Jordanian patients’ perception of stressors in critical care units: A questionnaire survey

Experiences on health-related quality of life of Jordanian patients living with heart failure: A qualitative study

BACKGROUND

Quantitative studies have provided valuable statistical insights into Health-Related Quality of Life (HRQoL) among patients with Heart Failure (HF), yet they often lack the depth to fully capture the nuanced, subjective experiences of living with HF particularly in the specific context of Jordan. This study explores the personal narratives of HF patients to understand the full impact of HF on their daily lives, revealing HRQoL aspects that quantitative metrics often miss. This is crucial in developing regions, where the increasing prevalence of HF intersects with local healthcare practices, cultural views, and patient expectations, providing key insights for tailored interventions and better patient care.

METHODS

Utilizing a phenomenological qualitative design, this study conducted face-to-face semi-structured interviews with 25 HF patients to deeply explore their lived experiences. Thematic analysis was employed to identify major themes related to their perceptions of HF as a disease, its impact on various HRQoL domains, and their recommended strategies to enhance HRQoL.

RESULTS

The study involved 25 participants (13 males, 12 females), aged 26-88 years (mean 63), with diverse education and heart failure (HF) severities. It revealed three themes: HF perceptions, its impact on health-related quality of life (HRQoL) across physical, psychosocial, spiritual, cognitive, and economic domains, and HRQoL improvement strategies. Participants had varied HF knowledge; some lacked basic understanding. The physical impact was most significant, affecting daily life and causing symptoms like breathing difficulties, coughing, edema, and fatigue. This physical aspect influenced their psychosocial and spiritual lives, cognitive functions, and economic stability, leading to fear, frustration, worry, social isolation, spiritual and cognitive challenges, and employment problems.

CONCLUSIONS

The results underscores the need for holistic healthcare approaches, integrating medical, psychological, and social support. Key recommendations include integrated care models, comprehensive patient education, support networks, and policy interventions to enhance HF patient care.

Changes in Physiological Indices Before and After Nursing Care of Postoperative Patients With Esophageal Cancer in the ICU

Introduction

Various stressors have been identified in patients in the intensive care unit (ICU), including postoperative pain, ventilatory management, and nursing care. However, sedated patients are less responsive, and nurses have difficulty capturing their stressors.

Objective

To investigate patient stress caused by nursing care performed in the ICU on sedated patients based on changes in physiological indices.

Methods

We observed nursing care performed on patients with postoperative esophageal cancer under sedation in the ICU. This included endotracheal suctioning and turning, the time required for the care, and the patients' behavioral responses. Information on arousal levels, autonomic nervous system indices, and vital signs were also obtained. The changes in indicators before and after care were then compared and analyzed.

Results

There were 14 patients in the study. The mean age of the patients was 68 years. Ninety-nine scenes of nursing care were observed, and in six of these, additional bolus sedation was administered because of the patient's significant body movements. In endotracheal suctioning, no significant changes were observed in all indicators. In turning, vital signs changed significantly, and when both were continued, all indicators changed significantly.

Conclusion

Our study found that different types and combinations of nursing care may cause different stresses to the patients. Moreover, the autonomic nervous system indices may be more likely to react to stresses in a variety of nursing care, while arousal levels may be more likely to react to burdensome stresses. If the characteristics of these physiological indicators can be understood and effectively utilized during care, it may be possible to better identify and reduce patient stress during sedation management.

Variability of environmental sound levels: An observational study from a general adult intensive care unit in the UK

Background

Intensive care units are significantly louder than WHO guidelines recommend. Patients are disturbed by activities around them and frequently report disrupted sleep. This can lead to slower recovery and long-term health problems. Environmental sound levels are usually reported as LAeq24, a single daily value that reflects mean sound levels over the previous 24-h period. This may not be the most appropriate measure for intensive care units (ICUs) and other similar areas. Humans experience sound in context, and disturbance will vary according to both the individual and acoustic features of the ambient sounds. Loudness is one of a number of measures that approximate the human perception of sound, taking into account tone, duration, and frequency, as well as volume. Typically sounds with higher frequencies, such as alarms, are perceived as louder and more disturbing.

Methods

Sound level data were collected from a single NHS Trust hospital general adult intensive care unit between October 2016 and May 2018. Summary data (mean sound levels (LAeq) and corresponding Zwicker calculated loudness values) were subsequently analysed by minute, hour, and day.

Results

The overall mean LAeq24 across the study duration was 47.4 dBA. This varied by microphone location. We identified a clear pattern to sound level fluctuations across the 24-h period. Weekends were significantly quieter than weekdays in statistical terms but this reduction of 0.2 dB is not detectable by human hearing. Peak loudness values over 90 dB were recorded every hour.

Conclusions

Perception of sound is sensitive to the environment and individual characteristics and sound levels in the ICU are location specific. This has implications for routine environmental monitoring practices. Peak loudness values are consistently between 90 and 100 dB. These may be driven by alarms and other sudden high-frequency sounds, leading to more disturbance than LAeq24 sound levels suggest. Addressing sounds with high loudness values may improve the ICU environment more than an overall reduction in the 24-h mean decibel value.

Noise Levels and Sleep in a Surgical ICU

Sleep is disturbed in critically ill patients and is a frequently overlooked complication. The aim of our study is to evaluate the impact of sound levels in our surgical ICU on our patients’ sleep on the first night of admission. The study was performed in a tertiary care university hospital, in a 12-bed surgical ICU. Over a 6-week period, a total of 148 adult, non-intubated and non-sedated patients completed the study. During this six-week period, sound levels were continuously measured using a type II sound level meter. Sleep quality was evaluated using the Richards–Campbell Sleep Questionnaire (RCSQ), which was completed both by patients and nurses on the first morning after admission. A non-significant correlation was found between night sound levels and sleep quality in the overall sample (r = −1.83, 95% CI; −4.54 to 0.88, p = 0.19). After multivariable analysis, a correlation was found between higher sound levels at night and lower RCSQ evaluations (r = −3.92, 95% CI; −7.57 to −0.27, p = 0.04). We found a significant correlation between lower sound levels at night and a better quality of sleep in our patients; for each 1 dBA increase in LAFeq sound levels at night, patients scored 3.92 points lower on the sleep questionnaire.

Patients' experiences in the intensive care unit in Jordan: A cross-sectional study

AIMS

The purpose of this study was to describe the experiences of Jordanian patients during their stay in intensive care unit (ICU) and to explore associated factors.

BACKGROUND

Various factors can negatively affect patients' experiences and lead to negative consequences that can affect their outcomes.

MATERIALS & METHODS

A descriptive, correlational design was used to collect data from 150 patients using the Intensive Care Experience Questionnaire through structured interviews after being transferred from medical and surgical ICUs to general wards.

RESULTS

The results showed that the longer the length of ICU stay (LOS) (>7 days) the higher frightening experience (r = 0.2, p < 0.05), the lower awareness of surrounding (r = -0.28, p < 0.01), and the lower satisfaction with care (r = -0.22, p < 0.01). The results showed a negative correlation between receiving sedation and awareness of surroundings (r = -0.33, p < 0.01), and recall of ICU experiences (r = -0.23, p < 0.01), and a positive correlation with frightening experiences (r = 0.2, p < 0.05).

CONCLUSION

Health care activities, clinical and socio-demographic factors can affect the psychological experiences of patients in the ICU. Longer ICU stay is associated with more negative experiences.

Perceived Severity of Stressors in the Intensive Care Unit: A Systematic Review and Semi-Quantitative Analysis of the Literature on the Perspectives of Patients, Health Care Providers and Relatives

The aim of this study was to synthesize quantitative research that identified ranking lists of the most severe stressors of patients in the intensive care unit, as perceived by patients, relatives, and health care professionals (HCP). We conducted a systematic literature search in PubMed, MEDLINE, EMBASE, PsycInfo, CINAHL, and Cochrane Library from 1989 to 15 May 2020. Data were analyzed with descriptive and semi-quantitative methods to yield summarizing ranking lists of the most severe stressors. We synthesized the results of 42 prospective cross-sectional observational studies from different international regions. All investigations had assessed patient ratings. Thirteen studies also measured HCP ratings, and four studies included ratings of relatives. Data indicated that patients rate the severity of stressors lower than HCPs and relatives do. Out of all ranking lists, we extracted 137 stressor items that were most frequently ranked among the most severe stressors. After allocation to four domains, a group of clinical ICU experts sorted these stressors with good to excellent agreement according to their stress levels. Our results may contribute to improve HCPs' and relatives' understanding of patients' perceptions of stressors in the ICU. The synthesized stressor rankings can be used for the development of new assessment instruments of stressors.

Pre-emptive remifentanil alleviates pain associated with tracheal suctioning in patients under mechanical ventilation and goal-directed sedation: A randomized controlled feasibility trial

AIMS

To investigate the efficacy of pre-emptive remifentanil in alleviating pain during tracheal suctioning in patients under mechanical ventilation.

BACKGROUND

Goal-directed sedation is recommended for patients under mechanical ventilation by the current guidelines. Whether goal-directed sedation can prevent pain during tracheal suctioning in these patients is unknown.

DESIGN

This was a two-centre, randomized, crossover, single-blind trial conducted between August and October 2019.

METHODS

Patients under mechanical ventilation received low-dose remifentanil, high-dose remifentanil or placebo prior to each tracheal suctioning in a random order. The primary outcomes were evaluated using the critical-care pain observation tool and Richmond agitation-sedation scale after tracheal suctioning. Adverse events were also documented.

RESULTS

A total of 39 patients who underwent 117 tracheal suctions were enrolled. After the tracheal suction, changes in the critical-care pain observation tool and Richmond agitation-sedation scale scores were significantly lower in the low-dose and high-dose groups than in the placebo group (P < 0.001). A non-significant increase in the absence of spontaneous breathing was observed in the high-dose group compared to that in the placebo group.

CONCLUSION

A pre-emptive remifentanil bolus of 0.5 μg/kg can mitigate the pain associated with tracheal suctioning.

Pain in intensive care unit patients-A longitudinal study

Aim

To assess occurrence of pain during the first 6 days of intensive care unit (ICU) stay and evaluate associations between occurrence of pain and selected patient-related variables.

Design

A longitudinal study.

Methods

Adult ICU patients from three units were included. Patients' pain was assessed with valid pain assessment tools every 8 hr during their first 6 days in ICU. Possible associations between occurrence of pain and selected patient-related variables were modelled using multiple logistic regression.

Results

When pain was assessed regularly with pain assessment tools, 10% of patients were in pain at rest and 27% were in pain during turning. The proportions of patients who were in pain were significantly higher for patients able to self-report pain, compared with patients not able to self-report (p < .001). Several predictors were associated with being in pain. It is important to be aware of these predictors in order to improve pain management.

Relationship Between the Needs of Turkish Relatives of Patients Admitted to an Intensive Care Unit and Their Coping Styles

Admission to an intensive care unit is a traumatic event for many patients' relatives. Also, the relatives may be subject to many requirements to during this process. Therefore, it is very important to determine their requirements and coping styles. This study used a descriptive, relational design. The sample of the research consisted of 247 relatives of patients staying in six intensive care units. It was found that, 65.2% of the patients' relatives were women, and their mean age was 37.25 ± 12.7 years. What they mostly needed was support, proximity, information, assurance and comfort. In that order; among the coping styles it was found that they usually used the following approaches: self-confident approach, an problem-focused coping method; was found to be used by relatives most frequently, followed by helpless approach, an emotion-focused coping style. Requirements: Assurance, information, support and comfort sub-dimension scores and problem-focused coping style; self-confident approach and social support search approach sub-dimension scores between statistically positive, significant relationship was found. Information, proximity, support and comfort sub-dimension scores and emotion-focused coping style; helpless approach and submissive sub-dimension scores between statistically positive, significant relationship was found (p<0.05). It was found that patients' relatives used the helpless approach and submissive approach to cope with stres: during this process their information needs increased and upon fulfillment of requirements, they started using self-confident approach and the social support approach, which are problem-focused coping styles.

The effects of environmental stressors in intensive care unit on anxiety and depression

BACKGROUND

Physical and emotional conditions of patients treated in an intensive care unit (ICU) may be adversely affected by environmental stressors.

AIMS AND OBJECTIVES

The aim of this study was to investigate the relationship between patients' anxiety and depression levels and environmental stressors in the ICU.

DESIGN

This was a descriptive cross-sectional study.

METHODS

The study was conducted between June 2018 and April 2019 with 150 patients treated in the ICUs of a training and research hospital. Patient information form and ICU environmental stressors and hospital anxiety and depression scales were used for data collection. Descriptive statistics, t-test, one-way analysis of variance, and Pearson's correlation coefficient were used to evaluate the data.

RESULTS

The mean hospital anxiety score of the patients in ICUs was 11.1 ± 2.7, and 77.3% of patients were at risk for anxiety (10-point cut-off). The mean hospital depression score was 10.6 ± 3.3, and 94% of patients were at risk for depression (7-point cut-off). The mean score of environmental stressors was 123.9 ± 13.1. A moderate positive correlation between hospital anxiety and hospital depression (r = .63, P < .001) and a weak negative correlation between environmental stressors and hospital anxiety (r = -.24, P = .003) were found. However, no significant correlation between environmental stressors and hospital depression was found (r = -.13, P = .12).

CONCLUSION

According to this study, the environmental stressors in the ICU were high, and the patients were at risk of anxiety and depression. The depression levels of the patients increased along with their anxiety levels. As environmental stressors increased, hospital anxiety levels of the patients decreased. However, there was no significant relationship between environmental stressors and patients' hospital depression levels.

RELEVANCE TO CLINICAL PRACTICE

Environmental stressors in ICUs are high, and the patients in the ICUs are at risk of anxiety and depression.

The impact of health literacy environment on patient stress: a systematic review

Background

There exists little literature on situational health literacy - that is, how an individual’s health literacy varies across different health literacy environments. However, one can consider the role of stress when examining the relationship between health situations and decision-making ability, and by proxy health literacy. The aim of this study was to assess the strength of the evidence on the relationship between health situations and patient stress, considered in the context of health professional perception, and determine what health situations act to influence patient stress.

Methods

A systematic review of English articles using PubMed, PsycINFO, CINAHL and Embase databases was conducted. Search terms focused on ‘patient’, ‘stress’, and ‘health care situations’. Only peer-reviewed original research with data on patient stress in the context of a health facility environment was included. Studies were screened and critically appraised by both authors. Study elements for extraction were defined by RO and extracted by JY.

Results

Twenty-four studies were included for narrative synthesis. Patients in Intensive Care Units were more stressed about factors relating to their physical discomfort, with some agreement from health care professionals. Parents of children in Intensive Care Units were more concerned with stressors relating to their child’s appearance and behaviour, and alteration in their parental role. Few studies examined health settings other than Intensive Care Units, and those that did varied greatly in terms of study design and population characteristics, lacking generalisability.

Conclusions

Overall, the findings of what patients find most stressful in Intensive Care Units can guide health care professionals practicing best practice care. However, the evidence on how patient stress is influenced by non-Intensive Care Unit health care settings is weak. Further research is needed to enhance current understanding of the interaction between patient stress and health care environments in both hospital and primary care settings.

Palliation of Thirst in Intensive Care Unit Patients: Translating Research Into Practice

BACKGROUND

Thirst is prevalent among patients in intensive care units. A research-based "thirst bundle" was shown to significantly decrease thirst in these patients.

OBJECTIVE

To implement a research-based thirst intervention performed by intensive care unit nurses and patients' family members.

METHODS

Nurses and family members were taught the thirst intervention through video training and project team reinforcement. The intervention was performed by nurses for 123 patients and by family members for 13 patients. Thirst was measured with a numeric rating scale of 0 to 10, a word scale of 0 to 3, or "yes/no" answers, whichever was easiest for the patient. Inferential statistics were used to assess changes in thirst scores over time. Also assessed were nurse and family member burden levels, family level of satisfaction, and patient enjoyment.

RESULTS

Thirst scores on the numeric rating scale decreased significantly: from a mean (SD) of 7.9 (2.0) before to 3.9 (2.7) after the intervention for nurses (P < .001); and from 9.2 (1.5) to 5.3 (2.6) for family members (n = 13; P = .002). Word scale scores also decreased significantly, from a median (interquartile range) of 3 (3-3) before to 2 (1-2) after the intervention for nurses (P < .001). Most patients (96%) reported enjoying the procedure. Median burden levels were less than 2 on a numeric rating scale of 0 to 10.

CONCLUSIONS

The palliative "thirst bundle" significantly alleviated patients' thirst and resulted in little caregiver burden. Further efforts are warranted to incorporate this intervention into intensive care unit practice.

The relationship between stressors and intensive care unit experiences

BACKGROUND

Patients in intensive care units (ICUs) face many physical and psychological stressors because of the environment of these units and their own critical conditions and experience stress in various degrees. Each stressor may affect patients' experiences in ICUs differently.

AIM AND OBJECTIVES

This study aimed to examine the relationship between stressors and patients' experiences in an ICU.

METHODS

This descriptive, cross-sectional study was conducted between September 2014 and June 2015 in a university hospital and included 116 patients who were admitted to the general ICU for at least 24 hours. Data were collected using the Intensive Care Experience Scale and a questionnaire that included questions about socio-demographic and disease-related characteristics of patients and their stressors.

RESULTS

The mean age of the patients was 57.81 ± 13.81 years, and the mean duration of ICU stay was 2.28 ± 3.88 days. There was a moderate positive relation between the stressors noise (r = .534; P < .01), thirst (r = .438; P < .01), loneliness (r = .410; P < .01), and pain (r = .404; P < .01) and the subscale frightening experiences. However, there was a moderate, negative relation between the stressors inability to speak (r = -.444; P < .01), surrounding speeches (r = -.458; P < .01), equipment noise (r = -.490; P < .01), and physical exercise (r = -.546; P < .01) and the subscale satisfaction with care.

CONCLUSIONS

The patients associated stressors with satisfaction and frightening experiences in the early period of their discharge from the ICU. As stressors increases, so do frightening experiences, and satisfaction with care is affected negatively.

RELEVANCE TO CLINICAL PRACTICE

Currently, stressors to which patients discharged from ICU are exposed during their admission to wards are not evaluated in practice. This study is important in that it can help health professionals be aware of effects of stressors on patients in the early period of their discharge.

Prevalence of depression and its associated factors in patients post-coronary artery bypass graft surgery

This research aimed to determine the depression level and its correlation experienced by post-coronary artery bypass graft patients after being discharged from cardiac intensive care units. A cross-sectional design was employed for assessing variables. The Self-rating Depression Scale, as proposed by Zung, was used by the researchers on a convenience sample of Jordanian patients (N = 143) who were approached soon after their discharge from the targeted units. The results suggested that the level of depression among Jordanian patients was relatively high (M = 62.7, SD = 5.6). Moreover, depression was significantly higher among female, unmarried and unemployed patients. Patients who received their information about coronary artery bypass graft surgery from nurses had a lower level of depression. Age, length of stay in the cardiac intensive care unit and hospital type significantly predicted the level of depression. The research concluded that the post-coronary artery bypass graft patients who experienced an early onset depression required more attention to highlight the importance of supportive interventions.

Evaluation of stressors in intensive care units

Objective

Physical and psychological stressors adversely affect the treatment and length of stay of patients in intensive care units. In this study, we aimed to describe environmental and psychological stressors affecting intensive care unit patients and to determine their priorities.

Material and Methods

In this study, the 40-item Intensive Care Unit Environmental Stressor Scale was administered to patients in the General Surgery Intensive Care Unit and the Anesthesiology and Reanimation Intensive Care Unit. The patients' age, gender, marital status, educational status, cause of hospitalization, and intensive care unit length of stay were questioned and recorded. Acute Physiology And Chronic Health Evaluation II scores were determined for intensive care unit patients.

Results

A total of 98 patients, 80 in the General Surgery Intensive Care Unit and 18 in the Anesthesiology and Reanimation Intensive Care Unit, were included in the study between May 1, 2015 and October 31, 2015. Fifty-six of the patients were male (57.1%) and 42 were female (42.9%). The mean age of the patients was 55.1±15.1 years. The mean intensive care unit length of stay was 3.4±1.6 days. The median Acute Physiology And Chronic Health Evaluation II score of the patients was 6 (0 to 17). The patients were most affected by thirst (mean 2.44). The second most stressful stress factor was the presence of tubes in the mouth and nose (mean 2.25). The least stressful factor for the patients was the presence of nurses constantly performing activities around the bed. Although 51% of the patients were postoperative, pain was ranked 5th among stress factors.

Conclusion

The environmental and psychological factors affecting intensive care unit patients varied according to age, sex, and educational and surgical status. These factors had adverse effects on the patients. The elimination or modification of these factors would contribute positively to the treatment of intensive care unit patients and shorten their length of stay in the intensive care unit.

Stressors perceived by patients in the immediate postoperative of cardiac surgery

OBJECTIVE

to investigate stressors perceived by patients in the immediate postoperative of cardiac surgery and their association with sociodemographic and clinical characteristics.

METHOD

a prospective correlational study conducted in a city in São Paulo, between August 2013 and December 2014. A non-probabilistic sample included patients submitted to their first coronary artery bypass graft or mitral valve surgery. The "Environmental Stressor Questionnaire" adapted to Portuguese was used.

RESULTS

105 patients participated in the study. The item "being thirsty" was evaluated as the most stressful and "the nursing staff member does not introduce himself/herself by the name" as the least stressful. Among sociodemographic and clinical variables (gender, age, type and time of surgery, pain, intubation time, use of psychotropic medications and length of stay in the intensive care unit), only pain presented a significant association with the stressors.

CONCLUSION

knowing stressors can help implement practices associated with their reduction, favoring patients' recovery.

The influence of care interventions on the continuity of sleep of intensive care unit patients

Objective:

to identify care interventions, performed by the health team, and their influence on the continuity of sleep of patients hospitalized in the Intensive Care Unit.

Method:

descriptive study with a sample of 12 patients. A filming technique was used for the data collection. The awakenings from sleep were measured using the actigraphy method. The analysis of the data was descriptive, processed using the Statistical Package for the Social Sciences software.

Results:

529 care interventions were identified, grouped into 28 different types, of which 12 (42.8%) caused awakening from sleep for the patients. A mean of 44.1 interventions/patient/day was observed, with 1.8 interventions/patient/hour. The administration of oral medicine and food were the interventions that caused higher frequencies of awakenings in the patients.

Conclusion:

it was identified that the health care interventions can harm the sleep of ICU patients. It is recommended that health professionals rethink the planning of interventions according to the individual demand of the patients, with the diversification of schedules and introduction of new practices to improve the quality of sleep of Intensive Care Unit patients.

The nocturnal acoustical intensity of the intensive care environment: an observational study

BACKGROUND

The intensive care unit (ICU) environment exposes patients to noise levels that may result in substantial sleep disruption. There is a need to accurately describe the intensity pattern and source of noise in the ICU in order to develop effective sound abatement strategies. The objectives of this study were to determine nocturnal noise levels and their variability and the related sources of noise within an Australian tertiary ICU.

METHODS

An observational cross-sectional study was conducted in a 24-bed open-plan ICU. Sound levels were recorded overnight during three nights at 5-s epochs using Extech (SDL 600) sound monitors. Noise sources were concurrently logged by two research assistants.

RESULTS

The mean recorded ambient noise level in the ICU was 52.85 decibels (dB) (standard deviation (SD) 5.89), with a maximum noise recording at 98.3 dB (A). All recorded measurements exceeded the WHO recommendations. Noise variability per minute ranged from 9.9 to 44 dB (A), with peak noise levels >70 dB (A) occurring 10 times/hour (SD 11.4). Staff were identified as the most common source accounting for 35% of all noise. Mean noise levels in single-patient rooms compared with open-bed areas were 53.5 vs 53 dB (p = 0.37), respectively.

CONCLUSION

Mean noise levels exceeded those recommended by the WHO resulting in an acoustical intensity of 193 times greater than the recommended and demonstrated a high degree of unpredictable variability, with the primary noise sources coming from staff conversations. The lack of protective effects of single rooms and the contributing effects that staffs have on noise levels are important factors when considering sound abatement strategies.

Patients' and Health Care Providers' Perception of Stressors in the Intensive Care Units

PURPOSE

The purposes of this study is first, to investigate intensive care patients' perceptions of stressors; second, to investigate the health care provider's perception of what constitutes a stressor from the patient's perspective; and third, to describe how health care providers manage their patients' stressors. This was a mixed-methods study; the quantitative section replicated Cornock's 1998 study of stress in the intensive care unit (ICU), with difference in sampling to include all health care providers in the ICU, in addition to nurses. The qualitative section added information to the current literature by describing how health care providers manage their patient's stressors. This article reports the quantitative findings of this study, as the qualitative section is presented in a separate article.

BACKGROUND AND SIGNIFICANCE

It is important to describe ICU patients' stressful experiences to assess patient's stressors, provide holistic care to eliminate stressors, and provide feedback to health care providers. There is a need to describe the clinical practice related to stress perception and management of stressors in the critical care environment.

METHODOLOGY

A mixed-methods comparative descriptive design was used for the quantitative section, and a phenomenological approach guided the qualitative section. Lazarus and Folkman's theory formed the bases for integrating all variables investigated in this study. The sample included 70 ICU patients and 70 ICU health care providers. After consenting to participate in this study, subjects were given a demographic form and a paper-based tool, the Environmental Stressors graphic data form Questionnaire. Questionnaires were filled out by subjects anonymously in the ICU and returned to the researcher in the same setting.

FINDINGS

Descriptive statistics were analyzed using SPSS data analysis software. The top 3 most stressful items ranked by the patients included "being in pain," followed by "not being able to sleep" and "financial worries"; on the other hand, health care providers perceived "being in pain" followed by "not being able to communicate" and "not being in control of yourself" as the top 3 stressors perceived by their patients.

IMPLICATIONS FOR PRACTICE

The findings of this study are crucial and may inform nursing assessments and care of the ICU patient. In addition, this information may encourage the ICU staff to manipulate and redesign the ICU environment to be less stressful. Also, the findings of this study guided the development of an ICU stressor control policy.

Care-related Pain in Critically Ill Mechanically Ventilated Patients

Despite advances in pain management, critically ill patients continue to have unacceptably high rates of uncontrolled pain. Using the Behavioural Pain Scale and physiological indicators of pain, this study examines pain levels in mechanically ventilated patients prior to and during routine nursing procedures. A prospective descriptive design was used to assess and describe care-related pain associated with nociceptive procedures (repositioning, endotracheal suctioning, and vascular punctures) and non-nociceptive procedures (mouth care, eye care and dressing change). A sample of 247 mechanically ventilated Jordanian patients was recruited from intensive care units in a military hospital. The overall mean procedural pain score of 6.34 (standard deviation [SD] 2.36) was significantly higher than the mean preprocedural pain score of 3.43 (SD 0.67, t[246] = 20.82, P <0.001). The highest mean procedural pain scores were observed during repositioning (9.25, SD 1.29). Few patients received analgesics and/or sedatives in the hour prior to the procedures. The mean Ramsay Scale score was 2.49 (SD 0.95), indicating that patients were either anxious or responsive to command only. The mean physiological indicators of pain increased during repositioning and endotracheal suctioning and decreased during the rest of the procedures. Mechanically ventilated patients experience pain prior to and during routine nursing procedures. Harmless and comfort procedures are actually painful. When caring for nonverbal critically ill patients, clinicians need to consider care-related pain associated with their interventions. Relying on changes in vital signs as a primary indicator of pain can be misleading.

Psychological consequences associated with intensive care treatment

Intensive Care Unit (ICU) treatment involves a range of physical and psychological stressors including serious illness, invasive medical procedures, and prolonged incapacity. In addition to physical health problems, those that survive ICU often experience long term psychological difficulties such as cognitive impairment, depression, anxiety, and post-traumatic stress disorder. This review will first consider the types of psychological problems that can occur both during ICU treatment and following discharge and some of the factors involved in their development. Second, consideration is given to medical and psychological intervention strategies that can be provided both during treatment and in follow-up.

Comparing average levels and peak occurrence of overnight sound in the medical intensive care unit on A-weighted and C-weighted decibel scales

PURPOSE

Sound levels in the intensive care unit (ICU) are universally elevated and are believed to contribute to sleep and circadian disruption. The purpose of this study is to compare overnight ICU sound levels and peak occurrence on A- vs C-weighted scales.

MATERIALS AND METHODS

This was a prospective observational study of overnight sound levels in 59 medical ICU patient rooms. Sound level was recorded every 10 seconds on A- and C-weighted decibel scales. Equivalent sound level (Leq) and sound peaks were reported for full and partial night periods.

RESULTS

The overnight A-weighted Leq of 53.6 dBA was well above World Health Organization recommendations; overnight C-weighted Leq was 63.1 dBC (no World Health Organization recommendations). Peak sound occurrence ranged from 1.8 to 23.3 times per hour. Illness severity, mechanical ventilation, and delirium were not associated with Leq or peak occurrence. Equivalent sound level and peak measures for A- and C-weighted decibel scales were significantly different from each other.

CONCLUSIONS

Sound levels in the medical ICU are high throughout the night. Patient factors were not associated with Leq or peak occurrence. Significant discordance between A- and C-weighted values suggests that low-frequency sound is a meaningful factor in the medical ICU environment.

Development of a pain management algorithm for intensive care units

OBJECTIVES

To develop a pain management algorithm for intensive care unit (ICU) patients and to evaluate the psychometric properties of the translated tools used in the algorithm.

BACKGROUND

Many ICU patients experience pain. However, an evidence-based algorithm for pain management does not exist.

METHODS

Literature review, expert panel, and pilot testing were used to develop the algorithm. The tools were evaluated for inter-rater reliability between two nurses. Discriminant validity was evaluated by comparing pain during turning and rest.

RESULTS

An algorithm was developed. The Behavioral Pain Scale (BPS) and the Behavioral Pain Scale-Non Intubated (BPS-NI) discriminated between pain scores during turning and rest. Inter-rater reliability for the BPS varied from moderate (0.46) to very good (1.00). Inter-rater reliability for the BPS-NI varied from fair (0.21) to good (0.63).

CONCLUSIONS

The content of the pain management algorithm is consistent with the latest clinical practice guideline recommendations. It may be a useful tool to improve pain assessment and management in adult ICU patients.

The Relationship Between Stressors and Anxiety Levels After CABG in Sari, Iran

Background

Hospitalization and surgery are crucial adverse life events that lead to considerable anxiety in patients.

Objectives

The present study aimed to investigate stressors after coronary artery bypass graft surgery and identify stressors that predict anxiety.

Patients and Methods

This is a descriptive-analytical study that uses a non-random convenience sampling method on patients undergoing coronary artery bypass graft surgery at the cardiac surgery intensive care unit of Fatemeh Zahra Cardiac center in Sari, Iran. A total of 186 patients completed the post-surgical stressors questionnaire and the Spielberger State-Trait Anxiety Inventory on postoperative days 2 or 3 in the cardiac surgery intensive care unit. Data were analyzed using descriptive statistics including frequencies, means, and standard deviations. The Mann–Whitney U test was used to determine the relationship between the observed variables, and the logistic regression model was used to identify the relationship between stressors and anxiety after-surgery.

Results

Post-surgical anxiety predictors included insufficient sleep during hospitalization (Odds ratio [OR]: 5.42; 95% confidence interval [CI]: 1.46 - 20.00; P = 0.010), treatment not explained to the patient by the nurse (OR: 4.83; 95% CI: 1.82 - 12.84; P = 0.002), being away from family members (OR: 3.88; 95% CI: 1.46 - 10.26; P = 0.006), presence of a chest tube (OR: 3.27; 95% CI: 1.83 - 5.84; P = 0.000), and pain in any part of the body (OR: 1.95; 95% CI: 1.06 - 3.58; P = 0.031).

Conclusions

Physical or physiological and psychological stressors impose greater stress and are predictors of anxiety. When preparing their nursing care plan, nurses should consider these stressors that affect anxiety levels in patients undergoing CABG surgery and those hospitalized in intensive care units.

'Providing good and comfortable care by building a bond of trust': nurses views regarding their role in patients' perception of safety in the intensive care unit

AIMS AND OBJECTIVES

To describe and understand intensive care unit (ICU) nurses' views regarding their role in ICU patients' perception of safety.

BACKGROUND

Feeling safe is an important issue for ICU patients. Not feeling safe may result in adverse effects including traumatic experiences, having nightmares and feeling depressed. Nursing care plays a major role in patients' perception of safety. However, it is unknown whether ICU nurses are aware of this role.

DESIGN

A grounded theory approach following Corbin and Strauss.

METHODS

A total of 13 participants were included in the study following maximum variation sampling, by selecting ICU nurses who differed in gender, age, work experience as registered ICU nurse, and were employed in different IC units. In-depth interviews were performed using open-ended questions guided by a topic list with broad question areas. Data collection and analysis were executed during an iterative process.

RESULTS

The core category, building a bond of trust to provide good and comfortable care, arose from four main categories: explaining and informing ICU patients, using patients' family bond, ICU nurses' attitudes and expertise, and creating physical safety.

CONCLUSION

The ICU nurses stated that they were not explicitly aware of ICU patients' perception of safety, but that they strived to provide good and comfortable care, through building a bond of trust with their patients. According to the nurses, a bond of trust is essential for patients to feel safe in the ICU.

RELEVANCE TO CLINICAL PRACTICE

The importance of feeling safe in ICU patients should be addressed within the education and clinical practice of ICU nurses, to ensure that they become aware of ICU patients' perception of safety.

Patient stress in intensive care: comparison between a coronary care unit and a general postoperative unit

OBJECTIVE

To evaluate and compare stressors identified by patients of a coronary intensive care unit with those perceived by patients of a general postoperative intensive care unit.

METHODS

This cross-sectional and descriptive study was conducted in the coronary intensive care and general postoperative intensive care units of a private hospital. In total, 60 patients participated in the study, 30 in each intensive care unit. The stressor scale was used in the intensive care units to identify the stressors. The mean score of each item of the scale was calculated followed by the total stress score. The differences between groups were considered significant when p < 0.05.

RESULTS

The mean ages of patients were 55.63 ± 13.58 years in the coronary intensive care unit and 53.60 ± 17.47 years in the general postoperative intensive care unit. For patients in the coronary intensive care unit, the main stressors were "being in pain", "being unable to fulfill family roles" and "being bored". For patients in the general postoperative intensive care unit, the main stressors were "being in pain", "being unable to fulfill family roles" and "not being able to communicate". The mean total stress scores were 104.20 ± 30.95 in the coronary intensive care unit and 116.66 ± 23.72 (p = 0.085) in the general postoperative intensive care unit. When each stressor was compared separately, significant differences were noted only between three items. "Having nurses constantly doing things around your bed" was more stressful to the patients in the general postoperative intensive care unit than to those in the coronary intensive care unit (p = 0.013). Conversely, "hearing unfamiliar sounds and noises" and "hearing people talk about you" were the most stressful items for the patients in the coronary intensive care unit (p = 0.046 and 0.005, respectively).

CONCLUSION

The perception of major stressors and the total stress score were similar between patients in the coronary intensive care and general postoperative intensive care units.

Pain assessment using the critical-care pain observation tool in Chinese critically ill ventilated adults

CONTEXT

The psychometric properties of the Critical-Care Pain Observation Tool (CPOT) need to be tested in general intensive care unit patient populations in China.

OBJECTIVES

To further evaluate the psychometric properties of the CPOT and provide a pain assessment method for Chinese critically ill ventilated adults by validating a translation of the CPOT.

METHODS

A total of 63 conscious ventilated Chinese adults were repeatedly assessed by two independent raters using the CPOT at rest as well as before and during the two procedures: 1) nociceptive procedure (turning) and 2) non-nociceptive procedure (taking noninvasive blood pressure). A total of 12 assessments were included.

RESULTS

The principal component factor analysis revealed that the domain structure of the CPOT was acceptable. Cronbach's α coefficient as a measure for the internal consistency ranged from 0.57 to 0.86; intraclass correlation coefficients as a measure for inter-rater reliability ranged from 0.80 to 0.91; Spearman nonparametric coefficients as a measure for test-retest reliability ranged from 0.81 to 0.93. The CPOT total score was significantly higher during the nociceptive procedure, indicating that its discriminant validity was good. Self-reported pain was obtained as the gold standard; the receiver operating characteristic curve analysis determined the best cutoff value of the CPOT (>2) with the specificity (73.3-81.8%) and sensitivity (80.8-89.4%) as well as the area under the curve (range 0.849-0.902).

CONCLUSION

The CPOT has good psychometric properties and can be used as a reliable and valid instrument for pain assessment in Chinese critically ill ventilated adults.

Sleep disturbance in older ICU patients

Maintaining a stable and adequate sleeping pattern is associated with good health and disease prevention. As a restorative process, sleep is important for supporting immune function and aiding the body in healing and recovery. Aging is associated with characteristic changes to sleep quantity and quality, which make it more difficult to adjust sleep–wake rhythms to changing environmental conditions. Sleep disturbance and abnormal sleep–wake cycles are commonly reported in seriously ill older patients in the intensive care unit (ICU). A combination of intrinsic and extrinsic factors appears to contribute to these disruptions. Little is known regarding the effect that sleep disturbance has on health status in the oldest of old (80+), a group, who with diminishing physiological reserve and increasing prevalence of frailty, is at a greater risk of adverse health outcomes, such as cognitive decline and mortality. Here we review how sleep is altered in the ICU, with particular attention to older patients, especially those aged ≥80 years. Further work is required to understand what impact sleep disturbance has on frailty levels and poor outcomes in older critically ill patients.

Stressors in intensive care units in Syria: patients' perceptions

The purpose of this cross-sectional study was to identify the stressors and the level of stress as perceived by hospitalised Syrian patients of intensive care units (ICUs). A convenience sample of 150 Syrians who were hospitalised in ICUs located in the Syrian capital, Damascus, were chosen as study participants and were interviewed using a structured interview guide of the Intensive Care Units Environmental Stressors Scale (ICUESS). The findings revealed that physical stressors were perceived as the most stressful ones, whereas psychological stressors were the least stressful. These findings are congruent with the majority of similarly available regional and international literature. It was also statistically noticed that participants with a higher level of education and income were more sensitive in perceiving the stressors than those who had a lower level of education and income. The findings suggested that nurses must utilise effective measures in ICUs to relieve patients' pain and provide a humane ICU environment and atmosphere in which rest is enabled. In conclusion, decreasing the stress level has a positive impact on patients' health outcomes, where adequate attention to patients' physical and psychological domains should equally be considered.

Family Perceptions of Intensive Care Unit Nurses' Roles: A Greek Perspective

This study was done in order to examine the role of the nurse in families with critically ill patients as perceived by family members. A descriptive design was conducted with 93 family members aged 18-53 years from a 6-bed intensive care unit in a Greek Hospital. An anonymous self-completed questionnaire recording demographic data and the questionnaire Family members perception of nurses behavioral role expectation/enactment scale of Hickey and Lewandowski was used. Parametric statistic tests were used to examine the research questions. Intensive care unit (ICU) patients’ family members expect nurses to make them feel they can ask whatever they want whenever they want, placing great emphasis on communicating with one another and on participating in decision making to the progress of patient care. The age seems to correlate with the expectation from nurse to meet the role of training on how to handle the patient. Nurses did well with regard to meeting family members’ expectations. Most family members assessed positively the role of ICU nurse confirming the need for communication, and clear support of families.

Literature review: patients' and health care providers' perceptions of stressors in critical care units

The purpose of this article was to provide a historical review and analysis of the research literature focusing on patients', nurses', and health care providers' perceptions of stressors in the critical care setting. A narrative historical literature review method was used. The inclusion criteria include English-language studies of stressors as perceived by patients and health care providers from 1984 to 2011. Several studies investigated perceptions of stressors using the Environmental Stressors Questionnaire and the findings did not show any significant changes of stress perception over time since 1989 until the present. There is a need to further investigate stress perceptions in the health care setting using a mixed qualitative and quantitative approach to provide a more precise description of stressors and stress perceptions in the critical care setting.

An investigation of sound levels on intensive care units with reference to the WHO guidelines

Introduction

Patients in intensive care units (ICUs) suffer from sleep deprivation arising from nursing interventions and ambient noise. This may exacerbate confusion and ICU-related delirium. The World Health Organization (WHO) suggests that average hospital sound levels should not exceed 35 dB with a maximum of 40 dB overnight. We monitored five ICUs to check compliance with these guidelines.

Methods

Sound levels were recorded in five adult ICUs in the UK. Two sound level monitors recorded concurrently for 24 hours at the ICU central stations and adjacent to patients. Sample values to determine levels generated by equipment and external noise were also recorded in an empty ICU side room.

Results

Average sound levels always exceeded 45 dBA and for 50% of the time exceeded between 52 and 59 dBA in individual ICUs. There was diurnal variation with values decreasing after evening handovers to an overnight average minimum of 51 dBA at 4 AM. Peaks above 85 dBA occurred at all sites, up to 16 times per hour overnight and more frequently during the day. WHO guidelines on sound levels could be only achieved in a side room by switching all equipment off.

Conclusion

All ICUs had sound levels greater than WHO recommendations, but the WHO recommended levels are so low they are not achievable in an ICU. Levels adjacent to patients are higher than those recorded at central stations. Unit-wide noise reduction programmes or mechanical means of isolating patients from ambient noise, such as earplugs, should be considered.

The influence of sex, race, and age on pain assessment and treatment decisions using virtual human technology: a cross-national comparison

PURPOSE

Studies in the United States have found that patients' sex, race, and age influence the pain assessment and treatment decisions of laypeople and medical professionals. However, there is limited research as to whether people of other nationalities make pain management decisions differently based on demographic characteristics. Therefore, the purpose of the following study was to compare pain assessment and treatment decisions of undergraduate students in Jordan and the United States as a preliminary examination of nationality as a potential proxy for cultural differences in pain decisions.

METHODS

Virtual human (VH) technology was used to examine the influences of patients' sex (male or female), race (light-skinned or dark-skinned), and age (younger or older) on students' pain management decisions. Seventy-five American and 104 Jordanian undergraduate students participated in this web-based study.

RESULTS

American and Jordanian students rated pain intensity higher in females and older adults and were more likely to recommend medical help to these groups, relative to males and younger adults. Furthermore, Jordanian participants rated pain intensity higher and were more likely to recommend medical help for all patient demographic groups (ie, sex, race, age) than American participants.

CONCLUSION

This is the first cross-national study that compares pain decisions between undergraduate students. The results suggest that sex, race, and age cues are used in pain assessment and treatment by both Americans and Jordanians, with Jordanians more likely to rate pain higher and recommend medical help to patients. Additional research is needed to determine the cultural determinants of these differences.

The EPICS Family Bundle and its effects on stress and coping of families of critically ill trauma patients

AIM

The aim of this study was to evaluate impact of the EPICS Family Bundle on stress and coping.

BACKGROUND

Critical care nurses frequently deal with family stress, but may be without knowledge and skills needed to assist families to cope.

METHODS

A non-equivalent control group design was used, with a convenience sample of 84 family members of critically ill patients. During the control phase, participants completed tools measuring stress and coping. The intervention included use of the EPICS Family Bundle. After implementation, participants completed the same tools as those administered during the control phase. Outcomes were analyzed using independent-sample t-tests.

RESULTS

The experimental group had a significantly higher coping score on two subscales; and although not statistically significant, it was also improved on an additional four.

CONCLUSION

After implementation of the intervention, families experienced improved coping. The study may have lacked sufficient power to detect all differences.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

OBJECTIVE

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.

METHODS

The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

CONCLUSION

These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Prevalence and profile of sleep disturbances in Guillain-Barre Syndrome: a prospective questionnaire-based study during 10 days of hospitalization

INTRODUCTION

Sleep disturbances in Guillain-Barre Syndrome (GBS), though common, have not received focused attention.

OBJECTIVES

To study frequency and nature of sleep disturbances in patients with GBS, using validated questionnaires, and analyze the contributing factors.

MATERIALS AND METHODS

This prospective study included 60 patients fulfilling National Institute of Neurological and Communicative Diseases and Stroke (NINCDS) criteria for GBS (mean age: 32.7 ± 12.9 years; median: 30 years; M:F = 46:14), evaluated from 2008 to 2010. Data regarding sleep were collected on 10 consecutive days following admission using Richard Campbell Sleep score, St Mary's Hospital Sleep Questionnaire, and Pittsburgh Sleep Quality Index (PSQI) and correlated with various possible contributing factors like pain, paresthesia, anxiety, depression, autonomic dysfunctions, severity of disease, and therapeutic interventions among others.

OBSERVATIONS

Qualitative and quantitative sleep disturbances were rather frequent and involved over 50% patients: abnormal PSQI - 13.3%, abnormal score on Richard scale - 51.6%, abnormal sleep onset latency - 35%, sleep fragmentation - 40%, and reduced sleep duration - 46.6%. The symptoms were severe during the first week of hospitalization and reduced thereafter. Sleep disturbances as scored on Richard scale significantly correlated with anxiety, pain, paresthesia, and severity of immobility (P < 0.05) but not with depression and use of analgesics or antineuritic drugs.

CONCLUSIONS

This study first of its kind suggests that sleep disturbance in GBS is frequent, multi-factorial, often disturbing, and varies during the course of illness. Routine enquiry into the sleep disturbances and timely intervention may reduce morbidity and improve their quality of life.

Jordanian patients' satisfaction with pain management

Pain is still undertreated among hospitalized patients. Recently, patient satisfaction with pain management has received significant attention. This field has not yet been explored among Jordanian patients. The purpose of this study was to determine the knowledge regarding pain characteristics, beliefs, and satisfaction that can be included in planning pain management strategies and protocols within Jordanian hospitals. Using descriptive cross-sectional methodology, the American Pain Society Patient Outcome Questionnaire (APS-POQ) was used to survey 375 inpatients from Jordanian hospitals. Participants reported relatively severe pain and pain interferences while being hospitalized and seemed to be well informed regarding pain and pain management. Participants reported high levels of pain management satisfaction. Also, the Arabic version of the APS-POQ was found to be reliable among the Jordanian population. Findings of this study are similar to those reported by earlier studies in other countries and support the need for applying the caring attitude in managing patients' reports of having pain. This study is the first in Jordan, opening the door for future studies to be conducted in this important field.