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Nurses working in an intensive therapy unit decided to implement a standard designed to produce long-term benefits in patient care. A standard was devised which reflected the needs and views of all members of the nursing team, as this was perceived as the best way of ensuring genuine change.
OBJECTIVES: To elicit healthcare provider perceptions of working together in a neonatal intensive care unit (NICU). STUDY DESIGN: We conducted focus groups to elicit descriptions of how providers work together. The groups included one each of transport nurses, staff nurses, residents, fellows, attending physicians and two multiple provider groups. To identify themes and their descriptive elements we performed qualitative data analysis. RESULTS: There were three to seven participants per group for a total sample of 36. Provider responses to questions about working together centered around three major themes: (1) Provider Characteristics; (2) Workplace Factors and; (3) Group Influences. Provider Characteristics were defined by personal attributes, reputation, and expertise. Workplace Factors included staffing, work organization, and work environment. Group Influences were described by communication and relationships. CONCLUSIONS: Providers in this NICU described three broad organizational and interpersonal factors that influence how they work together, yet no consistent descriptions of teams or teamwork were found. The organizational factors, often far removed from bedside, should be considered when evaluating how providers work together.
BACKGROUND: Constraint of nurses by healthcare organizations, from actions the nurses believe are appropriate, may lead to moral distress. OBJECTIVE: To present findings on moral distress of critical care nurses, using an investigator-developed instrument. METHODS: An instrument development design using consensus by three expert judges, test-retest reliability, and factor analysis was used. Study participants (N = 111) were members of a chapter of the American Association of Critical-Care Nurses, critical care nurses employed in a large medical center, and critical care nurses from a private hospital. A 32-item instrument included items on prolonging life, performing unnecessary tests and treatments, lying to patients, and incompetent or inadequate treatment by physicians. RESULTS: Three factors were identified using factor analysis after expert consensus on the items: aggressive care, honesty, and action response. Nurses in the private hospital reported significantly greater moral distress on the aggressive care factor than did nurses in the medical center. Nurses not working in intensive care experienced higher levels of moral distress on the aggressive care factor than did nurses working in intensive care. Of the 111 nurses, 12% had left a nursing position primarily because of moral distress. CONCLUSIONS: Although the mean scores showed somewhat low levels of moral distress, the range of responses revealed that some nurses experienced high levels of moral distress with the issues. Research is needed on conditions organizations must provide to support the moral integrity of critical care nurses.
Selective digestive decontamination (SDD) is the most extensively studied method for the prevention of infection in patients in intensive care units (ICUs). Despite 27 prospective randomized studies and six meta-analyses, routine use of SDD is still controversial. In this review, we summarize the available scientific information on effectiveness of SDD in ICU patients. The effects of SDD have been studied in different combinations of the concept, using different antibiotics. Comparison of the individual studies, therefore, is difficult. In most studies, SDD resulted in significant reductions in the number of diagnoses of ventilator-associated pneumonia. However, incidences of ventilator-associated pneumonia in control groups ranged from 5% to 85%. Moreover, these reductions in incidences of ventilator-associated pneumonia in individual studies were not associated with improved patient survival, reductions of duration of ventilation or ICU stay, or reductions in antibiotic use. The numbers of patients studied are too small to determine effects on patient survival. Although two meta-analyses suggested a 20% mortality reduction when using the full concept of SDD (topical and systemic prophylaxis) these results should be interpreted with caution. Formal cost-benefit analyses of SDD have not been performed. SDD is associated with the selection of microorganisms that are intrinsically resistant to the antibiotics used. However, the studies are too small and too short to investigate whether SDD will lead to development of antibiotic resistance. As long as the benefits of SDD (better patient survival, reduction in antibiotic use or improved cost-effectiveness) have not been firmly established, the routine use of SDD for mechanically ventilated patients is not advised.
AIMS: To identify the work factors that predict intense low back pain (LBP) and LBP related sick leaves in nurses' aides. METHODS: The sample comprised 4266 randomly selected Norwegian nurses' aides, not bothered or only a little bothered by LBP during the previous three months, and not on sick leave when completing a mailed questionnaire in 1999. Of these, 3808 (89.3%) completed a second questionnaire 3 months later and 3651 (85.6%) completed a third questionnaire 15 months later. Intensity of low back symptoms and certified sick leaves attributed to LBP during the observation period were assessed by self reports at the follow ups. RESULTS: After adjustments for LBP during the three months prior to baseline, baseline health complaints, demographic and familial factors, and a series of physical, psychological, and social work factors, logistic regression analyses revealed the following associations: intense low back symptoms were predicted by frequent positioning of patients in bed, perceived lack of support from immediate superior, and perceived lack of pleasant and relaxing culture in the work unit. LBP related sick leaves were predicted by frequent handling of heavy objects, medium level of work demands, perceived lack of supportive and encouraging culture in the work unit, working night shifts, and working in a nursing home. Long term LBP related sick leaves were associated with changes of work or work tasks during the observation period that resulted in a perceived reduction of support and encouragement at work. CONCLUSIONS: Not only frequent mechanical exposures, but also organisational, psychological, and social work factors, such as night shift work, perceived lack of support from superior, and perceived lack of a pleasant and relaxing or supporting and encouraging culture in the work unit, are associated with an increased risk of intense low back symptoms and LBP related sick leaves in nurses' aides.
AIMS AND OBJECTIVES: This study aimed to assess whether nurses working in intensive care units view the establishment of communication with patients beyond therapeutic possibilities as an effective palliative therapeutic resource, and which aspects of this communication they valued most. METHOD: Data were collected in November 2002, by semi-structured interviews with 10 nurses of both clinical and surgical intensive care unit at a school hospital in Sao Paulo city, Brazil. Interviews were recorded and transcribed to be further analysed according to the qualitative methodology of content analysis. RESULTS: Four categories of thematic order raised from the collected statements, which clarify (i) the value of communication with terminal patients; (ii) the obstacles found during this process; (iii) the need to identify the individual demands of each patient, (iv) be able to use communication as a tool in the palliative care of the dying patient. CONCLUSION: In conclusion, we found that the nurses working at the intensive care unit do consider communication with dying patients an effective therapeutic resource, in spite of their own difficulties in communicating with dying patients, viewing themselves as ill prepared to the task, and often, distancing themselves from the dying patients because of their inability to deal with their own feelings, which were brought forth by the confrontation with the imminence of death. RELEVANCE TO CLINICAL PRACTICE: Although the number of interviewed nurses in our study was small, the results corroborated the findings of other studies and revealed an educational aspect in nursing training that deserves serious consideration.
Recovery from a bout of exercise is associated with an elevation in metabolism referred to as the excess post-exercise oxygen consumption (EPOC). A number of investigators in the first half of the last century reported prolonged EPOC durations and that the EPOC was a major component of the thermic effect of activity. It was therefore thought that the EPOC was a major contributor to total daily energy expenditure and hence the maintenance of body mass. Investigations conducted over the last two or three decades have improved the experimental protocols used in the pioneering studies and therefore have more accurately characterized the EPOC. Evidence has accumulated to suggest an exponential relationship between exercise intensity and the magnitude of the EPOC for specific exercise durations. Furthermore, work at exercise intensities >or=50-60% VO2max stimulate a linear increase in EPOC as exercise duration increases. The existence of these relationships with resistance exercise at this stage remains unclear because of the limited number of studies and problems with quantification of work intensity for this type of exercise. Although the more recent studies do not support the extended EPOC durations reported by some of the pioneering investigators, it is now apparent that a prolonged EPOC (3-24 h) may result from an appropriate exercise stimulus (submaximal: >or=50 min at >or=70% VO2max; supramaximal: >or=6 min at >or=105% VO2max). However, even those studies incorporating exercise stimuli resulting in prolonged EPOC durations have identified that the EPOC comprises only 6-15% of the net total oxygen cost of the exercise. But this figure may need to be increased when studies utilizing intermittent work bouts are designed to allow the determination of rest interval EPOCs, which should logically contribute to the EPOC determined following the cessation of the last work bout. Notwithstanding the aforementioned, the earlier research optimism regarding an important role for the EPOC in weight loss is generally unfounded. This is further reinforced by acknowledging that the exercise stimuli required to promote a prolonged EPOC are unlikely to be tolerated by non-athletic individuals. The role of exercise in the maintenance of body mass is therefore predominantly mediated via the cumulative effect of the energy expenditure during the actual exercise.
The present study was conducted by culture with a modified broth wash technique to examine the frequency of yeast carriage on the hands of 60 nurses and 35 nonnursing hospital employees. Seventy two percent of the nurses and 80% of the nonnurses were harbouring yeast on their hands. Candida spp. were isolated in 57% on of nurses and 34% of nonnurses. Ninety percent of nurses working in nursing home care unit (NHCU), 50% working in intensive care unit (ICU) and 75% working in outpatient department (OPD) carried yeasts on their hands. Only 80% of nonnurses staff harboured yeasts on their hands.
OBJECTIVE: A multicenter survey to study the use of nutritional support in patients admitted to the ICU in Spain. DESIGN: The survey was announced during the annual Spanish Society of Intensive Care Medicine and Coronary Units (SEMIUC) congress meeting. SETTING: Questionnaires designed to determine current clinical practice concerning artificial nutrition were sent to the 27 ICU who accepted to participate. PATIENTS AND PARTICIPANTS: In each center the 235-question form was filled out individually for each patient admitted to the ICU during the month of March, 1992. INTERVENTIONS: To validate the study a preliminary pilot surveys were conducted to ensure that there was a correct interpretation of the questions. The replies were entered into a database for analysis. RESULTS: A total of 1261 patients were studied; 33.9% received artificial nutrition (AN). The administration of AN was significantly higher in the medical group (44%), than in the surgical (37%) and the trauma group (19%). AN was significantly lower in patients admitted to private clinic than public institutions (26.7% versus 34.7%). Among the patients who received AN, enteral nutrition (EN) was administered to 59.7% of the patients, total parenteral nutrition (TPN) to 38.5%, and peripheral parenteral nutrition (PPN) to 18.2%. Medical patients received significantly more EN than surgical and trauma patients. Surgical patients received more PN than medical and trauma groups. CONCLUSIONS: Nutritional support is a common practice in the treatment of ICU patients in our country. All information concerning its use is necessary to optimize it.
It has been determined that in erythrocytes of high-qualified and low-qualified sportsmen-volleyboll after use of biopreparation "Polien", contained polyunsaturated fatty acids, glycolysis and pentose phosphate pathway reactions are intensified and glutathione reductase activity are decreased. At the same time the affinity of haemoglobin to oxygen in stabilized in organism of sportsmen before and after intensive muscle work. It has been shown, that specific and nonspecific changes of biochemical indexes are realized in organism of sportsmen with different qualification under intensive muscle work.
Severe protein-calorie malnutrition is a major problem in many intensive care (ICU) patients, due to the increased catabolic state often associated with acute severe illness and the frequent presence of prior chronic wasting conditions. Nutritional support is thus an important part of the management of these patients. Over the years, enteral nutrition (EN) has gained considerable popularity, due to its favorable effects on the digestive tract and its lower cost and rate of complications compared to parenteral nutrition. However, clinicians caring for ICU patients are often faced with contradictory data and difficult decisions when having to determine the optimal timing and modalities of EN administration, estimation of patient requirements, and choice of formulas. The purpose of this paper is to provide practical guidelines on these various aspects of enteral nutritional support, based on presently available evidence.
The contribution of muscle strength to symptom intensity and work capacity was examined in normal individuals and patients with cardiorespiratory disorders. Respiratory muscle strengths (maximal inspiratory and expiratory pressures) and peripheral muscle strengths (leg extension, leg flexion, seated bench press, and seated row) were measured in 4,617 subjects referred for clinical exercise testing. Subjects then rated the intensity of leg effort, discomfort with breathing (dyspnea), and chest pain (Borg scale) during an incremental exercise task (100 kpm/min each minute) to capacity on a cycle ergometer. Subjects were classified into groups on the basis of pulmonary function, drug therapy for cardiac disorders, and the presence of chest pain during exercise with electrocardiographic changes indicative of myocardial ischemia. Respiratory and peripheral muscle strengths, normalized for differences in age, sex, and height, were significantly reduced in patients with cardiorespiratory disorders compared with normal individuals. Muscle strength was a significant contributor to symptom intensity and work capacity in both health and disease; a two-fold increase in muscle strength was associated with a 25 to 30% decrease in the intensity of both leg effort and dyspnea and a 1.4- to 1.6-fold increase in work capacity. These results emphasize the need for an integrative approach in the assessment and therapeutic management of exercise intolerance, which considers the contribution of muscle weakness to excessive symptoms and reduced work capacity, in addition to the contribution of ventilatory, gas exchange, and circulatory impairments.
In the present study, we aimed at verifying close to ICU nursing team the service representation and this unit meaning, looking at finding the sense of leisure and its implication in the professional environment. We worked with DUMAZEDIER framework, considering the application of leisure in health promotion, through a quali-quantitative survey. We have investigated 10 members of the nursing team, among different categories, most of them were women, half single, from 28 to 45 years old, with predominantly 10 years in service. They showed pleasure in their job (90%), although they consider it stressing (50%). The job was identified as assistance (80%) and requiring vocation/donation (50%). They also showed relationship and communication. They have the concept of leisure as entertainment/deconcentration (80%), relaxation (20%) etc., emphasizing the importance of discussing the theme. They admit tension/stress caused in the location, considering the need of leisure in the service, to help communication and alleviate the tension. We suggest to nurses special attention on this.
We studied a population of 463 nurses working in intensive care units--ICUs--(distributed in 51 italian hospitals), and 216 nurses working in general medicine units (distributed in 17 italian hospitals). They we asked to fill in a form including: 1) general data and his/her work environment, and 2) some standardized scales (HAD A and D, STAI Y-1 and Y-2, MBI) for estimation of anxiety, depression and "burnout" syndrome. We used also the "P questions", evaluating the different situations of work environment causing anxiety. The aims of the study were to evaluate the effectiveness of different scales and the influence of general medicine and intensive care environment on psychological features. Among different scales estimating anxiety, the STAI Y-2, valuing a chronic anxiety status, results to be efficient, beside the already tested HAD A. The intensive care environment did not seem to be more stressful for nurses staff rather than general medicine units. Furthermore, nurses operating in general medicine units have a major tendency to depression; their work environment seems to favour the development of anxiety. Finally, it results that general medicine units cause a more severe "burnout" syndrome in their nurses staff rather than ICUs.
The relationship between air contamination (cfu/m(3)) with fungal spores, especially Aspergillus spp., in three renovation areas of a neonatal intensive care unit (NICU) and colonization and infection rates in a high care area (HC) equipped with high efficiency particulate air (HEPA) filtration and a high pressure system, was evaluated. Data on the type and site of renovation works, outdoor meteorological conditions, patient crowding and nasopharyngeal colonization rate were collected. Factors not associated with Aspergillus spp. concentration were outdoor temperature, air pressure, wind speed, humidity, rainfall, patient density in the NICU, renovation works in the administrative area and in the isolation rooms. Multivariate analysis revealed that renovation works and air concentration of Aspergillus spp. spores in the medium care area (MC) resulted in a significant increase of the concentration in the HC of the NICU. The use of a mobile HEPA air filtration system (MedicCleanAir(R)Forte, Willebroek, Belgium) caused a significant decrease in the Aspergillus spp. concentration. There was no relationship between Aspergillus spp. air concentration and nasopharyngeal colonization in the neonates. Invasive aspergillosis did not occur during the renovation. This study highlights the importance of optimal physical barriers and air filtration to decrease airborne fungal spores in high-risk units during renovation works. The value of patient surveillance and environmental air sampling is questionable since no relationship was found between air contamination and colonization in patients.
Cluster analysis was used to identify subgroups of a sample of 40 patients with borderline personality disorder (BPD). The BPD patients were part of a larger sample that had participated in an intensive, group-oriented Evening Treatment Program. A set of pretherapy outcome measures was used to represent patient "attributes" for the cluster analysis. Eight clusters were identified. Two, each defined by a single patient with pronounced pathology, were deleted from further analyses. In a discriminant-function analysis, four dimensions emerged that differentiated the six remaining clusters. Significant relationships among the four dimensions and measures of therapeutic work and treatment outcome were identified. The relationships reflected the impact of behavioral characteristics associated with BPD on participation in and benefit from intensive group-oriented evening treatment. Implications of these exploratory findings for the understanding and treatment of BPD are discussed.
The objective of the study was to evaluate the physiological effectiveness and the influence of two modifications of aerobic training (interval and continuous) on the physical performance in the patients with coronary heart disease. 38 males with coronary heart disease (age 60 +/- 10.2 years) passed three months training programme of 60 min 3 times a week (10 min of warm up phase, 25 min of aerobic phase, 15 min of resistance training, 10 min of relaxing phase). Patients with coronarographically verified stenosis > 50% luminal diameter and/or left ventricular ejection fraction lower than 40 % (n = 22) had in terms of aerobic phase interval training prescribed (30 second work phases with work load intensity on the level of anaerobic threshold alternating with 60 second recovery phases with intensity of 5 W); other patients (n = 16) passed aerobic phase of the programme with continual work load of intensity on the level of ventilatory anaerobic threshold. After the determination of three month rehabilitation programme the maximal achieved performance as well as aerobic capacity evaluated by spiroergometric examination statistically significantly increased in the group of patients with interval training and also in the group with continuous training. Despite the group with interval training performed 2.5-3 times less work in each training unit (p < 0.01), the performance and aerobic capacity parameters after the termination of three month programme did not statistically significantly differ from the group with continuous training. The advantage of the continuous training is a possibility to achieve an improvement also in the patients with left ventricular dysfunction and chronic coronary heart disease who could have worse tolerance of the continual work load.
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