Original article
Foresight and awareness of incipient changes in a patient’ clinical conditions – Perspectives of intensive care nurses

https://doi.org/10.1016/j.iccn.2015.06.002Get rights and content

Summary

Objectives

The aim of this study was to explore the phenomenon of becoming aware of incipient changes in patient condition from the perspectives and experiences of intensive care nurses.

Research methodology

This study involved close observations of and in-depth interviews with 11 experienced intensive care nurses. The text was analysed using a hermeneutic phenomenological method that was inspired by van Manen.

Setting

This study was undertaken at two different high-technology intensive care units (ICUs) in Norwegian university hospitals.

Findings

Nurses formed images of individual patients composed of signs (of changes in a patient's condition) that were sensory, measurable, and manifested as the mood of the nurse. The signs may be viewed as separate from and opposed to one another, but they are tightly interwoven and interact with one another. Care situations are powerful stimuli for the patient, and it is of great importance for nurses to become aware of signs in these situations. Nurses also ascribe that following the patient over time is important for becoming aware of signs.

Conclusion

An awareness of incipient changes in patient clinical condition requires understanding the ever-changing dynamics of patient condition and dialogic images composed of signs. Care situations and the following of patients through shifts are essential in enabling nurses to detect these signs.

Introduction

Intensive care patients have life-threatening conditions and require close monitoring of their vital functions along with support from advanced equipment and medications to maintain bodily functions. The clinical scenario involving intensive care patients is complex. Such patients have unstable medical and surgical conditions that exhibit high levels of ambiguity, uncertainty and unpredictability. The condition of an intensive care patient can oscillate between good condition and ever-increasing deterioration (Klepstad, 2010, Lakanmaa et al., 2012, Rothschild et al., 2005).

In the new millennium, the context of intensive care has evolved towards a paradigm of lighter sedation (Egerod et al., 2013, Strom and Toft, 2014). Despite being more awake under this lighter sedation, intensive care patients are often unable to express themselves verbally due to their use of a ventilator and because nurses have few communication techniques (or tools) that allow conscious patients to communicate their feelings and needs (Guttormson et al., 2015, Karlsson et al., 2012). Intensive care nurses work in a highly technical environment and must be able to cope with stressful work conditions; moreover, their work has a high level of unpredictability and requires the ability to accurately define and rapidly change priorities (Benner et al., 2011, Swinny, 2010).

A study by Bringsvor et al. (2014) explored the sources of knowledge that intensive care nurses use in their daily nursing practice and described the variety and complexity of the knowledge base of intensive care nurses. Experience-based knowledge is one source of knowledge and is often linked to exercising judgement, tacit knowledge and the clinical gaze. Randen and Bjørk (2010) found that personal experience and intuition are considered by intensive care nurses as more important than research-based knowledge in assessing sedation needs. They also found that formal assessment tools, such as sedation or weaning protocols and objective scoring systems are rarely used in the intensive care unit (ICU) in relation to sedation practice. Additionally, Dykes et al. (2010) reported that critical care nurses identify, intercept, and correct several medical errors that may otherwise lead to serious and potentially lethal adverse events. Their study demonstrates the importance of critical care nurses in promoting patient safety. However, Randen et al. (2013) found that nurses underestimate unpleasant symptoms, such as pain, anxiety and delirium, in mechanically ventilated adult ICU patients. A deeper understanding of unpleasant symptoms and signs may aid nurses in the early recognition of patient problems and in providing improved care.

The deterioration of ward patients and the use of a rapid response system (RRS) team to improve patient outcomes have been the subjects of several studies (Howell et al., 2012, Jäderling et al., 2011, Rothschild et al., 2010). Early warning scores (EWSs) are used to activate the RRS team, and the criteria for summoning the team are typically based on the deterioration of the patient's vital signs (Rothschild et al., 2010). Clinical staff also use the “worried criterion” (intuition), which is based on clinical judgement, to activate the RRS team, regardless of whether the patient's condition satisfies any of the formal criteria (Jäderling et al., 2011, Rothschild et al., 2010).

Awareness of incipient changes in a patient's condition and the ability to foresee potential complications are viewed as important in preventing complications and in safeguarding the lives of critically ill patients (Benner et al., 2011, Dykes et al., 2010, Henneman et al., 2012, Swinny, 2010).

However, few studies have examined the actual process of becoming aware of incipient changes in a patient's condition from the perspective of intensive care nurses. Therefore, the aim of the present study was to explore the phenomenon of becoming aware of incipient changes in patient clinical condition from the perspectives of experienced intensive care nurses.

Section snippets

Study design

This study was qualitative and used the hermeneutic phenomenological approach (van Manen, 2007, van Manen, 2014). This approach is considered phenomenological (descriptive) because it considers how the phenomenon in question appears, and this approach is hermeneutic (interpretive) because uninterpreted phenomena do not exist (van Manen, 2007).

The aim of this approach is to describe and interpret the way in which we experience the world in everyday situations and relations (van Manen, 2007, van

Discussion

The main finding of this study was that nurses develop foresight and awareness of incipient changes in a patient's condition through images or impressions that are composed of signs. Through bodily senses (i.e., vision, hearing, smell, and touch), nurses sense signs of changes in patient condition, such as wakefulness, response to contact, body movements, eye contact, facial expression, and the smell and colour of secretions. According to Løgstrup (1995a), we exist emplaced in the world with

Conclusion

This study offers insights into the phenomenon of becoming aware of incipient changes in patient clinical condition from the perspectives and experiences of intensive care nurses. Nurses foresee and are aware of early changes in patients’ clinical conditions through living images composed of signs that may be viewed as separate from and opposed to one another but that are interdependent. In a nurse's daily practice, sensory signs are tightly interwoven and are included in the interaction with

Conflict of interest

The authors have no conflict of interest to declare.

Ethical statements

None declared.

Acknowledgements

We are grateful to the intensive care nurses who participated in this study and the ward managers for giving us access to the study locations. Financial support was obtained from the University of Tromsø, The Arctic University of Norway, and The Norwegian Nurses Organisation.

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