Original article24-Hour intensive care: An observational study of an environment and events
Introduction
During the intensive care unit period the patient is restricted to the bed, equipment and ward environment 24 hours a day. ICU care focuses on combating the life-threatening situation with drugs, monitoring and equipment supporting organ functions using the best available knowledge and evidence-based medicine. In an intensive care unit environment, efficacy and functionality is ensured with planning – vital functions must be easy to control and maintain. The rapid progress seen in technology and critical care medicine pose their own demands on the environment. Studies have shown that the intensive care unit environment can seem strange and hostile to patients, and it may even lead to post-traumatic psychological problems (Almerud et al., 2007, Dyson, 1999, Hweidi, 2007, Jones et al., 1994, Novaes et al., 1999, So and Chan, 2004). The problem of technology in health care lies in the choices made about what is humane and dignified care (Almerud et al., 2008). During the ICU period the patient is exposed to noise, lack of sleep and privacy, problems with communication and feelings of helplessness and frustration resulting from loss of control (Hupcey, 2000, Hweidi, 2007, McCuire et al., 2000, Russell, 1999). Some of the difficulties are found to be a consequence of medical treatment during ICU care. Previous studies have shown that survivors of critical care report physical and psychological disability after their ICU experience (Griffiths and Jones, 1999, Jones et al., 2000, Russell, 1999, Scragg et al., 2001, Strahan et al., 2003). There have not been any studies about the ICU environment from the patient's perspective and from the viewpoint of what can we do during the ICU treatment to make the environment more comprehensible to the patient. It is important to identify the things that are not important in terms of ICU patient care and that contribute to patients’ problems.
The term environment usually means the physical, social or symbolic environment (Kim, 2000). It can also be used to refer to the environment as a psychological environment (Gordon, 1998, Roper et al., 1990). The physical environment includes people's general surroundings, the concrete environment in which they live as well as their immediate surroundings, such as home or hospital sickroom. The physical environment can be seen as a resource that makes people's actions possible, but it can also be seen as a source of stress. Social environment refers to other people, attitudes, norms and institutions. It includes social networks, the challenges they pose and the support and control for people's lives and activities. People are in interaction with their environment (Lauri and Elomaa, 1999). Social environment takes place in physical space and it causes us to be in interaction with the material environment (Horelli, 1983). According to Kim (2000), the symbolic environment can be divided into ideal, normative and institutional elements, all of which have their own history. The ideological aspects of the symbolic environment consist of values, ideas, beliefs and knowledge. The normative element includes written or unwritten rules, laws, expectations and sanctions. The basis of the symbolic environment is made up by the social norms of culture, language, religion and community. It is also influenced by upbringing and education, the norms of behaviour set to individuals, role expectations as well as the ideas concerning health and sickness and taking care of patients that prevail in the community (Kim, 2000).
The psychological environment is a private emotional environment that protects people from damage. It includes the feelings, experiences and thoughts that are closely connected to the individual's own identity (Sarvimäki and Stenbock-Hult, 1996). Intelligence, personality, temper, self-confidence and stress level are things that interact with the safety of the psychological environment (Roper et al., 1990). The psychological environment could not be analysed in this research material.
The equipment and devices intended for the care of critically ill patients make the intensive care unit the most technologically sophisticated environment in any hospital (Almerud et al., 2007). Being connected to various devices, exposure to noise, lighting, a room that is too hot or cold, various smells and being able to see other patients as care objects can cause both physical and mental stress to patients (Almerud et al., 2007, Jones et al., 1994, Novaes et al., 1999, So and Chan, 2004). It has been found that short-term exposure to noise can cause reactions such as vasoconstriction, changes in heart rate, elevated blood pressure, increased breath rate, increased adrenaline secretion and changes in sleep quality (Hweidi, 2007, Mussalo-Rauhamaa et al., 2007).
Patients adapt to their environment. They trust in the skills of the staff and accept the ward environment and events taking place there as routines. Control over one's own body and opportunity to impact one's own situation disappears in daily routines (Almerud et al., 2007). Things that promote stress related to social situations include changing staff, communication difficulties, disorientation as to time, place and what has happened, and being away from loved ones (Almerud et al., 2007, Dyson, 1999, Hweidi, 2007, Wilkin and Slevin, 2004).
Although patients are closely monitored they feel that they are invisible to the staff. Careful observation and monitoring are very important from a medical perspective, but they do not promote patients’ feeling of being safe (Almerud et al., 2007, Almerud et al., 2008, Wilkin and Slevin, 2004). Dyson (1999) sees a direct relationship between sickness and environment: as sickness increases, the environment becomes more hostile and alien.
The aim of this study was to describe an intensive care environment during treatment from a patient point of view and the events and social contacts taking place during the patient's day.
Section snippets
Study design and setting
This study was an observational study with a qualitative design using digital versatile disc (DVD) recording. An observational study can be either participative or non-participative. It can take a place in real time or be carried out afterwards with the help of DVD recordings, for example. If the research material is gathered over a longer time period, it must be collected using non-participative observation (Polit and Beck, 2004). DVD recording was chosen because the researcher wanted to
Physical environment
The patients were treated in a 12-bed intensive care unit at a university hospital and they came from a 350 km radius. Two patients were in a double patient room and two were in a room with seven patient beds. The size of the bedspace was approximately 15 m2 in the double room and approximately 12.9 m2 in the room for seven patients. The bedspaces were separated from each other with curtains. The floor material was plastic, the walls were partially tiled and the ceiling was covered with gypsum
The physical environment
The patients treated in intensive care had one severe vital organ function disorder or several organ failures. A physician specialising in intensive care is available 24 hours a day, seven days a week, and the intensive care nurse-to-patient ratio is set at 1:1. Patients’ care is based on multiprofessional teamwork to make sure that functions that are vital in the unit and from a patient perspective are taken into consideration (Fontaine et al., 2001). Structural planning in an intensive care
Conclusions
Patients in an intensive care unit are in an environment which they cannot influence themselves, but which affects them in a comprehensive manner. There are features in an ICU patient's environment that may be harmful to recovery. This study supports earlier research on intensive care unit noise, lack of day and night rhythm and emphasis on technology. The noise, lighting and equipment in the physical environment can cause extra stress and difficulties for the patient. Noise can easily be
References (41)
- et al.
Patients’ experience of being critically ill or severely injured and cared for in an intensive care unit in relation to the ICU syndrome. Part 1
Intens Crit Care Nurs
(1998) - et al.
Evaluation of critical care space requirements for three frequent and high risk task
Crit Care Nurs Clin North Am
(2007) Jordanian patients’ perception of stressors in critical care units: a questionnaire survey
Int J Nurs Stud
(2007)- et al.
The importance of diagnosing and managing ICU delirium
Chest
(2007) - et al.
Perception of stressors by patients and nurses of critical care units in Hong Kong
Int J Nurs Stud
(2004) - et al.
Patient empowerment in intensive care—an interview study
Intens Crit Care Nurs
(2006) - et al.
Of vigilance and invisibility—being a patient in technologically intense environments
Nurs Crit Care
(2007) - et al.
Beleaguered by technology: care in technologically intense environments
Nurs Philos
(2008) - et al.
Korvasairaudet
- et al.
The practice of nursing research—conduct, critique & utilization
(2005)
Intensive Care Unit psychosis, the therapeutic nurse–patient relationship and the influence of the intensive care setting: analyses of interrelating factors
J Clin Nurs
The qualitative content analysis process
J Adv Nurs
Designing humanistic critical care environments
Crit Care Nurs Q
Issues surrounding preparation, information and handling the child and parent in nuclear medicine
J Nucl Med
ABC of intensive care. Recovery from intensive care
BMJ
Video recording as a method of data collection in nursing research
Vård I Norden
Psycho-affective disorder in intensive care units: a review
J Clin Nurs
Ihminen ja hoitoympäristö – terapeuttisten ympäristöjen kehittäminen ja rakentaminen
Feeling safe: the psychosocial needs of ICU patients
J Nurs Scholarsh
Providing psychological support for patients after critical illness
Clin Intens Care
Cited by (43)
Sound in Time: An observational study to identify the sources of sound and their relative contribution to the sound environment of an intensive care unit
2022, Applied AcousticsCitation Excerpt :Future unit design should consider the impact of reverberation, ingress of noise, identifying sound power levels for essential equipment similar to domestic devices [105] and ideally include the removal of noise sources from the head end of the bed, although limited study to date has not demonstrated a significant impact [106]. The average SPL in the ICU under study was higher [18–19,30,32,39–40,45,47,49–50,52,55,57,26–28,34–36] or consistent [29,31,33,38,41,46,48,51,53,21–24] with other studies measuring sound in the ICU, although direct comparison is difficult due to the varying methods of reporting results across these studies. The pattern of sound over a 24hr period compares well with results from preliminary work completed on site in 2011 and 2012 [37,43], the high noise levels might in part be explained by the lack of single rooms and the built environment.
Technology integration in complex healthcare environments: A systematic literature review
2021, Applied ErgonomicsThe role of place on healthcare quality improvement: A qualitative case study of a teaching hospital
2018, Social Science and MedicineCitation Excerpt :Given that “place identities affiliate the self with significant locales, bringing a sense of belonging and order to one's sociospatial world” (Cuba and Hummon, 1993:113), such a significant change in the perceived hospital's identity is expected to challenge staff's own identity. This article thus contributes to the literature on the symbolic dimension of a hospital environment which has received little consideration (Gesler et al., 2004; Papoulias et al., 2014) and has primarily focused on patient's perspectives (e.g. Adams et al., 2010; Meriläinen et al., 2010). Additionally, whereas some of the previous studies explored the impact of space on clinicians' identities (Ainsworth et al., 2009; Halford and Leonard, 2003), findings from this study extend this by highlighting the role of the built environment on framing an organisation's own identity and how this identity is perceived by staff.
The effect of cycled lighting in the intensive care unit on sleep, activity and physiological parameters: A pilot study
2017, Intensive and Critical Care NursingCitation Excerpt :During one 24-hour observation, illumination levels were measured at the patients’ bedside. On average, the illumination was 318 lux during the daytime and 145 lux at night (Meriläinen et al., 2010). Hu et al. (2016) measured illumination levels in seven different ICUs near the patients’ eyes.
Circadian disruption of ICU patients: A review of pathways, expression, and interventions
2017, Journal of Critical CareCitation Excerpt :In critical illness, acute inflammatory response or prolonged systemic inflammation can lead to desynchronization of circadian cues and consequently to organ failure and death [35,36]. Patients with severe sepsis, the most demanding of the immune responses [36], also exhibit loss of circadian melatonin rhythms, whereas nonseptic patients in the ICU are relatively more able to maintain circadian rhythms that track similarly to nonhospitalized controls [23,37,38]. Hormonal changes may be a component of protective mechanisms triggered by disease (eg, cortisol elevation may assist in the resolution of inflammation), may be a dysfunctional response to the disease process, or may even contribute to its etiology.
To feel strong in an unfamiliar situation; Patients' lived experiences of neurosurgical intensive care. A qualitative study
2016, Intensive and Critical Care Nursing