Bakgrund: munvård är en grundläggande omvårdnadsåtgärd som bidrar till att förebygga respirator-relaterad lunginflammation, s.k. VAP (”ventilator-associated pneumonia”) och en rad diverse systemiska infektioner. Trots vikten med munvård och förekomsten av PM som beskriver utförande av munhygien på intensivvårdsavdelningar, så tycks det vara en lågprioriterad handling hos intensivvårdspatienter. Syfte: att beskriva sjuksköterskans inställning kring munvård hos patienter som vårdas på intensivvårdsavdelning. Metod: kvantitativ studie med beskrivande design som grundas på statistisk analys av data insamlade utifrån ett enkätformulär. Resultat: denna enkätstudie visar att sjuksköterskor prioriterar munvård högt men samtidigt tycker de att det delvis är en undersköterskeuppgift och delegerar ofta uppgiften. Hinder som t.ex. brist på tid kan förklara denna inställning. De flesta sjuksköterskor kände till att det finns ett styrdokument gällande munvård på deras avdelning. Ett antal sjuksköterskor som inte kände till grundläggande munvårdsåtgärder för förebyggandet av VAP, visar bristfälligt kunskap om ämnet. Utbildningsnivå har konstaterats ha ett samband med sjusköterskans inställning kring munvård, då dessa sjuksköterskor har en högre prioritering kring denna åtgärd. Slutsatser: resultatet visar att sjuksköterskor är olika involverade i munvård hos patienter som är i behov av intensivvård. Förbättrad kunskap om evidensbaserad munvård skulle i positiv riktning ändra sjuksköterskans attityd kring munvård i allmänhet, förbättra kvalitén av vården i synnerhet samt minska sjukhusvistelse. Det skulle även leda till minskad mortalitet och utgifter för sjukvården. / Background: mouth care is a basic nursing activity which contributes to prevent ventilator associated pneumonia (VAP) and a number of different systemic infections. Despite the importance of mouth care and the presence of protocols which describe how to perform mouth hygiene in the intensive care units, there is still low priority in mouth care on the critically ill patient. Aim: to describe nurses attitude on mouth care in patients who takes care of in the intensive care unit. Method: quantitative study with a describing design which is based on the statistical analysis of data collected from a questionnaire. Results: this survey shows that nurses prioritizes mouth care high but at the same time they have the opinion that it is partly a nursing assistants’ task and often delegates it. Barriers like for example lack of time can explain this attitude. It was to the knowledge of most of the nurses that there is a policy on mouth care in their wards. A number of nurses, who did not know basic mouth care for preventing VAP, demonstrate lack of knowledge on the subject. Education level has shown to have a connection with nurses’ attitude about mouth care, when these nurses prioritize higher this action. Conclusions: the results show that nurses are at different levels involved in oral care of patients who are in need of intensive care.  An improved knowledge about evidence based mouth care would change nurses’ attitude in a positive direction in general, improve the quality of health care in particular and reduce hospital stay. It would also lower mortality and the economic strain on health care.

Introduction. MRSA is a major healthcare problem with particular relevance to morbidity and mortality in ICU (Byers & Decker 2008). Due to the increased infection risks associated with cardiac surgery, MRSA screening and surveillance is widely used as a standard preoperative Investigation In many settings (Teoh, Tsim & Yap, 2008). The results, in conjunction with appropriate hygiene precautions, are used to control and prevent infection with MRSA. Following an outbreak of MRSA in cardiac patients an MRSA protocol (MRSAP) was implemented In the cardiac intensive care unit in this study. Purpose. To evaluate how nurses implement the MRSAP in the surgical cardiac intensive care unit in this study, and to evaluate the change in MRSA infection rates following implementation of the MRSAP. From the results obtained, to identify any areas for improvement in nursing practice with respect to the MRSAP. Methods. Nursing staff knowledge with respect to the MRSAP was assessed using a survey questionnaire. Their compliance with required Infection control practice for control of MRSA was assessed through periods of observation on the unit. Screening compliance and reduction in infection rates were investigated using a retrospective records review. Results. The survey revealed good awareness of the MRSAP (88%, n=23), but knowledge of the detailed content was variable. Most staff were apparently satisfied with the existing standards of infection control in CICU (84.6%, n=22). Observation revealed that, compliance with routine hygiene measures was good (66% correct contacts, n=144) by the standard of other studies, but, given the high risk of postoperative infection for these patients improvements are required. Inadequate data in sampled records prevented meaningful analysis of screening compliance, and hence the systems for handling screening swabs and results need to be reviewed. The change in infection rates between the pre and post MRSAP periods, which incorporated use of infection risk stratification data to demonstrate comparability of the two groups of patients, revealed that despite the high MRSA infection rate in 2005 (1.18%), and subsequent drop post MRSAP (0.35%), the actual number of cases found was too small to test statistically for significant difference. An incidental finding was that female cardiac surgery patients were getting significantly younger (p<0.01). There was a significant decrease in hospital MRSA infection rates for matched periods (p<0.0001 ). Conclusions. Evidence was found to support the efficacy of the MRSAP in the reduction of MRSA infections. Deficits in staff knowledge and infection control practice were identified and feedback has been implemented in order to improve compliance with the MRSAP and maintain the improved infection rates. Further research with respect to implementation of, and compliance with, infection control measures could both improve quality of patient care and decrease the burden of preventable infectious disease such as health care associated infections (HAls) in South Africa. / Thesis (M.N.)-University of KwaZulu-Natal, Durban, 2008.

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.

Hyperglycaemia is a common condition in the very low birth weight infant and is linked to mortality and increased risks of morbidities such as sepsis and retinopathy of prematurity. The preterm neonate is in a state of transition from complete dependence on the mother to physiological independence. Many metabolic regulation systems are under-developed, attenuating the natural metabolic hormonal control response. Tight regulation of glucose levels can significantly reduce the negative outcomes associated with hyperglycaemia, but achieving it remains clinically elusive for the neonate. Glucose control in adult critical care is a highly researched topic, and several studies have demonstrated significantly improved outcomes with protocols that modulate the insulin and/or nutrition inputs into the patient. Despite the potential, no standard protocol exists for neonates. Glucose restriction is often used as a treatment for neonatal hyperglycaemia, however this deprives the infant of much needed energy for growth. Limited trials of insulin infusions have been reported, based on fixed protocols or ad-hoc clinical decisions that do not objectively account for an individual patient's metabolic state. Model-based methods can deliver control that is patient-specific and adaptive to handle highly dynamic patients. A physiological model of the glucose-insulin regulatory system is presented in this thesis, adapted from adult critical care. This model has three compartments for glucose utilisation, effective interstitial insulin and its transport, and insulin kinetics in blood plasma, with emphasis on clinical applicability. The predictive control for the model is driven by the patient-specific and time-varying insulin sensitivity parameter. A novel integral-based parameter identification enables fast and accurate real-time model adaptation to individual patients and patient condition. Validation on retrospective clinical data demonstrated the model's ability to capture the major dynamics of the glucose-insulin system in the critically ill neonate. Model fit and prediction performance analysis resulted in a similar level of performance as adult intensive care models and thus suitable for model-based targeted control. Comparison of insulin sensitivity profiles with adult critical care patients highlighted the glycaemic control problem as one of managing inter- and intra-patient variability. Stochastic models and time-series methods for forecasting future insulin sensitivity are presented in this thesis. These methods can deliver probability intervals to support clinical control interventions. The risk of adverse glycaemic outcomes given observed variability from cohort-specific and patient-specific forecasting methods can be quantified to inform clinical staff. Hypoglycaemia can thus be further avoided with the probability interval guided intervention assessments. Simulation studies of clinical control trials on `virtual patients' derived from retrospective clinical data provided a framework to optimise control protocol design in-silico. Comparisons with retrospective control showed substantial improvements in glycaemia within the target 4 - 7 mmol/L range by optimising the infusions of insulin. The simulation environment allowed experimentation with controller parameters to arrive at a protocol that operates within the constraints imposed by the clinically fragile state of the preterm infant. The resulting control system was piloted in seven 12-24 hour clinical trials at the Christchurch Women's Neonatal Department. Glucose levels were tightly controlled in all cases over a trial cohort that represented a wide range of patient conditions and severity of illness. Model predictive performance agreed with simulation results and the stochastic model forecast bounds maintained patient safety. Overall, the research presented takes model-based neonatal glycaemic control from concept to proof-of-concept clinical pilot trials. The thesis develops the full range of models, tools and methods to optimise the protocol design and problem solution. This research thus provides a template for model-based glycaemic control development in general that could be extended to other glycaemic control and similar problems.

Bakgrund: Hjärtkirurgi är idag ett av de vanligaste större kirurgiska ingreppen i Sverige. Smärta efter hjärtkirurgi kan hindra patienter från att ta djupa andetag eller att röra sig. Om smärtan blir underbehandlad kan det resultera i postoperativa komplikationer. Intensivvårdssjuksköterskor ska ha kunskap om postoperativ smärta, smärtbehandling samt regelbundet dokumentera patienternas smärta. Syfte: Att undersöka postoperativ smärta hos patienter som genomgått hjärtkirurgi med median sternotomi. Metod: Kvantitativ deskriptiv tvärsnittsundersökning med konsekutivt urval. Totalt 22 patienter inkluderades i studien. Materialet samlades in med hjälp av enkäter som ansvariga sjuksköterskor hade som underlag vid skattning av patienternas postoperativa smärta två timmar efter avslutad respiratorbehandling. Smärtskattningsinstrumenten som användes var visuell analog skala (VAS) eller numerisk skala (NRS). Övrig information inhämtades via journalgranskning av övervakningsjournalerna. Resultat: Det var fler patienter som skattade sin smärta till VAS &gt; 3 vid djupandning eller hosta än i vila. 17 av 22 patienter skattade sin smärta till VAS &gt; 3 vid djupandning eller hosta två timmar efter avslutad respiratorbehandling. Intensivvårdssjuksköterskornas behandling av den postoperativa smärtan varierade och dokumentationen av patienternas skattade smärta var bristfällig. Slutsats: Majoriteten av patienterna hade ont två timmar efter avslutad respiratorbehandling och det talar för att patienternas smärtbehandling inte var tillräcklig. Patienternas smärtintensitet var svår att följa under det första postoperativa dygnet på grund av bristfällig dokumentation. Förklaringen till detta kan vara att intensivvårdssjuksköterskorna inte prioriterar dokumentation av smärta. Klinisk betydelse: Eftersom otillräcklig behandling av smärta kan leda till komplikationer är det av klinisk betydelse att fokusera på smärta efter hjärtkirurgi och optimera behandlingen av postoperativ smärta. / Background: Today, heart surgery is one of the most common larger surgical interventions in Sweden. Pain after heart surgery can prevent patients from taking deep breaths or keep them from participating in activities. If the pain remains undertreated, post-operative complications can occur. Intensive care nurses must have knowledge about post-operative pain and its treatment and regularly document patients’ pain. Aim: To examine post-operative pain in patients that has undergone heart surgery with median sternotomy. Method: Quantitative descriptive cross-sectional survey with consecutive selections. In total 22 patients were included in the study. The material was gathered with questionnaires that intensive care nurses used to estimate the patients’ post-operative pain two hours after extubation. The pain assessment tool that was used was VAS or NRS. Other information was acquired from medical record review of the monitoring records. Results: More patients rated their pain VAS &gt; 3 during deep breathing or coughing than during rest. 17 patients rated their pain during deep breathing or coughing to VAS &gt; 3 two hours after the completion of respiratory therapy. The intensive care nurses’ treatment of the postoperative pain varied and the documentation of the pain estimate was inadequate. Conclusion: The majority of the patients experienced pain two hours after the completion of respiratory therapy, and this may indicate that the treatment of patients’ pain was not sufficient. The intensity of the patients’ pain was difficult to follow during the first post-operative day and night due to inadequate documentation. Possibly, the documentation of patients’ estimated pain was not prioritized. Clinical importance: Since insufficient treatment of pain can lead to complications, it is of clinical importance to focus on pain after heart surgery and to optimize the treatment of post-operative pain.

Bakgrund: Sömn är ett mänskligt grundläggande behov och bör därför tillgodoses hos patienter som vårdas på sjukhus. Patienter som vårdas på intensivvårdsavdelningar upplever dock ofta upprepade avbrott på sömnen och sömnbrist vilket kan leda till både fysiska och psykiska negativa konsekvenser. Intensivvårdsmiljön med dess oljud, starka belysning och frekventa vårdrelaterade interaktioner leder ofta till oförmåga hos patienterna att få en adekvat sömn. Syfte: Att belysa olika interventioner sjuksköterskan kan tillämpa för att förbättra sovmiljön och sömnkvaliteten hos patienter som vårdas på en intensivvårdsavdelning. Metod: En litteraturöversikt med grund i analys av kvantitativ forskning. Resultat: I resultatet framkom sju interventioner som delades in i tre olika kategorier: skapa en bättre sovmiljö, avskärmning från ljud och ljus samt förbereda patienten för sömn. De sju interventionerna som identifierades var: tysta/störningsfria perioder, riktlinjer/ramverk innefattande aktiviteter för att kontrollera yttre störande faktorer, utbildning, öronproppar och ögonmask, adderat "white noise", musik samt akupressur. Slutsats: Genom att tillämpa en eller fler av de sju interventionerna kan sovmiljön och sömnkvalitet förbättras för patienter som vårdas på intensivvårdsavdelningar. Dock krävs ytterligare forskning inom området då vissa interventioner ger motstridiga resultat. Klinisk betydelse: Sömn är ett nödvändigt behov och har en stor betydelse för återhämtning från sjukdom och bör därför tillgodoses av sjuksköterskan. Resultatet i denna litteraturöversikt kan ge en ökad förståelse för vilka interventioner sjuksköterskan kan tillämpa i sitt omvårdnadsarbete för att förbättra sovmiljön och sömnkvalitet för patienter som vårdas på intensivvårdsavdelningar. / Background: Sleep is a basic human need and should be addressed in patients being treated in hospital. Patients cared for in intensive care units often experience repeated interruptions of sleep and sleep deprivation, which can lead to both physical and psychological adverse consequences. The intensive care environment with its noise, strong lighting and frequent care-related interaction often leads to the inability of patients to get adequate sleep. Aim: To illustrate the various interventions the nurse can implement to improve the sleep environment and quality of sleep in patients who are cared for in an intensive care unit. Methods: A literature review with its basis in an analysis of quantitative research. Results: The result emerged in seven interventions that were divided into three different categories: creating a better sleep environment, shielding from light and sound, and preparing the patient for sleep. The seven interventions identified were: quiet/non-disturbance periods, guidelines/framework including activities to control disturbing environmental factors, education, ear plugs and eye mask, added "white noise", music and acupressure. Conclusion: By applying one or more of the seven interventions the sleep environment and sleep quality for patients cared for in intensive care units may improve. However, as some interventions produced conflicting results, further research in the area is required. Clinical significance: Sleep is an essential requirement and has great importance in the recovery from illness and should therefore be carefully understood by the nurse. Findings from the literature review can provide a better understanding of which interventions nurses can apply in their work to improve the sleep environment and sleep quality for patients cared for in intensive care units.

The purpose of this study was to examine burnout in the critical care nurse. One hundred-eighty eight nurses employed at Community Hospitals of Indiana were surveyed to determine the relationship between burnout, level of expertise and social support systems. Frequency and intensity of burnout was measured by the Maslach Burnout Inventory. Social support systems were measured by the Norbeck Social Support Questionnaire. Level of expertise was determined by question 1 of the demographic questionnaire length of time employed as a critical care nurse.Findings of this study revealed no significant differences in level of expertise related to intensity and frequency of burnout (F= .232). Results of ANOVA indicated the sampled nurses experienced a low to average degree of burnout for both frequency and intensity of burnout. Similarly using Pearson correlate there was no relationship between level of support systems and frequency also concluded that level of support systems did not and intensity of burnout (novice, p= -.23; competent, p= .11; expert, p= .07). Conclusions of this study indicated level of expertise was not a factor in determining intensity and frequency of burnout.It was burnout need to be readily available for all nurses in influence intensity and frequency of burnout in the novice, competent or expert critical care nurse.Implications indicate that preventative measures for critical care settings. Other implications were that nursing support systems may not be an effective strategy for burnout prevention and resources may need to focus on other strategies. / School of Nursing

Caring is a universal need of all humans and is central to the practice of nursing (Watson, 1979). Considerable research has been conducted in the study of caring behavior and caring. However, there has been little nursing research which focuses on the meaning of care as perceived by the patient. The purpose of this study was to further determine the patient's perceptions of caring behaviors of nurses by using Watson's (1979) theory of carative nursing.Watson's theory identified ten carative factors which served as the basis for the caring behavior's assessment instrument's (CBA) seven subscales. The instrument was administered to a convenience sample of 100 adults, 59% female, 40% male over 21 years of age hospitalized during 1997-1998 on the progressive care unit of a large Midwest hospital.Data were analyzed using descriptive and correlational statistics as well as MANOVA. The Cronbach's alpha reliability coefficient for each subscale ranged from 0.88 to 0.98. Principle components factor analysis revealed seven factors which accounted for 71% of the variance in the data and provided support for construct validity of the instrument.Finding showed that critical care patients perceived caring behaviors of nurses in a critical care setting as having much importance on all seven subscales of the CBA. Overall, they perceived technical professional, helping/ trusting subscale and teaching/learning subscale as having much importance. There were no significant differences found on behaviors based on age, sex, education, length of hospital stay and number of hospital admissions.There were no significant differences between those who were married and not married. Married patients perceived as less caring behavior on humanism helping/trusting and teaching subscales.A major conclusion was that patients in the critical care setting overall perceived all behaviors of nurses in a critical care setting as identified in the CBA's seven subscales of the instrument as having the most importance. The behaviors identified as having the most important were technical-professional including giving shots and taking care of equipment (monitor). / School of Nursing

Critical care nurses need finely honed critical thinking skills in order to be safe, competent, and skillful practitioners of their profession. If clinical nurses do not learn how to reason effectively, they may make inappropriate decisions about their patients' care, ultimately resulting in increased patient mortality (Fonteyn, 1991). In addition, increasing nurses' decision-making and autonomy has been shown to improve job satisfaction and retention (Prescott, 1986).There are many authors who write about the need for developing critical thinking skills among practicing professional nurses (Creighton, 1984; Jenkins, 1985; Levenstein, 1981, 1983, 1984). However, research assessing the impact of continued education and clinical experience on the development of critical thinking skills is sparse.The purpose of this exploratory study is to determine if there is a relationship between the level of critical thinking skills (as measured by the Watson-Glaser Critical Thinking Appraisal Tool, 1980) in critical care nurses and the length of nursing experience, amount of continuing education pursued annually, and the level of formal nursing education completed. The conceptual framework that provides the basis for this study is Patricia Benner's (1984) application of the Dreyfus Model of Skill Acquisition to clinical nursing practice.Participants (N = 61) were obtained on a voluntary basis from the population of critical care nurses working in the intensive Care Unit, Coronary Care Unit, Cardiac Catheterization Laboratory, or Emergency Care Center of a 600 bed midwestern acute care facility. Each participant in the study was asked to sign an informed consent agreeing to participate after receiving a written and oral explanation of the study. Confidentiality of the participants was maintained by substituting identification numbers for the subjects' names on the data collection instruments. The investigator supervised the administration of the critical thinking instrument and demographic questionnaire.The Pearson product-moment correlation coefficient and a two-tailed t-test for independent samples were used to determine if there were any significant relationships between the WGCTA score and the length of critical care experience, attendance of continuing education programs, or completion of additional formal education. This data analysis supported hypothesis one with the results revealing a significant positive correlation (r = .46, p = <.001) between the WGCTA scores and the length of critical care experience. In addition, a statistically significant but weak positive correlation was found between the WGCTA scores and the length of experience in CCU (r = .52, p = .001). No significant correlation existed between the WGCTA scores and length of experience in ECC, ICU, or CCL. Hypothesis two was supported with a significant difference (t = 3.58, df = 59, p = .001) found between the critical thinking ability of the two groups, with those who have completed an additional formal program of nursing education scoring higher. A significant but weak positive correlation (r = .30, p =.020) was found between the number of continuing education programs attended annually and the WGCTA scores. Multiple regression was performed with the total WGCTA score being the dependent variable and total critical care experience, completion of additional formal education, and attendance of continuing education programs being the independent variables. Only total critical care experience entered the equation (E = 16.03, p = <.001) explaining 21% of the variance.The information gained from this study will provide direction for the review of existing orientation, continuing education, and staff development programs provided at different levels of nursing experience and make suggestions for change to enhance critical thinking skill development. / School of Nursing

Intensivvårdssjuksköterskor uttrycker upplevelser av moralisk stress i det dagliga arbetet och detta kan leda till utbrändhet eller behov av att byta yrke då de inte lyckas bemästra sin situation. Studiens syfte var att kartlägga moralisk stress hos intensivvårdssjuksköterskor med hjälp av Moral Distress Scale(MDS). Studien utfördes med en deskreptiv metod av tvärsnittsdesign där 45 sjusköterskor med intensivvårdsutbildning i västsverige tillfrågades att vid ett tillfälle besvara en enkät med en validerad svensköversatt MDS. Resultatet påvisade att det finns signifikant höga nivåer av moralisk stress hos intensivvårdssjuksköterskor yngre än 45 år(p=0,044) och även i gruppen med kandidat/-magisterexamen(p=0,003). De högsta nivåerna av moralisk stress kunde uppmätas när intensivvårdssjuksköterskorna ställdes inför situationer där de upplevde att ingen var beredd att fatta beslut om att avsluta livsuppehållande behandling. Bristande kompetens, "onödiga" behandlingar och resursbrist medförde också hög moralisk stress. För att motverka moralisk stress behövs enligt studier; debriefing, etiska vårdkonferenser och stöd från arbetsledningen. Denna studie kan bidra till att åskådliggöra moralisk stress och intesnifiera diskussionen samt skapa ett gemesnamt språk kring moralisk atress bland intensivvårdssjuksköterskor.