Original article
24-Hour intensive care: An observational study of an environment and events

https://doi.org/10.1016/j.iccn.2010.06.003Get rights and content

Summary

Background

In intensive care, patients are exposed to a strange and sometimes hostile environment, which can lead to post-traumatic psychological problems. The aim of this study was to describe an intensive care environment from a patient point of view and the events and social contacts during a patient's day.

Methods

The study had an observational qualitative design. The data were generated by recording on DVD four adult intensive care patients in an intensive care unit over one day (n = 96 hours). The DVD recording of two patients also included daylight (lx) and decibel (db) measurement. The material was analysed by inductive and deductive content analysis.

Results

An intensive care patient environment is made up of physical, social and symbolic environments. The hospital, ward and patient room constitute an environment that is indirectly connected to the patient. The patient bed and all that is included in it are directly connected to the ICU patient's physical environment. The social environment includes the people who are near the patient and in direct or indirect contact with them. ICU norms, regulations, values, expectations and knowledge make up the symbolic environment. Taken together, these factors constitute an intensive care unit's way of action. The symbolic environment is connected to the social environment through people and the way of action.

Conclusion

The patient is connected to the ICUs environment, but is usually not able to influence it. It is important to eliminate things that prevent recovery and to promote feeling safe. Besides the physical environment, things that prevent recovery and increase a feeling of being safe can be found in both the social and the symbolic environment. We also need to learn more about ICU patients’ subjective experiences in order to be able to describe the psychological environment.

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

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