Preventing the ITU syndrome or how not to torture an ITU patient! Part I

Critical care at the end of life: balancing technology with compassion and agreeing when to stop

Modern intensive care saves lives. However, the substantial related financial costs are, for many, married to substantial costs in terms of suffering. In the most sick, the experience of intensive care is commonly associated with the development of profound physical debility, which may last years after discharge. Likewise, the negative psychological impact commonly experienced by such patients during their care is now widely recognized, as is the persistence of psychological morbidity. Such issues become increasingly important as the population of the frail elderly increases, and the health and social care services face budgetary restriction. Efforts must be made to humanize intensive care as much as possible. Meanwhile, an open conversation must be held between those within the medical professions, and between such healthcare workers and the public in general, regarding the balancing of the positive and negative impacts of intensive care. Such conversations should extend to individual patients and their families when considering what care is genuinely in their best interests.

Building Connections With Patients and Families in the Intensive Care Unit: A Canadian Top-Performer Success Story

Consumers are increasingly becoming the voice and impetus for hospital organizational change in the United States. This is in part due to their increased stake in cost sharing with hospitals, health systems, and the ambulatory setting and revisions to health plans with higher deductibles and copays. With customers wanting services better, faster, and more economical than in the past, organizations need to break the ceiling on improvement levels for exceeding expectations of patient experience. Of interest is the hospital critical care area, because of the heightened patient needs, support, and resources that are required in this acute setting. Bluewater Health, located in Sarnia, Ontario, Canada, is a top-industry performer on the patient experience access-to-care dimension. Much can be learned from the multiple practices it has used to create an environment that embraces patients and families to the fullest extent, ensuring the resources needed for optimizing care are received.

Enhancing Hospital Well-being and Minimizing Intensive Care Unit Trauma: Cushioning Effects of Psychosocial Care

CONTEXT

Hospitalization has the potential to induce hospital anxiety, while admission in the Intensive Care Unit (ICU) is found to surpass the anxiety and result in what is termed as "ICU Trauma."

AIMS

This study aimed to determine the impact of psychosocial care and quality of ICU on ICU trauma and hospital well-being in patients who underwent coronary artery bypass grafting (CABG).

SETTINGS AND DESIGN

This correlational study involved 250 CABG patients, who were recruited from five major corporate hospitals.

PARTICIPANTS AND METHODS

The ICU Psychosocial Care Scale, Hospital Wellbeing Scale, and ICU Trauma Scale were used. Each of the participants was assessed individually. The ICU Practices Checklist was used to assess the environment of the ICU in the hospital.

STATISTICAL ANALYSIS USED

Descriptive statistics, correlation, and simple and multiple linear regression analyses were done.

RESULTS

The results revealed the significant contribution of psychosocial care in ICU in enhancing hospital well-being as well as minimizing ICU trauma of patients who underwent CABG. The results of multiple regressions clearly indicated that psychosocial care was a powerful predictor of hospital well-being and ICU trauma.

CONCLUSIONS

Although psychosocial care was not a component of hospital well-being and had a negative correlation with ICU trauma, it contributed significantly with a cushioning effect to minimize trauma and helped enhance the feelings and experiences of well-being among patients in ICU.

Quality of life improves with return of voice in tracheostomy patients in intensive care: An observational study

PURPOSE

To measure patient-reported change of mood, communication-related quality of life, and general health status with return of voice among mechanically ventilated tracheostomy patients admitted to the intensive care unit (ICU).

MATERIALS AND METHODS

A prospective observational study in a tertiary ICU was conducted. Communication-related quality of life was measured daily using the Visual Analogue Self-Esteem Scale. General health status was measured weekly using the EuroQol-5D.

RESULTS

Aspects of communication self-esteem that significantly improved with the return of voice were ability to be understood by others (P = .006) and cheerfulness (P = .04), both with a median difference from before to after return of voice of 1 on the 5-point scale. Return of voice was not associated with a significant improvement in confidence, sense of outgoingness, anger, sense of being trapped, optimism, or frustration. Reported general health status did not significantly improve.

CONCLUSIONS

Return of voice was associated with significant improvement in patient reported self-esteem, particularly in being understood by others and in cheerfulness. Improved self-esteem may also improve quality of life; however, further research is needed to confirm this relationship. Early restoration of voice should be investigated as a way to improve the experience of ICU for tracheostomy patients.

Case series: the application of "third wave" cognitive behavioural therapies in difficult to treat asthma

OBJECTIVE

This paper provides for the first time cases of individual psychological therapy undertaken in tertiary, difficult to treat asthma services using "third wave" cognitive behavioural therapy (CBT) approaches.

METHODS

These cases were selected to represent common psychological presentations in difficult to treat asthma clinics, namely denial of severity and over-identification with asthma. Assessment, formulation, intervention and results are outlined.

RESULTS

Case 1 demonstrated change from severe to mild depression and anxiety, reduction in shame and improved well-being. Case 2 demonstrated improvements in well-being and psychological symptoms. Both interventions were experienced by the patients as highly satisfactory.

CONCLUSIONS

It is concluded that a psychological understanding of patients' presentations can open up new avenues for intervention. Further research into the potential utility of third wave cognitive therapies in difficult to treat asthma is warranted.

Interpersonal touch: physiological effects in critical care

INTRODUCTION

Nurses use several forms of touch in patient encounters. Interpersonal touch elicits specific physiological and psychological responses, including neuroendocrine effects and reduction of stress. Critical illness is a state of excessive physiological and psychological stress.

AIMS

To critically review evidence on the effect of touch on physiological outcomes in critically ill individuals. Results of intervention studies in adult critical care settings were reviewed along with supportive evidence from studies in other populations.

METHODS

Critical literature review based on studies published in MEDLINE, PubMed, Cinahl, Embase, and Cochrane databases.

RESULTS

Eleven studies were reviewed. Significant effects of interpersonal touch included lower systolic and diastolic blood pressure and respiratory rate, improved sleep, and decreased pain. Almost no results were replicated owing to discrepancies among studies. Although the effect of touch on cardiovascular autonomic status appears considerable, several confounders must be considered. In noncritically ill populations, replicable findings included increased urinary dopamine and serotonin, natural killer cytotoxic activity, and salivary chromogranin. Effects on plasma cortisol and immune cells were variable. Effects appear to vary according to amount of pressure, body site, duration, and timing: Moderate pressure touch may elicit a parasympathetic response in contrast to light touch, which may elicit a sympathetic response. Moreover, touch effects may be mediated by the density of autonomic innervation received by the body areas involved and repetition of sessions.

CONCLUSION

The physiological pathway mediating the effects of touch is unclear. Although no concrete conclusions can be drawn, research evidence suggests that touch interventions may benefit critically ill individuals.

Therapeutic relationships in critical care nursing: a reflection on practice

AIMS

The aim of this paper is to gain a greater understanding of the emotional intelligence required to form therapeutic nurse-patient relationships in the context of critical care nursing.

CONTEXT

There is currently a demand for patient-centred nursing in all aspects of health care to improve both quality of care and consumer satisfaction. Central to patient-centred care is the presence of a therapeutic nurse-patient relationships, but the development of these relationships present a challenge in the acute and technological world of critical care nursing.

THEORETICAL FRAMEWORK

Using Titchen's Skilled Companionship Model as a guide as well as empirical and theoretical knowledge on nurse-patient relationships, this paper presents a reflection on a relationship that the author developed with a patient and his family encountered in her practice as a critical care nurse. REFLECTIVE CONCLUSIONS: Engaging in therapeutic nurse-patient relationships can expose nurses to emotional pain in the context of critical care nursing. The process of reflection can facilitate critical care nurses in the development of the emotional intelligence required to develop and maintain these relationships and this enhances the care of critically ill patients and their families.

A journey in quest of meaning: a hermeneutic-phenomenological study on living with memories from intensive care

BACKGROUND

In a short-term perspective, a high incidence of psychological problems linked to memories from intensive care has been found in survivors of critical illness. Little is known about what kinds of memories patients might carry with them and what it is like to live with memories from intensive care as years go by.

AIM

The aim of this study was to explore the meaning of living with memories from intensive care.

METHODS

A hermeneutic-phenomenological approach. In-depth interviews with ten former intensive care patients 10 years after their admission.

FINDINGS

Memories of bodily sensations and memories containing strong emotions were surprisingly well kept. Memories residing in the body at a prereflective level and that could be awakened without being triggered by will or conscious thought comprised an important segment of the memory spectrum. Complaints such as panic attacks and anxiety were strongly linked to these kinds of memories and experienced as flashbacks of frightening experiences that entailed strong emotions. Some informants still strove to understand experiences and reactions. Living with these memories and flashbacks was interpreted as a journey in quest of meaning. Having someone and something to live for implied strength on the journey. The presence of close relatives at the bedside provided strength to go on and someone with whom to share experiences afterwards.

CONCLUSION

A period of critical illness and intensive care stay for treatment may leave durable traces in the patient's life. Finding meaning of existential and ontological nature seems to be of decisive significance for how people fare in their lives after having lived through intensive care treatment. The identified journey in quest of meaning points to the need for follow-up programmes, and we must acknowledge close relatives as important resources for the patient both at the bedside and in the subsequent process of discovering meaning in lived experience.

Confusion assessment method for the intensive care unit (CAM-ICU): translation, retranslation and validation into Swedish intensive care settings

BACKGROUND

Becoming critical ill or severely injured leads to a process of worry, anxiety and pain. Patients in intensive care sometimes have strange and frightening experiences and may show symptoms of acute confusion or delirium. CAM-ICU, the confusion assessment method for the intensive care unit, was based on the DSM IV, the Diagnostic and Statistic Manual of Mental Disorders IV, and today, healthcare professionals and researchers are increasingly accepting this concept of diagnosing ICU delirium. In Sweden, there is no commonly used, single instrument or method to test the development of ICU delirium. The aim of this study was to translate, retranslate and validate CAM-ICU for use in Swedish ICU settings.

METHODS

The translation of the instrument was done according to the guidelines suggested by The Translation and Cultural Adaptation group which includes preparation, forward translation/reconciliation, back translation, back translation review, harmonization, cognitive debriefing and validation. In the validation process, the applicability of the Swedish version of the instruments was tested in a Swedish intensive care unit.

RESULTS

Fourteen adult patients were included in the study, 40 paired tests were carried out, and 80 CAM-ICU instruments were completed. The participating patients were given CAM-ICU ratings using independent paired evaluations by two nurses, specialized in intensive care, at least twice during the patients' stay in the ICU. Interrater reliability was calculated using kappa statistics. In the 40 paired observations, interrater reliability was 'very good' (kappa statistics > 0.81). In our material, we recognized a delirium rate of 48%, which is in accordance with previous studies.

CONCLUSION

The translation of the instrument CAM-ICU showed good correlation with the original version and could therefore be applicable in a Swedish ICU setting. In the 40 paired observations, interrater reliability was very good. Although there are limitations in using CAM-ICU, previous studies reveal a need for a homogeneous screening instrument making it possible to detect and determine ICU delirium; and from this basis are able to implement and make the necessary decisions required in medical and nursing care practice preventing ICU delirium.

Patient empowerment in intensive care--an interview study

Intensive care patients often experience a lack of control, as well as inner chaos. Experiences from intensive care can continue to affect patients for a long time. Empowerment is a positive and dynamic process that focuses on people's strengths, rights and abilities. It takes on different expressions for different people in different environments and must be described by the people involved. The aim of this study was to describe patient empowerment in an intensive care situation. The study was based on open-ended interviews with 11 patients in two intensive care units. The interviews were analysed according to the empirical phenomenological psychological method. The results showed that patient empowerment in intensive care consists of strengthening and stimulating the patients' own inherent joy of life and will to fight. A positive environment that encouraged feelings of value and motivation and in which the patient felt safe, received additional care and participated as he/she wished had a positive influence.

Psychological implications of admission to critical care

Admission to critical care can have far-reaching psychological effects because of the distinct environment. Critical care services are being re-shaped to address long-term sequelae, including post-traumatic stress disorder, anxiety and depression. The long-term consequences of critical illness not only cost the individual, but also have implications for society, such as diminished areas of health-related quality-of-life in sleep, reduced ability to return to work and enjoy recreational activities (Audit Commission, 1999; Hayes et al, 2000). The debate around the phenomenon of intensive care unit (ICU) syndrome is discussed with reference to current thinking. After critical care, patients may experience amnesia, continued hallucinations or flashbacks, anxiety, depression, and dreams and nightmares. Nursing care for patients while in the critical care environment can have a positive effect on psychological well-being. Facilitating communication, explaining care and rationalizing interventions, ensuring patients are oriented as to time and place, reassuring patients about transfer, providing patients,where possible, with information about critical care before admission and considering anxiolytic use, are all practices that have a beneficial effect on patient care. Follow-up services can help patients come to terms with their experiences of critical illness and provide the opportunity for them to access further intervention if desired. Working towards providing optimal psychological care will have a positive effect on patients' psychological recovery and may also help physical recuperation after critical care.

An exploration of the support available to children who may wish to visit a critically adult in ITU

There has been growing evidence to suggest that by not actively supporting children who have a critically ill loved one in an Intensive Therapy Unit (ITU), we may be doing them a great disservice. Decreased understanding and feelings of abandonment and helplessness can prevail. The primary purpose of this research was to explore the resources currently available to support a child with a critically ill adult member of their family (or significant other) in ITU, whom they may wish to visit. Available support for nursing staff that enables them to do this has also been explored. A descriptive postal survey was used in 2003 to collect data from 46 adult general and cardiothoracic ITUs nationally. The findings illustrated that there was a lack of written policy and very little written information for adult visitors regarding the needs of children who have a loved one in ITU. There was also a dearth of resources for nursing staff pertaining to children and their needs (when visiting a critically ill adult), including a lack of any formal or informal education on the subject. Clearly, restrictions were still being imposed on children visiting a loved one either by the well parent/carer or by the nursing staff, mainly for reasons unsubstantiated by research.

The intensive care experience: development of the ICE questionnaire

BACKGROUND

Previous research has shown that patients' reported memories of intensive care are often of unpleasant events which are described as frightening and persecutory in nature. Currently, there is no standardized way of assessing perceptions of such an experience or relating it to long-term outcome.

AIMS

This paper describes the development of an intensive care experience questionnaire which aims to (a) identify the domains of such an experience, (b) assess and quantify that experience, and (c) explore its impact on short- and long-term emotional outcome.

METHODS

Data from two studies are reported. Participants were non-elective patients and > or =18 years of age with an ICU stay > or =24 hours. Study 1 (n = 34) generated and developed items. Study 2 (n = 109) allowed evaluation of the factor analytic structure and psychometrics of the questionnaire.

RESULTS

From a set of 31 items, exploratory factor analysis identified four components of the intensive care experience: 'awareness of surroundings' (nine items), 'frightening experiences' (six items), 'recall of experience' (five items), and 'satisfaction with care' (four items). Cronbach's alpha statistics were acceptable for each component (0.71-0.93). Correlational analysis with the subscales of the Hospital Anxiety and Depression Scale and Impact of Event Scale demonstrated concurrent and univariate predictive validity. The intensive care experience was associated with adverse emotional outcome in both the short- and long-term.

DISCUSSION

The intensive care experience questionnaire identified four dimensions of experience and performed satisfactorily in these developmental analyses. Further study of an independent intensive care unit data set is necessary to confirm these findings, including the four-component structure. Development of a standardized measure provides the opportunity to increase our understanding of the intensive care experience. The questionnaire may be useful to inform the development of effective interventions to improve subsequent outcomes for these patients.

Intensive care nurses' experiences of assessing and dealing with patients' psychological needs

Several authors have highlighted the short- and long-term psychological effects of an intensive care unit (ICU) stay. Few authors have discussed the nurses' perceptions of psychological care. In this research, 12 nurses, who currently work in ICU, were interviewed using a semi-structured technique. Six categories were developed about issues in psychological care. Implications for practice included the important role of the family, need for improved communication and improved staff awareness of issues.

Managing anxiety in ICU patients: the role of pre-operative information provision

Hospital-induced patient anxiety and coping mechanisms are discussed. The value of giving pre-operative information to reduce anxiety in elective admissions to intensive care unit is discussed. Recommendations are given based on the literature evidence to aid service and practice development.

Developing and evaluating critical care follow-up

The effects of critical illness not only affect the patient and relative during the intensive care stay but often affect for a considerable time afterwards. A growing body of opinion and evidence suggests that many of the needs of those who have been critically ill can be met through critical care follow-up services. A growing number of follow-up services now exist. Their establishment, development and evaluation pose significant challenges for those involved. This paper describes Bassetlaw hospital's critical care follow-up service, how it was established and what an elementary service evaluation project has shown. The findings and experiences are compared with others in published literature, and the paper may be of interest to those who are currently involved in follow-up or who plan to develop such services in the future.

Immediate follow-up after ICU discharge: establishment of a service and initial experiences

Follow-up of patients discharged from the intensive care unit (ICU) is recommended as a means of service evaluation (Department of Health (2000). Comprehensive Critical Care: a Review of Adult Critical Care Services), in order to monitor the quality of the services provided Without patient follow-up, ICU staff have only 'death' or 'discharge alive from hospital' as clinical outcomes from which to judge practice performance, and limited evidence exists on which to base decisions about improvements to critical care practice (Audit Commission (1999). Critical to Success--the Place of Efficient and Effective Critical Care Services Within the Acute Hospital) To address these issues the Regional Intensive Care Unit (RICU) obtained information from patient assessment/interview on problems experienced by patients within 8-9 days (mean), following discharge from RICU A nurse-administered questionnaire was used to identify functional outcomes, nutrition and psychological issues such as anxiety and sleep disturbances Benefits of patient follow-up introduced and planned include: patient diaries for long-term patients, input from clinical psychologis, review of sedation used in RICU.

Psycho-affective disorder in intensive care units: a review

This paper reviews the literature related to the Intensive Care Unit (ICU) Syndrome. The intention of the paper is to explore the range of psychotic and affective phenomena that may be observed in practice, together with the management of contributory stressors. Patients experience a range of psycho-affective disturbances that may be triggered by drugs, the environment, dehumanizing practices and sleep deprivation. Symptoms do not always disappear following discharge and further research is required to determine the long-term psychological effects of an ICU. Comprehensive assessment of the patient's psychological state, using an appropriate tool, is necessary and should form an integral part of ongoing care. Interventions identified include eradication of dehumanizing behaviour, modification of environmental stimuli, effective communication and therapeutic touch. Where possible, communication needs should be addressed prior to admission, and patients and their families prepared for the unfamiliar world of the ICU.

Verbal communication: what do critical care nurses say to their unconscious or sedated patients?

The importance of using verbal communication in the care of critically ill patients has long been known. Both qualitative and quantitative studies have presented evidence of the benefits of effective communication. This non-participant observational study aimed to explore how much and what types of verbal communication critical care nurses use when caring for unconscious or sedated patients. Sixteen critical care nurses were observed in 4-hour episodes and their verbal communication was transcribed and timed at source. Seven categories of verbal communication and a 'core concept' emerged on analysis of the raw data. Medical investigations/interventions performed on the patients increased the amount of communication used. The participants in this study were found to use a greater variety and amount of verbal communication than participants in other studies. The findings of this study highlight the need for formal support systems and continued education for nurses about the benefits of verbal communication.

Intensive care unit psychosis, the therapeutic nurse-patient relationship and the influence of the intensive care setting: analyses of interrelating factors

It has been estimated that between 12.5% and 38% of conscious patients admitted to critical care settings experience Intensive Care Unit psychosis, a condition which seems to resolve upon transfer to the ward. This phenomenon was traditionally recognized when the patient outwardly exhibited abnormal behaviours and signs in the form of confusion, delirium, anxiety, depression, delusions and audiovisual hallucinations, yet it has been argued that due to the illness of the patient and their suppressed ability to communicate, such overt displays of unusual behaviour are the tip of the iceberg. In recognizing this phenomenon, it is felt that a relationship exists between Intensive Care Unit Psychosis, the therapeutic nurse-patient relationship, and the environment in which nurses' interactions with their clients occur. This paper will explore the interaction between these three elements while considering the implications for contemporary nursing practice.

Follow-up services and the development of a clinical nurse specialist in intensive care

There is little information available regarding quality of life following critical illness. The consequences of a stay in an intensive care unit (ICU) can result in considerable psychological and physical morbidity. At the Homerton Hospital, London, UK an intensive care follow-up outpatient clinic was established to ascertain patients' experiences after discharge from the ICU. This exploratory study examines narrative data collected from 26 patients by means of unstructured client-led interviews. Themes are derived that have implications for staff, patients and relatives. The findings suggest that patients experience a variety of psychological and physical symptoms. Patients experienced vivid dreams, flashbacks, relocation and convalescent stress as well as profound tiredness and weakness. These are consistent with previous research findings. New themes were identified which suggest that mood changes, inability to cope, the need to talk about their ICU experience and indistinct memories of the ICU made recovery at home difficult for both the patients and their families. As a result of these findings, the role of a clinical nurse specialist has developed in order to improve liaison between and within departments, the hospital and the community. Future research will aim to focus on the role of the critical care/community liaison clinical nurse specialist and in improving outcomes through the use of action research.

Sensoristrain: an exploration of nursing interventions in the context of the Neuman systems theory

Defining what nurses do and why has been the endeavour of many researchers, both academic and clinical. Nursing interventions are a fundamental component of nursing practice and a focus on accountability means that nurses must be able to justify their actions. The sensoristrain experience of intensive care patients is widely acknowledged in nursing literature, though without the use of the word 'sensoristrain'. The aim in this paper is to place patients, their experience and the role of nurses within the practical framework of a suitable nursing theory which will elucidate and guide everyday practice in preventing and alleviating the causes (stressors), symptoms (reactions) and emotional aftermatch. Nursing interventions appropriate for the three modalities of intervention elucidated by the Neuman systems theory have been outlined, paralleled by a discussion of how these could relate to the three dimensions of nursing care: comfort care; knowing the patient; and the therapeutic presence of the nurse. Nurses must use each opportunity to advance practice through emphasizing the value of nursing in today's cost-conscious health care climate. In order to do this, and to ensure nurses' continued presence at the bedside, clear articulation of the contribution of nursing interventions to improved patient outcomes is essential.

A concept analysis of the sensoristrain experienced by intensive care patients

Psychological disturbances that patients may experience during admission to intensive care units (ICUs) can have distressing implications for their emotional and physical integrity, progress and subsequent recovery. It is widely believed by practitioners and reflected in professional literature that these disturbances are precipitated by sensory deprivation or overload in the physical environment of intensive care units. In this paper the sources and mechanism of the sensory imbalances experienced by these patients are examined. A new concept--sensoristrain--has been developed in an attempt to promote awareness and improve understanding of the phenomenon among nurses. Once this has been achieved, assessment and identification of patients at risk are optimized and appropriate interventions can be formulated. Using an eclectic approach to analyse sensoristrain, both causes and effects of the phenomenon have been identified from the literature. This information has been combined with practical examples in the development of a model of the concept sensoristrain. The paper concludes by outlining the resulting implications for nursing practice, which may be used to guide future research both in concept development and identification of effective prevention of the phenomenon conceptualized and interventions if it occurs.

Meeting the informational, psychosocial and emotional needs of each ICU patient and family

The acquisition of counselling skills and a review of current practice within a cardiothoracic intensive care unit (ICU) have revealed the need for a nursing development that will focus on meeting the informational, psychosocial and emotional needs of patients and their families. The findings from a literature search suggest that these needs are not always adequately met. Difficulties may be encountered by patients and their families whilst trying to adjust to a stay in the ICU, to transfer to the ward, and following discharge home. Providing a client-driven service that effectively meets these complex needs could be achieved by developing a specialist role in intensive care nursing. The patients and their families could be offered provision of information and supportive strategies that extend from admission to the ICU, through transfer to a ward, and beyond. The aim of the service would be to provide patient- and family-centred continuity of care throughout the acute and rehabilitative stages of the crisis (Turner 1992). The utilization of counselling skills could help to facilitate the service, and help each client to feel supported (Tschudin 1995, p 33).

Critically ill children: the case for short-term care in general intensive care units

This paper contests the claim that all children should be nursed in paediatric intensive care units (PICUs). Although there is an undoubted need for prolonged care to be undertaken within PICUs, they are a scarce resource and many children's critical illness is of short duration. Following a discussion on the negative aspects of transferring a critically ill child this paper then establishes how a general intensive care unit (GICU) can maintain-awareness and standards which make it a safe environment for children with a short-term critical illness, as well as contribute towards future management and practice.

Revisiting visiting in intensive therapy units

The aim of this study is to investigate whether, 2 years after the study by Biley et al (1993), visiting in intensive therapy units (ITU) remains restricted. The study was conducted over the summer months of 1995, and ITUs in southern England were contacted. It revealed more favourable results regarding some aspects of visiting practices, but not others.

Intensive care syndrome: a literature review

The aim in this literature review is to describe the definitions, denominations, clinical signs and symptoms, explanations, causative factors and interrelationships of the intensive care syndrome discussed since 1950. It was found that there is no agreement about which symptoms should be included in the syndrome, when the syndrome may appear and how many patients may be affected. Furthermore, it is unclear what causes the development of the syndrome; most authors conclude that there are many reasons for it. The syndrome has generally been examined by using a medical or psychological approach, but during the last few years it has also been described and analysed from a nursing care perspective. From this nursing perspective the syndrome may be seen as an individual pattern developed by patients during their stay in an intensive care unit (ICU) and sometimes this pattern of clinical signs and symptoms lasts for a shorter or longer period even after discharge from the unit. From a wider viewpoint the development of the syndrome can be seen as an increase by degrees or as a vicious circle. finally, most authors agree that the ICU syndrome consists of, and is caused by, a complex interaction between many factors.

'Take me away from all this' ... can reminiscence be therapeutic in an intensive care unit?

'Stuart had been with us in the ICU for 4 weeks; weaning attempts from his artificial ventilation were difficult, leaving him frightened, exhausted and despondent. Depression, hopelessness and apathy were beginning to take a hold on him ... until one day something changed everything. A way had been found to help him escape, temporarily, from his intensive care situation. Three days later Stuart was breathing spontaneously and was being prepared for discharge from the ICU.' In this paper potential benefits of reminiscence sessions with patients in a critical care unit are discussed. Background and context are reviewed, leading to some suggestions for practice.

Preventing the ITU syndrome or how not to torture an ITU patient! Part 2

Admission to an intensive therapy unit (ITU) has been described as a 'necessary evil' (Barrie-Shevlin 1987), and some of the 'tortures' described in Part I of this article (Dyer 1995) may be an inevitable result of ITU care. This does not mean that the development of the ITU syndrome should be regarded as inevitable. Many potential causes of the syndrome can be avoided or at least ameliorated. Some suggested means of preventing the syndrome include designing ITUs with windows (Keep et al 1980), use of noise reducing materials when building ITUs (Hopkinson 1994, Topf & Davis 1993), using noise level as a criterion when purchasing equipment (Dracup 1988) or using remote telemetry for monitoring (Fisher & Moxham 1984). These would undoubtedly be beneficial but they are not practical propositions for nurses who wish to improve psychological care in the short term. For this reason, this article, concentrates mainly on immediately applicable, relatively cost-free interventions. Methods of preventing the syndrome should begin, whenever possible, before admission and should continue throughout the patients' stay. The main emphasis should be placed on prevention, but early detection and treatment of problems should also be given high priority. If a patient exhibits symptoms of psychological disturbance physical causes should be considered, but at the same time the ITU syndrome should be suspected and attempts made to alleviate possible causes of this. Nurses play a vital role in any attempts to alleviate problems and in 'humanising' the technical ITU environment (Ashworth 1987, Mackellaig 1990).(ABSTRACT TRUNCATED AT 250 WORDS)