The pediatric intensive care unit (PICU) has been described as a stressful place for parents of critically ill children. Research to date has examined parents’ needs and stressors with a child in PICU. There is a paucity of research examining the experience for parents of a child who is transferred from the PICU to the hospital ward. Open-ended interviews were conducted with 10 parents within 24-48 hours after transfer from a PICU to a hospital ward at a children’s hospital in Canada to understand this experience. Parents revealed that the experience involved a search for comfort through transitions as expressed through the themes of: ‘being a parent with a critically ill child is exhausting’, ‘being kept in the know’, ‘feeling supported by others’, and ‘being transferred’. The findings from this study can help nurses and other health professionals working with parents to support them through the transition from PICU. Recommendations are made for the inclusion of family-centered care practices to assist parents through transitions.

The unexpected admission of a child to the pediatric intensive care unit (PICU) creates feelings of uncertainty, distress, and fear and is a devastating experience for primary caregivers. Health care providers must address primary caregivers` concerns to enhance primary caregivers’ coping abilities. While a family-centred approach to care can assist in diminishing uneasy feelings experienced by primary caregivers, this philosophy of care is not consistently used in everyday practice. The PICU is a unique area of care that focuses on restoring the health of critically ill children with the use of machines and equipment. However, the use of technology for life sustaining measures creates additional responsibilities for health care providers, potentially compromising the quality of patient care. There is evidence to support that the involvement of the primary caregiver in the care of the critically child can address the gap that commonly exists between technology and holistic patient care. Furthermore, involvement in care increases primary caregivers’ satisfaction with the care their child receives and may also improve patient outcomes. Most importantly, the involvement of primary caregivers in the care of the critically ill child encompasses a family-centred approach to care. By increasing health care provider’s awareness of family-centred care within the PICU, primary caregiver’s needs may be more effectively addressed during this devastating and vulnerable time. Health care providers are key players in the promotion of family-centred care in the PICU; however, they are often faced with multiple challenges and barriers. Increasing health care providers’ awareness around the components of family-centred care can facilitate its implementation into practice by understanding how primary care givers define and experience ii family-centred care. Accordingly, a qualitative study guided by the philosophy of hermeneutic phenomenology was conducted to elicit a detailed description of the lived experience of family-centred care from the perspective of the primary caregiver. Participants in this study consisted of those primary caregivers who had previously had a child admitted to the PICU. Participants were recruited from a large mid-western hospital. In total nine primary caregivers ranging in age from 33 to 44 years with the mean age being 37 years participated in the study. Nine of the participants were mothers and two were fathers. All participants took part in semi-structured, open-ended interviews. A total of nine interviews were conducted with two of the interviews involving both parents. Demographic data and field notes were recorded. All field notes and interview data were transcribed. The transcripts were reviewed repeatedly for significant statements in an attempt to find meaning and understanding through themes. The data analysis revealed the essence of the lived experience of family-centred care to be being present. Three themes communicated the essence and included: (a) physical presence, (b) participation in care and, (c) advocating. Three themes from the data emerged around how primary caregivers defined family-centred care and included: (a) collaboration, (b) being updated and, (c) continuity of care. Finally, primary caregivers identified four conditions that needed to be in place to experience family-centred in the PICU which included: (a) being present for rounds, (b) caring behaviours, (c) feeling welcomed and, (d) support. The findings from this study may be used to guide policy around family-centred care and improve on, or bring new insights around interventions related to family-centred care. Future recommendation for nursing practice, education and research are presented.

SAMMANFATTNING Bakgrund: Risken för att drabbas av ett intensivvårds-delirium under vårdtiden är av varierande storlek. Om patienten drabbas av ett delirium kan det leda till allvarliga konsekvenser. Konsekvenserna innefattar en ökad mortalitet, längre vårdtid, ett ökat lidande och även att kostnaderna blir högre. De bedömningsinstrument som finns används i varierande grad på olika intensivvårds-avdelningar världen över. Det mest valida och användbara är Confusion Assesment Method, CAM-ICU; ett mätverktyg utarbetat för att användas inom intensivvården där det kan användas på patienter som fortfarande är intuberade och således inte har en möjlighet att uttrycka sig verbalt. Syfte: Belysa den aktuella forskningen gällande omvårdnad av patienter som drabbats av intensivvårds-delirium. Metod: Studien är en litteraturöversikt med mixad metod och konvergent design. Resultat: Studien visar att omvårdnadsåtgärder gällande behandling av intensivvårdsdelirium används men det finns inga riktlinjer för hur patienterna ska behandlas. Den forskning som finns visar få signifikanta resultat. De kategorier av omvårdnadsåtgärder som litteraturen visar är kognitiv stimulans, miljö, läkemedelsanvändning och fysisk fasthållning. Slutsats: Studien visar att det är svårt att mäta effekterna av olika omvårdnadsåtgärder som patienter med intensivvårds-delirium blir behandlade med. Klinisk betydelse: Genom fördjupad kunskap om delirium får sjuksköterskan en bättre förståelse för tillståndet och således även för omvårdnaden som ges. Att belysa det faktum att forskningen kring omvårdnadsåtgärderna vid delirium är bristfällig skapas möjlighet till vidare efterforskning. / ABSTRACT Background: The risk for intensive care delirium during hospitalization is of varying size. If the patient experiences a delirium it can lead to serious consequences. The consequences include increased mortality, longer hospital stay, increased suffering and even higher costs. The screening tools that are available are used in varying degrees in different intensive care units worldwide. The most valid one are the Confusion Assessment Method, the CAM-ICU; a screening tool developed for use in intensive care where it can be used on patients who are still intubated and thus do not have a chance to express themselves verbally. Aim: Highlighting the current research regarding the care of patients suffering from intensive care delirium. Method: The study is a literature review with a mixed approach and convergent design. Results: The study shows that nursing interventions regarding the treatment of intensive care delirium are used but there are no guidelines for how the patients should be treated. The research shows few significant results. The categories found from the literature were cognitive stimulation, environment, medication and physical restraint. Conclusion: The study shows that it is difficult to measure the impact of nursing interventions that patients with intensive care delirium are treated with. Relevance to clinical practice: Increased knowledge of delirium may give the nurse a better understanding of the condition and thus also for the care they provide. To highlight the fact that the research on nursing interventions for delirium is flawed which creates the opportunity for further research.

Bakgrund Djup sedering är associerat med förlängd vårdtid och ett flertal komplikationer för intensivvårdspatienten. Även för ytlig sedering medför komplikationer, stress och lidande. Studier visar på vikten av adekvat sedering, samt att skalor och protokoll används. Syftet med denna studie var att beskriva sederingsnivå, andel optimalt, över- och undersederade patienter, vårdtid i ventilator och vårdtid inom intensivvården för patienter på en svensk intensivvårdsavdelning. Metod Studien, med deskriptiv design, inkluderade konsekutivt sederade, ventilatorbehandlade patienter, 18 år och äldre, på en svensk intensivvårdsavdelning under nio månader. Primära utfallsvariabler var sederingsnivå, utifrån Motor Activity Assessment Scale och andel optimalt, över- och undersederade patienter. Sekundära variabler var vårdtid i ventilator och vårdtid på intensivvårdsavdelningen. Resultat Studien omfattade 34 patienter. Under vårdtid i ventilator med endotrackealtub hade 28  patienterna optimal sedering mer än två tredjedelar av vårdtiden. Medianvärdet för sederingsnivå under vårdtid med endotrackealtub var MAAS 2 (kvartilavstånd 2-2,25) jämfört med medianvärdet för sederingsnivån med trackealkanyl som var MAAS 3 (kvartilavstånd 2-3) (P < 0,001). Trettio patienter (88,2 %) var optimalt sederade med ett MAAS-värde på 2-3 (md) sett till hela vårdtiden. Fyra patienter (11.8 %) var översederade med ett MAAS-värde på 0-1,5 (md). Ingen patient var undersederad sett till hela vårdtiden. Konklusion Studien visar att majoriteten av intensivvårdspatienterna var optimalt sederade under större delen av vårdtiden i ventilator. Endast ett fåtal patienter var översederade och ingen patient var undersederad större delen av vårdtiden. Patienter vårdade med trackealkanyl var ytligare sederade än de med endotrackealtub.

This essay presents a Wittgensteinian analysis of the rationales, beliefs, and contributing factors that supported the denial of neonatal pain until the late 80's. It provides an historical review of the denial of neonatal pain and describes the main events leading to its recognition. It explores the link between enduring erroneous conceptions and scientific assumptions about the nature of pain, and the denial of neonatal pain. Wittgenstein's work on the origin of pain-language in the natural tendency of human beings to exhibit pain-behaviour and to react to the pain manifestation of others by engaging in meaningful activities provides the background for this investigation of neonatal pain. The lack of training in pain assessment techniques and the unique pain manifestation of sick and premature infants is considered. The impact of Neonatology's driving concepts and the overreaching scientifical approach of medicine is also discussed. Finally, it is recognized that individual, scientific, and sociopolitical forces have influenced neonatal pain research and clinical practice. The essay concludes with a reflection on the consequence of privileging the biological function over the experiential dimension of life for sick infants presently in the N.I.C.U but also for the quality of their long-lasting memories.

Introduction: Weaning from mechanical ventilation is defined as the gradual reduction of mechanical support, and replacing this support with spontaneous ventilation. It is a complex process involving assessing the patient's readiness to wean, optimising factors that can impede the process, selecting the most appropriate weaning mode and continually assessing the patient's progress. In paediatric intensive care the clinician must also account for the unique physiological and psychosocial needs of the child. Aim: The aim of the study was to explore the need for, and impact, of guidelines for weaning children from mechanical ventilation on patient outcomes and staff practice. Method: The study was multi-dimensional using the Model for Improvement as the conceptual framework and decided into four phases. Phase one: A survey of Australian PICUs in 2000 revealed that over 2500 children were ventilated over a 12 month-period, with a potential population of 625 children experiencing difficulties with weaning from mechanical ventilation. No guidelines for weaning children from mechanical ventilation were identified at the time. Standardising the approach to weaning had proven successful with the adult population. Phase two: Collaborative guidelines for weaning, based on available evidence and expert opinion, were drawn up, validated by a panel of experts and safely piloted. Phase three: The guidelines were then tested using a time series design over two years on a PICU at a tertiary referral children's facility. Results demonstrated that total ventilation time, weaning duration and length of stay were not significantly improved in the experimental group. However, quality indicators were slightly improved and a survival analysis also showed a slightly reduced probability of long term ventilated patients remaining ventilated. Results also demonstrated a reduction in the fluctuation of outcome variables over time indicating improved consistency in weaning due to the guidelines Phase four: A qualitative analysis of focus group interviews with staff about the impact of guidelines on their practice generated themes, centred on practice development, framework, relationships and challenges. Few previous studies have investigated the perceptions of staff regarding use of practice guidelines. This study identified that staff viewed the use of weaning guidelines favourably and perceived that their implementation improved patient outcomes. Weaning is a relatively neglected area of intensive care because much of the initial focus of management is resuscitation and stabilisation. This study has demonstrated the positive impact that standardised and collaborative practice can have on patient outcome and clinical practice.

Thesis (PhD)--University of South Australia, 2002.

Thesis (MNursing (Advanced Practice))--University of South Australia, 1995

Abstract Introduction: Physiotherapy in the human intensive care setting is in common use and supported by Level 1 evidence. In the canine intensive care setting, however, physiotherapy is novel, despite many studies published to support aspects of human physiotherapy being conducted on experimental dogs and there being 83 canine intensive care beds in Sydney alone. As veterinary care progresses and people place more importance on their pet’s health care, an opportunity arises to examine the potential for physiotherapy to augment the veterinary care of client-owned dogs in a veterinary referral hospital setting. The first objective of this thesis was therefore to determine which common conditions cause dogs to present recumbent to veterinary referral hospitals, and then to conduct a literature review on these conditions and ways in which physiotherapy has the potential to add to the treatment of them. The next objective was to describe the short-term effects of recumbency on a number of key body systems in clinically unwell dogs, as concern was that recumbency itself may contribute to pathogenesis and/or poorer recovery, however this could not be investigated before preliminary studies like this were performed. The next objective was to conduct clinical trials of the use of two well-proven techniques in human physiotherapy on dogs with conditions commonly reported in the earlier studies of this thesis. The chosen techniques were continuous positive airway pressure (CPAP) to assist in the recovery of dogs with brachycephalic airway obstructive syndrome (BAOS) from general anaesthetic, and the use of manual chest physiotherapy in dogs with aspiration pneumonia following tick (Ixodes holocyclus) poisoning. Design: Retrospective epidemiological study; Literature review; Cross-sectional descriptive study; Randomised controlled trial; Clinical trial. Results: Dogs admitted recumbent represented 3.18% of total admissions, however had a confirmed survival rate of only 43.5%. Sydney canine intensive care units have a combined capacity of 83 beds, so many other dogs experience recumbency as part of their veterinary management, despite being admitted ambulant, and therefore also have the potential to benefit from physiotherapy. Diagnoses were split into categories, with suspected intervertebral disc disease the most common neurological diagnosis, hit by car the most common orthopaedic diagnosis, collapse the most common diagnosis in the ‘otherwise unwell’ category and tick (Ixodes holocyclus) poisoning and poison (e.g. metaldehyde) ingestion the most common toxicology diagnosis, all of which have the potential to be just as amenable to physiotherapy in dogs as they are in people. However, interspecies comparisons revealed that although the dogs studied had broadly comparable diagnoses to humans, they had a higher mortality rate and received much less physiotherapy than humans. Key body systems were therefore measured in recumbent dogs, with the finding that the dogs included under the strict definition of recumbency in this study maintained a fairly consistent clinical state in the short-term of their period of recumbency (median days 3 to 5 of hospitalization). This finding supported the investigation of physiotherapy as a potential to not only reduce the mortality rate but to speed return to function, which has the potential to also lower the economic burden of prolonged hospitalization on owners. Continuous positive airway pressure was therefore investigated for its potential to improve the safety of recovery from general anaesthetic in dogs with BAOS. Tolerance and effect of CPAP were investigated with positive results demonstrated to improve time to recovery, with no additional distress, in dogs with BAOS recovering from a general anaesthetic. An evidence-based protocol of manual chest physiotherapy was then tested on dogs with aspiration pneumonia following tick (Ixodes holocyclus) poisoning. Demeanour, saturation of peripheral oxygen and auscultation all improved following the first manual chest physiotherapy session, demonstrating tolerance and effect. Conclusions: Primary recumbency is an uncommon but serious condition in dogs that warrants attention by physiotherapy researchers, as dogs admitted ambulant but who spend part of their hospitalization recumbent also have the potential to benefit. This thesis determined the common causes of recumbency in dogs and determined that key body systems of recumbent dogs are clinically stable without the assistance of physiotherapy to improve their short-term rate of recovery. Positive short-term results were yielded from the use of CPAP and manual chest physiotherapy that may benefit other clinically unwell dogs with similar respiratory conditions. Further research should be conducted into other ways in which physiotherapy can augment the care of recumbent dogs, as well as lower the mortality rate and speed the return to function in dogs in the intensive care setting, as it is possible that not all positive findings in human research were replicated in these studies due to Type II error resulting from small sample sizes due to abnormal weather patterns that reduced the number of presentations of dogs with BAOS or tick poisoning during the study period.

Problem investigated: The activation and implementation of the Medical Emergency Team (MET) system. Procedures followed: The ability of the objective activation criteria to accurately identify patients at risk of three serious adverse events (cardiac arrest, unexpected death and unplanned intensive care admission) was assessed using a nested, matched case-control study. Sensitivity, specificity and Receiver Operating Characteristic curve (ROC) analyses were performed. The MET implementation process was studied using two convenience sample surveys of the nursing staff from the general wards of twelve intervention hospitals. These surveys measured the awareness and understanding of the MET system, level of attendance at MET education sessions, knowledge of the activation criteria, level of intention to call the MET and overall attitude to the MET system, and the hospital level of support for change, hospital capability and hospital culture. The association of these measures with the intention to call the MET and the level of MET utilisation was assessed using nonparametric correlation. Results obtained: The respiratory rate was missing in 20% of subjects. Using listwise deletion, the set of objective activation criteria investigated predicted an adverse event within 24 hours with a sensitivity of 55.4% (50.6-60.0%) and specificity of 93.7% (91.2-95.6%). An analysis approach that assumed the missing values would not have resulted in MET activation provided a sensitivity of 50.4% (45.7- 55.2%) and specificity of 93.3% (90.8-95.3%). Alternative models with modified cut-off values provided different results. The MET system was implemented with variable success during the MERIT study. Knowledge and understanding of the system, hospital readiness, and a positive attitude were all significantly positively associated with MET system utilisation, while defensive hospital cultures were negatively associated with the level of MET system utilisation. Major conclusions: The objective activation criteria studied have acceptable accuracy, but modification of the criteria may be considered. A satisfactory trade-off between the identification of patients at risk and workload requirements may be difficult to achieve. Measures of effectiveness of the implementation process may be associated with the level of MET system utilisation. Trials of the MET system should ensure good knowledge and understanding of the system, particularly amongst nursing staff.