Introdução: As complicações decorrentes da permanência prolongada na ventilação mecânica invasiva (VMI) contribuem negativamente na funcionalidade do paciente crítico. A intervenção fisioterapêutica busca diminuir este impacto negativo, promovendo a recuperação e preservação funcional. Geralmente suas condutas são baseadas em julgamentos clínicos, estilos individualizados e sem padronização, gerando questionamentos sobre o real impacto da sua inserção no manejo destes pacientes. Objetivos: Avaliar a eficácia da intervenção fisioterapêutica no centro de terapia intensiva (CTI) em pacientes críticos que foram submetidos a um protocolo de extubação da VMI e também a efetividade da fisioterapia nos seguintes itens: percentual de sucesso no protocolo de extubação, tempo de permanência na VMI, permanência no CTI, tempo de internação hospitalar e taxa de mortalidade; através da comparação entre os grupos (com e sem intervenção fisioterapêutica). Material e Métodos: Foram incluídos neste trabalho pacientes que necessitaram de VMI por um período maior que 48 horas e que foram considerados aptos para extubação pela equipe médica assistente. Foram excluídos pacientes que não fossem extubados em até 6 horas após ventilação espontânea em tubo T, paciente com traqueostomia e com doença neuromuscular periférica. Após, o paciente foi colocado em ventilação espontânea com tubo T, e em seguida foi registrado o índice de respiração rápida e superficial (IRRS) através da relação freqüência respiratória/volume corrente, sendo este calculado no 1º (IRRS 1) e 30o (IRRS 2) minuto do teste. Os dados foram expressos em freqüência e percentual, média e desvio padrão e mediana (percentil 25-percentil 75), a variável sucesso foi corrigida por análise de covariância (ANCOVA), com nível de significância p<0,05. Resultados: Foram incluídos 265 pacientes neste estudo, divididos em dois grupos: grupo 1 (sem intervenção fisioterapêutica) possuindo 149 pacientes e o grupo 2 (com intervenção fisioterapêutica) possuindo 116 pacientes. Na comparação entre o grupo 1 e 2 encontramos os seguintes resultados: média de idade 58,3 versus 57,7 (p = 0,79), média de APACHE II (Acute Physiology Chronic Health Evaluation) 18,9 versus 22,3 (p=0,003), sucesso de extubação 80,5% versus 88,8% (p=0,05), IRRS 1 58,2 versus 50,5 (p=0,11), IRRS 2 56,0 versus 45,0 (p=0,01), dias de intubação 7,0 versus 7,0 (p=0,34), dias de internação no CTI 13,0 versus 10,0 (p<0,05), dias de internação hospitalar 33,0 versus 35,0 (p=0,25), óbito 21 versus 25 (p=0,13). Conclusão: O grupo com intervenção fisioterapêutica demonstrou um aumento no sucesso da extubação orotraqueal e diminuição nos dias de internação no CTI. Também apresentou maior tempo de internação hospitalar e taxa de mortalidade, podendo ser justificado pela maior gravidade demonstrada no grupo pelo APACHE II. / Introduction: Complications arising from prolonged invasive mechanical ventilation (IMV) contribute negatively to the functionality of the critically ill patient. The physiotherapy intervention seeks to reduce this negative impact, promoting the recovery and functional preservation of the patient. Generally the physiotherapist’s conducts are based on clinical trials and individualized styles without standardization, raising questions about the real impact of their insertion in the management of these patients. Objectives: To evaluate the efficacy of physical therapy intervention in the intensive care unit (ICU) in critically ill patients who were submitted to a protocol of extubation from IMV and also the effectiveness of physiotherapy in the following items: percentage of success in the extubation protocol implementation, length of stay at IMV, length of stay in ICU, length of hospital stay and mortality rate; by comparing the groups (with and without physical therapy intervention). Material e Methods: This study enrolled patients who required IMV for a period longer than 48 hours and who were considered suitable for extubation by medical assistant staff. We excluded patients who were not extubated within 6 hours after spontaneous breathing in T-tube, tracheostomy and patients with peripheral neuromuscular disease. After, the patient was placed on spontaneous ventilation with T-tube and then it was recorded the rapid shallow breathing index (RSBI) using the ratio of respiratory rate / tidal volume, which is calculated on the 1st (RSBI 1) and 30th (RSBI 2) minutes of the test. The data were expressed as frequency and percentage, mean and standard deviation and median (25th percentile – 75th percentile), the variable ‘success’ was adjusted by analysis of covariance (ANCOVA), with significance level p < 0.05. Results: 265 patients were included in this study, divided into two groups: group 1 (no physiotherapy intervention) with 149 patients and group 2 (physical therapy) with 116 patients. In the comparison between groups 1 and 2, we found the following results: mean age 58.3 versus 57.7 (p = 0.79), mean APACHE II (Acute Physiology Chronic Health Evaluation) 18.9 versus 22.3 (p = 0.003) , successful extubation 80.5 % versus 88.8 % (p = 0.05) , RSBI 1 58.2 versus 50.5 (p = 0.11) , RSBI 2 56.0 versus 45, 0 (p = 0.01) , days of intubation 7.0 versus 7.0 (p = 0.34) , days of ICU stay 13.0 versus 10.0 (p < 0.05) , days of hospitalization 33.0 versus 35.0 (p = 0.25) , deaths 21 versus 25 (p = 0.13). Conclusion: The group with physiotherapy intervention showed an increased success in performing orotracheal extubation and a decrease in ICU stay. Also, it resulted in longer hospital stay and higher mortality rate, which can be explained by the greater severity demonstrated in the group by APACHE II.

Bakgrund: Att vårdas på en barnintensivvårdsavdelning (BIVA) är en stressande miljö för både barn och föräldrar. Detta kan hindra föräldrar från att vara delaktiga i vården och nära sitt barn som är kritiskt sjuk. Barnets upplevelse av trygghet påverkas av förälderns mående och delaktighet i vården. Syfte: Studiens syfte var att undersöka föräldrars upplevelse av delaktighet i vården och förekomst av symptom på posttraumatisk stress (PTS) efter att deras barn vårdats på BIVA.  Metod: En retrospektiv deskriptiv design med kvantitativ och kvalitativ ansats användes, där 40 föräldrar besvarade två enkäter om upplevelse av delaktighet på BIVA och symptom på PTS. Resultat: Åttio procent av föräldrarna upplevde sig i stor utsträckning ha varit delaktiga i vården och i de beslut som rörde barnets vård. Föräldrarnas upplevelse av delaktighet resulterade i två huvudteman: Främjande och Hindrande faktorer för delaktighet. Det var en större andel mammor (41%) som visade symptom på PTS jämfört med pappor (12%) (p=0,038). Det var en större andel föräldrar som inte hade högskoleutbildning som visade symptom på PTS jämfört med föräldrar som hade högskoleutbildning (64% versus 14%). Slutsats: Föräldrar upplevde sig i stor grad vara delaktiga i beslut och barnets vård. Identifierade faktorer bland föräldrar med ökad förekomst att utveckla symptom på PTS var att vara mamma, yngre ålder och att inte ha en högskoleutbildning. / Background: Parents whose child was admitted to the pediatric intensive care unit (PICU) found it to be a stressful environment for both child and parent. This can restrict parents from being close and involved in their child's care. The child's sense of security is affected by the parents' feelings and involvement in care. Purpose: The aim of the study was to investigate parents' experiences of participation in the care and parents' symptoms of post-traumatic stress (PTS) after their child was discharged from the PICU. Method: A retrospective descriptive design was used with a quantitative and qualitative approach, where 40 parents answered two surveys about the experience of participation in PICU and symptoms of PTS. Result: Eighty percent of the parents felt that they had been involved in the care and in the decisions concerning the child's care. The parents’ experience of participation resulted in two main themes: promoting and inhibiting factors for participation. There was a higher proportion of mothers (41%) who showed symptoms of PTS compared to fathers (12%) (p=0,038). A higher percentage of parents who didn't have post-secondary education showed PTS symptoms, compared to those who did have post-secondary education (64% versus 14%). Conclusion: Parents reported that they had been involved in the care and in the decisions concerning the child's care. Symptoms of PTS among parents correlated with being a mother, younger age and lower educational level.

Bakgrund: Intensivvård är den högsta vårdinstansen på ett sjukhus, en av sjukvårdens mest resurskrävande behandlingsformer. När en patient blir kritiskt sjuk eller påvisar försämrade vitalparametrar kontaktar vårdpersonalen mobil intensivvårdsgrupp (MIG) som utgår ifrån intensivvårdsavdelningen (IVA). Problemformulering: De kritiskt sjuka patienterna vårdas inte längre bara på IVA men också på vårdavdelningar. I ett omvårdnads- och professionsperspektiv som intensivvårdssjuksköterska är det av betydelse och centralt att förstå orsakerna till kontakt med MIG. Syfte: Att kartlägga kontakter, orsaker och skillnader med mobil intensivvårdsgrupp på ett sjukhus i Västra Götalandsregionen. Metod: En icke-experimentell studie med ett konsekutivt urval och retrospektiv journalgranskning av 386 patientkontakter med MIG under åren 2017–2019. Resultat: Studiens resultat påvisar en hög medelålder. Ingen skillnad återfanns i patientgruppen ur ett könsperspektiv. Den framträdande gruppen är den geriatriska patienten ≥65år som är utsatt och en högriskgrupp vid kontakt med MIG. De utgör majoriteten av alla kontakter med MIG åren 2017–2019. Diskussion: Studiens kartläggning och resultat påvisar behov av kompetenshöjande utbildning och optimeringsteam. Geriatriska patientgruppen behöver vårdinsatser i rätt tid och med rätt kompetens för att minska antalet MIG kontakter och initiera insatser i förtid och motverka svikt av vitala parametrar.

Bakgrund: En vanligt förekommande företeelse är att en akut sjuk patient drabbas av delirium. Detta ställer stora krav på sjuksköterskan att vara lyhörd på symtomen. Det finns ett fåtal kvalitativa studier om sjuksköterskans erfarenhet av delirium, dessa studier visar att sjuksköterskor har kunskapsbrist om delirium. Det finns framtagna riktlinjer som endast används sporadiskt och sjuksköterskor upplever den ökade arbetsbördan, som delirium kan orsaka, som stressande. Syfte: Syftet var att belysa sjuksköterskans erfarenhet av att vårda en patient med delirium. Metod: Resultatet baseras på en litteraturstudie av artiklar som ej är äldre än tio år. Datainsamling gjordes från databaserna CINAHL och PsycINFO. 14 vetenskapliga artiklar inkluderades. Artiklarna analyserade med en kvalitativ innehållsanalys på manifest nivå. Resultat: I studiens resultat framkom sju underkategorier, som genererade tre kategorier: ”Vårdandets komplexitet”, ”Att identifiera och behandla delirium” och ”Sjuksköterskans behov av kompetens och stöd”. Slutsats: För att på bästa sätt tillgodose en patients behov, som drabbats av delirium, behöver sjuksköterskan ha en bra kommunikation. Vårdarbetet med en patient med delirium kan ge sjuksköterskan en känsla av otillräcklighet, som ofta beror på tidsbrist på grund av hög arbetsbelastning. Mycket tyder på att det idag saknas forskning och utbildning inom området. Genom att öka kunskapen om vården för patienter med delirium så skulle sjuksköterskans professionella roll stärkas. / Background: A common occurrence is that an acutely ill patient suffers from delirium. This places great demands on the nurse to be responsive to the symptoms. There are a few qualitative studies on the nurse's experience of delirium; these studies show that nurses have a lack of knowledge about delirium. There are guidelines that are only used sporadically, and nurses experience the increased workload, that delirium can cause as stressful. Aim: The purpose was to highlight the nurse´s experiences of caring for a patient with delirium. Method: The result is based on a literature review of articles no older than ten years. Data collection was done from the databases CINAHL and PsycINFO. 14 scientific articles were included and a qualitative content analysis at manifest level was used. Results: The results emerged in seven categories, which generated three themes: "The complexity of care", "Identifying and treating delirium" and "The nurse´s need of competence and support”. Conclusions: To meet the needs of a patient affected by delirium, the nurse needs good communication. Caring for a patient with delirium can give the nurse a feeling of inadequacy, which is often due to lack of time due to high workload. Much indicates that today there is a lack of research and education in this area. By increasing the knowledge about care for patients with delirium, the nurse´s professional role would be strengthened.

Höftfrakturer är en vanlig ortopedisk orsak till sjukhusvård hos äldre. Att vara äldre och drabbas av höftfraktur är förknippat med hög risk för död. Stora fysiologiska avvikelser preoperativt samt försenad operation är kopplat till ökad risk för komplikationer och död. Äldre, sköra patienter har små marginaler och kan i samband med operation av höftfraktur behöva intensivvård. Det har uppmärksammats på ett sjukhus i Västra Götaland att denna patientgrupp vid ankomst till preoperativ avdelning ibland ej bedöms vara i operabelt skick, vilket medför ett förehavande där patienten förs till postoperativa intensivvårdsavdelningen för optimering inför operation. Syftet med studien är att undersöka hur det postoperativa förloppet hos äldre patienter med akuthöftfraktur påverkas efter införande av preoperativ optimering, stöttat av intensivvårdssjuksköterskan, på vårdavdelning. Studien har en kvantitativ ansats med en kombination av kvantitativ retroperspektiv registerstudie och en kvantitativ prospektiv interventionsstudie. Sammanställningen påvisar en minskning av den totala vårdtiden från 9 dagar till 6 dagar i median. Sammanfattningsvis betonas att intensivvårssjuksköterskan tillsammans med övriga professioner i teamet runt patienten har betydelse för att förbättra den äldre patientens möjlighet att återhämta sig efter akut höftfraktur.

Bakgrund: Att vårda potentiella donatorer är en svår uppgift för sjuksköterskan och på grund av den komplexitet och stress som situationen medför är det utmanande för sjuksköterskan på intensivvårdsavdelningen. Syfte: Syftet var att belysa intensivvårdssjuksköterskans uppfattningar och erfarenheter av att vårda patienter med konstaterad hjärndöd och som är potentiella organdonatorer. Metod: Denna litteraturstudie baserades på 14 kvalitativa vetenskapliga artiklar. Systematisk dataanalys användes där data analyserades genom en manifest innehållsanalys. Resultat: Den systematiska dataanalysen resulterade i åtta subkategorier och tre kategorier. Dessa kategorier var: Sjuksköterskans perspektiv påverkar vårdandet, Den utmanande vården och En vård som väcker starka känslor. Resultatet visade att begreppet hjärndöd var svårt att förstå då patienten såg levande ut. Sjuksköterskans kunskap och syn på organdonation påverkade vården och det var en utmanande uppgift att balansera vården mellan den potentiella donatorn och de närstående. I vården av den potentiella donatorn och mötet med de närstående väcktes starka känslor. Slutsats: Situationen kring den potentiella donatorn och kommunikationen med de närstående är mycket utmanande för sjuksköterskan. En god arbetsmiljö och utbildning i kommunikation är av största vikt för att stärka sjuksköterskans professionella roll. / Background: To care for potential donors is a difficult task for nurses and due to the complexities and stressors the situation creates, it is a big challenge for nurses in the intensive care units. Aim: The aim was to clarify the intensive care nurse´s perceptions and experiences caring for patients with the diagnosis of brain death and that are potential organ donors. Method: This literature review was conducted by composing 14 qualitative scientific articles. A systematic data analysis was used where data was analysed through a manifest content analysis. Results: The systematic data analysis resulted in eight subcategories and three categories. The three categories described as: The nurse´s perspectives influence the care, The challenging care and A care that evokes strong emotions. The result showed that the concept of brain death was hard to understand when the patient actually looks alive. The knowledge of the nurse and the perception of organ donation influenced the care and it was a challenging duty to balance the care of the potential donor and the relatives. When caring for the potential donor and meeting with the relatives, strong emotions were created. Conclusion: The situation around the potential donor and the communication with the relatives is very challenging for the nurse. A healthy work environment and education in communication are crucial to improve the professional role of the nurse.

Bakgrund: Intensivvården är en högteknologisk miljö och är utformad för att kunna rädda liv. Trots det avlider omkring 3–4000 patienter årligen på intensivvårdsavdelningar i Sverige, vilket har föranlett till att vård i livets slutskede börjat uppmärksammas inom intensivvården. När beslut tagits om att avbryta livsuppehållande behandling blir omvårdnaden det centrala i vårdandet, och målet är att skapa bästa möjliga livskvalitet för patienten och de närstående samt ett värdigt avslut.  Syfte: Att belysa intensivvårdssjuksköterskors upplevelser av att vårda patienter i livets slutskede. Metod: En kvalitativ intervjustudie med semistrukturerade intervjuer genomfördes med tio intensivvårdssjuksköterskor. Insamlat datamaterial analyserades med hjälp av en kvalitativ innehållsanalys med induktiv ansats. Resultat: Resultatet utgörs av tre kategorier; att övergå till vård i livets slutskede, att vårda till livets slut och att främja ett patientsäkert vårdande. Dessa kategorier återger intensivvårdssjuksköterskornas upplevelser av att vårda patienter i livets slutskede, och resultatet visar tydligt att det finns en vilja att skapa ett värdigt slut för patienten och de närstående.  Slutsats: Det finns en enighet i att det är viktigt att känna sig säker och kompetent i sin yrkesroll för att kunna ge god och värdig vård i livets slutskede. Det föreligger ett behov av utbildning, tydliga rutiner och konkreta riktlinjer som skulle kunna öka patientsäkerheten och säkerställa en god vårdkvalitet. Fortsatt forskning kring vård i livets slutskede inom intensivvård skulle dessutom ytterligare kunna utveckla och förbättra vården samt stärka intensivvårdssjuksköterskans professionella roll. / Background: The intensive care unit is a high-technological environment and designed to save lives, despite this about 3–4000 patients die annually in intensive care units in Sweden, which have led to the attention of end-of-life care in intensive care. When a decision is made to withdraw life-sustaining treatment, nursing becomes central and the goal is to create a good quality of life for the patients and the relatives and a dignified end of life.  Aim: To highlight intensive care nurses’ experiences of providing end-of-life care. Method: A qualitative method with semi-structured interviews with ten intensive care nurses was used to conduct the study. Collected data were analysed using a qualitative content analysis with an inductive approach. Results: The result consists of three categories; the transition to end-of-life care, to care to the end-of-life and to promote patient-safe care. These categories reflects the experiences of providing end-of-life care among intensive care nurses, and the results clearly demonstrates that there was a common will to create a dignified end-of-life for the patient and the relatives. Conclusion: There is a consensus among the intensive care nurses that it is important to feel secure and competent in the professional role in order to provide good and dignified end-of-life care. Furthermore, there is a need for education, clear routines and concrete guidelines that could increase patient safety and ensure a good quality of care. In addition, further research on end-of-life care in the intensive care unit is necessary, and could improve care and strengthen the professional role of the intensive care nurse.

The goal of this study was to explore the factors impacting on the well-being of ICU employees. The objectives of the study were: <ul> <li> To theoretically conceptualise the factors impacting on employees in a hospital ICU.</li> <li> To explore the role of personal factors such as personality, behaviour risks and resilience that impact on the well-being of ICU employees.</li> <li> To explore the organisational and work related factors that impinge on ICU employees and the impact these factors have on their well-being.</li> <li> To make recommendations regarding the implementation of proactive strategies.</li></ul> The research question of the qualitative study is: What are the factors impacting on the well-being of intensive care employees at the Chris Hani Baragwanath Hospital? This is an applied, qualitative research study. The research design used was a collective case study using focus group interviewing. The research study was conducted at Chris Hani Baragwanath Hospital Intensive Care Unit. The sample was selected using non-probability, purposive sampling. The sample consisted of ten doctors, thirteen nursing personnel and seven allied professionals (four physiotherapists and three dieticians). A pilot study was conducted with two doctors, two nurses and a social worker to test the interview schedule. This group did not form part of the sample. The researcher did her best to adhere to ethical considerations. Participants were informed of the nature of the research and completed informed consent forms. Anonymity was ensured through presenting responses collectively. No individual names or responses will be identified. A semi-structured interview schedule was used to collect data during focus group interviewing. The four focus group sessions were tape recorded. After completion of the focus group interviewing, the data was transcribed verbatim and then the data was organised into themes and sub-themes. The findings were released in a mini-dissertation. The report is accurate and reflects the true facts. All sources, references and assistance are acknowledged. The themes and sub-themes identified were: <ul> <li> Theme one: Job Satisfaction and sub-themes-Fulfilment, Meaning to Work, Emotions experienced, Changes healthcare workers would like implemented.</li> <li> Theme two: Stressors and sub-themes- What the stressors are, Control over the Stressors, Self-care techniques utilised, Personal Resources and Ways of de-stressing.</li> <li> Theme three: Trauma</li> <li> Theme four: Interpersonal Relationships and sub-themes- Connectivity amongst team, Impact connectivity has on functioning and Teamwork.</li> <li> Theme five: Role Demands and sub-themes- Job Description, Role Conflict and Balance between work and personal life.</li> <li> Theme six: Job Resources and sub-themes- Adequacy of resources, Resources Lacking and Impact job resources have on functioning.</li> <li> Theme seven: Job Conditions and sub-themes- Work Overload, Job Security and Working Conditions.</li></ul> The findings of the study were as follows: <ul> <li> CHBH employees experience high job satisfaction as they are doing what they want to do. They feel that they make a difference and enjoy trauma work. They are where things happen and where they want to be.</li> <li> The stressors faced by ICU employees can be divided into emotional and physical/resource stressors. The physical stressors were found to be: long working hours, lack of resources, untrained staff, budget, procuring equipment and resources, lack of human resources, equipment and linen shortages. The emotional stressors were related to having to deal with trauma and the impact thereof, dealing with death and dying, decisions regarding the switching off of life support machines, not always knowing if you did the right thing and wondering if you did everything you could for the patient to save their life.</li> <li> Daily, employees are faced with dealing with trauma and the impact thereof. This has an impact on well-being and can lead to compassion fatigue or soul weariness.</li> <li> It is important to examine the interplay of job resources and job demands. If job demands are high and job resources lacking, well-being is impacted. Job resources may buffer the impact of job demands and thus reduce burnout, exhaustion and increase motivation.</li> <li> If job demands are high and job resources low, job demands will exceed the individuals’ capacity to cope and overtax or stretch ability to cope. ICU employees experience being overstretched and overtaxed due to high job demands and being under-resourced. Work overload results in exhaustion.</li> <li> Relationships are an important aspect of organisational support. Employees value their relationships with colleagues and this provides opportunities for discussing patients, sharing knowledge and obtaining assistance with patient care. By pooling resources the team has additional resources to resolve complex situations.</li> <li> The working conditions of ICU employees are impacted by shortages in human and equipment resources.</li></ul> Recommendations arising from the study are: <ul> <li> A lifestyle and health management program dealing with issues of nutrition, exercise, relaxation, self awareness and disease management.</li> <li> An educative stress management program which is presented at induction and orientation.</li> <li> Preventative programs that enhance knowledge and skills on coping and self-care.</li> <li> Self awareness programs designed to assist employees in understanding their own stressors and reactions, enhance their self-esteem by developing strengths, resilience and coping.</li> <li> Human capital management- developing strategies to attract retain and reduce staff shortages.</li> <li> Facilities for exercise and relaxation- the provision of a gym facility.</li> <li> Program to reduce fatigue and recovery time.</li> <li> Group sessions focussing on catharsis and ventilation of feelings.</li> <li> A comprehensive Employee Wellness Program. </ul> / Dissertation (MSW)--University of Pretoria, 2010. / Social Work and Criminology / Unrestricted

Bakgrund: I Sverige föds omkring 7000 prematura barn varje år. Föräldrars närvaro och delaktighet är viktig för att de ska lära känna sitt barn och ta på sig rollen som barnets primära vårdare, men även för barnets välbefinnande och trygghet.  Syfte: Beskriva barnsjuksköterskors erfarenheter av att göra föräldrar delaktiga i omvårdnaden av sitt prematurfödda barn på neonatalavdelning.  Metod: Studien genomfördes på en neonatalavdelning i södra Sverige. Totalt deltog 12 barnsjuksköterskor. Intervjuerna analyserades utifrån en kvalitativ innehållsanalys med induktiv ansats.  Resultat: När föräldrarna träffade samma personal byggdes en relation mellan föräldrar och barnsjuksköterska vilket främjade föräldrarnas delaktighet. Det var viktigt att låta föräldrarna sköta omvårdnaden men att barnsjuksköterskan fanns vid sidan om som stöd. Genom information och förberedelse hade föräldrarna bättre förutsättningar till delaktighet. Barnets tillstånd, vårdmiljön och familjesituation menade barnsjuksköterskan kunde påverka huruvida föräldrarna ville eller kunde vara delaktiga i omvårdnaden. Genom delaktighet främjades anknytningen genom att föräldrarollen stärktes och föräldrarna lärde känna sitt barn.  Slutsats: Barnsjuksköterskan har en viktig roll där hon bör sträva att få med sig föräldrarna i omvårdnaden så att deras delaktighet ökar. Vikten av att föräldrar är delaktiga grundar sig i att stärka anknytningen vilket har stor betydelse för barnets välbefinnande. / Background: Every year 7000 children are born premature in Sweden. Parents presence and participation is important to get to know their child and to take the role as the primary caregivers, but also for the child’s well-being and safety.   Aim: The aim of the study was to describe paediatric nurses’ experiences of involving parents in the care of their preterm child in the neonatal intensive care unit (NICU). Method: The study took place at a NICU in southern Sweden. Interviews were carried out with 12 paediatric nurses. The analysis was made using qualitative content analysis with an inductive approach.    Results: When parents met the same paediatric nurse a relationship was built which promoted parent participation. It was important to have the parents take care of the nursing but the pediatric nurse was on the side as support. Through information and preparation, the parents had better conditions for participation. The paediatric nurse meant that the child's condition, care environment and family situation nurse could influence whether the parents wanted or could be involved in the care. Through participation, the bonding was promoted by strengthening the parent role and the parents getting to know their child.  Conclusion: The paediatric nurse has an important role and should strive to increase parents participation in their child’s care. The importance of parent participation is because it promotes bonding which is important for the child’s well-being.

Chaque année, plusieurs milliers de patients aux prises avec une maladie chronique terminale s’ajoutent à la liste d’attente pour une transplantation d’organe, espérant ainsi prolonger leur espérance de vie. Le plus souvent, le don d’organes survient suite au décès neurologique d’un donneur, une condition qui n’est pas sans conséquence sur la qualité des organes. Les traitements pharmacologiques visant à rétablir l’homéostasie et à protéger les organes à transplanter ont été majoritairement étudiés dans des études observationnelles, au début des années 80. Depuis, très peu d’essais randomisés ont évalué l’impact d’interventions chez des donneurs sur des issues cliniques chez des receveurs. Conséquemment, le bénéfice net des traitements pharmacologiques utilisés de routine chez les donneurs d’organes après décès neurologique demeure inconnu et la rationnelle physiopathologique supportant leur utilisation est questionnable. Cette thèse a pour visée de recenser les évidences supportant les traitements pharmacologiques employés pour la stabilité hémodynamique des donneurs d’organes après décès neurologique et de décrire le niveau d’évidence supportant leur usage. Nous visons également à identifier des cibles de recherche potentielles basées sur de nouvelles observations pathophysiologiques. Pour atteindre ces objectifs, nous avons dressé un large portrait de la prise en charge actuelle des donneurs après décès neurologique, ceci menant ensuite à l’exploration des perceptions des médecins intensivistes canadiens en regard de ces interventions. Nous avons également exploré la présentation clinique cardiaque des donneurs et nous avons identifié des barrières à la recherche clinique dans le domaine. Notre thèse a mené à 4 articles scientifiques. D’abord, nous avons démontré à l’aide d’une revue systématique des lignes directrices internationales sur la prise en charge des donneurs après décès neurologique que les recommandations actuelles sont incohérentes et que leur faible qualité méthodologique reflète la lenteur de l’émergence de la recherche dans le domaine. Ensuite, nous avons effectué un sondage national auprès de médecins des soins intensifs ayant de l’expérience dans la prise en charge des donneurs. Nous avons ainsi démontré que les perceptions de pratiques sont très variables au pays et avons attribué ces divergences d’opinions au manque de données probantes, et à la possible inexpérience relative des médecins face aux rares cas de don d’organes sur une unité de soins intensifs. Notre troisième article a démontré que la dysfonction ventriculaire droite est fréquente après un décès neurologique, bien que la littérature actuelle ne mette l’emphase que sur la dysfonction ventriculaire gauche et ses conséquences. Nous émettons l’hypothèse que la description actuelle des conséquences hémodynamique du décès neurologique est incomplète et qu’une meilleure compréhension des mécanismes sous-jacents à la dysfonction ventriculaire droite permettrait d’identifier de nouvelles cibles thérapeutiques. Finalement, en s’appuyant sur nos observations, nous questionnons l’efficacité et la pertinence d’interventions pharmacologiques administrées de routine chez les donneurs telles que l’hormonothérapie de remplacement. Nous avons donc effectué un essai randomisé pilote visant à évaluer la faisabilité d’une étude multicentrique déterminante comparant la levothyroxine au placebo chez des donneurs potentiels. Cette étude pilote a démontré qu’une étude d’envergure était nécessaire afin d’évaluer le bénéfice de l’intervention et a permis d’identifier des barrières à la recherche spécifiques au domaine. Nous proposons que des activités de transfert de connaissances sur le niveau d’évidence supportant les interventions pharmacologiques actuelles soient implantées en préparation d’un essai randomisé contrôlé multicentrique. Cette thèse a permis de mettre en lumière la validité questionnable du traitement pharmacologique pour la prise en charge de l’instabilité hémodynamique des donneurs d’organes tel qu’il est utilisé présentement. Nous avons fait ressortir que le traitement actuel est historiquement basé sur des données de faible évidence. Nous suggérons que l’avenir de la recherche interventionnelle chez les donneurs d’organes repose sur la capacité des cliniciens et des chercheurs à reconnaitre les zones d’incertitude dans les connaissances actuelle et à accepter des changements dans leur pratique. / Every year, thousands of chronically ill patients are added to the transplant list, in the hope of an organ transplant that could save their life. Most frequently, organ donation occurs following neurological death of a donor, a clinical pathological condition that can jeopardize the quality and stability of organs. The body of literature on the hemodynamic consequences of neurological death and their treatment exist since the early 80’s. Since then, very few randomized trials have been performed on the neurologically deceased donor population. As a consequence, the benefit of routine pharmacological therapies for the hemodynamic management of neurologically deceased donors on recipients’ outcomes is still uncertain, and the pathological theory underlying their use remains questionable. Consequently, this thesis aims at describing the actual body of evidence supporting the pharmacological treatment for the hemodynamic management of neurologically deceased donors and the theoretical rationale for their use. We also aimed at adding to the actual knowledge of brain death physiological hemodynamic consequences. To achieve this goal, we drew a broad portrait of the actual management of hemodynamic instability in organ donors, leading to the exploration of perceptions on these interventions. We then explored physiological consequences of neurological death at the heart level and evaluated the feasibility of conducting a multicentre trial on a pharmacological intervention in donors. Our thesis let to four research articles. First, we demonstrated through a systematic review of international guidelines for the management of neurologically deceased donors that the existing recommendations are inconsistent and that their poor methodological quality reflects the slow emergence of clinical research in the field. Then, in a national survey of intensive care physicians with experience in organ donor clinical management, we identified varying perceptions of practices in the country. We attributed this difference in opinions to the paucity of research in the field and to the possible relative inexperience of some physicians when managing deceased donors, a relatively rare condition in the intensive care unit. Our third article suggested that right ventricular dysfunction is frequent after neurological death, although existing literature focus mainly on the occurrence and consequences of left ventricular dysfunction. We postulate that the actual description of hemodynamic consequences of neurological death is incomplete and that a better understanding of the mechanisms underlying right ventricular dysfunction would permit to identify new therapeutic targets. Finally, based on our previous conclusions, we questioned the relevance and efficacy of levothyroxine routine administration in donors and designed a pilot randomized controlled trial to evaluate the feasibility of a multicenter definitive trial. This pilot trial permitted to identify important barriers to interventional research including neurologically deceased donors. We propose that knowledge translation activities on the actual level of evidence supporting routine interventions be implemented in the preparation of a future randomized trial. This thesis permits to question the validity of the actual pharmacological management of neurologically deceased donors highlighting the paucity of high-evidence literature in the field and the penetrance of historical interventions and concepts. We suggest that the future of research in the field lies on the ability to recognize areas of uncertainties and the acceptance of practice change.