Tracheal intubation in critically ill patients is a high-risk procedure. The risk of complications increases with repeated or prolonged attempts, making expedient first attempt success the goal for airway management in these patients. Patient-related factors often make visualization of the airway and placement of the tracheal tube difficult. Physiologic derangements reduce the patient's tolerance for repeated or prolonged attempts at laryngoscopy and, as a result, hypoxaemia and haemodynamic deterioration are common complications. Operator-related factors such as experience, device selection, and pharmacologic choices affect the odds of a successful intubation on the first attempt. This review will discuss the 'difficult airway' in critically ill patients and highlight recent advances in airway management that have been shown to improve first attempt success and decrease adverse events associated with the intubation of critically ill patients.

UA Open Access Publishing Fund / Background: Noninvasive positive-pressure ventilation (NIPPV) use has increased in the treatment of patients with respiratory failure. However, despite decreasing the need for intubation in some patients, there are no data regarding the risk of intubation-related complications associated with delayed intubation in adult patients who fail NIPPV. The objective of this study is to evaluate the odds of a composite complication of intubation following failed NIPPV compared to patients intubated primarily in the medical intensive care unit (ICU). Methods: This is a single-center retrospective cohort study of 235 patients intubated between 1 January 2012 and 30 June 2013 in a medical ICU of a university medical center. A total of 125 patients were intubated after failing NIPPV, 110 patients were intubated without a trial of NIPPV. Intubation-related data were collected prospectively through a continuous quality improvement (CQI) program and retrospectively extracted from the medical record on all patients intubated on the medical ICU. A propensity adjustment for the factors expected to affect the decision to initially use NIPPV was used, and the adjusted multivariate regression analysis was performed to evaluate the odds of a composite complication (desaturation, hypotension, or aspiration) with intubation following failed NIPPV versus primary intubation. Results: A propensity-adjusted multivariate regression analysis revealed that the odds of a composite complication of intubation in patients who fail NIPPV was 2.20 (CI 1.14 to 4.25), when corrected for the presence of pneumonia or acute respiratory distress syndrome (ARDS), and adjusted for factors known to increase complications of intubation (total attempts and operator experience). When a composite complication occurred, the unadjusted odds of death in the ICU were 1.79 (95% CI 1.03 to 3.12). Conclusions: After controlling for potential confounders, this propensity-adjusted analysis demonstrates an increased odds of a composite complication with intubation following failed NIPPV. Further, the presence of a composite complication during intubation is associated with an increased odds of death in the ICU.

Intensive care unit nursing shortages are an ongoing issue within the Canadian healthcare system. The goal of this thesis research was to better understand Manitoban intensive care unit (ICU) nurses’ intent to leave or stay. An adapted version of the Conceptual Framework for Predicting Nurse Retention provided the framework to examine ICU nurses’ perceived empowerment, caring, job satisfaction and intent to leave or stay. An online survey was distributed by the College of Registered Nurses of Manitoba to 630 ICU nurses in Manitoba. Ethical approval was obtained from the Education Nursing Research Ethics Board at the University of Manitoba. Findings indicate the majority of ICU nurses who participated in this research were satisfied with their job. Multivariate analyses indicated that job satisfaction was statistically significantly associated with intent to stay. / October 2016

Opioids are used routinely in the pediatric intensive care population for analgesia, sedation, blunting of physiologic responses to stress, and safety. In children, physical dependence may occur in as little as two to three days of continuous opioid therapy. Once the child no longer needs the opioid, the medications are reduced over time. A review of the literature revealed that the majority of the published studies used either a neonatal opioid assessment tool or no assessment tool. A subsequent international survey of pediatric providers found a wide range of opioid tapering practices and sporadic use of opioid withdrawal instruments to guide practice. Since tapering routines vary among practitioners, it is not uncommon to see signs and symptoms of opioid withdrawal. A prospective, descriptive study was conducted to describe the frequency of opioid withdrawal signs and symptoms and to identify factors associated with these opioid withdrawal signs and symptoms. The sample of 25 was drawn from all patients, ages 2 weeks to 21 years admitted to the Children’s Hospital of Richmond Pediatric Intensive Care Unit (PICU) and who have received continuous infusion or scheduled opioids for at least 5 days. Data collected included: opioid withdrawal score (WAT-1), opioid taper rate (total dose of opioid per day in morphine equivalents per kilogram [MEK]), pretaper peak MEK, pretaper cumulative MEK, number of days of opioid exposure prior to taper, and age. Out of 26 enrolled participants, only 9 (45%) had opioid withdrawal on any given day. In addition, there was limited variability in WAT-1 scores. The most common symptoms notes were diarrhea, vomit, sweat, and fever. For optimal opioid withdrawal assessments, clinicians should use a validated instrument such as the WAT-1 to measure for signs and symptoms of opioid withdrawal. Further research is indicated to examine risk factors for opioid withdrawal in children.

This study examined illness-related uncertainty and primary appraisals of threat, centrality, and challenge as predictors of acute stress disorder (ASD) symptoms in parents of children hospitalized in a pediatric intensive care unit (PICU). Ultimately, a mediational pathway was tested to determine if primary appraisal was a mechanism that accounted for the impact of uncertainty on ASD symptoms. Ancillary study aims were to assess the degree to which parents perceived uncertainty in the PICU environment, and to determine the prevalence of ASD among parents in this setting. Self-report data was collected from 77 parents (57 mothers, 19 fathers) of children hospitalized in a PICU for a minimum of 48 hours. Descriptive analyses showed that parents perceived a high degree of uncertainty and 57% of parents met diagnostic criteria for ASD. Unexpected admission was the only objective medical status variable significantly related to uncertainty, threat appraisal, and ASD symptoms. Consistent with hypotheses, results from hierarchical regression analyses showed that perceived uncertainty and primary appraisals of threat accounted for significant variance in parents’ ASD symptoms; however, neither centrality nor challenge appraisals were related to parents’ ASD symptoms. Because threat was the only appraisal dimension found to be directly related to ASD symptoms, it was the only dimension tested in the mediational model. Consistent with the hypothesis, threat appraisals fully mediated the effect of uncertainty on ASD symptoms; results from a Sobel test confirmed the significance of full mediation. This study is the first to examine uncertainty, primary appraisal, and ASD symptoms in this population. Results clarify that it is not the mere perception of uncertainty that adversely impacts parental adjustment, but rather how it is appraised, and therefore, point to a practical area for in-hospital interventions targeting parents’ pediatric medical traumatic stress symptoms. Although a substantial body of empirical research supports a relation between uncertainty and maladaptive outcomes, studies also link uncertainty to positive outcomes. Future research should include positive indicators of adjustment and examine how appraisals vary according to sources of uncertainty.

There are no reliable tools that evaluate pain in adult critical care patients who cannot communicate as a result of sedation or illness. This was an observational study in which postoperative cardiothoracic intensive care patients were assessed for pain using both the newly devised Corbett Pain Scale (CPS) and the Numerical Pain Scale (NPS). The CPS was evaluated for content validity, criterion validity, construct validity, test re-test reliability and internal consistency. Thirteen male and seven female patients (n=20) were enrolled and underwent a maximum of five pain assessments each. The mean total scores of the CPS (.740, SD+1.03) and the NRS (.000, SD+1.00) were compared using a paired t-test. No significant differences were found. There was poor internal consistency (-.1225) and there was insignificant correlation between the scales. Pain measurement of sedated, non-communicative patients continues to be problematic.

patients and their families. The purpose of the study was firstly, to explore and interpret the meaning of the experiences of critical care nursing students about clinical accompaniment in open distance learning (ODL). This aspect has not been researched before and as such, there is no empirical data about the clinical accompaniment of the critical care-nursing students in ODL. Secondly, to develop guidelines for facilitation of clinical accompaniment in critical care nursing in ODL. A qualitative hermeneutic phenomenological study was conducted. Non-probability purposive sampling was used to select participants to provide information about clinical accompaniment in ODL. Data was obtained through in-depth interviews supplemented by field notes compiled during fieldwork. The study findings revealed that participants regard relationships and communication as important for clinical accompaniment. The distance factor inherent in distance learning was problematic for student’s motivation and support. The presence and visibility of the lecturer was pivotal for the students. Of importance also were the relationships with the managers and colleagues. The perception of participants was that managers of clinical facilities were not as readily accessible as would have been the lecturer. Although negative experiences were described, paradoxically these experiences seemed to have empowered the student to develop survival skills, patience and assertiveness to take action on how to deal with the situation. From the findings the researcher was able to develop guidelines the implementation of which, is hoped to ensure effective clinical accompaniment of critical care nursing students in ODL. / Health Studies / D. Litt. et Phil. (Health Studies)

Det övergripande syftet med avhandlingen var att beskriva och undersöka patienters - vårdade inom intensivvård - upplevelser och effekter av en cyklisk belysningsintervention utifrån hälsa, välbefinnande och återhämtning. Metod: En intervention bestående av ett automatiskt styrt belysningssystem var installerat på ett intensivvårdsrum. Belysningsinterventionens mål var att efterlikna dagsljuset i styrka, kvalitet, och lokalisation. Ett ordinarie intensivvårdsrum fungerade som kontrollmiljö. I studie I eftersöktes i en systematisk litteratursammanställning tidigare forskningsresultat rörande cykliska belysningsinterventioner inom intensivvård. Belysningsmiljöerna i intervention- och kontrollmiljön bedömdes i studie I av besökare och i studie II av patienter samt jämfördes och analyserades statistiskt. Ljus och belysningsmätningar utfördes i både forsknings- och kontrollmiljön. I studie II undersöktes patienters upplevelser av den cykliska belysningsmiljön genom kvalitativa intervjuer vilka analyserade med innehållsanalys. I studie II mättes och jämfördes patienters sömn, dygnsrytm samt fysiologiska parametrar och analyserades statistiskt. I studie IV undersöktes och jämfördes patienternas självskattade återhämtning efter sex och tolv månader. Resultat: Cykliska belysningsinterventioner exponerade för vuxna patienter var få. Resultatet visade dock att interventioner med cykliskt ljus inom neonatal intensivvård kunde inverka positivt på förtidigt födda barns hälsa. Den cykliska interventionsmiljön bedömdes som mer trivsam och mätningar av belysningen utförda i interventionsmiljön visade på samstämmighet med europeiska rekommendationer. Belysningsnivåerna i kontrolmiljön var manuellt styrda och mätningarna visade på antingen för låga eller för höga belysningsnivåer under dagtid jämfört med europeiska rekommendationer. Patienterna bedömde den cykliska belysningsmiljön som starkare dagtid och under nattetid bedömdes belysningen i kontrolmiljön som mer varierande. Patienters individuella upplevelser av den cykliska belysningsinterventionen presenterades i fyra kategorier: en dynamisk belysningsmiljö, belysningens påverkan på patientens sömn, ljus/belysnings påverkan på dygnsrytm samt en lugnande belysning. Patienternas dygnsrytm stärktes inte av den cykliska belysningsmiljön under deras sista 24-timmarsperiod. Patienternas självrapporterade återhämtning efter intensivvård var bättre efter 12-månader efter utskrivning hos de som vårdats i interventionsmiljön. Slutsatser: Genom att studera de båda forskningsområdena vårdvetenskap och ljus/belysning tillsammans skapades ny kunskap till vårdvetenskapen. Trots svår sjukdom eller skada kunde patienterna bedöma och reflektera kring belysningsmiljön. Ämnesområdet lämpar sig väl för att undersökas med både kvantitativa och kvalitativa metoder. / Aim: The overall aim of this thesis was to describe and evaluate patients’, who were cared for in the intensive care unit (ICU), experiences and effects concerning a cycled lighting intervention based on health, wellbeing and recovery. Methods: An automatically controlled cycled lighting intervention aimed to mimic natural light levels, quality and position throughout the day was evaluated. An ordinary lit room was used as a control. A multiple-method approach was used. In study I, there were three aspects: a systematic review of the previous research concerning cycled lighting interventions in the intensive care; visitor evaluations of the lighting environments in the intervention and ordinary room; and measurements of illuminance, luminance and irradiance in both conditions. In study II, the patients evaluated the lighting environment in the two rooms. Data were compared and analysed. Furthermore, patients’ experiences regarding the cycled lighting environment were investigated through qualitative interviews, which were subsequently analysed by content analysis. In study III, patients’ sleep, activity and physiological parameters were measured and compared. Study IV consisted of statistical analysis of a questionnaire concerning patients’ self-reported recovery six and 12 months after their ICU treatments. Results: The literature review on cycled lighting interventions in adult ICUs was rare but more common in the neonatal ICU (NICU). Findings showed that cycled lighting interventions improved health in preterm infants, but there were also non-significant results reported. The visitors reported the cycled lighting environment as more pleasant, and based on measurements, the lighting levels were at equivalent levels with European recommendations for hospitals. The lighting levels in the ordinary room were manually controlled and were reported as being either too low or too bright during the daytime. Patients evaluated the cycled lighting environment as brighter in daytime, and this was in coherence with the results from the measurements of illumination. Patients’ individual experiences concerning the cycled lighting environment were reported in four categories: a dynamic lighting environment, the impact of lighting on patients’ sleep, the impact of light/lighting on the circadian rhythm and the degree to which the lighting calmed them. Patients’ circadian rhythms were not further strengthened by the cycled lighting intervention during their final 24-period in the ICU. Twelve months after their ICU treatments, patients cared for in the intervention environment self-reported their recovery as significantly better than those who received treatment in the ordinary room. Conclusions: A multiple methodology was used to explore theresearch field from a wider perspective. Combining knowledge from both the lighting research field and caring science has brought new knowledge to both and especially to the practice of nursing. Despite their severe illnesses or injuries, patients were able to assess their experiences with the lighting environment and reflect on how the lighting was able to support their health. This thesis reports findings that indicate that environmental/lighting interventions may improvepatients’ health. Lighting interventions are harmless, safe, sustainable and, in comparison to technical and medical interventions, considerably cheaper. With this knowledge, we believe all vulnerable patients in the ICU should be surrounded by a lighting environment around the clock to support their health, wellbeing and recovery.

This dissertation documents the oral historical narratives of the lived school experiences of eleven participants in school at the passing of Brown v. The Board of Education. It is organized as a three-article dissertation where each article examines one topic that surfaced during my research. Article One critically interrogates the idea that integration over segregation is always in the best interest of students. It describes the positive experiences of Black students in segregated schools. Article Two describes the type of care Black teachers in segregated schools showed their students, which had a positive impact on their lives both academically and socially. It is this type of care that is often times missing in classrooms with White teachers in integrated schools. Article Three is a reflection about my journey as a Black, bilingual teacher in a teacher preparation program at a predominately White university. It highlights the importance of Black teacher voices in teacher preparation programs.

Philosophiae Doctor - PhD / Critical Care Outreach Services (CCOSs) recognize early sign of deterioration in medical units, regarding the condition of the patient, by using elements of vital sign tracking namely modified early warning score (MEWS). Nurses as leaders should be proactive by using influence to obtain a desired outcome. It is unclear how nurses experience self-leadership in this outreach service in a private hospital in Pretoria. The purpose of this research was to understand nurses’ experience of their self-leadership in the current CCOS at a private hospital in Pretoria, in order to develop self-leadership strategies that could contributes to the implementation of a CCOS (for the broader population of nurses) in a private hospital group in Gauteng. In this research the steps as outlined in the self-leadership strategic framework of Neck and Milliman (1994) were adapted for this research. The theoretical assumptions furthermore informed the methodological steps followed in the research process. The theoretical assumptions of the Practice Orientated Theory of Dickoff, James and Wiedenbach (1968) were adapted and the survey lists of this theory served as a reasoning map in this research. The central statement of this research was that, nurses need to lead themselves in implementing a CCOS in general wards in a private hospital group in Gauteng.