Bakgrund Sedering, delirium, agitation och smärta är viktiga områden inom intensivvård. Studier har visat på goda resultat vid bedömning av sederade patienter med validerade mätinstrument. Intensivvårdssjuksköterskan möter den sederade patienten dagligen i sitt arbete och ska enligt kompetensbeskrivningen ta hand om kritiskt sjuka patienter med svikt i ett eller i flera organ och utifrån patientens individuella behov förebygga, behandla, lindra och utvärdera omvårdnadsåtgärder. Den komplexa vården ställer stora krav på kunskap, kompetens och interprofessionellt omhändertagande på individnivå. Syfte Syftet med studien var att beskriva intensivvårdssjuksköterskors erfarenheter av teamarbete och bedömning av sederade patienter med validerade mätinstrument. Metod Kvalitativa individuella intervjuer valdes som metod för att besvara studiens syfte. Sju intensivvårdssjuksköterskor intervjuades och analyserades med kvalitativ innehållsanalys. Deltagarna i studien var intensivvårdssjuksköterskor i åldrarna 33-59 år med 1-21 års erfarenhet av intensivvård. Fem av deltagarna var kvinnor och två var män. Resultat Resultatet presenterades under kategorierna: Kunskap om bedömning av den sederade patienten och Teamarbete kring den sederade patienten och styrks av citat. Resultatet i studien visar på en bred kunskap och kompetens inom området. Flera exempel på god vård, teamarbete och professionellt förhållningssätt beskrevs. Det framkom dock en del brister och flera av deltagarna kände frustration över exempelvis teamarbete. Det belystes att kunskapsnivån om validerade mätinstrument var ojämn samt viljan med att använda dem inte alltid fanns. Slutsats Mer utbildning samt en tydligare motivering och uppmuntran till varför alla instrument används önskades. Ett område som återkom var svårigheterna och utmaningarna med ett effektivt teamarbete.

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Background: Loading conditions are recognized to influence ventricular function according to the Starling relationship for length/stretch and force.  Many modern echocardiographic parameters which have been announced as describing ventricular function and contractile status, may be confounded by uncontrolled and unmeasured load.  These studies aimed to measure the relation between four differ­ent types of assessments of ventricular dysfunction and degrees of load.  Study examined the ‘myo­cardial performance index’ (MPI).  Study II examined long axis segmental mechanical dyssynchrony.  Study III examined tissue velocities, and Study IV examined ventricular twist.  All studies aimed to describe the relation of these parameters both to load and to inotropic changes. Methods:  In anesthetized juvenile pigs, left ventricular (LV) pressure and volume were measured continuously and their relationship (LVPVR) was analysed.  Preload alterations were brought about by inflation of a balloon tipped catheter in the inferior vena cava (IVCBO).  Inotropic interventions were brought about by either an overdose of anesthetic (combine intravenous pentobarbital and inhaled isoflurane, Study I), or beta blocker and calcium channel blocker given in combination (Stud­ies III and IV).  In one study (II), global myocardial injury and dysfunction was induced by endotoxin infusion.  MPI measurements were derived from LVPVR heart cycle intervals for isovolumic contrac­tion and relaxation as well as ejection time.  Long axis segmental dyssynchrony was derived by ana­lyzing for internal flow and time with segmental dyssynchronous segment volume change during systole, hourly before and during 3 hours of endotoxin infusion.  Myocardial tissue velocities were measured during IVCBO at control, during positive and then later negative inotropic interventions.  The same for apical and base circumferential rotational velocities by speckle tracking.  Load markers (including end-diastolic volume) were identified for each beat, and the test parameters were analysed together with load for a relation.  The test parameters were also tested during single apneic beats for a relation to inotropic interventions. Results: MPI demonstrated a strong and linear relationship to both preload and after-load, and this was due to changes in ejection time, and not the isovolumic intervals.  Long axis segmental dyssyn­chrony increased during each hour of endotoxin infusion and global myocardial injury.  This dysyn­chrony parameter was independent of load when tested by IVCBO. Peak systolic velocities were strongly load-independent, though not in all the inotropic situations and by all measurement axes.  Peak systolic strain was load-dependent, and not strongly related to inotropic conditions.  Peak sys­tolic LV twist and untwist were strongly load-dependent. Conclusions: MPI is strongly load-dependent, and can vary widely in value for the same contractile status if the load is varied.  Mechanical dyssynchrony measures are load-independen in health and also in early global endotoxin myocardial injury and dysfunction.  Peak sytole velocities are a clinically robust parameter of LV regional and global performance under changing load, though peak systolic strain seems to be load-dependent.  Left ventricular twist and untwist are load-dependent in this pig model.

Kangaroo Mother Care (KMC) is an alternative model of care that prevents parent-infant separation when preterm infants need neonatal intensive care by skin-to-skin contact between infants and their parents. KMC is also a strategy that involves parents in their infants’ care and enables them to assume the responsibility for the care. Furthermore, KMC promotes parent-infant bonding and attachment. The overall aim of this thesis was to gain a deeper understanding and knowledge about parents’ capacity, willingness, and experiences of KMC and to which extent parents choose to use KMC throughout their infants' hospital stay. These studies were conducted in the NICUs at two Swedish university hospitals (NICU A and NICU B). Mothers of infants cared for at NICU A (n=17) answered a questionnaire about their experiences of KMC (Paper I). Twenty parents of infants cared for at NICU A recorded the duration of each KMC session during a period of 24 hours and the identity the KMC provider (Paper II). Seven fathers were interviewed about their experiences of KMC (Paper III) and 76 mothers and 74 fathers completed a questionnaire about what facilitated or rendered it difficult to perform KMC (Paper IV). The time of initiation of KMC and duration in minutes, and the identity of the KMC providers was recorded continuously during the infants’ (n=104) hospital stay: 83 mothers and 80 fathers also completed a questionnaire during their infants’ hospital stay (Paper V). This thesis provides new knowledge about parents’ practice of KMC, also continuously day and night, in a high tech NICU in an affluent society, with good resources for infant care in an incubator by trained staff. The accuracy of parents’ records of KMC were comparable to nurses’ records. The results indicate that parents want to be together with their infant in the NICU and be actively involved in the infants’ care. Although parents may experience KMC as exhausting and uncomfortable, they still prefer KMC to conventional neonatal intensive care as it supports their parental role. Early initiation of KMC after birth appears to result in a longer total duration of KMC during the infants’ hospital stay.

"Improved survival rates for premature infants have resulted in extended hospital stays in neonatal nurseries with consequent challenges for mothers assuming a parental role. Additionally, maternal medical complications associated with surgical birth, and a need to locate themselves in unfamiliar clinical environments, exacerbate women's experiences and transition to a maternal role competes with other roles at this time. For women living in rural and regional areas, who experience premature birth, there is additional hardship due to isolation, distance and limited support services. There has been little research on women's experiences with infants in special care nurseries in regional Australia."--(leaf ii). / Master of Nursing

"Improved survival rates for premature infants have resulted in extended hospital stays in neonatal nurseries with consequent challenges for mothers assuming a parental role. Additionally, maternal medical complications associated with surgical birth, and a need to locate themselves in unfamiliar clinical environments, exacerbate women's experiences and transition to a maternal role competes with other roles at this time. For women living in rural and regional areas, who experience premature birth, there is additional hardship due to isolation, distance and limited support services. There has been little research on women's experiences with infants in special care nurseries in regional Australia."--(leaf ii). / Master of Nursing

The Intensive Care Unit (ICU) is a unit that manages the most critically ill, complex and unstable patients in the hospital. As a result, the ICU is characterised by a high degree of clinical and organisational unpredictability and uncertainty. In Western discourse, uncertainty is often portrayed as problematic, and as something to be controlled and reduced. This research challenges this discourse by examining the productive relationship between certainty and uncertainty in the work practices of ICU clinicians, and subsequently, how intensive care clinicians utilise uncertainty to construct order in a highly unpredictable work environment. To understand how order can coexist with ICU’s unremitting unpredictability, complexity theory is used to frame this investigation. This research engaged an emergent, interventionist methodology, deploying multiple methods. Using ethnography, video-ethnography, and video-reflexivity, this research relied on clinicians’ participation in the construction and analysis of video data of the ICU clinicians’ work practices. This resulted in clinician-led practice change in the ICU. This research suggests that methods need to be deployed adaptively in order to deal with the complexity of ICU, in addition to the moment-to-moment emergence of events that require the researcher’s own work plans to be revisited. Moreover, in order to gain traction with, and understand highly complex and changeable environments, the researcher needs to also enter and experience uncertainty herself. Using complexity theory as its analytical tool, this research shows an inseparability of uncertainty and certainty in the ICU which is labeled ‘un/certainty’. Three main conclusions emerge from this research. First, un/certainty predominates in intensive care, and due to this, ordering is a process rather than a final state. Un/certainty is at the heart of the adaptive practices that clinicians enact. These adaptive practices are highly interconnected to the changes that the ICU environment may require, and thus produce a dynamic order in the unit. Second, the researcher herself, in order to come to terms with the complexity and un/certainty of the ICU environment must also enter un/certainty in order to gain traction with the ICU environment: unpredictability and complexity cannot be studied from a neat and disengaged distance. Third, the presence of un/certainty in the ICU can be significant and enabling rather than disabling for clinicians in their ongoing pursuit of dynamically ordering practice. The contribution of un/certainty to frontline practice is as a central driver to managing change and complexity. Therefore it should be positively revalued by health services researchers, policy makers and clinicians alike.

Until recently, long-term effects of a critical illness (CI) have received little attention from intensive care staff, who have traditionally measured outcome from an intensive care unit (ICU) by morbidity and mortality. However, it is now acknowledged that CI is a continuum that begins before ICU and continues to impact on a patient�s quality of life after they have been discharged home. Measuring health related quality of life (HRQOL) is a complex matter due to its multifaceted, subjective and dynamic nature. There has been a lack of consensus in the literature regarding the most appropriate methodological approaches and measuring instruments to use. This disparity has impeded comparison between studies. The aim of this thesis was to review the literature between January 1998 and December 2003 that focused on HRQOL for patients after a CI to identify and summarise themes and key outcomes. There were two main areas of focus - the methods used to measure the effects of the CI, and evaluation of the patient outcomes. An electronic search for relevant articles was conducted using the common clinical research databases and key words such as health related quality of life, outcomes and critical illness. Reference lists from these articles and conference proceedings were reviewed to identify further studies. There were 74 primary papers identified that reflected a number of subcategories including general ICU, Acute Respiratory Distress Syndrome (ARDS), and elderly patients. There were four categories of instruments used in the literature including those that measured acuity of illness, physical functioning, psychological functioning and HRQOL. The majority of studies used more than one measuring instrument, most of which had been previously validated. Results from the studies were diverse, but it is apparent that physical and psychological recovery from a CI may be a slow and varied process. Most studies were observational; only one randomised control study examined the benefits of a physical exercise program for patients post-hospital discharge. In general, there was no evidence of how to translate the study findings into some form of structured program to assist the patient with any identified problems. To enhance continuum of care, integration of ICU, hospital and rehabilitation services could target identified physical and psychological problems to assist patient recovery. However, strong evidence on the benefits of initiatives such as inpatient follow-up, outpatient clinics and use of ICU diaries is yet to be demonstrated.

Globally the population is ageing and as a consequence people are living longer with multiple chronic conditions. A range of factors, including decreased lengths of hospital stay and a greater focus on community based care, has lead to an increasing acuity of patients admitted to acute care settings, many with complex care needs. To date, models of nursing care in acute settings have been configured to focus on acute, procedural care and do not meet the unique needs of the older person. In order to ensure optimal health outcomes of older hospitalised people, nursing care needs to be responsive to the priorities and needs of patients and their families. This study sought to collaboratively develop a model of nursing care with nurse clinicians to improve the care of older people in the acute care setting. Model development was driven by an action research framework, using evidence-based principles and a comprehensive needs assessment. A three phased, mixed method design was embedded within the overarching conceptual and philosophical framework of action research. The first phase of the study comprised a needs assessment and allowed appraisal of the needs of patients as perceived by patients, carer’s and nurses, this was performed using the Caring Activity Scale [CAS](1). Qualitative data and semi-structured interviews added depth to the survey data and qualified responses by confirming that patients thought that nurses did the best they could within a culture of busyness, while patients strived to maintain and sustain their own independence. Managing the discharge process and carer burden arose mainly from the carer semi-structured interviews only. Data revealed significant differences between patients, carer’s and nurses in relation to priority and satisfaction with care. Patients did not place a large importance on discharge care which contrasted with the focus of nursing initiatives. During the subsequent phases of the study a collaborative approach, using action research principles, was used to develop and implement a model of nursing care. A key feature of this model was the introduction of a team structure with a focus on patient centred care. Significant differences were identified in the pre model and post model patient groups in relation to satisfaction with care, with the post model group more satisfied than the pre group model group. Further, improvements in functional status and medication knowledge were demonstrated among patients cared for under the new model. This study has demonstrated that developing a model of care appropriate to the needs of patients, carer’s and nurses can be achieved through the use of action research principles. Study data illustrates the importance of collaboration, empowerment and change management principles in driving clinical improvement and patient satisfaction with care. The findings also underscore the importance of promoting and educating patients and carers as well as nurses about the importance of discharge planning to optimise post-discharge health outcomes. / Doctor of Philosophy (PhD)

Diss. (sammanfattning) Göteborg : Göteborgs universitet, 2006. / Härtill 4 uppsatser + 1 bil.