The unspoken disease: symptom experience in women with vulval neoplasia and surgical treatment: a qualitative study.

Women with vulval neoplasia often experience severe post-surgical complications. This study focuses on symptom experience of women during the first 6 months following surgical treatment for vulval neoplasia considering their socio-cultural context. In this qualitative study using a critical hermeneutic approach, narrative interviews were conducted. A purposeful sample of 20 patients was recruited from one Swiss and two German university hospitals. Content analysis was employed to analyse the transcribed interviews considering women's experiences and social perceptions. Narratives showed eight interrelated themes: delayed diagnosis, disclosed disease, disturbed self-image, changed vulva care, experienced wound-related symptoms, evoked emotions, affected interpersonal interactions and feared illness progression. The women experienced a general lack of information pertaining to above themes and all described strategies used to handle their situation, which affected their distress. The communication, assessment and treatment of symptoms were hampered by the society's and the health system's tendency to overlook these symptoms and leave them in the realm of the unspeakable. Health professionals need new strategies to support these women to recognise, assess and evaluate the seriousness of symptoms, and to communicate their symptom experience so that timely medical treatment is sought. This support may minimise potentially preventable complications and symptom-related distress.

The use of medical emergency teams in medical and surgical patients: impact of patient, nurse and organisational characteristics.

Medical emergency teams (METs) were developed to respond more rapidly to changes in patient condition. While effective, METs do not address events prior to the response. This study examined differences in patient, nurse, and organisational characteristics for 108 MET calls on five medical and five surgical units in a university hospital. MET calls occurred more often on the day shift (p = 0.007) for medical (p = 0.036), but not surgical, patients. Of the 108 events, 44% were delayed, defined as events with documented evidence that pre-established criteria for a MET call were present for >30 min. More delays occurred on the night shift (p = 0.012). Delayed events were not related to the number of patients assigned (p = 0.608). However, there was a trend for more delays when more patients were assigned (4:1 = 21% vs 6:1 = 43%). In a logistic regression model, shift and patient-unit-match (medical, surgical) were significant predictors of delays. The model correctly predicted 68% of delayed events. Study findings indicate that a combination of patient, nurse and organisational characteristics influence timely rescue.

Methodological considerations for grounded theory research in critical care settings.

BACKGROUND: The context of critical care and human phenomena involved in critical illness offer rich opportunity for nursing research. Naturalistic investigation with grounded theory methods can uncover previously unexamined elements and interactions in the critical care setting. This article presents methodological considerations for conducting grounded theory research in fast-paced physiologically and technologically complex critical care settings. APPROACH: Critique and recommendations are based in review and analysis of grounded theory research in adult critical care settings and on the literature describing grounded theory methods. The authors' experiences in medical and surgical intensive care units provide added practical context for this article. RESULTS: Barriers to achieving grounded theory in critical care settings, such as communication impairments, participant attrition, and observational difficulties, are explored. Methodological strategies and data sources particular to critical care settings are also discussed. Critical care settings offer a variety of data sources that should be rigorously pursued in grounded theory research. DISCUSSION: Given current trends in healthcare treatments and demographics, future research must examine physiological and technological data as integral components of basic social psychological or social structural processes in critical care interactions and should include technology as a component of nurse-patient interaction.

Communicating with mechanically ventilated patients: state of the science.

The literature clearly establishes the problems and difficulties of loss of speech among mechanically ventilated patients in the intensive care unit. Critical care nurses typically receive little or no training in the interpretation of nonvocal communication or in the assessment and application of augmentative communication methods. This article presents an integrative review of the research and related literature on communication with adult patients in critical care settings. Clinical issues and technological advancements in assistive and augmentative communication applicable to critical care are discussed and a new research agenda is proposed.

Using a best practice approach to prevent treatment interference in critical care.

Treatment interference, also known as therapy disruption, device disruption, or self extubation, is a common and especially difficult clinical problem in critical care. This paper presents creative and practical clinical innovations and relevant research findings as a "best practice approach" to prevent treatment interference in critical care settings. Key principles are presented to guide patient assessment and selection of nursing strategies. Nursing assessment parameters are described and a wide range of nonrestraint strategies are discussed.

Interpretation of nonvocal behavior and the meaning of voicelessness in critical care.

This paper presents two interrelated psychosocial constructs, voicelessness and interpretation, which were derived from a participant observation study of critically ill older adults in the USA. Voicelessness occurs when physiological, psychosocial and/or technological barriers limit the abilities of critically ill patients to represent their thoughts, feelings, desires and needs fully to others. Voicelessness influences not only the responses of critically ill patients to their condition, environment and caregivers, but also profoundly effects the responses of family members and clinicians. Thus, communicative interactions as well as certain clinical and treatment decisions in ICU hinge on clinician and family member interpretation of patients' nonvocal behaviors. Conditions and factors contributing to interpretation are described and a hypothesis proposed, that interpretation mitigates the detrimental effects of voicelessness.

Preventing treatment interference: the nurse's role in maintaining technologic devices.

BACKGROUND: Treatment interference, the disruption or self-removal of technologic devices, is a primary reason for application of physical restraints in acute and critical care settings. The processes of care surrounding treatment interference and the prevention of device disruption have not been comprehensively analyzed. OBJECTIVES: To describe the processes used by critical care nurses to prevent treatment interference in critically ill older adults. METHODS: Participant observation field research was conducted in medical and intermediate medical intensive care units. Data were analyzed by using the constant comparative method and event analysis. RESULTS: Maintaining technologic devices is almost exclusively a nursing responsibility and involves the skillful assessment of patient awareness and trustworthiness and interpretation of behaviors. Critical care nurses are most protective of those devices for which accidental removal is perceived as life threatening: endotracheal tubes, arterial catheters, and central venous catheters. Nurses assess patients' cognitive status, mobility, strength, and trustworthiness, as well as device considerations such as replacement difficulty and device necessity. In addition to verbal strategies, such as explaining, nurses use distraction, deception, comfort measures, watchful family members, physical restraints, and sedation to prevent treatment interference. CONCLUSION: This analysis considers the social context of the intensive care unit, including roles and the human-technology interaction. It illustrates the tremendous responsibility that nurses assume in maintaining technologic devices. Next steps in research and policy development are also considered.

Nurse practitioner services: content and relative work value.

The resource-based relative value scale is used to quantify work for reimbursement of services in the Medicare Fee Schedule. This pilot study explored use of the resource-based relative value scale for services provided by nurse practitioners. Estimation of relative work values for office visits by nurse practitioners was consistent with the Medicare Fee Schedule. Content analysis revealed that nurse practitioners provide additional services including comprehensive patient evaluation and education and attendance to social factors. Future research is needed to examine systems that identify and reimburse nurse practitioners for their services.

Treatment interference in acutely and critically ill adults.

OBJECTIVES: To examine the state of knowledge of treatment interference, the self-removal of technological devices, in acutely or critically ill adults and to propose a multidisciplinary research agenda to further understanding of this clinical problem. METHOD: A combined computerized and hand search of the nursing and medical literature (MEDLINE, 1966 to June 1996; Cumulative Index to Nursing and Allied Health Literature, 1985 to June 1996; and holdings at the Center for the Study of Nursing History at the University of Pennsylvania) was conducted. Literature on specific technological devices and articles that contained the terms self-removal, withdrawal, devices, self-extubation, unplanned extubation, and involuntary treatment were searched. RESULTS: Literature on treatment interference was found in four main topic areas: (1) maintaining treatment, (2) unplanned extubation, (3) disruption or manipulation of a medical device, and (4) involuntary treatment. CONCLUSIONS: The results clearly establish the clinical importance of treatment interference and underscore the multidisciplinary and multifactorial nature of this perplexing, life-threatening clinical problem. Future research on treatment interference should emphasize systematically building an understanding of the processes involved, including patients' attributes, behavioral cues, and consequences, to develop appropriate multidisciplinary strategies to prevent patients' self-removal of technological devices.

Factors contributing to rehospitalization of elderly patients with heart failure.

This article describes factors contributing to rehospitalizations of elderly patients with heart failure. Advanced practice nurses' logs, study questionnaires, and medical record summaries from a recent clinical trial provided rich, descriptive information about a variety of social and behavioral factors surrounding rehospitalization in these medically fragile older people. Medication and dietary nonadherence were factors affecting symptom appearance and rehospitalization. Social and behavioral factors, such as the absence of strong social support or motivation, contributed to nonadherence. These results suggest that social and behavioral factors must be identified and addressed in an individualized manner to prevent recurrent hospitalizations for elderly patients with heart failure.

Individualized care for frail elders: theory and practice.

Individualized care for frail elders is defined as an interdisciplinary approach which acknowledges elders as unique persons and is practiced through consistent caring relationships. The four critical attributes of individualized care for frail elders are: 1) knowing the person, 2) relationship, 3) choice, and 4) participation in and direction of care. Cognitively impaired elders can direct their care through the staff's knowledge of individual past patterns and careful observation of behavior for what is pleasing and comfortable to each resident.

Sociotechnical systems theory. Analysis and application for nursing administration.

Work and system redesign are national trends in service organizations, especially healthcare. The sociotechnical systems theory of organizational design provides a framework for structure and evaluation of work redesign. Sociotechnical systems theory has recently been the framework for several innovations in the redesign of patient care. The author presents a description and analysis of sociotechnical systems theory for use in nursing administration with illustrations from research and practice.

Nursing effort and the exchanging human response pattern.

This descriptive, comparative study was done to determine the nursing effort required to treat actual and potential nursing diagnoses from the Exchanging Human Response Pattern in two patient care specialties: acute medical-surgical and postpartum. Patterns of diagnosis identification are described for the two groups, and differences in allocation of nursing resources (nursing effort) are examined. The sample included 200 observations (hospital days) for 50 patients: 33 postpartum patients, and 17 medical-surgical patients. Data were collected daily during the study period by nurses who provided direct care to the selected patients using an investigator-developed version of the Nurse-Patient Summary (NPS) nursing information and patient classification tool (Halloran, 1985). Potential nursing diagnoses received most of the nursing effort in the postpartum area (mean effort = 5.28), whereas actual nursing diagnoses in the Exchanging Human Response Pattern received a higher priority in the medical-surgical area (mean effort = 12.03). Statistically significant differences existed between groups in total nursing effort (t = -4.73, p less than .0001) and in nursing effort required to treat actual (t = -7.42, p less than .0001) and potential diagnoses (t = 3.99, p less than .0001) in the Exchanging Human Response Pattern. This study provides unique information about how nurses allocate their time to patients for the treatment of actual and potential nursing diagnoses, and outlines areas for further development in diagnosis-based patient classification.

Development of a special care unit for chronically critically ill patients.

Intensive care units (ICUs) are recognized as one of the most expensive services provided by hospitals. Within these ICUs are a growing population of patients whose stays are extensively prolonged because of complications or underlying chronic health conditions that are exacerbated by a critical illness. These patients can be described as "chronically critically ill" and are costly to hospitals both in terms of actual dollars and in terms of the burden of care to nurses and physicians. This article describes the creation of a special care unit (SCU) designed specifically to meet the needs of chronically critically ill patients. The SCU environment is composed of a physical design that accommodates limited technology and care aimed at family involvement and rehabilitation, a case management practice model, and a shared governance management model. This structure is in contrast to traditional ICU environments, which include physical layouts that allow for high technology and close monitoring of patients, a primary nursing delivery system, and a bureaucratic management model. A research project to compare the effects of the SCU with the effects of the traditional ICUs on nurse and patient outcomes is described.