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Interhospitala överföringar har ökat de senaste åren och tidigare forskning har fokuserat på transportfasen utifrån olika perspektiv. Det saknas däremot forskning kring intensivvårdssjuksköterskans upplevelse av att ta emot och vårda patienter efter interhospital överföring, därför valde vi att fokusera på detta ämne. Syftet med studien är att beskriva intensivvårdssjuksköterskans upplevelser av vårdandet av patienter efter en interhospital överföring. En kvalitativ intervjustudie genomfördes. Nio specialistsjuksköterskor inom intensivvård med erfarenhet av att vårda patienter efter interhospitala överföringar intervjuades. Dataanalysen är baserad på kvalitativ innehållsanalys och resulterade i åtta subteman och tre teman: Upplevelse av kontroll, Upplevelse av ambivalens kring överföringar, Upplevelse av samhörighet med andra. Det upplevs positivt att ta emot och vårda patienter efter interhospital transport när det finns möjlighet till förberedelse, både praktiskt och mentalt. Samma känsla infinner sig när mötet med patienten och anhöriga blir bra och när samarbetet på avdelningen och mellan enheterna är tillfredställande. Dock upplevs viss stress om det finns brister i dokumentation och informationsöverföring eller om mottagandet av patienten och dess närstående känns otillräckligt. Resultatet illustrerar komplexiteten av mottagandet efter överföring och betonar vikten av en bra överlämning. Utvecklingsområden finns såsom enhetliga journalsystem mellan regioner och att undvika interhospitala överföringar på grund av resursbrist. / Interhospital transfers have increased in number over the last years and at this point there is a good amount of research focussed on the transport phase of transfers that even includes different perspectives. There is, however, a lack of research concerned with the aftermath of a patient transfer such as taking over and caring for the patient. We therefore decided to make this the focus of our study. The aim of this study was to investigate the experience of critical nurses of caring for patients after interhospital transfer. We conducted a qualitative interview study where we interviewed nine critical care nurses from two mid-level general intensive care units. Data analysis was performed using qualitative content analysis. This resulted in 8 sub-themes and 3 main themes: Experience of control, Ambivalence regarding transfers and Experiencing fellowship. The result demonstrates that critical care nurses have a positive experience of receiving and caring for patients after interhospital transfer given that they had to opportunity to be mentally and practically prepared. Meeting the patient and their family members also generates a positive experience when the cooperation and information transfer between units has been satisfactory. Critical care nurses experience stress when they perceive threats to patient safety such as incomplete transfer of information or documentation or when the encounter with the patient and their family members was marked by problems. The result shows the complexity of taking over patients after transfer and the importance of a high-quality patient handover. Areas of improvement for transfers are seen by introducing a unified national medical record system and avoiding interhospital transfers due to lack of resources.

Sepsis is a clinical syndrome characterized by the systemic activation of inflammatory and coagulation pathways in response to microbial infection of normally sterile parts of the body. Despite considerable advances in our understanding of sepsis pathophysiology, sepsis remains the leading cause of death in non-coronary intensive care units (ICU) with a global disease burden between 15 and 19 million cases per year (Dellinger et al., 2008). Severe sepsis, defined as sepsis associated with organ dysfunction is associated with mortality rates of 33% to 45%. The incidence of severe sepsis continues to increase by 1.5% per annum due to the aging population, a rise in the prevalence of comorbidities, and the wider use of immunosuppressive agents and invasive procedures (Angus et al., 2001). Over the past several decades, many potential treatments for sepsis have shown early promise, yet have failed to improve survival in over 100 Phase II and Phase III clinical trials (Marshall, 2014) suggesting that some fundamental knowledge is lacking in our understanding of sepsis pathophysiology. Emerging studies on cell-free DNA (cfDNA), DNA released extracellularly into the circulation, demonstrate that cfDNA is a crucial link between inflammation and coagulation . In various conditions characterized by excessive inflammatory responses or aberrant prothrombotic responses, cfDNA has been implicated in exacerbating disease pathology (Atamaniuk, Kopecky, Skoupy, Säemann, & Weichhart, 2012; Fuchs, Brill, & Wagner, 2012; Swystun, Mukherjee, & Liaw, 2011). In clinical sepsis, levels of cfDNA upon admission into the ICU have strong prognostic value in predicting mortality (Dwivedi et al., 2012; Saukkonen et al., 2008). However, it is unclear whether these increases in cfDNA are an epiphenomenon during sepsis progression, or whether cfDNA actively plays a role in sepsis pathophysiology. In this work, in vivo studies were conducted to characterize the role of cfDNA in sepsis, the effects of DNase administration, and the potential mechanism by which cfDNA is released during experimental sepsis. In addition, mortality studies were conducted to identify surrogate markers of death to promote the design of humane and ethical animal studies in conducting sepsis research. Polymicrobial sepsis was induced via a surgical procedure whereby the cecum is exteriorized, ligated and punctured twice to introduce a continuous source of microorganisms, a model termed cecal ligation and puncture (CLP). In our CLP sepsis model, levels of cfDNA increased in a time-dependent manner. These increases accompanied an early pro-inflammatory response marked by increased pro-inflammatory IL-6, a transient increase in anti-inflammatory IL-10, and elevated lung myeloperoxidase (MPO) activity. Septic mice with elevated cfDNA levels also had high bacterial loads in the lungs, blood, and peritoneal cavity fluid. Organ damage was also observed in mice following CLP surgery versus mice subjected to the non-septic sham control surgery marked by increased levels of creatinine and alanine aminotransferase (ALT) indicative of kidney and liver injury, respectively. Histological analyses further confirmed lung and kidney damage following CLP surgery. Changes in coagulation were also observed in septic mice as mice subjected to CLP had sustained increases in thrombin-antithrombin (TAT) complexes. In addition, plasma from CLP-operated mice had increased thrombin generation (i.e. increased endogenous thromin potential, increased peak thrombin, decreased time to peak, and decreased lag time) mediated by FXIIa and enhanced by platelets. Following CLP-induced sepsis, elevations in cfDNA levels accompanied pro-inflammatory and pro-coagulant responses. The effects of in vivo DNase treatment in septic mice were time-dependent. Early DNase treatment when cfDNA levels were low resulted in an exaggerated pro-inflammatory response marked by increased plasma IL-6 levels and increased lung damage. In contrast, delayed DNase treatment at time-points when cfDNA levels were elevated suppressed inflammation characterized by an increase in anti-inflammatory IL-10 and reductions in cfDNA, IL-6, lung MPO, and ALT activity. Furthermore, delayed DNase administration resulted in decreased bacterial load in the lungs, blood, and peritoneal cavity fluid. Delayed DNase treatment also resulted in blunted pro-coagulant responses as levels of TAT complexes were suppressed and thrombin generation from septic mouse plasma was normalized. Moreover, DNase treatment when cfDNA levels were elevated increased survival in CLP-operated mice by 80% and reduced lung and liver damage. These findings suggest that administration of DNase when cfDNA levels are elevated may reduce pro-inflammatory and pro-coagulant responses and that delayed DNase treatment may infer protection in the CLP model of sepsis. One mechanism by which cfDNA is released is via the formation of neutrophil extracellular traps (NETs). Upon inflammatory stimulation, some neutrophils release chromatin material and antimicrobial proteins (i.e. neutrophil elastase, MPO, and histones) in an active process termed NETosis. Although NETs ensnare bacteria and exert antimicrobial properties, NETs may also exert harmful effects on the host by activating inflammation and coagulation. While some in vitro evidence suggest that neutrophils are the main source of cfDNA released following inflammatory stimulation, others have reported that neutrophils are not the main source of circulating cfDNA following septic challenge. To determine whether NETs contribute to cfDNA released during CLP sepsis, genetically modified mice that are incapable of forming NETs, PAD4-/- mice, were used. Levels of cfDNA in PAD-/- mice were significantly lower than cfDNA levels in C57Bl/6 mice following CLP surgery, suggesting that NETs were a source of cfDNA in our model. Levels of IL-6, MPO, and bacterial load in the lungs, blood, and peritoneal cavity were significantly reduced, indicating that NETs exert pro-inflammatory effects in CLP sepsis. Thrombin generation was also suppressed in PAD4-/- mice which suggests that NETs contribute to thrombin generation following CLP sepsis. NETs contribute to increases in circulating cfDNA and may exacerbate pathology by driving pro-inflammatory and pro-coagulant responses in CLP-induced sepsis. Appreciating the implications of conducting research using animals, it is pertinent that researchers ensure the highest ethical standards and design animal studies in the most humane, yet scientifically rigorous manner. Using mortality studies, we validated the utility of physiological and phenotypic markers to assess disease severity and predict death in murine sepsis. Temperature via a rectal probe monitor and sepsis scoring systems which assess components such as orbital tightening, level of consciousness, and activity were effective surrogate markers of death. These tools offer a non-invasive assessment of disease progression which do not artificially exacerbate sepsis pathology and immediate information regarding any changes in the health status. Surrogate markers of death also provide reliable monitoring to meet increasing standards of ethical, humane animal research and a feasible and cost-efficient means to obtain vital signs in small rodents. We have proposed a scoring system which can be used for assessing disease severity, endpoint monitoring, and predicting death to obviate inhumane methods of using death as an endpoint in sepsis studies. In summary, cfDNA levels are elevated in CLP-induced sepsis and these elevations accompany pro-inflammatory and pro-coagulant responses. NETosis may be a mechanism by which cfDNA is released and NETs may drive inflammation and coagulation in CLP sepsis. Delayed DNase administration may suppress inflammation and coagulation and may be protective in polymicrobial sepsis. In future animal sepsis studies, surrogate markers of death and a sepsis scoring system can be used in place of death as an endpoint to raise the standards in conducting ethical, humane sepsis research. / Thesis / Doctor of Philosophy (PhD)

Le manque de rétention des infirmières en soins critiques au Québec déjà observé depuis plusieurs années perdure et s’est aggravé depuis la pandémie de COVID-19. Les programmes d’orientation à l’embauche permettraient de contribuer à la rétention des infirmières débutant dans ces milieux. À ce jour, cependant, aucune revue de la littérature n’a été effectuée dans l’objectif de mieux comprendre ces effets. Une revue rapide des écrits a été réalisée dans le but de mieux comprendre les effets des programmes d’orientation sur la rétention des infirmières en soins critiques. Les caractéristiques des programmes menant à des effets favorables ont également été recherchées. L’approche de Dobbins (2017) a été utilisée aux fins d’élaboration de cette revue rapide. Sept écrits ont pu être sélectionnés et analysés selon des critères d’inclusion. Les études considérées devaient se rapporter à des programmes ou interventions de formation auprès des infirmières débutant en soins critiques. Les études devaient se dérouler dans un milieu de soins critiques, tel que l’unité de soins intensifs adulte, pédiatrique ou néonatale. L’analyse des études recensées montre une rétention améliorée chez les infirmières après l’implantation d’un programme d’orientation. Les résultats indiquent également des améliorations en ce qui a trait au recrutement, taux de départ, connaissances, satisfaction, coûts et disponibilité des lits. Les programmes d’orientation qui ont eu des effets bénéfiques sur la rétention des infirmières comportent plusieurs éléments : le recourt à la théorie « novice à experte » de Benner (1984), le préceptorat accompagné de mentorat ou le recours à une personne-ressource, la formation des précepteurs, les méthodes évaluant le progrès des recrues et l’emploi de stratégies éducatives variées. Cette revue rapide des écrits a permis d’alimenter la réflexion sur les effets des programmes d’orientation sur la rétention des infirmières en soins critiques, tout en mettant en évidence des pistes pour poursuivre l’étude de ces programmes. / Critical care settings in Quebec are struggling with low retention of nursing staff which has worsened under the effect of the COVID-19 pandemic. Orientation programs could help to overcome low retention rates. To date, no review of the literature has been carried out with the aim of better understanding these effects. A rapid review of the literature was conducted to better understand the effects of orientation programs on the retention of critical care nurses. Program characteristics leading to positive effects on retention were also investigated. The Dobbins (2017) approach was used for the development of this rapid review. Seven writings were selected and analyzed according to inclusion criteria. The studies considered had to relate to training intervention or orientation programs for nurses new to critical care. Studies had to take place in a critical care setting, such as the adult, pediatric or neonatal intensive care unit. The analysis of the studies reviewed shows improved retention among nurses after implementation of an orientation program. The results also point to improvements in recruitment, attrition rates, knowledge, satisfaction, costs, and bed availability. Orientation programs that have had beneficial effects on the retention of nurses include several elements: the use of Benner’s "novice to expert" theory (1984), preceptorship, mentoring or the use of a resourceful person, training of preceptors, evaluation of the progress of recruits and the use of various educational strategies. This study provides an initial insight into the characteristics of orientation programs to be reviewed in the critical care unit to increase the nurse retention while highlighting avenues for further study of these programs.

The intent of this thesis was to examine compassion fatigue in nurses through analysis of research studies conducted within the past five years in an effort to identify predisposing factors to the experience of compassion fatigue. Individual and institutional factors were identified as well as current strategies to assist with management of compassion fatigue. Findings indicated that being new to practice, having a trait negative affect, being younger in age, having a history of exposure to trauma and working in high emotionally stressful units predisposed individuals to the experience of compassion fatigue. Institutional factors included a lack of managerial support, organizational commitment, group cohesion, work engagement and conflicting expectations of the nurse. Institutional interventions to assist in mitigating compassion fatigue include improving managerial support, developing group cohesion and communication and providing continuing education opportunities. Institutions can also assist by offering training in resiliency techniques such as negative thought pattern identification, meditation, peer-to-peer discussions, journaling about traumatic experiences, identification and maintenance of personal/professional boundaries and physical wellness through exercise and yoga. These proposed interventions address institutional accountability in health care worker wellness as defined by the quadruple aim. Such interventions also address use of Watson’s Caring Theory to emphasize the importance of nurse wellness as essential to creating caring nurse-patient relationships.

Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in the intensive care unit, resulting in a high burden of illness, mortality and increased cost. The literature around the cost-effectiveness of probiotics in prevention of health-care associated infections has not been previously well-described, and a definitive health economic evaluation alongside a well-designed randomized control trial assessing probiotic prophylaxis has not been previously performed. This thesis consists of 3 separate manuscripts (with 2 published in peer-reviewed journals and 1 pending). The theme of this thesis was to: (1) describe the literature about the cost-effectiveness of probiotics in hospitalized patients in preventing healthcare-associated infections; (2) design a protocol for an economic evaluation alongside a randomized control trial (RCT) examining probiotic prophylaxis of VAP; and then (3) perform and analyze the health economic evaluation presented in the protocol. The first component of this thesis is a systematic review of probiotic prophylaxis of healthcare-associated infections in hospitalized patients. We performed an extensive search including multiple databases which found 7 studies. Probiotics demonstrated favourable cost-effectiveness in 6 of 7 (86%) economic evaluations, with 3 studies being manufacturer-supported, all suggesting cost-effectiveness. Certainty of cost-effectiveness evidence was very low due to risk of bias, imprecision and inconsistency using the GRADE approach. Hence further RCTs with economic evaluations were stated as a solution. The second component of this thesis is a study protocol for an economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT), which assessed the efficacy of probiotic prophylaxis in the prevention of healthcare-associated infections (specifically VAP). The third component of this thesis is the cost-effectiveness analysis performed utilizing the individual patient data from PROSPECT to produce the economic evaluation (E-PROSPECT). As of the date of thesis submission, PROSPECT is still pending publication, and hence E-PROSPECT is also pending analysis and publication. However, I have prepared a draft manuscript (along with figures and tables) that will be produced at the conclusion of E-PROSPECT for thesis committee review. / Thesis / Master of Health Sciences (MSc) / Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in the intensive care unit, resulting in a high burden of illness, mortality and increased cost. The literature around the cost-effectiveness of probiotics in prevention of health-care associated infections has not been previously well-described, and a definitive health economic evaluation alongside a well-designed randomized control trial assessing probiotic prophylaxis has not been previously performed. This thesis consists of 3 separate manuscripts (with 2 published in peer-reviewed journals and 1 pending). The theme of this thesis was to: (1) describe the literature about the cost-effectiveness of probiotics in hospitalized patients in preventing healthcare-associated infections; (2) design a protocol for an economic evaluation alongside a randomized control trial (RCT) examining probiotic prophylaxis of VAP; and then (3) perform and analyze the health economic evaluation presented in the protocol. The first component of this thesis is a systematic review of probiotic prophylaxis of healthcare-associated infections in hospitalized patients. We performed an extensive search including multiple databases which found 7 studies. Probiotics demonstrated favourable cost-effectiveness in 6 of 7 (86%) economic evaluations, with 3 studies being manufacturer-supported, all suggesting cost-effectiveness. Certainty of cost-effectiveness evidence was very low due to risk of bias, imprecision and inconsistency using the GRADE approach. Hence further RCTs with economic evaluations were stated as a solution. The second component of this thesis is a study protocol for an economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT), which assessed the efficacy of probiotic prophylaxis in the prevention of healthcare-associated infections (specifically VAP). The third component of this thesis is the cost-effectiveness analysis performed utilizing the individual patient data from PROSPECT to produce the economic evaluation (E-PROSPECT). As of the date of thesis submission, PROSPECT is still pending publication, and hence E-PROSPECT is also pending analysis and publication. However, I have prepared a draft manuscript (along with figures and tables) that will be produced at the conclusion of E-PROSPECT for thesis committee review.

Bakgrund: Bristande kommunikation är ett stort problem vid överrapportering och är en vanlig orsak till vårdskador. Att jobba med kritiskt sjuka intensivvårdspatienter i en högteknologisk miljö kan vara en utmaning. Intensivvårds- och anestesisjuksköterskor har ett nära samarbete vid omhändertagande och vårdövergångar av svårt sjuka patienter. Att undersöka upplevelser av att vara både avsändare och mottagare vid överrapportering kan medföra ökad förståelse och kunskap för de olika perspektiven vilket kan leda till förbättring av kommunikation vid överrapportering.  Syfte: Att beskriva intensivvårds- och anestesisjuksköterskors upplevelser vid överrapportering av kritiskt sjuka intensivvårdspatienter i respirator.  Metod: En kvalitativ intervjustudie med fyra intensivvårdssjuksköterskor och fyra anestesisjuksköterskor. Intervjuerna analyserades med kvalitativ innehållsanalys. Resultat:  Resultatet presenteras i fem kategorier: Att strukturerad och öppen kommunikation är viktigt; att relationer och professionstillhörighet påverkar innehåll och upplevelser; att arbetsmiljön spelar roll vid överrapportering; att erfarenhet har en betydande roll vid överrapportering; och att ha olika arbetsrutiner försvårar överrapportering. Slutsats: Överrapportering kräver effektiv kommunikation och är avgörande för informationsöverföring mellan intensivvårds- och anestesisjuksköterskor. Författarna ser variationen i upplevelser som en möjlighet att komplettera varandra och förbättra helhetsbilden av patienten. Det är ett gemensamt ansvar för vårdpersonal och ledning att främja ett öppet arbetsklimat för bättre sammanhållning. Arbetsmiljön behöver förbättras då den direkt påverkar kommunikationen och patientsäkerheten, vilket ledningen måste uppmärksamma. Erfarenhet är en viktig faktor för att strukturera information, vilket innebär att sjuksköterskor med mindre erfarenhet behöver tid och stöd för att utveckla denna färdighet. / Background: Poor communication is a significant issue in patient handover and is a common cause of patient harm. Working with critically ill intensive care patients in a high technological environment can be challenging. Critical care nurses and nurse anesthesiologists collaborate closely in the management and handover of severely ill patients. Exploring experiences as both sender and receiver during handover may lead to a better understanding and knowledge of the different perspectives that can improve the communication in patient handovers.  Aim: To explore critical care nurse and nurse anesthesiologists’ handover experiences of critically ill ICU patients with mechanical ventilator Method: A qualitative interview study involving four intensive care nurses and four anesthesia nurses. The interviews were analyzed using qualitative content analysis. Result: The results are presented in five categories: the importance of structured and open communication; working relationships and professional affiliations influence handover content and experiences.; the role of the work environment in handover; length of work experience has a significant role; and the presence of different work routines can complicate patient hand-off. Conclusion: Handover requires effective communication and is crucial for information transfer between critical care nurses and nurse anesthesiologists. The authors view the variation in experiences between the two professions as an opportunity to complement each other and enhance the overall understanding of the patient. It is a shared responsibility of the healthcare staff and management to foster an open work environment. The work environment in general needs improvement as it directly impacts communication and patient safety, which management must address. Experience is essential for structuring information, and newly trained nurses need time and support to develop this skill.

No / Non-invasive positive pressure ventilation (NPPV) provides respiratory support to patients without the need for invasive intubation. Although it has been used for several years in critical care, NPPV has come to prominence as a management option for certain patients with respiratory complications of coronavirus disease 2019 (COVID-19). This has led to increased care provision by nurses with little or no experience and expertise in critical care and NPPV. This article provides an overview of the principles of NPPV and its use in type 1 and type 2 respiratory failure. It explains the pathophysiology of several conditions that often lead to respiratory failure and how NPPV can mitigate respiratory failure and improve gas exchange. An individualised assessment of the patient’s suitability for NPPV and an evaluation of the effectiveness of the therapy are crucial to ensure its safe and effective use. Nurses also have an important role in providing explanations and support to patients.

Effective pain management and time to treatment is essential in patient care. Despite scientific evidence supporting the need to treat pain and an emphasis on addressing pain as a priority, pain management continues to be an unresolved issue. As a member of the health care team, nurses are integral to optimal pain management. Currently, nursing schools have limited innovative or alternative methods for teaching pain assessment and management. Simulation in nursing education provides a unique opportunity to expose students to realistic patient situations and allow them to learn and make mistakes without causing harm. However, modern low- and high-fidelity simulation technology is unable to display emotion, pain, or any facial expression. This limits training and education of conditions that may partially rely on the identification of symptoms based on the alteration of facial appearance, such as pain or stroke. This research explored student nurses’ perception of new technology that displayed computer-generated faces, each expressing varying degrees of physical expressions of pain. A total of 15 nursing students participated in the study. Students were asked to interpret the level of pain in four sequential faces using a numeric rating scale of 0-10, with 0 indicating no pain, and 10 the most severe pain possible. After scoring the faces, students were asked to answer four open-ended questions addressing the technology. Results of the study indicate a majority of nursing students believe the technology should be implemented into nursing curriculum and interacting with the projected faces was more beneficial than traditional teaching methods. Eventually, the potential for increased identification of conditions requiring observation of subtle facial changes will be explored.

Critical care nurses experience stressful situations in their daily working environments. The question arises for nurses: are there adequate support systems in the critical care environment and what are critical care nurses doing to mantain their own health and well-being. Facilitating conscious awareness among critical care nurses could enhance their resiliency and their hardiness, strengthening their coping capacities in stressful working situations. The contextual framework adopted for this research was the Neuman Systems Model. A qualitative research approach (exploratory, descriptive and contextual) was used to explore and describe the stress experienced by critical care nurses. Focus group interviews were conducted with critical care nurses and individual interviews with nurse managers. The results revealed their perceptions and experiences about the effects of stress in the critical care environment, as well as some of their coping strategies. Raising critical care nurses' levels of conscious awareness about their coping strategies with stressful events in their daily working lives, could enhance their resiliency and hardiness, enabling them to continue working effectively in stressful environments. This could enhance the general well-being of individual critical care nurses, the nursing care rendered to critically ill patients, and save money for the health care services by reducing turnover rates among critical care nurses. / Health Studies / D.Litt. et Phil. (Health Studies)