ACCCN's Critical Care Nursing

128 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



Research vignette, Continued
treatment groups. Further, it is always possible that the group who the protocols were adhered to although data on intervention
were lost to follow up differed in some unknown way to those who fidelity was not provided. Ensuring those delivering the interven-
had complete baseline and day three CPIS values. tion were not involved in CPIS assessment and ensuring
those undertaking the CPIS assessments were blinded to group
The researchers acknowledge and explain several study limitations allocation are strengths of this study. The results were clearly
including how it was that patients with pneumonia were inadver- described with tables easy to understand. The research team
tently recruited into the study despite pneumonia being an was comprised of a number of nursing professors and a professor
exclusion criteria. They identify that the smaller samples on day of critical care medicine, and they received National Institutes of
five and seven did not allow conclusions about the effect of the Health funding, suggesting that peer review of the detailed
interventions on late-onset VAP. The researchers also describe research plan was undertaken and that the study was judged to
several difficulties in undertaking research with ICU patients. be of very high quality. Overall, the researchers should be com-
Overall, this study was carefully thought through. It had a powerful mended on the quality of their study and the limitations identified
design and was powered to detect a difference between groups. highlight the difficulties in conducting clinical trials in the ICU
The researchers carefully detailed the mouthcare interventions, population. Finally, and very importantly, other researchers inter-
although the meaning of usual care was not explained. Employing ested in this work could replicate the study because it was clearly
study staff to deliver the intervention made it more likely that described.










Learning activities

1. Review the patient hygiene products available in your unit. Do 7. State the evaluation tools used for pressure area risk assess-
you have a range of products suitable for your patient ment and the strategies implemented in your unit for pressure
population? sore prevention.
2. Can you identify, assess and plan definitive management spe- 8. Describe the risk evaluation and protocols for VTE prophylaxis
cific to skin tears, pressure ulcers and venous ulcers? in your unit.
3. A patient with a closed head injury has conjunctival oedema 9. What is the patient bowel management protocol for your unit,
and still needs frequent neurological assessment, including and is it effective? Why/why not?
assessment of pupil reactions. Outline the process to follow to 10. What are the protocols for surveillance, detection and manage-
ensure both eye assessment and eye protection. ment of influenza and nosocomial infections in your unit?
4. Describe the key components of good oral hygiene. 11. Outline the practices used to prevent ventilator-associated
5. Observe the positioning in bed of patients in your unit. Evalu- pneumonia and catheter-related sepsis in your unit.
ate the position for (a) patient comfort, (b) patient security, (c) 12. Review the key features of the beds and mattresses in use in
device and equipment safety, and (d) therapeutic benefit of your unit. Do you have scope to match specific patient require-
the position. ments for beds or pressure relief mattresses?
6. What prompts decisions for patients to sit out of bed or mobil- 13. Describe the preparation, equipment and monitoring of a ven-
ise in your unit? Do you have positioning, turning or mobilisa- tilated patient with multiple infusions for transfer from the ICU
tion protocol in your unit? to the imaging department.






ONLINE RESOURCES National Institute of Clinical Studies NICS, <http://www.nhmrc.gov.au/nics/
index.htm>
Therapeutics Goods Australia, <http://www.tga.gov.au/index.htm>
Australian Wound Management Association, <http://www.awma.com.au>
Australian Department of Health and Ageing, <http://www.health.gov.au> US Centers for Disease Control and Prevention, <http://www.cdc.gov>
Cochrane Collaboration, <http://www.cochrane.org> World Health Organization, <http://www.who.int/en/>
College of Intensive Care Medicine of Australia and New Zealand, <http://
www.cicm.org.au> FURTHER READING
Communicable Diseases Network Australia (CDNA), <http://www.nphp.gov.au/
workprog/cdna> College of Intensive Care Medicine of Australia & New Zealand. Minimum stan-
European Pressure Ulcer Advisory Panel, <http://www.epuap.org> dards for transport of critically ill patients IC-10. 2010. [Cited December 2010].
Hand Hygiene Australia, <http://www.hha.org.au> Available from: http://www.cicm.org.au/cmsfiles
Joint Faculty of Intensive Care Medicine, <http://www.jficm.anzca.edu.au> Khoury J, Jones M, Grim A, Dunne WM Jr, Fraser V. Eradication of methicillin-
National Health and Medical Research Council, <http://www.nhmrc.gov.au> resistant Staphylococcus aureus from a neonatal intensive care unit by active

Essential Nursing Care of the Critically Ill Patient 129

surveillance and aggressive infection control measures. Infect Control Hosp 24. Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care
Epidemiol 2005; 26(7): 616–21. reduces incidence of ventilator-associated pneumonia in ICU populations.
Levy MM, Baylor MS, Bernard GR, Fowler R, Franks TJ et al. Clinical issues and Intens Care Med 2006; 32(2): 230–36.
research in respiratory failure from severe acute respiratory syndrome. Am J 25. O’Reilly M. Oral care of the critically ill: a review of the literature and guide-
Resp Crit Care Med 2005; 171(5): 518–26. lines for practice. Aust Crit Care 2003; 16(3): 101–10.
Wright M, Hebden JN, Harris AD, Shanholtz CB, Standiford HC et al. Concise 26. Berry AM, Davidson PM. Beyond comfort: oral hygiene as a critical nursing
communications: aggressive control measures for resistant Acinetobacter bau- activity in the intensive care unit. Intens Crit Care Nurse 2006; 22(6):
mannii and the impact on acquisition of methicillin-resistant Staphylococcus 318–28.
aureus and vancomycin-resistant Enterococcus in a medical intensive care unit. 27. Fitch JA, Munro CL, Glass CA, Pellegrini JM. Oral care in the adult intensive
Inf Control Hospl Epidemiol 2004; 25(2): 167–8. care unit. Am J Crit Care 1999; 8(5): 314–18.
28. Binkley C, Furr LA, Carrico R, McCurren C. Survey of oral care practices in
REFERENCES 29. Furr LA, Binkley C, McCurren C, Carrico R. Factors affecting quality of oral
US intensive care units. Am J Infect Control 2004; 32(3): 161–9.
1. Larson EL, Ciliberti T, Chantler C, Abraham J, Lazaro EM et al. Comparison care in intensive care units. J Adv Nurs 2004; 48(5): 454–62.
of traditional and disposable bed baths in critically ill patients. Am J Crit 30. Barnason S, Graham J, Wild MC, Jensen LB, Rasmussen D et al. Comparison
Care 2004; 13(3): 235–41. of two endotracheal tube securement techniques on unplanned extubation,
2. Nguyen D, MacLeod WB, Phung DC, Cong QT, Nguyen VH et al. Incidence oral mucosa, and facial skin integrity. J Acute Crit Care 1998; 27(6):
and predictors of surgical-site infections in Vietnam. Infect Control Hosp 409–17.
Epidemiol 2001; 22(8): 485–92. 31. Treloar DM, Stechmiller JK. Use of a clinical assessment tool for orally
3. Shackell S. Cooling hyperthermic and hyperpyrexic patients in intensive care. intubated patients. Am J Crit Care 1995; 4(5): 355–60.
Nurs Crit Care 1996; 1(6): 278–82. 32. Jenkins D. Oral care in the ICU: an important nursing role. Nurs Stand 1989;
4. Holtzclaw BJ. Shivering in acutely ill vulnerable populations. AACN Clin 4(7): 24–8.
Issues 2004; 15(2): 267–79. 33. Evans G. A rationale for oral care. Nurs Stand 2001; 15(43): 33–6.
5. Burr S, Penzer R. Promoting skin health. Nurs Stand 2005; 19(36): 57– 34. Holmes S. The oral complications of specific anticancer therapy. Int J Nurs
65. Stud 1991; 28(4): 343–60.
6. NHS Quality Improvement Scotland. Ear Care Best Practice Statement. 2006 35. Levine R. The scientific basis of dental health education, 3rd edn. London:
[cited 2010 November]; Available from: http://www.nhshealthquality.org/ Health Education Authority; 1993.
nhsqi/files/EARCARE_BPS_MAY06.pdf. 36. Pearson LS, Hutton JL. A controlled trial to compare the ability of foam
7. Baranoski S. Skin tears: guard against this enemy of frail skin. Nurs Manag swabs and toothbrushes to remove dental plaque. J Adv Nurs 2002; 39(5):
(Harrow) 2001; 32(8): 25–32. 480–89.
8. Hernandez EV, Mannis MJ. Superficial keratopathy in intensive care unit 37. Berry AM, Davidson PM, Masters J, Rolls K. Systematic literature review of
patients. Am J Ophthalmol 1997; 124(2): 212–16. oral hygiene practices for intensive care patients receiving mechanical venti-
9. Joyce N. Eye Care for the Intensive Care Patient. Adelaide: Joanna Briggs insti- lation. Am J Crit Care 2007; 16(6): 552–62.
tute for Evidence Based Nursing and Midwifery; 2002. 38. Fields LB. Oral care intervention to reduce the incidence of ventilator-
10. Newswanger DL, Warren CR. Guillain–Barré syndrome. Am Fam Physician associated pneumonia in the neurologic intensive care unit. J Neurosci
2004; 69(10): 2405–10. Nursing 2008; 40(5): 291–8.
11. Cortese D, Capp L, McKinley S. Moisture chamber versus lubrication for the 39. Munro CJ, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine,
prevention of corneal epithelial breakdown. Am J Crit Care 1995; 4(6): toothbrushing, and preventing ventilator-associated penumonia in critically
425–8. ill adults. Am J Crit Care 2009; 18(5): 428–37.
12. Imanaka H, Taenaka N, Nakamura J, Aoyama K, Hosotani H. Ocular surface 40. Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO.
disorders in the critically ill. Anesth Analg 1997; 85(2): 343–6. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing preva-
13. Farrell M, Wray F. Eye care for ventilated patients. Intens Crit Care 1993; 9(2): lence of nosocomial pneumonia in patients undergoing heart surgery. Am J
137–41. Crit Care 2002; 11(6): 567–70.
14. Dawson D, Dawson D. Development of a new eye care guideline for critically 41. Tombes MB, Gallucci B. The effects of hydrogen peroxide rinses on the
ill patients. Intens Crit Care 2005; 21(2): 119–22. normal oral mucosa. Nurs Res 1993; 42(6): 332–7.
15. Lenart SB, Garrity JA. Eye care for patients receiving neuromuscular blocking 42. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory
agents or propofol during mechanical ventilation. Am J Crit Care 2000; 9(3): Panel. Pressure ulcer prevention and treatment clinical practice guideline.
188–91. Washington DC: National Ulcer Advisory Panel; 2009.
16. Sorce LR, Hamilton SM, Gauvraeu K, Mets MB, Hunter DG et al. Preventing 43. Todres L, Fulbrook P, Albarran J. On the receiving end: A hermeneutic-
corneal abrasions in critically ill children receiving neuromuscular phenomenological analysis of a patient’s struggle to cope while going
blockade: a randomized, controlled trial. Paediatr Crit Care Med 2009; 10(2): through intensive care. Nurs Crit Care 2000; 5(4): 277–87.
171–5. 44. Fan E, Zanni JM, Dennison CR, Lepre SJ. Critical illness neuromyopathy and
17. Bates J, Dwyer R, O’Toole L, Kevin L, O’Hegarty N, Logan P. Corneal protec- muscle weakness in patients in the intensive care unit. AACN Advanced Crit
tion in critically ill patients: a randomized controlled trial of three methods. Care 2009; 20(3): 243–53.
Clin Intensiv Care 2004; 15(1): 23–6. 45. de Jonghe B, Lacherade JC, Sharshar T, Outin H. Intensive care unit-acquired
18. Koroloff N, Boots R, Lipman J, Thomas P, Rickard C, Coyer F. A randomised weakness: risk factors and prevention. Crit Care Med 2009; 37(10):
controlled study of the efficacy of hypromellose and Lacri-Lube combination S309–15.
versus polyethylene/cling wrap to prevent corneal epithelial breakdown in 46. de Jonghe B, Sharshar T, Lefaucheur JP, Authier FJ, Duand-Zaleski I et al.
the semiconscious intensive care patient. Intens Care Med 2004; 30(6): Paresis acquired in the Intensive care unit. J Med Assoc 2002; 288(22):
112–16. 2859–67.
19. Mercieca F, Suresh P, Morton A, Tullo AB. Ocular surface disease in intensive 47. Griffiths RD, Hall JB. Intensive care unit-acquired weakness. Crit Care Med
care patients. Eye 1999; 13(Pt2): 231–6. 2010; 38(3): 779–87.
20. Ezra DG, Chan MP, Solebo L, Malik AP, Crane E et al. Randomised trial 48. Needham DM, Chandolu S, Zanni J. Interruption of sedation for early reha-
comparing ocular lubricants and polyarylamide hydrogel dressings in the bilitation improves outcomes in ventilated, critically ill adults. Aust J Physio
prevention of exposure keratopathy in the critically ill. Intens Care Med 2009; 2009; 55(3): 210.
35(3): 455–61. 49. Needham DM. Mobilizing patients in the intensive care unit: improving
21. So HM, Lee CC, Leung AK, Lim JM, Chan CS, Yan WW. Comparing the neuromuscular weakness and physical function. J Med Assoc 2008; 300(14):
effectiveness of polyethylene covers (Gladwrap) with lanolin (Duratears) eye 1685–90.
ointment to prevent corneal abrasions in critically ill patients: a randomized 50. Morris PE. Moving our critically ill patients: mobility barriers and benefits.
controlled study. Int J Nurs Stud 2008; 45(11): 1565–71. Crit Care Clin 2007; 23: 1–20.
22. Miller M, Kearney N. Oral care of patients with cancer: a review of the litera- 51. Morris PE, Goad A, Thompson C, Taylor K, Harry B et al. Early intensive care
ture. Cancer Nurs 2001; 24(4): 241–54. unit mobility therapy in the treatment of acute respiratory failure. Crit Care
23. Kunis KA, Puntillo KA. Ventilator-associated pneumonia in the ICU: its Med 2008; 36(8): 2238–43.
pathophysiology, risk factors and prevention. Am J Nurs 2003; 103(8): 52. Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E et al. Early
64AA–64GG. physical medicine and rehabilitation for patients with acute respiratory

130 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

failure: a quality improvement project. Arch Phys Med Rehabil 2010; 91(4): 81. Kakkos SK, Caprini JA, Geroulakos G, Nicolaides AN, Stansby GP, Reddy DJ.
536–42. Combined intermittent pneumatic leg compression and pharmacological
53. Vollman KM. Introduction to progressive mobility. Crit Care Nurse 2010; prophylaxis for prevention of venous thromboembolism in high-risk
30(2): S3–5. patients. Cochrane Database of Systematic Reviews 2008; 4.
54. Schweickert WD, Pohlman MC, Pohlman SA, Nigos C, Pawlik AJ et al. Early 82. Access Economics. The burden of venous thromboembolism in Australia. 2008.
physical and occupational therapy in mechanically ventilated , critically ill Report for the Australian and New Zealand working party on the manage-
patients: a randomised controlled trial. Lancet 2009; 373(9678): 1874–82. ment and prevention of venous thromboembolism. [Cited November 2010].
55. Truong AD, Fan E, Brower RG, Needham DM. Bench-to-bedside review: Available from: http//www.accesseconomics.com.au/publicationsreports/
mobilizing patients in the intensive care unit – from pathophysiology to showreport.php
clinical trials. Crit Care 2009; 13(4): 167. 83. Chong BH, Braithwaite J, Harris MF, Fletcher JP. Venous thromboembolism
56. Krishnagopalan S, Johnson EW, Low LL, Kaufman LJ. Body positioning of – A major health and financial burden: how can we do better to prevent this
intensive care patients: clinical practice versus standards. Crit Care Med 2002; disease. Med J Aust 2008; 189(3): 134–5.
30(11): 2588–92. 84. Geerts WH, Bergqvist D, Pineo GF et al. Prevention of venous thromboem-
57. Batson S, Adam S, Hall G, Quirke S. The development of a pressure area bolism: American College of Chest Physicians evidence-based clinical prac-
scoring system for critically ill patients: a pilot study. Intens Crit Care 1993; tice guidelines (8th edition). Chest 2008; 133: S381–453.
9(3): 146–51. 85. Cohen AT, Tapson VF, Bergmann JF et al. Venous thromboembolism risk and
58. Berenholtz SM, Dorman T, Ngo K, Pronovost PJ. Qualitative review of inten- prophylaxis in the acute hospital care setting (ENDORSE study): a multina-
sive care unit quality indicators. J Crit Care 2002; 17(1): 1–12. tional cross-sectional study. Lancet 2008; 371(9610): 387–94.
59. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a 86. Sachdeva A, Dalton M, Amaragiri SV, Lees T. Elastic compression stockings
bundle approach to improve ventilator care processes and reduce ventilator- for prevention of deep vein thrombosis. Cochrane Database of Systematic
associated pneumonia. Joint Commiss J Qual & Patient Safety 2005; 31(5): Reviews 2010; 7.
243–8. 87. Douketis J, Cook D, Meade M et al. Prophylaxis against deep vein thrombo-
60. Clavet H, Hebert PC, Fergusson D, Doucette S, Trudel G. Joint contracture sis in critically ill patients with severe renal insufficiency with the low-
following prolonged stay in the intensive care unit. Can Med Assoc J 2008; molecular-weight heparin dalteparin: an assessment of safety and
178(6): 691–7. pharmacodynamics: the DIRECT study. Arch Intern Med 2008; 168:
61. Jankowski IM. Tips for protecting critically ill patients from pressure ulcers. 1805–12.
Crit Care Nurse 2010; 30(2): S7–9. 88. Griffen M, Kakkos SK, Geroulakos G, Nicolaides AN. Comparison of three
62. Stiller K. Safety issues that should be considered when mobilizing critically intermittent pneumatic compression systems in patients with varicose veins:
ill patients. Crit Care Clin 2007; 23(1): 35–53. a hemodynamic study. Int Angiol 2007; 26(2): 158–64.
63. Timmermann RA. A mobility protocol for critically ill adults. Dimens Crit 89. Lachiewicz PF, Kelley SS, Haden LR. Two mechanical devices for prophylaxis
Care Nurs 2007; 26(5): 175–9. of thromoboembolism after total knee arthroplasty. A prospective, ran-
64. Adam S, Forrest S. ABC of intensive care: other supportive care. BMJ 1999; domised study. J Bone Joint Surg 2004; 86(8): 1137–41.
319(7203): 175–8. 90. Kakkos SK, Griffin M, Geroulakos G, Nicolaides AN. The efficacy of a new
65. Koch SM, Fogarty S, Signorino C, Parmley L, Mehlhorn U. Effect of passive portable sequential compression device (SCD Express) in preventing venous
range of motion on intracranial pressure in neurosurgical patients. J Crit Care statis. J Vasc Surg 2005; 42(2): 296–303.
1996; 11(4): 176–9. 91. Thorpe D, Harrison L. Bowel management: development of guidelines.
66. Brimioulle S, Moraine JJ, Norrenberg D, Kahn RJ. Effects of positioning and Connect 2002; 2(2): 61–5.
exercise on intracranial pressure in a neurosurgical intensive care unit. Phys 92. Hill S, Anderson J, Baker K, Bonson B, Gager M, Lake E. Management of
Ther 1997; 77(12): 1682–9. constipation in the critically ill patient. Nurs Crit Care 1998; 3(3): 134–7.
67. Powers GC, Zentner T, Nelson F, Bergstrom N. Validation of the mobility 93. McKenna S, Wallis M, Brannelly A, Cawood J. The nursing management of
subscale of the Braden Scale for predicting pressure sore risk. Nurs Res 2004; diarrhoea and constipation before and after the implementation of a bowel
53(5): 340–46. management protocol. Aust Crit Care 2001; 14(1): 10–16.
68. Jastremski C. Back to basics: can body positioning really make a difference 94. van Welzen M, Carey T. Autonomic dysreflexia: guidelines for practice.
in the intensive care unit? Crit Care Med 2002; 30(11): 2607–8. Connect 2002; 2(1): 13.
69. Wheeler H. Positioning: one good turn after another? Nurs Crit Care 1997; 95. Powell M, Rigby D. Management of bowel dysfunction: evacuation difficul-
2(3): 129–31. ties. Nurs Stand 2000; 14(47): 47–54.
70. Winkelman C, Peereboom K. Staff-perceived barriers and facilitators. Crit 96. Dorman BP, Hill C, McGrath M, Mansour A, Dobson D et al. Bowel manage-
Care Nurse 2010; 30(2): S13–16. ment in the intensive care unit. Intens Crit Care Nurs 2004; 20(6): 320–29.
71. Jones A, Dean E. Body position change and its effect on hemodynamic and 97. International Foundation for Functional Gastrointestinal Disorders. Stool
metabolic status. J Acute Crit Care 2004; 33(5): 281–90. Form Guideline. 21 April 2005 [Cited October 2005]; Available from: http://
72. Boyle M, Green M. Pressure sores in intensive care: defining their incidence www.aboutconstipation.org/bristol.html.
and associated factors and assessing the utility of two pressure sore risk 98. Riegler G, Esposito I. Bristol scale stool form. A still valid help in medical
assessment tools. Aust Crit Care 2001; 14(1): 24–30. practice and clinical research. Techniques in Coloproctology 2001; 5(3):
73. Weststrate J, Heule F. Prevalence of pressure ulcers, risk factors and use of 163–4.
pressure-relieving mattresses in ICU patients. Connect 2001; 1(3): 77. 99. Robinson CB, Fritch M, Hullett L, Petersen MA, Sikkema S et al.
74. Jackson C. The revised Jackson/Cubbin Pressure Area Risk Calculator. Intens Development of a protocol to prevent opioid-induced constipation in
Crit Care 1999; 15(3): 169–75. patients with cancer: a research utilization project. Clin J Oncol Nurs 2000;
75. Swaderner-Culpepper L. Continuous lateral rotation therapy. Crit Care Nurse 4(2): 79–84.
2010; 30(2): S5–7. 100. Guerrant RL, van Gilder T, Steiner TS, Thielman NM, Slutsker L et al. IDSA:
76. Goddard R. Use of rotational therapy in the treatment of early acute respira- practice guidelines for the management of infectious diarrhea. Clin Infect Dis
tory distress syndrome (ARDS): a retrospective case report. Connect 2004; 2001; 32: 331–50.
3(3): 82–5. 101. Rushdi TA, Pichard C, Khater YH. Control of diarrhea by fiber-enriched diet
77. Kirschenbaum L, Azzi E, Sfeir T, Tietjen P, Astiz M. Effect of continuous in ICU patients on enteral nutrition: A prospective randomized controlled
lateral rotational therapy on the prevalence of ventilator-associated pneu- trial. Clin Nutr 2004; 23(6): 1344–52.
monia in patients requiring long-term ventilatory care. Crit Care Med 2002; 102. Padmanabhan A, Stern M, Wishin J, Mangino M, Richey K, DeSane M. Clini-
30(9): 1983–6. cal evaluation of a flexible fecal incontinence management system. Am J Crit
78. Goldhill DR, Imhoff M, McLean B, Waldman C. Rotational bed therapy to Care 2007; 16(4): 384–93.
prevent and treat respiratory complications: a review and meta-analysis. Am 103. Huang W-C, Wann S-R, Lin S-L, Kunin C, Kung M-H et al. Catheter-associated
J Crit Care 2007; 16(1): 50–62. urinary tract infections in intensive care units can be reduced by prompting
79. Rauen CA, Flynn-Makic MB, Bridges E. Evidence-based practice habits: trans- physicians to remove unnecessary catheters. Infect Control Hosp Epidemiol
forming research into bedside practice. Crit Care Nurse 2009; 29(2): 2004; 25(11): 974–8.
46–59. 104. Marklew A. Urinary catheter care in the intensive care unit. Nurs Crit Care
80. NHMRC. Clinical practice guideline for the prevention of venous thromboembolism 2004; 9(1): 21–7.
(deep vein thrombosis and pulmonary embolism) in patients admitted to Australian 105. Simpson L. Indwelling urethral catheters. Nurs Stand 2001; 15(46): 47–54,
hospitals. Melbourne: National Health and Medical Research Council; 2009. 56.

Essential Nursing Care of the Critically Ill Patient 131

106. Pomfret I. Catheter care in the community. Nurs Stand 2000; 14(27): 133. Lau PY, Chan CWH. SARS (severe acute respiratory syndrome): reflective
46–52. practice of a nurse manager. J Clin Nurs 2005; 14(1): 28–34.
107. NHS Quality Improvement Scotland. Urinary catheterisation and catheter 134. Ho W, Hong Kong Hospital Authority Working Group on SARS Central
care best practice statement. June 2004. [cited November 2010]; Available Committee of Infection Control. Guideline on management of severe acute
from: http://www.nhshealthquality.org/nhsqi/files/PUREMAN_BPW_ respiratory syndrome (SARS). Lancet 2003; 361(9366): 1313–15.
MARCH09.pdf. 135. Chan D. Clinical management of SARS patients in ICU. Connect 2003; 2(3):
108. Mayes J, Bliss J, Griffiths P, Mayes J, Bliss J, Griffiths P. Preventing blockage 76–9.
of long-term indwelling catheters in adults: are citric acid solutions effective? 136. Moore D, Gamage B, Bryce E, Copes R, Yassi A, other members of The B. C.
Brit J Comm Nurs 2003; 8(4): 172–5. Interdisciplinary Respiratory Protection Study Group. Protecting health
109. Getliffe K. The dissolution of urinary catheter encrustation. Brit J Urology care workers from SARS and other respiratory pathogens: organizational
International 2000; 86(4): 60–64. and individual factors that affect adherence to infection control guidelines.
110. Hurst S, Blanco K, Boyle D, Douglass L, Wikas A. Bariatric implications care Am J Infect Control 2005; 33(2): 88–96.
nursing. Dimens Crit Care Nurs 2004; 23(2): 76–83. 137. WHO. Hospital Infection Control Guidance for Severe Acute respiratory Syndrome
111. Pieracci FM, Barie PS, Pomp A. Critical care of the bariatric patient. Crit Care (SARS). 2003 [cited September 2005]; Available from: http://www.who.int/
Med 2006; 34(6): 1796–804. csr/sars/infectioncontrol/en.
112. Puhl R, Brownell KD. Confronting and coping with weight stigma: an inves- 138. Webb SA, Seppelt IM, ANZIC Influenza Investigators. Pandemic (H1N1)
tigation of overweight and obese adults. Obesity 2006; 14: 1802–15. 2009 influenza (“swine flu”) in Australia and New Zealand intensive care.
113. Brown I. Nurses’ attitudes towards adult patients who are obese: literature Crit Care Resus 2009; 11(3): 170–72.
review. J Adv Nurs 2006; 53: 221–32. 139. Cepeda JA, Whitehouse T, Cooper B, Hails J, Jones K et al. Isolation
114. Bejciy-Spring SM. Respect: a model for the sensitive treatment of the bariatric of patients in single rooms or cohorts to reduce spread of MRSA in
patient. Bariatric Nurs Surg Patient Care 2008; 3(1): 47–56. intensive-care units: prospective two-centre study. Lancet 2005; 365(9456):
115. King DR, Velmahos GC. Difficulties in managing the surgical patient who is 295–304.
morbidly obese. Crit Care Med 2010; 38(9): S478–82. 140. Pratt RJ, Pellowea CM, Wilson JA et al. National evidence-based guidelines
116. Hignett S, Griffiths P. Risk factors for moving and handling bariatric patients. for preventing healthcare associated infections in NHS hospitals in England.
Nurs Stand 2009; 24(11): 40–48. J Hosp Infect 2007; 65: S1–64.
117. Nowicki T, Burns C, Fulbrook P, Jones J. Changing the mindset: an inter- 141. Rowley S, Clare S. Improving standards of aseptic practice through an ANTT
disciplinary approach to management of the bariatric patient. Collegian trust-wide implementation process: a matter of prioritisation and care.
2009; 16: 171–5. British J Infect Prevention 2009; 10(1): S18–23.
118. Boyce JR, Ness T, Castroman P, Gleysteen JJ. A preliminary study of the 142. Bayea SC. Nosocomial infections; hand-washing compliance; comparing
optimal anesthesia positioning for the morbidly obese patient. Obes Surg hand hygiene protocols; sensor-operated faucets. Assoc Perioperative Reg
2003; 13(1): 4–9. Nurses J 2003; 77(3): 671–2.
119. NHMRC. Australian Guidelines for the Prevention and Control of Infection in 143. Coffin S, Klompas M, Classen D, Arias K, Podgorny K et al. Strategies to
Healthcare. 2010 [cited November 2010]; Available from: http:// prevent ventilator-associated pneumonia in acute care hospitals. Infect
www.nhmrc.gov.au. Control Hosp Epidemiol 2008; 29(1): S31–40.
120. WHO. Guidelines on Hand Hygiene in Healthcare 2009 [cited November 144. Sole ML. Overcoming the barriers: a concerted effort to prevent ventilator-
2010]; Available from: http://www.who.int/patientsafety/information_ associated pneumonia. Aust Crit Care 2005; 18(3): 92–4.
centre/documents/en/index.html. 145. Lorente L, Lecuona M, Galvan R, Ramos MJ, Mora ML, Sierra A. Periodically
121. Grayson L, Russo P, Ryan K. Hand hygiene Australia manual. Australian Com- changing ventilator circuits is not necessary to prevent ventilator-associated
mission for Safety and Quality in healthcare 2009 [cited November 2010]; pneumonia when a heat and moisture exchanger is used. Infect Control Hosp
Available from: http://www.hha.org.au/. Epidemiol 2004; 25(12): 1077–82.
122. Orsi GB, Raponi M, Franchi C, Rocco M, Mancini C, Venditti M. Surveillance 146. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for pre-
and infection control in an intensive care unit. Infect Control Hosp Epidemiol venting health-care-associated pneumonia, 2003: recommendations of
2005; 26(3): 321–5. CDC and the Healthcare Infection Control Practices Advisory Committee.
123. Troche G, Joly LM, Guibert M, Zazzo JF. Detection and treatment of Morbidity & Mortality Weekly Report Recommendations & Reports 2004; 53(3):
antibiotic-resistant bacterial carriage in a surgical intensive care unit: a 6-year 1–36.
prospective survey. Infect Control Hosp Epidemiol 2005; 26(2): 161–5. 147. Zeitoun SS, De Barros ALB, Diccini S. A prospective, randomized study of
124. Lemmen SW, Zolldann D, Gastmeier P, Lutticken R. Implementing and ventilator-associated pneumonia in patients using a closed vs. open suction
evaluating a rotating surveillance system and infection control guidelines in system. J Clin Nurs 2003; 12(4): 484–9.
4 intensive care units. Am J Infect Control 2001; 29(2): 89–93. 148. Safdar N, Crnich CJ, Maki DG. The pathogenesis of ventilator-associated
125. Haley RW, Culver DH, White JW, Morgan WM, Emori TG et al. The efficacy pneumonia: Its relevance to developing effective strategies for prevention.
of infection surveillance and control programs in preventing nosocomial Respir Care 2005; 50(6): 725–39.
infections in US hospitals. Am J Epidemiol 1985; 121(2): 182–205. 149. Braun BI, Kritchevsky SB, Wong ES, Solomon SL, Steele L et al. Preventing
126. Lim S-M, Webb SAR. Nosocomial bacterial infections in inensive care units. central venous catheter-associated primary bloodstream infections: charac-
I: organisms and mechanisms of antibiotic resistance. Anaesthesiology 2005; teristics of practices among hospitals participating in the evaluation of pro-
60(9): 887–902. cesses and indicators in infection control (EPIC) study. Infect Control Hosp
127. Hardy KJ, Hawkey PM, Gao F, Oppenheim BA. Methicillin resistant staphy- Epidemiol 2003; 24(12): 926–35.
lococcus aureus in the critically ill. Br J Anaesth 2004; 92(1): 121–30. 150. Calandra T, Cohen J. The international sepsis forum consensus conference
128. Martins ST, Moreira M, Furtado GH, Marino CG, Machado FR et al. Applica- on definitions of infection in the intensive care unit. Crit Care Med 2005;
tion of control measures for infections caused by multi-resistant gram- 33(7): 1538–48.
negative bacteria in intensive care unit patients. Mem Inst Oswaldo Cruz 2004; 151. Zuschneid I, Schwab F, Geffers C, Rüden H, Gastmeier P. Reducing central
99(3): 331–4. venous catheter-associated primary bloodstream infections in intensive care
129. Johnson PDR, Martin R, Burrell LJ, Grabsch EA, Kirsa SW et al. Efficacy of units is possible: data from the German nosocomial infection surveillance
an alcohol/chlorhexidine hand hygiene program in a hospital with high system. Infect Control Hosp Epidemiol 2003; 24(7): 501–5.
rates of nosocomial methicillin-resistant staphylococcus aureus (MRSA) 152. Maki DG, Stolz SM, Wheeler S, Mermel LA. Prevention of central
infection. Med J Aust 2005; 183(10): 509–14. venous catheter-related bloodstream infection by use of an antiseptic-
130. Widmer AF, Dangel M. Alcohol-based handrub: evaluation of technique and impregnated catheter: a randomized, controlled trial. Ann Intern Med 1997;
microbiological efficacy with international infection control professionals. 127(4): 257.
Infect Control Hosp Epidemiol 2004; 25(3): 207–9. 153. Hosoglu S, Akalin S, Kidir V, Suner A, Kayabas H, Geyik MF. Prospective
131. Gamage B, Moore D, Copes R, Yassi A, Bryce E. Protecting health care surveillance study for risk factors of central venous catheter-related blood-
workers from SARS and other respiratory pathogens: a review of the infection stream infections. Am J Infect Control 2004; 32(3): 131–4.
control literature. Am J Infect Control 2005; 33(2): 114–21. 154. Berenholtz S, Pronovost P, Lipsett P, Hobson D, Earsing K et al. Eliminating
132. Lee NE, Siriarayapon P, Tappero J, Chen K, Shuey D. SARS Mobile Response catheter-related bloodstream infections in the intensive care unit. Crit Care
Team Investigators. Infection control practices for SARS in Lao People’s Med 2004; 32(10): 2014–20.
Democratic Republic, Taiwan and Thailand: experience from mobile SARS 155. Hanna HA, Raad II, Hackett B, Wallace SK, Price KJ et al. Antibiotic-
containment teams. Am J Infect Control 2004; 32(7): 377–83. impregnated catheters associated with significant decrease in nosocomial

132 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

and multidrug-resistant bacteremias in critically ill patients. Chest 2003; 161. Warren J, Fromm RE, Orr RA, Rotello LC, Horst M. Medicine. ACoCC.
124(3): 1030–38. Guidelines for the inter- and intrahospital transport of critically ill patients.
156. Rickard C, Lipman J, Courtney M, Siversen R, Daley P. Routine changine of Crit Care Med 2004; 32(1): 256–62.
intravenous administration sets does not reduce colonization or infection in 162. Gray A, Bush S, Whiteley S. Secondary transport of the critically ill and
central venous catheters. Infect Control Hosp Epidemiol 2004; 25(8): 650–55. injured adult. Emergency Med J 2004; 21(3): 281–5.
157. Moureau NL, Deschneau M, Pyrek J. Evaluation of the clinical performance 163. Wallace PGM, Ridley SA. ABC of intensive care: transport of critically ill
of a chlorhexidine gluconate antimicrobial transparent dressing. J Infect patients. BMJ 1999; 319(7206): 368–71.
Prevention 2009; 10: S13–17. 164. Waydhas C. Intrahospital transport of critically ill patients. Crit Care
158. College of Intensive Care Medicine Australia and New Zealand. Minimum (London) 1999; 3(5): 83–9.
standards for transport of critically ill patients. 2010 [cited December 2010]; 165. Lovell MA, Mudaliar MY, Klineberg PL. Intrahospital transport of critically
Available from: http://www.cicm.org.au/. ill patients: complications and difficulties. Anaesth Intens Care 2001; 29(4):
159. Australian and New Zealand College of Anaesthetists. Minimum standards 400–405.
for intrahospital transport of critically ill patients; 2003. [Cited November 166. Day D. Keeping patients safe during intrahospital transport. Crit Care Nurse
2010]. Available from: http://www.anzca.edu.au/resources/professional- 2010; 30(4): 18–32.
documents/ps39.html. 167. Chang YN, Lin LH, Chen WH, Liao HY, Hu PH et al. Quality control work
160. Gray A, Gill S, Airey M, Williams R. Descriptive epidemiology of adult critical group focusing on practical guidelines for improving safety of critically ill
care transfers from the emergency department. Emergency Med J 2003; 20(3): patient transportation in the emergency department. J Emerg Nurs 2010;
242–6. 36(2): 140–45.

Psychological Care 7





Leanne Aitken
Rosalind Elliott


often additive or synergistic. While it is important to
Learning objectives ensure that assessment incorporates each of the indivi-
dual concepts, management may often target multiple
After reading this chapter, you should be able to: aspects concurrently.
● implement appropriate evidence-based strategies to reduce
patient anxiety ANXIETY
● describe the different instruments available to assess Anxiety can occur both during and following a period of
sedation needs in critically ill patients and discuss the critical illness. Anxiety has been defined as an unpleasant
benefits and limitations of each emotional state or condition. Within that broad defini-
1
● describe the three subtypes of delirium tion Spielberger recognises two related, but conceptually
● recognise risk factors for the development of delirium in the different constructs, specifically state and trait anxiety.
critically ill Trait anxiety, a personality characteristic, refers to the
● implement and evaluate delirium assessment screening relatively stable tendency of people to perceive stressful
1
instruments for the critically ill situations as stressful or anxiety-provoking. In contrast,
● implement appropriate evidence-based strategies to and of more immediate concern during the care of criti-
manage patients’ sedative needs cally ill patients, is state anxiety, an emotional state that
● integrate best practice into pain assessment and exists at a given moment in time and is characterised by
management ‘subjective feelings of tension, apprehension, nervous-
1
● determine methods to promote rest and sleep for critically ness, and worry’. In addition, activation of the auto-
ill patients nomic nervous system is present during state anxiety.
Factors that have been identified as precipitating anxiety
include: 2,3

Key words ● concern about current illness as well as any underlying
chronic disease
anxiety ● current experiences and feelings such as pain, sleep-
lessness, thirst, discomfort, immobility
delirium ● current care interventions including mechanical ven-
sedation assessment and management tilation, indwelling tubes and catheters, repositioning
sedation protocols and suctioning
pain assessment and pain management ● medication side effects
sleep promotion ● environmental considerations such as noise and light
● concern about the ongoing impact of illness on
recovery.
INTRODUCTION Anxiety has been identified in approximately half of criti-
cally ill patients, with the majority of patients reporting
Care of the psychological health and wellbeing of patients moderate to severe anxiety in most cohorts. Further, the
4-7
is essential in the complex and multifactorial care of presence of anxiety in acute myocardial patients has been
critically ill patients. Patients experience an ongoing reported to be similar across multiple cultures. 4
compromise of their psychological health well beyond
hospitalisation, with this psychological compromise also There are both physiological and psychological responses
affecting their physical health. Aspects of psychological to anxiety, associated with feelings of apprehension,
health most relevant in the care of the critically ill include uneasiness and dread from a perceived threat. These
the recognition and management of anxiety, delirium, responses reflect a stress response and incorporate
sedation needs, pain and sleep. Although each of these avoidance behaviour, increased vigilance and arousal,
concepts is reviewed sequentially through this chapter, in activation of the sympathetic nervous system and release
reality it is often difficult to separate the issues as they are of cortisol from the adrenal glands. The humoral 133
8

134 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



TABLE 7.1 Clinical indicators of anxiety

Physiological Behavioural Psychological/cognitive Social
● ↑ heart rate ● Restlessness ● Confusion ● Seeking reassurance
● ↑ blood pressure ● Agitation ● Anger ● Need for attention/
● Chest pain ● Sleeplessness ● Negative thinking companionship
● ↑ respiratory rate ● Hypervigilance ● Verbalisation of anxiety ● Limiting interaction
● Shortness of breath ● Fighting ventilator ● Facial expression
● Altered O 2 saturation ● Uncooperative ● Inability to retain and process
● Coughing/choking feeling ● Rapid speech information
● ↑ diaphoresis ● Difficulty verbalising
● Pallor ● Distrustful/suspicious
● Cold and clammy ● Desire to leave stressful area
● Dry mouth
● Pain
● Headache
● Nausea and vomiting
● Swallowing difficulty




response, mediated by the hypothalamic-pituitary- The relationship between a patient’s self report of anxiety
adrenal (HPA) axis, regulates this activity. Physiological and clinician assessment of anxiety has been inconsistent.
changes occur to multiple body systems, with the most When chart reviews were undertaken to determine the
relevant including inhibition of salivation and tearing, relationship between clinicians’ routinely documented
constriction of blood vessels, increased heart rate, relax- anxiety and patient self-report of anxiety, no relationship
5
ation of airways, increased secretion of epinephrine and was found. In contrast, when clinicians were prompted
norepinephrine as well as increased glucose production, to assess anxiety in intensive care patients their rating of
8
which all contribute to the range of clinical indicators the severity of anxiety did have moderate correlation with
outlined in Table 7.1. These physiological manifestations patients’ self report of anxiety. 7
illustrate the importance of early identification, active
reduction and minimisation of anxiety in critically ill A number of self-reporting scales exist to measure anxiety
patients. (Table 7.2). These scales require cognitive interpretation
and an ability to communicate responses, which presents
13
Clinical indicators of anxiety are broad and relate to four challenges to many critically ill patients. In addition,
major categories including physiological, behavioural, some of these scales have up to 21 items, making them
psychological/cognitive and social (Table 7.1). 9,10 both time-consuming and unmanageable for regular use
in the critical care setting. Patients with visual and audi-
Appropriate recognition of anxiety is important as there
is beginning evidence that the physiological effects of tory impairments will require additional assistance, such
anxiety can have important effects on outcomes for criti- as larger print, hearing aids or glasses in order to com-
cal care patients. Many of the clinical signs listed in Table plete the forms.
7.1, for example, increased blood pressure and respira- The visual analogue scale–anxiety (VAS–A) is fast and
tory rate, are likely to lead to poorer outcomes for the simple to complete as it is a single-item measure. It has
critically ill patient. In addition, in acute myocardial been evaluated against a recognised anxiety scale (SAI)
infarction patients, in-hospital complications such as with 200 mechanically ventilated patients. The VAS–A
13
recurrent ischaemia, infarction and significant arrhyth- comprises a 100-millimetre vertical line, with the bottom
mias were significantly higher in patients with high levels marker labelled ‘not anxious at all’ and the top marker
of anxiety compared to those with low levels of anxiety. 11 labelled ‘the most anxious I have ever been’. Patients were
able to successfully mark, or indicate, their present level
ANXIETY ASSESSMENT of anxiety.
The importance of anxiety assessment with the aim of The Faces Anxiety Scale, another single-item scale that has
reducing or preventing the adverse effects it produces, is recently been developed by a group of Australian research-
supported by the literature. However, recognition and ers, has five possible responses to assess anxiety (see Figure
interpretation of anxiety is complex, particularly when 7.1). Initial testing with small numbers of critically ill
19
signs and symptoms are masked by critical illness, the patients indicates that the self-reporting single-item scale
effect of medications and/or mechanical ventilation. appears to accurately detect a patient’s anxiety. 20,21
Further, alterations in levels of biochemical markers such
as cortisol and catecholamines that are frequently associ-
ated with anxiety may also be attributed to physiological ANXIETY MANAGEMENT
12
stress. Thus, anxiety rating scales are advocated and Critical care nurses recognise that anxiety is
may offer benefits not found with unstructured clinical detrimental to patients and that anxiety management is
22
assessment. important. Although pharmacological interventions

Psychological Care 135



TABLE 7.2 Anxiety self-report scales TABLE 7.3 Non-pharmacological measures to
reduce anxiety
Scale Number of Items Comments
Nurse-initiated treatments Environmental factors
Hospital 14 (including 7 Easy and fast to complete
Anxiety and anxiety items) Extensively used and Patient massage 26 Provision of natural light 27,28
Depression therefore international
Scale comparisons are Aromatherapy 24,29 Calming wall colours such as
(HADS) 14 available blue, green and violet 27,28
Demonstrated validity 15 Music therapy 2,30-32 Noise reduction with
Depression 21 (including 7 Items measured on scale consideration of alarms,
Anxiety and anxiety items) of 0 (did not apply to paging systems, talking, etc.
Stress Scale me at all) to 3 (applied
21 (DASS to me very much or
21) 16 most of the time)
Demonstrated validity in consent. Beneficial effects that have been reported include
clinical populations 17
lowered blood pressure, heart rate and respiratory rate,
Spielberger 20 items Items measured on a improved sleep and reduced stress, anxiety and pain,
State scale of 1 (not at all) to although as with any therapy, each non-pharmacological
Anxiety 4 (very much so)
Inventory Validity demonstrated in treatment may have different effects on individual
23-25
(SAI) 1 various populations 1 patients, consequently ongoing assessment is essential.
Too long for routine In addition, the safety of these therapies within the criti-
clinical use, but may cal care environment has not been well demonstrated,
be useful in associated necessitating a high level of monitoring through
research
administration.
Visual 1 item 10 cm/100 mm line from
Analogue ‘not at all anxious’ to
Scale ‘very anxious’
– Anxiety Demonstrated validity 18
(VAS–A) Practice tip
Faces Anxiety 1 item 5 possible responses or
Scale 19 ‘faces’ to reflect anxiety Ask your patient or his/her family if he/she likes music to help
Fast and easy to use relax. Have the family bring in a music player with some favou-
Validity has been rite music and headphones. Prepare the patient for a rest
demonstrated in a period. Ensure that pain relief is sufficient, all interventions are
small number of ICU complete, and the patient is comfortable. Assess the anxiety or
cohorts 20,21
level of sedation beforehand and then commence at least 30
minutes of uninterrupted music. Reassess after the session, and
record and report results.





Practice tip
FIGURE 7.1 Faces anxiety scale. Prioritise the assessment and treatment of discomfort, pain
19
and anxiety. This will greatly reduce sedative medication
requirements.

such as anxiolytic and pain-relieving medication are well-
recognised and often-used ways to reduce anxiety,
non-pharmacological treatments are also useful, and can Other strategies to reduce anxiety include interpersonal
be divided into environmental and nurse-initiated interventions such as communication and information
interventions. sharing by the healthcare team and inclusion of family
22
members in care processes. The presence of a family
Non-pharmacological Treatments member can provide additional reassurance and can
An advantage of the non-pharmacological treatments is facilitate communication between the health team and
that they can be nurse-initiated or implemented when patients.
units are designed or refurbished (see Table 7.3). Although
the benefits of non-pharmacological treatments may be Pharmacological Treatment for Anxiety
widely accepted in the community, incorporation of com- Treatment for pain and other reversible physiological
plementary therapies is dependent on their acceptance causes of anxiety and agitation should be a priority.
within the clinical context and appropriate patient Should anxiety and agitation continue despite the

136 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



TABLE 7.4 Anxiety drug therapy

Drug group Drug/dose range Action Side effects Comment
Benzodiazepine Diazepam ● Long-acting metabolites 34 ● Most widely used despite being
sedative 5–10 mg bolus ● Hypotension no longer advocated for regular
● Respiratory depression 35 use in critical care 34
Block encoding on GABA ● No analgesia properties 35
Midazolam receptors 33 ● Less likely to have above ● Useful as continuous infusion
0.5–10 mg/h (infusion) side effects 35 ● Rapid onset
1–2 mg (bolus) ● No analgesia properties
● Amnesic effect 35
Sedative hypnotic Propofol General anaesthetic agent ● Hypotension ● Dedicated intravenous line
agent 25–100 µg/kg/min ● Myocardial depression ● Infusions recommended
(infusion) when given as bolus ● High metabolic clearance
● Reported to affect ● Patients wake quickly once drug
memory is ceased 34
● May cause dreams ● Expensive
Non-benzodiazepine Dexmedetomidine Highly selective alpha 2 - ● Initial hypertension may ● Sedative and analgesic 36
sedative 0.2–1 µg/kg/h adrenoceptor agonist 36 be experienced ● Minimal respiratory depression 38
(infusion) ● Bradycardia may persist 37 ● No amnesic effect 39
● Rapid onset 40
● Infusions preferred 40




incorporation of non-pharmacological interventions, voltage electroencephalography pattern present during
pharmacological treatment with relevant agents may delirium in which slow wave activity is evident even
be initiated. Table 7.4 gives a brief overview of these during wakefulness. 54
medications in the treatment of unrelieved anxiety.
Lethargy, slow quiet speech and reduced alertness are
52
typical behaviours of hypoactive delirium. It is hypo-
DELIRIUM thesised that clinicians may not recognise the ‘quietly’
55
confused patient so the condition may be untreated
Delirium is a significant concern for critically ill patients 56
41
and the clinicians who care for them. It is a category or misdiagnosed as depression. Behaviours evident in
52
42
of central nervous dysfunction where behaviours and hyperactive delirium such as hyperactivity and agitation
physiological responses are not conducive to healing cannot go unnoticed by clinicians and present overt
and recovery. Early detection and treatment of delirium risks of self harm such as unintentional extubation/
is vital, as it is associated with adverse clinical outcomes decannulation and intravenous/arterial device removal.
such as prolonged duration of ventilation, length of Combined delirium is characterised by fluctuations in
ICU and hospital stay and higher rates of morbidity activity and attention levels including the behaviours of
52
and mortality. 43-48 Furthermore increased duration of both hyperactive and hypoactive subtypes.
delirium has been associated with long-term cognitive Reports in the healthcare literature about the prevalence
49
impairment. Arguably the condition has been under- of delirium in ICU vary widely from 15–70%; 57,58 an
50
recognised and under-treated and has only recently unsurprising finding given that it is notoriously difficult
received the attention it deserves. 46,51 Under-recognition to diagnose in patients who are unable to communicate
59
is probably related to a number of factors including the verbally. Rates of delirium in Australian and New
high incidence of the hypoactive subtype as well as lack Zealand ICUs have fallen within this range, with 45% of
of use of formal screening instruments (without which the patients who were in the ICU for longer than 36 hours
exists a high degree of subjectivity when assessing reported to have delirium, while 21% of 56 patients in
60
61
delirium). a smaller study had delirium. The prevalence in other
critical care areas such as emergency departments is
There are three subtypes of delirium: hypoactive, hyper- 62
52
active or combined (a combination of both). A sudden thought to be lower.
reversible reduction in cognitive ability (e.g. inattention, The exact pathophysiology of delirium is not yet fully
reduced problem-solving ability and disorientation) and understood, however, imbalances in brain cholinergic
onset of perceptual disturbances (e.g. hallucinations) and dopaminergic neurotransmitter systems are thought
over hours or days are characteristic of all subtypes of to be responsible. Many predisposing and precipitating
42
delirium. This is in contrast to dementia in which cogni- risk factors have been identified and current opinion sug-
tive decline occurs over months and years. Cognitive and gests that there is an additive effect; patients with more
perceptive ability often fluctuates through the day wors- than one predisposing factor will require less noxious
ening at night. Sleep–wake cycle disturbance is also a precipitating factors to develop delirium than patients
feature of delirium. In addition there is a unique low who have none. Predisposing factors include:
53

Psychological Care 137

● advanced age The ICDSC contains eight items based on the Diagnostic
● dementia and Statistical Manual of Mental Disorders (DSM-IV) cri-
● illicit substance use teria for delirium and was validated in a study conducted
● excessive intake of alcohol within ICU. It has been shown to be simple to use and
69
● smoking easily integrated into existing patient documentation. 60,69
● sensory deficits All features of delirium are incorporated such as sleep
● renal insufficiency pattern disturbances and hypo- or hyperactivity. The
69
● previous cerebral damage first step in using the ICDSC is an assessment of con-
● hypertension scious level using a five point scale (A–E). Only patients
● congestive heart failure who are adequately conscious, that is, responsive to mod-
● a history of depression erate physical stimuli (C–E on the scale), are able to be
● genetic propensity. 44,63,64 assessed. The eight items of the ICDSC are rated present
Precipitating risk factors occur during the course of (1) or absent (0). A score of four or higher is considered
critical illness and may be disease-related or iatrogenic. to be indicative of delirium.
Increased severity of illness is a precipitant of delirium The CAM–ICU has also been shown to be valid for diag-
in ICU. Metabolic, fluid and electrolyte disturbances nosing delirium in the ICU population (see Further
have also been implicated, particularly in the presence reading for more information). Acute onset of mental
65
58
of infection (inflammatory response) or hypoxia. Acute status changes or fluctuating course is assessed using neu-
injuries affecting the central nervous system (and espe- rological observations conducted over the previous 24
cially those manifesting in coma) are predictive of hours. Inattention is tested in patients who are unable to
44
developing delirium. Given the hypothesised mecha- communicate verbally by using either a picture recogni-
nism underpinning delirium, medications that affect tion or a random letter test. Disorganised thinking is
acetylcholine transmission such as atropine and fentanyl assessed by listening to the patient’s speech and for
are potential precipitants. The risk associated with opioid, patients who are unable to verbally communicate, a
benzodiazepine and other psychoactive medication use simple instruction is administered such as asking the
is less clear-cut, 63,66 although ‘emergence’ delirium, a patient to hold up some fingers. Any conscious level other
rare complication during recovery from anaesthesia, is than ‘alert’ is considered ‘altered’. Scores are not derived
thought to be strongly related to the administration from the CAM-ICU; delirium is either present or absent. 58
of benzodiazepines. Sudden cessation of benzodiaz-
67
epines and tricyclic antidepressants and multiple medi-
51
cation administration may lead to delirium. Other PREVENTION AND TREATMENT OF DELIRIUM
iatrogenic factors such as pain, excessive noise levels, As previously stated, prevention and management of risk
sleep deprivation and immobility have the most poten- factors is the mainstay of delirium treatment therefore
tial to be modifiable. Prevention and therapeutic patients’ risk factors should be identified and where pos-
68
management of risk factors is the mainstay of treatment sible modified (even in the absence of delirium). Poten-
for delirium. tial preventative measures include:
● adequate pain relief
● reassurance to reduce anxiety
Practice tip ● judicious use of sedative medications
● correction of the physiological effects of critical illness
Interview the patient or their family to identify predisposing (for example hypoxia, hypotension and fluid and
risk factors for delirium. Document your findings and incorpo- electrolyte imbalance)
rate these into the plan of care. ● treatment of the underlying illness.
Research into preventative interventions has not been
conducted in ICU, however trials conducted in acute
ASSESSMENT OF DELIRIUM care with the elderly show that many risk factors are
The higher morbidity and mortality associated with delir- potentially modifiable. In one trial a multifaceted inter-
ium and the relative ease of assessing its occurrence vention which included: reorientation strategies, a non-
makes it imperative to incorporate relevant assessment in pharmacological sleep regimen, frequent mobilisation,
routine care. Delirium is diagnosed when both the fea- provision of hearing devices and glasses and early treat-
tures of acute onset of mental status changes or fluctuat- ment of dehydration, led to a significant reduction in the
70
ing course and inattention are present, together with incidence of delirium. The creation of environmental
either disorganised thinking or altered level of consci- conditions that are conducive to rest and sleep, in par-
ousness. A practical delirium assessment screening ticular noise reduction and adjusting light levels appro-
instrument for the critically ill cannot be reliant on priate for the time of day, may also help.
patient–assessor verbal communication. Both the Inten- In cases where non-pharmacological strategies have not
sive Care Delirium Screening Checklist (ICDSC) (Figure succeeded medications such as haloperidol and atypical
34
69
71
7.2) and the Confusion Assessment Method for the Inten- antipsychotics (e.g. Olanzapine) are recommended.
58
sive Care Unit (CAM-ICU) (Figure 7.3) have been However it should be noted that firm evidence of the
shown to fulfil these requirements. efficacy of these medications is lacking, any medication

138 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E


PATIENT EVALUATION DAY 1 DAY 2 DAY 3 DAY 4 DAY 5
Altered level of consciousness* (A-E)
If A or B do not complete patient evaluation for the period
Inattention
Disorientation
Hallucination – delusion – psychosis
Psychomotor agitation or retardation
Inappropriate speech or mood
Sleep/wake cycle disturbance
Symptom fluctuation
TOTAL SCORE (0-8)
Score
Level of consciousness*: A: no response none
B: response to intense and repeated stimulation (loud voice and pain) none
C: response to mild or moderate stimulation 1
D: normal wakefulness 0
E: exaggerated response to normal stimulation 1
SCORING SYSTEM:
The scale is completed based on information collected from each entire 8-hour shift or from the previous 24 hours,
Obvious manifestation of an item = 1 point. Nomanifestation of an item or no assessment possible = 0 point.
The score of each item is entered in the corresponding empty box and is 0 or 1.
1. Altered level of consciousness:
A) No response or B) the need for vigorous stimulation in order to obtain any response signified a severe alteration in
the level of consciousness precluding evaluation. If there is coma (A) or stupor (B) most of the time period than a
dash (-) is entered and there is no further evaluation during that period.
C) Drowsiness or requirement of a mild to moderate stimulation for a response implies an altered level of
consciousness and scores 1 point.
D) Wakefulness or sleeping state that could easily be aroused is considered normal and scores no point.
E) Hypervigilance is rated as an abnormal level of consciousness and scores 1 point.
2. Inattention: Difficulty in following a conversation or instructions. Easily distracted by external stimuli
Difficulty in shifting focuses. Any of these scores 1 point.
3. Disorientation: Any obvious mistake in time, place or person scores 1 point.
4. Hallucination, delusion or psychosis: The unequivocal clinical manifestation of hallucination or of behaviour
probably due to hallucination (e.g, trying to catch a non-existent object) or delusion. Gross impairment in reality
testing. Any of these scores 1 point.
5. Psychomotor agitation or retardation: Hyperactivity requiring the use of additional sedative drugs or restraints in
order to control potential dangerousness (e.g, pulling out IV lines, hitting staff), Hyperactivity or clinically noticeable
psychomotor slowing. Any of these scores 1 point.
6. Inappropriate speech or mood: Inappropriate, disorganised or incoherent speech. Inappropriate display of emotion
related to events or situation. Any of these scores 1 point.
7. Sleep/wake cycle disturbance: Sleeping less than 4 hours or waking frequently at night (do not consider wakefulness
initiated by medical staff or loud environment). Sleeping during most of the day. Any of these scores 1 point.
8. Symptom fluctuation: Fluctuation of the manifestation of any item or symptom over 24 hours (e.g, from one shift to
another) scores 1 point.
FIGURE 7.2 Intensive care delirium screening checklist. 69


designed to enhance cognition has the potential to make While adequate sedation is essential for all patients, it is
it worse and there are many unwanted side effects (e.g. paramount for those receiving muscle relaxants. In asso-
Q-T interval prolongation). Therefore any psychoactive ciation with sedation management, it is essential that
medication should be used judiciously in the critically ill. adequate pain relief and anxiolysis is provided to all criti-
cally ill patients.
SEDATION
Maintaining adequate levels of sedation is a core compo- ASSESSMENT OF SEDATION
nent of care in critical care environments, where patients Assessment of the effect of all sedative treatments is
are treated with invasive and difficult-to-tolerate proce- essential. When pharmacological agents are used there is
dures and treatments. A primary aim of nursing critically always a risk of over- or undersedation, and both can have
ill patients is to provide comfort, and adequate sedation significant negative effects on patients. Oversedation
is fundamental to this. Individualising sedation manage- can lead to detrimental physiological effects including
ment is crucial to the effective management of each cardiac, renal and respiratory depression and can result
patient, with accurate assessment a core nursing skill. in longer duration of mechanical ventilation, associated

Psychological Care 139

CAM-ICU Worksheet

Feature 1: Acute Onset or Fluctuating Course Positive Negative
Positive if you answer ‘yes’ to either 1A or 1B.
1A: Is the patient different than his/her baseline mental status? Yes No
Or
1B: Has the patient had any fluctuation in mental status in the past 24 hours
as evidenced by fluctuation on a sedation scale (e.g. RASS), GCS, or
previous delirium assessment?
Feature 2: Inattention Positive Negative
Positive if either score for 2A or 2B is less than 8.
Attempt the ASE letters first. If patient is able to perform this test and the score
is clear, record this score and move to Feature 3. If patient is unable to perform
this test or the score is unclear, then perform the ASE Pictures. If you perform
both tests, use the ASE Pictures’ results to score the Feature.
2A: ASE Letters: record score (enter NT for not tested) Score (out of 10):______
Directions: Say to the patient, “I am going to read you a series of 10 letters. Whenever
you hear the letter ‘A’, indicate by squeezing my hand.” Read letters from the following
letter list in a normal tone.
SAVEAHAART
Scoring: Errors are counted when patient fails to squeeze on the letter “A” and when the
patient squeezes on any letter other than “A”.
2B: ASE Pictures: record score (enter NT for not tested) Score (out of 10):______
Directions are included on the picture packets.
Feature 3: Disorganised Thinking Positive Negative
Positive if the combined score is less than 4
3A: Yes/No Questions Combined Score (3A + 3B):
(Use either Set A or Set B, alternate on consecutive days if necessary): ______ (out of 5)
Set A Set B
1. Will a stone float on water? 1. Will a leaf float on water?
2. Are there fish in the sea? 2. Are there elephants in the sea?
3. Does one pound weigh more than 3. Do two pounds weigh
two pounds? more than one pound?
4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood?
Score___(Patient earns 1 point for each correct answer out of 4)
3B: Command
Say to patient: “Hold up this many fingers” (Examiner holds two fingers in
front of patient) “Now do the same thing with the other hand” (Not repeating
the number of fingers). (If pt is unable to move both arms, for the second part of
the command ask patient “Add one more finger)
Score___(Patient earns 1 point if able to successfully complete the entire command)
Feature 4: Altered Level of Consciousness Positive Negative
Positive if the Actual RASS score is anything other than “0” (zero)
Overall CAM-ICU (Features 1 and 2 and either Feature 3 or 4): Positive Negative

58
FIGURE 7.3 Confusion Assessment Method – Intensive Care Unit. Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved.



complications and recovery. 72,73 Undersedation has the (Figures 7.4 and 7.5). A number of different sedation
opposite effect on the cardiac system, with hypertension, scales have been developed for use in the intensive care
tachycardia, dysrhythmias, ventilator dyssynchrony, agita- environment (Table 7.5). Essential requirements of effec-
tion and distress, with the potential for incidents con- tive sedation scales include that it measures what is
cerning patient safety. 72,73 There is some evidence that intended, is reliable and is easy to use. 75
heavy sedation is associated with psychological recovery,
particularly in relation to delusional memories. 74 Bispectral index (BIS) monitoring is an assessment tool
that provides an objective measure of sedation. It uses a
Objective sedation scales provide an effective method of self-adhesive pad secured to the patient’s forehead to con-
assessing and monitoring a patient’s level of conscious- tinuously record cortical activity that is scored on a scale
ness or arousal, as well as to evaluate parameters such as from 0 (absence of brain activity) to 100 (completely
cognition, agitation and patient-ventilator synchrony awake). There is not yet consensus on the most

140 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



Richmond Agitation Sedation Scale (RASS)*
Sore Term Description
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
+1 Restless Anxious but movements not aggressive vigorous
0 Alert and calm
−1 Drowsy Not fully alert, but has sustained awakening
(eye-opening/eye contact) to voice (≥10 seconds) Verbal
−2 Light sedation Briefly awakens with eye contact to voice (<10 seconds) Stimulation
−3 Moderate sedation Movement or eye opening to voice (but not eye contact)
−4 Deep sedation No response to voice, but movement or eye opening Physical
to physical stimulation Stimulation
−5 Unarousable No response to voice or physical stimulation
Procedure for RASS Assessment
1. Observe patient
a. Patient is alert, restless, or agitated. (score 0 to +4)
2. If not alert, state patient’s name and say to open eyes and look at speaker.
b. Patient awakens with sustained eye opening and eye contact. (score −1)
c. Patient awakens with eye opening and eye contact, but not sustained. (score −2)
d. Patient has any movement in response to voice but no eye contact. (score −3)
3. When no response to verbal stimulation, physically stimulate patient by
shaking shoulder and/or rubbing sternum.
e. Patient has any movement to physical stimulation. (score −4)
f. Patient has no response to any stimulation. (score −5)

77
FIGURE 7.4 Richmond Agitation–Sedation Scale.


The Vancouver Interaction and Calmness Scale
Strongly Mildly Mildly Strongly
Interaction Score /30 agree Agree agree disagree Disagree disagree
Patient interacts 6 5 4 3 2 1
Patient communicates 6 5 4 3 2 1
Information communicated by patient is reliable 6 5 4 3 2 1
Patient cooperates 6 5 4 3 2 1
Patient needs encouragement to respond to questions 1 2 3 4 5 6
Strongly Mildly Mildly Strongly
Calmness Score /30 agree Agree agree disagree Disagree disagree
Patient appears calm 6 5 4 3 2 1
Patient appears restless 1 2 3 4 5 6
Patient appears distressed 1 2 3 4 5 6
Patient is moving around uneasily in bed 1 2 3 4 5 6
Patient is pulling at lines/tubes 1 2 3 4 5 6
80
FIGURE 7.5 Vancouver Interactive and Calmness Scale.

appropriate level of activity for intensive care patients or patient care with prearranged outcomes. Protocol directed
what role BIS might offer in their care. 81,82 Continued sedation is ordered by a doctor, contains guidance regard-
studies to evaluate the efficacy of BIS are required. ing sedation management, and is usually implemented
by nurses although it may have input from pharmacists
or other members of the health care team. Aspects of
SEDATION PROTOCOLS sedation management that are incorporated into seda-
The sedation needs of patients are complex, with various tion protocols include:
reports of patients receiving sub-optimal care and incon- ● the sedation scale to be used, as well as frequency of
sistent practice in this area. 72,83 One of the responses to assessment
this gap in nursing practice has been the development of ● an algorithm-based process for selecting the most
protocols.
appropriate sedative agent
Sedation protocols offer a framework, or algorithm, ● the range of sedative agents that might be considered
within which health professionals can manage specific and associated administration guidelines

Psychological Care 141



TABLE 7.5 Sedation scales

Scale Description Comment
Ramsay sedation scale 76 ● Scores from 1 (agitated/restless) to 6 (no ● Easy to administer
response) ● No differentiation between different levels of anxiety,
● 4 levels of sedation, 1 level of ‘cooperative, restlessness and agitation
oriented and tranquil’ and 1 level of ‘anxious, ● Unable to distinguish between a light plane of
agitated or restless’ unconsciousness and a deep coma
● Lack of clarity between each score
Richmond Agitation– ● Scores from −5 (unarousable) to +4 (combative) ● Assesses patient’s responses in relation to the type of
Sedation Scale ● 4 levels of agitation, 1 level for ‘calm and alert’, stimulus given (i.e. verbal or physical), plus consideration
(RASS) 77 5 levels of sedation of cognition and sustainability
● Good inter-rater reliability
Sedation – Agitation ● Scored from 1 (unarousable) to 7 (dangerous ● Good inter-rater reliability
Scale (SAS) 78 agitation) ● Multiple criteria for each level which, although increase
● 3 levels of agitation, 1 level of ‘calm and complexity, result in better discrimination between scores
cooperative’, 3 levels of sedation
Motor Activity ● Scored from 0 (unresponsive) to 6 (dangerously ● Very similar to SAS
Assessment Scale agitated) ● Limited psychometric testing
(MAAS) 79 ● 3 levels of agitation, 1 level of ‘calm and ● Multiple criteria for each level which, although increase
cooperative’, 3 levels of sedation complexity, result in better discrimination between scores
Vancouver Interactive ● Two domains (interaction and calmness) each ● Thorough assessment of calmness (in contrast to
and Calmness Scale containing five questions agitation) with multiple levels of scoring available
(VICS) 80 ● Each question is scored on a 6 point scale from ● Differentiation between each of the points on the 6 point
‘strongly agree’ to ‘strongly disagree’, resulting scale difficult
in a potential total score of 30 for each domain




● when to commence, increase, decrease or cease use of Pain is almost certainly a sensation widely experienced
sedative agents by critical care patients as it is one of the stressors most
● when to seek review by a medical officer. commonly reported by critically ill patients. 85,86 Arguably
pain management is often not afforded the same empha-
Many sedation protocols will also incorporate an analge- sis as more ‘life-threatening’ conditions such as haemo-
sia component. dynamic instability in critical care. However its alleviation
The aim of sedation protocols is to improve sedation is an essential element of critical care nursing. Myths such
management by encouraging regular discussion of seda- as the possibility that patients may become addicted to
tion goals among the healthcare team, while enabling analgesics and the very young and elderly having higher
nurses to manage the ongoing sedative needs of the tolerance for pain and our cultural tendency to reward
patient. Not all patients’ sedative needs will be met within high pain tolerance may lead to inadequate pain manage-
the sedation protocol; in these instances specific care ment. This is evidenced by a study performed in post-
should be planned and implemented by the multi- coronary bypass surgery patients. Nurses administered
disciplinary healthcare team. only 47% of the patient’s prescribed analgesic medica-
Although sedation protocols have widespread support, tion, and yet these patients reported moderate to severe
87
there is mixed evidence regarding the benefits of imple- pain. In critical care, nurses assume a fairly autonomous
mentation of such protocols. A number of studies have role in titrating pain-relieving medication. With this
demonstrated the benefits associated with nurse-led seda- increased autonomy comes a responsibility to be knowl-
tion protocols, yet other studies do not demonstrate a edgeable and aware of effective pain management and
84
benefit. Until further research is undertaken, sedation assessment of the ‘fifth vital sign’.
protocols should be implemented on a local basis where
current practice conditions indicate potential benefit PATHOPHYSIOLOGY OF PAIN
from standardisation of care. Appropriate evaluation
of the impact of protocol implementation should be Pain is defined as ‘an unpleasant sensory and emotional
undertaken. experience associated with actual or potential tissue
damage …’. 88, p. 250 Although unpleasant it has a role in
PAIN protecting against further injury. There are three catego-
89
ries of pain receptors or nociceptors: mechanical nocicep-
Pain is an unobservable, inherently subjective, experi- tors, that respond to damage such as cutting and crushing;
ence. The nebulous multifaceted nature of pain has led thermal nociceptors, that respond to temperature; and
to significant difficulties in not only understanding the polymodal nociceptors, that respond to all types of
mechanisms underlying the experience for individuals stimuli including chemicals released from injured tissue.
but also assessing and managing the phenomenon. Prostaglandins released from fatty acids in response to

142 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

tissue damage reduce the threshold for activation of the Whenever patients cannot verbally communicate other
nociceptors. 89 strategies must be established and used consistently. For
example strategies involving nodding, hand movements,
Pain is transmitted to the central nervous system via one
of two pathways. The fast pain pathway occurs where the facial expressions, eye blinks, mouthing answers and
stimuli are carried by small myelinated A-delta fibres, writing can be highly effective, not only for the self-
producing a sharp, prickling sensation that is easily assessment of pain but also to express other feelings and
localised. The slow pathway acts in response to polymo- concerns. In extremely challenging cases when there is
dal nociceptors, is carried by small unmyelinated C fibres, very limited motor function but the patient is cognitively
and produces a dull, aching or burning sensation. It is able, the speech pathologist may be able to advise on
difficult to locate, acts after fast pain, and is considered alternative communication strategies.
to be more unpleasant than fast pain. 89 If at all possible, a history of the patient’s health status,
including any existing painful conditions, should be
Perceptions of pain are thought to occur in the thalamus, taken. A family member or close friend may be willing to
whereas behavioural and emotional responses occur in assist if the patient is unable to provide one. Quite apart
89
the hypothalamus and limbic system. Perceptions of from the presenting condition which may be painful
pain are influenced by prior experience, and by cultural many critical care patients have significant co-morbidities
and normative practices, and help to explain individual such as rheumatoid/osteoarthritis and chronic back pain.
reactions to pain. 89
It is imperative that the patient’s usual pain management
There are negative physiological effects of pain that strategies are identified and implemented if possible. For
include a sympathetic response with increased cardiac example, factors that relieve the pain or increase its inten-
work, thus potentially compromising cardiac stability. sity should be recorded, along with its relationship to
90
Respiratory function may be impaired in the critically ill daily activities such as sleep, appetite and physical ability.
undergoing surgical procedures where deep-breathing
and coughing is limited by increased pain, thus reducing Regardless of the patient’s communication capability,
airway movement and increasing the retention of strategies to ensure consistent objective assessment and
secretions and possibility of nosocomial pneumonia. management should be implemented. Laminated cards
Other known effects of unrelieved pain are nausea and displaying body diagrams, words to describe pain and
vomiting. pain intensity measures (including visual analogues and
numerical scales) are useful instruments in meeting these
Adverse psychological sequelae of poorly-treated pain requirements. Verbal numerical scale and visual analogue
include diminished feelings of control and self-efficacy scales (VAS) are commonly used. These are outlined in
and increased fear and anxiety. Inattention with an inabil- Table 7.6. Visual analogue scales can be difficult to
ity to engage in rehabilitation and health-promoting administer to critically ill patients however a combined
activities is not uncommon. Pain is commonly cited by VAS and numerical scale includes the benefit of a visual
patients as a significant negative memory of their ICU cue with the ability to quantify pain intensity.
experience. 85,86,91 The long-term effects of pain are not Other physiological and behavioural pain indicators may
clearly understood but they almost certainly impact on be used to assess pain in less responsive or unconscious
92
recovery and may even lead to worsening chronic pain. patients. Research indicates that consistent assessment
95
When these unwanted outcomes are considered along- of a number of indicators together provides an adequate
side the physiological effects of poorly treated pain, the substitute for self-assessments. 95,96 Several instruments
vital importance of pain management is evident.
have been developed and validated for use in the critically
ill adult patient including the Behavioural Pain Scale
PAIN ASSESSMENT (BPS) (see Figure 7.6), Checklist of Nonverbal Pain Indi-
97
‘Pain is whatever the experiencing person says it is, exist- cators (CNPI) and the Critical Care Pain Observation
98
ing whenever he says it does’. 93, p. 26 The nebulous quality Tool (CPOT) (see Table 7.6). Briefly, scores are assigned
99
and subjective nature of the pain experience leads to to categories such as altered body movements, restlessness
considerable problems in assessing it. Compounding this and synchronisation with the ventilator, providing
is the challenge of assessment in the critically ill who a global score for comparison after pain relief interven-
often have insufficient cognitive acumen to articulate tions. The BPS is one of the most widely used scales for
their needs and an inability to communicate verbally. A use in patients unable to communicate verbally. 97,100,101
common language and process in which to assess pain is
essential in ameliorating some of these challenges. Fur- Nurses are urged against solely relying on changes in
thermore, accurate assessment and consistent recording physiological parameters, including cardiovascular (ele-
are fundamental aspects of pain management. Without vated blood pressure and heart rate) and respiratory
these vital components, it is impossible to evaluate inter- recordings, as other pathophysiological or treatment
95
ventions designed to reduce pain. 94 related factors may be responsible. Classic reactions
such as increased heart rate and blood pressure, to stress-
Since the pain experience is subjective, all attempts should ors, e.g. pain, do not always occur in ICU patients and are
be made to facilitate the patient to communicate the therefore unreliable methods of assessing pain in this
104
nature, intensity, body part and characteristics of their patient group. A potential explanation is that auto-
pain. For example the patient’s usual communication nomic tone may be dysfunctional in a large proportion of
105
aids such as glasses and hearing aid should be used. ICU patients. In haemodynamically-stable long-term

Psychological Care 143



TABLE 7.6 Pain scales

Scale Description Comments
Verbal numeric scale ● Self-rating scale ● Patient has to be able to communicate verbally
● Single-item scale ● Needs to understand concept of rating pain
● Scale from 0 (no pain) to 10 (worst pain ever) ● Dependent on prior pain experiences
● Simple, easy to use
Visual Analogue ● Self-rating scale ● Patient can communicate by pointing
Scale (VAS) ● Single-item ● Needs to understand concept of rating pain
● A horizontal line with equal divisions is used for the ● Dependent on patient’s prior pain experiences
patient to rate current pain level (no pain is on far left and ● Simple, easy to use
worst pain is far right)
McGill short pain ● Measures quality of pain ● Gives more information about the patient’s pain 103
questionnaire 102 ● Uses 15 descriptor words to measure sensory effect of pain ● Takes longer to administer
● Can be used in conjunction with a pain intensity scale
Behavioural Pain ● Based on pain related behaviours: the sum of three items ● Patient does not have to communicate
Scale (BPS) (Figure ● Higher scores indicate higher pain intensity (range: 3–12) ● Simple, easy to use
7.6) 97 ● Includes ‘ventilator compliance’ (may no longer be
relevant for pain assessment when using modern
ventilators)
Checklist of ● Developed for cognitively impaired adults ● Patient does not have to communicate
Nonverbal Pain ● Based on the presence/absence of five non-verbal pain ● Simple, easy to use
Indicators (CNPI) 98 behaviours (one is non-verbal vocalisation, e.g. groaning) ● No patient report at all
and verbal complaints ● Not as reliable for immobile patients 98
● Score 0 to 6 (score of 1 allocated for the presence of a pain
behaviour/verbal complaint), higher scores indicate more
pain
Critical Care Pain ● Based on previously developed instruments using pain ● Patient does not have to communicate
Observation Tool related behaviour to assess pain, e.g. BPS ● Simple, easy to use
(CPOT) 99 ● Four items: facial expression, body movements, muscle ● Includes ‘ventilator compliance’ (may no longer be
tension and compliance with ventilator or vocalisation relevant for pain assessment when using modern
● Higher scores indicate more pain (range: 0–8) ventilators) or vocalisation in extubated patients




Item Description Score
Facial expression Relaxed 1
Partially tightened (e.g. brow lowering) 2
Fully tightened (e.g. eyelid closing) 3
Grimacing 4
Upper limbs No movement 1
Partially bent 2
Fully bent with finger flexion 3
Permanently retracted 4
Compliance with ventilation Tolerating movement 1
Coughing but tolerating ventilation for most of the time 2
Fighting ventilator 3
Unable to control ventilation 4
FIGURE 7.6 Behavioural pain scale.
97


critical patients, vital signs may be useful if used in con- PAIN MANAGEMENT
junction with other forms of assessment. 95
Although pain management is discussed here indepen-
In addition it is particularly important to regularly dently, in practice pain management is often combined
consider and search for potential sources of pain in with sedative administration to reduce anxiety. However
un responsive patients and those who are unable to com- pain management should always be the first goal for
municate. Nurses are implored to assume pain is present achieving overall patient comfort. Efforts to improve
if there is a reason to suspect pain. If pain is suspected an patient comfort for intubated patients favour the
94
analgesic trial may assist in diagnosing sources of pain. concurrent use of both forms of medication. This
As a general rule, analgesia medication should be admin- practice therefore makes it difficult to assess the single
istered to patients who are heavily sedated or receiving effect of each medication on the patient’s pain, and
muscle relaxants as a precaution. highlights its multidimensional properties. In addition to

144 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

pharmacological treatment of pain, non-pharmacological
strategies can prove effective as an adjunct to drug therapy TABLE 7.7 Non-pharmacological treatment for pain
or as an alternative.
Pain relief may be required for preexisting injuries or prior Comfort measures Diversional measures
to specific procedures to prevent its occurrence. Being ● Repositioning 34 ● Relaxation
turned is often cited as the most painful procedure, ● Oral and endotracheal suctioning ● Breathing exercises
however wounds, drain removal, tracheal suction, femoral ● Mouth, oral and/or wound care ● Visual imagery 107
catheter removal, placement of central-line catheter and ● Reassurance and information ● Music therapy
● Massage
non-burn wound dressings, and coughing may also cause ● Heat or cold therapy 34
considerable discomfort. 90,103 Guidelines and written pro-
tocols for procedures such as femoral sheath removal and
insertion of central-line catheter, can significantly reduce Non-Pharmacological Treatment for Pain
pain intensity as they often contain reminders to provide
106
analgesia. Some procedures, such as insertion of a Non-pharmacological strategies to reduce pain are linked
central-line catheter, require additional pain management to some key strategies to reduce stress. Excessive pain may
considerations such as administration of local anaes- lead to stress as the body attempts to maintain homeo-
thetic. This highlights the potential need for additional stasis and stress can exacerbate pain. Strategies to reduce
pain protocols linked to key standard procedures (e.g. stress and pain include both comfort measures and diver-
patient turning) to reduce patients’ pain experience. sional interventions, which require the critical care nurse
to individualise and adapt strategies to match the patient’s
Pain relieving medication can be given by a number of needs and preferences. Diversional methods may include
routes, including oral, enteral feeding tube, intravenous, strategies to distract the patient, and aim to refocus the
rectal, topical, subcutaneous, intramuscular, epidural and patient’s thinking away from the pain and on to other
intrathecal. For all routes of administration, assessment more pleasant thoughts or activities. Table 7.7 lists some
of the patient’s suitability and contraindications for use interventions that may prove effective.
is an essential part of the decision-making process.
Patient-controlled analgesia for intravenous and, more Non-pharmacological interventions have the benefit of
recently, epidural analgesia is commonly part of critical being nurse-initiated, non-invasive and able to be person-
care nursing. alised for each patient. These strategies alone may not
achieve a pain-free experience but they have the capacity
Epidural pain management requires additional evalua- to enhance the effects of analgesic medication and huma-
tion, including sensory and functional assessment, due nise the critically ill patient’s experience.
to the use of local anaesthetic agents in addition to opioid
drugs. Sensory function should be regularly checked Pharmacological Treatment for Pain
using a dermatome chart to gauge segments that are Pharmacological treatment for pain in critically ill patients
blocked by the local anaesthetic agent. In addition to centres on opioid drugs which act as opioid agonists
sensory blockade, regular assessment for lower limb binding to the µ-receptors in the brain, central nervous
motor deficit is required to detect changes in motor system and other tissues. Opioid drugs have a rapid
88
response, which may impair ability to mobilise safely. action, are readily titrated and their metabolites, if
Sudden or subtle changes may also indicate a complica- present, are less likely to accumulate. Morphine sulphate
tion such as epidural haematoma. The Bromage Assess- and fentanyl are routinely used in critical care, and their
ment Scale is often used for assessing motor response. properties, side effects and nursing implications are out-
Regular checks of the catheter site are essential to identify lined in Table 7.8. For ischaemic chest pain, nitrates will
complications such as bleeding, haematoma and infec- be used together with morphine sulphate as first-line
tion early but also to ensure catheter patency. Intrathecal pain measures (see Chapter 10).
administration of analgesic medications has similar con-
traindications and complications to epidural analgesia Other medications such as non-steroidal anti-
and requires similar precautions. It is important to note inflammatory drugs (NSAIDs) act by inhibition of an
that intrathecal (as compared to intravenous) administra- enzyme within the inflammatory cascade, and may
tion does not eliminate all of the side effects of opioids produce analgesia (especially when combined with
(see Further reading). opioids) for bone and soft tissue injuries. As with all
medication, side effects and contraindications for use can
be serious and, in the case of NSAIDs, include gastroin-
Practice tip testinal bleeding, renal insufficiency and exacerbation of
asthma. Paracetamol is another medication that may be
Epidural administration of medication does not preclude
mobilisation. However certain safety measures should be highly effective for mild pain and when combined with
taken. Ensure that the epidural catheter is well secured: view opioid medications provides analgesia for bone and soft
the site before mobilising and apply extra tape. Monitor blood tissue injuries.
pressure and heart rate before and during the initial stages of An alternative to opioid medication for procedural pain
mobilising. Two health care personnel should assist during the is ketamine. 108,109 Single doses of the medication are effec-
first attempt to mobilise. tive in achieving analgesia during severely painful inter-
ventions such as deep wound care (for example, a burn

Psychological Care 145



TABLE 7.8 Analgesics

Drug/drug dose Properties Side Effects Nursing implications
Morphine sulphate ● Water-soluble ● Vasodilatory effect ● Intermittent doses rather the
1–10 mg/h (IV infusion), ● Peak effect 30 min ● Decreased gastric motility need for continuous
1–4 mg (IV bolus) ● Half-life: 3–7 h ● Respiratory depression infusions 34
● Sedative effect and release of ● Nausea and vomiting 89
histamines 34
Fentanyl 25–200 µg/h (IV ● Lipid-soluble ● Respiratory depression Useful where:
infusion), 25–100 µg/h (IV ● Synthetic opioid ● Bradycardia ● Hypotension or tachycardia
bolus) ● 80–100 times more potent than ● Muscular rigidity needs to be avoided
morphine ● Gastric and/or histamine side
● Peak effect in 4 min effects occur with morphine
● Half-life: 1.5–6 h 90
Tramadol hydrochloride ● Soluble in water and ethanol ● Nausea, vomiting ● Intermittent doses only
100 mg (IV bolus), then ● Synthetic ● Dizziness, dry mouth
50–100 mg 4–6/24 ● Centrally acting opioid-like ● Headache
analgesic ● Sweating
NSAIDs ● Analgesia and antipyretic ● Gastrointestinal ● Oral or rectal
● Some have anticoagulant ● Renal clearance
side effects
Ketamine 20 mg (IV bolus), ● Analgesic and dissociative ● Hypertension and ● Use for painful procedures e.g.
then 10–20 mg every anaesthetic for painful procedures respiratory depression wound dressings
5–10 min 89 ● Onset of action 1–2 min (administer slowly) ● Administer 2 mg of midazolam
● Analgesic/anaesthetic effects last ● Increased intracranial at the start of the procedure or
5–15 min pressure continue midazolam infusion
● Half-life 3 h ● Hallucinations to minimise the dysphoric and
hallucinogenic side effects
NSAIDs = non-steroidal anti-inflammatory drugs



injury). Ketamine is usually administered in conjunction with very few experiencing deep or rapid eye movement
with midazolam to reduce any potential emergent effects. sleep. 114-116 Sleep is highly disrupted and distributed
across 24 hours with roughly equal amounts occurring in
Pain relief is a primary goal for critical care nursing and 117
requires regular assessment of pain intensity using reli- the day and at night. These findings obtained using
able, objective, patient friendly instruments. No single polysomnography (PSG) have been corroborated by
118
medication is ideal for all patients, and clinicians need patients’ self reports of their sleep in critical care.
to carefully select, monitor and titrate the doses of any Patients consistently rate the overall quality of their sleep
agent selected. In the case of, for example, cardiac surgery as poor and more specifically they report light sleep with
patients, patient-controlled analgesia may provide the frequent awakenings and considerable difficulty falling
119-121
most effective pain management strategy (see Chapter asleep and returning to sleep. Many factors are
12). Non-pharmacological strategies add to the relief of thought to affect the patient’s ability to sleep, including
pain and come under the domain of nursing care. Without discomfort, treatment, medications, environmental noise
117,122
adequate pain management, patients will be unable to and illness.
achieve adequate rest and sleep, both essential to healing Sleep in the healthy adult comprises one consolidated
processes and wellbeing. period of 6–8 hours (mean 7.5 hours) in each 24 hour
period occurring at night according to natural circadian
rhythms. 123 There are two main sleep states; rapid eye
SLEEP movement sleep (REM) (approximately 25% of total
sleep time [TST]) and non-rapid eye movement sleep
The function of sleep is not yet fully understood however (non-REM) (approximately 75% of TST). Non-REM sleep
it is considered to be required for many bodily func- is comprised of 4 stages*; stages 1 and 2 or light
110
tions. It is vital for wellbeing and sleep disruption or sleep and stages 3 and 4 or slow wave sleep (SWS) or
deprivation leads to psychological and physical ill deep sleep, which must be completed in sequence in
health. 111-113 Sleep is considered to be physically and psy- order to enter REM sleep. The consolidated sleep period
chologically restorative and essential for healing and consists of 4 to 6 sleep cycles; stages 1–4 followed by REM
recovery from illness. Arguably critically ill people are in
greater need of undisrupted sleep but are more likely to
experience poor quality sleep. *More recent sleep staging guidelines have combined stages 3 and 4 so that there
Evidence suggests that although critically ill patients may are now only 3 stages of non-REM sleep. 162 However the system has not yet been
widely adopted and up to the date of publishing, few studies published on sleep
experience normal quantities of sleep, the quality is poor in critical care have used the system.

146 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

sleep, that lasts 60–90 minutes. Time spent awake during critical care. Actigraphy is another method of recording
the sleep period is less than 5% of TST. 123 All sleep stages sleep that has been attempted in the critically ill. Modern
are important to health and unfortunately critically actigraphs are small wristwatch devices (they may also be
ill patients commonly experience very little deep or located on the trunk or leg) containing accelerometers
REM sleep. that detect motion in a single axis or multiple axes. 127,128
Data obtained from actigraphy provides an over-
There are changes in sleep architecture over the adult
lifespan which require consideration in the context of estimation of sleep time (critically patients are typically
critical care nursing. TST and percentage of SWS decline immobile for long periods regardless of sleep state). The
(TST by 10 minutes and SWS by 2% per decade) and light other objective method which has been attempted in
129,130
sleep increases slightly (only by 5% between 20 and 70 critical care is BIS monitoring. At present, consider-
years) with age. 124 REM sleep remains fairly constant with able algorithm development using comparisons with
an approximate 0.6% decline per decade until age 70 PSG data are required before it is a viable option to
when REM increases with a simultaneous decrease in measure sleep accurately in any setting.
TST. 125 Time spent awake after sleep onset increases with The most reliable option for the critical care clinician to
age by 10 minutes per decade after age 30. 124 assess sleep is a patient self-report (in any case the patient
is best placed to judge the quantity and quality of
their sleep if they are able). Two instruments have been
SLEEP ASSESSMENT/MONITORING specifically developed for use in critical care; the Richards-
131
An assessment of the patient’s sleep history should be Campbell Sleep Questionnaire (RCSQ) and the Sleep
118
performed as soon as possible after admission. The in Intensive Care Questionnaire (SICQ). The RCSQ
person closest to the patient (ideally living in the same comprises five 100mm visual analogue scales (VAS): sleep
home) may be willing to provide a sleep history if the depth, latency, awakenings, time awake and quality of
patient is unable to communicate verbally. The require- sleep. It was pilot tested in a medical ICU (n = 9, 100%
ment for nocturnal non-invasive ventilation or sleep male) 132 and validated in a more extensive investigation
medication should be conveyed to the medical team for involving 70 male patients. There was a moderate cor-
133
consideration. Particular attention should be paid to relation between total RCSQ score and PSG sleep effi-
reports of daytime sleepiness, dissatisfaction with sleep ciency index (SEI); r = 0.58, (p < 0.001). 133 The SICQ was
and bed partner reports of excessive snoring as this may not validated against polysomnography. Therefore it is
indicate an undiagnosed sleep disorder. Usual sleep better suited for use when assessing a unit/organisation-
habits such as ‘going to bed’, ‘getting up’ and shower wide change in practice rather than for individual patients
times should be accommodated while the patient is (see Table 7.9).
treated in critical care whenever possible.
Up to 50% of all patients treated in critical care may be
Unfortunately, few objective methods of assessing sleep unable to complete a self-assessment of their sleep; in
reliably in the critically ill are available. Polysomnogra- which case the only remaining option is nurse assess-
phy (PSG), a method of recording electroencephalogra- ment. 119,134 The Nurses’ Observation Checklist (NOC) 135
phy, electrooculography and electromyography, is the can be used to obtain the bedside nurses’ assessment of
‘gold standard’ for assessing sleep. PSG data are analysed the quantity of the patient’s sleep. It is a relatively simple
126
according to Rechtschaffen and Kales’ criteria and instrument to use. However, evidence from many studies
provide TST and sleep stage times. However a trained suggests that nurses tend to overestimate sleep time, so
operator is required to ensure satisfactory signal quality, sleep time derived from the NOC may be better used as
continuous recording and interpretation. 123 This draw- a trend rather than a definitive report for an individual
back precludes its routine use in clinical practice in night’s sleep. 134,136-138





TABLE 7.9 Sleep assessment instruments

Instrument Description Comments
Richards Campbell Sleep ● Five visual analogue scales (0–100 mm) ● Patient does not need to able to write (nurse can mark the
Questionnaire 131 ● Total score derived from average of the 5 line as instructed by patient)
scales (high scores indicate good sleep) ● Patient requires sufficient level of cognitive function to use it
Sleep in Intensive Care ● Seven questions (some have more than ● Patient does not need to able to write (nurse can circle the
Questionnaire 118 one item) response as instructed by patient)
● Likert scales 1–10 ● Patient requires sufficient level of cognitive function to use it
● No global score ● Not yet validated
● Good for organisational changes in practice
Nurses’ observation ● Tick box table ● No training required
checklist 135 ● Assignment of a category; ‘awake’, ‘asleep’, ● Typically nurses tend to overestimate sleep
‘could not tell’ and ‘no time to observe’ ● Better for trend over several nights
every 15 minutes.

Psychological Care 147

SLEEP PROMOTION AND MAINTENANCE ● Provide the daily bath to suit patient needs rather than
In the absence of conclusive evidence to support sleep organisational needs (either before settling for the
promoting interventions in ICU, recommendations are night or during normal waking hours).
based on practices that would be likely to improve sleep
in health, e.g. noise reduction, limiting the number of
interruptions to which patients are subjected and main- Practice tip
tenance of an environment that is generally conducive to
normal night-time sleep. Individualised approaches to all The importance of sleep to critically ill patients cannot be over-
aspects of care are best and this is particularly important stated. Enabling the patient to experience good quality and
when promoting and maintaining sleep in the critically quantities of sleep should be a major priority for critical care
ill. The following information, based on research and nursing. Demonstrate your commitment to improving rest and
expert opinion, provides some general advice which may sleep for intensive care patients by incorporating sleep into the
promote and maintain sleep and at the very least create treatment reminder system used in the unit of your practice
conditions conducive to rest. setting (e.g. FASTHUG becomes FASSTHUG).
Comfort Measures
Environmental
● Ensure pain relief is offered and administered if pain
is suspected. ● Reduce noise levels especially during rest times and
● Reduce anxiety by providing information and the at night (this may require a unit-wide change in prac-
opportunity to have questions answered. Anxiolytics tice) as several studies conducted in critical care have
such as benzodiazepines may also be required. highlighted the association between noise levels and
● Provide night time sedation as required (remember sleep disruption. 114,143,144 Continuous noise levels in
sedation is not natural sleep and patients may only adult critical care areas consistently exceed hospital
appear to be asleep however it is possible to be sedated noise standards, for example, the Environmental
and asleep). Protection Agency (EPA) 35dB(A) at night and
● Provide a light massage unless contraindicated. 139 45dB(A) during the day 145 and the Australian Stan-
● Offer guided relaxation and imagery (audio guided dard AS/NZS 2107/2000 minimum 40dB(A) and
relaxation and imagery sessions may be maximum 45dB(A). 146-148
purchased). 140 ● Ensure lights are sufficiently dimmed and window
● Provide an extra cover for warmth (metabolic rate blinds drawn during rest times and at night and that
typically drops during sleep). lighting is bright and blinds opened at all other times.
● Request the patient’s family to provide some of the It is known that critically ill patients’ melatonin
patient’s own personal belongings such as pillows and metabolism is non-circadian so it is particularly
toiletries. important to attempt to use lighting that encourages
● Ear plugs and eye covers may assist some patients, normal circadian rhythm. 149,150 Generally critical care
however it should be highlighted that studies have areas contain fluorescent lights which may emit up to
shown that neither provide protection from excessive 600 lux. Light levels between 50 and 100 lux at night
151
141
noise and light levels. Patients provided with ear even for relatively brief periods are known to suppress
plugs and eye covers should have the ability to remove melatonin production, a vital hormone in the promo-
them without assistance if they wish.
tion of sleep and maintenance of circadian rhythm. 123
Care Activities It is well known that artificial lights emit light with
sufficient short wave content to affect melatonin
● Attend to nursing care at the beginning of the night secretion.
to reduce the likelihood of disturbing during the night
for example:
● redress wounds and empty drainage bags Practice tip
● wash, clean teeth and change gown and sheets
● reposition with suitable pressure support Ask your patient (or his/her relatives) about his/her usual night-
measures time ‘settling routine’ for sleep. Try to emulate the routine as
● level the transducer at the phlebostatic axis to closely as possible. Ask the patient if this improved their sleep.
ensure accurate haemodynamic monitoring
without the need to disturb the patient 142
● ensure intravenous lines and drains are accessible
● Plan care activities to allow the patient 1.5–2 hour Treatments
periods of undisturbed time during the night. (Nego-
tiate with other health care personnel to allow these ● Discuss the need for alternative mechanical ventila-
uninterrupted periods at night and during daytime tion settings at night with the medical team. Hyper-
rest times). ‘Cluster care’, for example, time medica- ventilation caused by inappropriately high inspiratory
tion administration and blood samples to coincide pressure can cause hypocapnia which may lead to
with pressure area care. central apnoeas and sleep disturbance. 152

148 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

● Many medications administered in critical care affect adverse drug reactions is important in the prevention
sleep architecture. Even vasoactive medications such of escalating sleep disturbances.
as adrenaline have the capacity to affect the quality ● Specific sleep-promoting medications may be admin-
of sleep. Sedatives, especially benzodiazepines and istered once non-pharmacological interventions have
opioids, reduce time in stage 3 and 4 and REM, thus been attempted. Table 7.10 contains a summary of the
reducing the amount and quality of sleep. 153,154 commonly used medications for the general manage-
However pain relief and anxiolysis may be essential ment of insomnia. It should be noted that investiga-
for sleep to occur, but an awareness of potential tions of the effectiveness of these medications have
not been undertaken in the critically ill.

Practice tip
Practice tip
Next time you are at work in ICU take the time to attend to the
noise level. At an appropriate time and position in the ICU close After interviewing the patient or their family about their usual
your eyes for one minute and consider whether you would be sleep and assessing their sleep in ICU you suspect they might
able to rest. In addition find a patient who is well enough to be have an existing untreated sleep disorder. Request the treating
discharged to the hospital ward and ask them about the factors medical team to make a sleep medicine referral. Research indi-
which they found most disruptive to rest and sleep while they cates that untreated sleep problems long-term are associated
were being treated in ICU. with increased risk of cardiovascular disease and cancer.




TABLE 7.10 Summary of commonly used sleep promoting medications
Medication Medication class Typical hypnotic dose range (adult) Cautions
Temazepam Benzodiazepine Oral/enteral: 10–20 mg once per night Reduce dose in liver failure.
(30 minutes before settling) Check liver function
Propofol Intravenous sedative/ Intravenous: Mechanical ventilation: 1.0 to Short-term use only.
anaesthetic agent 3.0 mg/kg/hour Continuous respiratory monitoring.
Self-ventilating: no greater than 0.5 mg/ Check liver function
kg/hour
Zolpidem Nonbenzodiazepine Oral/enteral: 5–10 mg once per night Short-term use only (2–4 weeks).
hypnotic (immediately before settling) Associated with hallucinations.
Extended half life in liver
impairment
Zopiclone Nonbenzodiazepine Oral/enteral: 3.75–7.5 mg once per night Short-term use only (2–4 weeks).
hypnotic (immediately before settling). Associated with hallucinations.
Extended half life in liver
impairment
Haloperidol Typical antipsychotic Provide maintenance doses used for Monitor QT interval and liver
treatment of delirium for night-time function.
settling Observe for extrapyramidal
Intravenous (slow): 2–10 mg which can be symptoms. No more than
repeated 100 mg/day
Oral/enteral: 5–15 mg per day
Olanzapine Atypical antipsychotic Oral/enteral: 2.5–20 mg once per night Short term use only. May cause
several hours before settling hypotension
Quetiapine Atypical antipsychotic Oral/enteral: 25–200 mg once per night Short term use only. May cause
an hour before settling hypotension. Monitor QT interval.
Amitriptyline Tricyclic Oral/enteral: 25–150 mg once per night Monitor QT interval and for
antidepressant one to two hours before settling anticholinergic effects. Increased
seizure risk
Doxepin Tricyclic Oral/enteral: 25–150 mg once per night Monitor QT interval and for
antidepressant one to two hours before settling anticholinergic effects. Increased
seizure risk
Mirtazapine Noradrenergic and Oral/enteral: 15–60 mg once per night Higher doses may have a
specific serotonergic one to two hours before settling stimulatory effect
antidepressant
Dexmedetomidine Alpha agonist Intravenous: Loading dose 1 microgram/ Not to be used as a continuous
kg over 10–20 mins followed by infusion for more than 24 hours.
maintenance infusion 0.2 to 1 mcg/kg/ Continuous respiratory monitoring.
hr titrated to effect.

Psychological Care 149

A Note on Melatonin The current advice of the authors is that it is better to
Melatonin is used for the short-term alleviation of insom- provide conditions that encourage the normal circadian
nia. This naturally-occurring hormone is both sleep- secretion of endogenous melatonin (i.e. provide lighting
promoting and maintaining. Despite its popularity in the and activity levels appropriate for the time of day) than
treatment of primary insomnia, e.g. jet lag and shift to administer exogenous melatonin.
work, the effectiveness of exogenous melatonin as a sleep
medication is yet to be clearly elucidated. 155,156 Investiga- SUMMARY
tions performed in ICU did not use polysomnography
and were largely inconclusive. 157-159 Difficulties occur in Meeting the psychological needs of patients is essential
emulating the typical endogenous pulsatile secretion of in the care of critically ill patients. This chapter outlines
the hormone 160 together with its short half-life probably various methods that are available to assess and then
explain why many study results are inconclusive. The effectively manage aspects of patient care related to
high doses required to achieve an adequate plasma level anxiety, delirium, pain, sedation and sleep. Assessment
overnight when administered once at the beginning of of these aspects of patient condition require thorough
the night are likely to persist in the body and may upset clinical assessment, with a range of instruments available
normal circadian rhythm. Some studies investigating the to help improve consistency over time and between clini-
effect of melatonin on insomnia suggest that it may be cians, as well as to inform decisions regarding the most
more effective when administered to adults older than 55 appropriate interventions. Although these aspects of care
years as there is an age-related decrease in endogenous have been reviewed sequentially in this chapter, in reality
161
melatonin. The typical dose is 2 mg once a day (1–2 they are closely inter-related and should be considered
hours before settling). concurrently.



Case study

A 57-year-old man, Brad Smith was admitted to the intensive care agitated requiring both physical and chemical restraint. His agita-
unit with polytrauma following a road traffic incident in which he tion and reduced cognitive function meant that progress was
was involved in a collision with a car while riding his bicycle to slowed. For example the cervical collar could not be removed and
work. His injuries included extensive rib left sided fractures includ- his mobility was restricted because he was unable to provide
ing a flail segment, haemopneumothorax, lung contusions, frac- appropriate responses during assessment for soft tissue injury, and
tured scapula, liver laceration and contusions, lacerated head of he moved around the bed so that his injured leg could not be
pancreas, an adrenal gland haematoma, pelvic fractures with intra- elevated.
peritoneal bleeding and an open left tibial fracture. He had no After two days of delirium in which multiple doses of midazolam
obvious spinal injuries (no fractures were located on X-ray either) were administered and physical limb restraints were used to main-
however a cervical collar was applied at the accident scene.
tain Brad’s safety, a full assessment was performed. All of the pre-
Although he was conscious and orientated at the scene of the disposing and precipitating factors for delirium for Brad were
accident, Brad became profoundly hypotensive in the ambulance. considered:
On arrival his blood pressure was 80/40 and he was hypoxic. He ● Predisposing factors
was intubated and initially stabilised in the emergency department ● occasionally smoked marijuana but only while on holiday
until he was transferred to the operating theatre for surgery to ● ‘often anxious and frequently stressed by his job as a train
stabilise his tibial fracture. Upon arrival in ICU and for the first 36 driver’
hours Brad required pressure control ventilation with a high frac- ● briefly hypoxic on arrival at hospital
tion of inspired oxygen. At times muscle relaxants (vecuronium) ● sudden illness (traumatic injury)
were administered to enable ventilation together with high doses ● Precipitating factors
of analgesic (fentanyl) and sedative (midazolam) medication. ● large doses of opioids (fentanyl and oxycodone later) and
Copious blood was suctioned from his trachea. After five days benzodiazepines (midazolam) in ICU
during which he received multiple blood products he stabilised ● frequent infections
and after ten days Brad underwent tracheostomy which enabled a ● elevated liver function tests (LFTs)
reduction in sedative medication. Respiratory support was gradu- ● unrelieved pain. Pain intensity was 6/10 during movement
ally reduced with further reductions of sedative medications from on one occasion
day 14. Brad had several infections during his ICU admission: ● severity of illness (APACHE II score was 20)
urinary tract and chest. His liver function blood test results became ● noise from another patient.
increasingly elevated and only declined after ICU discharge.
Despite early administration of stool softeners and aperients, Brad Brad was assessed formally using the CAM-ICU and ICDSC; he had
was constipated for a five day period. Brad was discharged from all four features of the CAM-ICU and his ICDSC score was 7. Both
ICU after 21 days. brain CT and MRI scans revealed no abnormalities. However an
assessment of his EEG revealed slow wave activity even when he
From the time that sedative medication was reduced to discharge was awake making purposeful movements. Polysomnography
from ICU Brad experienced delirium. At times he was extremely revealed profound sleep disruption with a great deal of total sleep

150 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



Case study, Continued
time during daytime hours. The drug and alcohol liaison nurse was Brad’s delirium gradually improved during his stay but he remained
consulted but made no recommendations (his marijuana use was intermittently delirious up to five days after ICU discharge. The only
thought to be very small). The elevated LFTs were thought to be physiological factor that appeared to change dramatically during
mainly a result of a combination of the administration of multiple that period was that his LFTs started to return to normal (on dis-
blood products and antibiotics. The ICU pharmacist was consulted charge: ALP:605, AST 45, ALT 69, GGT 519 and five days later ALP:
and suggested a gradual reduction in benzodiazepines, a trial of 205, AST 39, ALT 51, GGT 219).
dexmedetomidine and the administration of the atypical antipsy-
chotic, quetiapine, twice a day. Recovery
Physically Brad’s recovery was largely uneventful. He went to a
Treatment private rehabilitation hospital for two weeks after hospital dis-
In the first instance a dexmedetomidine infusion (a request was charge. However over time he became increasingly disturbed by
made for ‘off label’ use) was administered with good effect. At the circumstances of his injury and his lack of memory of ICU. He
the same time a multifaceted intervention was devised and returned to ICU three months later while attending an orthopaedic
implemented: outpatient’s appointment to speak to the ICU team. He visited the
● Regular assessments using the ICDSC were performed. It was bed spaces where he had been a patient while in ICU but could not
agreed that a score of >6 (or behaviour likely to cause acciden- recall the experience. He described his increasing distress when-
tal self-harm) was the cut-off for ICU staff specialist review. ever road traffic incidents were mentioned on the TV or radio news
● The midazolam infusion was gradually discontinued. and his attempts to avoid listening. Brad also expressed exaspera-
● Small bolus doses of diazepam (2 mg) were administered tion with his inability to sleep (a new problem) and his constant
when Brad was extremely anxious ruminating about the incident in which he could see ‘the scenario
● Quetiapine 100mg was administered twice a day replaying’ in his mind (i.e. ‘flashbacks’). This social worker was called
● Brad was moved into a quieter area of the intensive care unit. and he received a referral for a specialist centre for post traumatic
● His wife and children were encouraged to provide constant stress disorder. Brad made a full recovery after several months.
reminders of the time and place, read to him and play music
during the day. Discussion
● Photographs and personal items were placed around Brad’s Brad’s story is not an unusual one. His injuries were extensive and
bedspace. His wife brought his pillow from home. complicated. He was at high risk of developing delirium. His delir-
● Extra attention was given to ensuring that the room lighting ium may have improved despite the instigation of the intervention.
was appropriate for the time of day. The only risk factors which remained present for his ICU stay were
● A settling period was implemented in which a routine was the elevated LFTs and unrelieved pain (pain assessment was diffi-
established to encourage Brad to go to sleep by 2300hrs. cult, his response to the visual numerical analogue scale varied).
● Care was clustered (members of the ICU team consulted with His cognition improved dramatically after the LFTs began to return
the nurse to time their visit/treatment so that Brad had several to normal. Despite the administration of analgesics and use of
1.5–2 hour intervals in which he was not disturbed). other pain relieving interventions it is possible that pain led to
● The speech pathologist was involved to improve communica- agitation. Dexmedetomidine is an alpha 2 -adrenoreceptor with
tion (both before and after the tracheostomy cuff was able to both analgesic and sedative effects. Either or both effects may have
be deflated). reduced the agitation. Nevertheless Brad was less agitated and
● During a period when Brad was not delirious, an assessment of appeared to be less distressed once the multifaceted intervention
his C spine was performed and the protective collar was began. The multi-disciplinary healthcare team approach was also
removed. undoubtedly responsible for his recovery.







Research vignette
Arbour C, Gelinas C. Are vital signs valid indicators for the assess- design was used. A convenience sample of 105 patients from a
ment of pain in postoperative cardiac surgery ICU adults? Intensive cardiology health centre in Canada participated. Patients were
and Critical Care Nursing 2010; 26(2): 83–90. observed during three testing periods: (1) unconscious and
mechanically ventilated, (2) conscious and mechanically ventilated
Abstract and (3) after extubation. For each of these testing periods, vital
The aim of this study was to examine the discriminant and criterion signs were assessed using the ICU monitoring at rest, during a
validity of vital signs (mean arterial pressure [MAP], heart rate nocioceptive procedure and 20 min postprocedure. Conscious
[HR], respiratory rate [HR], transcutaneous oxygen saturation patients’ self-reports of pain were obtained. Discriminant validity
[SpO 2 ], and end-tidal CO 2 ) for pain assessment in postoperative was supported with significant changes in most vital signs during
cardiac surgery ICU adults. A repeated-measure within-subject the nociceptive procedure. Some of the vital signs (HR, RR, and

Psychological Care 151



Research vignette, Continued
SpO 2 ) were associated with the patients’ self-reports of pain but specifically for use in the current study and has not been validated
were dependent on the patients’ status (mechanically ventilated outside this cohort. The limited validation of both these self-report
or not). Findings regarding the use of vital signs for pain assess- instruments represents a major methodological weakness in the
ment are not consistent and should be considered with caution. testing of criterion validity in the current study.
As recommended by experts, vital signs should only be used as A further limitation, as noted by the authors, was the inconsistent
a cue when behavioural indicators are no longer available in nature of the nocioceptive procedure. Although all patients
mechanically ventilated or unconscious patients.
were turned, approximately 3 of the patients also received endo-
2
Critique tracheal suctioning, while a minority received turning alone or
This study deals with an interesting and universal area of critical turning and hyperventilation. Further, the associated procedures
care nursing practice, that of pain assessment. Although in practice of endotracheal suctioning or hyperventilation may have been
many clinicians use vital signs as an indicator of pain, particularly more responsible for the changes in vital signs (particularly end-
citing the increase in parameters as an indicator of pain or the tidal CO 2 and SpO 2 ) than the turning and quantifying this influence
decrease as an indicator of the absence of pain, this practice is not is exacerbated by the inconsistent application of the procedure.
supported by the evidence. Inconsistent findings as to whether
vital signs are significantly related to the experience of pain have A strength of this study was the measurement of vital signs at three
been reported and this study is designed to help clarify any rela- points across the postoperative period including while the patient
tionship. The cohort enrolled in this study included 105 post- was unconscious and mechanically ventilated, conscious and
operative cardiac surgical patients, although those with significant mechanically ventilated and conscious after extubation. It is essen-
cardiac compromise or other comorbidities and complications tial that we have reliable markers of pain for critically ill patients at
were excluded. all these points in their illness continuum. This design strength was
somewhat compromised by the collection of data from only 33
The findings of this study suggest the vital signs that were tested patients in the first of these time periods when the patient was
do have discriminant validity, with MAP, HR, RR and end-tidal CO 2 unconscious and mechanically ventilated. A further strength was
all increasing significantly during the nocioceptive procedure and the measurement of a range of vital signs rather than focusing on
SpO 2 decreasing significantly. In contrast, criterion validity of the just one or two physiological parameters.
vital signs was not demonstrated, with only RR significantly associ- In summary, this study continues the theme of examining the value
ated with patient’s reports of pain.
of vital signs as an indicator of pain in the critically ill population.
Patients’ self-report of pain was achieved using the Verbal Descrip- The results further suggest that vital signs do not represent valid
tor Scale (VDS) and the Faces Pain Thermometer (FPT). The VDS was indicators of pain in this population. Further exploration of whether
developed in the early 1990s and has only been tested in a small vital signs can be used in conjunction with other indicators is
group of 30 post-anaesthetic care patients. The FPT was developed essential.









Learning activities
Activities 1–2 relate to the clinical case study ● Consider how family could help with the management of
1. Discuss possible strategies for assessing Brad’s pain levels, the patient’s anxiety.
including considering various pain assessment instruments 4. Critically ill patients who experience delirium require highly
that may have been used. You should particularly consider the skilled and informed nursing. The following exercises may
problems created by Brad’s variable response to the VAS being enhance your ability to manage delirium:
used to assess his pain. ● Identify nursing interventions which may reduce the poten-
2. Outline possible strategies that might be used to assist Brad to tial for delirium
fill in the gaps in his memory that appear to be causing him ● Describe the rationale for your selection of nursing interven-
some distress during his recovery after leaving ICU. Discuss the tions using current research
potential advantages and detrimental effects of each of these ● Outline the differences between delirium and dementia
strategies. ● Develop a nursing plan for a patient you cared for previously
3. The assessment of anxiety, sedation and pain intensity is inte- with delirium. Identify interventions you did not use but
gral to critical care nursing. would use in the future.
● Differentiate between each of these parameters and outline 5. Compare and contrast the various sedation assessment instru-
a method you would use to assess them. List any special ments, and discuss the relative merits and disadvantages of
considerations associated with your choices. using each of these instruments. Now repeat the exercise for
● Suggest a non-pharmacological strategy you could employ each of the pain assessment instruments and the delirium
to reduce anxiety and pain. assessment instruments.

152 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



Learning activities, Continued
6. Using the references provided in this chapter: ● Mood
● Highlight the importance of good quality sleep in health ● Cognitive function
and illness ● Physical function
● Identify theories that explain the function of sleep ● Appetite
7. Think about the last time you experienced fragmented sleep ● Motivation
or insufficient sleep and describe how you felt in terms of your:






ONLINE RESOURCES 16. Lovibond S, Lovibond P. Manual for the depression anxiety stress scales, 2nd
edn. Sydney: Psychology Foundation; 1995.
ICU Delirium and Cognitive Impairment Study Group, www.icudelirium.org 17. Ng F, Trauer T, Dodd S, Callaly T, Campbell S, Berk M. The validity of the
Australasian Sleep Association, http://www.sleepaus.on.net/ 21-item version of the Depression Anxiety Stress Scales as a routine clinical
outcome measure. Acta Neuropsychiatrica 2007; 19: 304–10.
FURTHER READING 18. Hornblow AR, Kidson MA. The visual analogue scale for anxiety: a validation
study. Aust NZ J Psychiatry 1976; 10(4): 339–41.
19. McKinley S, Coote K, Stein-Parbury J. Development and testing of a Faces
Ballantyne J, Bonica JJ, Fishman S. Bonica’s management of pain. Philadelphia: Scale for the assessment of anxiety in critically ill patients. J Adv Nurs 2003;
Lippincott Williams & Wilkins; 2009. 41(1): 73–9.
Bergeron N, Dubois MJ, Dumont M et al. Intensive Care Delirium Screening 20. Gustad L, Chaboyer W, Wallis M. Performance of the faces anxiety scale in
Checklist: evaluation of a new screening tool. Intensive Care Med 2001; 27: patients transferred from the ICU. Inten Crit Care Nurs 2005; 21(6):
859–64. 355–60.
Ely EW, Inouye SK, Bernard GR et al. Delirium in mechanically ventilated patients: 21. McKinley S, Madronio C. Validity of the Faces Anxiety Scale for the assess-
validity and reliability of the confusion assessment method for the intensive ment of state anxiety in intensive care patients not receiving mechanical
care unit (CAM-ICU). JAMA 2001; 286: 2703–10. ventilation. J Psychosom Res 2008; 64(5): 503–7.
Hardin KA. Sleep in the ICU: potential mechanisms and clinical implications. 22. Frazier SK, Moser DK, Daley LK, McKinley S, Riegel B et al. Critical care
Chest 2009; 136: 284–94.
nurses’ beliefs about and reported management of anxiety. Am J Crit Care
2003; 12(1): 19–27.
REFERENCES 23. Chan MF, Chung YF, Chung SW, Lee OK. Investigating the physiological
responses of patients listening to music in the intensive care unit. J Clin Nurs
1. Spielberger C, Gorsuch R, Lushene R. Manual for the state-trait anxiety inven- 2009; 18(9): 1250–57.
tory. Palo Alto, CA: Consulting Psychologist Press; 1983. 24. Halm MA. Essential oils for management of symptoms in critically ill
2. Chlan L. A review of the evidence for music intervention to manage anxiety patients. Am J Crit Care 2008; 17(2): 160–63.
in critically ill patients receiving mechanical ventilatory support. Arch Psy- 25. Richards K, Nagel C, Markie M, Elwell J, Barone C. Use of complementary
chiatr Nurs 2009; 23(2): 177–9. and alternative therapies to promote sleep in critically ill patients. Crit Care
3. Sessler CN, Varney K. Patient-focused sedation and analgesia in the ICU. Crit Nurs Clin North Am 2003; 15(3): 329–40.
Care Med 2008; 133: 552–65. 26. Halcon LL, Chlan LL, Kreitzer MJ, Leonard BJ. Complementary therapies and
4. De Jong MJ, Chung ML, Roser LP, Jensen LA, Kelso LA et al. A five-country healing practices: faculty/student beliefs and attitudes and the implications
comparison of anxiety early after acute myocardial infarction. Eur J Cardio- for nursing education. J Prof Nurs 2003; 19(6): 387–97.
vasc Nurs 2004; 3(2): 129–34. 27. Fontaine DK, Briggs LP, Pope-Smith B. Designing humanistic critical care
5. Frazier SK, Moser DK, O’Brien JL, Garvin BJ, An K, Macko M. Management environments. Crit Care Nurs Q 2001; 24(3): 21–34.
of anxiety after acute myocardial infarction. Heart Lung 2002; 31(6): 28. Stichler JF. Creating healing environments in critical care units. Crit Care Nurs
411–20. Q 2001; 24(3): 1–20; quiz following p. 97.
6. Nelson JE, Meier DE, Oei EJ, Nierman DM, Senzel RS et al. Self-reported 29. Maddocks-Jennings W, Wilkinson JM. Aromatherapy practice in nursing:
symptom experience of critically ill cancer patients receiving intensive care. literature review. J Adv Nurs 2004; 48(1): 93–103.
Crit Care Med 2001; 29(2): 277–82. 30. Chan MF. Effects of music on patients undergoing a C-clamp procedure after
7. McKinley S, Stein-Parbury J, Chehelnabi A, Lovas J. Assessment of anxiety in percutaneous coronary interventions: a randomized controlled trial. Heart
intensive care patients by using the Faces Anxiety Scale. Am J Crit Care 2004; Lung 2007; 36(6): 431–9.
13(2): 146–52. 31. Twiss E, Seaver J, McCaffrey R. The effect of music listening on older adults
8. Bear M, Connors B, Paradiso M. Neuroscience, exploring the brain, 2nd edn. undergoing cardiovascular surgery. Nurs Crit Care 2006; 11(5): 224–31.
Baltimore, MD: Lippincott Williams & Wilkins; 2001. 32. Hellstron A, Fagerstrom C, Willman A. Promoting sleep by nursing interven-
9. Moser DK, Chung ML, McKinley S, Riegel B, An K et al. Critical care nursing tions in health care settings: A systematic review. Worldviews on Evidence-
practice regarding patient anxiety assessment and management. Intensive Crit Based Nursing. 2010. In Press. DOI: 10.1111/j.741-6787.2010.000203.x.
Care Nurs 2003; 19(5): 276–88. 33. Liu LL, Gropper MA. Postoperative analgesia and sedation in the adult
10. Porth C, Matfin G. Pathophysiology, Concepts of Altered Health States, 8th edn. intensive care unit: a guide to drug selection. Drugs 2003; 63(8): 755–67.
Philadelphia, PA: Lippincott, Williams & Wilkins; 2009. 34. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D et al. Clinical practice
11. Moser DK, Dracup K. Is anxiety early after myocardial infarction associated guidelines for the sustained use of sedatives and analgesics in the critically
with subsequent ischemic and arrhythmic events? Psychosom Med 1996; ill adult. Crit Care Med 2002; 30(1): 119–41.
58(5): 395–401. 35. Young C, Knudsen N, Hilton A, Reves JG. Sedation in the intensive care unit.
12. Schelling G. Effects of stress hormones on traumatic memory formation and Crit Care Med 2000; 28(3): 854–66.
the development of posttraumatic stress disorder in critically ill patients. 36. Ramsay MA, Luterman DL. Dexmedetomidine as a total intravenous anes-
Neurobiol Learn Mem 2002; 78(3): 596–609. thetic agent. Anesthesiology 2004; 101(3): 787–90.
13. Chlan LL. Relationship between two anxiety instruments in patients receiv- 37. Tan JA, Ho KM. Use of dexmedetomidine as a sedative and analgesic agent
ing mechanical ventilatory support. J Adv Nurs 2004; 48(5): 493–9. in critically ill adult patients: a meta-analysis. Intensive Care Med 2010; 36(6):
14. Zigmond A, Snaith R. The hospital anxiety and depression scale. Acta Psychi- 926–39.
atrica Scandinavica 1983; 67(6): 361–70. 38. Venn RM, Hell J, Grounds RM. Respiratory effects of dexmedetomidine
15. Snaith RP, Taylor CM. Rating scales for depression and anxiety: a current in the surgical patient requiring intensive care. Crit Care 2000; 4(5):
perspective. Br J Clin Pharmacol 1985; 19(Suppl 1[1]): S17–20. 302–8.

Psychological Care 153

39. Grant SA, Breslin DS, MacLeod DB, Gleason D, Martin G. Dexmedetomidine 68. Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit.
infusion for sedation during fiberoptic intubation: a report of three cases. Crit Care 2008; 12 (Suppl 3): S3.
J Clin Anesth 2004; 16(2): 124–6. 69. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delir-
40. Venn RM, Bradshaw CJ, Spencer R, Brealey D, Caudwell E et al. Preliminary ium Screening Checklist: evaluation of a new screening tool. Intensive Care
UK experience of dexmedetomidine, a novel agent for postoperative sedation Med 2001; 27(5): 859–64.
in the intensive care unit. Anaesthesia 1999; 54(12): 1136–42. 70. Inouye SK, Bogardus ST, Jr., Charpentier PA, Leo-Summers L, Acampora D
41. McGuire BE, Basten CJ, Ryan CJ, Gallagher J. Intensive care unit syndrome: et al. A multicomponent intervention to prevent delirium in hospitalized
a dangerous misnomer. Arch Intern Med 2000; 160(7): 906–9. older patients. N Engl J Med 1999; 340(9): 669–76.
42. Trzepacz PT. Update on the neuropathogenesis of delirium. Dement Geriatr 71. American Psychiatric Association. Practice guideline for the treatment of
Cogn Disord 1999; 10(5): 330–34. patients with delirium. Am J Psychiatry 1999; 156(5 Suppl): 1–20.
43. Lin SM, Liu CY, Wang CH, Lin HC, Huang CD et al. The impact of delirium 72. Jackson DL, Proudfoot CW, Cann KF, Walsh TS. The incidence of sub-
on the survival of mechanically ventilated patients. Crit Care Med 2004; optimal sedation in the ICU: a systematic review. Crit Care 2009; 13(6):
32(11): 2254–9. R204.
44. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and 73. Schweickert WD, Kress JP. Strategies to optimize analgesia and sedation. Crit
consequences of ICU delirium. Intensive Care Med 2007; 33(1): 66–73. Care 2008; 12 (Suppl 3): S6.
45. Han JH, Shintani A, Eden S, Morandi A, Solberg LM et al. Delirium in the 74. Samuelson KA, Lundberg D, Fridlund B. Light vs. heavy sedation during
emergency department: an independent predictor of death within 6 months. mechanical ventilation after oesophagectomy – a pilot experimental study
Ann Emerg Med 2010 Apr 2 XXX. focusing on memory. Acta Anaesthesiol Scand 2008; 52(8): 1116–23.
46. Pun BT, Ely EW. The importance of diagnosing and managing ICU delirium. 75. Sessler CN, Grap MJ, Ramsay MA. Evaluating and monitoring analgesia and
Crit Care Med 2007; 132(2): 624–36. sedation in the intensive care unit. Crit Care 2008; 12(Suppl 3[3]): S2.
47. Ely EW, Gautam S, Margolin R, Francis J, May L et al. The impact of delirium 76. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with
in the intensive care unit on hospital length of stay. Intensive Care Med 2001; alphaxalone-alphadolone. BMJ 1974; 2(5920): 656–9.
27(12): 1892–900. 77. Sessler CN, Gosnell M, Grap MJ et al. The Richmond Agitation-Sedation
48. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM et al. Delirium as a Scale: validity and reliability in adult intensive care patients. Am J Resp Crit
predictor of mortality in mechanically ventilated patients in the intensive Care Med 2002; 166: 1338–44.
care unit. JAMA 2004; 291(14): 1753–62. 78. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation–
49. Girard TD, Jackson JC, Pandharipande PP, Pun BT, Thompson JL et al. Agitation Scale for adult critically ill patients. Crit Care Med 1999; 27(7):
Delirium as a predictor of long-term cognitive impairment in survivors of 1325–9.
critical illness. Crit Care Med 2010; 38(7): 1513–20. 79. Devlin JW, Boleski G, Mlynarek M, Nerenz DR, Peterson E et al. Motor
50. Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is Activity Assessment Scale: a valid and reliable sedation scale for use with
severely underestimated in the ICU during daily care. Intensive Care Med mechanically ventilated patients in an adult surgical intensive care unit.
2009; 35(7): 1276–80. Critical Care Medicine 1999; 27(7): 1271–5.
51. Arend E, Christensen M. Delirium in the intensive care unit: a review. Nurs 80. de Lemos J, Tweeddale M, Chittock D. Measuring quality of sedation in
Crit Care 2009; 14(3): 145–54. adult mechanically ventilated critically ill patients. the Vancouver Interaction
52. Meagher DJ, Trzepacz PT. Motoric subtypes of delirium. Semin Clin Neuro- and Calmness Scale. Sedation Focus Group. J Clin Epidemiol 2000; 53(9):
psychiatry 2000; 5(2): 75–85. 908–19.
53. American Psychiatric Association. Diagnostic and statistical manual of mental 81. Anderson J, Henry L, Hunt S, Ad N. Bispectral index monitoring to facilitate
disorders: DSM-IV, 4th edn. Washington, DC: American Psychiatric Associa- early extubation following cardiovascular surgery. Clin Nurse Spec 2010;
tion; 1994. 24(3): 140–48.
54. Jacobson S, Jerrier H. EEG in delirium. Semin Clin Neuropsychiatry 2000; 5(2): 82. Weatherburn C, Endacott R, Tynan P, Bailey M. The impact of bispectral
86–92. index monitoring on sedation administration in mechanically ventilated
55. Peterson JF, Pun BT, Dittus RS, Thomason JW, Jackson JC et al. Delirium and patients. Anaesth Intensive Care 2007; 35(2): 204–8.
its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc 83. Mehta S, McCullagh I, Burry L. Current sedation practices: lessons learned
2006; 54(3): 479–84. from international surveys. Crit Care Clin 2009; 25(3): 471–88, vii–viii.
56. Armstrong SC, Cozza KL, Watanabe KS. The misdiagnosis of delirium. Psy- 84. Chaboyer W, Aitken L. Do nurse-led protocols reduce ICU stay? In:
chosomatics 1997; 38(5): 433–9. Chiche J, Moreno R, Putensen C, Rhodes A, eds. Patient safety and quality of
57. Easton C, MacKenzie F. Sensory-perceptual alterations: delirium in the inten- care in intensive care medicine. Berlin: Medizinisch Wissenschaftlicke Ver-
sive care unit. Heart Lung 1988; 17(3): 229–37. lagsgesellschaft; 2009
58. Ely EW, Margolin R, Francis J, May L, Truman B et al. Evaluation of delirium 85. Roberts BL, Rickard CM, Rajbhandari D, Reynolds P. Factual memories of
in critically ill patients: validation of the Confusion Assessment Method ICU: recall at two years post-discharge and comparison with delirium status
for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001; 29(7): during ICU admission – a multicentre cohort study. J Clin Nurs 2007; 16(9):
1370–79. 1669–77.
59. Bergeron N, Skrobik Y, Dubois MJ. Delirium in critically ill patients. Crit 86. Rotondi AJ, Chelluri L, Sirio C, Mendelsohn A, Schulz R et al. Patients’ recol-
Care 2002; 6(3): 181–2. lections of stressful experiences while receiving prolonged mechanical
60. Roberts B, Rickard CM, Rajbhandari D, Turner G, Clarke J et al. Multicentre ventilation in an intensive care unit. Crit Care Med 2002; 30(4):
study of delirium in ICU patients using a simple screening tool. Aust Crit 746–52.
Care 2005; 18(1): 6, 8–9, 11–14 passim. 87. Watt-Watson J, Stevens B, Garfinkel P, Streiner D, Gallop R. Relationship
61. Shehabi Y, Botha JA, Boyle MS, Ernest D, Freebairn RC et al. Sedation and between nurses’ pain knowledge and pain management outcomes for their
delirium in the intensive care unit: an Australian and New Zealand perspec- postoperative cardiac patients. J Adv Nurs 2001; 36(4): 535–45.
tive. Anaesth Intensive Care 2008; 36(4): 570–78. 88. Bonica JJ. The need of a taxonomy. Pain 1979; 6(3): 247–8.
62. Han JH, Zimmerman EE, Cutler N, Schnelle J, Morandi A et al. Delirium in 89. Ballantyne J, Bonica JJ, Fishman S. Bonica’s management of pain, 4th edn.
older emergency department patients: recognition, risk factors, and psycho- Philadelphia, PA: Lippincott Williams & Wilkins; 2009.
motor subtypes. Acad Emerg Med 2009; 16(3): 193–200. 90. Milgrom LB, Brooks JA, Qi R, Bunnell K, Wuestfeld S, Beckman D. Pain levels
63. Dubois MJ, Bergeron N, Dumont M, Dial S, Skrobik Y. Delirium in an experienced with activities after cardiac surgery. Am J Crit Care 2004; 13(2):
intensive care unit: a study of risk factors. Intensive Care Med 2001; 27(8): 116–25.
1297–304. 91. Adamson H, Murgo M, Boyle M, Kerr S, Crawford M, Elliott D. Memories
64. Ely EW, Girard TD, Shintani AK, Jackson JC, Gordon SM et al. Apolipopro- of intensive care and experiences of survivors of a critical illness: an interview
tein E4 polymorphism as a genetic predisposition to delirium in critically study. Intensive Crit Care Nurs 2004; 20(5): 257–63.
ill patients. Crit Care Med 2007; 35(1): 112–17. 92. Boyle M, Murgo M, Adamson H, Gill J, Elliott D, Crawford M. The effect of
65. Aldemir M, Ozen S, Kara IH, Sir A, Bac B. Predisposing factors for delirium chronic pain on health related quality of life amongst intensive care survi-
in the surgical intensive care unit. Crit Care 2001; 5(5): 265–70. vors. Aust Crit Care 2004; 17(3): 104–6, 108–13.
66. Pandharipande P, Shintani A, Peterson J, Pun BT, Wilkinson GR et al. Loraz- 93. McCaffery M. Understanding your patient’s pain. Nursing 1980; 10(9):
epam is an independent risk factor for transitioning to delirium in intensive 26–31.
care unit patients. Anesthesiology 2006; 104(1): 21–6. 94. Gélinas C, Fortier M, Viens C, Fillion L, Puntillo K. Pain assessment and
67. Lepousé C, Lautner CA, Liu L, Gomis P, Leon A. Emergence delirium in management in critically ill intubated patients: a retrospective study. Am J
adults in the post-anaesthesia care unit. Br J Anaesth 2006; 96(6): 747–53. Crit Care 2004; 13(2): 126–35.

154 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

95. Herr K, Coyne PJ, Key T, Manworren R, McCaffery M et al. Pain assessment 123. Kryger MH, Roth T, Dement WC. Principles and practice of sleep medicine, 4th
in the nonverbal patient: position statement with clinical practice recom- edn. Philadelphia: Elsevier Saunders; 2005.
mendations. Pain Manag Nurs 2006; 7(2): 44–52. 124. Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV. Meta-analysis
96. Puntillo KA, Miaskowski C, Kehrle K, Stannard D, Gleeson S, Nye P. Relation- of quantitative sleep parameters from childhood to old age in healthy indi-
ship between behavioral and physiological indicators of pain, critical care viduals: developing normative sleep values across the human lifespan. Sleep
patients’ self-reports of pain, and opioid administration. Crit Care Med 1997; 2004; 27(7): 1255–73.
25(7): 1159–66. 125. Floyd JA, Janisse JJ, Jenuwine ES, Ager JW. Changes in REM-sleep in percent-
97. Payen JF, Bru O, Bosson JL, Lagrasta A, Novel E et al. Assessing pain in criti- age over the adult lifespan. Sleep 2007; 30(7): 829–36.
cally ill sedated patients by using a behavioral pain scale. Crit Care Med 2001; 126. Rechtschaffen A, Kales A. A manual of standardized terminology: Techniques and
29(12): 2258–63. scoring system for sleep stages of human subjects. Los Angeles: UCLA Brain
98. Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Manag Nurs Information Service/Brain Research Institute; 1968.
2000; 1(1): 13–21. 127. Ancoli-Israel S, Cole R, Alessi C, Chambers M, Moorcroft W, Pollak CP. The
99. Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical- role of actigraphy in the study of sleep and circadian rhythms. Sleep 2003;
care pain observation tool in adult patients. Am J Crit Care 2006; 15(4): 26(3): 342–92.
420–27. 128. Bourne RS, Minelli C, Mills GH, Kandler R. Clinical review: sleep measure-
100. Young J, Siffleet J, Nikoletti S, Shaw T. Use of a Behavioural Pain Scale to ments in critical care patients: research and clinical implications. Critical Care
assess pain in ventilated, unconscious and/or sedated patients. Intensive Crit 2007; 11: 226.
Care Nurs 2006; 22(1): 32–9. 129. Nieuwenhuijs D, Coleman EL, Douglas NJ, Drummond GB, Dahan A.
101. Aissaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. Validation of a Bispectral index values and spectral edge frequency at different stages of
behavioral pain scale in critically ill, sedated, and mechanically ventilated physiologic sleep. Anesth Analg 2002; 94(1): 125–9.
patients. Anesth Analg 2005; 101(5): 1470–76. 130. Sleigh JW, Andrzejowski J, Steyn-Ross A, Steyn-Ross M. The Bispectral index:
102. Melzack R. The short-form McGill Pain Questionnaire. Pain 1987; 30(2): a measure of depth of sleep? Anesth Analg 1999; 88: 659–61.
191–7. 131. Richards KC, O’Sullivan PS, Phillips RL. Measurement of sleep in critically
103. Puntillo KA, White C, Morris AB, Perdue ST, Stanik-Hutt J et al. Patients’ ill patients. J Nurs Meas 2000; 8(2): 131–44.
perceptions and responses to procedural pain: results from Thunder Project 132. Richards KC, Bairnsfather L. A description of night sleep patterns in the
II. Am J Crit Care 2001; 10(4): 238–51. critical care unit. Heart Lung 1988; 17(1): 35–42.
104. Arbour C, Gelinas C. Are vital signs valid indicators for the assessment of 133. Richards KC, O’Sullivan PS, Phillips RL. Measurement of sleep in critically
pain in postoperative cardiac surgery ICU adults? Intensive Crit Care Nurs ill patients. J Nurs Measure 2000; 8(2): 131–44.
2010; 26(2): 83–90. 134. Bourne RS, Minelli C, Mills GH, Kandler R. Clinical review: Sleep measure-
105. Frazier SK, Moser DK, Schlanger R, Widener J, Pender L, Stone KS. Auto- ment in critical care patients: research and clinical implications. Crit Care
nomic tone in medical intensive care patients receiving mechanical ventila- 2007; 11(4): 226.
tion and during a CPAP weaning trial. Biol Res Nurs 2008; 9(4): 135. Edwards GB, Schuring LM. Pilot study: validating staff nurses’ observations
301–10. of sleep and wake states among critically ill patients, using polysomnogra-
106. Puntillo KA, Wild LR, Morris AB, Stanik-Hutt J, Thompson CL, White C. phy. Am J Crit Care 1993; 2(2): 125–31.
Practices and predictors of analgesic interventions for adults undergoing 136. Beecroft JM, Ward M, Younes M, Crombach S, Smith O, Hanly PJ. Sleep
painful procedures. Am J Crit Care 2002; 11(5): 415–29; quiz 430–31. monitoring in the intensive care unit: comparison of nurse assessment,
107. Nilsson U. The anxiety- and pain-reducing effects of music interventions: a actigraphy and polysomnography. Intensive Care Med 2008; 34(11):
systematic review. AORN J 2008; 87(4): 780–807. 2076–83.
108. MacPherson RD, Woods D, Penfold J. Ketamine and midazolam delivered 137. Aurell J, Elmqvist D. Sleep in the surgical intensive care unit: continuous
by patient-controlled analgesia in relieving pain associated with burns dress- polygraphic recording of sleep in nine patients receiving postoperative care.
ings. Clin J Pain 2008; 24(7): 568–71. BMJ (Clin Res Ed) 1985; 290(6474): 1029–32.
109. Zor F, Ozturk S, Bilgin F, Isik S, Cosar A. Pain relief during dressing changes 138. Richardson A, Crow W, Coghill E, Turnock C. A comparison of sleep assess-
of major adult burns: ideal analgesic combination with ketamine. Burns ment tools by nurses and patients in critical care. J Clin Nurs 2007; 16(9):
2010; 36(4): 501–5. 1660–68.
110. Siegel JM. Why we sleep. Scientific American 2003; 289(5): 92–7. 139. Richards KC. Effect of a back massage and relaxation intervention on sleep
111. Bonnet MH, Berry RB, Arand DL. Metabolism during normal, fragmented, in critically ill patients. Am J Crit Care 1998; 7(4): 288–99.
and recovery sleep. J Appl Physiol 1991; 71(3): 1112–18. 140. Richardson S. Effects of relaxation and imagery on the sleep of critically ill
112. Banks S, Dinges DF. Behavioral and physiological consequences of sleep adults. Dimens Crit Care Nurs 2003; 22(4): 182–90.
restriction. J Clin Sleep Med 2007; 3(5): 519–28. 141. Richardson A, Allsop M, Coghill E, Turnock C. Earplugs and eye masks: do
113. Ferrie JE, Shipley MJ, Cappuccio FP, Brunner E, Miller MA et al. A prospective they improve critical care patients’ sleep? Nurs Crit Care 2007; 12(6):
study of change in sleep duration: assocications with mortality in the White- 278–86.
hall II cohort. Sleep 2007; 30(12): 1659–66. 142. Honkus VL. Sleep deprivation in critical care units. Crit Care Nurs Q 2003;
114. Freedman NS, Gazendam J, Levan L, Pack AI, Schwab RJ. Abnormal sleep/ 26(3): 179–89.
wake cycles and the effect of environmental noise on sleep disruption in the 143. Aaron JN, Carlisle CC, Carskadon MA, Meyer TJ, Hill NS, Millman RP.
intensive care unit. Am J Respir Crit Care Med 2001; 163(2): 451–7. Environmental noise as a cause of sleep disruption in an intermediate respi-
115. Friese RS, Diaz-Arrastia R, McBride D, Frankel H, Gentilello LM. Quantity ratory care unit. Sleep 1996; 19(9): 707–10.
and quality of sleep in the surgical intensive care unit: are our patients sleep- 144. Gabor JY, Cooper AB, Crombach SA, Lee B, Kadikar N et al. Contribution of
ing? J Trauma 2007; 63(6): 1210–14. the intensive care unit environment to sleep disruption in mechanically
116. Hardin KA, Seyal M, Stewart T, Bonekat HW. Sleep in critically ill chemically ventilated patients and healthy subjects. Am J Respir Crit Care Med 2003;
paralyzed patients requiring mechanical ventilation. Crit Care Med 2006; 167(5): 708–15.
129(6): 1468–77. 145. Environmental Protection Agency US. EPA identifies noise levels affecting health
117. Drouot X, Cabello B, d’Ortho M-P, Brochard L. Sleep in the intensive care and welfare 1974. Cited Nov 2008. Available from: http://www.epa.gov/
unit. Sleep Medicine Reviews 2008; 12: 391–403. history/topics/noise/01.htm
118. Freedman NS, Kotzer N, Schwab RJ. Patient perception of sleep quality and 146. Ryherd EE, Waye KP, Ljungkvist L. Characterizing noise and perceived work
etiology of sleep disruption in the intensive care unit. Am J Respir Crit Care environment in a neurological intensive care unit. J Acoust Soc Am 2008;
Med 1999; 159(4 Pt 1): 1155–62. 123(2): 747–56.
119. Frisk U, Nordström G. Patients’ sleep in an intensive care unit – patients’ 147. Tijunelis MA, Fitzsullivan E, Henderson SO. Noise in the ED. Am J Emerg
and nurses’ perception. Intensive Crit Care Nurs 2003; 19(6): 342–9. Med 2005; 23(3): 332–5.
120. Knapp-Spooner C, Yarcheski A. Sleep patterns and stress in patients having 148. Topf M, Davis JE. Critical care unit noise and rapid eye movement (REM)
coronary bypass. Heart Lung 1992; 21(4): 342–9. sleep. Heart Lung 1993; 22(3): 252–8.
121. Nicolás A, Aizpitarte E, Iruarrizaga A, Vázquez M, Margall A, Asiain C. Per- 149. Frisk U, Olsson J, Nylén P, Hahn RG. Low melatonin excretion during
ception of night-time sleep by surgical patients in an intensive care unit. mechanical ventilation in the intensive care unit. Clin Sci (Lond) 2004;
Nurs Crit Care 2008; 13(1): 25–33. 107(1): 47–53.
122. Simpson T, Lee ER, Cameron C. Relationships among sleep dimensions and 150. Olofsson K, Alling C, Lundberg D, Malmros C. Abolished circadian rhythm
factors that impair sleep after cardiac surgery. Res Nurs Health 1996; 19(3): of melatonin secretion in sedated and artificially ventilated intensive care
213–23. patients. Acta Anaesthesiol Scand 2004; 48(6): 679–84.

Psychological Care 155

151. Perras B, Meier M, Dodt C. Light and darkness fail to regulate melatonin 157. Ibrahim MG, Bellomo R, Hart GK, Norman TR, Goldsmith D et al. A double-
release in critically ill humans. Intensive Care Med 2007; 33(11): blind placebo-controlled randomised pilot study of nocturnal melatonin in
1954–8. tracheostomised patients. Crit Care Resusc 2006; 8(3): 187–91.
152. Cabello B, Thille AW, Drouot X, Galia F, Mancebo J et al. Sleep quality in 158. Bourne RS, Mills GH, Minelli C. Melatonin therapy to improve nocturnal
mechanically ventilated patients: comparison of three ventilatory modes. sleep in critically ill patients: encouraging results from a small randomised
Crit Care Med 2008; 36(6): 1749–55. controlled trial. Crit Care 2008; 12(2): R52.
153. Bourne RS, Mills GH. Sleep disruption in critically ill patients – pharmaco- 159. Shilo L, Dagan Y, Smorjik Y, Weinberg U, Dolev S et al. Effect of melatonin
logical considerations. Anaesthesia 2004; 59(4): 374–84. on sleep quality of COPD intensive care patients: a pilot study. Chronobiol
154. Hardin KA. Sleep in the ICU: potential mechanisms and clinical implica- Int 2000; 17(1): 71–6.
tions. Crit Care Med 2009; 136(1): 284–94. 160. Claustrat B, Brun J, Chazot G. The basic physiology and pathophysiology of
155. Buscemi N, Vandermeer B, Hooton N, Pandya R, Tjosvold L et al. Efficacy melatonin. Sleep Med Rev 2005; 9(1): 11–24.
and safety of exogenous melatonin for secondary sleep disorders and 161. Brzezinski A, Vangel MG, Wurtman RJ, Norrie G, Zhdanova I et al. Effects of
sleep disorders accompanying sleep restriction: meta-analysis. BMJ 2007; exogenous melatonin on sleep: a meta-analysis. Sleep Med Rev 2005; 9(1):
332(7538): 385–93. 41–50.
156. Buscemi N, Vandermeer B, Hooton N, Pandya R, Tjosvold L et al. The efficacy 162. Iber C, Ancoli-Israel S, Chesson A, Quan SF. AASM manual for the scoring of
and safety of exogenous melatonin for primary sleep disorders: a meta sleep and associated events: rules, terminology and technical specification. West-
analysis. J Gen Intern Med 2005; 20(12): 1151–8. chester, IL: American Academy of Sleep Medicine; 2007.

Family and Cultural Care of
8 the Critically Ill Patient






Marion Mitchell

Denise Wilson
Vicki Wade




the psychosocial health and wellbeing of patients are
Learning objectives intimately related to their wellness and eventual illness
outcome. There is a tendency, due to the technologically
After reading this chapter, you should be able to: complex nature of nursing in critical areas, for novice
● describe models of care and evaluate how they meet nurses to focus their attention on the management of
patient needs medical treatment regimens. This is an important part
● recognise appropriate resources to enhance communication of their learning trajectory. However, nurses need to be
● develop an understanding of the needs of families and guided to see beyond the waveforms and physical para-
patients who die in the ICU meters to see the patient in the bed as an individual
● evaluate and implement appropriate strategies for working with unique needs. The previous chapter examined
specific aspects of the psychological wellbeing of the
with families from a different culture critically ill with strategies to improve patient outcomes.
● recognise and implement the needs of the critically ill and/ This chapter extends the focus to incorporate the family
or dying patient who is either an indigenous Australian or into the caring paradigm and introduces the concept of
Māori family-centred care. Nursing practices that incorporate
● develop an understanding of Indigenous spirituality as it the patient’s family into the care of the critically ill
relates to Aboriginal and Torres Strait Islander people dying acknowledge the vital part families play in the illness
or have died continuum.
● recognise the various religious considerations for patients
who are dying or who have died. The assessment, understanding and incorporation of the
patient and families’ cultural needs are essential elements
of nursing the critically ill, and involve the entire multi-
disciplinary team. These elements are important for both
the recipients of the care (the patient and family) and the
critical care nurse, as the practice of nursing all aspects of
Key words the patient’s wellbeing brings humanity into critical care
nursing. Cultural factors include social factors and human
models of care behaviours associated with emotional and spiritual
1
communication needs. In this chapter, models of nursing are examined
end of life with particular reference to the philosophy of family-
bereavement centred care, which may be an appropriate nursing model
family care for use within critical care settings. The specific needs of
continuity of care the families of critically ill patients are discussed, also the
cultural care and cultural safety implications for critical care nursing. The differing world
views on health and illness are highlighted for consider-
Indigenous Australians
ation of appropriate care. Effective communication is
crucial to meet both family members’ needs and those of
the patient. The complexity of patient communication
together with the addition of linguistically diverse patients
INTRODUCTION is outlined and suggestions for clinical practice provided.
End-of-life care is discussed in general terms and specific
Care of critically ill patients is complex and multifacto- cultural considerations are highlighted with particular
rial. Although management of the haemodynamic reference to Aboriginal and Torres Strait Islander people
parameters and healthcare interventions is an essential of Australia and New Zealand Māori patients and
156 component of effective care of the critically ill, families.

Family and Cultural Care of the Critically Ill Patient 157

OVERVIEW OF MODELS OF CARE healthcare that is governed by mutually beneficial part-
nerships among healthcare providers, patients and fami-
The way that nurses manage their daily activities and lies’. Patient-and-family centred care applies to patients
17
patient care is affected by both the critical care unit’s of all ages, and it may be practised in any healthcare
model of care delivery and the nurse’s personal setting.
philosophy of what and how nursing is constructed.
Alternative models of care are examined in this section Family-centred care is founded on mutual respect and
and their use in critical care areas discussed. Nursing partnership among patients, families and healthcare
models define shared values and beliefs that guide prac- providers. It incorporates all aspects of physical and psy-
tice. Various philosophies and models of nursing care chosocial care, from assessment to care delivery and
18
delivery have evolved over the decades and contrast with evaluation. Healthcare providers that value the family/
the ‘medical model’, which focuses on the diagnosis patient partnership during a critical illness strive to facili-
and treatment of disease. Models such as primary tate relationship building and provide amenities and
2
nursing and team nursing include organisational or services that facilitate families being near their hospital-
19
management properties, whereas client- or patient- ised relative. When a clinical unit’s staff embrace a
centred practice is another model in which a partnership family-centred care philosophy and partner with families
relationship is developed between health professionals and make changes to the physical environment such as
and the patient. Patient empowerment is a key benefit improved privacy and aesthetically pleasing decor, it
3-8
8
of this philosophy. However, a shared partnership with can have the added advantage of positive culture changes
the patient may be problematic in critical care, where for the staff. This indicates there is a benefit beyond
critical illness restricts patient involvement in decision the family members for whom the changes were
20
9
making and care planning. In reality, it is generally initiated.
family members who provide the link between the In trying to understand family-centred care, neonatal and
patient and healthcare team. paediatric ICU studies have focused on parents’ percep-
During the 1980s, the role of the family was one focus tion of care in the three key components of family-centred
21-23
of nursing debate and discussion. Friedman believed care: respect, collaboration, and support. In the area
families were the greatest social institution influencing of respect, families rated ‘feeling welcome when I come
10
individuals’ health in our society. A worldwide trend to the hospital’ and ‘I feel like a parent, not a visitor’ most
21
is for health professionals to value the role of family highly. Within the area of collaboration, feeling well
11
members in providing ongoing, post-acute care with the prepared for discharge and being given honest informa-
reality that families provide considerable support during tion about care were rated the highest. The familiarity of
rehabilitation phases of critical illnesses. 12,13 The family nurses with the special needs of patients was rated highest
21
is strongly incorporated within the philosophies of the in the area of support.
professionally-centred model and family-centred model. Strategies to improve family-centred care within adult
The professionally centred model is patient- and family- critical care areas include involving family members in
focused, but the nurse or doctor decides on what is partnering with the nursing staff to consider the involve-
needed rather than involving the family and patient in ment they would like which may include providing fun-
14
identifying their actual needs. The professionally- damental care to their sick relative. Family members can
24
centred model retains a component of paternalism, as decide in consultation and negotiation with the bed-side
health professionals act from their own perspective, nurse the care that they want, and are able to provide;
rather than as a result of a shared decision-making this may vary from moisturising their relative’s skin to a
process. The emphasis of this model, when used in the full sponge and will require negotiation. This act of caring
context of nursing, centres on autonomous nursing deci- allows family members to connect in what they see as a
sion making, albeit in an environment of collaboration meaningful way with their sick relative. In addition, it can
with other healthcare providers. It espouses the require- also improve communication with critical care nurses
ment for accountable practice and respect for individuals and facilitate close physical and emotional contact with
15
and their right to make decisions. In contrast, the their relative. An independent nursing intervention such
25
family-centred model shares the responsibility with the as partnering with family to provide care provides
family and aims to meet their needs. Whichever model an understanding of how to operationalise a family-
is selected, it must be practical in the clinical setting for centred care model in the clinical setting and assists in
which it is intended. 2 the evaluation of other future interventions directed to
improve an area’s family-centred approach. Further
FAMILY-CENTRED CARE research on the benefits of family-centred care is needed
24,26,27
The family-centred model of care, developed during the in all critical care areas.
early 1990s, primarily in North America, in the area of It is greatly acknowledged that taking care of critically
children’s nursing, considered incorporating the family ill patients requires considerable knowledge and skill.
16
was fundamental to the care of the patient. Over the When family members are incorporated into the caring
past two decades, the scope and extent of family-centred paradigm, as advocated within family-centred care,
care has broadened and the Institute for Family-Centered health professionals equally need specific knowledge and
28
Care defines family-centred care as ‘an innovative skills. This should be initiated in foundation degrees,
approach to the planning, delivery, and evaluation of postgraduate studies and via ongoing professional

158 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

28
development opportunities. A feature of family-centred area for further research. 35,40 Meeting the needs of families
care that makes it desirable in the critical care setting is during this stressful and demanding time has the capacity
how it strives to meet the needs of family. 21 to reduce their stress and promote positive coping
strategies.
Needs of family during critical illness
A combined healthcare team approach is needed to meet
Family members of critically ill patients contribute a the family’s needs, as differing perceptions among the
significant and ongoing involvement to patients’ well healthcare team can result in non-unified approaches
41
being. Patients need and want their family members with that are potentially confusing. The needs of families with
29
them and health care professionals also need their critically ill relatives are complex and multifactorial, rein-
30
41
input. Family members’ satisfaction with the care their forcing the need for an all-of-team approach. Family
relative receives is considered a legitimate quality indi- members’ needs were recognised in Molter’s influential
cator in many areas which routinely assess family study in 1979 where she researched the specific needs of
satisfaction. 31,32 ICU patients’ family members. Although Molter’s sample
On a very practical level within a critical illness situation, was small (n = 40), 45 potential needs of family members
42
family members are often the decision makers on treat- were identified and ranked in order of importance.
34,43-48
ment options due to the impaired cognitive state of the Family needs continue to be researched and can
patient. Their contribution to health care decisions is be generally grouped into the need for (a) information,
sought in both acute and ongoing care situations as they (b) reassurance, (c) closeness, (d) support, and (e)
36
have insight and knowledge of the patient on an entirely comfort. More specifically, families’ needs include the
36
33
different level to health professionals. In addition, following:
family members provide not only support in the critical ● to know their relative’s progress and prognosis
illness situation, but also continuity of care through reha- ● to have their questions answered honestly
bilitation. This responsibility together with the often ● to speak to a doctor at least once a day
sudden critical illness situation creates stress and anxiety ● to be given consistent information by staff
34
for family members. A primary aim of family-centred ● to feel their relative is looked after by competent and
care is to reduce the risk of stress related reactions to caring people
the ICU experience that is often traumatic for family ● to feel confident that staff will call them at home if
members. 35 changes occur in their relative’s condition
● to be given a sense of hope
● to know about transfer plans as they are being made.
Practice tip Meeting information needs

Where appropriate, invite the family to remain by the bedside Families’ needs for information and reassurance are para-
when you might normally ask them to leave. At first it may feel mount during a critical illness, which is often unexpected
daunting, as the family member may seem to watch your every or unexplained. Seven out of the top ten needs of families
49
move and action, but if you start doing this when you are are related to information needs. When information is
performing interventions with which you feel confident, provided, it is important to spend sufficient time with
50
you will find that having them there seems natural. There is family members. The information has to make sense to
less fuss with family coming and going and talking about what them and it is imperative that health care professionals
44
you are doing, and it promotes information sharing and check their understanding. It is not sufficient to think,
understanding. But I told them all that yesterday. Communication is a
two-way process and as such needs to be received in a
meaningful way as well as given appropriately. Repeated
and current information is suggested as it helps to reduce
family members’ anxiety. In a case study report of a
44
Stress and anxiety associated with having a critically ill mother with her adult war-injured son, the mother tells
relative can hinder a family’s coping ability, adaptation, how she tried to remember things the staff told her. She
36
decision making and long-term health with the possi- said, ‘I loved how my questions would be answered when
bility that post-traumatic stress disorder (PTSD) may we asked (except for the daily one about his brain
35
develop in family members of ICU patients. Families damage) and how most people did not take offense at
that experience stress before the critical illness do not me writing down everything. I know that I was scared to
37
cope as well, and may need additional assistance. As death most of the entire time’.
34, p. 18
many as half of family members report symptoms of
anxiety and depression, indicating it is a very real Strategies to improve communication with family
38
problem. These figures are concerning particularly when members include nurse-led education sessions designed
symptoms continue beyond six months post ICU. 35,39 to identify and meet the needs of family members. Once
In addition, post-traumatic stress symptoms are also the needs have been identified, a specific program can be
reported by family members which is consistent with a developed to meet the needs. This strategy was found to
moderate to major risk of PTSD, resulting in ongoing be effective when two one-hour sessions were conducted
35
health-related concerns for the family members. Early with family members who reported significantly lower
45
identification and preventions strategies are an important levels of anxiety and higher levels of satisfaction. Other

Family and Cultural Care of the Critically Ill Patient 159

units may choose to have a designated critical care nursing Family-friendly policies with few restrictions that centre
position in their unit which focused on family advocacy on genuine patient care issues require the support of criti-
within a family-centred care philosophy. 51 cal care nurses and medical officers for them to work
58
effectively. Flexible visiting policies have been found to
Multidisciplinary patient rounds that meaningfully
include the family show an inclusive and open com- improve quality indicators with higher patient and family
59
munication process that values all contributors as they satisfaction levels and fewer formal complaints. Restric-
34
make an individual plan of care for the patient. Alter- tive visiting policies limit families’ access to their
natively, consider routine family meetings with the relatives and restrict their involvement. Family members
healthcare team aimed at improving communication and are different from other visitors in critical care areas
understanding. 46,47 Frequently, family meetings are called because of their intimate relationship, which helps to
60-62
when the family is needed to make critical decisions form crucial components of the patient’s identity.
about the ongoing care of their relative rather than as a Remember that there are often different meanings or
proactive and positive strategy that allows for patient and interpretations of ‘family’, with it often meaning’s more
family preferences to be integrated into patient care. 47 than just the immediate nuclear family (e.g. the Māori
whānau [extended family]). Negotiation of visiting pro-
It is suggested that a family conference with the inter- cesses that take into account these cultural understand-
disciplinary team should be organised in a staged and ings is imperative.
planned manner with the first occurring within the first There is a genuine concern by some parents or carers
48 hours of admission; the second after three days, and that children should not visit family members who are
a third when there is a significant change in treatment critically ill as they may find the ICU environment and
49
goals. Fundamental topics for the interdisciplinary visit traumatic. This, however, is not the case when chil-
meetings with the family could include the patient’s dren are appropriately supported in visiting a critically
condition and prognosis together with short- and long- ill close family member; they are more likely to be not
31
term treatment goals. Family conferences provide time frightened but rather curious of their surroundings.
28
for discussion amongst the family with the health care Children may have questions and it is recommended that
team as a resource and also for the team to make an they be prepared well with adequate information before,
assessment of the family’s understanding of the situation. during and after their time with their relative in the criti-
In addition, it provides an opportunity to develop cal care area.
an awareness of specific family needs which the team can
31
endeavour to meet. Unhurried family conferencing Patients, however, may want visiting restricted as some
13
allows for opportunities for families to pose questions patients find them stressful or tiring. Contrary to popular
and longer family conferences can result in families belief, unrestricted visiting hours is not associated with
feeling greater support and significantly reduced long visits. In two separate European studies where unre-
53
PTSD symptoms. Although family conferencing has stricted visiting hours were introduced, the number of
been found beneficial, it is advocated that multiple hours family members spent with the patient was low.
modes of communication and information sharing are They stayed for one to two hours per day and usually
required. Leaflets and brochures that have either indi- came during the day. This suggests that when family
vidualised or set information are also helpful. 31,52,53 members have free access to their sick relative they do
not perceive a sense of duty to be there all day and
To promote communication, nurses can discuss with the 63,64
family whether they would like a phone call at night night.
updating them on their relative’s condition. Alternatively, Barriers that restrict family presence require attention as
29
nurses can give them a time to phone before change family attendance is beneficial to the patient and a
36
of shift. This will help to allay their anxiety and promotes primary need for family members. Although some criti-
positive communication and trust. When patients are cal care staff indicate feeling performance anxiety with
transferred from critical care, families and patients may the family present during procedures 29,65 or with extended
13
become anxious or concerned by the reduced level of care family visits, many nurses are comfortable providing
66
in the new ward area. This can be alleviated by providing care with the family present. Staff who do not feel com-
families with verbal and individualised written transfer fortable with this methodology require support and
information as a means to help prepare them for mentoring to facilitate this fundamental aspect of family-
54
transfer. In addition, a structured transferring plan helps centred care.
critical care nurses feel better equipped to ensure they Participating in patient care is one way for family
give families the information they need at this important members to feel closer to their critically ill family
time of transfer. 55
member 57,67,68 and at the same time promote family integ-
67
rity. Most family members, however, will not ask if
Visiting practices they can help with care as this is seen as the nurses’
38
One of the primary needs of families is listed as a need domain in adult critical care areas. 69,70 Nurses therefore
to be physically close to their sick relative. Patient confi- should invite family members to be part of the patient’s
dentiality and privacy remain central and need to be care, with massaging and providing a sponge being
56
balanced with family presence. Patients find that family popular activities. 24,69,70 Providing care allows the family
provides a link with their pre-illness self and provide members to feel connected emotionally with their
support and comfort. 57 relative and provides a means to get to know and

160 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



TABLE 8.1 Family participation in patient care

Principle Procedure
Consent Gain patient consent beforehand where possible.
Building of trust Introduce the concept of family members’ involvement in care after a period during which a
rapport is developed.
Individualise for patient and family Offer suitable options from which family members can choose: for example massaging feet and
hands, cleaning teeth and feeding may be appropriate options for short-term patients, whereas
additional options may exist for long-term patients.
Safety The registered nurse should remain physically close by at all times.
Promote achievement of goals Provide sufficient information to the family member to support successful completion of the care.
Reflect on outcomes Provide feedback to family members on how they performed the task.
Continuity of care Document the care the family members participated in and any relevant information.






communicate with the nurses which families consider unconscious patients can hear and recall some verbal
important. Family members appreciate invitations from communication once they regain consciousness. 81,82
nurses as this allows them to feel more in control in Meeting information needs builds trust between the
24
a situation where family members do not often experi- nurse and patient and their family as a relationship devel-
ence this. 71,72 ops. The nurse’s understanding of the person behind
79
For family participation to work effectively and safely, the patient is important to families, and can be achieved
a number of guiding principles should be incorporated, by talking to the family about the patient’s life before the
as outlined in Table 8.1. It is useful for critical care nurses illness. 83
to explore their beliefs and practices concerning family Good communication is a prime patient need and
participation, as many support family participation inspires patient confidence, making patients feel safe.
84
but do not always implement these beliefs in their When nurses reassure patients they provide a sense of
practice. 73 hope and a feeling of safety, which is further supported
by family members’ presence and the patients’ religious
COMMUNICATION beliefs. 77,84 Constructive strategies should be identified
The ability to communicate effectively is an underlying to overcome difficulties with patient communication.
tenet of nursing practice and a fundamental need for This is worthwhile pursuing as it reduces both nurse
75
people. As mentioned previously in the context of caring and patient frustration and improves nursing care. The
for family members, for communication to occur, there following methods of communication may be used
needs to be a two-way passage of ideas or information. individually or together to enhance communication,
In the patient context the inability to communicate and should be readily employed in critical care
causes, or adds to, anxiety, frustration and stress 74-76 as settings: 74,85
77
they lose control over their life and decisions. It is ● body language
therefore imperative for health care professionals to find ● lip reading
ways to communicate with patients. Critically ill patients ● writing
commonly have communication difficulties due to either ● alphabet boards
74
mechanical devices (e.g. endotracheal tubes), cognitive ● communication boards
impairment from the disease and/or pharmacological ● pictures
78
medications or language difficulties. Therefore, effec- ● gestures, including nodding and blinking of the eyes.
tive communication is challenging, and nurses need
additional knowledge and understanding of these Although electronic voice output communication aids
complex situations to meet medicolegal obligations and are used with disabled children and adults, they have not
to assist in meeting the key information needs of patients been evaluated sufficiently with an ICU population.
79
and families. As many critically ill patients are These aids use prerecorded digitalised voice messages or
unconscious, it is important to understand the need for synthesised speech, with the phrases accessed by the
85
verbal communication to continue. Such communication patient via a computer screen or keyboard. This device
did not occur in one Jordanian setting where in-depth would be restricted to those patients who are dexterous
interviews and observations used in three critical care and able to select an appropriate key, which limits its
areas identified that nurses communicated less with utility in the ICU setting. However, some patients in a
80
unconscious patients than with conscious patients. small study found electronic voice output beneficial, par-
It has been known for decades that sedated and ticularly when communicating with family. 85

Family and Cultural Care of the Critically Ill Patient 161

and they’d be saying stuff and I’d think “Oh no!” They
Practice tip would ask me, “Do you understand?”, “Are there any
questions?” And I … “I don’t even know what you just
77
Routinely, both document and inform the nurse taking over the said; how do I know if I have questions or not?” ’. In this
patient’s care, any points of patient and family discussion and case, both parties were speaking to the other, but it was
any codes that have been developed during the shift to apparent that the patient was not able to take in and
promote communication. This fosters continuity of care and process the information about her current condition and
consistencies in information sharing and is useful to the entire therefore had difficulty comprehending. Basic principles
health care team. of patient autonomy and respect need to be used cau-
tiously with critically ill patients who may appear com-
9
petent, when in reality their cognitive ability is impaired.
An effective strategy to promote good communication is Effective communication with the family is vital in order
for health professionals to seek and maintain eye contact to determine the cultural beliefs and practices of patients
(if culturally appropriate). This may mean the nurse or and their family to further enhance communication and
doctor sitting down on a chair beside the bed to facilitate understanding.
79
face-to-face communication. This act also conveys a
sense of the importance the health professional is placing CULTURAL CARE
on the interaction by taking time to ensure they under- The challenge for critical care nurses is to establish posi-
stand each other. Associated with this is the need to use tive working relationships with the patient (when possi-
commonly understood language. One method of check- ble) and the family so their important values, beliefs and
ing patients’ responses is to repeat these back to them. A practices can be shared and incorporated in plans of
quiet environment reduces extraneous noise and poten- intervention and treatment. It is not always possible to
tial interruptions, and may promote communication and ‘know’ another person’s culture in any great depth, or
concentration. Codes may also be developed by the nurse ‘know’ all cultural beliefs and practices of the patients
and patient, with facial expression, head nods and eye and families a critical care nurse comes into contact with.
75
blinks used to respond to questions. These codes should Therefore, relationships with the patient and the family
be passed on to the next nurse and recorded in the during their critical care experience are crucial, and also
patient’s notes to promote continuity of care. demonstrate both respect for, and valuing of, patients
When communication seems unsuccessful, talking loudly and their families and the cultural beliefs and practices
will not improve the interaction; one good strategy is for they hold. This enables health teams to better meet their
the nurse and patient to agree to try again later. Com- needs. While people’s ethnicities may provide a clue to
75
munication can also occur through physical contact, and their culture, it is not a reliable indicator and ignores the
touch often communicates empathy and provides spiri- multiple cultural groups people belong to that extend
tual comfort. Spiritual needs may further be met by pro- beyond ethnicity, such as age and gender. Making assump-
1
viding comfort, reassurance and respect for privacy, and tions about a person’s culture and reliance on universal
by helping patients relate to others. 86 approaches to direct nursing practice engenders risks to
nursing practice and potentially compromises the out-
comes of interactions and interventions. Even within cul-
tural groups (e.g. indigenous and immigrant groups),
Practice tip variation in beliefs and practices can exist. Such differ-
ences result from factors such as colonisation, interac-
Communication with the family is essential: when family tions with the various groups a person belongs to, and
describe the patient as the 35-year-old partner of Jack and responses to societal changes, and the socialisation of
mother of two young children, Rob and Charlotte, who works immigrants into a new country. Thus, patient-centred,
one day a week as a pharmacy assistant, they help to individualised care of patients and their families is imper-
individualise the patient for the staff. ative to incorporating specific cultural needs in the plan-
ning and delivery of interventions. This section outlines
important strategies critical care nurses can develop for
Language barriers may necessitate the assistance of an working with patients and their families to identify the
interpreter with knowledge of healthcare terminology to essential beliefs and practices they need to have incorpo-
ensure the content is adequately translated. An indepen- rated into treatment and intervention plans during a
dent person ensures that the patient receives the message stressful time in an unfamiliar environment. Such actions
79
in its entirety from the health professional. Interviews can optimise their spiritual wellbeing and lessen some of
with previously intubated patients after discharge from the stress they feel.
the ICU capture, from the patients’ perspective, issues
with communication and highlight the need for further DEFINING CULTURE
improvement and understanding of the two-way process. Wepa describes culture: ‘Our way of living is our culture.
An example of this was from an ex-patient, who related It is our taken-for-grantedness that determines and defines
her situation: ‘They would come into the room in masses our culture. The way we brush our teeth, the way we bury
to talk to me. One doctor would stand there and read off people, the way we express ourselves through art, reli-
a summary: “[Subject’s name], we find her this and that”, gion, eating habits, rituals, humour, science, law and

162 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

sport; the way we celebrate occasions … is our culture. drives its service delivery. The result is that consequently,
All these actions we carry out consciously and uncon- patients and their families become sandwiched between
87, p. 31
sciously’. Simply, culture refers to the values, beliefs differing world views.
and practices that an individual, family members and
nurses undertake on a daily basis. It determines how the Research highlights the lack of alignment that can occur
world is viewed, and their orientation to health, illness, between the needs of consumers of health services and
96
life and death. 88-90 the intentions of healthcare providers such as nurses. It
is the potential for the non-alignment between patients
Culture involves a shared set of rules and perspectives and families and healthcare providers that critical care
acquired through the processes of socialisation and inter- nurse need to be aware of, as dissatisfaction with the care
nalisation, which provide a frame of reference to guide being delivered may arise when the patient’s and family’s
97
how members interpret such phenomena as health and needs are not recognised or attended to, leading to
illness and death and dying. This in turn influences their unnecessary tensions and conflicts between patients, fam-
91
actions and interactions. Culture is a more specific way ilies and nurses. A nurse’s willingness to acknowledge
of describing how groups of people function on a daily and respect patients’ world views and the things that are
basis, influenced by their beliefs, relationships and the important to them minimises the occurrence of any dis-
activities they engage in. satisfaction, as it values their specific needs during their
94
critical care experience.
Understanding that culture, ethnicity and race are not
the same thing is crucial to meeting the cultural needs
of patients and their families. Race is generally deter-
mined on the basis of physical characteristics and Practice tip
is often used to socially classify people broadly as
Caucasians, Europeans, Polynesians or Asians, for Being able to deliver culturally appropriate and safe
example. 87,92 However, assigning people to a homoge- nursing care requires the nurse to undergo a process of
neous group is problematic, the antithesis of cultural education and self-examination of culture, own cultural beliefs
diversity, and does not account for the diversity that and practices, and the possible influence these may have on
87
exists within many groups in contemporary society. practice.
Ethnicity extends beyond the physical characteristics
associated with race to include such factors as common
origins, language, history and dress – it is usually asso-
87
ciated with nations, although a number of ethnic Where the world views of patients and families are con-
groups may exist within a nation. siderably different from that of the nurse, Ramsden urges
nurses to identify the beliefs they hold about the patient
DIFFERING WORLD VIEWS and family, the impact of these interactions on the patient
and family, and the power the nurse can utilise during
Culture influences how people view the world, what they such interactions. 98,99 Sometimes the nurse’s personal
believe in and how they do things, particularly with beliefs will be in conflict with professional nursing beliefs,
regard to practices around health, dying and death. The which necessitates choosing between personal and pro-
critical care environment is unfamiliar for patients and fessional beliefs in the practice setting. For example, a
families, especially as health professionals’ beliefs, prac- nurse’s personal beliefs about life, death and body tissues
tices and world views may not align with their own. What may be compromised by the duty to care for a patient
is important for critical care nurses may not be important with brain death awaiting the removal of organs for trans-
for the patient or the family, and may lead to tension plant. This may also be compounded by nursing staff
and dissatisfaction when the way patients’ and families’ shortages, less-than-desirable skill mixes, and the acuity
views are at variance. This does not mean that one world and complexity that critical care nurses are faced with on
view is necessarily more right or wrong – they are a daily basis. Therefore, it is vital, not only for the indi-
different. vidual nurse, but also for the team of critical care nurses
The biomedical model influences the way healthcare ser- to develop strategies that can optimise the development
93
vices are structured and delivered. As a dominant model of working relationships with patients from different cul-
it heavily influences the necessary focus on the physical tural backgrounds.
wellbeing of patients within critical care environments.
Focusing on the management of disease and illness, and CULTURAL COMPETENCE
using processes that lead to health issues being frag- Different models exist to assist in the integration of the
mented and reduced to presenting signs and symptoms cultural beliefs and practices of patients and their family
and diagnoses, risks excluding what is important for the in critical care nursing practice. For example, Leninger’s
94
89
patient and family. This contrasts with indigenous cul- cultural care diversity and universality theory requires
tures, for example, which tend to have a holistic eco- nurses to deliver culturally congruent nursing care for
spiritual world view, with a strong spiritual dimension people of varying or similar cultures. Ramsden’s work on
95
that extends beyond a disease and illness focus. The cultural safety 98,99 focuses on the delivery of nursing care
world view of critical care nurses is influenced by the to patients (whose cultural beliefs and practices differ
cultural beliefs, practices and life circumstances of each from that of the nurse) that is determined appropriate
nurse, and the ‘world view’ of the critical care service that and effective by the patients and families who are the

Family and Cultural Care of the Critically Ill Patient 163



TABLE 8.2 Levels of cultural practice 100 Practice tip

Level of cultural The ability to deliver culturally competent nursing practice
practice Indicators involves self-awareness, the nurse’s actions undertaken to
improve the patient’s and family’s health experience, and
1 Awareness Recognition that differences between integrating their beliefs and practices into treatment and
groups of people extend beyond
socioeconomic differences. intervention plans.
2 Sensitivity Recognition that difference is valid, which
initiates a critical exploration of personal
cultural beliefs and practices as a ‘bearer’ Cultural competency is about practising in a sound
104
of culture that may affect others. manner rather than about behaving correctly. Durie
encouraged the development of cultural safety (which
3 Safety Delivery of a safe service as a result of
undergoing education about culture and focuses on the experience and determination of the
nursing practice, and reflecting on their appropriateness of care received), to a construct that can
own and others’ practice. measure the capability of the health worker, such as the
critical care nurse. Culturally competent nursing prac-
104
tice is about:
● the nurses’ knowledge about their own cultural beliefs
recipients of that care. These models have been used to
guide nursing practice in Australia and New Zealand, and practices and the impact these may have on others
respectively. Such models require that critical care nurses ● the actions of the nurse to improve the patient’s health
recognise patients’ and families’ views of their health experience, and the integration of culture in clinical
93
experience and any that subsequently have discordant practice 103
priorities. Wood and Schwass have described three levels ● delivering culturally competent and safe care.
at which a nurse may practise with respect to cultural Cultural competence provides a framework to objectively
100
issues (see Table 8.2). These levels, ranging from cul- measure the nurse’s performance. The ability of the criti-
tural awareness to cultural safety, describe the differing cal care nurse to deliver culturally competent and safe
characteristics of nurses’ cultural care. For example, a care is dependent on determining the cultural needs of
nurse practising in an organisation where cultural safety patients and families, and the provision of patient-
was required would need not only to recognise differ- centred, individualised care.
ences between groups of people, but also to deliver dif-
fering cultural care to individuals after undergoing DETERMINING THE CULTURAL NEEDS
appropriate education. OF PATIENT AND FAMILY
From a transcultural nursing perspective, culturally com- The concepts of health and illness are generally con-
petent nursing care requires the nurse to incorporate cul- structed within the context of people’s sociocultural envi-
tural knowledge, the nurse’s own cultural perspective and ronment and the groups they belong to; these vary from
the patient’s cultural perspective into intervention plans. person to person and group to group. To this end, culture
90
However, Ramsden argued that it is not possible to collate influences how health and illness experiences are con-
cultural knowledge specific to various groups owing to structed and lived. When people become critically ill,
the diversity that exists both among and within groups. their cultural beliefs and practices can be just as impor-
98
Therefore, critical care nurses are advised to critically tant as their physical health status. Yet cultural beliefs
105
examine theories and models to guide their practice, to and practices are often compromised when healthcare
ensure they deliver appropriate and effective care for the providers’ concern about physical health takes prece-
patients and families they work with. dence – invariably, health services also do things differ-
ently than patients and families would do them. While
Competence is an important dimension of nursing prac- the importance of psychosocial and cultural needs is the
tice, as it provides users of nursing services with confi- focus of this chapter, the presence of life-threatening
dence in nurses’ knowledge, skill and attitudes necessary events or crises experienced by the patient in critical care
to undertake their practice. Given the importance of must rightfully take precedence. However, on stabilisa-
culture in the delivery of nursing care, the measurement tion of the patient, creating a positive working relation-
of cultural competence is also important. There is evi- ship with the family can facilitate the determination of
dence of numerous variations on the concept of cultural their perspectives and needs and negotiation about how
competence. 101-103 The attributes of cultural competence these can be included in a potentially complex plan of
include cultural awareness, cultural knowledge, cultural care. Incorporating cultural requirements becomes vital
understanding, cultural sensitivity, cultural interaction in a delivery of nursing care that is both appropriate and
101
and cultural skill. However, the inherent need for the acceptable. Therefore, given the nature of critical care set-
acquisition and use of culturally specific information tings, the quality of interactions with the patient’s family
limits the application of these attributes: the collation of is just as crucial as interactions with the patient.
culturally specific information is becoming increasingly
problematic as our communities become more diverse in Promoting a genuine, welcoming atmosphere and the
their composition. use of effective communication invites the family to be

164 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

involved early in the patient’s critical care experience, and convenience. The critical care nurse is discouraged from
is essential to determine the cultural needs of the patient adopting a ‘one-size-fits-all’ approach to nursing practice,
and family. While communication has been mentioned as this disregards the cultural systems of the patient and
94
earlier, interpreting cultural needs requires the critical care family. Individualised care is optimised by nurses having
nurse to be attentive to communication. Nurses are sufficient information about the patient and family in
advised to talk less, attend to details that may arise, and order to identify the needs and plan interventions. Incor-
simply listen. The need to intervene and to dominate porating each family’s cultural beliefs and practices pro-
105
discussions and ‘interviews’ with the family from the vides a ‘bigger picture’ of the patient than would have
107
nurse’s perspective needs to be curbed, so time is made been gained by simply focusing on the presenting disease
available for cultural beliefs and practices to be shared. 20,94,105 or illness and its management. Such an approach to indi-
Understanding and supporting the patient and family can vidualised care enables the critical care nurse to become
be improved by the nurse’s empowering them through familiar with the context of the patients’ life circum-
the processes of listening, understanding and validating stances and how they interpret illness, and also improves
what they have to say. 106,107 Conning and Rowland’s the quality of care and interactions they have with patients
research on the attitudes of mental health professionals and families. 112,113
towards management practices and the process of assess-
ing patients and decision making found that those who Sometimes the nurse will want to have a full understand-
had a greater ‘client orientation’ (versus management ori- ing of a cultural belief or practice before being willing to
entation) were more likely to engage in assessment pro- incorporate it. For example, several years ago a Māori
cesses that facilitate patient-centred, individualised care. 108 patient was dying and the family wanted to organise the
patient’s expedient removal from the hospital environ-
Working in partnership with a family can bridge the cul- ment on the patient’s death. This was necessary so that
tural ‘gap’. However, this is not always easy to achieve in the spiritual and cultural grieving processes could be
challenging situations, such as when various members of commenced. But the nurse blocked the family’s desire to
a large family come and go, compounded by changing plan and organise a prompt postmortem on death
nurses with shift changes. Receiving clear and consistent because the patient had not yet died. This created unnec-
messages about the patient, including his/her progress essary tension and conflict between the nurse and the
from all members of the health care team, can reduce family. Clearly the nurse’s and the family’s beliefs about
cross-cultural confusion and misunderstanding, espe- death and dying were different, and the apparent position
cially as messages are prone to distortion and change of ‘power’ adopted by the nurse did not encourage com-
when many are involved. A strategy to manage this may munication and negotiation about how this situation
involve discussing the management of information dis- could be resolved to the satisfaction of both parties. This
semination with the family, and the identification of one is an example of where the identification and acceptance
or two family members who become the point of contact of cultural beliefs and practices of the family (to the
through which staff discuss and communicate informa- extent that they will not deliberately harm the patient),
tion about the patient. Often apparent ‘cultural con- and working with the family on how these are incorpo-
94
flicts’ will arise as a result of communication problems rated in an intervention plan, can be beneficial to all
with the family; communicating information in a clear parties. Once this has occurred, it is crucial this informa-
and understandable manner helps prevent these prob- tion is documented thereby making visible the patient’s
lems from occurring. individualised care. 114
INDIVIDUALISED CARE
‘Individualised care requires the patient and nurse to Practice tip
work together to identify a path towards health that
maintains the integrity of the patient’s sense of self and Determining cultural needs means the critical care nurse must:

is compatible with their personal circumstances’. 109, p. 46 ● identify a spokesperson to communicate information to so
This means the critical care nurse ideally working in part- the messages the family receives are consistent;
nership with the family to identify important cultural ● engage in genuine communication and partnership with
beliefs and practices that need to be observed during the the patient and family;
patient’s critical care experience; in other words eliciting ● be willing to listen, understand and validate information
110
a patient’s view to individualise care. It is recognised received.
that ‘the work’ of the nurse involves responding, antici-
pating, interpreting and enabling, all of which are crucial
111
for individualised care. Indeed, partnership requires the
nurse not only to work with the patient and family but Practice tip
also to identify the power that the nurse possesses and
the potential for its inadvertent misuse. 94 To optimise interactions with people from a culture different
from yours as a critical care nurse:
Facilitating the inclusion of cultural beliefs and practices ● Avoid making assumptions.
requires them to be identified and then incorporated in ● Avoid culturally offensive practices that are known and
an individualised plan of care. However, given the resource learned.
constraints and the culture of some health services, uni- ● Remember that actions speak louder than words.
versal approaches to planning care may be adopted for

Family and Cultural Care of the Critically Ill Patient 165


WORKING WITH CULTURALLY fundamental belief that illnesses are caused by some
AND LINGUISTICALLY DIVERSE external force.
PATIENTS AND FAMILIES For many cultural groups the presence of family is vital to
Globalisation has resulted in increasing immigration and both the patients’ and family’s spiritual wellbeing. There-
migration in both Australia and New Zealand, thus popu- fore, facilitating family presence at the patient’s bedside
lations are increasing in their cultural and linguistic diver- and possibly including them in the care of the patient is
sity. In 2006 Australians and New Zealanders comprised important. For some cultures there is a belief that family
24% and 20%, respectively, of peoples who were born members should shoulder the burden of information and
overseas. Immigrants arrive from various countries glob- decision making so the patient can expend their energy
ally, but especially the European, Asian and African con- and focus on getting better. In some cases to burden the
tinents. Labels assigned to groups of ‘immigrants’, such patient with information about their condition, espe-
as Asians, are misleading and far from the homogeneity cially its gravity, or having to make decisions, is believed
they infer. Added to the complexity of trying to determine to contribute to a negative outcome. Thus, positively
ways of working with culturally and linguistically diverse engaging families and where practical patients in collab-
patients and families is the variation in their degree of orative relationships, involving them in the care and deci-
acculturation – for example, some may be second- or sion making, and ensuring their cultural values, beliefs
third-generation Australian- or New Zealand-born and and practices are protected, are ways critical care nurses
highly acculturated into the respective culture, or they can respect the cultural traditions of those patients who
may be new immigrants with traditional cultural beliefs are from different cultural and linguistic backgrounds.
115
and practices. Therefore, given this diversity it is difficult Campinha-Bacote’s mnemonic, ASKED, provides a
to provide specific guidelines on working with culturally process for self-reflection to make explicit your knowl-
and linguistically diverse patients and their families, edge and skills and desires to work with people who are
although some common principles exist. culturally and linguistically diverse. The following ques-
A fundamental starting point for working with culturally tions can be asked:
and linguistically diverse patients is to establish their ● Awareness: what awareness do you have of the stereo-
capacity to communicate in English. Determining the types, prejudices and racism that you hold about those
language a patient uses on a daily basis and whether they in cultural groups that are different from your own?
can speak and write in English, will indicate whether an ● Skill: what skills do you have to undertake a cultural
interpreter is needed. Family members or friends can be assessment in an appropriate and safe manner?
used as interpreters when care is being undertaken on a ● Knowledge: how knowledgeable are you about the
daily basis, although a professional or accredited inter- worldviews of the various cultural and ethnic groups
preter should be used when important information is to within your community?
be shared or when decisions need to be made. This avoids ● Encounters: what face-to-face interactions have you
the potential for family members or friends ‘censoring’ initiated with people from different cultural groups
the information conveyed during discussions. How the than yourself?
patient prefers to be addressed, cultural values and beliefs ● Desire: what is the extent of your desire to be cultur-
related to communication (e.g. eye contact, personal ally safe or competent in your nursing practice?
space or social taboos), preferences related to health care
providers (that is culture, gender or age), the nature of By critical care nurses understanding their position on
family support, and usual food and nutrition are other nursing people from other cultures, strategies can be
areas that should be explored with the patient or family, adopted to improve their responsiveness and quality of
whichever is appropriate. care delivered. Working with culturally and linguistically
diverse people should be based on the following
Given the great diversity that occurs within contemporary framework:
cultural groups, it is crucial to develop a relationship so
important cultural values, beliefs and practices can be 1. Partnership: aim to work in partnership with the
identified and incorporated into the patient’s plan of care. patient and family. Prior negative experiences may
Critical care nurses can then better understand patients’ influence the development of a productive rela-
or families’ behaviours when the patient is critically tionship. A respectful, genuine, non-judgmental
unwell. Discovering the values and beliefs patients and attitude is necessary to develop a productive rela-
their family have about health, illness, death and dying, tionship with the patient and family, and provid-
and what they believe may make their health worse, is a ing time for responses is important.
good starting point, and will provide insight into the 2. Participation: where possible the patient and
type of support and caring behaviours that may be family should be involved in their care, if this is
observed. In addition to this, identifying how health and appropriate. This will involve the critical care
illnesses are managed will provide an indication of nurse explaining the treatment and intervention
whether traditional healers are used, along with healing routines.
remedies, such as herbs and prayer for example. Also 3. Protection: involves the critical nurse determining
understanding the patient’s locus of control can also specific cultural and spiritual values, beliefs and
provide an indication of whether they will play an active practices, and enabling these to be practicsed
role in the outcome of an illness, or whether there is a during the patient’s time in the critical care unit.

166 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Where possible these should be accommodated, Māori have a collective, rather than an individual, orien-
although there may be instances when this is not tation, with whakapapa and kinship having an important
119
possible. In such situations, the patient and family place. Reilly outlines the variations that occur in the
119
should be fully informed of the rationale for this. contemporary social organisation of Māori. The whānau
is the social group that critical care nurses will generally
Considerations when caring for indigenous people are
reviewed in the next section. Closely related to cultural interact with. Turia stresses that whānau encompasses
120
aspects of care is spirituality, which for some is based in more than the common notion of the family. Whānau
religion. Aspects to consider when patients have religious are inclusive and are made up of multiple generations,
needs are reviewed later in this chapter. extending widely to include those who have ‘kinship’ ties.
This contrasts with the ‘nuclear’ family concept. Elders,
WORKING WITH MĀORI PATIENTS especially kuia (older respected women) and kaumatua
(older respected men) possess mana (power, authority
AND FAMILIES and prestige) and important status that commands
Māori are the indigenous people of New Zealand, and respect. Because of the status of kuia and kaumatua in
like other indigenous people who have survived the pro- Māori society, if they become ill it is especially important
cesses of colonisation, they experience poorer health for the whānau and wider Māori community to support
status, health outcomes and socioeconomic disadvantage them during this time.
than other groups in the New Zealand population. Māori
were not a homogeneous group of people before settle- Because of the collective orientation of many Māori,
ment by European people, and contemporary Māori con- whānau support is exceedingly important. Thus, critical
tinue to be diverse in their iwi (tribal) affiliations, cultural care nurses often have to explore how they manage rela-
116
identity, backgrounds, beliefs and practices, and in the tionships with large numbers of people within confined
colour of their hair, eyes and skin. The critical care nurse physical spaces, which may necessitate establishing rela-
ideally needs to recognise the diversity that exists, and tionships and identifying one or two people who will be
have a sociopolitical and historical analysis of contempo- the point of contact through which information can be
105
rary Māori. This positions the critical care nurse to under- communicated. Establishing connections and links can
stand the importance of, and respecting the need to be a positive way of engaging with Māori patients and
undertake assessments with Māori patients and whānau whānau; this is often called whanaungatanga, and Māori
regarding their cultural needs (see Table 8.3). will do this by sharing their whakapapa, or genealogy. This
means identifying where you have come from and who
The Treaty of Waitangi (commonly known as ‘the Treaty’) you are. It is crucial that the critical care nurse be able to
is based on an agreement between Māori and the Queen demonstrate a genuine intent and a willingness to listen
of England, Queen Victoria, which establishes the rights to what the whānau feel is important. Forming effective
of Māori as tangata whenua, or people of the land. There working relationships with Māori whānau can never be
are two versions of the Treaty – one in English and one underestimated. It is also useful for critical care nurses to
in te reo Māori (Māori language). Māori understood that establish working relationships with Māori health ser-
while they gave governorship to the Queen, under Article vices within their health service and to get to know the
One of the Treaty, they would retain their right to control local Māori community.
and self-determination over their lands, villages and
taonga (which includes health) under Article Two. Under Many Māori view themselves as spiritual beings, 116,121 and
Articles Three and Four Māori are guaranteed protection ill-health may therefore be seen to have a spiritual as
and the same rights as British citizens, including the pro- opposed to a physical cause. The way Māori interpret the
tection of beliefs and customs. Nurses working within the world is a unique blend of cultural artefacts from the past
New Zealand health setting can be considered agents of and present, also the nature of their interactions within
116
the Crown, 67,117 and therefore have a responsibility and contemporary society. Despite the diversity that exists,
obligation to honour the Treaty when working with many Māori have a world view that is holistic and eco-
Māori. The principles of partnership, participation and spiritual in nature. 92,120 This holistic and spiritual world
118
protection are used to apply the Treaty in practice view interconnects the physical world and the world of
120
within health settings such as critical care. others. Māori creation stories are cosmological in
nature, and establish the link Māori have to the atua
The commitment that critical care nurses have to estab- (gods) and tupuna (ancestors) who created the world and
lish, and maintain, a positive relationship with Māori all living things through the separation of Ranginui (the
patients and their families, is as important as being ‘sky father’ in mythology) and Papatuanuku (the ‘earth
willing to facilitate the inclusion of cultural beliefs and mother’ in mythology). 122 For some Māori, acknowledg-
practices in the care of the patient. Such a commitment ing atua and tupuna in karakia (ritual chants or prayer) is
can influence the outcome of the critical care experience spiritually important, as well as maintaining their strong
for Māori patients and their whānau. It is not the purpose links to others and the land. Some Māori also have reli-
of this section to provide a ‘recipe’ for working with Māori gious faiths originating from the processes of colonisa-
in the critical care setting. An overview of the fundamen- tion, and may include Christianity or the Māori-based
tal issues to consider, and the importance of critical care Ratana and Ringatu faiths. 121
nurses establishing working relationships with local
Māori health services and/or local iwi and Māori com- The activities of individuals and groups of Māori that
munity groups, is stressed. serve to control human activities and life, and maintain

Family and Cultural Care of the Critically Ill Patient 167




































Māori consideration ● Most Māori hold a holistic and spiritual view of the world that is interconnected with the physical environment. ● Determine the person’s and the whānau understanding of health, illness and dying. ● Māori also have a collective orientation (rather than an individualistic one), so having whānau present is important. ● Find out any concerns the person and their whānau may have. ● Be aware of tapu and its influence on a pers











Considerations for working with Aboriginal or Māori people







Aboriginal consideration ● Consider both the mind and body when delivering health care. ● Talk to the family and Aboriginal health workers in an attempt to alleviate fears. ● Explore how traditional medicine can complement Western medicine. ● Acknowledge Aboriginal peoples’ needs to connect to the land and possible need to return to their land to die. ● Respect of community elders. ● Elders are often spokespersons for the family so the













Holistic, spiritual world view Beliefs around hospitali- sation and places to die Establishing relationships Women’s business and




TABLE 8.3 Issue Traditional healing Connections Elders Diversity Language men’s business Relocation

168 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

health and wellness, are restricted spiritually and practi- and Torres Strait Islander people lived in tribes, clan, skin
cally (through rituals) by the concept of tapu (sacred or and language groups. Contemporary Aboriginal society
restricted). 121,123 Breaches of tapu, while spiritual in lives in a mixture of communities and families; some still
nature, often manifest in physical forms such as illness. live in old mission sites and homes and others live a
Often illness is seen as a failure to observe tikanga traditional life.
121
(custom) and tapu, and is known as makatu (a spell or Aboriginal and Torres Strait Islander people of Australia
curse) or mate Māori (sickness or death). Traditional suffer a greater burden of social disadvantage and poor
healers and healing practices (such as the use of rongoa health than other groups of the Australian population.
[medicine] and karakia [ritual chant or prayer]) play an There is a well-documented gap in life expectancy between
important role in healing someone who is ill. Accessing Aboriginal and Torres Strait Islander people of Australia
traditional healers, such as a tohunga (expert), may be an and other Australians. This gap is mainly due to diseases
important part of the critically ill person’s recovery or that are preventable, for example heart disease is three
dying process. However, cultural expressions of spiritual- times more prevalent in the Aboriginal and Torres Strait
ity differ among Māori, and for some, traditional cultural Islander population than in the broad Australian popula-
approaches may not be acceptable. The critical care nurse tion. 125 As a result of this poor health status, many critical
needs to identify the beliefs and practices related to well- care nurses will come into contact with Aboriginal and
being and illness.
Torres Strait Islander people. Critical care nurses are
There are some things that are done in one culture that placed in an ideal situation where the experiences of
are perceived to be offensive in another, and thus disrupt Aboriginal and Torres Strait Islander people and their
the formation of relationships. The concept of tapu families who are critically ill or dying can be positive
(sacred or restricted), mentioned above, is also associated whilst maintaining their cultural integrity.
with the concept of noa (common), or to make ordinary.
Thus, a person’s body, body fluids and body parts are Aboriginal view of health and health beliefs
considered tapu, whereas food is often used to make Aboriginal people of Australia have a different view of
something ordinary. In practical terms this means that health from the dominant Western view. This view incor-
food should be kept separate from the person’s body and porates notions of body, spirit, family and community. 126
body fluids. For example, do not put urine in urinals or The patient-centred model described by Espezel and
collecting chambers for faeces in pans on surfaces where Canam fits nicely with the Aboriginal view of health.
15
food will be put. Body tissue and body parts and their Described as far back as 1989 in the National Aboriginal
disposal is a major consideration in the care of Māori. For Health Strategy, 124 the Aboriginal view of health is a holis-
some Māori, having their body parts and any tissues tic view in which the sense of family is integral to the
removed returned to them so they can bury them is spiri- sense of oneself, which is in turn essential to health. 127
tually important: they are returning these to Papatuanuku
(the Earth Mother). However, again it is important to The Aboriginal view of health and how Aboriginal people
identify what is important for each patient and their relate to the healthcare system influences the care given.
whānau, as some Māori may not want their body tissue The following are specific beliefs Aboriginal people have
or parts returned to them. about health and medicine:
● The use of traditional or bush medicine is
WORKING WITH ABORIGINAL AND TORRES important.
STRAIT ISLANDER PEOPLE OF AUSTRALIA ● Access to their own ‘medicine man’ or traditional
healers is important.
Aboriginal and Torres Strait Islander peoples make up ● Health problems are attributed to higher spiritual
about 2.3% of the total population of Australia, although beings, such as pointing the bone or ‘payback’.
it is important to recognise that they are two distinct ● Hospitals are places where you go to die.
Indigenous groups each with their own cultural identity. ● White man’s medicine can make you sick.
Of the total population 90% identify as Aboriginal while
6% identify as Torres Strait Islander, and 4% identify as These are important points for nurses to understand, as
both Aboriginal and Torres Strait Islander. Aboriginal these health beliefs may influence people’s perceptions
124
and Torres Strait Islander people live throughout Austra- and may be mistaken for non-compliance with medica-
lia – some live in discrete communities in remote areas tions, or feelings of doom and not wanting to get better.
whilst others live in rural or urban areas. Aboriginal and It is important to explore how traditional Aboriginal
Torres Strait Islander people were forced off their tradi- medicine and health beliefs can be used complementarily
tional lands during colonisation and some have never with Western medicine – a particularly important point
returned. There are also the Stolen Generations who were for the palliative care of Aboriginal people.
removed from families and sent to missions often in
other states or overseas. Importance of family, community and land
Aboriginal and Torres Strait Islander people of Australia Aboriginal people have a strong connection to family,
have some of the oldest living cultures in the world. Their community and the land they live on. Some Aboriginal
culture is as dynamic and diverse as the areas in which people have a number of communities: the one they
they live. Their culture today is based on their rich spiri- were born into, the one they move to, and the one they
tual connection to the land and to each other. Aboriginal work in. There are a number of Aboriginal people who

Family and Cultural Care of the Critically Ill Patient 169

have never left their original community or land. The Aboriginal Health Workers
ties Aboriginal people have to their people and land Aboriginal people access health care in two ways: through
are so strong that, rather than receiving lifesaving care, Aboriginal Community Controlled Health Services and
many prefer to refuse the treatment and die on the land through mainstream health services. There are many
that they belong in, with their family and community reasons why Aboriginal people do not access mainstream
present.
health services. Some of these barriers are related to
There are members (elders) of the community who often transport, fear of institutions, or culturally inappropriate
speak on behalf of that community and its people. A healthcare services. Anecdotally, Aboriginal people are
similar approach occurs within families, where spokes- more likely to access mainstream health services if there
people speak on behalf of the family and its members. is an Aboriginal person employed in the services.
These spokespeople could be either male or female There have been efforts to increase the number of Aborig-
(brothers, sisters, ‘Aunties’ or ‘Uncles’), and spokesper- inal registered nurses to improve the competency of the
sons differ from community to community. Some Aborig- Australian nursing workforce in delivering appropriate
inal communities have lores that dictate that only women care to Aboriginal people. 126 This move is supported by
talk (women’s business) or only men talk (men’s busi- the ‘getting ’em ‘n’ keeping ’em’ report of the Indigenous
ness). It is important that critical care nurses identify who Nursing Education Working Group, 128 the Common-
is the spokesperson of the patient from the outset and wealth Department of Health and Ageing and the Office
who is the right person to talk to about all aspects of the for Aboriginal and Torres Strait Islander Health. 128
patient’s care.
Issues around death and dying
Often, Aboriginal people are transferred from remote or
rural areas to major hospitals for specialist services. This There are a number of important cultural factors sur-
can cause great anxiety for the patient, family and com- rounding death and dying relating to Aboriginal patients
munity and can often lead to the patient refusing care or and families. Aboriginal people have a deep spiritual con-
transfer. It is important that the family be informed about nection to the land, the country; this is part of their
the potential for relocation, that it is important and that dreaming. The most important factor will be the need for
the family be given time to talk it over. In reality, the the Aboriginal patient to go ‘back to country’, back to
importance of the family being able to spend as much their traditional lands to die or to heal. The critical care
time as possible with the patient cannot be underesti- nurse should allow time and facilitate discussion with the
mated. Having the opportunity to pass on knowledge team around these issues and to also make sure that the
through stories to family members is important for relevant family or community member is present.
Aboriginal people. The critical care nurse can facilitate However, many times the Aboriginal patient will die in
this by allowing the time and the space for this impor- the critical care setting. If this happens there are certain
tant storytelling to occur. However, financial constraints protocols that need to be considered. Gender-appropriate
and geographical distance may make family visiting care may be needed, as often male elders will not allow
difficult.
women into their room, and will request a male nurse to
The interface between critical care, the hospital and care for them. It is important to note that some Aborigi-
primary health care is a critical part of the patient’s nal communities do not allow health professionals to
journey. It is important that critical care teams have part- handle the body after death. The critical care nurse needs
nerships with their local Aboriginal Community Con- to discuss with the family issues that relate to handling
trolled Health Services. This enables planning of care of the body. Some Aboriginal communities do not allow
across the continuum, as Aboriginal people will often the body to be cremated.
have follow-up visits with their local Aboriginal health- Aboriginal people have a distinct culture and health
care services.
beliefs that can interfere with the Western view of medi-
cine and health. It cannot be stressed enough that the
Communication integration of the patient’s culture into the critical care
Aboriginal culture is one of the oldest living cultures, one setting is important to achieving health gains. The critical
that is based on a deep sense of spirituality and oral care nurse needs to know the Aboriginal community or
history. Traditionally, knowledge has been passed down communities and develop relationships in order to
from generation to generation through storytelling and improve the health experience of Aboriginal people.
yarning. In some communities traditional languages are This section has highlighted the importance of consider-
still being used, and English may be a second or third ation of cultural differences in nursing care of the criti-
language for many Aboriginal people. Critical care nurses cally ill Aboriginal person, with important points
may need to identify interpreters to optimise communi- summarised in Table 8.3. Some important cultural aspects
cation with patient and family. Interpreters can be family that need to be taken into account are:
members, Aboriginal Health Workers or Aboriginal
Liaison Officers. Health information and health literacy ● Each Aboriginal community is different and has dif-
is a vital part of communicating with Aboriginal people. ferent lores; these need to be considered on a one-to-
It is important to identify the need for culturally appro- one basis.
priate resources, including visual aids, and to take steps ● Aboriginal health is holistic, and the community and
to access these. family are central to health.

170 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

● Aboriginal Health Workers are central to the transfusions for those belonging to the Seventh Day
care of Aboriginal people and are the links between Adventist religion. Having a standardised list of religions
the Aboriginal communities and mainstream health. and procedural considerations is flawed due to the varia-
● Aboriginal culture influences health beliefs, and this tions that exist, and in some instances the variations are
can act adversely if not recognised. great. Thus, as part of the initial assessment the critical
nurse should determine whether the patient has religious
RELIGIOUS CONSIDERATIONS beliefs and practices that must be observed or not, and
incorporate these into the care plan.
Religious beliefs and practices contribute to a person’s
spiritual wellness on one hand, while on the other a criti- When a family member becomes critically ill, religious
cal care nurse’s religion may influence how care is deliv- beliefs and practices become an important coping mecha-
ered. 129 Religion can be closely aligned with a person’s nism in terms of making sense of the experience, as well
culture, and vary in how life, dying and death are viewed as being a source of faith and hope. While it can be
and may dictate how life is conducted. 1,130,131 Any breaches helpful to the critical care nurse to have an overview of
can have profound affects on a patient’s wellbeing, and the main religious beliefs and practices (see Table 8.4),
in some cases how family member may consequently caution must be used, and should not preclude working
interact with the patient. This has important implications with the patient’s family to ascertain exactly what their
for critical care nurses undertaking everyday practices, beliefs and preferences are. The involvement of family
and common procedures where religious beliefs dictate requires critical care nurses to broaden their focus from
a different approach. A common example is blood the patient to include the family who are often ideal




TABLE 8.4 Overview of key religious beliefs and practices 132,165

Religion Practices to be aware of Beliefs about illness, life and death
Protestantism Prayer and the Bible are important for support. Minister, Illness is an accepted part of life, although euthanasia
vicar or pastor may visit the sick person and the is not allowed. There is a belief in the afterlife, with
family. the dead being buried or cremated.
Roman Catholicism Prayer and the Bible are important. Some may have Illness is an accepted part of life, although euthanasia
restrictions on eating meat on Fridays of Lent, Ash is forbidden. There is a belief in the afterlife, with
Wednesday and Good Friday. Priest may undertake the dead being buried or cremated.
communion with and anoint the sick person.
Judaism There are orthodox and non-orthodox forms of Illness is an accepted part of life, with euthanasia
Judaism. Procedures should be avoided on the being forbidden, thus prolonging life is important
Sabbath (from sundown on Friday to sundown on and those on life support stay on it until death. The
Saturday). Dietary restrictions around pork, shellfish, Sabbath is a time that is considered sacred and
and the combination of meat and dairy products, when restrictions on activities are observed. There
extends to the use of dishes and utensils. Frequent is a belief that the human spirit is immortal. There
praying, especially for the sick person who should are special processes for managing the dead
not be left alone. The Rabbi will attend the sick person, who should be buried as soon as possible
person. after death. Thus, consultation with the Rabbi is
important. Postmortem examination is allowed only
if necessary.
Buddhism Prayer and meditation are important, using prayer Illness originates from a sin in a previous life. There is
books and scriptures, supported by teacher and a belief in afterlife, and the dead are buried or
Buddhist monks. The Buddhist is generally cremated. Living things should not be killed; this
vegetarian. Patients may refuse treatments (e.g. belief extends to euthanasia.
narcotic medications) that alter consciousness.
Hinduism Prayer and meditation are important, and are Illness is usually a punishment and must be endured.
supported by a Guru. Some Hindus are vegetarian. Some Hindus have healing practices based on their
The dying patient may have threads tied around the faith. There is a belief that the dead are
neck or wrist and be sprinkled with water; these reincarnated; they are usually cremated.
threads are sacred and are not removed after death.
The body is not washed after death.
Islam (Muslims) Private prayer, facing Mecca several times a day, Life and death are predetermined by Allah, and any
requires a private space. The patient may like to be suffering must be endured in order to be rewarded
positioned towards Mecca. Guided by the Qur’an in death. It is believed that dying the death of a
(Koran), which outlines the will of Allah (the creator martyr will be rewarded in death by going to
of all) as given through Muhammad (the prophet). paradise. Thus, staying true to the Qur’an is crucial.
Muslims fast during Ramadan, and eating pork and There is a belief in the afterlife, and the dead are
drinking alcohol is forbidden. Stopping treatment buried as soon as possible after death, on the side
goes against Allah. Talking about death should be facing Mecca.
avoided; designated male relatives will decide what
information patient and family should receive.

Family and Cultural Care of the Critically Ill Patient 171

informants regarding the religious needs of the patient. enable a person’s spiritual or religious needs to be deter-
Having said this, some patients have adopted religions mined. The critical care nurse needs to ascertain whether
separate from their family of origin, and in these circum- the patient and family have any spiritual or religious
stances family cannot be relied upon as informants, and beliefs and practices to be observed during their time in
in some situations there may be a conflict between the the critical care setting. 1,132 Once the spiritual or religious
religious values and practices of the patient and those of beliefs and practices have been determined, the critical
the family. Religious beliefs and practices, like cultural care nurse can facilitate opportunities for the patient and/
beliefs and practices, will vary between orthodox or tra- or family to carry out their beliefs and practices, and will
ditional and contemporary interpretations. importantly avoid any insensitive actions. 132 In this way
the critical care nurse can be sensitive to, and recognise,
Patients generally fall into three groups with regard to any spiritual distress evident in the patient and family
their religious practices. 132 There are those who: members.
1. practise their religious beliefs regularly A person’s spirituality, whether informed by religion or
2. practise their religious beliefs on an irregular basis, some other basis, manifests in a variety of relationships
often in times of need and stress with self, others, nature and ‘divine’ beings. It is the
3. have no religious interests. essence of who a person is, or who groups of people are.
While assessing spiritual or religious needs is one aspect,
All patients should have access to religious support where presence and being with, empathetic listening, reality ori-
they indicate a need. Therefore, it is beneficial for critical entation of the family, and enabling visiting and contact
care nurses to have knowledge of how to access the rel- are all important nursing activities that can support the
evant religious resources if needed. The focus of the criti- spiritual and religious needs of patients and their fami-
cal care setting often involves going to extreme lengths to lies. When families are confronted with the possibility
1
keep patients alive, which may well be in direct opposi- of death, the documentation of a death plan that outlines
tion to some religious beliefs. Religious beliefs can either the preferred care during the process of dying and death
facilitate or disrupt the process of living or dying. 130,131 is recommended. 132 Death plans are about empower-
There are a number of principles critical care nurses ment, and differ from advance directives, which outline
should underpin their practice with when nursing patients what is not wanted (e.g. cardiopulmonary resuscitation).
with specific religious needs (see Table 8.5).
Through formal discussion with the patient and/or
In addition to these principles, contact and communica- family, religious and end-of-life needs can be determined
1
tion with the critical care nurse is important, and can and a management plan developed for implementation.




TABLE 8.5 Principles for recognising religious needs
Principles Areas for consideration
Diversity exists between and within the various religions. Determine values and beliefs related to health, illness, dying, death, and any
specific requirements for undertaking everyday nursing cares and
procedures.
Spirituality is an essential part of care planning and the Spiritual and religious needs should be documented in the care plan to
delivery of quality care. ensure continuity and quality of care.
Interpersonal skills and therapeutic use of self is essential Approaching the patient with a genuine, non-judgemental attitude.
to engaging and being present with the patient and Avoid imposing own religious or spiritual beliefs on the patient and family.
family.
Being knowledgeable about a patient’s religious values Consult family, if they share same religion, and/or consult appropriate
about life, health, illness, death and dying enables the representative of the patient’s religion. Areas to explore should include the
critical care nurse to be respectful and accommodates following to determine:
in their care. ● religious values regarding life, health, illness, dying, and death
● nature of the ideal environment
● processes surrounding dying, if appropriate to the patient
● beliefs regarding nutrition and hydration
● use of touch
● gender-specific care
● family presence, involvement and support
● care after death.
Philosophies and policies should be cognisant of the Policies should be cognisant of cultural and religious diversity, and include
cultural and religious diversity within the critical care management of the following:
patient population. ● visiting
● modesty
● gender-specific care
● communication
● language and the use of interpreters.

172 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

END-OF-LIFE ISSUES patient by speaking and touching as this can have a
AND BEREAVEMENT calming influence. Comfort measures to enhance holistic
care delivery should continue and may include:
Over 80,000 Australians are admitted to critical care areas ● hygiene care
each year with a critical illness and although around 92% ● position changes
survive the critical illness, many still die in these areas. 133 ● foot and hand massages
End-of-life questions and bereavement in critical care ● hair washes and other individual preferences
areas are therefore important issues involving patients, ● artificial nutrition and hydration. 139
families and staff. Death can occur as a result of sudden
decline in the patient’s condition, or as a result of with- Patient dignity should be a priority, with gowns or per-
drawal of life support in anticipation of demise. Patient sonal attire essential elements of care. The management
death in critical care areas is found to have a significantly of symptoms further allows patients to maintain their
different effect on family members from a death in dignity. Privacy for patients and their families allows an
another in-hospital area. 134 This is perhaps due to the opportunity for them to communicate without the con-
heightened anxiety associated with a critical care environ- straints of observers. 143 As indicated in previous sections
ment 134 or due to the perception of an ability to cure in of this chapter, patient and family culture, beliefs and
highly medicalised areas. 135 Where possible, family- spiritual values are important considerations that under-
centred decision making with patient involvement, pin care. 137
together with effective communication and attention to
symptom management, is optimal. Practical and emo-
tional support for family and patients is important and FAMILY CARE
scrutiny of the way we manage these important areas Care of the family is supported by proactive palliative
provide quality indicators for critical care areas. 31,136 care interventions that include empathic, informative
communication with interdisciplinary team meetings
and family conferences that are not rushed where families
PATIENT COMFORT AND PALLIATIVE CARE are integral to decision making and goal planning. 31,52,144
Maintaining patient comfort and support for families and The desire to participate in decision making varies from
staff are primary requirements of nursing patients during family to family, and cannot be assumed. Ascertaining
the end stages of life. Advanced directives and ‘not for individual families’ needs for decision making is there-
resuscitation’ orders should be in place to prevent mis- fore recommended 145 as families are best placed to have
management and understanding of patient care (see an understanding of patients’ wishes, which can be taken
146
31
Chapter 5). Maintenance of patient comfort through into account when decisions are made. Structured com-
137
care guidelines to facilitate a ‘good death in ICU’ are munication between the health care team and families
designed to control symptoms such as agitation, pain and can assist with earlier decisions and goal formation about
breathlessness and are extremely important from the care. 147 Emotional and practical support can be given to
patient, family and nurses’ perspective. 138-140 Although families by providing written material about the critical
this may seem fundamental, there is evidence to suggest care area, local facilities and specific information on
52
this is not always achieved, with 78% of over 900 North bereavement. Privacy is not always possible in the busy
American critical care nurses perceiving that patients critical care environment, but maximising efforts in this
received inadequate pain medications ‘sometimes’ or ‘fre- regard for dying patients and their families provides a
quently’ during end-of-life nursing in critical care areas. 141 more conducive environment for strengthening patient–
family relationships and communication. 148
Collaboration and early involvement by palliative care
teams is one way to integrate end-of-life care for patients While the family grapple with some or all of the five
who either remain in critical care areas or are transferred stages of grief defined by Kubler-Ross: denial, anger, bar-
from the unit to other areas. 139 Withdrawal of mechanical gaining, depression, and acceptance, nurses need to
149
ventilatory support requires adequate provision for provide the physical and psychological care for patients
150
management of potential agitation, pain and hypoxia. 140 and families. This can be achieved when there is patient
Opioid and benzodiazepine agents should be considered and family-centred decision making, good communica-
for administration before and after extubation to prevent tion, continuity of care, emotional and practical support;
agitation and pain. Choices of bolus or infusion admin- and spiritual support can assist with this. Individualis-
151
istration need to be based on patient comfort issues. ing the care to the family is essential, and support mea-
Oxygen therapy is continued in the most appropriate sures should be instituted after a full assessment of their
form, and an oral airway may improve patient comfort needs. Without support, abnormal grief reactions can
and aid secretion clearance. Atropine and scopolamine occur, which decreases the family’s ability to cope with
have been reported to successfully reduce copious oral everyday needs and may progress to unresolved grief. 152
secretions and enhance comfort. 142
The detrimental effects of long-term unresolved grief after
The attainment of humane nursing care must include the death of a loved one are well documented. Current
heightened efforts in achieving quality indicators, such as terminology favours the term of prolonged grief disorder
mentioned above – adequate management of pain and (previously called complicated grief) which has clinically
nausea, agitation and restlessness. Both critical care staff disabling grief symptoms including, amongst others: a
and families should continue to communicate with the preoccupation with thoughts of the loss; avoidance of

Family and Cultural Care of the Critically Ill Patient 173

reminders of the loss; disbelief over the person’s death; guidance and support to critical care nurses as they
feeling lonely since the loss; feeling that the future holds develop better organisational and emotional support for
no purpose; and feeling stunned or shocked by the loss. 153 each other. 160 Effective palliation occurs when the multi-
These symptoms can result in elevated morbidity and disciplinary team, including senior management, collec-
mortality levels associated with depression, cardiac events tively develops a philosophy for palliative care and
(including a higher risk of sudden cardiac death), hyper- bereavement services. 151,139
tension, neoplasms, ulcerative colitis, suicidal tendencies, Nurses depend on colleagues and friends for support
and social dysfunction (including alcohol abuse and vio- when patients die, and value debriefing sessions. 156
lence). 154 These potentially harmful outcomes provide ‘Debriefing’ sessions can have a number of interpreta-
strong motivation for critical care clinicians to initiate tions. For example, ‘debriefing’ in critical care often takes
family support mechanisms such as bereavement ser- the form of an opportunity to share feelings. Alterna-
vices. 139 Bereavement programs aim to reduce the imme- tively, it may be for a procedural clinical review of events
diate physical and emotional distress for those grieving, where the objective is to understand and learn from the
while improving the long-term morbidity associated with situation. 160 Both components of debriefing are impor-
unresolved grief. 155
tant, together with the opportunity to provide mutual
156
Although critical care clinicians in the UK, USA, 139 support within the multidisciplinary team. The effective-
Europe and Canada 145 are conducting dialogue and devel- ness of sessions should be evaluated.
oping guidelines for bereavement care in critical care,
little evidence-based research has been conducted on A ‘grief team’ provides more formalised support from
bereavement care strategies. 139 An exception is a bereave- colleagues that have been given additional education on
158
ment program developed by a group of nurses from a grief, dying and death. This enables a program of care,
British ICU, who instituted a booklet on ‘coping with and may include such strategies as assessing the welfare
bereavement’, an after-care form for the clinical nurse to of the staff immediately after the death of the patient;
complete with details for follow-up with the family, and being present for staff members to express their feelings;
a sympathy card and letter inviting family to participate providing follow-up and information on coping mecha-
158
in support group meetings. 156 Although initial evaluation nisms during grief. Accessing experts from outside the
of the program through feedback from participating unit’s usual resources may be helpful with de-briefing in
160
family members was positive, the team acknowledges especially challenging situations. Dealing with death is
that this does not constitute rigorous research. Evaluation never easy; however, an awareness of colleagues’ needs is
of bereavement services in Australian adult ICUs was also a key to providing the support they require.
reported to be inadequate, as no data could be located
concerning bereavement services in other areas of critical SUMMARY
care. Only 30% of ICUs provided some follow-up care, The psychosocial, cultural and religious needs of critically
and only four units had any evaluation other than anec- ill patients and their families are just as important as their
dotal evidence. 157 It is imperative to assess new and exist- physical needs, and care needs to be taken not to overlook
ing bereavement interventions and how well they meet these. This chapter presents a holistic and patient- and
the needs of families through rigorous evaluation. Legiti- family-centred approach to practice, which enables indi-
mising research on this vulnerable group is required to vidualised plans of care that includes specific psychoso-
improve end-of-life care for families and patients. 156
cial, cultural and religious needs of critically ill patients
and their families. Indigenous Māori, Aboriginal and
CARE OF THE CRITICAL CARE NURSE Torres Strait Islander patients generally have a holistic and
The two previous sections have focused on care for the spiritual world view, and consequently have specific cul-
dying patient and the patient’s family. Critical care nurses tural practices that are vital to their spiritual wellbeing.
who care for both patients and families also require care Culturally and linguistically diverse patients and families
in bereavement situations. Caring for dying patients is also have specific cultural values, beliefs and practices that
emotionally draining and highly demanding of the critical critical care nurses need to determine, which may involve
care nurse, who often fails to notice or acknowledge the the assistance of an interpreter. These patients require the
need to grieve. 158,159 In addition, critical care nurses may critical care nurse to interact with them in a manner that
not have the knowledge and understanding of palliative facilitates the identification of their needs on an indi-
care and death in the critical care environment and a vidual basis. The old adage ‘actions speak louder than
specific educational program and unit guidelines on pal- words’ is worthy of consideration when working with
liative care may provide support and reduce burnout. 137,139 these patients in the critical care setting. It is important
that individual plans of care be developed that include
Once the patient has died, nurses may not have the the participation of Māori, Aboriginal and culturally and
opportunity to mourn publicly and may feel they are linguistically diverse patients and whānau or family,
acting unprofessionally if they show overt signs of grief. 158 reflecting the beliefs and practices that need to be included
Dealing with the death of patients may be exacerbated in in their critical care experience. In order to meet the needs
some critical care environments, particularly in the rural of the critically ill patient and family, the critical care
setting, where the nurse may know the patient outside nurse is advised to identify personal beliefs, practices and
the work environment. Collaboration with colleagues expectations that may influence professional decision
from oncology areas or palliative care teams will provide making and interactions with the patient and family.

174 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



Case study
A 56-year-old woman, Mrs Supitayaporn, has been admitted to the 2. The family have specific requests that potentially impact on
critical care unit with a severe head injury, following being struck the critical care environment, and Mrs Supitayaporn’s process
by a car while she was out walking. She also has a fractured of care.
humerus and pelvis. A decision has been made for surgical inter- 3. The critical care nurse realises she knows little about the
vention to relieve her increasing intracranial pressure (ICP). Just as Buddhist faith.
the critical care nurse is preparing her for surgery, her family arrives.
It is explained that Mrs Supitayaporn needs urgent surgery to sta- Discussion
bilise her condition and prevent further deterioration. During this This critical care nurse has identified early the need for an
process it becomes clear that Mrs Supitayaporn’s husband does not interpreter in order for Mrs Supitayaporn’s husband to understand
understand what is happening.
the information about his wife’s condition and impending surgery.
The critical care nurse asks if any of the family members speak The son indicated he could speak English, and while in the short-
English, and a son steps forward. The critical care nurse also asks if term he could be used as an interpreter, in the long-term a
there are any important beliefs or practices Mrs Supitayaporn has professional interpreter should be sought. This removes the
that should be considered prior to going to surgery, and in the pressure from the son having to convey information between the
planning of her care. Mrs Supitayaporn belongs to the Buddhist critical care nurse and the Mrs Supitayaporn’s husband. It is clear
faith, and it is important that her family are present to ensure her that the nurse has engaged in genuine communication, and is
mind is put at peace, and to tell her about her merits. It is also working with the family – the beginnings of a partnership. A
important for her to be in an environment that is quiet and unhur- feature of this critical care nurse’s communication is her willingness
ried. The son informs the critical care nurse that they believe to listen and understand the information the son was sharing. In
strongly in the law of karma, and Mrs Supitayaporn should not be the course of this discussion the critical care nurse discovers
resuscitated. The critical care nurse realises she does not know information related to Mrs Supitayaporn’s religious faith, and at the
much about the Buddhist faith, and endeavours to find a local same time realises she knows little about the Buddhist faith.
Buddhist monk to help staff understand Mrs Supitayaporn’s faith. However, she has determined the need for a quiet environment,
As a first contact, the critical care nurse approaches the hospital the importance of the family being present, and the patient’s
chaplain for advice on how to contact a Buddhist monk. beliefs about karma and the potential impact this will have on
her treatment and intervention. This information should be
Major issues documented in Mrs Supitayaporn’s clinical file for continuity and
There are a number of potential issues in this case study: quality of care. The critical care nurse is also attempting to make
1. The critical care nurse was alerted to a problem with contact with a Buddhist monk to become better informed about
Mr Supitayaporn not understanding the explanations this faith. This case study demonstrates the beginning of delivering
being given about his wife’s condition, and the plan for culturally appropriate care to someone who is culturally and
treatment. linguistically different from the nurse, with specific religious needs.







Research vignette
Roberti SM, Fitzpatrick JJ. Assessing family satisfaction with care of units share a common waiting room with families of theatre
critically ill patients: a pilot study. Critical Care Nursing 2010 30: patients.
18–26.
Results
Introduction From the 31 survey responses received, the overall satisfaction was
This paper does not have a published abstract, however, it was a high with scores of 94 out of a possible 100. Satisfaction with the
pilot study designed to evaluate satisfaction with the overall care support received scored highest on the subscales (4.74) and
of critically ill patients by way of a patient proxy – the patient’s comfort the lowest score (4.62). The individual item that received
family. Patients in critical care areas are generally too ill to evaluate the highest score was satisfaction with the quality of care given to
their level of satisfaction with their care. The authors state that their the patient (4.87) and the lowest was the time families had to wait
aim is to use the results to identify areas for future research. for test results (4.48).
Methods
A survey method was used with a convenience sample. The Critical Conclusion
Care Family Satisfaction Scale (CCFSS) was selected to elicit fami- Families were satisfied with the care their relative received. Con-
lies’ satisfaction with care. It contains 20 items with five subscales: cerns of families need to be considered and potentially addressed
assurance, information, proximity, support and comfort. Two by the entire health care team as it is important to improve family
related sites were used – one a 10-bed surgical intensive care unit members’ satisfaction with the care their critically ill relative
and the other a 14-bed telementry/intermediate care unit. The receives.

Family and Cultural Care of the Critically Ill Patient 175



Research vignette, Continued
Critique units’ results are combined for further analysis which could be
This pilot study focuses on the satisfaction family members experi- problematic if family members rate different items poorly in one
ence when their relative is in a critical care unit. The aim of the unit as opposed to the other. If they were kept separate, no
study is clearly stated as advancing the research in the area of in-depth reporting occurs. Of particular interest for the units is the
overall satisfaction with care from a legitimate surrogate (the items which scored lowest on the survey as this provides direction
family) of critically ill patients. The justification for improving ser- for future interventions and improvements. Family members
vices highlights the different nature of health care in USA com- scored waiting time for results and X-rays lowest and the noise
pared with other countries which have public sector funded care. levels in the unit the second lowest. It may have been more mean-
The authors comment on the need to excel in a market that sees ingful to present Table 3 (which gives the mean scores for each
health care facilities compete for clients. item) with the items listed from the highest score down to the
lowest score rather than as it is listed in order of how the items
The authors give a very good overview of previous research in the occur in the survey. That way the reader can readily see how items
area and provide a useful table that summarises pertinent studies. scored in relation to others. Once again, there may have been unit
It would be helpful for completeness to have the names of all of specific differences that are not apparent in the reported results
the scales used in the research projects incorporated into the table. with the exception of the worst scored item.
For example, the Family Satisfaction–Intensive Care Scale (FS-ICU)
was used in four of the studies but it is not noted in the table or The support subscale had the highest level of satisfaction and the
elsewhere in the paper whereas other scales are mentioned. This comfort subscale the lowest. The items within the comfort subscale
extra information helps the reader become familiar with validated pertain to the waiting room’s cleanliness, appearance and noise.
162
scales for evaluating family satisfaction. The authors justify their Other authors acknowledge that providing a comfortable envi-
choice for using the Critical Care Family Satisfaction Scale (CCFSS) ronment for families is important particularly as they can spend
which they consider is more inclusive. There is no definition given considerable time there during a relative’s critical illness as they
for who constitutes a family member. Some argue that a broad wait to be allowed in to be with their relative.
definition is desirable and that one’s family is made up with whom- The authors suggest a number of useful interventions aimed to
ever they indicate is their family and this may not be based on improve families’ satisfaction and these include the following:
blood or legal relationships and include those with a sustained ● Conduct a root cause analysis to identify reasons for wait time
relationship with the patient. 11 for test results.
● Improve communications with families to ensure both realistic
A survey was distributed to a convenience sample of family
members in two units: one a surgical intensive care unit (SICU) with timeframes and prompt attention when results are received.
10 beds and the other a telementary/intermediate care unit with ● Prioritise critical care tests within the hospital.
14 beds in a community hospital. No description is given in regards ● Patient/family communication board to document questions
to the acuity of the patients in the unit and one assumes that the or concerns.
patients in the SICU are more critically ill than in the other unit. One ● Provide vibrating pagers rather than audible systems to reduce
family member per patient was invited to complete the survey noise levels.
which reduces the potential for skewing the data with many family ● Implement decibel alarm system in unit to identify if noise
members from one patient. Families of dying patients were not levels go above a predetermined acceptable level.
invited to provide feedback. The authors give a humanitarian ratio- ● Play soothing music in unit which may minimise perceptions
nale of not adding to their dire situation, however, it could be of noise levels.
argued that this group is an under-researched and important ● Recognise environment of care is an important part of families’
163 p. 24-25
group in intensive care whose satisfaction with care is equally satisfaction.
161
important to the staff. Sensitivity would be key to their The authors clearly identify the limitations of a small convenience
inclusion. sample with families of patients of unknown acuity levels. The
degree of illness has been found to be associated with low sat-
164
The instrument is described well and the scoring is clearly outlined isfaction levels in a Moroccan study and this patient charac-
with an overall score out of a possible 100 and mean scores calcu- teristic may be worthy of inclusion in future studies. The authors
lated for the five subscales. Thirty-one surveys were returned and highlight the benefit of such a study to provide baseline
analysis was conducted with results showing the participants from measurements against which future interventions can be
both units were satisfied with the care. It appears that the two measured.

176 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



Learning activities
1. Delivering patient- and family-centred nursing care can be and dying, by identifying situations when your personal and
assisted by a philosophy for nursing practice. To develop and professional beliefs are in conflict. Once these beliefs have
articulate your own nursing philosophy, or way of doing things, been identified, the critical care nurse may ask:
complete the following activities: ● ‘How do these personal and professional beliefs influence
● List any organisational practices you can identify in the clini- my practice?’
cal practice setting in which you most recently worked that ● ‘What strategies do I need to implement to minimise nega-
might influence the model of nursing. tive impacts?’
● Write out a list of characteristics of a clinician you admire ● ‘When faced with a conflict between personal and profes-
and indicate how these complement good nursing care. sional beliefs and practices, which one is more likely to
● If you were a patient in the critical care unit in which you direct practice decisions, and why?’
recently worked, what would be important to you about the 3. Using the information established in Learning Activity 2,
nursing care you received? identify:
● If you had a family member in a critical care unit, write down ● your personal cultural beliefs and practices, and the impact
the top eight things you consider most important about the these have on the patients and families that use the services
care that you and your family member receive. Compare this of critical care
with the list provided earlier in the chapter in the section ● what actions you take to meet the patient’s and family’s
Needs of family during critical illness. needs during their critical care experience
● Having completed the above four activities, write three sen- ● how you can integrate culture into nursing practice and the
tences that reflect your desired way of nursing which can critical care setting that you work in.
constitute your philosophy of nursing. This information can serve as a baseline for the development
2. Ascertain the personal and professional beliefs you hold as a of strategies to improve practice.
critical care nurse about (a) health and illness, and (b) life, death






ONLINE RESOURCES 5. Berry L, Seiders K, Wilder S. Innovations in access to care: a patient-centered
approach. Ann Intern Med 2003; 139(7): 568–74.
Patient-centered care: improving quality and safety by focusing care on patients 6. Briggs L, Kirchhoff K, Hammes B, Song M, Colvin E. Patient-centered
and consumers, http://www.health.gov.au/internet/safety/publishing.nsf/ advance care planning in special patient populations: a pilot study. J Profess
Content/36AB9E5379378EBECA2577B3001D3C2B/$File/PCCC- Nurs 2004; 20(1): 47–58.
DiscussPaper.pdf 7. Franck L, Callery P. Re-thinking family-centred care across the continuum
Australian Indigenous Health InfoNet, http://www.healthinfonet.ecu.edu.au/ of children’s healthcare. Child: Care, Health Devel 2004; 30(3):
frames.htm 265–77.
eMJA articles on Aboriginal health: http://www.mja.com.au/Topics/Aboriginal%20 8. Gallant M, Beaulieu M, Carnevale F. Partnership: an analysis of the concept
health.htm within the nurse-client relationship. J Adv Nurs 2002; 40(2): 149–57.
Office of Aboriginal Health–WA, http://www.aboriginalhealth.wa.gov.au/ 9. Misak C. The critical care experience: a patient’s view. Am J Respir Crit Care
Cooperative Research Centre for Aboriginal Health, http://www.crcah.org.au/ Med 2004; 170(4): 357–60.
index.cfm 10. Friedman M. Family nursing: research, theory and practice, 5th edn. Stamford:
New Zealand Ministry of Health website (access to Māori health-related publica- Appleton & Lange; 2003.
tions and resources), www.moh.govt.nz 11. Wright LM, Leahey M. Nurses and families: a guide to family assessment and
Information about Māori protocol and beliefs can be obtained from the website intervention, 3rd edn. Philadelphia: FA Davis & Company; 2000.
Māori.org.nz (http://www.Maori.org.nz/tikanga/?d=page&pid=sp44&parent= 12. Hook ML. Partnering with patients – a concept ready for action. J Ad Nurs
42). 2006; 56(2): 133–43.
13. Olsen KD, Dysvik E, Hansen BS. The meaning of family members’ presence
FURTHER READING during intensive care stay: A qualitative study. Intens Crit Care Nurs 2009; 25:
190–98.
14. Shields L, Pratt J, Flenady V, Davis L, Hunter J. Family-centred care for chil-
Wright LM, Leahey M. Nurses and families: A guide to family assessment and interven- dren in hospital. Cochrane Database of Systematic Reviews 2003; 4: CD004811.
tion, 5th edn. Philadelphia: FA Davis; 2009. 15. Harwood L, Ridley J, Boyle L. Implementation challenges of a renal nursing
Wepa D. Cultural safety in Aotearoa New Zealand. Auckland, NZ: Pearson Education; professional practice model. Nephrol Nurs J 2003; 30(5): 503–15.
2004. 16. Espezel HJE, Canam CJ. Parent-nurse interactions: care of hospitalized chil-
Durie M. Whaiora. Auckland, NZ: Oxford University Press, 1998.
dren. J Adv Nurs 2003; 44(1): 34–41.
17. Institute for Patient-and Family-Centred Care, 2005. What is patient-
REFERENCES and family-centered care? [cited August 2010] Available from: http://
www.ipfcc.org/faq.html.
1. Nussbaum GB. Spirituality in critical care: patient comfort and satisfaction. 18. Webster P, Johnson B. Developing family-centered vision, mission, and philosophy
Crit Care Nurse 2003; 26(3): 214–20. of care statements. Bethesda, MD: Institute of Family Centered Care; 1999.
2. Alsop-Shields L. The parent–staff interaction model of pediatric care. J Pediat 19. Cypress BS. The intensive care unit: experiences of patients, families, and
Nurs 2002; 17(6): 442–9. their nurses. DCCN 2010; 29(2): 94–101.
3. Wilkins S, Pollock N, Rochon S, Law M. Implementing client-centred prac- 20. Frost M, Green A, Gance-Cleveland B, Kersten R, Irby C. Improving family-
tice: why is it so difficult to do? Can J Occup Health 2001; 68(2): 70–79. centered care through research. J Paed Nurs 2010; 25: 144–7.
4. McLaughlin C, Kaluzny A. Building client centered systems of care: choosing 21. Galvin E, Boyer L, Schwartz P, Jones M, Mooney P, Warwick J. Challenging
a process direction for the next century. Health Care Manage Rev 2000; 25(1): the precepts of family-centered care: testing a philosophy. Pediatr Nurs 2000;
73–82. 26(6): 625–32.

Family and Cultural Care of the Critically Ill Patient 177

22. Shields L, Tanner A. Pilot study of a tool to investigate perceptions of 50. Azoulay E, Pochard F, Chevret S, Lemaire F, Mokhtari M et al. Meeting the
family-centered care in different settings. Pediatr Nurs 2004;30(3): needs of intensive care unit patient families. Am J Respir Crit Care Med 2001;
189–97. 163: 135–9.
23. Bruce B, Letourneau N, Ritchie J, Larocque S, Dennis C et al. A multisite 51. Nelson DP, Polst G. An interdisciplinary team approach to evidence-based
study of health professionals’ perceptions and practices of family-centered improvement in family-centered care. Crit Care Nurs Q 2008; 31(2):
care. J Family Nurs 2002; 8(4): 408–29. 110–18.
24. Mitchell ML, Chaboyer W, Burmeister L, Foster M. The positive effects of a 52. Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S et al. A commu-
nursing intervention on Family-Centered-Care in adult critical care. Am J Crit nication strategy and brochure for relatives of patients dying in the ICU.
Care 2009; 18(6): 543–52. N Engl J Med 2007; 356: 469–78.
25. Mitchell M L, Chaboyer W. Family-centred care–a way to connect patients, 53. Soltner C, Lassalle V, Galienne-Bouygues S, Pottecher J, Floccard B et al.
families and nurses in critical care–a qualitative study using telephone inter- Written information that relatives of adult intensive care unit patients would
views. Inten Crit Care Nurs 2010; 26: 154–60. like to receive – A comparison to published recommendations and opinion
26. Courtney M. Evidence for nursing practice. Sydney: Churchill Livingstone; of staff members. Crit Care Med 2009; 37(7): 2197–202.
2005. 54. Mitchell ML, Courtney M. Improving ICU transfer, an intervention study:
27. Shields L. Questioning family-centered care. J Clin Nurs 2010; the family members’ perspective. Aust Crit Care 2005; 18(2): 61–9.
19: 2629–38. 55. Mitchell ML, Courtney M. An intervention study to improve the transfer of
28. Knutsson SEM, Bergbom IL. Custodians’ viewpoints and experiences from ICU patients to the ward: evaluation by ICU nurses. Aust Crit Care 2005;
their child’s visit to an ill or injured nearest being cared for at an adult 18(3): 123–8.
intensive care unit. J Clin Nurs 2007; 16: 362–71. 56. Kirchhoff KT, Faas AI. Family support at end of life. AACN Adv Crit Care
29. Duran CR, Oman KS, Abel JJ, Koziel VM, Szymanski D. Attitudes and beliefs 2007; 18(4): 426–35.
about family presence: a survey of health care providers, patients’ family and 57. Gonzalez C, Carroll D, Elliott J, Fitzgerald P, Vallent H. Visiting preferences
patients. Am J Crit Care 2007; 16(3): 270–79. of patients in the Intensive Care Medical Unit. Am J Crit Care 2004; 3(3):
30. Johnson BH, Abraham MR, Shelton TL. Patient- and family-centered care: 194–7.
partnerships for quality and safety. N C Med J 2009; 70(2):125–30. 58. Gavaghan S, Carroll D. Families of critically ill patients and the effect of
31. Nelson JE, Mulkerin CM, Adams LL, and Pronovost PJ. Improving comfort nursing interventions. Dimens Crit Care Nurs 2002; 21(2): 64–71.
and communication in the ICU: a practical new tool for palliative care 59. Roland P, Russell J, Richards KC, Sullivan SC. Visitation in critical care:
performance measurement and feedback. Qual Saf Health Care 2006; 15: processes and outcomes of a performance improvement. J Nurs Care Qual
264–71. 2001; 15(2): 18–26.
32. Ekwall A, Gerdtz M, Manias E. The influence of patient acuity on satisfaction 60. Molter NC. Family are not visitors in the critical care unit. Dimen Crit Care
with emergency care: perspectives of family, friends and carers. J Clin Nurs Nurs 1994; 13(1): 2–3.
2008; 17(6): 800–9. 61. Carnevale F. Avoiding family induced stress: effective strategies for working with
33. Szalados JE. Legal issues in the practice of critical care medicine: a practical families. Melbourne: 29th Australian and New Zealand Annual Scientific
approach. Crit Care Med 2007; 35(2 suppl): S44–58. Meeting on Intensive Care; 7–10 Oct; 2004.
34. Aiken LJ, Bibeau PD, Cilento BJ, Boutin R. A personal reflection: a case study 62. Mitchell ML. [Editorial] Family-centred care – are we ready for it? An
in family-centered care at the National Naval Medical Center in Bethesda, Australian perspective. Nurs Crit Care 2005; 10(2): 54–5.
Maryland. DCCN 2010; 29(1): 13–19. 63. Garrouste-Orgeas M, Philippart F, Timsit JF, Diaw F, Willems V et al. Percep-
35. Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J et al. Risk of tions of a 24-hour visiting policy in the intensive care unit. Crit Care Med
post-traumatic stress symptoms in family members of Intensive Care Unit 2008; 36(1): 30–35.
patients. Am J Respir Crit Care Med 2005; 171: 987–94. 64. Fumagalli S, Boncinelli L, Lo Nostro A et al. Reduced cardiocirculatory
36. Lee L, Lau Y. Immediate needs of adult family members of adult intensive complications with unrestrictive visiting policy in an intensive care
care patients in Hong Kong. J Clin Nurs 2003; 12: 490–500. unit: Results from a pilot, randomized trial. Circulation 2006; 113:
37. Leske JS. Protocols for practice: applying research at the bedside, interven- 946–52.
tions to decrease family anxiety. Crit Care Nurse 2002; 22(6): 61–5. 65. Lee MD, Friedenberg AS, Mukpo DH, Conray K, Palmisciano A, Levy MM.
38. Garrouste-Orgeas M, Willems V, Timsit JF, Diaw F, Brochon S et al. Opinions Visiting hours policies in New England intensive care units: strategies for
of families, staff, and patients about family participation in care in intensive improvement. Crit Care Med 2007; 35(2): 497–501.
care units. J Crit Care 2010; 25(4): 634–40. 66. Whitcomb JA, Roy D, Blackman VS. Evidence-based practice in a military
39. Jones C, Skirrow P, Griffiths RD, Humphris G, Ingleby S et al. Post-traumatic intensive care unit family visitation. Nurs Res 2010; 59(1 Suppl): S32–9.
stress disorder-related symptoms in relatives of patients following intensive 67. Van Horn ER, Kautz D. Promotion of family integrity in the acute care
care. Intens Care Med 2004; 30: 456–60. setting. Dimens Crit Care Nurs 2007; 26(3): 101–7.
40. Paparrigopoulos T, Melissaki A, Efthymiou A, Tsekou H, Vadal C et al. 68. Maxwell KE, Stuenkel D, Saylor C. Needs of family members of critically ill
Short-term psychological impact on family members of intensive care unit patients: a comparison of nurse and family perceptions. Heart Lung 2007;
patients. J Psychosomatic Res 2006; 61: 719–22. 36(5): 367–76.
41. Takman A, Severinsson E. The needs of significant others within intensive 69. Davidson JE, Powers K, Hedayat KM, Tieszen M, Kon AA et al. Clinical
care: the perspective of Swedish nurses and physicians. Intens Crit Care Nurs practice guidelines for support of the family in the patient-centered intensive
2004; 20: 22–31. care unit: American College of Critical Care Medicine Task Force 2004–2005.
42. Molter N. Needs of relatives of critically ill patients: a descriptive study. Heart Crit Care Med 2007; 35(2): 605–22.
Lung 1979; 8(2): 332–9. 70. Williams CMA. The identification of family members’ contribution to
43. Agard AS, Harderb I. Relatives’ experiences in intensive care – Finding a place patients’ care in the intensive care unit: a naturalistic inquiry. Nurs Crit Care
in a world of uncertainty. Intensive Crit Care Nurs 2007; 23: 170–77. 2005; 10(1): 6–14.
44. Alvarez GF, Kirby AS. The perspective of families of the critically ill patient: 71. Davidson JE. Meeting the needs of patients’ families and helping families
their needs. Curr Opin Crit Care 2006; 12: 614–18. adapt to critical illness. Crit Care Nurs 2009; 29(3): 28–34.
45. Chien WT, Chiu YL, Lam LW, Ip WY. Effects of a needs-based education 72. Arockiasamy V, Holsti L, Albersheim S. Fathers’ experiences in the neonatal
programme for family carers with a relative in an intensive care unit: intensive care unit: a search for control. Pediatr 2008; 121(2): 215–22.
A quasi-experimental study. Int J Nurs Stud 2006; 43: 39–50. 73. Azoulay E, Pochard F, Chevret S, Arich C, Brivet F et al. Family participation
46. Davidson JE, Daly BJ, Agan D, Brady NR, Higgins PA. Facilitated sensemak- in care to the critically ill: opinions of families and staff. Intens Care Med
ing: a feasibility study for the provision of a family support program in the 2003; 29: 1498–504.
intensive care unit. Crit Care Nurs Q 2010; 33 (2): 177–89. 74. Patak L, Gawlinski A, Fung NI, Doering L, Berg J, Henneman EA. Commu-
47. Hickman RL, Douglas SL. Impact of chronic critical Illness on the psycho- nication boards in critical care: patients’ views. Appl Nurs Res 2006; 19:
logical outcomes of family members. AACN Adv Crit Care 2010; 21(1): 182–90.
80–91. 75. Hemsley B, Sigafoos J, Balandin S, Forbes R, Taylor C et al. Nursing the
48. Kentish-Barnes N, Lemiale V, Chaize M, Pochard F, Azoulay E. Assessing patient with severe communication impairment. J Adv Nurs 2001; 35(6):
burden in families of critical care patients. Crit Care Med 2009; 37(10 Suppl): 827–35.
S448–56. 76. Casbolt S. Communication with the ventilated patient: a literature review.
49. Mitchell ML, Courtney M, Coyer F. Understanding uncertainty and minimiz- Nurs Crit Care 2002; 7(4): 198–202.
ing families’ anxiety at the time of transfer from intensive care. Nurs Health 77. Hupcey JE, Zimmerman HE. The need to know: experiences of critically ill
Sci 2003; 5(3): 207–17. patients. Am J Crit Care 2000; 9(3): 192–8.