'Viewing in slow motion': patients', families', nurses' and doctors' perspectives on end-of-life care in critical care.

AIMS AND OBJECTIVES: To explore the meaning of end-of-life care for critically ill cancer patients, families, oncologists, palliative care specialists, critical care consultants and nurses. BACKGROUND: End-of-life care for critically ill patients, of whom nearly 20% will die in critical care, remains somewhat problematic (Truog et al. 2008). End-of-life care is an established domain in cancer; however, research has not been conducted previously into dying, critically ill cancer patients' experiences. DESIGN: Qualitative, phenomenological in-depth interviews were undertaken. METHODS: Phenomenology was used to explore experiences of 27 participants: surviving patients at high risk of dying, bereaved families, oncologists, palliative and critical care consultants, and nurses. Purposive sampling from a UK critical care unit was carried out. In-depth interviews were taped analysed using Van Manen's phenomenological analysis framework. RESULTS: A phenomenological interpretation of dying in cancer critical illness, and the impact on opportunities for end-of-life care, is presented. Three main themes included: dual prognostication; the meaning of decision-making; and care practices at end of life: choreographing a good death. End-of-life care was an emotive experience for all participants; core tenets for good end-of-life care included comfort, less visible technology, privacy and dignity. These findings are discussed in relation to end-of-life care, cancer and critical illness. CONCLUSION: The speed of progressing towards dying in critical illness is often unknown and subsequently affects potential for end-of-life care. Caring was not unique to nurses and end-of-life care in critical care came with considerable emotional cost. RELEVANCE TO CLINICAL PRACTICE: There is an opportunity for nurses to use the care of patients dying in critical care to develop specialist knowledge and lead in care, but it requires mastery and reconciliation of both technology and end-of-life care. Healthcare professionals can help facilitate acceptance for families and patients, particularly regarding involvement in decisions and ensuring patient advocacy.

Development and implementation of a noise reduction intervention programme: a pre- and postaudit of three hospital wards.

AIMS: By developing, implementing and delivering a noise reduction intervention programme, we aimed to attempt to reduce the high noise levels on inpatient wards. BACKGROUND: Sleep is essential for human survival and sleep deprivation is detrimental to health and well being. Exposure to noise has been found to disrupt sleep in hospitalised patients which is to be expected as noise levels have been measured and reported as high. DESIGN: A primarily nursing focused, multi-method approach, involving development of clinical guidelines, ward environment review and a staff noise awareness and education programme, was used to target mainly nursing staff plus other healthcare staff on three wards within one hospital. METHODS: This practice development initiative was carried out in three key phases (1) Preaudit of ward noise levels, (2) The development, implementation and delivery of a noise reduction intervention programme, (3) Postaudit of ward noise levels. RESULTS: Preintervention average peak decibel levels over 24 hours were found to be 96.48 dB(A) and postintervention average peak decibel levels were measured at 77.52 dB(A), representing an overall significant reduction in noise levels (p < 0.001). CONCLUSIONS: This study describes one way to reduce peak noise levels on inpatient hospital wards. RELEVANCE TO CLINICAL PRACTICE: Sleep deprivation is detrimental to patients with acute illness, so any developments to improve patients' sleep are important. Nurses have a key role in leading, developing and implementing changes to reduce peak noise levels on inpatient wards in hospitals. This nurse-led practice development programme has demonstrated how improvements can be achieved by significantly reducing peak noise levels using simple multi-method change strategies.

Earplugs and eye masks: do they improve critical care patients' sleep?

Disturbed sleep and sleep deprivation is common in patients in critical care settings. Noise and inappropriate use of light/dark cycles are two of the causes of sleep interruptions. The purpose of the study was to evaluate eye masks and earplugs to help control patients' exposure to noise and light within the critical care environment. An intervention study using a two group post-test quasi-experimental design of high dependency patients within a cardiothoracic critical care unit was undertaken by a group of critical care nurses. Sleep assessment rating scales and open-ended questions were used to obtain patients' reported experiences of their sleep. Patients self-selected into either an intervention or non-intervention group. Sixty-four patients consented to take part in the study, 34 patients tried the interventions earplugs and eye masks and many found they improved sleep. However, noise was still a factor preventing sleep for both groups of patients. Mixed reports were found with the interventions from very comfortable to very uncomfortable. At a cost of 2.50 pounds sterling/patient, earplugs and eye masks were a relatively cheap intervention with notable improvements for some critically ill patients. Further research is required with a larger sample size, plus an examination of both earplugs and eye masks separately. Offering patient's earplugs and eye masks to improve sleep should be considered as a matter of routine nursing practice, this should include time to show patients how to use and try them out for comfort.

Development of a critical care nursing research strategy: a tripartite approach.

The building of nursing research capacity is important, as it improves the quality of nurse education, the talent of nurses and the standard of patient care. A local critical care nursing research strategy was developed using a tripartite model applied to practice. This was a collaborative approach to critical care research as a model to direct, deliver, facilitate and support nursing research in practice through planned and protected investment in nursing research time. The tripartite model was evaluated and recommendations made with the aim of sharing findings so that other nurses can utilize these experiences to set up similar secondment opportunities for the promotion of nursing research.

Exploring the challenges and successes of the Lecturer Practitioner role using a stakeholder evaluation approach.

RATIONALE: Plans for NHS reform include strategies to reduce the gap between theory and the realities of clinical practice, with the aim of improving patient care. The role of Lecturer Practitioners (LPs) as educators for nurses who 'bridge' the theory-practice gap forms a central part of this strategy. Given the amount of investment in the role and its potential, this study sought to evaluate the impact of the LP role within the education and practice setting from the perspective of key stakeholders. METHODOLOGY: The study, which included five LPs from a range of backgrounds, followed the principles of stakeholder evaluation. Each LP and their line manager identified six informants who were familiar with the LP's role. The total sample consisted of 36 participants. Semi-structured interviews were used to gain the perceptions of stakeholders about the LP role. The emerging themes were then discussed, consensus reached, and a collaborative project report produced. FINDINGS: The findings were derived from the perceptions of the stakeholders. Minimally interpretive analysis of the data resulted in identification of five themes: (i) general overview of LP's individual qualities; (ii) preconceived notions of the post; (iii) reality of the post; (iv) areas of concern; and (v) developing the role. CONCLUSIONS: The findings indicated that the LP role provides a credible and valuable link between theory and practice and, as such, is an important contribution to the modernization agenda of the NHS. It was apparent, however, that there are a number of areas in which developments are needed, and that organizational and individual actions are necessary in order to achieve the most from these posts.