Increased levels of stress in the workplace have led the American Psychological Association to predict a looming public health crisis. Critical care nurses (CCNs) are highly exposed to stressors in the workplace, more than other nurses. Tens of billion dollars were reported lost in productive work time yearly due to ill health from depression alone. An important gap remains in understanding the relationships of stressors with the amount of stress. Supported by the biopsychosocial stress theory, the purpose of this study was to determine the relationship between frequencies of perceived stressors (IVs) as a source of perceived levels of stress (DV) or allostasis. The mixed-methods study included an online questionnaire and an e-mail interview of 400 hospital-based CCNs from professional nurses' associations in the United States. The Nursing Stress Scale was used to determine the kinds and frequencies of IVs, while the Psychological Stress Measure was used to assess the DV. Multiple regression analysis assessed the strength and direction of the relationships between IVs and DV. Interviews fell short of the minimum sample size for saturation and were not analyzed. Quantitative findings indicated workload as the most frequently perceived stressor, correlating positively with allostasis (p = .0005). Death and dying, conflict with other nurses, and lack of support for CCNs were also statistically significant (p < .05). Implications to practice and social change include promoting changes in policy with management support to reduce workload, death and dying, conflict with other nurses, and lack of social support for CCNs. Personal behavior changes like relaxation and physical exercises as coping methods may also reduce levels stress.

Compassion fatigue (CF), also known as secondary traumatic stress (STS), impacts critical care nurses (CCN) through exposure to pain, suffering, and loss of those for whom they provide care and results in a reduction of compassion satisfaction (CS). High incidence of CF and turnover (TO) rates at the project site were identified among CCNs. The institution's CCN TO rate was at 81% in comparison to peers in other areas at 29%–35%. The practice-focused question asked whether leadership education on CF might ameliorate CF at the project site. The purpose of the Doctor of Nursing Practice project was to reduce the incidence of CF and TO among CCN through leadership education. Watson's theory of human caring was used as a framework. Two hundred twenty-nine CCNs completed the Professional Quality of Life survey that measures CS, STS, and burnout (BO). Comparison of 28 nursing leaders' pretest scores to posttest scores indicated a statistically significant improvement (z = -4.625, p < .001) and knowledge acquisition. BO and CF taken together explained 86% (adjusted R2 = .86) of the variance in CS (F [2, 227] = 691.33, p < .001). Identifying the nursing units with the highest CF scores and providing CF education to the leadership provides a path to reduce turnover and provide needed support to CCNs, a positive social change.

This thesis has three main research aims. First the development of a questionnaire to measure HRQOL of ICU patients. Second, to examine a model of HRQOL proposed to assist with the development of the questionnaire. Third, to examine the HRQOL outcomes of patient after hospital discharge. The proposed model is based on a review of conceptual issues related to Quality of Life (QOL), Health Status and HRQOL. After a content analysis of a broad range of definitions of QOL, Health Status and HRQOL, QOL was defined as a dynamic attitude, continually being modified by experience. It is a function of the cognitive and affective appraisals of the discrepancies between domain specific perceptions and expectations. HRQOL was defined as an individuals cognitive and affective response to, or the QOL associated with, their health status. Health status was seen to consist of two health dimensions, physical and psychological health, with each dimension being composed of a number of component measures assessed subjectively. The developed questionnaire, the Sydney Quality of Life (SQOL) had good construct validity, based on substantial correspondence between qualitative and quantitative data, and internal consistency data (factor analysis and Cronbach's alpha). It had good concurrent validity in relation to the Sickness Impact Profile. The second order factor analysis of the SQOL suggested that health status may consist of three dimensions, physical health, positive mental health and negative mental health. The HRQOL model when formally examined, using Structural Equation Modelling (using LISREL), was not supported. However, exploratory modelling supported the separation of mental health into positive and negative components. The structure of HRQOL was different for patients than for the community from which they came. Patients QOL was determined largely by positive mental and physical health, whereas community members QOL was largely determined by negative mental health. Sixty three percent of patients at 12 months after discharge had significantly worse physical and functional health, lower satisfaction with their lives, lower positive affect and poorer QOL. Overall, mental health adapts rapidly to the impact of serious physical ill health and hospitalisation. Implications for clinical practice are examined.

Patient safety is of particular importance within intensive care units (ICUs), where critically ill, vulnerable patients receive complex multidisciplinary care. Prior research has indicated that improving patient safety and reducing errors within healthcare requires a focus on systems and organisational culture issues. This thesis was concerned with three studies. One focused on assessing the patient safety culture and two on quality improvement initiatives within an intensive care unit (ICU) of a large teaching hospital. The first study involved a survey of ICU consultant, registrar and nursing staff regarding aspects of safety culture. This was conducted using an existing Hospital Survey on Patient Safety Culture. Of the twelve patient safety culture composites assessed, eight had scores lower than 50%, highlighting these as areas for improvement. Overall, while the survey results revealed that teamwork within the ICU was considered a strength, event reporting and patient care handovers and transitions were both considered areas with potential for improvement. The second study focused on the evaluation of a change initiative designed to improve the handover of patient clinical information in the ICU. This study involved a survey and interviews with consultant, registrar and nursing staff before and after the introduction of a Patient Management, Plan and Progress (PMPP) document. Examination of the survey responses involved both quantitative and qualitative analysis; respondent interview transcripts were analysed using thematic analysis. The results of this study revealed resistance to, and criticisms of, the introduction of the PMPP document; the initiative failed and use of the document was discontinued. The second initiative concerned an evaluation of the impact of a hospital-wide document on improving documentation of withdrawal of patient treatment within the ICU. This involved both quantitative and qualitative analysis, with a patient medical record audit of decisions to withdraw patient treatment within the ICU before and after the introduction of an Advance Care Plan (ACP) document. ICU consultant, registrar and nursing staff were interviewed regarding the process of withdrawal of patient treatment within the ICU. Interview transcripts were analysed using a modified grounded theory approach. Results revealed that the attempt to improve the documentation of withdrawal of treatment within the ICU failed, with the ACP document remaining unused in 89% of cases and incomplete in the remaining 11%. Also, documentation of decision-making and of the process within the medical records did not improve. Before-introduction findings revealed that only 26% of medical records met the pre-existing requirements for treatment withdrawal in the ICU, and after-introduction findings revealed that only 19% of medical records audited met the requirements of the ACP document. After-audit findings also revealed significant and inappropriate increases in the involvement of an ICU registrar both as primary and secondary decision-makers. In spite of an increased awareness of ICU staff concerning the importance of improving documentation, the medical record audit revealed less compliance with the standards required for documentation. Possible reasons for the document remaining essentially unused, as revealed from interviews with staff, included: previous criticisms by the coroner when they failed to complete a similar formalised document properly; perceived logistical issues associated with obtaining required staff signatures; disagreement concerning who should be involved in documenting the withdrawal of treatment process; and the existence of an ICU subculture of practice that, in one particular aspect of documentation, was not consistent with established hospital and ICU protocol and documentation requirements. The final chapter of this thesis considered implications of the results of the studies for the planning, development, implementation and evaluation of improvement programs within the ICU setting. The results were considered within the context of organisational change management theory and research, including factors that have been found to be critical in the success or failure of change programs, such as resistance to change, the involvement of key stakeholders in the change process, leadership, communication and organisational culture. It is suggested that management consultants with organisational change expertise in the planning, development, implementation and evaluation of such programs should be involved in future quality improvement initiatives. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1297608 / Thesis (Ph.D.) -- University of Adelaide, School of Psychology, 2007

Royal Perth Hospital is the largest hospital in Western Australia and also has the largest intensive care unit (ICU) in the State. It was the first public hospital to provide intensive care services in Western Australia. This thesis examines the intermediateand long-term outcomes of patients admitted to the Royal Perth Hospital ICU between 1987 and 2002. Intermediate-term survival, defined as survival after discharge from hospital to one year and long-term survival, that exceeding one year after discharge, are important outcomes. Information on outcomes can be used by ICU staff in discussions with patients and their families and to inform policy decision-making and future research. The aim of this research was to examine one-year and long-term outcomes of patients admitted to the ICU between 1987 and 2002 and explore the factors that might be associated with the outcomes for 22,298 patients admitted to the ICU. A clinical ICU database was linked to morbidity and mortality databases by Data Linkage WA. A wide range of demographic and clinical factors were examined for their effect on outcome. These included age, sex, comorbidity, severity of illness, organ failure, ICU diagnostic groups, type of admission (medical, elective surgical and non-elective surgical), length of stay in ICU and era of admission (1987-1990, 1991-1994, 1995-1998, 1999-2002). Patients were followed-up to study end, 31st December 2003 or death if it occurred before study end, that is, up to 17 years after the index ICU admission. Kaplan Meier survival curves and Cox regression models were used to examine intermediate and long-term survival for patients who survived to hospital discharge. A comparison of admissions to hospital before and after the index ICU admission was made using descriptive statistics and logistic regression. Throughout the study period survival for the ICU cohort was shorter when compared to the Australian population. This was consistent throughout the follow-up period. The most important determinants of long-term survival were age, comorbidity, severity of illness and diagnostic group but the strength of association varied with the duration of follow-up. Although age, comorbidity and severity of illness increased among the critically ill survival improved over time. Hospital admissions were more frequent after a discharge from hospital that required an admission to ICU than before the index admission, even after adjusting for the ageing of the cohort. This study provides unique information about the survival and other outcomes of patients discharged from a hospital admission that included an ICU stay. The strength of this study lies in the follow-up to 17 years and the more comprehensive range of explanatory factors than in previous studies. This thesis demonstrates that follow-up studies after intensive care should be of sufficient duration to account for the changes that occur in survival over time and indicates the range of factors that should be taken into account when making comparisons of long-term survival.

<p> </p><p>Intensivvårdsjuksköterskan möter i sitt dagliga arbete många patienter som behandlas i respirator. Långvarig respiratorbehandling innebär ofta ökade risker för komplikationer. Med anledningen av detta är det viktigt att minska tiden i respirator med effektiv urträning. Att tränas ur respiratorn är en individuell process och bör därför anpassas efter patientens förmåga. Syftet med examensarbetet<strong> </strong>var att beskriva intensivvårdssjuksköterskors<strong> </strong>erfarenheter av tracheostomerade patienters urträning ur respirator. Metoden var kvalitativ och datainsamlingen genomfördes med intervjuer av fem intensivvårdsjuksköterskor på ett sjukhus i Mellansverige. Intervjuerna analyserades med latent kvalitativ innehållsanalys. Resultatet visar att urträningsprocessen är ett komplext fenomen och beskriver intensivvårdssjuksköterskors erfarenheter av olika möjligheter och hinder som kan påverka patienten i urträningsprocessen. Dessa beskrivs närmare under tre kategorier: IVA sjuksköterskans kompetens, att vara medveten om patientens olika förutsättningar och ett fungerande samarbete har betydelse för urträningen. Intensivvårdssjuksköterskan ansågs ha en betydelsefull roll i patientens urträning och för det krävdes kunskaper och erfarenheter. Dokumentation och utvärdering har betydelse för en framgångsrik urträning. Varje patient har olika förutsättningar och det är individuellt hur mycket patienten klarar av. Urträningen påverkas av patientens välbefinnande, andning och cirkulation. Kommunikation och medverkan av både personal och patient ansågs även viktigt i urträningsprocessen.</p><p> </p> / <p>The critical care nurse faces in her daily work, many patients who are mechanically ventilated. Prolonged ventilated treatment often means increased risk of complications therefore it is important to reduce the time on the ventilator with effective weaning. Weaning from ventilator is an individual process and should<em> </em>be adapted<strong><em> </em></strong>to the patient’s ability. The aim was to describe<strong> </strong>the<strong> </strong>critical care nurses’ experiences of tracheotomy patient’s weaning from ventilator. The research method was qualitative and the data collection was conducted with interviews of five critical care nurses in a hospital in central Sweden. The interviews were analyzed with latent qualitative content analysis. The result shows that the weaningprocess is a complex phenomenon and describes the critical care nurses´ experiences of different opportunities and barriers that may affect the patient in the weaning process. These experiences are described in detail in three categories; the critical care nurse’s competence, to be aware of the patient’s different conditions and good cooperation has been important for weaning. The critical care nurse was considered to have a significant role in the weaning process and for that she requires knowledge<strong> </strong>and experience. Documentation and evaluation are important for a successful weaning. Each patient has different circumstances and it is an individual process how much the patient can cope. The weaning process is affected by the patient’s wellbeing, breathing and circulation. Communication and involvement of both staff and patient was also considered important in the weaningprocess.</p> / Specialistsjuksköterska med inriktning mot intensivvård

Patients and next of kin in intensive care often experience powerlessness, anxiety and distress and intensive care staff are repeatedly exposed to traumatic situations and demanding events. Empowerment has been described as a process of overcoming a sense of powerlessness and a model through which people may develop a sense of inner strength through connections with others. The aim of this thesis was to describe empowerment as experienced by patients, next of kin and staff in intensive care and to compare patient's experiences with staff and next of kin beliefs. Empowerment is reflected in this thesis as experiences of inner strength and power and of participation/self-determination. The study was based on open-ended interviews with 11 patients, 12 next of kin and 12 staff members from two intensive care units in southern Sweden. A phenomenological perspective was applied in three studies, while a qualitative content analysis was used in the forth study. Findings showed that nourishing relationships were of crucial importance, and contributed to every participant's experiences of empowerment regardless of whether he/she was an intensive care patient, a next of kin or a staff member. Patients were found to be strengthened and empowered by a positive environment where their own inherent joy of life and will to fight was stimulated, where they felt safe and a sense of value and motivation were encouraged and where they were taken seriously and listened to. Next of kin were extremely important to patients' experiences of safety, value, human warmth and motivation, and patients were strengthened when their next of kin were acknowledge and welcomed by staff. Next of kin in intensive care were strengthened and empowered by a caring atmosphere in which they received continuous, straightforward and honest information that left room for some hope and in which closeness to the patient was facilitated and medical care was experienced as the best possible. Some informants were also empowered by family support and/or participation in caring for the patient. Intensive care staff were empowered by both internal processes such as feelings of doing good, increased self-esteem/self-confidence and increased knowledge and skills, and by external processes such as nourishing meetings, excitement and challenge, well functioning teamwork and good atmosphere. When comparing patient experiences with staff and next of kin beliefs, there was agreement regarding joy of life and will to fight being essential to patients' experiences of inner strength and power, but staff and next of kin seemed to see this as a more constant individual viewpoint or characteristic than the patient did. Next of kin, and especially staff, seemed to regard the patient as more unconscious and unable to participate in the communication and interaction process than the patient him/herself experienced. A mutual and friendly relationship was experienced by the patients as highly empowering, while a more professional relationship was emphasized by the staff. These findings could serve as a basis for reflection about patient, next of kin and staff experiences of strength and power and if empowerment is seen as a dimension in quality of care, the findings from this thesis ought to be taken into consideration to increase the quality of care in intensive care. / Patienter och närstående inom intensivvård upplever ofta maktlöshet, oro och inre stress. Upplevelser från intensivvårdstiden har visat sig kunna påverka patienters och närståendes psykologiska välbefinnande under lång tid, även efter det fysiska tillfrisknadet. Intensivvårdspersonal utsätts mer eller mindre frekvent för svåra och traumatiska händelser, vilket kan orsaka stress och utbrändhetssymtom. Empowerment har beskrivits som en process för att övervinna upplevelser av maktlöshet eller en modell genom vilken människor kan utveckla en känsla av inre styrka. Syftet med denna avhandling var att beskriva patienters, närståendes och personals upplevelser av empowerment inom intensivvård. Syftet var också att jämföra patienters upplevelser med vad närstående och personal tror att de upplever. Med empowerment avses här upplevelser av inre kraft och styrka samt av delaktighet/självbestämmande. Avhandlingen är baserad på öppna intervjuer med 11 patienter, 12 närstående och 12 personal vid två intensivvårdsavdelningar i södra Sverige. Alla intensivvårdspatienter upplevde att den egna livsgnistan och kämparvilja var avgörande för deras upplevelser av inre kraft och styrka och inverkade på deras möjlighet att tillfriskna. Livsgnistan och kämparviljan påverkades i sin tur av vad som hände runt omkring patienterna. En positiv atmosfär där de kände sig trygga, betydelsefulla och blev lyssnade på, stärkte deras livsgnista och kämparvilja, liksom extra omsorg, uppmuntran och stärkt motivation. Närstående spelade en viktig roll i att förstärka patienternas upplevelser av trygghet, värde och motivation och öka deras upplevelse av inre kraft och styrka. Atmosfären hade stor betydelse för närståendes upplevelser av kraft och styrka och de påverkades mer av hur något utfördes än av vad som utfördes. Det var viktigt för närstående att känna att det fanns både en kapacitet och en vilja att hjälpa och lindra och de upplevde det stärkande att känna att personalen brydde sig såväl om patienten som om dem. En kontinuerlig, rak och ärlig information som lämnade rum för hopp, tillsammans med möjlighet att få vara nära den svårt sjuke familjemedlemmen samt en upplevelse av att patienten fick bästa möjliga medicinska vård, upplevdes av närstående som stärkande. Några stärktes även av stöd från andra familjemedlemmar och av att få vara delaktiga i vården. Vårdpersonalen fick kraft och styrka både av interna och externa processer. Exempel på stärkande interna processer var upplevelsen av att göra gott, av att ha kunskaper och färdigheter för att klara de uppgifter och utmaningar man ställdes inför, samt av att känna sig trygg både i sig själv (självkänsla) och i det man gjorde (självförtroende). Närande möten med närstående och patienter, spänning och utmaningar, välfungerande teamarbete och en positiv atmosfär är exempel på externa processer som bidrog till personalens upplevelse av inre kraft och styrka. När patienternas upplevelser jämfördes med vad närstående och personal trodde att de upplevde, fanns en samsyn i att patienternas egen livsgnista och kämparvilja hade stor betydelse för deras upplevelse av kraft och styrka. Närstående och personal betraktade emellertid patientens livsgnista och kämparvilja som ett tämligen statiskt karaktärsdrag, medan patienterna själva menade att livsgnistan och kämparviljan i hög utsträckning påverkades av atmosfären runt omkring dem och av hur de blev bemötta. Närstående och personal, tycktes betrakta patienterna som mer omedvetna och oförmögna att kommunicera och samverka med omgivningen än vad patienterna själva upplevde. Patienterna upplevde det som ytterst stärkande när de fick känna sig som medlemmar i vårdteamet och inte ”bara som en patient”.

Intensivvårdsjuksköterskan möter i sitt dagliga arbete många patienter som behandlas i respirator. Långvarig respiratorbehandling innebär ofta ökade risker för komplikationer. Med anledningen av detta är det viktigt att minska tiden i respirator med effektiv urträning. Att tränas ur respiratorn är en individuell process och bör därför anpassas efter patientens förmåga. Syftet med examensarbetet var att beskriva intensivvårdssjuksköterskors erfarenheter av tracheostomerade patienters urträning ur respirator. Metoden var kvalitativ och datainsamlingen genomfördes med intervjuer av fem intensivvårdsjuksköterskor på ett sjukhus i Mellansverige. Intervjuerna analyserades med latent kvalitativ innehållsanalys. Resultatet visar att urträningsprocessen är ett komplext fenomen och beskriver intensivvårdssjuksköterskors erfarenheter av olika möjligheter och hinder som kan påverka patienten i urträningsprocessen. Dessa beskrivs närmare under tre kategorier: IVA sjuksköterskans kompetens, att vara medveten om patientens olika förutsättningar och ett fungerande samarbete har betydelse för urträningen. Intensivvårdssjuksköterskan ansågs ha en betydelsefull roll i patientens urträning och för det krävdes kunskaper och erfarenheter. Dokumentation och utvärdering har betydelse för en framgångsrik urträning. Varje patient har olika förutsättningar och det är individuellt hur mycket patienten klarar av. Urträningen påverkas av patientens välbefinnande, andning och cirkulation. Kommunikation och medverkan av både personal och patient ansågs även viktigt i urträningsprocessen. / The critical care nurse faces in her daily work, many patients who are mechanically ventilated. Prolonged ventilated treatment often means increased risk of complications therefore it is important to reduce the time on the ventilator with effective weaning. Weaning from ventilator is an individual process and should be adapted to the patient’s ability. The aim was to describe the critical care nurses’ experiences of tracheotomy patient’s weaning from ventilator. The research method was qualitative and the data collection was conducted with interviews of five critical care nurses in a hospital in central Sweden. The interviews were analyzed with latent qualitative content analysis. The result shows that the weaningprocess is a complex phenomenon and describes the critical care nurses´ experiences of different opportunities and barriers that may affect the patient in the weaning process. These experiences are described in detail in three categories; the critical care nurse’s competence, to be aware of the patient’s different conditions and good cooperation has been important for weaning. The critical care nurse was considered to have a significant role in the weaning process and for that she requires knowledge and experience. Documentation and evaluation are important for a successful weaning. Each patient has different circumstances and it is an individual process how much the patient can cope. The weaning process is affected by the patient’s wellbeing, breathing and circulation. Communication and involvement of both staff and patient was also considered important in the weaningprocess. / Specialistsjuksköterska med inriktning mot intensivvård

Objective The aim of this study was to explore nurses' experiences of informing relatives to critically ill patients in the intensive care unit (ICU). Method The study was descriptive with a qualitative approach. Nine nurses were interviewed. The study took place in a university hospital in the midst of Sweden. An interview guide was used, designed in consensus with the study questions. Data was analyzed via qualitative content analysis . Findings Meeting and preparing relatives at the arrival at the ICU seemed valuable and led to safety and participation among relatives. The information given to relatives focused on the patient's current condition and nursing interventions. The information, however, often tended to be medical. It felt difficult to give distinct and clear information, since the patients´ condition could change rapidly. A simple language and repetition seemed important for the relatives´ possibilities to understand information. Personal and professional qualities and experience seemed to be important skills when informing relatives. Environment, stress and lack of space seemed aggravating for informing relatives, while co-operation, documentation and development of working routines were simplifying factors. Conclusion Nurses found informing relatives, as one of the most important nursing tasks, leading to increased comfort, participation and understanding among relatives.

Utgångspunkten för denna litteraturstudie är att ventilatorassocierad pneumoni (VAP) går att förebygga. Syftet med detta arbete var att kartlägga olika evidensbaserade munvårdsmetoder som används av intensivvårdssjuksköterskor för att förebygga VAP hos ventilatorbehandlade patienter. Syftet var också att belysa vilka faktorer som påverkar intensivvårdssjuksköterskans utförande av evidensbaserad munvård till ventilatorbehandlade patienter. Studien utfördes som en systematisk litteraturstudie. Till resultatet användes 16 vetenskapliga artiklar. För att kunna bedöma artiklarnas vetenskapliga kvalitet granskades artiklarna utifrån en modifierad granskningsmall. Samtliga artiklar fick höga kvalitetspoäng, vilket innebär hög vetenskaplig relevans. Resultatet av litteraturstudien visar att i flera av de evidensbaserade munvårdsprotokoll som publicerats den senaste tiden finns några återkommande punkter. Dessa punkter är; bedömning av munhålans status, tandborstning med barntandborste, munsköljmedel och att munnen fuktas med ett intervall av två till sex timmar. Flera faktorer påverkar intensivvårdssjuksköterskans utförande av evidensbaserad munvård. Genom att införa ett evidensbaserat munvårdsprotokoll för ventilatorbehandlade intensivvårdspatienter och ge personalen utbildning i munvård kan incidensen av VAP minska. Resultatet visar också att generellt sett är kunskapsnivån låg hos intensivvårdssjuksköterskor gällande förebyggande åtgärder för att förhindra VAP. Om sjuksköterskan anser att hon/han har tid att utföra munvård blir resultatet av högre kvalitet och hon/han upplever också åtgärden som mindre obehaglig. Detta innebär att försök att förbättra omvårdnaden och därmed minska antalet vårdrelaterade infektioner även är en organisatorisk fråga.