At St. Vincent's Hospital, Sydney, numbers of patients are admitted to the Intensive Therapy Unit (ITU) for observation and management following major surgery. This study examined the feasibility of providing an orientation program for these patients in order to reduce their anxiety once admitted to the ITU post-operatively. The study was conducted in two phases. Phase 1 used tape-recorded interviews based upon open-ended questions, to determine the perceptions of 17 elective surgical patients who had been in ITU post-operatively. In Phase 2, a questionnaire was used to determine the opinions of nurses towards such an orientation programme. Results showed that patients and nurses feel there is a need for a program to orientate patients to the ITU. Patients identified various stressors that could be used in formulating this program. Nursing staff predicted that job satisfaction would increase as they would be providing more holistic care to their patients. The study provides a framework for the design and implementation of an orientation program to St. Vincent's ITU.
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Cindy Skacel, RN, Intensive Therapy Certificate. Fiona McKenna. RN, Intensive Therapy Certificate. This study was undertaken as part of the Intensive Therapy Course, 1989 - 1990 at St. Vincent's Hospital, Sydney. |
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Much is written in the literature about pre-operative education of patients by Operating Room personnel and ward nursing staff, but little about the specific area of orienting patients to an intensive care environment.
The researchers' clinical experience suggests that many intensive care patients are anxious. The Intensive Therapy Unit (ITU) is a place unfamiliar to a large part of the population. Disorientation leads to stress and anxiety. Education reduces stress. These principals provided the rationale for this study.
Rothrock (1989) reviewed pre-operative nursing research and concluded that psychoeducational interventions are valuable in increasing patient knowledge, compliance and satisfaction with care and in improving physiological recovery, length of recovery and psychosocial response to surgery. Rothrock categorised this information into three groups:
Rothrock also refers to the concept of patient-centered care, in which patients decide what they want to know as opposed to the nurse deciding what they should know. This concept is used in this study.
Rothrock also discusses the effect on nurses of pre-operative patient visits. She states that nurses benefit from such visits, because they know more about a patient as an individual and are therefore more satisfied with the care they give.
Murray and Stephens (1987) state that the primary objective of preoperative visits is to initiate and maintain communication between the nurse, patients and their significant others. They also state that visiting a patient pre-operatively and providing information about the ITU provides better co-operation and enhanced personal involvement for the nurse.
Miller and Shada (1978) found that patients can identify specific areas of unmet needs related to their post-operative course. The immediate postoperative period (first 24 hours) was identified as an area in which information was lacking. The patients also considered this period the most crucial and complex time of the entire hospitalisation. The authors conclude that if pre-operative instruction is given by the same nurse who will give primary care in the immediate postoperative period, the instruction will be very effective and the subjects will feel secure in knowing that the same nurse will be giving care the next day.
Miller and Shada failed to offer any suggestions for the allocation of staff, which such a programme would require. Their study was also limited by the fact that their sample was of only nineteen patients.
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This explorative study was divided into two parts, the first concerning patients and their thoughts and the second pertaining to nursing staff.
Phase I of the study was retrospective and investigated the stressors identified by 17 elective surgical patients who had experienced a postoperative period in ITU. Data was collected from the patients by a structured tape-recorded interview, based on an open-ended questionnaire. Using Rothrock's (1989) categories, it was predicted that the data collected in this study could be analysed and categorised into stressors of a sensory, procedural and psychological nature. This categorisation would then act as a guideline for developing a structured orientation program by identifying the predominant stressors as perceived by the patients and proposed strategies to cope with them.
Phase II was a prospective study in which all the registered nurses working in the ITU (n=46) were invited to complete a written open-ended questionnaire. This questionnaire aimed to determine the opinions of the nurses regarding the benefits of introducing an orientation program and to assess the feasibility of such a programme.
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The research proposal was approved by the Nursing Research Ethics Committee of St. Vincent's Hospital. Permission was obtained from surgeons in writing prior to commencement of the study. A consent form was designed so that all patients could give their written, informed consent to participate in the study.
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The study was conducted in the ITU of St. Vincent's Hospital Sydney, a 500 bed teaching hospital under the care of the Sisters of Charity. The ITU has nine beds and accommodates all critically ill patients in the hospital, except for those recovering from cardiac surgery and those requiring specialised coronary care. Its role includes the observation and management of patients following major surgery. It is from this group that the convenience sample for Phase I of the study was selected. Seventeen patients were selected who had undergone either craniotomy or major vascular surgery. Their names were selected from the ITU patient discharge records. Three females (18%) and 14 males (82%) participated in the study. The age of the patients ranged from 28 to 71 years, with a mean age of 56 years.
Patients excluded from the study, who had otherwise fulfilled our criteria, were those who were unable to speak English and those unable to give informed consent due to confusion and disorientation.
At the time of the survey, the ITU nursing staff comprised 46 registered. All were invited to participate in Phase II of the study. Twenty-five of the 46 questionnaires distributed (54%) were returned completed.
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The researchers conducted structured interviews comprising five open-ended questions with the 17 patients. Each interview was recorded on a portable tape recorder. Patients were asked to participate in the interview after they had been discharged from the ITU. The interviews took place at the patients' bedside in their postoperative ward. The interviews were conducted after a minimum period of three days following the patients' discharge from ITU. This provided the patients time to recover physically from their surgical procedure, consequently optimising the recollection of their personal experiences in ITU. A tape recording of the interview allowed the interviewer to maintain eye contact and establish a friendly rapport with the patient. It also provided an accurate record of the patients' responses.
Figure 1 lists the open ended questions which were designed to elicit a wide range of responses. The aim of the questions was to focus on the experiences of ITU from the patients' vantage and therefore minimise bias or influence from the interviewer.
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Figure 1. Patient Questionnaire
A take home, open-ended questionnaire was hand delivered to each member of the nursing staff of the ITU. The questionnaire focused on determining the opinions of the nurses regarding the benefits and feasibility of introducing an orientation program to ITU.
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Data was collated from the transcripts of the interviews with the patient.
Question 1
Ten patients described the postoperative period in the ITU as being a time of constant observation and attention, given to one patient by one nurse. Two patients described the continuous activity of the ITU environment and one patient described the postoperative period in the ITU as an unpleasant experience... it was pretty horrific. The remaining four patients evaded answering the question.
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Question 2
Responses to this questions were:
| Response | Number |
| Yes | 8 |
| No | 3 |
| No Answer | 4 |
| Undecided | 2 |
Two of the three patients whose response was no, found the experience to be worse than expected:
I imagined it to be dark, not so bright and fully lit it was noisy
The other patient found the experience better than expected.
It was a surprise, I expected more pain
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Question 3
There was a number of detailed, descriptive responses of the specific experiences that caused the patients stress. These included:
Tube in throat, chatter of staff, craving for water, blood pressure monitoring, not knowing what is going to happen to you.
A number of patients preferred to describe experiences as discomforting rather than stressful.
Five patients did not find the ITU experience stressful and four patients did find the experience stressful. Three patients did not answer.
Eight patients described procedural stressors. These included:
the endotracheal tube, chest physiotherapy, nasogastric tube. intravenous fluid and drug therapy, venepuncture and manual observations.
Eleven patients described sensory stressors. These included:
dry mouth, difficulty in talking and swallowing, disturbed sleep, light and noise.
Two patients described psychological stressors. These included:
uncertainty of what was happening, or inadequate knowledge of their medical condition resulting in anxiety and irritability.
It is evident from these results that a degree of overlap occurred as several patients identified both procedural and sensory stressors.
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Question 4
Responses to this questions were:
| Response | Number |
| Yes | 14 |
| No | 1 |
| No Answer | 2 |
| Undecided | 5 |
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Question 5
The responses to this question were placed into three groups, based on Rothrock's categories:
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Procedural Information |
Psychological | Sensory |
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Function and reason for:
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An additional category was created for patients who preferred not to be given information. These patients feared being overwhelmed by predetermined information. Instead, they preferred that an ITU nurse be available to answer particular questions.
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Results of the six questions that nursing staff asked were:
Question 1. If this research study confirms our research statement would you be willing to implement an ITU orientation programme?
Twenty-four nurses answered yes to this question. One nurse was unsure.
Comments included that the programme should be quick and easy to carry out and that there should be a clear goal stated. Also that the first priority should be the patients already in the unit, that is if time, staff or money is short, the visits should be cancelled to ensure optimal care for current ITU patients.
Question 2a. Do you agree that evening staff as part of their afternoon ward duties could visit surgical patients booked to be admitted to ITU post-operatively?
Half of the respondents suggested that the patients should be brought down to tour ITU during the overlap in shifts. Reasons for this included that the patients could then meet various nurses and would therefore be more likely to at least see one familiar face following their admission to the unit, and also that if patients' families were to accompany them, they too would become familiar with the ITU.
Other comments included that this time would only be suitable if some of the existing ward duties were carried out at other times, and there was a suggestion that the visits carried out by one specific Clinical Nurse Specialist or educator whose role included this task.
Question 2b. Can you suggest a more appropriate time for visiting patients?
Suggestions included:
Question 3. Do you think it would be feasible for the visiting nurse to be allocated the care of that patient upon their admission to the ITU?
Fifteen nurses thought this was a feasible proposition. Four nurses indicated this was not a feasible proposition. Reasons for this included that this was a half-hearted attempt at primary nursing which, because of lack of experience, wisdom and expertise in this ITU, could not be introduced and that it may lead to Inappropriate patient allocation (ie. experience of staff vs intraoperative events). Six of the respondents were unsure. Hesitations concerned the difficulty with staff rostering and theatre cancellations.
Suggestions included that if more than one nurse visited the patients or if the patients came down to the unit, they would meet more than one nurse and it would therefore be more likely that they would be allocated to a familiar face. Also it was proposed that it was not important for the visiting nurse to actually receive the patient from theatre as they are often heavily sedated anyway, but perhaps to be allocated the patient's care sometime during the first twenty-four hours.
Other nurses suggested filling in a pre-operative information sheet during the orientation programme, supplying information such as what the patient prefers to be called and specific fears they have for example, so the nurses caring for the patient will know more about them.
Question 4a. Do you feel that by meeting with the patient pre-admission to ITU you would be able to give more individualised holistic care?
Eighty percent responded positively to this question. Sixteen percent answered no as they felt that they already provided individualised holistic care to their patients.
One nurse was unsure, and indicated that they would have to experience the situation first.
Comments included that the nurses would feel they were showing an interest in the emotional care of the patient and that the patients would 'know you cared' if they were visited pre-operatively. A number of nurses indicated that it would build up trust and communication between the patient and the nurse, some nurses stating that they find it difficult to build up a rapport with an unconscious patient. It was also expressed that knowing about specific problem areas in advance would allow the nurse to plan and implement strategies to overcome them.
Question 4b. Would this increase your work satisfaction?
Seventeen nurses thought that carrying out such an orientation programme would increase their work satisfaction. Reasons for this included that nurses could be better patient advocates if they knew their patients better, that the patients would feel less anxious and may recover quicker leading to greater nurse satisfaction. A concept expressed by seven nurses was that primary nursing should be encouraged as it would certainly lead to increased work satisfaction.
Four nurses answered no to this question indicating that their work satisfaction has more to do with factors such as shifts worked and staff on duty.
Four nurses were unsure indicating they would have to experience the situation first.
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The results of Phase I of this study indicate that patients do perceive the need for an orientation programme to ITU. However the results of this study must be viewed in the light of the study's limitations which include the small sample size, the possibility of interviewer bias and the structure of the questionnaire.
A larger sample size interviewed in an extended time period may have revealed more defined themes or patterns from the responses. An extended time period would have allowed the employment of alternative methods to establish the specific information patients wish to have included in a structural orientation programme.
The method of nurses interviewing patients may have created a degree of bias. Patients may have been less likely to respond honestly to questions delivered face to face than with a totally confidential written questionnaire. Patients may also direct their responses to what they perceive the interviewer wished to hear rather than focusing solely on the question. For example patients may have thought the researchers wished to hear that intensive care was not a stressful experience.
The style of an open-ended questionnaire inherently produces diverse responses. This style of questioning is obviously beneficial in illustrating the importance of the individual needs of every patient. In this study it reduced the bias and subjectivity of the nurse in deciding what information patients need to know in an orientation programme. However patients can evade questions or respond with non-specific information.
When analysing patients' responses to this questionnaire, some variables required identification and consideration. For example, in the questionnaire used in this study, there were varying degrees to which patients could recall their experiences of intensive care. The patients had differing levels of education. Prior experiences of hospitalisation and in ITU may have had an influence on their responses to questions. The physical wellbeing of the patient on the day of the interview is also a factor to consider.
A considerable number of the questions were unanswered in this study. A possible reason for this fact is the majority of patients ranged in age from fifty to sixty-five years of age. This age group is perhaps unfamiliar with the notion of defining their specific nursing needs as they may believe that nursing care is delivered to them as deemed appropriate by the care givers.
It is also instructive to consider the cultural differences between a sample of Australian and American patients. American researchers, for example, Miller and Shada, (1978) state that patients can identify specific areas of need. Rothrock (1989) states that nursing research in the last ten years has revealed that the structured pre-operative psychoeducational programmes are the most effective in decreasing the stress of a patient. The data from this study does not definitely support these American research studies findings. It is perhaps relevant that American patients seem to be more aware of their rights and needs in the hospital environment. They are familiar with voicing their specific individual needs within the Health Care System.
The results of this explorative study support the research statement that patients would find their post-operative period in ITU less distressing psychologically if they had undergone an orientation programme prior to their admission to the unit. The results also reflect the diversity of information patients wish to have included in the orientation programme. Some patients wish to know all the procedural details relevant to their stay in ITU. Many prefer information given through the form of constant reassurance of their care while others prefer to have the opportunity to ask only what they wish to know.
The patient responses were of sufficient detail and specificity to facilitate their classification into procedural, sensory and psychological categories. The results confirm that the patients' individual needs must be considered when designing and implementing an orientation programme. It is proposed that a further study be developed using the above data and taxonomical system, preferably employing the Q Sort Technique. (A Q Sort Technique is a controlled and more specific method of collecting data). It would reassess patients' responses to the collected data and to our system of classification, therefore more precisely determining the specific information patients wish to be told in an orientation programme.
The results of Phase II of the study indicate that the majority of the ITU nurses feel there is a need for some type of orientation programme in ITU. The responses indicated that such a programme would lead to the delivery of more individualised holistic nursing care and increased job satisfaction.
The practicalities of implementing a pre-operative orientation programme were examined and it was concluded that the most appropriate time would be during the overlap in shifts. This would need to be flexible, enabling visits to be cancelled if necessary after considering the needs of the patients already in the ITU.
Ideally, the nurse visiting a patient pre-operatively would also be responsible for the patient's post-operative care. This allocation would need to be flexible, taking into account the condition of the patient, the experience of the nurse and the demands of the other ITU patients. It is anticipated that this would avoid an inappropriate patient allocation.
The idea of bringing patients to ITU to familiarise them with the setting requires further investigation. It would be necessary to question Ward Nurses about their feelings toward bringing patients into the ITU. It would also be essential to determine the opinion of the patients to this method of orientation.
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This study has presented a concept of continuity in patient care. It has been demonstrated that there is a patient demand for an orientation programme for the elective surgical patients of the ITU at St Vincent's Hospital. The nursing staff have displayed their enthusiasm and support for the delivery of an orientation programme
Relevant data has been presented which future researchers may employ as a guideline for formulating programmes which address the specific design and content of an orientation programme.
This project has presented the researchers with a basic introduction to research. We have come to appreciate the complexity of nursing research.
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