Acute and critical care patients experience significantly more pain than those patients on a general nursing unit. Due to the severity of their condition, acute care patients may be nonverbal and unable to self-report their pain. Behavioral pain assessment tools are a method of objectively measuring pain in patients who are unable to communicate. While the use of these tools has been shown to improve short- and long-term outcome for patients, there is a paucity of evidence as to nurses' perceptions related to their use. The purpose of this study is to investigate acute care nurses' perceptions of the relationship between the use of behavioral pain assessment tools and pain outcomes in nonverbal patients. A survey was developed to determine the perception of this relationship. A total of 23 acute and critical care nurses participated. The survey asked multiple perception-based questions related to pain assessment and management in nonverbal patients including but not limited to, the importance of pain assessment, the frequency of use of behavioral pain assessment tools, the use of pain scores in patient hand-off, and education related to behavioral pain assessment tools. Open ended questions were also posed inquiring as to participants perceptions of the effect of using behavioral pain assessment tools on pain assessment and pain outcomes. Survey results showed a majority (82.6%, n=19) of participants think the use of behavioral pain assessment tools improves pain assessment and outcomes. Participants reported they perceive the use of these tools allows for a thorough standardized assessment which allows for the objective evaluation of pain outcomes, and ultimately, effective pain relief.

Introduction: Oral hygiene is a significant aspect of nursing care. Endocarditis, stroke, lung cancer, and hypertension have been associated with poor oral hygiene. Research exploring oral care practices for mechanically ventilated patients is well documented. In contrast, oral hygiene for the non-mechanically ventilated acute care population remains underestimated. The purpose of this study was to establish a baseline of the type, frequency, and consistency of oral hygiene being performed on non-mechanically ventilated ICU patients and explore how the oral care provided was documented. Methodology: A literature search was conducted and reported as a literature review. The databases CINAHL Plus with Full Text, MEDLINE, PsychINFO, Academic Search Premier, and Cochrane Database of Systematic Reviews were searched. Key terms used were "oral hygiene," "oral care," "oral intensity," "mouth rinse," "mouth care," chlorhexidine rinse and ICU, "intensive care unit," "critical care" and infection*, pneumonia*, NV, non-ventilat*, and nonventilat*. The articles' selection addressed type, frequency, consistency, and/or documentation of oral hygiene in ICU patients, particularly non-mechanically ventilated patients, if available. Inclusion criteria consisted of English language, and academic journal articles. No specified publication date was placed as a restriction. The results were limited to English language, academic journal articles, peer reviewed research articles, evidence-based articles or practices, and articles published within the last ten years (2006 to 2016). All articles on oral hygiene practices in the ICU or critical care population were included. Articles that did not relate to oral hygiene practices in acute care, ICU patients, or critically ill hospitalized patients were excluded. Articles focused solely on the mechanically ventilated or intubated population were also excluded. Results: The review yielded very few articles focusing solely on non-mechanically ventilated ICU patients. Nevertheless, resulting data showed four areas common to oral hygiene practices in non-mechanically ventilated patients in the ICU: type of documentation, type of products, frequency of care, and personnel providing care. Documentation was found to be lacking compared to personnel's self-reported frequency of oral care. Oral hygiene products were found to be consistent in non-mechanically ventilated patients, while there was no consistency of products used in the general acute care population. Oral hygiene was self-reported by staff members to have been performed an average of two to three times per day for non-mechanically ventilated patients. Oral hygiene self-reported frequency was found to be inconsistent among the general acute care population. Lastly, registered nurses (RNs) were the primary providers of oral hygiene to patients. Conclusions: Findings support the existing gap in the literature on oral hygiene practices in non-mechanically ventilated patients in the ICU. Despite evidence documenting the impact of oral hygiene on health, further research is guaranteed.

Text in English / The purpose of this study was to develop strategies to overcome the challenges in the management of large intensive care units (ICUs). Qualitative, research was conducted to explore and describe the challenges and needs experienced by the ICU managers and critical care nurses in the management of large ICUs. Data was collected through interviews. The study was conducted in two phases, that is, Phases I and II which involved compilation of evidence in preparation for development of the strategies and development of the strategies respectively. Two groups of critical care nurses participated in the steps of data collection in Phase I of the study. The unit managers participated in Phase I step 1 which was individual interviews and the critical care nurses not in the management role participated in Phase I, step 2 which was focus group interviews. Data was analysed using the descriptive analysis method of Tesch (1990). The study has highlighted the challenges and needs in the management of large ICUs, through seven themes that emerged from the findings. Ten strategies were developed to overcome the challenges and address the identified needs. The strategies have been presented as a contribution to literature. / Health Studies / D. Litt. et Phil. (Health Studies)

This research study explored the meanings former patients attributed to being on long-term mechanical ventilation in a critical care unit (CCU). An interpretive phenomenological-ontological perspective informed by the philosophical tenets of Heidegger (1927/1962) was used to examine the lived experience of a group of people who had previously been hospitalised in one of three critical care units in southeast Queensland, Australia, during which time they were on a mechanical ventilator for a period of seven days or more. Data were collected using 14 unstructured audio-taped interviews from participants, who had indicated that they were willing and able to recall aspects of their critical care experience. The data were analysed using the method developed by van Manen (1990). A total of nine people participated in the study, of which six were male and three female. Their ages ranged from 21 to 69 years. Thematic analysis of the data revealed four themes: Being thrown into an uneveryday world; Existing in an uneveryday world; Reclaiming the everyday world; and Reframing the experience. Throughout the description of these themes, excerpts from the interviews with the participants are provided to demonstrate, and bring to light the meaning and interpretations constructed. From this thematic analysis, a phenomenological description drawing on Heidegger's tenets of Being was constructed. Titled Being at its most elusive, this description showed that participants experienced momentary lapses of: situation, engagement, concern and care, temporality, and the ability to self-interpret. These findings highlight and affirm the relevance of Heidegger's ontological tenets to reveal Being. The findings of this study served as a basis for a number of recommendations relating to nursing practice, education and research. Recommendations relating to practice include: constructing a more patient-friendly critical care environment, increased involvement of patients and their families in decision making and patient care activities; ensuring adequate critical care nursing staff levels; ensuring and maintaining appropriate skill level of critical care nurses; enhancing methods of communication with patients; planning for effective patient discharge and adoption of a designated nurse position for discharge planning; providing opportunities for follow up contact of patients once they are discharged from CCU; and promoting the establishment of follow up services for former CCU patients, and their families. Recommendations relating to critical care education include: incorporating more in-depth information of the psychological and social aspects of patient and family care into care planning; incorporating communication and counselling education and training to assist nurses caring for mechanically ventilated patients, and their families; further education regarding the role and responsibilities of patient discharge planning from CCU; incorporating more advanced research skills training and utilisation of research findings into practice; and the provision of appropriate and ongoing training and education in areas such as manual handling and communication skills for all health care staff involved in the direct care of CCU patients. This study also recommended that further research be undertaken to: examine and compare different sedative and analgesic protocols and their effects on the incidence of nightmares and hallucinations reported by CCU patients; replicate this study in a group of patients from different cultural or ethnic backgrounds; evaluate the efficacy of current methods for communicating with intubated and mechanically ventilated patients in the CCU; develop, test and evaluate the efficacy of new methods for communicating with intubated and mechanically ventilated patients in the CCU; examine CCU patients' perceived level of control and power; explore the extent and type of involvement patients would like to have in their care whilst in the CCU; investigate the extent and type of problems experienced by CCU patients after discharge; explore the usefulness and appropriateness of personal diaries for individual patients as an aid to assist in understanding and resolving their CCU experience; and examine the value of follow up contacts by CCU staff to former patients and their families. In summary, the findings from this study add substantial knowledge to critical care nurses' understanding and knowledge about what it means to be on long-term mechanical ventilation in a critical care unit. Findings will help inform future critical care nursing practice and education, and the provision of holistic and evidenced-based care.

Text in English / The purpose of this study was to develop strategies to overcome the challenges in the management of large intensive care units (ICUs). Qualitative, research was conducted to explore and describe the challenges and needs experienced by the ICU managers and critical care nurses in the management of large ICUs. Data was collected through interviews. The study was conducted in two phases, that is, Phases I and II which involved compilation of evidence in preparation for development of the strategies and development of the strategies respectively. Two groups of critical care nurses participated in the steps of data collection in Phase I of the study. The unit managers participated in Phase I step 1 which was individual interviews and the critical care nurses not in the management role participated in Phase I, step 2 which was focus group interviews. Data was analysed using the descriptive analysis method of Tesch (1990). The study has highlighted the challenges and needs in the management of large ICUs, through seven themes that emerged from the findings. Ten strategies were developed to overcome the challenges and address the identified needs. The strategies have been presented as a contribution to literature. / Health Studies / D. Litt. et Phil. (Health Studies)

The hospitalization of a family member in an intensive care unit can be a very stressful time for the family. Family bedside rounds is one way for the care team to inform family members, answer questions, and involve them in care decisions. Few studies have examined the experiences of family members with ICU bedside rounds. A qualitative descriptive study, undergirded by the Family Management Style Framework developed by Knafl and Deatrick (1990, 2003) and Knafl, Deatrick, and Havill (2012), was done at an academic medical center examining families who both participated and did not participate in the family bedside rounds. The majority of families who participated (80%) found the process helpful. One overarching theme emerged from the data of participating families: Making a Connection: Comfort and Confidence. Two major factors influenced how that connection was made: consistency and preparing families for the future. Three types of consistency were identified: consistency with information being shared, consistency about when rounds were being held, and consistency with being informed of delays. The second major contributing factor was preparing families for the future. When a connection was present, families felt comfortable with the situation. When any of the factors were missing, families described feelings of anger, frustration, and fear. Family members who did not participate described feelings of disappointment and frustration about not having participated. As healthcare providers, what we say to families matters. They need to be included in decision-making with honest, consistent, easy-to-understand information.

Injury is a global health problem and in the United States is the leading cause of death for persons aged 1 – 44 years. The primary causes of trauma related death are head injury and hemorrhage; hemorrhagic shock is difficult to recognize in the first hours after trauma. Identification of specific and optimal criteria upon which to base effective triage decisions for trauma patients has been an elusive goal for decades. The purpose of this dissertation was to identify measures available in the prehospital phase of care and in the Emergency Department that should be included for a more comprehensive definition of the trauma patient who will require trauma center care to better allocate trauma care and resources available. The first paper is a critical review of early physiologic markers of occult tissue hypoperfuson in which we examine markers of cardiovascular function and markers of tissue perfusion. In this review, we found surrogate measures of tissue perfusion include shock index as a measure of hemodynamic stability and acid-base indicators as measures of tissue oxygenation. This review guides the variable selection for the research study. The second paper is a report of a study conducted to examine shock index calculated from the first available prehospital vital signs and first available emergency department vital signs as a predictor of mortality within 48-hours in trauma compared to the Injury Severity Score. Shock index can be calculated in real-time during the course of treatment and provides continuous input into the ever changing condition of the patient. Injury severity score is calculated once, at the time of hospital discharge and is used primarily as a marker for comparison of injury severity in research and quality measures of trauma care. The study consisted of 516,156 trauma patient data reported to the National Trauma Data Bank (NTDB) in 2009. The results revealed SI as calculated in both the pre-hospital phase of care by Emergency Medical Services and in the Emergency Department to be significant independent predictors of mortality within forty-eight hours from trauma injuries. The third paper is a report of a study conducted to examine potential markers of occult tissue hypoperfusion within forty-eight hours of injury. The variables included four major variable categories, physiologic measures, anatomic measures, injury severity and presence of reported comorbid illness. The variable most predictive of death from trauma related injuries within forty-eight hours was the need for intubation. The findings from this dissertation provide further evidence of the value of multiple physiologic markers in early recognition of occult tissue hypoperfusion. Data from neither the review of the literature nor the two data-based studies are sufficient to identify a brief, accurate, easily used clinical instrument. Further work is needed to develop a clinically useful instrument to identify the occult tissue hypoperfusion in the trauma patient.

Background: Tanzania is a low-income country where many people struggle to afford health care. Previous research on emergency health care in Tanzania shows that there are limited resources when it comes to both education in emergency care and acute care equipment. Furthermore, there is limited information concerning experiences from nurses working with emergency care under these conditions. Aim: The aim of this study was to examine the Tanzanian nurses’ experience of caring for patients with life threatening conditions at a hospital in a small community. Method: The study has a qualitative design with a semi-structured interview method where six registered nurses with experience of caring for patients who suffers from life threatening conditions at the Bagamoyo District Hospital in Tanzania were interviewed. The interview transcriptions where analyzed with a qualitative content analysis method described by Granheim and Lundman (2004). Results: The result shows that the nurses works in an environment where recourses are limited and how they have found alternative ways to provide care under the given circumstances. It reveals how the nurses’ cope with these situations, their emotional challenges and how they manage feelings that comes from caring for patients with life threatening conditions under the prevailing circumstances. Discussion: The result was discussed in relation to Roy’s adaption theory where the main focus was on the human being and its ability to adapt in order to maintain health and quality of life while interacting with a changing environment. / Bakgrund: Tanzania är ett utvecklingsland där många människor har svårt att bekosta sjukvård. Tidigare forskning rörande akutsjukvård i Tanzania visar att det finns en brist på utbildning och utrustning inom akutsjukvården. Det finns få studier som undersöker sjuksköterskans erfarenheter från att arbeta med akutsjukvård under de bristande förhållandena. Utifrån detta väcktes ett intresse för att utforska sjuksköterskans upplevelser utav att vårda patienter i livshotande tillstånd under dessa bristfälliga förhållanden. Syfte: Syftet med studien var att utforska den Tanzanianska sjuksköterskans upplevelser av att vårda patienter i livshotande tillstånd på ett sjukhus i ett litet samhälle. Metod: Studien har en kvalitativ utformning med semistrukturerade intervjuer. Intervjuer hölls med sex sjuksköterskor som arbetar på Bagamoyo District Hospital i Tanzania med erfarenhet av att vårda patienter i livshotande tillstånd. Intervjuerna transkriberades och bearbetades enligt en kvalitativ innehållsanalys som beskriven utav Granheim och Lundman (2004). Resultat: Resultatet visade att sjuksköterskorna arbetar i en miljö där resurser saknas och hur de funnit alternativa vägar för att kunna ge omvårdnad trots detta. Resultatet visar också att sjuksköterskorna ställs inför känslomässiga utmaningar och hur de hanterar känslorna som uppkommer då de vårdar patienter i livshotande tillstånd under bristfälliga förhållanden. Diskussion: Resultatet diskuterades i relation till Roys adaptionsteori med tyngdpunkt på människan och dess förmåga att adaptera för att upprätthålla hälsa och livskvalitet i en föränderlig miljö.

Thesis (MCur (Nursing Science))--University of Stellenbosch, 2010. / Thesis presented in partial fulfilment of the requirements for the degree of Master of Nursing at Stellenbosch University / ENGLISH ABSTRACT: The trend towards specialisation in nursing has resulted in the development of the role of the Clinical Nurse Specialist (CNS) since the 1960s and 1970s in North America and the United Kingdom respectively. A Clinical Nurse Specialist should demonstrate excellent skills in leadership, communication, critical thinking, clinical and collaborative ethical decision-making, as well as mentoring. Research done internationally has shown that advanced practice nursing leads to higher patient satisfaction and compliance, fewer hospitalisations and shorter length of stays. The development of the CNS role in SA is slow in implementation. The South African Qualifications Authority has only recently published qualification rules for a master’s certificate and master’s degree in Nursing for advanced specialist nurses in SA. This situation led to the following research question: What is the expected role of the Critical Care Clinical Nurse Specialist in private hospitals in the northern and southern suburbs of the Cape Peninsula, South Africa? A non-experimental, explorative, descriptive study with a quantitative orientation was conducted in eight private hospitals in the Cape Peninsula. Through non-probability sampling 73 critical care health professionals (critical care professional nurses, clinical nurse specialists, nursing managers, unit managers, nurse educators, clinical facilitators, clinical coordinators and doctors) out of a population of 170 critical care health professionals participated in the study. A survey tool was designed and validated to collect the data. Quantitative data was analysed through Statistica® and qualitative data was analysed thematically. It was found that 81% of the participants agreed that Clinical Nurse Specialists should be appointed in the South African critical care environment as soon as possible to improve patient outcomes, to contribute to safer nursing care, to relieve work stress of shift leaders and bedside nurses and to improve the professional status of nursing. It is recommended that greater awareness regarding the Clinical Nurse Specialist should be developed. The relevant educational requirements should be finalised and a clear job description should be compiled. Nursing managers should appoint Clinical Nurse Specialists in each critical care unit as soon as possible. / AFRIKAANSE OPSOMMING: Die rol van die Kliniese Verpleegspesialis het as uitvloeisel van spesialisering in verpleging sedert 1960 en 1970 in Noord-Amerika en Groot-Brittanje onderskeidelik ontwikkel. `n Kliniese Verpleegspesialis behoort die volgende eienskappe te openbaar: uitmuntende vaardighede met betrekking tot leierskap, kommunikasie, kritiese denke, kliniese en etiese besluitneming en mentorskap. Internasionale navorsing het aangetoon dat gevorderde verpleegkunde tot `n hoër vlak van pasiënttevredenheid en nakoming van behandelingsvoorskrifte, minder hospitalisasie en korter hospitaalverblyf aanleiding gee. Die ontwikkeling van die rol van die Kliniese Verpleegspesialis in Suid- Afrika geskied langsaam. Die Suid-Afrikaanse Kwalifikasie-Outoriteit (SAKO) het eers onlangs die reëls vir `n meestersertifikaat en meestersgraad in Verpleegkunde vir gevorderde spesialisverpleegkundiges gepubliseer. Hierdie situasie het tot die onderstaande navorsingsvraag aanleiding gegee: Wat is die verwagte rol van die Kritiekesorg- Kliniese Verpleegspesialis in privaathospitale in die noordelike en suidelike voorstede van die Kaapse Skiereiland, Suid-Afrika? `n Nie-eksperimentele, beskrywende studie met `n kwantitatiewe benadering is in agt hospitale in die Kaapse Skiereiland onderneem. Deur nie-waarskynlikheids-, toevallige steekproefneming is 73 professionele betrokkenes by kritiekesorggesondheid (professionele kritiekesorgverpleegkundiges, kliniese verpleegspesialiste, verpleegbestuurders, eenheidsbestuurders, opvoeders in verpleegkunde, kliniese fasiliteerders, kliniese koördineerders en dokters) uit `n populasie van 170 professionele betrokkenes by kritiekesorggesondheid in die studie ingesluit. `n Vraelys is ontwerp en gevalideer vir die insameling van data. Kwantitatiewe data is deur middel van Statistica® ontleed terwyl die kwalitatiewe data tematies ontleed is. Daar is gevind dat die meerderheid van die deelnemers saamgestem het dat Kliniese Verpleegspesialiste so gou moontlik in die kritiekesorgomgewing in Suid-Afrika aangestel behoort te word. Die Kliniese Verpleegspesialis dra by om pasiëntuitkomste te verbeter, om tot veiliger verpleegsorg by te dra, om werkspanning van skofleiers en verpleegsters te help verlig en om die professionele status van verpleging te verbeter. Daar word aanbeveel dat daar groter bewusmaking aangaande die Kliniese Verpleegspesialis moet wees. Vereistes vir opleiding behoort gefinaliseer te word en `n duidelike werksbeskrywing moet opgestel word. Verpleegbestuurders behoort Kliniese Verpleegspesialiste so gou moontlik in die kritiekesorgomgewing aan te stel.

The purpose of this study was to explore and describe nurse-patient communication during critical illness events. The theoretical structure of the study was drawn from communication, sociolinguistic, and nursing theory. Data were collected in a 374-bed private hospital in the Southwest. The sample consisted of six registered nurses and nine patients experiencing cardiac surgery. Nine observed and audiotaped nurse-patient interactions, and fourteen audiotaped partcipant interviews provided the data base for analysis. Content analysis was used to organize the data. Findings were presented in terms of language, paralanguage, and nonverbal expression, and in terms of content, process, and product of nurse-patient communication. Participants used biomedical-technical language and casual-everyday language during the interactions. Nurses talked about what patients would experience while patients talked about themselves as a way of establishing their credibility within the biomedical setting. Nurses viewed nurse-patient communication as variable depending on the patients' needs and responses. Patients viewed nurse-patient communication as straightforward, not requiring adjustment for the needs of the participants. Products of communication for patients involved increased knowledge, reassurance, and increased confidence. Products of communication for nurses involved relieving the patients' anxieties, considering the patients' remembering, and increasing the nursing staff's knowledge about the patient while helping the patient to know the goals of the nursing staff. The introduction and closure segments of the six nurse-patient interactions for preoperative preparation of the patient were analyzed. Nurses began the introductions by assuming that the patients needed relief from anxiety but the patients demonstrated politeness more than anxiety. Nurses used strategies of questioning, starting the physical assessment, topic persistence, and self-monitoring to control the closure segments. Patients used narratives and humor as control strategies. The study findings suggest conceptual areas relevant to nurse-patient communication which may ground theoretical model development for nurse-patient communication. Nurses in clinical settings can compare their patient communication experiences with the findings of the study in order to increase their understanding of expression, form, and function of nurse-patient communication.