The patient's perceived caring needs as a message of suffering

The aim of the study was to arrive at a deeper understanding of the patient's experience of caring needs, that is, of problems, needs and desires, by investigating and explaining how these will be expressed and shaped in the caring relation and to illuminate its implications for caring. The target population consisted of 38 patients in a medical ward and 37 patients in a surgical ward in a central hospital in Western Finland. The patients were interviewed in the wards and asked about perceived caring needs. By means of a hermeneutical process of interpretation a pattern emerged which was interpreted as pictures of themselves and of the nurses. These types of patients fell into three groups: the satisfied, the complaining and satisfied, and the complaining and dissatisfied patients. The types of nurses were divided into the competent and friendly, the competent and contact-creating and the competent and courageous. The patients' caring needs can be interpreted and understood from the standpoint of their experience of suffering, but also in relation to their experience of pleasure and comfort. The most conspicuous caring needs were experiencing confidence in the competence of the nurses, comfort, guidance, dialogue and closeness, which the patients expressed as problems, needs and desires. The patients' caring needs can contain new possibilities of growth and development. The nurse can relieve patients' suffering by promoting their experience of comfort. If the nurses' view of the limits of reality are extended to comprise the existential/ spiritual dimension of human beings as well, new possibilities will emerge of interpreting and understanding patients' caring needs as a message of suffering.     

Lack of effectiveness of bed rest for sciatica

BACKGROUND AND METHODS: Bed rest is widely advocated for sciatica, but its effectiveness has not been established. To study the effectiveness of bed rest in patients with a lumbosacral radicular syndrome of sufficient severity to justify treatment with bed rest for two weeks, we randomly assigned 183 subjects to either bed rest or watchful waiting for this period. The primary outcome measures were the investigator's and patient's global assessments of improvement after 2 and 12 weeks, and the secondary outcome measures were changes in functional status and in pain scores (after 2, 3, and 12 weeks), absenteeism from work, and the need for surgical intervention. Neither the investigators who assessed the outcomes nor those involved in data entry and analysis were aware of the patients' treatment assignments. RESULTS: After two weeks, 64 of the 92 patients in the bed-rest group (70 percent) reported improvement, as compared with 59 of the 91 patients in the control (watchful-waiting) group (65 percent) (adjusted odds ratio for improvement in the bed-rest group, 1.2; 95 percent confidence interval, 0.6 to 2.3). After 12 weeks, 87 percent of the patients in both groups reported improvement. The results of assessments of the intensity of pain, the bothersomeness of symptoms, and functional status revealed no significant differences between the two groups. The extent of absenteeism from work and rates of surgical intervention were similar in the two groups. CONCLUSIONS: Among patients with symptoms and signs of a lumbosacral radicular syndrome, bed rest is not a more effective therapy than watchful waiting.     

Current feeding policies for patients with stroke

It is well known that policies for feeding patients who have suffered a recent stroke vary enormously. The choice of method used may depend on the severity of the stroke, i.e. swallowing ability, conscious level, ability to communicate and the level of sensory and motor dysfunction. Other considerations may include age and previous nutritional status. However, in the absence of evidence from controlled clinical trials, the preferences of individual physicians and nurses may have a significant influence. As part of the preparatory work before the start of a clinical trial of different feeding policies, the author wished to assess both the degree of variability of feeding practice on wards in the same hospital and also whether there were reasons other than lack of evidence which influenced feeding policies. One nurse from each of 19 wards (one neurology, nine medical and nine care of the elderly) in two hospitals of the same trust was interviewed to ascertain their current feeding practice for patients with stroke. The results showed the expected variability in feeding practice, possibly reflecting the uncertainties felt by physicians and nurses in this area. However, many comments revealed the concerns that nurses have in trying to meet the nutritional needs of their stroke patients in busy acute general hospitals.     

Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree?

BACKGROUND: The complex environment and technology of intensive care unit (ICU) care may impair the ability of patients to participate in medical decision making or give informed consent. We studied the agreement of the intuitive assessments of residents and nurses of ICU patients' cognition, judgment, and decision-making capacity, and whether those assessments agreed with abbreviated formal mental status testing. METHODS: Using a prospective survey case study, we assessed 200 English-speaking patients within 24 hours of their ICU admission. Formal assessment of cognition, judgment, and insight was performed by a research assistant. We obtained independent intuitive ratings by nurses and residents of patient cognition, judgment, and ability to participate in medical decision making or give informed consent. RESULTS: Residents' and nurses' assessment of cognition and judgment showed a high degree of agreement with weighted ks of greater than 0.76. Assessments of cognition by residents and nurses agreed with Folstein Mini-Mental State Examination in 70% and 73.6% of cases, respectively. Forty percent of the population had an unimpaired Mini-Mental State Examination score of greater than 23, and an additional 12% of the subjects were mildly impaired with scores of 20 to 23. When asked whether they would approach patient or family for consent for an invasive procedure, nurses and physicians said they would request informed consent from 66% and 62% of the patients, respectively. CONCLUSIONS: Residents and nurses caring for patients newly admitted to the ICU agree in their assessment of cognition, judgment, and capacity to participate in medical decision making, and are not unduly influenced by ventilator status. Their assessments correlate highly with abbreviated formal mental status testing.     

A team approach to geriatric case management

Monash Medical Centre, a large major hospital in Melbourne Australia, recently opened a high dependency unit (HDU) at its Moorabbin campus. The present study was designed to examine two patient groups admitted to the unit after major and non-major surgical procedures. Another aim in the study was to describe the services required by these patients and to compare the two groups with regard to length of stay in the HDU, severity of illness, and pain control. The results of this study indicate that the HDU provided a valuable and needed service to a population of patients who have been identified as at risk of postoperative complications. The findings appear to agree with other research which suggests that nurses consistently rate patients' pain as less severe than patients' own ratings of pain indicate. Thus nurses appear to overestimate patients' perception of pain control. This study again indicates that even though it is generally recognised by nurses that patients are in pain the management of it is such that pain continues to be inadequately controlled.     

Cardiovascular assessment--Part 2

This is the fifth part of the Care is Critical series, which looks at the more complex assessments and technological interventions nurses may now have to deal with on general wards or in the community. This article aims to provide a more in-depth understanding of assessing patients' cardiovascular function in relation to low cardiac output states in two types of patients--the post-operative patient with hypovolaemia and the patient with chronic heart failure.     

Occupational stress among student nurses: A natural experiment.

164 student nurses were randomly assigned to 1 of 4 ward types such that 2 factors—type of nursing (medical/surgical) and sex of patients—were systematically varied with counterbalancing of order effects. Self-reported levels of affective symptoms and perceptions of the work environment, together with independent data on sickness/absence, performance, and the objective work environment, were recorded over the 2 ward periods. Within-Ss analyses showed significant differences between medical and surgical wards in affective symptoms and in perceived and objective measures of the work environment. Male and female wards differed primarily in perceived environment, work satisfaction, and performance. Analysis of the main effects, with control for covariance, indicated that the perceived work environment contributed to the observed differences in affective distress between medical and surgical wards while mitigating differences between male and female wards. (45 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Quality assessment instruments in nursing: towards validation

The aim of this study was to explore the validity of the nursing quality assessment instruments, Monitor, Senior Monitor and Qualpacs. This follows recommendations in the literature for the need for more comprehensive validation of instruments than has been the case hitherto. A multiple triangulation research design was used which included observation of and interviews with nurses and patients as well as administration of the instruments with the same patients and a questionnaire completed by the nurses in charge on ward organisation and their approach to nursing care. Results reported here focus on our experiences of using the instruments, their inter-rater reliability and comparisons of instrument scores within medical, surgical and elderly care wards. Difficulties were encountered in using the instruments but most of these can be overcome given sufficient time for preliminary discussions. Inter-rater reliability of all three instruments taken as a whole reached acceptable levels, although some of the section score correlation coefficients were low, especially for Qualpacs. Convergent validity was achieved for the Senior Monitor-Qualpacs comparisons in four elderly care wards. The results were less clear for the Monitor-Qualpacs comparisons in seven medical and surgical wards. Explanations for the equivocal results are suggested and subsequent hypotheses were tested which supported these explanations.     

Medical complications during stroke rehabilitation

BACKGROUND AND PURPOSE: We sought to evaluate the effect of setting on the rate of medical complications during stroke rehabilitation. METHODS: A study of the frequency and nature of medical complications in stroke rehabilitation was undertaken in 245 patients managed either on a stroke rehabilitation unit (n = 124) or on general medical wards (n = 121). The stroke unit setting was characterized by established protocols for prevention, early diagnosis, and management of complications (eg, aspiration, infections, thromboembolism, pressure sores, depression, stroke progression). Similar protocols did not exist on general medical wards except for thromboembolism, pressure sores, and secondary stroke prevention. RESULTS: Medical complications were documented in 147 patients (60%) and were more common in patients with severe strokes (97%). The frequency of reported complications was similar in both settings. Aspiration (33% versus 20%; P < .01) and musculoskeletal pain (38% versus 23%; P < .05) were more commonly documented on the stroke unit, whereas urinary problems (18% versus 7%; P < .01) and infections (49% versus 25%; P < .01) were more commonly seen on general medical wards. The reported frequency of deep vein thrombi, pressure sores, and stroke progression was similar in both settings. Although depression was reported equally in both settings (34% on the stroke unit versus 27% on general wards), patients on the stroke unit were more likely to be treated compared with general wards (67% versus 36%; P < .05). CONCLUSIONS: The study shows that inpatient stroke rehabilitation is a medically active service. Management on specialist units is associated with earlier detection and management of stroke-related problems and prevention of potentially life-threatening complications.     

Pain therapy after thoracotomies--systemic patient-controlled analgesia (PCA) with opioid versus intercostal block and interpleural analgesia

Both regional analgesia and systemic opioid therapy (e.g. PCA) are commonly used for pain relief following thoracic surgery. Many anaesthesiologists are reluctant to use thoracic epidural analgesia on general surgical wards. Therefore, we investigated in a prospective randomised study the efficacy of intercostal blocks (ICB) or interpleural analgesia (IPA) compared to PCA with systemic opioids (PCA). Following ethics committee approval and informed consent, 45 thoracotomy patients were randomised for postoperative pain management: group 1: intravenous PCA with piritramide (PCA-control), group 2: intercostal blocks of the segments concerned with 5 ml bupivacaine 0.5% at the end of surgery and 6 hours thereafter (ICB), group 3: interpleural analgesia with 20 ml bupivacaine 0.25% applied every 4 hours using a catheter placed during surgery near the apex of the pleural space (IPA). Patients in the ICB and IPA groups were able to obtain additional pain relief by PCA with piritramide. Alternative medication for all groups in case of insufficient analgesia was metamizol. Both regional analgesia groups used significantly less piritramide up to the 3rd (IPA) or 7th (ICB) postoperative day than the control group (p < 0.05). The consumption of metamizol was lower as well (n. s.). No significant differences between the study groups were observed with regard to pain scores (visual analogue scale VAS) at rest, during deep inspiration, coughing or mobilisation. Respiratory parameters as forced vital capacity, forced expiratory volume (1 sec) and peak flow (FVC; FEV1; PF) were reduced significantly following thoracotomy and showed a slow restitution in all three study groups without major inter-group differences. Intercostal blocks and interpleural analgesia significantly reduce opioid demand following thoracotomy and are effective means of postoperative pain management. Nevertheless, in contrast to epidural analgesia, both methods have to be supplemented by, or combined with, systemic analgesics in most patients. On the other hand, compared to epidural analgesia, ICB and IPA are less invasive and easier to manage on general surgical wards.     

Patients and family members: the role of knowledge and attitudes in cancer pain

Cancer pain theoretically comprises sensory, affective, and cognitive dimensions, implying that patients and family members perceive and report cancer pain based on these factors. The study reported here investigated the relationship between specific knowledge and attitudes (cognitive factors), and patients' and family members' reports of pain due to cancer. The relationship between cognitive factors and reports of cancer pain was investigated in interviews with 122 patients and their family members. Pain was measured using the Brief Pain Inventory; knowledge and attitudes were measured using a form previously developed by the authors. Patients' and family members' reports of patient pain and performance status were highly correlated, although family members consistently reported more pain and disability. Using regression analysis, cognitive factors were strongly related to family reports of patients' pain (R2 = 0.27), but contributed little to explaining pain reported by patients themselves (R2 = 0.06). Improved understanding of patients' pain assessments depends on further investigation of other cognitive factors and of sensory and affective factors. Family members' assessments of pain are significantly related to appropriate knowledge and attitudes.     

Patient empowerment and feedback did not decrease pain in seriously ill hospitalized adults

We tested a nurse clinician-mediated intervention to relieve pain in a group of seriously ill hospitalized adults using a randomized controlled trial at five tertiary care academic centers in the US. The study included 4804 patients admitted between January 1992 and January 1994 with one or more of nine high mortality diagnoses; 2652 were allocated to the intervention and 2152 to usual care. Specially-trained nurse clinicians assessed patients' pain, educated them and their families about pain control, empowered patients to expect pain relief, informed patients' nurses and physicians about level of pain and suggested or used other pain management resources. Patients' pain was determined from hospital interviews with patients and surrogates. Pain 2 and 6 months later or after death and satisfaction with its control at all time periods were also assessed. All analyses were adjusted for baseline risk of being in pain and propensity to be in the intervention group. Overall, 50.9% of patients reported some pain. After adjustment for other variables associated with pain, comparing the intervention to the control group, there was not a statistically significant difference in level of pain (OR for higher levels of pain 1.15; CI 1.00-1.32) or satisfaction with control of pain during the hospitalization (OR for higher levels of pain 1.12; CI 0.91-1.39), 2 or 6 months after discharge, or during the last 3 days of life. A multifaceted intervention using information, empowerment, advocacy, counseling and feedback was ineffective in ameliorating pain in seriously ill patients. Control of pain in these patients remains an important problem. More intensive pain treatment strategies addressing the needs of seriously ill hospitalized adults must be evaluated.     

Family caregiving of hospitalized patients. Caregiver and nurse perceptions at admission and discharge

To ensure patients will be discharged to stable, health-promoting home environments, nurses must understand family caregivers' perceptions of the patients' needs and problems in caring for them. At the time patients were admitted to and discharged from the hospital, there was little agreement between family caregivers and nurses about the kinds of things caregivers needed to care for older patients or about problems that might prevent the continuation of caregiving. There was slightly more overall agreement between family care-givers and admission nurses than discharge nurses, despite the fact that discharge nurses reported spending more time with patients and being more knowledgeable about them. Future discharge planning models should build opportunities for nurses to communicate with other health care colleagues who can contribute to a more accurate and complete picture of patients' and family caregivers' needs and problems in the transition from hospital to home.     

Evaluation of local anesthesia techniques for small incision cataract surgery

PURPOSE: To evaluate the surgical experiences and patient preference with 3 local anesthesia techniques for small incision cataract surgery. SETTING: Department of Ophthalmology, Hj?rring Hospital, Denmark. METHODS: This prospective, randomized study included 66 patients having simultaneous bilateral cataract surgery. There were 3 test groups, each containing 2 of the following local anesthesia techniques: retro/peribulbar (RBA), sub-Tenon's (STA), or topical (TA). Each patient served as his or her own control. No medical sedation was used. Patient response to each anesthesia technique was evaluated by the surgeon based on surgical difficulties, a nurse using hand-holding tension and verbal interaction, and a visual analog pain score. Patients were also asked which of the 2 techniques they preferred and their reasons. RESULTS: No local anesthesia techniques interfered with surgery. The order of a positive pain/discomfort response during surgery was TA > STA > RBA. Significantly more pain occurred with application of RBA than with STA or TA. No postoperative pain was recorded with any method. Fifty-six percent of patients said they preferred 1 technique over the other; 16% of patients having STA would not do so again, 19% would not have TA again, and 40% would not have RBA again. The main reasons for preferring STA and TA were fear of or pain from a retrobulbar injection. The main reasons for preferring RBA were less awareness, anxiety, and surgical pain. Immediate visual recovery seemed to be of minor importance in patients' choice of an anesthesia technique. CONCLUSION: Although less discomfort/pain occurred during surgery with RBA, patients preferred STA and TA primarily because of the inconvenience or pain of the retrobulbar injection. Although medical sedation was not used in this study, the pain/discomfort ratio from surgery was not greater than in studies using intravenous sedation, indicating that the use of medical sedation should be re-evaluated.     

Poor leadership behind poor pain relief. Medical audit of cancer-related pain treatment

A clinical audit of the treatment of cancer-related pain, ordered by Stockholm County Council and the Karolinska Institute, was performed at two Stockholm hospitals. Of 153 consecutive cancer patients interviewed while attending the preoperative out-patient clinic of the Dept. of Anaesthesiology at Karolinska Hospital, 93 (61%) reported pain varying in intensity from 2.4 to 6.6 on a 10-point visual analogue scale. The pain was cancer-related in 20 patients, treatment-related in 28 patients, and associated with disease in 40 patients (e.g., post-herpetic neuralgia, urethritis, decubital ulcer or constipation). Nine patients had undetected neuropathic pain components, and 18 patients reported both significant pain intensity and dissatisfaction with the treatment. The auditors found these patients to have persistent pain problems despite the availability of time and opportunity to resolve them. The audit included interviews with staff at three hospital departments, who filled in questionnaires, and scrutiny of the medical records of about 120 cancer patients, 5-10 records from each department being selected to illustrate the management of pain problems. Findings from the staff questionnaires and interviews were compared with the picture of pain management elicited from the patients' records. The hospital departments were all found to be characterised by similar problems: lack of pain analysis or diagnosis, failure to detect neuropathic pain components, and underdosing of opioid analgesics irrespective of pain intensity. The auditors' conclusions included a need of pain education, particularly for doctors as fewer doctors than nurses had attended pain courses.     

Psychosocial concerns of Nigerian women with breast and cervical cancer

Many studies have demonstrated that the management of pain after surgery was unsatisfactory. New pain management techniques have been developed in recent years (patient-controlled analgesia, epidural analgesia). To extend the number of patients who may benefit from these recent techniques and/or to obtain the best efficacy from existing methods of pain relief, re-organisation should take place on surgical wards. For example, protocols describing pain management strategies should be written. Surveys and audits should be carried out regularly to check their efficacy. Moreover, patients should be fully informed of the range of treatments available and their adverse effects. Finally, all staff involved in providing acute pain relief should undergo training.     

Predictors of patient outcomes following interactions with nurses

A research and theory-based model was used to identify outcome predictors of hospitalized patients' perceptions of caring and support by nurses. The model tested the effects of cogent personal characteristics of patients (general level of self-esteem and need for control while hospitalized) on their perceptions of humanistic caring and support from nurses and, in turn, considered the effect of these variables on situational appraisal, coping strategies, psychological distress, and coping effectiveness. The 120 hospitalized adult patients indicated that the moderate amount of humanistic caring they received was beneficial. Several factors influenced caring ratings. Higher positive ratings were received from younger patients; however, people with low self-esteem and those desiring more control over their care or reporting a high degree of pain tended to perceive more threat and psychological distress as a results of their encounters with nurses. Following positive caring experiences with nurses, patients with higher self-esteem levels reported effective coping. Overall, positive caring experiences, along with coping strategies and decreased psychological distress levels, explained 40% of the variance of hospitalized patients' ability to cope effectively following their encounters with nurses.     

Factors influencing CPR outcome in Siriraj Hospital

This prospective study of cardiopulmonary resuscitation was surveyed in Siriraj Hospital from 1 March 1996 to 31 May 1996. In a 3-month-period, 94 resuscitated patients were reported with initial survivors 31 cases (33%) and 3 patients (3%) were alive until discharged from the hospital. Most of the resuscitated patients belonged to the emergency department (47%) with the lowest survival rate (23%). The common causes of cardiac arrest were heart diseases (31%) and respiratory failure (21%). All survivors who were able to be discharged from the hospital had suffered cardiac arrest from heart diseases. After resuscitation, only half of the initial survivors received postarrest care in the intensive care units, the rest remained in general wards and outpatient department. By using logistic regression for multivariate analysis, the survival rate was correlated with locations of CPR, duration of CPR and duration of attempt endotracheal intubation. The initial survival outcome of CPR was not related to sex, age, time of day of CPR, duration of hospitalization before CPR, types of arrhythmia, delay in doctors' arrival and performers of CPR.