Impact of Replacing Fentanyl With Hydromorphone as the First-Line Postoperative Opioid Among Patients Undergoing Outpatient Cancer Surgery.

PURPOSE: In response to a nationwide fentanyl shortage, our institution assessed whether changing our first-line postoperative intravenous opioid from fentanyl to hydromorphone impacted patient outcomes. The primary research aim was to evaluate the association between first-line opioid and rapidity of recovery. DESIGN: The study team retrospectively obtained data on all consecutive patients extracted from the electronic medical record. The rapidity of recovery was defined as the time from entry into the postanesthesia care unit to the transition to Phase 2 for ambulatory extended recovery patients and as the length of total postanesthesia care unit stay for outpatients. METHODS: Following intent-to-treat-principles, we tested the association between study period and rapidity of recovery (a priori clinically meaningful difference: 20 minutes) using multivariable linear regression, adjusting for anesthesia type (general vs monitored anesthesia care), American Society of Anesthesiologst physical status (ASA) score (1-2 vs 3-4), age, service, robotic procedure, and surgery start time. FINDINGS: Ambulatory extended recovery patients treated in the hydromorphone period had, on average, a 0.25 minute (95% confidence interval [CI] -6.5, 7.0), nonstatistically significant (P > .9) longer time to transition. For outpatient procedures, those who received hydromorphone had, on average, 8.5-minute longer stays (95% CI 3.7-13, P < .001). Although we saw statistical evidence of an increased risk of resurgery associated with receiving hydromorphone (0.5%; 95% CI -0.1%, 1.0%; P = .039 on univariate analysis), the size of the estimate is clinically and biologically implausible and is most likely a chance finding related either to multiple testing or confounding. CONCLUSIONS: The multidisciplinary team concluded that the increase in postoperative length of stay associated with hydromorphone was not clinically significant and the decrease waste of prefilled syringes outweighed the small potential increased risk of resurgery compared to the shorter-acting fentanyl. We will therefore use hydromorphone moving forward.

Being a patient in the intensive care unit: a narrative approach to understanding patients' experiences of being awake and on mechanical ventilation.

PURPOSE: Intensive care patients often struggle to communicate due to the technical equipment used for mechanical ventilation and their critical illness. The aim of the study was to achieve a deeper understanding of how mechanically ventilated intensive care patients construct meaning in the unpredictable trajectory of critical illness. METHODS: The study was a part of a larger study in which ten patients were video recorded while being in the intensive care. Five patients engaged in interviews about their experiences from the intensive care stay after being discharged and were offered the possibility to see themselves in the video recordings. A narrative, thematic analysis was applied to categorize the patients' experiences from the intensive care. RESULTS: A pattern of shared experiences among intensive care patients were identified. Three main themes capture the patient's experiences: 1) perceiving the intensive care stay as a life-changing turning point, 2) being dependent on and cared for by others, and 3) living with negative and positive ICU experiences. CONCLUSION: The patients' narratives revealed how being critically ill affected them, and how they understood their experiences in relation to themselves and their surroundings. The results can be used to pose important questions about our current clinical practice.

Non-invasive ventilation in the care of patients with chronic obstructive pulmonary disease with palliative care needs: a scoping review.

BACKGROUND: Patients with severe chronic obstructive pulmonary disease (COPD) could have palliative care (PC) needs because of unmet needs such as dyspnoea. This may lead to anxiety and may have an impact on patients' ability to perform daily activities of living. PC can be started when patients with COPD have unmet needs and can be provided alongside disease-modifying therapies. Non-invasive ventilation (NIV) could be an important measure to manage dyspnoea in patients with COPD in need of PC. A scoping review was conducted to gain an overview of the existing research and to identify knowledge gaps. The aim of this scoping review was to systematically map published studies on the use of NIV in patients with COPD with PC needs, including the perspectives and experiences of patients, families, and healthcare professionals (HCPs). METHODS: This review was conducted following the framework of Arksey and O'Malley. The reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. The review protocol was published. AMED, CINAHL, Embase, MEDLINE, PEDro, and PsycInfo were searched from inception to November 14, 2022. The included studies had to report the perspectives and experiences of COPD patients, relatives, and HCPs regarding NIV in the care of patients with COPD with PC needs. In pairs, the authors independently assessed studies' eligibility and extracted data. The data were organised thematically. The results were discussed in a consultation exercise. RESULTS: This review included 33 papers from 32 studies. Four thematic groupings were identified: preferences and attitudes towards the use of NIV; patient participation in the decision-making process of NIV treatment; conflicting results on the perceived benefits and burdens of treatment; and heterogenous clinical outcomes in experimental studies. Patients perceived NIV as a 'life buoy' to keep them alive. Many patients wanted to take part in the decision-making process regarding NIV treatment but expressed varying degrees of inclusion by HCPs in such decision-making. Conflicting findings were identified regarding the perceived benefits and burdens of NIV treatment. Diversity in heterogeneous clinical outcomes were reported in experimental studies. CONCLUSIONS: There is a need for more studies designed to investigate the effectiveness of NIV as a palliative measure for patients with COPD with PC needs using comprehensive outcomes. It is especially important to gain more knowledge on the experiences of all stakeholders in the use of home-based NIV treatment to these patients.

Combining clinical practice and education in critical care nursing-A trainee program for registered nurses.

AIM: The aim of this study was to describe the experiences of a master's-level critical care nursing program for trainees in postoperative and intensive care units. DESIGN: An exploratory design with a multidimensional approach was chosen. METHODS: The study was conducted from 2018 to 2019 at a university hospital in southern Norway in collaboration with a university college of nursing. Data were collected through seven focus group interviews with trainees, preceptors, heads of departments, clinical nurse educators and professors (n = 26). The thematic analysis progressed from description to a deeper understanding, searching for manifest and latent patterns across the data. The COREQ checklist was used for reporting the study. RESULTS: The analysis resulted in one overarching theme: 'To walk the critical care nursing pathway - balancing competency, time, and challenges to become proficient'. The subthemes were 'expectations, obligations, and workload in unknown environments', 'constantly assessing while being assessed', 'continuous precepting and challenges', 'vulnerability and commitment' and 'thriving in the role, mastering new skills'. The study provides valuable insights into a complex learning environment and the importance of caring aspects for trainees during their critical care nursing education. CONCLUSION: Precepting, continuous competence assessment and clear learning outcomes are necessary to create a safe environment for the trainees during their development. IMPLICATIONS FOR THE PROFESSION: The results advocate investing in inexperienced trainees' competency development to become proficient, creating a safe learning environment in a highly complex setting. This may also, as previous studies suggest, increase staff retention.

Communication with mechanically ventilated patients in intensive care units: A concept analysis.

AIMS: The aim of this study was to perform a concept analysis of communication with mechanically ventilated patients in intensive care units and present a preliminary model for communication practice with these patients. DESIGN: The Im & Meleis approach for concept analysis guided the study. SEARCH METHODS: A literature search was performed in January 2022 in MEDLINE, Embase, CINAHL, psycINFO and Scopus, limited to 1998-2022. The main medical subject headings search terms used were artificial respiration, communication and critical care. The search resulted in 10,698 unique references. REVIEW METHODS: After a blinded review by two authors, 108 references were included. Core concepts and terminology related to communication with mechanically ventilated patients were defined by content analytic methods. The concepts were then grouped into main categories after proposing relationships between them. As a final step, a preliminary model for communication with mechanically ventilated patients was developed. RESULTS: We identified 39 different phrases to describe the mechanically ventilated patient. A total of 60 relevant concepts describing the communication with mechanically ventilated patients in intensive care were identified. The concepts were categorized into five main categories in a conceptual map. The preliminary model encompasses the unique communication practice when interacting with mechanically ventilated patients in intensive care units. CONCLUSION: Highlighting different perspectives of the communication between mechanically ventilated patients and providers through concept analysis has contributed to a deeper understanding of the phenomena and the complexity of communication when the patients have limited possibilities to express themselves. IMPACT: A clear definition of concepts is needed in the further development of guidelines and recommendations for patient care in intensive care, as well as in future research. The preliminary model will be tested further. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution, as this is a concept analysis of previous research.

Caught between ideals and reality: Phenomenological-hermeneutic study of healthcare providers' experiences while interacting with mechanically ventilated patients.

This study aimed to explore healthcare providers' experiences of their communication and interaction with conscious patients on mechanical ventilation in intensive care. Nurses, physicians, and physiotherapists were interviewed after they had been video recorded in naturally occurring interactions with patients. The interviews were analyzed using a phenomenological-hermeneutical approach. Three themes were identified: The willingness to engage and understand the mechanically ventilated patient, the potential risk of neglecting the patient in the encounters, and provider interdependence as the core of intensive care. The themes elicited how providers handled the dissonance between their own personal ideals of care and their real-world encounters with patients and other professionals. The healthcare providers were aware of how easily patients could be neglected while being non-vocal, and therefore invested time and effort communicating with the patients. Based on their personal ideals of patient participation and autonomy, it was difficult to perform procedures, such as weaning off the ventilator or mobilization, to which the patient was opposed. Interprofessional collaboration was valued by the providers in such situations. The study revealed that providers need to consider the communication barriers that exist on the individual and team levels when interacting with patients on mechanical ventilation.

Nonpharmacologic Pain Management for Patients in Ambulatory Extended Recovery After Minimally Invasive Gynecologic and Urologic Surgery.

PURPOSE: To determine the effectiveness of an evidence-based postoperation nonpharmacologic pain management bundle for patients recovering from minimally invasive gynecologic and urologic surgeries. PARTICIPANTS & SETTING: This study focused on patients recovering from minimally invasive gynecologic and urologic surgery at a comprehensive cancer center. The first cohort consisted of patients three months preimplementation (n = 96) and the second consisted of those three months postimplementation (n = 86). METHODOLOGIC APPROACH: The project used a pre- and postintervention design and deployed the bundle as a nursing order. Nurses and patients were educated about the bundle and comprehensive postoperation pain management strategies. FINDINGS: Postimplementation, the documented use of nonpharmacologic pain management interventions significantly increased and postoperation opioid use significantly decreased without negatively affecting pain scores or lengths of stay. IMPLICATIONS FOR NURSING: Nonpharmacologic pain interventions can decrease the need for postoperation opioids, and ordering a bundle of interventions alongside analgesia is an effective way patients can manage pain.

Non-invasive ventilation in the palliative care of patients with chronic obstructive pulmonary disease: a scoping review protocol.

INTRODUCTION: Patients with advanced chronic obstructive pulmonary disease (COPD) experience a great symptom burden. Breathlessness is a very frequently reported symptom that negatively affects all aspects of daily life and could lead to fear of dying. Non-invasive ventilation (NIV) could be an important palliative measure to manage breathlessness in patients with advanced COPD. We decided to conduct a scoping review to attain an overview of the existing research and to identify knowledge gaps. This scoping review aims to systematically map published studies on the use of NIV in the palliative care of COPD patients, including the perspectives and experiences of patients, families and healthcare professionals. METHODS AND ANALYSIS: This scoping review will employ the framework of Arksey and O'Malley. The reporting will be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. A comprehensive and systematic search strategy will be developed in cooperation with an experienced librarian. Database searches will be conducted in AMED, PEDro, Embase, CINAHL, PsycInfo and MEDLINE in February 2021. Pairs of authors will independently assess studies' eligibility and extract data using a standardised data-charting form. The data will be inductively summarised and organised thematically. The results will be discussed with an advisory board consisting of nurses and physicians from respiratory and intensive care units. ETHICS AND DISSEMINATION: Approval for the workshop with the advisory board has been attained from the Norwegian Centre for Research Data (480222), and approval will be attained from the Personal Data Protection Officers of the participating hospitals. All advisory board participants will sign an informed written consent before participation. The results could contribute to developing the body of evidence on the use of NIV in the palliative care of COPD patients and serve to identify directions for future research.

Advancing communication skills in intensive care: Caring for relatives of critically ill patients.

OBJECTIVE: The aim of this study was to explore critical care nursing students' experiences with simulation-based communication skills training focusing on relatives. METHODS: Two complex scenarios were developed using professional actors in the role as relatives. A survey was conducted with critical care nursing students from 2017 to 2020. We performed descriptive and correlational analysis of the quantitative data and thematic analysis of the open-ended questions. RESULTS: The total learning outcome was 4.10 (SD = 0.79, N = 98) on a Likert scale from 1 to 5. The learning outcome with the use of a professional actor was 4.65 (SD = 0.6, N = 118), and the experience of realism was 4.16 (SD = 0.85, N = 67). The students rated the debriefing as 4.38 (SD = 0.73, N = 118), and they experienced more positive emotions than negative during the simulation. CONCLUSION: High learning outcomes were reported. The use of professional actors with fine-tuned improvisational skills enhanced the sense of realism in the scenarios. However, the impact of emotions on learning outcomes should be further investigated. PRACTICE IMPLICATIONS: By obtaining advanced communication skills focusing on relatives during their nursing education, critical care nursing students can improve the care they give.

Patient involvement in micro-decisions in intensive care.

OBJECTIVE: The objective of this study was to explore how bedside micro-decisions were made between conscious patients on mechanical ventilation in intensive care and their healthcare providers. METHODS: Using video recordings to collect data, we explored micro-decisions between 10 mechanically ventilated patients and 60 providers in interactions at the bedside. We first identified the types of micro-decisions before using an interpretative approach to analyze the decision-making processes and create prominent themes. RESULTS: We identified six types of bedside micro-decisions; non-invited, substituted, guided, invited, shared and self-determined decisions. Three themes were identified in the decision-making processes: 1) being an observer versus a participant in treatment and care, 2) negotiating decisions about individualized care (such as tracheal suctioning or medication),and 3) balancing empowering activities with the need for energy restoration. CONCLUSION: This study revealed that bedside decision-making processes in intensive care were characterized by a high degree of variability between and within patients. Communication barriers influenced patients' ability to express their preferences. An increased understanding of how micro-decisions occur with non-vocal patients is needed to strengthen patient participation. PRACTICE IMPLICATIONS: We advise providers to make an effort to solicit patients' preferences when caring for critically ill patients.

Attention-seeking actions by patients on mechanical ventilation in intensive care units: A phenomenological-hermeneutical study.

AIMS AND OBJECTIVES: The aim of this study was to explore the interaction between mechanically ventilated patients and healthcare personnel in intensive care units (ICUs), with a special emphasis on patients' initiative to communicate. BACKGROUND: Patients on mechanical ventilation in ICUs tend to be less sedated today compared to standard care in the past. Their experiences of being voiceless may cause emotional distress, and for many patients, communication is difficult. Healthcare personnel are reported to be the main initiators of the communication exchanges that occur. DESIGN: An observational study with a phenomenological-hermeneutical approach. METHODS: Video recording was used to collect data on the naturally occurring communication and interaction. Ten conscious and alert patients from two Norwegian ICUs were recruited. Two relatives and a total of sixty healthcare personnel participated. Content analysis was conducted, with focus on both the manifest and latent content meaning. RESULTS: We found a total of 66 situations in which patients attempted to attract the attention of others on their own initiative in order to express themselves. Attention-seeking actions, defined as the act of seeking attention and understanding without a voice, became an essential theme. Four patterns of interaction were identified: immediately responded to, delayed response or understanding, intensified attempts or giving up. Patients had a variety of reasons for seeking attention, which were classified into four domains: psychological expressions, physical expressions, social expressions and medical treatment. CONCLUSIONS: Patients' attention-seeking actions varied in content, form and the types of responses they elicited. The patients had to fight to first gain joint attention and then joint understanding. This was both energy-draining and time-consuming. RELEVANCE TO CLINICAL PRACTICE: Healthcare personnel need to spend more time for communication purposes, giving attention and being more alert to bodily or symbolic gestures to understand the patient's needs.

Communication with patients in intensive care units: a scoping review.

BACKGROUND: Patients in intensive care units are generally more conscious and alert when they are on mechanical ventilation than in previous years because of the many potential benefits of being under less sedation. The endotracheal tube blocks the vocal cords when patients are on ventilation, thus making it impossible to speak. Many patients report that they struggle to make themselves understood. AIM: The aim of this study was to assess previous knowledge about interaction and communication between health care personnel and conscious and alert patients under mechanical ventilation in intensive care units. DESIGN AND METHODS: A literature review was performed following the steps of a scoping review. Studies published between 1998 and 2017 were identified in several databases: Cinahl, Embase, Medline, PsycINFO and Scopus. The first search returned 7386 unique references. The inclusion criteria consisted of empirical studies or studies related to interactions between health care personnel and patients over 18 years of age on mechanical ventilation. The relevant studies were summarized in a standardized data-charting sheet. RESULTS: The inclusion criteria were met by 46 articles; 16 were qualitative studies, 17 were quantitative, 6 were mixed-methods studies, and 7 were pilot or feasibility studies. Of the studies, 37 were from nurses, 4 from physicians, 4 from speech language pathologists and 1 from psychologists. The most common topics investigated in the studies were 'experiences with communication on mechanical ventilation' and 'communication exchanges'. CONCLUSIONS: A variety of communication aids that appear to have some effect on patients should be made available in intensive care units. More multidisciplinary approaches in future studies could enhance the knowledge in the field. RELEVANCE TO CLINICAL PRACTICE: The education of intensive care unit personnel in the use of such aids should be a prioritized field, as should be the implementation of a variety of communication aids.

Intensive care nursing students' perceptions of simulation for learning confirming communication skills: A descriptive qualitative study.

AIM: The aim of this study was to explore intensive care nursing students experiences with confirming communication skills training in a simulation-based environment. RESEARCH METHODOLOGY: The study has a qualitative, exploratory and descriptive design. The participants were students in a post-graduate program in intensive care nursing, that had attended a one day confirming communication course. Three focus group interviews lasting between 60 and 80min were conducted with 14 participants. The interviews were transcribed verbatim. Thematic analysis was performed, using Braun & Clark's seven steps. FINDINGS: The analysis resulted in three main themes: "awareness", "ice-breaker" and "challenging learning environment". The participants felt that it was a challenge to see themselves on the video-recordings afterwards, however receiving feedback resulted in better self-confidence in mastering complex communication. CONCLUSION: The main finding of the study is that the students reported improved communication skills after the confirming communication course. However; it is uncertain how these skills can be transferred to clinical practice improving patient outcomes.