Physical challenges Maintaining constant state of hyper-vigilance ‘you just don’t take your eyes of them otherwise infusion lines and tubes become dislodged (F4, F)’
    12. 12. Clinical challenges of caring for the long-term intensive care patient However… Maintaining constant patient surveillance to ensure patient safety made caring for these individuals demanding: ‘He [long-term patient] had not been orientated, pulling… ventilator alarms every five minutes, so I am running around the bed space, like every five minutes… I don’t want to go to that situation every day’ (F3, K)
    13. 13. Clinical challenges of caring for the long-term intensive care patient Physical challenges - physical characteristics could also complicate care delivery ‘struggled to care for long-term patient patients who were obese’ (F4, C)
    14. 14. Clinical challenges of caring for the long-term intensive care patient Psychological Challenges: Supporting the patient emotionally/dealing with psychological dependency ‘…he used to be like wean, wean, wean…we would say do half an hour weaning and he will say, I will do an hour, but now it’s no, I don’t want to do anything! That’s hard!’ (F2, L) ‘…Mr A has been really depressed, he is really frustrated and doesn’t want to do anything and… you think, what am I going to do’ (F3, H)
    15. 15. Clinical challenges of caring for the long-term intensive care patient Psychological Challenges: Trying to keep long-term patients upbeat and interested appeared to take it’s toll on nurses ‘…if you have been there [with long-term patient] for a quite a while, like 3-4 days it’s mentally knackering’ (F3, H) ‘… sometimes it’s just so hard [caring for long- term patient] you are just exhausted, physically and emotionally (F4, A)
    16. 16. Clinical challenges of caring for the long-term intensive care patient Psychological Challenges: Supporting the patient emotionally ‘…if there was someone in a role who could actually focus on the psychological care of the long-term patients as I find it very difficult sometimes’ (F4, C)
    17. 17. Clinical challenges of caring for the long-term intensive care patient Psychological Challenges: Facing manipulative and intimidating behaviours ‘…you will go in there thinking what else is he [long-term patient] watching, what else is he going to say, because then you are not as free as you would always be…, it takes you a while to build up your confidence to work with that patient’ (F4, B) ‘ …long-term patients can be very manipulative… difficult to manage, playing people off against each other…there will be a lot of she does it this way… (F2, L)
    18. 18. Clinical challenges of caring for the long-term intensive care patient Psychological Challenges: Manipulative and intimidating behaviours Emotionally scarred by threats from a long-term patient ‘…a particular long-term patient I am recalling, threw a bowl of water over me and told me he would kill me when he got out of hospital and I really believed he might do it. I never wanted to go near that man again, I was really frightened’ (F2, O)
    19. 19. Clinical challenges of caring for the long-term intensive care patient Dealing with difficult behaviour not isolated to patient Relatives’ anger and hostility: ‘ The wife of the gentleman that we have at the moment is lovely if everything goes her way, but there are certain members of staff that she doesn’t really like looking after J… and she can be quite rude…’ (F2, L) ‘…if she is having a bad day, she becomes confrontational… she is like a pressure cooker and unfortunately it is the person stood in front of her gets the brunt of it’ (F2, O)
    20. 20. Clinical challenges of caring for the long-term intensive care patient Long-term ICU patients not seen as part of ‘typical’ ICU population Often perceived as less exciting and stimulating to care for: ‘…with the acute patient…dealing with all the pumps all the filters…to look after a long-term patient…isn’t quite so rewarding and challenging’ (F2, P) ‘…if I had may choice, I would want the sickest patient there basically…that would be the most acute patient…the most stimulating’ (F1, T) ‘ …it’s just so monotonous; you know what is going to happen, with that patient [long-term patient] same thing, same story’ (F4, A)
    21. 21. Core Theme: rewarding aspects of caring for long-term patients in ICU Connecting and forming bonds ‘…it feels so good to look after those patients [long- term patients] if you have been looking after them for quite some time and you really get a chance to bond with them… you feel like you are one of the family’ (F3, H)
    22. 22. Rewarding aspects of caring for long-term patients in ICU Connecting and forming bonds It just depends on their personality: ‘…she [long-term patient] was a lovely person…she had a lovely smile, she made contact with you’ (F1, T) Patient responsiveness Positive attributes ‘ humorous’ ‘chatty’ ‘…you could talk to her, she never got particularly pissed off and she had a lucid sense of humour’ (F1, T)
    23. 23. Rewarding aspects of caring for long-term patients in ICU Connecting and forming bonds Young patients ‘…she [young patient] should not have been stuck in that bed with that god awful disease’ (F2, M) ‘…we had that young woman who died…she got a long way and she was a character, she was a lovely woman and her husband and the children…that was really sad’ (F1, T)
    24. 24. Rewarding aspects of caring for long-term patients in ICU Feeling you have made a difference ‘… sitting them out in the chair and wash their hair and someone comes in and goes wow…and that is like your reward…and they say I feel great’ (F2, L) ‘… hair washing and shaving, that sort of thing gives you a sense of satisfaction, relatives think you have cared for them, the patient, they look so much better … they maybe haven’t advanced in terms of weaning, but they just look so much better’ (F1, T)
    25. 25. Rewarding aspects of caring for long-term patients in ICU Striking the balance between technology and caring ‘it is quite rewarding when you are giving really nice care… you can make the long-term patient feel relaxed and you don’t have to worry about all the other things… where you think of changing a pump every 5 seconds… with the acute patients that is often the case that those really nice things that we all like to do are the last things you get a chance to do, because all the other things are so much more life-threatening and have to be maintained (F1, U)
    26. 26. Staff allocation – finding the ‘right person for the right patient’ (F1, S) ‘the problem I find, is often that with the long- term patients that’s when you actually need the less technically skilled nurses. …when it comes to allocation you think, well that’s a really sick patient, but in the next bed- space is a really, really sick patient …you then start to run out of people who ideally you would like to look after the long-termers’ (F1, T) Core Theme: Organisational challenges associated with long-term ICU patients
    27. 27. Organisational challenges associated with long-term ICU patients Staff allocation – safest option for all patients however… Recognition that junior staff did not always have relevant skills
    28. 28. Organisational challenges associated with long-term ICU patients Supporting and protecting the nursing team Senior nurses emphasised need to support junior nurses: ‘What I try to do if it is a junior nurse with a long- term patient…I will go and briefly discuss what we are going to do. It is just about getting a vague structure and them knowing that they get your support to do it’ (F1, T)
    29. 29. Organisational challenges associated with long-term ICU patients Supporting and protecting the nursing team Likewise, junior nurses described the need to feel supported and the opportunity to talk things through. That said, not always readily available: ‘…many people are in and out…they will say everything OK? And without waiting for the answer they will walk off’ (F3, K) ‘ …the long-term patient in bed 3 is very big, lack of staff and most of the nurses are busy, that day we just couldn’t cope’ (F4, J)
    30. 30. Organisational challenges associated with long-term ICU patients Supporting and protecting the nursing team ‘…if I have been there for a few days…I really need a change if I want to carry on with my positivity and energy. I need a couple of days out’ (F3, G) ‘…I have had a couple of people who have said, I need a break, I had had J [long-term patient] for so many days…I think it is probably the psychological care, for people to give it is really wearing’ (F2, N)
    31. 31. Implications and Recommendations Providing adequate support:  Regular breaks  Senior staff visibly on hand  De-briefing meetings  Formal support mechanisms – Action Learning Sets Equipping ICU nurses with relevant skills/knowledge to meet needs of long-term patients more effectively Equipping ICU nurses with necessary practical skills to deal with difficult patient or relative behaviours
    32. 32. Conclusions This small study identified that the idea of the unpopular patient still pervades and exists in a modern ICU setting Evidence to suggest that caring for long-term critically ill patients can be difficult and demanding Equally, such patients were viewed as producing rewarding and satisfying experiences of caring Adequate formal and informal support mechanisms would help ICU nurses to meet the very complex set of needs of long-term critically ill patients. This will do much to maximise the quality of care long-term patients receive while minimising the stress ICU nurses experience during care delivery
    33. 33. Questions? Lisa Mace lisa.mace@uhbristol.nhs.uk MSc, BSc (Hons), RGN Cardiac Nurse Specialist

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