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This project offers evidence and data to measure how progressive and sustained mobilization strategies that are implemented by nurses impact early discharge on a single stay Cardiothoracic Intensive Care Unit for patients undergoing first-time Coronary Artery Bypass Surgery (CABG) surgery.

Indiana University-Purdue University Indianapolis (IUPUI) / Healthcare workers are responsible for providing evidence-based care to patients; however, many patients receive unnecessary or harmful care. Successful implementation of evidence-based guidelines can improve patient outcomes, particularly among vulnerable neuroscience patients. Focused efforts to improve nursing knowledge of and adherence to these guidelines are warranted. The purpose of this dissertation was to determine the most effective strategies for implementing evidence-based guidelines into nursing practice. First, an integrative review of the literature was conducted to explore studies addressing implementation of evidence-based guidelines in nursing. Implications from the review suggested further research to better understand which strategies should be utilized to best implement evidence-based nursing practices. Two pre- and posttest studies were then designed to identify a bundle of implementation strategies to improve neurocritical care nurses' knowledge of and adherence to stroke and spinal cord injury guidelines. The tailored, multi-faceted strategies consisted of local opinion leaders, printed educational materials, and educational outreach. Improvements in nursing knowledge of and adherence to these guidelines were noted. Lastly, program evaluations were conducted using a mixed-methods study to understand neurocritical care nurses' perceptions of the usefulness of the strategies employed during the two studies. Findings from this research provided support for the most effective implementation strategies to enhance knowledge development and guideline adherence among neurocritical care nurses for implementation of stroke and spinal cord guidelines.

This dissertation aims to enhance our understanding of the experiences of surrogates (e.g., family, close friends) who make medical decisions for a loved one in the intensive care unit (ICU) after a cardiac arrest. Nearly 500,000 Americans experience a cardiac arrest annually; given high mortality (80%-90%), most surrogates become bereaved. For those who receive post-cardiac arrest care in an ICU, almost three in four surrogates make decisions to limit life-sustaining treatments. The burden of medical decision-making for a loved one has been well-documented and those who serve as surrogate decision-makers in the ICU are known to experience symptoms (e.g., depression, post-traumatic stress) for months after their loved one’s hospitalization. However, it is unknown to what extent decision-making experiences near a loved one’s end-of-life influence symptom burden among bereaved surrogates after cardiac arrest. Decisional conflict, uncertainty about which course of action to take, is reported by half of surrogates faced with ICU treatment decisions and one in five report regret around their decisions after 6 months. Following a cardiac arrest, prognostic uncertainty can complicate surrogate decision-making and potentially worsen decisional conflict and/or regret. The overall objective of this dissertation is to inform future interventions to improve outcomes for this highly vulnerable group. The dissertation study aims were to (1) evaluate the efficacy of interventions for ICU surrogates facing end-of-life decisions, (2) explore differences in surrogate decision-making experiences by level of decisional conflict reported around end-of-life decisions after cardiac arrest, (3) assess physical and psychological symptoms among surrogates during the first 6 months of bereavement after a loved one’s cardiac arrest, and (4) explore relationships between decisional conflict, decision regret, and symptoms. To address these aims, three studies were conducted. Study 1 was a systematic review and meta-analysis to evaluate the efficacy of interventions to improve symptoms among surrogates whose loved one had either died in the ICU or had high predicted likelihood of mortality. The study demonstrated that interventions have yielded only small, significant improvement in depression and post-traumatic stress at 3 months and anxiety at 6 months; findings derived from the meta-analysis have moderate-to-very-low certainty of evidence and have potentially limited clinical utility. Most interventions were delivered in the ICU, suggesting that different approaches (e.g., beyond the ICU) warrant exploration. Studies 2 and 3 report findings from a convergent mixed methods study of bereaved cardiac arrest surrogates. Study design was informed by the Integrative Risk Factor Framework for the Prediction of Bereavement Outcome which includes various inter- and intrapersonal risk factors in addition to bereavement-related stressors that influence outcomes such as symptoms. Surrogates were recruited and enrolled ~1-month after the death of their loved one and were followed through 6 months. Survey data were collected at ~1-, 2-, 3-, and 6-months. Most surrogates also completed interviews which were conducted at ~1-month and 3-months. Study 2 aimed to explore differences in surrogate decision-making experiences by decisional conflict reported around end-of-life decisions in the ICU. Among the 16 surrogates who completed both surveys and interviews at ~1-month, decisional conflict survey scores were relatively low with more than half reporting no decisional conflict. Three themes emerged from interview data, two related to decision-making experiences and one related to broader experiences during the first month after the loved one’s death. Compared to those who reported no decisional conflict, those who did described lack of clarity around their loved one’s preferences for treatment, less support from other family or clinicians, and a poorer understanding of medical treatments or prognosis. All surrogates described challenges navigating life after the loss. Qualitative data provided insight into limitations of retrospective assessment of decisional conflict, highlighted opportunities for enhanced measurement of the construct among surrogate decision-makers, and identified potential areas of focus for future interventions. Study 3 aimed to assess physical and psychological symptoms during the first 6 months of bereavement and explore relationships between decisional conflict, decision regret, and symptoms. Findings demonstrated that more than a third experienced high grief intensity and/or post-traumatic stress 6 months after medical decision-making. Strong correlations were seen between 1-month and 6-month symptoms (i.e., depression, post-traumatic stress, fatigue, sleep disturbance), suggesting that those with high symptom burden early on are likely to have symptoms that persist. Decisional conflict moderately correlated with decision regret at 6 months which moderately correlated with other psychological symptoms (i.e., anxiety, post-traumatic stress, grief intensity). The exploratory findings suggest that early screening may be helpful in identifying surrogates at highest risk for poor outcomes at 6 months and may help target future interventions towards those who need them most. This dissertation makes valuable contributions to our current understanding of the experiences of surrogate medical decision-making near a loved one’s end-of-life in the ICU after cardiac arrest and of surrogate experiences during bereavement. Chapter 5 summarizes each study, reviews key findings, identifies strengths and limitations, and discusses implications for future research, clinical practice, and health policy. Together, these studies support the need for enhanced care for surrogates bereaved after a loved one’s cardiac arrest/critical illness. Surrogates described the burden of medical decision-making near a loved one’s end-of-life in the ICU and the challenges encountered during bereavement. Findings suggest that end-of-life decision-making experiences may influence symptoms through the first 6 months of bereavement. Novel approaches to supporting surrogates are warranted to improve health outcomes for this important, vulnerable group.

Text in Afrikaans / In hierdie beskrywende, verkennende en kontekstuele studie is ondersoek gedoen na redes waarom opgeleide intensiewesorgverpleegkundiges uit die intensiewesorgomgewing bedank en buite die intensiewesorgomgewing werk in die noordelike gedeelte van Gauteng. Doelwitte vir die studie was om die faktore te bepaal wat bydra tot die bedanking uit die intensiewesorgeenheid, die identifisering van die nie-verpleegkundige beroepe wat tans beoefen word en die bepaling van die faktore wat bydra tot die beoefening van 'n nie-verpleegkundige beroep. Die data is ingesamel deur middel van 'n vraelys wat voltooi is deur opgeleide intensiewesorgverpleegkundiges wat bedank het uit die intensiewesorgomgewing. Die sneeubalsteekproeftegniek is gebruik. Die data-analise het getoon dat redes vir bedanking uit die intensiewesorgomgewing die volgende insluit: onvoldoende salarisse, te veel stres en emosionele uitputting, ongerieflike werkure, personeeltekort en onbevredigende werkomstandighede. Daar is bevind dat verpleeg-sessiewerk steeds deur die respondente gedoen word, al werk hulle huidig voltyds buite die intensiewesorgomgewing. / In this exploratory, descriptive and contextual study research has been done to establish the reasons why intensive care nursing personnel resign from the intensive care environment in the northern Gauteng region. The researcher aimed to establish the factors that contributed to the resignations from the intensive care environment, to identify the non-nursing careers currently being practised by former intensive care nursing staff and to establish the factors that influenced them to practice non-nursing careers. The data was collected through questionnaires completed by former intensive care nursing personnel. The snowball test sampling method has been used. Data analysis has shown the following to be inter alia the reasons for the resignations from the intensive care environment: insufficient income, exhaustion and emotional stress, inconvenient working hours, staff shortages and unsatisfactory working conditions. One finding is that respondents are still doing nursing session work although they are working full-time in nonnursing capacities. / Health Studies / M.A. (Verpleegkunde)

The aim of the study was to describe the perceptions of critical care nurses concerning family witnessed resuscitation, presenting arguments for or against the practice thereof. A quantitative, descriptive and exploratory approach was used. For the study, a non- probability convenience sample of 100 critical care nurses from five critical care units were used. A combined open-ended and closed-ended questionnaire was used. The majority of critical care nurses in the study disapproved of the idea of family witnessed resuscitation. They believed it to be traumatic for relatives, threatening to the resuscitation process and increasing litigation. Although the dominant feeling was one of disapproval, some critical care nurses felt that family witnessed resuscitation was beneficial to relatives. Recommendations for future practice included incorporation of educational programmes for critical care nurses concerning family witnessed resuscitation and providing training to deal with the stresses of family witnessed resuscitation. / Health Studies / M.A (Health Studies)

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

The abstract on the file is incorrect, use the the one in the system as it summerizes the full text. / This attempted to describe factors contributing to sleep deprivation in the a multidisciplinary intensive care unit in KwaZulu-Natal Province. A quantitative, descriptive research design was adopted and structured interviews were conducted with 34 adult patients. Most factors contributing to these patients' sleep deprivation are basic physiological needs. Much can be done to enhance patients' abilities to sleep if noise (from alarms, monitors, televisions, telephones and footsteps) could be controlled, patients' pain would be managed effectively, doctors would visit the patients regularly, doctors and nurses use lay terms when talking to patients. Visible clocks and windows will help patients to maintain time orientation. Friendly, approachable and respectful nurses who introduce themselves to the patients help' to reduce patients' stress levels and improve their abilities to sleep. / Health Sciences / M.A. (Health Studies)

Unplanned extubation is premature removal of endotracheal tube, is an adverse event; which can either, be accidental during a nursing procedure or self deliberate by the patient. The AACN Synergy Model for Patient Care was used as conceptual model for this study. A retrospective descriptive design revealed that over a period of two years, 327 patients admitted to the intensive care unit require intubation of which 40.4% were self-deliberate extubation and 59.4% accidental extubation. Of the accidental extubated patients, 29.8% had physical restrains, 57.6% received sedation, 43.9% had analgesic infusion and 38.9% were on neuromuscular blockade. A means Glasco Coma Scale was 9.4 and 56% of the patients were reported as being. Most patients (89.9%) required re-intubation. The findings also revealed that 49.1% of the nurses who cared for the patients when the extubation occured had one patient at the time. Also, 84.2% of nurses had 0-6 years of nursing experience and 74% of nurses had less than five years of ICU experience. / Health Studies / M.A. (Health Studies)

The purpose of the study was to explore and describe the lived experiences of neophyte professional nurses working in ICU during their first year post graduation with the aim to discover strategies to support the nurse in critical care unit. An explorative, descriptive, interpretative qualitative design was conducted to uncover the nurse’s experiences. A purposive sampling was used which is based on belief that the researcher’s knowledge about the population can be used to hand pick sample elements. Data was collected through in-depth unstructured interviews and written narratives. Collaizi’s method of data analysis was used. The study findings revealed that neophyte professional nurses experienced difficulties and challenges in adjusting to the unit because of lack of mentors emanating from the shortage of staff. Nurses experienced mixed feelings regarding the relationship with colleagues in terms of support received. / Health Studies / M.A. (Health Studies)