'It's not like the wards'. Experiences of nurses new to critical care: a qualitative study.

BACKGROUND: Critical care is both emotionally and intellectually challenging, yet little is currently known about the experience of nurses' new to this environment. AIMS: The aims of the study were to: 1. Explore the experience of nurses' new to critical care. 2. Identify what factors influence the nurses' experiences during this time. 3. Evaluate methods used to facilitate nurses' development such as education and preceptorship. METHODS AND PARTICIPANTS: This longitudinal qualitative study was undertaken using hermeneutic phenomenology and involved all nurses (n=14) recruited to the unit during two cohort intakes in 2002. Data collection was by means of semi-structured interviews at one, three and six months. All interviews were tape recorded, transcribed, and analysed for emerging themes and concepts. FINDINGS: Participants described a variety of unique experiences throughout the interviews, many of these related to four key themes: support, knowledge and skills, socialisation and moving on. There were also a number of key factors influencing these experiences including foundation programme, support, preceptors, staff and pre-requisites. Although strategies such as education and preceptorship were positively evaluated, areas for improvement were also identified. CONCLUSION: This study captures the unique experiences of nurses new to critical care and demonstrates the complexity of socialisation to the critical care milieu.

Are tympanic thermometers a source of cross-infection?

AIM: To find out if tympanic thermometers are a source of cross-infection in critical care and whether cleaning is effective. METHOD: An observational study. RESULTS; In most of the inspections the surfaces of the tympanic thermometers looked clean, but three inspections revealed spots of dried fluid and one revealed a dirty base. None of the swabs taken before or after cleaning was positive, but seven of the inspections identified that the lens of the tympanic thermometer was dirty, poSsibly with cerumen (earwax). CONCLUSION: The findings from this study do not support the assumption that tympanic thermometers are a source of cross-infection in critical care, but a potential risk of cross-infection by this route cannot be excluded.

Temperature measurement: comparison of non-invasive methods used in adult critical care.

AIMS AND OBJECTIVES: To assess accuracy and reliability of two non-invasive methods, the chemical (Tempa.DOT) and tympanic thermometer (Genius First Temp M3000A), against the gold standard pulmonary artery catheter, and to determine the clinical significance of any temperature discrepancy using an expert panel. BACKGROUND: There is continued debate surrounding the use of tympanic thermometry in clinical practice. DESIGN: Prospective study. METHODS: A total of 160 temperature sets were obtained from 25 adult intensive care patients over a 6-month period. RESULTS: About 75.2% (n = 115) of chemical and 50.9% (n = 78) of tympanic readings were within a +/-0.0-0.4 degrees C range of the pulmonary artery catheter. Both the chemical and tympanic thermometers were significantly correlated with temperatures derived from the pulmonary artery catheter (r = 0.81, P < 0.0001 and r = 0.59, P < 0.0001) and limits of agreement were -0.5-0.9 degrees C and -1.2-1.2 degrees C respectively. The chemical thermometer was associated with a mean temperature difference of 0.2 degrees C, which increased 0.4 degrees C when used in conjunction with a warming blanket. With regard to clinical significance 15.3% (n = 26) of chemical and 21.1% (n = 35) of tympanic readings might have resulted in patients receiving delayed interventions. Conversely 28.8% (n = 44) of chemical and 37.8% (n = 58) of tympanic readings might have resulted in patients receiving unnecessary interventions. CONCLUSIONS: The chemical thermometer was more accurate, reliable and associated with fewer clinically significant temperature differences compared with the tympanic thermometer. However, compared with the pulmonary artery catheter both methods were associated with erroneous readings. In the light of these findings and previous research evidence, it is becoming increasingly difficult to defend the continued use of tympanic thermometry in clinical practice. However, as chemical thermometers are not without their limitations, further research needs to be undertaken to evaluate the accuracy and reliability of other non-invasive methods. RELEVANCE TO CLINICAL PRACTICE: Chemical and tympanic thermometers are used in both adults and children in a wide variety of settings ranging from community to intensive care. As such these findings have significant implications for patients, users and budget holders.

Practical considerations in the administration of intravenous vasoactive drugs in the critical care setting. Part II--how safe is our practice?

INTRODUCTION: Vasoactive drugs (e.g. inotropes), namely adrenaline and noradrenaline, are frequently used in critical care to maintain cardiovascular function. This is achieved by ensuring that a continuous infusion of the vasoactive drug is administered so that when one infusion is about to finish another infusion is commenced. This is known as "double pumping" or "piggy backing". Failure to administer these drugs appropriately may result in haemodynamic instability (hypotension and hypertension) and in extreme cases death. AIMS: The aim of this study was to evaluate current practice and identify the safest method for inotrope administration. METHODS: A series of three consecutive audits were undertaken to determine which 'Method' and 'Syringe Driver' were associated with the least adverse effects to patient blood pressure. RESULTS: The findings suggest that Modified Method 2, when used in conjunction with a high-risk syringe driver and guidelines, proved to be the safest method for 'double pumping' inotrope drugs. Modified Method 2 instructed nurses to: 'Run both syringe drivers together until a rise in systolic blood pressure is seen (>5 mmHg), then turn the near empty infusion off'. CONCLUSION: As a direct result of these audits, and the development of guidelines, inotrope administration practice on the unit has improved.

Suctioning: a review of current research recommendations.

Effective suctioning is an essential aspect of airway management in the critically ill. However, there are many associated risks and complications. These range from trauma and hypoxaemia to cardiac dysrhythmias and, in extreme cases, cardiac arrest and death. This paper identifies the current research recommendations for safer suctioning practices. The literature is reviewed in three parts: prior to suctioning; during suctioning; and post-suctioning. The recommendations prior to suctioning include patient assessment, patient preparation and hyperoxygenation. The recommendations during suctioning include appropriate catheter selection, depth of insertion, negative pressure, duration of procedure and number of suction passes. Measures for maintenance of asepsis, such as hand-washing, wearing gloves, goggles and aprons are other essential considerations, which must not be overlooked. The recommendations post-suctioning include reconnection of oxygen, patient assessment, reduction of oxygen to baseline level, and providing patient reassurance. In order to improve standards of care, it is imperative that nurses are aware of current research recommendations. This will enable nurses to make informed decisions about their own suctioning practices, based on the individual needs of the patient.

Tracheal suctioning: an exploration of nurses' knowledge and competence in acute and high dependency ward areas.

BACKGROUND AND RATIONALE: With an increasing demand for intensive care beds more nurses in acute and high dependency wards will be expected to care competently for patients with tracheostomy tubes. Tracheal suctioning is an essential aspect of effective airway management. However, this has many associated risks and complications, ranging from trauma and hypoxaemia to, in extreme cases, cardiac arrest and death. It is imperative that nurses are aware of these risks and are able to practice according to current research recommendations. Aims. This study was designed to explore nurses' knowledge and competence in performing tracheal suctioning in acute and high dependency ward areas and to investigate discrepancies between knowledge and practice using method triangulation. METHODS: Twenty-eight nurses were observed using nonparticipant observation and a structured observation schedule. Each subject was interviewed and questioned about their tracheal suctioning practices, and subsequently completed a knowledge-based questionnaire. Scores were allocated for knowledge and practice. FINDINGS: The findings demonstrated a poor level of knowledge for many subjects. This was also reflected in practice, as suctioning was performed against many of the research recommendations. Many nurses were unaware of recommended practice and a number demonstrated potentially unsafe practice. In addition, there was no significant relationship between knowledge and practice. However, during the interviews, many nurses were able to provide a rationale for specific aspects of practice that were perhaps not based on current research recommendations. CONCLUSIONS: The study raised concern about all aspects of tracheal suctioning and has highlighted the need for changes in practice, clinical guidelines and focused practice-based education.