Different ways of thinking about patients in critical careChris McLean PhDLecturerUniversity of Southampton
Background and methodsA focus on the whole person is central to nursing (RCN 2004) Critical care nurses experience moral distress whilst attempting to care for the whole person (Cronqvist et al. 2006; Lawrence 2011; McAndrew et al. 2011) Depersonalising is usually seen as a coping strategy or response to anxiety (Menzies Lyth 1959; Benner 1999)
MethodsResearch question: How do critical care nurses think about patients?
Ethnographic approach. Data collected through participant observation and interview with 7 primary participants during 2006 to 2007.
Data analysis adopted the approach of Discourse Analysis (Foucault 1969)Discourses are patterns in what people say and do Different discourses ascribe patients an identity as a particular kinds of being hence reflect different ways of thinking
Findings part 1
Different ways of thinking
Thinking about a patient as a whole person is literally unachievable because nurses think about patients in different ways:
As a valued individualAs a social beingAs a set of needsAs routine workAs a bodyAs (un)stableAs a medical case
She comments as the patients systolic blood pressure drops to 55 that even if the patient is lucid I dont like 55
The hip yesterday I think with those things you probably have depersonalised youve taken the person away Manages time
Ensures safetyMonitoring and supporting body systemsAssessment / examinationUnderstanding and communicating patterns.
Knowing how the patient is doing
Patient as FeaturesFunctionsRoutine workTime dominates obs oclock
Habitual tidying (Un)stableA focus on aims / targets / parameters
Precise and quantified
BodyFocus on surface features
Prodding or pokingMedical caseUnderstanding the significance of physiology
Findings part 2
*I dont know if this is a really un-nursey thing to say ((laughter)) but I think the most important thing is making sure the patients safe
with the sickest ICU patients you are unfortunately focusing more on their observations.Its nice for us to see her as a person as well as the patient in the bedbut at the same time its something for him to focus on as well Privacy and dignity is one of the nursing things that nurses are supposed to ((laughs)) But the most important thing was to make sure that they maintained their airway and they were breathing.
Participants often characterised these aspects of their practice as problematic. ..Its actually quite bad isnt it ?Thinking in impersonal ways was not consistent with being a nurse who cares for persons
Nurses are socialised to believe it is impersonal to think and talk about patients in certain waysThinking about patients as routine work, as a body, as (un)stable or as a medical case is essential to critical care nursing practiceCritical care nurses can hold ideals of whole person care which are dissonant with aspects of their role This dissonance is important because:Critical care nurses may struggle to describe, reflect upon or celebrate aspects of their practiceIt is a potential source of stress and distress to critical care nursesDisparity between nurses ideals and the realities of care can lead to emotional exhaustion and burnout (Maben et al. 2007)*
RecommendationsFor the individual reflective practitioner:Nurses must think and talk about patients in many different ways. Judgements about whether these ways of thinking and talking are appropriate is dependent on contextFor education:Recognise that critical care nurses must gain skills in moving between different ways of thinkingAirway or person?Look at the patient: Difficulty prioritising may reflect a failure to move between ways of thinkingFor nurse leaders:Nurse leaders, scholars and policy-makers must communicate the ideals of whole person care clearly, and legitimise the fact that that nurses must think about patients in different ways
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