Few studies have explored how medical ethics works in practice specifically in terms of the social processes that result in a decision regarding an ethical problem. This is particularly so in the case of children’s intensive care. More than a decade of teaching healthcare ethics to both nurses and doctors prompted a study to examine how ethical problems are resolved in a children’s intensive care unit. This qualitative study addressed this question in a single large children’s intensive care unit in England. The study was guided by grounded theory in examining via individual face to face unstructured and semi-structured interviews what ethical problems were encountered and how they were resolved. Interviews were conducted mainly with doctors and nurses working on an intensive care unit. Two admitting consultant doctors and three parents were also interviewed. The analysis of data gathered in 20 interviews was developed using Strauss and Corbin’s (1998) framework. A theory emerged from the analysis of the data that revealed the most prominent ethical problems in children’s intensive care related to end-of-life situations. Most significant among these was the decision to withdraw life-preserving interventions from a child. The theory outlines a process by which health professionals involved in the care and treatment of a child in intensive care negotiated a consensus on the point at which it was no longer appropriate to continue life-preserving interventions. This consensus was then presented to parents. Parental assent to withdrawal was facilitated, when not immediately forthcoming, by a process of persuasion.

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Samfattning   Bakgrund: I vår vardag världen över drabbas människor oavsett kön och ålder av olyckor, dödsfall och andra traumatiska händelser. Vissa yrken medför en större risk att utsättas för traumatiska händelser. Exempel på dessa är ambulans, räddningspersonal, polis och vårdpersonal inom främst akutsjukvård. Dessa händelser kan ibland bli personen övermäktigt. Ett sätt att motverka bl.a. utbrändhet och posttraumatiskt stressymptom (PTSD) hos vårdpersonalen är att genomföra debriefingsamtal. Detta genomförs med den vårdpersonal som varit delaktig i en traumatisk händelse.     Syfte: Syftet med denna studie var att beskriva erfarenheten av debriefing hos vårdpersonal inom akutsjukvården i samband med traumatiska händelser i sin yrkesutövning.   Metod: Litteraturstudie som totalt innehåller 10 vetenskapliga artiklar varav fem är kvalitativa och fem är kvantitativa.   Resultat: Studieresultatet påvisar att debriefing uppfattas som ett positiv redskap när det gäller avlastning efter en traumatisk händelse för vårdpersonalen inom akutsjukvården. De främsta faktorerna som lyfts i studien är tid och plats för debriefing, debriefingens inverkan på kommunikationen mellan vårdpersonalen, val av debriefingledare och behovet av väl utformade riktlinjer för debriefingen.   Slutsats: I föreliggande studie påvisas att debriefing bör betraktas som ett effektivt verktyg att motverka psykisk ohälsa hos vårdpersonalen och att debriefing även förstärker kommunikationen mellan de olika professionella yrkesgrupperna inom akutsjukvården. Studien visar även att det är viktigt med väl utformade riktlinjer för att debriefingens syfte skall uppnås. / Abstract Background: In our everyday lives worldwide, people are affected regardless of gender and age by accidents, deaths and other traumatic events. Some professions involve a greater risk of being exposed to traumatic events. Examples of these are ambulance, emergency personnel, police and health care personnel, primarily in emergency care. These events can sometimes become overpowering. One way to counteract burnout and post-traumatic stress symptom (PTSD) in healthcare professionals is to carry out debriefing talks. This is done with the healthcare staff who has participated in a traumatic event.   Aim: The purpose of this study was to describe the experience of debriefing in healthcare professionals in emergency care in connection with traumatic events in their professional practice.   Method: Literature study that contains a total of 10 scientific articles, five of which are qualitative and five are quantitative.   Results: The study results show that debriefing is perceived as a positive tool when it comes to unloading after a traumatic event for the healthcare staff in emergency care. The main factors raised in the study are time and place for debriefing, debriefing impact on the communication between the healthcare staff, the choice of debriefing leader and the need for well-designed guidelines for debriefing.   Conclusion: The present study demonstrates that debriefing should be regarded as an effective tool for counteracting mental illness in the healthcare staff and that debriefing also reinforces communication between the various professional occupational groups in emergency care. The study also shows that well-designed guidelines are important for achieving the purpose of the debriefing.

Thesis submitted in fulfillment of the requirements for the degree of Masters of Science in Nursing, Faculty of Community and Health Sciences, Department of Nursing Education, University of the Witwatersrand Johannesburg, 2012 / Studies generally agree the survival of the mechanically ventilated patient in the ICU is largely reliant upon the competence of the nurse undertaking this highly specialized role (Alphonso,Quinones,Mishra,et al. 2004; Burns 2005) However, an audit undertaken by the Critical Care Society of Southern Africa (2004) revealed that 75 % of nurses working in ICU are inexperienced and do not hold an ICU qualification, and as such are unlikely to have acquired the level of competency required to care for the mechanically ventilated patient (Binnekade 2004). A high index of suspicion exists around the competence levels of nurses‟ currently working in ICU in SA as revealed by local studies (Khoza & Ehlers 1998; Scribante & Bhagwanjee 2003; Moeti, van Niekerk, van Velden, 2004; Morolong & Chabeli 2005; Windsor 2005; Perrie & Schmollgruber 2010). The purpose of the study was to determine and describe the level of competence with regard to mechanical ventilation, of nurses working in ICU, who have varying years of experience and training backgrounds, using study specific designed clinical vignettes, in two tertiary healthcare institutions in Gauteng. A descriptive two phase design was utilized for the study. Phase one comprised the development and validation of three clinical vignettes to determine the level of competence of nurses working in ICU‟s with regard to mechanical ventilation. A modified Delphi technique technique using purposively sampled experts from medical technical and nursing backgrounds was used to validate the three clinical vignettes. Content validity was strengthened by computing CVI of the instrument. In Phase two consecutive sampling was used, and data collection comprised of participants (n=136) completing three validated clinical vignettes in the ICU‟s of two tertiary healthcare institutions in Gauteng. All nurses who participated in the study completed the same three clinical vignettes and demographic data. Nurses‟ perceptions regarding their own level of competence with regard to mechanical ventilation were quantified and compared with actual scores achieved in the clinical vignettes. Descriptive and inferential statistics were used to analyse the data. The level of significance was set at <0,05 and confidence levels at 95%. The competency indicator for the vignettes was set at 75% by the expert group, and nurses‟ level of competence was graded according to vignette score outcomes using a grading scale. Statistical assistance was obtained from a statistician from the Medical Research Council (MRC). Results: Results of the study showed that nurses regardless of training background, age, or experience showed a poor level of knowledge, the average score being 48% for ICU qualified nurses and 31% for non-ICU qualified nurses. There was a small significant difference between ICU qualified and non-ICU qualified nurses‟ competence levels in mechanical ventilation when analysed using a two tailed- t- test (p=0.039). Nurses also experienced a misperception regarding their own competence levels in mechanical ventilation when compared to their actual competence levels as determined by three clinical vignettes.

MSc (Nursing), Faculty of Health Sciences, University of the Witwatersrand / The purpose of this study was to elicit and compare nurses’ and families’ perception of family needs in intensive care unit. A quantitative non-experimental, comparative and descriptive research design was used to achieve research objectives. Participants (nurses, n= 65; family members, n= 61) were drawn from three intensive care units. Data were collected using a questionnaire developed from the Critical Care Family Needs Inventory (CCFNI). Descriptive and inferential statistics were used to analyze the data. Majority (more than 50%) of both groups agreed with 42 out of 45 family need statements. All the nurses (100%, n=65) agreed with the need ‘to have explanations that are understandable’ while most family members (98%, n=58) agreed with the need ‘to feel that health care professionals care about the patient’. Seven out of ten statements agreed by majority of both groups were similar. Most of these statements were related to assurance and information need categories. In addition, both groups scored high on the two categories, assurance and information. However, family members scored higher than nurses in two categories, assurance and proximity with statistically significant difference (p-value < 0.05). Based on the research findings, it can therefore be concluded that generally there were similarities between nurses’ and families’ perception of family needs. These findings support evidence in literature resulting from previous studies.

Purpose: To introduce the simplified therapeutic intervention scoring system (TISS-28), the original therapeutic intervention scoring system (TISS-76) and simplified acute physiological score (SAPS) version II in critically ill adult patients, in order to describe the validity and reliability of TISS-28 as a suitable measure of quantifying nursing workload in the adult intensive care units (ICU) of a public sector hospital in Johannesburg. Objectives: To describe the profile of patient admissions to the intensive care units, to investigate the impact of the patients’ profile on the requirements for nursing workload and to validate the use of TISS-28 as a measure of quantifying nursing workload in this setting. Design: A non-experimental, comparative descriptive, correlational and prospective two-staged design was utilized to meet the study objectives. Stage I involved face and content validation of TISS-28 by a panel of ICU nurse experts (n=6). Stage II involved assessment of concurrent and construct validity as well as inter-rater reliability of TISS-28 using participants (n=105) drawn from trauma, cardiothoracic and multidisciplinary ICUs. Data necessary for the calculation of TISS-28, TISS-76 and SAPS II were recorded for each patient in the ICU at 24 and 48 hours after admission and in the wards after discharge within 24-48 hours. Descriptive and inferential statistics were used to analyze data. Results: Content Validity Index (CVI) of 0.93 was found for TISS-28. A significant positive correlation was found between TISS-28 and TISS-76 scores (r = 0.7857, p = 0.0001) as well as TISS-28 and SAPS II scores (r = 0.2098, p = 0.0317). A significant difference was found between TISS-28 scores among patients in the ICU and patients in the ward (t = 25.59, p = 0.0001; t = 21.48, p = 0.0001) respectively. A significant correlation was found between the data collected from a sample of patients by the researcher and the expert assistant researcher with an intra-class correlation coefficient of 0.99 and a p-value of 0.0001. Conclusions: The findings support validity and reliability of TISS-28 hence its feasibility for use in South African ICUs. Recommendations for nursing education, practice, management and research are proposed.

A aplicação de instrumentos que mensuram carga de trabalho de enfermagem prospectivamente é de fundamental interesse, pois a pontuação obtida de forma retrospectiva não reflete em tempo real a carga de trabalho de enfermagem necessária para atender as demandas de cuidados dos pacientes nas horas subseqüentes. Este estudo teve como objetivos analisar o desempenho do NAS para a medida prospectiva da carga de trabalho de enfermagem em UTI e comparar as medidas entre o NAS de aplicação prospectiva e retrospectiva. Trata-se de um estudo metodológico desenvolvido em uma UTI geral pertencente a um hospital privado do município de São Paulo. A amostra foi constituída por 104 pacientes com idade igual ou superior a 18 anos, admitidos na UTI e que permaneceram, no mínimo, 24 horas no primeiro dia de internação, no período de setembro a novembro de 2006. Foram coletados dados demográficos e de internação, SAPS II, LODS e o NAS de aplicação prospectiva e retrospectiva. Para comparar as médias do NAS e verificar a correlação e homogeneidade entre o NAS prospectivo e retrospectivo utilizou-se o teste t-student e os Coeficientes de Pearson e de Correlação Intraclasse (ICC). Para avaliar a concordância entre cada item do NAS nas duas formas de aplicação utilizou-se o índice Kappa. Prevaleceram pacientes do sexo masculino (55,8%), provenientes do pronto-socorro (35,6%) e que internaram por razões clínicas (76,0%). A pontuação média SAPS II e LODS foram de 31,8 e 2,9 pontos, respectivamente, com mortalidade encontrada de 17,3%. Houve diferença estatisticamente significativa (p< 0,001) entre as médias do NAS prospectivo e retrospectivo e correlação moderada (Pearson 0,65; ICC 0,623) entre as duas medidas. Observou-se que do total de 32 itens do instrumento, em 11 não foi possível aplicar o índice Kappa devido à elevada porcentagem de concordância em uma única categoria de respostas e que, dos 21 em que a análise foi possível, 10 itens (47,6%) apresentaram concordância igual ou maior do que moderada, sendo apenas um item nessa última classificação (1a). Quanto a concordância por itens, verificou-se que aqueles com concordância muito forte (itens 5, 10, 12, 14 e 20) e forte (9, 17, 18 e 21), referiam-se a dados mais objetivos, de fácil avaliação e monitoramento pelos profissionais de enfermagem e que geralmente não apresentam discordâncias quanto ao tipo de cuidado que deve ser prestado. Os itens com divisão em sub-itens (a, b e c) apresentaram as concordâncias mais fracas, quer devido às avaliações subjetivas das coletadoras e enfermeiros, quer pela ausência de registros com informações fidedignas. Conclui-se que o NAS prospectivo pode ser usado quando se deseja projetar os cuidados de enfermagem a serem prestados, sobretudo, quando se tem a intenção de distribuir os profissionais de enfermagem necessários para prestar assistência de qualidade no decorrer de um período de trabalho. No entanto, existe a necessidade de uma efetiva uniformização entre os enfermeiros da UTI para que esta projeção seja fidedigna / The using of measuring instruments of nursing workload prospectively is the fundamental interest, therefore the obtained pointing in retrospective way don´t show in real time nursing workload necessary to attend the requirements of patients care on the subsequent hours. The aims of this study were analysis NAS performing for prospective measuring of nursing workload in ICU and comparing them among NAS of prospective and retrospective application. It is methodological study developed in ICU of a private hospital of São Paulo city. The sample was constituted by 104 patients with ages equal or superior 18 years old, admitted in ICU that stayed there at least 24 hours in the first day of internation, during the period of September until November 2006. It has been collected demographic and internation data, SAP II, LODS and NAS of prospective and retrospective application. To compare the average of NAS and check the correlation and homogeneity between NAS retrospective and prospective had been used t-student test, Pearson Coefficients and Intraclass Correlation (ICC). To valuate the concordance among each item of NAS on the two ways of application had been used Kappa index. Patients of masculine sex were superior (55,8%), coming from first-aid clinic (35,6%) and they were admitted for clinical reasons (76,0%). The average pointing SAPSII and LODS were 31,8 and 2,9 points, respectively, with mortality of 17,3%. There was significative statistical difference (p< 0,001) between NAS average prospective and retrospective and moderate correlation (Pearson 0,65; ICC 0,623) between the measures. It had been observed that of the total 32 items of the instrument, at 11 weren’t possible to apply Kappa index due high percentage of concordance on a unique category of answers and that among 21 the analysis was possible, 10 items (47,6%) showed concordance equal or bigger than moderated, it was being only one item on the last classification (1a). In relation to the concordance for items, it was checked that some with high concordance (items 5, 10, 12, 14, and 20) and strong (9, 17, 18 and 21) they were referring to more objective data, with easy valuation and checking of nursery professionals and that generally don´t shown discordances as the type of caring that should be done. The items with sub-items (a, b and c) shown very weak concordance, or because of the subjective evaluation of searchers and nurses. Concluding that prospective NAS can be used when we wish to plan nursing care to will be afford, mainly, when we have the intention of distributing necessary nursing professional to afford assistance of quality during work schedule. However, there is the necessity of an effective uniformation among the ICU nursery for this projection become reliable

Trata-se de um estudo com abordagem quantitativa, de corte transversal e retrospectivo, que teve como objetivo analisar a carga de trabalho de enfermagem e os fatores associados a ela, no primeiro dia de internação de pacientes na Unidade de Terapia Intensiva (UTI). Os dados foram extraídos de um banco de dados que reuniu informações de 5 UTI(s) de dois hospitais privados, de nível terciário, de grande e médio porte, no município de São Paulo. A amostra foi constituída por 214 pacientes adultos, admitidos nas instituições nos meses de abril de 2002 e outubro de 2004, respectivamente, e que permaneceram na UTI por um período mínimo de 24 horas. Os dados foram coletados dos prontuários por meio de três instrumentos: ficha de levantamento de dados que incluiu informações demográficas e clínicas; índice NAS (Nursing Activities Score), para medir a carga de trabalho de enfermagem e SAPS II (Simplified Acute Physiology Score II), aplicado para medir a gravidade dos pacientes. Esses dados foram armazenados e analisados utilizando o programa SPSS (Statistical Package for the Social Sciences) versão 12.0 (SPSS, 2002), estabelecendo-se as análises descritivas e inferenciais pertinentes ao estudo. A média do escore total do NAS foi de 69,9% e mediana de 68,0%. Verificou-se, segundo a mediana, que 109 (50,9%) indivíduos exigiram alta carga de trabalho de enfermagem e 105 (49,1%) baixa carga. Comparando as médias da carga de trabalho de enfermagem segundo as variáveis demográficas e clínicas, observou-se que as únicas estatisticamente significativas foram a condição de saída e o tempo de permanência na UTI. Ao serem comparadas com os grupos alta e baixa carga de trabalho de enfermagem, constatou-se associação apenas entre a variável tempo de permanência. Conclui-se, portanto, que a gravidade, a idade do paciente e o tipo de tratamento não foram fatores associados à demanda de trabalho de enfermagem, nas primeiras 24 horas na UTI. Os resultados indicam a necessidade de investigar outras variáveis, entre elas o grau de dependência de enfermagem do paciente em estado crítico. / This is a qualitative and retrospective study with transversal cut that aimed both to analyse the nursing workload on the first day of admission in the Intensive Care Unite (ICU) and the factors related to it. The data were taken from a database that gathered information from 5 ICUs from two private hospitals, of a terciary level, large and medium-sized in the city of São Paulo, Brazil. The sample was constituted of 214 adult patients, admitted from April 2002 to October 2004, in the large and medium-sized hospitals respectively. They remained in the ICU for at least 24 hours. The data were collected from their recordings through three instruments: A data form which brings information such as demographic, clinical and instruments, NAS (Nursing Activities Score) and SAPS II (Simplified Acute Physiology Score II) respectively applied in order to measure the nursing workload and patients severity. The data were stored and analysed through the SPSS (Statistical Package for the Social Sciences) program, version 12.0 (SPSS, 2002). It was established descriptive and inferential analysis of the study. NAS total score average was 69.9% and the median was 68.0%. According to the median, it was verified that 109 (50.9%) individuals had high nusing workload and 105 (49.1%) low load.. When the nursing workload averages were compared according to clinical and demographic variables, it was observed that the only statistically significative ones were discharge conditions and time spent in the ICU. When compared to the groups with high and low nursing workload, the relation was only observed between the variable time spent in the ICU. Therefore, it was concluded that severity of illness, patient age and kind of treatment were not factores related to nursing workload in the first 24 hours in the ICU. Based on these results, further investigations on other variables considering dependency level of the critical patient are necessary.

Construir mudanças é imprescindível no sistema de saúde atual e, mais especificamente, no contexto da terapia intensiva, na busca de contemplar a humanização do cuidado, envolvendo, dentre outros aspectos, o reconhecimento dos usuários como cidadãos, em sua integralidade e subjetividade. O objetivo deste estudo é apreender o que significa, para os profissionais da equipe de saúde que atua na terapia intensiva, a humanização do cuidado, ou seja, compreender sua percepção e experiências acerca do que seja, para cada um, no contexto do Centro de Terapia Intensiva (CTI), ações humanizadoras. Aproximando-me de algumas idéias do referencial da fenomenologia, foram realizadas entrevistas com profissionais das várias categorias que atuam no CTI de um hospital escola da cidade de Ribeirão Preto, no período de setembro de 2007 a janeiro de 2008, partindo da seguinte questão norteadora: \"considerando seu trabalho no dia a dia, conte-me sobre as experiências que tem vivido neste CTI, em relação a situações que você considera \"humanizadoras\" e aquelas que considera \"desumanizantes\". Da análise das entrevistas, emergiram as seguintes temáticas: \"Humanização implica reconhecer o paciente em sua singularidade e integralidade\", \"Fazer técnico X humanização no cotidiano do CTI\", \"As condições de trabalho e suas implicações na humanização do cuidado em UTI\", \"O preparo da equipe para construir um cuidado humanizado\". Algumas situações que consideram o paciente em sua integralidade e singularidade no CTI nem sempre são compreendidas e valorizadas pela equipe, havendo dificuldades em reconhecer as diferenças entre as necessidades das pessoas internadas. Ainda se faz significativamente presente no CTI, principalmente para a equipe de enfermagem, a dicotomia \"fazer técnico/humanização\", como pólos distintos e difíceis de serem conciliados no ato complexo de cuidar. Quanto às condições de trabalho, a equipe de saúde aponta aspectos relacionados ao número insuficiente de profissionais, sobrecarga de atividades, o lidar cotidiano com situações de sofrimento humano, a estrutura física do CTI e a gestão tradicional do trabalho, principalmente no que concerne ao serviço de enfermagem, como aspectos que dificultam a construção da humanização do cuidado, uma vez que o profissional com desgaste físico e psicológico, em sofrimento, não tem abertura para o acolhimento do outro. O preparo da equipe para o cuidado humanizado foi pouco enfatizado, mas mostra-se com limites, sendo o processo formativo, seja na formação inicial como continuada, estratégia significativa para a reflexão e recriação cotidianas do cuidar. Nesse contexto, algumas sugestões são feitas para o cenário em foco, no sentido de promover a reflexão e a construção de novos modos de conceber e agir no que se refere à humanização na terapia intensiva. / Building up changes is essential in the current health system, and more specifically in the intensive care context, with a view to care humanization. This involves, among other aspects, acknowledging users as citizens, in their integrality and subjectivity. This study aims to apprehend what care humanization means to health team professionals working in intensive care, that is, to understand their perception and experiences about what humanizing actions are for each of them in the context of the Intensive Care Unit (ICU). Approaching some ideas from the phenomenological reference framework, interviews were held with professionals from the different categories working at the ICU of a teaching hospital in Ribeirão Preto, Brazil, between September 2007 and January 2008, based on the following guiding question: \"considering your daily work, tell me about your experiences at this ICU, with respect to situations you consider \"humanizing\" and others you consider \"dehumanizing\". The following themes emerged from the analysis of the interviews: \"Humanization implies acknowledging the patient in his/her singularity and integrality\", \"Technical practice X humanization in daily reality at the ICU\", \"Work conditions and their implications in the humanization of care at the ICU\", \"The team\'s preparation to build up humanized care\". Some situations that consider patients in their integrality and singularity at the ICU are not always understood and valued by the team, facing difficulties to acknowledge differences between the needs of hospitalized patients. Moreover, the dichotomy \"technical practice/humanization\" is significantly present at the ICU, mainly for the nursing team, as distinct poles that are hard to conciliate in the complex care act. As to the work conditions, the health team appoints aspects related to the insufficient number of professionals, activity overload, daily handling of situations marked by human suffering, physical structure at the ICU and traditional work management, mainly what the nursing service is concerned, as factors that make the construction of care humanization more difficult, as physically and mentally exhausted professionals, who are suffering, are not open to welcome the other. The team\'s preparation for humanized care received little emphasis, but reveals to be limited. The training process, either initial or permanent, is a significant strategy for daily reflection and recreation of care delivery. In this context, some suggestions are presented for the research scenario, so as to promote reflection and the construction of new ways of conception and action with respect to humanization in intensive care.

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