The meanings of ICU patient room as a place of care from the perspective of patients, next of kin and staff

Transcription

1 The meanings of ICU patient room as a place of care from the perspective of patients, next of kin and staff

2 BACKGROUND The place of care matters: View from a window (Ulrich, 1982) Studies focusing on light and sound environment (Alimoglu & Donmez, 2005; Johansson et al., 2012) The relationship between intensive care related delirium and environment (Granberg-Axel et al., 2002; Van Rompaey, et al., 2008) Patient safety (Leaf et al., 2010) Follow up studies (Storli & Lind, 2009) Concept of healing environments (Bauzin & Cordon, 2011) Healing design (Rashid 2010) Evidenced based design (Ulrich, 2012)

3 My interest has been to study: What are the meanings of ICU patient room in caring for the critically ill? How is to be cared for in ICU patient room? How is it to watch over a loved one in a ICU patient room?

4 Some examples of Swedish ICUs

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7 Theoretical approach Caring from a philosophical/existential approach (Dahlberg, et al., 2010, Galvin and Todres, 2013) Reflective Lifeworld Research, RLR(Dahlberg et al., 2008) and Phenomenological hermeneutical approach (Lindseth & Norberg, 2004)

8 Studies Study I, is a phenomenological hermeneutical study focusing on next of kin s perspective. Study II, is a phenomenological study examining the patients perspective. Study III, is a phenomenological study examining staff s perspective Study IV, is a theoretical study describing how photovoice can be employed in ICU for the purpose of research.

9 The aim- study I The aim of this study was to describe and interpret the meanings of ICU patient room as lived by next of kin.

10 Participants Purposeful sampling was employed 14 next of kin to patients in a stable mood of treatment were invited to the study. Five men, nine women (28-70 yrs.) and the time in ICU varied between 5-60 days.

11 Data collection Data was collected by photovoice and research /lifeworld interviews (Kvalé and Brinkman, 2008). Next of kin were invited to photograph various aspects of the patient room that they associated with a feeling, regardless of what the feeling was about. The photos were used during a follow up interview later. Data was collected at two ICUs and I was present during the whole process.

12 Mobil phone prohibited It is ridiculous, there is no way that the mobile would disturb the technological devices! I work with these things.it is forbidden to have your phone on, but I had mine on! We have baby, 9 months old and I need to have my phone on just in case anything happens!

13 Swedish flagg It gives a nice and positive feeling! my brother in law and his wife came to visit P.. and it was the midsummer day, they brought a flag for him to remind him of this day.and of course we have been talking a lot about old memories

14 Decoration in a conversation room well we were having a conversation the doctors and us and it was really awful you know bad news every single thing was dropping and we knew it wouldn t be a cheerful meeting then you see they let us in here to this room and it was a large table here...we sat at one end and they at the other it was not like we are gonna make it...it felt rather like we and them And on the topp of that the décor...here..i mean I don t mind alcohol but it is better to have a neutral photo or a picture here I can buy this from the staff and put it on my living room wall back home and the staff can buy a new one

15 Public phone in a waiting room This phone here.it has given me like.you sit here because you have no where else to go and people use it like for urgent matter I mean you can t put up it with other peoples trouble..when you hear it makes me sad when I think of it (sad/almost crying) // You have enough of your own why can t it be at least around the corner?

16 Hand sanitizer They told us It has been very important to keep our hands clean all the time! Because he has been very susceptive to infections and there is nothing wrong with it when you are going to see him, but on the way out it feels very uncomfortable because it means that he is dirty and unclean, I am embarrassed. I wonder how he feels?

17 Data analysis The data (only the interview text) were analysed by using a phenomenological hermeneutical approach developed by Lindseth & Norberg (2004). Phenomenological hermeneutic is method for interpreting texts, based on the philosophy of Ricoeur (1981;1976). Naïve understanding, structure analysis/es, comprehensive understanding.

18 The findings Next of kin had many suggestion for improving the ICU patient room. Therefore the first step of analysis focused on the suggestions. Searching for a place to be- A chair Searching for privacy

19 Next of kin s suggestions for improving the environment of ICU Subcategories The walls and the ceiling Textiles Single-room / multi-bed rooms The Staff The decoration The waiting room and the corridors The accommodation and the conversation room Category The inner place/space The outer place/space

20 The meanings of ICU patient room Subthemes Equipments and interiors being the object of attraction Living in a temporary living room Being a witness Living the time Themes Dwelling the room and time Being welcomed and invited to the room Search for ones place- chair Having a face Searching one s privacy Becoming a family Being exposed Being together Waiting in uncertainty Becoming at home The extension of the room

21 Comprehensive understanding ICU patient room is a lived place and space. There is an extension to other areas outside the patient room. Time is intertwined with the ICU patient room and therefor also lived. The design of ICU patient room coupled with how the next of kin are received and welcomed shape their experiences of ICU patient room and in what extent they can be a part of patients life in ICU.

22 The aim- study II The aim of this study was to reveal the meanings of the ICU patient room as a place of care from the critically ill patients perspective.

23 Participants Purposeful sampling was employed Inclusion criteria for sedated patients: MAAS 3/RASS 0 Being able to communicate in Swedish Minimum of three days stay in ICU Inclusion criteria for none sedated patients: Absence of delirium (OBS-Scale) Being able to communicate in Swedish Minimum of three days stay

24 Participants Seventeen people were included in the study. Seven passed away before the process of data collection was completed and one denied to participate. In total nine patients (both sedated and none sedated) from three different ICUs participated in the study Days of stay varied 5-90 days, five women and four men (38-80 yrs.)

25 Data collection For sedated patients After oral consent from the next of kin and approval from staff I photographically documented patients bed area, by taking photos from patient s view angle. I avoided to take pictures from a close angle that could reveal patients identity or body. The photos were used for an interview after discharge from ICU.

26 Patient s view- front

27 Patients view- up/ ceiling

28 Patient s view- beside

29 Patients view- front

30 Patient s view- ceiling

31 Patient s view- front

32 Data collection None sedate patients They were ask to photograph various aspects of the patient room that they associated with a feeling regards of what that feeling was about. Photos were used during a follow up interview after discharge from ICU, except one patient. (This patient had become depended on a ventilator and had a very long ICU stay)

33 Patient s photos It s a positive you see makes me feel happy, my grandchildren I like to have the pictures (have they visited you?) Yes but it was a while ago they live far from here (what does it mean to you when ) Oh makes me happy to see them and my son I want to know how they are.don t see them often now a days

34 Patient s photo My workmates and friends have been here with the flowers and teddies and its like you are still there or I mean I Still have my life even though I m not participating actively

35 Patient s photo I love this person! I do!!! She is an angel I was in pain and vomiting a lot all the time It was never a problem I just needed to look at her and she was there. It means a whole world when someone you are not left alone (hm..) do you understand??

36 Data analyse Phenomenological analyse/rlr, according to Dahlberg et al., (2008) Searches for the essences of phenomenon in lifeworld. Studies the intention relation between the subject and the world, based on Husserl s philosophy. The essence of the phenomenon is the what-ness of ICU patient room as lived by the patients, i.e., what makes the ICU patient room to what it is.

37 Findings- essence ICU patient room is intertwined with the staff, technological equipment, Tone of caring, The room emerged as a result of interplay with the staff and occurrences taking place in room, The room is lived bodily and in dreams, Tension between suffering and wellbeing, being secure or abandoned.

38 The constituents- themes A place of vulnerability A place in-between A place of trust and security A life-affirming place A place of tenderness and care An embodied place

39 Study III The aim of this study was to explore nurses lived experiences of ICU bed spaces as a place of care for the critically ill.

40 Participants Strategic sampling was employed: Staff from the same ICUs in study I & II Fourteen bedside nurses both trained ICU nurses and auxiliary nurses were invited to participate in the study. Variation in years of experience, 13 female and 1 male nurse.

41 Data collection Photovoice and lifeworld interviews. Nurses were invited to photograph various aspects of the ICU patient room that was of importance when caring for the critically ill patients and that they associated with a feeling.

42 Data analyse Phenomenological analyse - Reflective lifeworld approach (Dahlberg et al., 2008).

43 Photos taken by the staff This is the monitor (ref. to technologies) I m really glad we have them, makes my job so much easier save a lot of time you know. It s like a kit that belongs to an ICU patient room otherwise it could be any patient room

44 I have taken this picture to show how overcrowded this place is! We need a lot of apparatus and other stuff and lines and I feel this affects me so so so much in my work! All the time! And it has got nothing to do with the way I treated the patient in the bed...(pause) but of course it does indirectly because for example we can t mobilise the patients easily and it is confining!

45 I took this picture because this looks very boring.. simply very boring! It is very practical and a solution to our problem instead of putting the cables on the floor we can connect them and adjust the height of it. But if you use all the outlets and wires are hanging out and down from this and you have been sedate or are under sedation...i can imagine that must be very awkward!!!

46 It the cubical Just want to show how the room can be like a prison, wearing that pyjamas (patient dress).not being able to leave.. It holds you there and I mean a window provides an opportunity to open up (the room) and a door is even a bigger possibility! Imagine to get out and sit there having coffee with your family.

47 Took this to It s about how things can work easy and smooth so it s a calm or nice photo.(laughter)..you just have to look at each other and every one knows what to do..

48 Secrecy is none-existing here! // Every body sees and hears everything about each other. I try my best to make people to talk in a lower voice but its no use! We talk about very very sensitive matters like to end the treatment and so

49 Findings- essence Being uncompromisingly on call, A continual strive to preserve and promote patients and families wellbeing. Bed space are constituted by an inner existential and outer spatial dimension Proximity between the nurse-patients and patients-technologies Divergent feelings; uncertainty, powerpowerlessness, control and lack of control

50 Constituents- themes Observing and being observed A broken promise Cherishing life Ethical predicament Creating a caring atmosphere

51 Study IV- photovoice The aim of this study is to describe photovoice as a data collection method in ICU. Theoretical paper Literature, photos generated and experiences from study I-III

52 Photovoice Reflection over place, space and lifeworld Place and space in ICU Ontological and epistemological underpinnings How photovoice was employed in the project described in detail

53 Photovoice Developed by Wang & Burris (1997) The theoretical foundation is based on critical consciousness (Freire s pedagogy), feministic theory and photo documentation Is often employed for interventional purposes and in order to empower the marginalized people in society.

54 Why did I chose photovoice? In order to ensure validity of the studies. In order to bring patients and next of kin s attention to the phenomenon under study.

55 A few suggestions What are the goal and purposes of employing photovoice in the project? How are we going to instruct people? How are we going to use photovoice during the interviews? Do an ethical analysis about the advantages versus disadvantages Is photovoice in the project considered as a method or a methodology?

56 Conclusions It seems unclear who is charge for the environment of ICU once it has been built. Need for polices for how to keep the ICU patient room a healing, caring and functional place for care. Obvious and small interventions improve the environment All ICUs should consist of single bed rooms Most important of all, every single intervention in the physical environment should be coupled with caring or pedagogical interventions.

57 Clinical implications Suggestions to the staff Provide a place for families in the patient room- family chair Invite the family to perform small tasks if appropriate Make the waiting areas a friendly place to stay by providing enough seats and beverages, magazines, blankets and toys Please remember that the family members are also in state of crisis, a friendly smile or gaze mean a lot

58 Clinical implications Use natural decoration- avoid abstract photos or art work Avoid conversation about sensitive topics in the patient room Use a sign family is waiting hang it on the end of the bed as a reminder that the family is waiting outside Stand at the patients upper bedside and estimate what is in the patients view, and take away things that doesn t need to be there If possible make sure that dying patients and their family are cared for in a single bed room. Orientate the patients to time, place and room

59 Clinical implications Prepare; inform the patients prior to nursing activities Place the bed close to the window as much as possible to facilitate patients view to the world outside Create a personal place around the bed by using patients photos and personal belongings Adjust the light after performing nursing activities

60 Clinical implications Organisational suggestions If possible start the round out side the patient room in order to maintain patients and families integrity and secrecy. Evaluate the physical environment from the perspective of staff, patients and families. Use the best available evidence when intervening the environment Install sound absorbent screens between the beds

61 Continuation? Small project about the meanings of comfort, data collection in collaboration with Chalmers University, CVA Workshops Patients and next of kin interviews

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63 References Dahlberg, K., Dahlberg, H., & Nyström, M. (2008). Reflective lifeworld research. Lund: Studentlitteratur. Olausson, S., Ekebergh, M., & Lindahl, B. (2012). The ICU patient room: Views and meanings as experienced by the next of kin: A phenomenological hermeneutical study. Intensive & Critical Care Nursing, 28(3), Olausson, S., Lindahl, B., & Ekebergh, M. (2013). A phenomenological study of experiences of being cared for in a critical care setting: The meanings of the patient room as a place of care. Intensive & Critical Care Nursing, 29(4), Olausson, S., Ekebergh, M., & Österberg, S. A. (2014). Nurses' lived experiences of intensive care unit bed spaces as a place of care: a phenomenological study. Nursing in Critical Care, 19(3), n/a-n/a. Olausson, S., Ekebergh, M., & Lindahl, B. (2014). On doing photovoice application and reflection. [submitted] Lindseth, A., & Norberg, A. (2004). A phenomenological hermeneutical method for researching lived experience. Scandinavian Journal of Caring Sciences, 18(2), Wang, C., & Burris, M. A. (1997). Photovoice: Concept, Methodology, and Use for Participatory Needs Assessment. Health Education & Behavior, 24(3), doi: / World Medical Association. (2008). Declaration of Helsinki: ethical principles for medical research involving human, from Assecced from,