Mobilisation during mechanical ventilation: A qualitative study exploring the practice of conscious patients, nurses and physiotherapists in intensive care unit.

AIM: To explore the practice of mobilisation of conscious and mechanically ventilated patients and the interaction between patients, nurses and physiotherapists. BACKGROUND: Long-term consequences of critical illness can be reduced by mobilisation starting in Intensive Care Units, but implementation in clinical practice is presently sparse. DESIGN: A qualitative study with a phenomenological-hermeneutic approach. METHODS: Participant observations in three Intensive Care Units involved twelve conscious mechanically ventilated patients, thirty-one nurses and four physiotherapists. Additionally seven semi-structured patient interviews, respectively at the ward and after discharge and two focus group interviews with healthcare professionals were conducted. The data analysis was inspired by Ricoeur's interpretation theory. The study adhered to the COREQ checklist. FINDINGS: Healthcare professionals performed a balance of support and guidance to promote mobilisation practice. The complexity of ICU mobilisation required a flexible mobility plan. Furthermore, interaction with feedback and humour was found to be 'a leverage' for patient's motivation to partake in mobilisation. The practice of mobilisation found patients striving to cope and healthcare professionals promoting a 'balanced standing by' and negotiating the flexible mobility plan to support mobilisation. CONCLUSION: The study revealed a need to clarify interprofessional communication to align expectations towards mobilisation of conscious and mechanically ventilated patients. RELEVANCE TO CLINICAL PRACTICE: The study demonstrated the important role of healthcare professionals to perform a stepwise and 'balanced standing by' in adequately supporting and challenging the mobilisation of mechanically ventilated patients. Furthermore, a synergy can arise when nurses and physiotherapists use supplementary feedback and humour, and cooperate based on a flexible situation-specific mobility plan in intensive care.

Delirium and delirium severity screening in the intensive care-correspondence of screenings tools.

BACKGROUND: Delirium severity scores are gaining acceptance for measuring delirium in the intensive care unit (ICU). OBJECTIVE: The aim of this study was to evaluate the concordance between the Confusion Assessment Method for the intensive care unit (CAM-ICU)-7 and the Intensive Care Delirium Screening Checklist (ICDSC) as delirium severity measurement tools. METHODS: This was a prospective, comparative, observational multicentre study. This study was conducted in 18 Danish ICUs. Delirium was assessed in adult critically ill patients admitted to an ICU with a Richmond Agitation and Sedation Score (RASS) of -2 or above. ICU nurses assessed delirium with randomised paired delirium screening instruments, using the CAM-ICU, the ICDSC, and the CAM-ICU-7. The correlation between the CAM-ICU-7 and the ICDSC severity scores was evaluated for all predefined patient subgroups. RESULTS: A total of 1126 paired screenings were conducted by 127 ICU nurses in 850 patients. The patients' median age was 70 years (interquartile range: 61-77), 40% (339/850) were female, and 54% (457/850) had at least one positive delirium score. Delirium severity ranges (CAM-ICU-7: 0-7; and ICDSC: 0-8) were positively correlated (Pearson's correlation coefficient, r = 0.83; p < 0.0001). The overall agreement between the CAM-ICU-7 and the ICDSC for delirium measurement (CAM-ICU-7: >2, and ICDSC: >3) was substantial (kappa = 0.74), but the agreement decreased to fair (kappa = 0.38) if a patient had a RASS less than 0. CONCLUSIONS: The agreement between the CAM-ICU-7 and the ICDSC for delirium severity measurement was substantial but might be affected by the patient's sedation and agitation level at the time of assessment. IMPLICATIONS FOR PRACTICE: Both CAM-ICU-7 and ICDSC can be implemented for delirium severity measurement. Attention is warranted in both scores if a patient has a RASS of -2.

Functional and cognitive rehabilitation interventions during intensive care admission: A protocol for a systematic integrative review.

BACKGROUND: Long-term cognitive impairment occurs in up to 60% of intensive care unit (ICU) survivors. Early use of functional and cognitive rehabilitation interventions, while patients are still in ICU, may reduce cognitive decline. We aim to describe the functional and cognitive interventions used during the ICU stay, the healthcare professionals providing interventions, and the potential impact on functional and cognitive rehabilitation. METHOD: In this integrative systematic review, we will include empirical qualitative, quantitative, mixed- and multiple-methods studies assessing the use of functional and cognitive rehabilitation provided in ICU. We will identify studies in relevant electronic databases from 2012 to 2022, which will be screened for eligibility by at least two reviewers. Literature reported as narrative reviews and editorials will be excluded. We will assess the impact of interventions evaluating a cognitive and functional function, quality of life, and all-cause mortality at 6-12 months after ICU discharge. The Revised Cochrane risk-of-bias Tool will be used for assessing risk of bias in clinical trials. For observational studies, we will use the National Institutes of Health Quality Assessment tool for Observational Cohort and Cross-Sectional Studies. Furthermore, we will use the critical appraisal skills programme for qualitative studies and the mixed methods appraisal tool for mixed methods studies. We will construct four matrices, including results describing which ICU patients and healthcare professionals were engaged in rehabilitation, which interventions were included in early rehabilitation in ICU, the potential impact on patient outcomes of rehabilitation interventions provided in ICU and a narrative synthesis of themes. A summary of the main results will be reported using modified GRADE methodology. IMPACT: This integrative review will inform the feasibility randomised clinical trial testing the development of a complex intervention targeting functional and cognitive rehabilitation for patients in ICU.

Intensive care unit nurses' perception of three different methods for delirium screening: A survey (DELIS-3).

BACKGROUND: Delirium is common in critically ill patients with detrimental effects in terms of increased morbidity, mortality, costs, and human suffering. Delirium detection and management depends on systematic screening for delirium, which can be challenging to implement in clinical practice. OBJECTIVES: The aim of this study was to explore how nurses in the intensive care unit perceived the use of Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), the Confusion Assessment Method for the Intensive Care Unit-7 (CAM-ICU-7), and Intensive Care Delirium Screening Checklist (ICDSC) for delirium screening of patients in the intensive care unit. METHODS: This was a cross-sectional, electronic-based survey of nurses' perceptions of delirium screening with the three different instruments for delirium screening. Nurses were asked to grade their perception of the usability of the three instruments and how well they were perceived to detect delirium and delirium symptom changes on a 1- to 6-point Likert scale. Open questions about perceived advantages and disadvantages of each instrument were analysed using the framework method. RESULTS: One hundred twenty-seven of 167 invited nurses completed the survey and rated the CAM-ICU-7 as faster and easier than the ICDSC, which was more nuanced and reflected changes in the patient's delirium better. Despite being rated as the fastest, easiest, and most used, the CAM-ICU provided less information and was considered inferior to the CAM-ICU-7 and ICDSC. Using familiar instruments made delirium screening easier, but being able to grade and nuance the delirium assessment was experienced as important for clinical practice. CONCLUSIONS: Both the ICDSC and the CAM-ICU-7 were perceived well suited for detection of delirium and reflected changes in delirium intensity. The CAM-ICU was rated as fast and easy but inferior in its ability to grade and nuance the assessment of delirium. Emphasis on clinical meaningfulness and continued education in delirium screening are necessary for adherence to delirium management guidelines.

Development of a core outcome set for general intensive care unit patients-A protocol.

INTRODUCTION: Different outcomes are reported in randomised clinical trials (RCTs) in intensive care unit (ICU) patients, and no core outcome set (COS) is available for ICU patients in general. Accordingly, we aim to develop a COS for ICU patients in general. METHODS: The COS will be developed in accordance with the Core Outcome Measures in Effectiveness Trials (COMET) Handbook, using a modified Delphi consensus process and semi-structured interviews involving adults who have survived acute admission to an ICU, family members, clinicians, researchers and other stakeholders. The modified Delphi process will include two steps. Step 1: conduction of a modified Delphi survey, developed and informed by combining the outputs of a literature search of outcomes in previous COSs and semi-structured interviews with key stakeholders. We plan at least two survey rounds to obtain consensus and refine the COS. Step 2: a consensus process regarding instruments or definitions to be recommended for the measurements of the outcomes selected in Step 1. A 'patient and public involvement panel' consisting of a smaller group of patients, family members, clinicians and researchers will be included in the development, analysis and interpretation of the COS. DISCUSSION: The outlined multiple method studies will establish a COS for ICU patients in general, which may be used to increase the standardisation and comparability of results of RCTs conducted in patients in the ICU setting.

Does rocking motion calm delirious patients in ICU? A multicentre randomised clinical trial protocol (RockingICU).

BACKGROUND: Rocking chair therapy has been explored in patients with dementia to promote the feeling of relaxation, but not in Intensive Care Unit (ICU) patients with delirium. AIM: The aim is to investigate the effect of a chair with or without rocking motion on the duration of delirium and intensity of agitation in critically ill patients admitted to the ICU. DESIGN: This is an investigator-initiated pragmatic, multicentre, parallel-grouped, centrally randomised, stratified, data analyst-blinded trial. METHOD: We will include patients for 1:1 web-based randomisation, stratified by site in patients 18 y or older with a positive delirium score identified by a validated tool. We will exclude patients mainly due to mobilisation restrictions, body weight exceeding 130 kg, inability to provide consent, and presence of multiresistant bacteria or viral droplet infections. The intervention group will receive a minimum of 20 min of rocking therapy daily. The control group will be transferred to the same type of chair but without rocking therapy daily. A power calculation with a risk reduction of 20%, a power of 80% with an alpha cut-off on 5% and further 20% inclusion gives 76 patients in intervention and control group reaching a total of n = 152 inclusion in the trial. CONCLUSION: The RockingICU trial will provide important new knowledge and raise research questions regarding nonpharmacological interventions to alleviate delirium in ICU patients.

Negotiated mobilisation: An ethnographic exploration of nurse-patient interactions in an intensive care unit.

AIMS AND OBJECTIVES: To explore nurse-patient interactions in relation to the mobilisation of nonsedated and awake, mechanically ventilated patients in the intensive care unit. BACKGROUND: Lighter sedation has enabled the early mobilisation of mechanically ventilated patients, but little is known about the nurses' role and interaction with critically ill patients in relation to mobilisation. DESIGN AND METHODS: The study had a qualitative design using an ethnographic approach within the methodology of interpretive description. Data were generated in two intensive care units in Denmark, where a strategy of no sedation was applied. Participant observation was conducted during 58 nurse-patient interactions in relation to mobilisation between nurses (n = 44) and mechanically ventilated patients (n = 25). We conducted interviews with nurses (n = 16) and patients (n = 13) who had been mechanically ventilated for at least 3 days. The data were analysed using inductive, thematic analysis. The report of the study adhered to the COREQ checklist. FINDING: We identified three themes: "Diverging perspectives on mobilisation" showed that nurses had a long-term and treatment-oriented perspective on mobilisation, while patients had a short-term perspective and regarded mobilisation as overwhelming in their present situation. "Negotiation about mobilisation" demonstrated how patients actively negotiated the terms of mobilisation with the nurse. "Inducing hope through mobilisation" captured how nurses encouraged mobilisation by integrating aspects of the patient's daily life as a way to instil hope for the future. CONCLUSIONS: Exploring the nurse-patient interactions illustrated that mobilisation is more than physical activity. Mobilisation is accomplished through nurse-patient collaborations as a negotiated, complex and meaningful achievement, which is driven by the logic of care, leading to hope for the future. RELEVANCE TO CLINICAL PRACTICE: The study demonstrated the important role of nurses in achieving mobilisation in collaboration and through negotiation with mechanically ventilated patients in the intensive care unit.

No-sedation during mechanical ventilation: impact on patient's consciousness, nursing workload and costs.

BACKGROUND: Evidence is growing that less or no-sedation is possible and beneficial for patients during mechanical ventilation. AIM: To investigate if there was a difference in patient consciousness and nursing workload comparing a group of patients receiving no-sedation with a group of sedated patients with daily wake up, and also to estimate economic consequences of a no-sedation strategy. DESIGN AND METHODS: Data were collected during a prospective trial of 140 mechanically ventilated patients randomized to either no-sedation or to sedation with daily wake up. From day 1 to 7 in the intensive care unit (ICU), patients were Richmond Agitation and Sedation Scale (RASS) scored, nursing workload was measured with the Nursing Care Recording System (NCR11) and nurse's self-assessment of workload was reported on a Numeric Rating Scale from 1 (low) to 10 (high). RESULTS: Patients from the no-sedation group had a median RASS score of -0·029 compared with -2 in the sedated group (P < 0·00001). The NCR11 scores were higher in the sedated group compared with the no-sedation group: 19·054 versus 17·05 (P = 0·00001). The nurses self-reported workload was the same in both groups (P = 0·085). Because of a shorter ICU stay and shorter hospital length of stay in the no-sedation group, we estimated that there will be no cost benefit with the use of sedation and a higher patient to nurse ratio. CONCLUSION: Patients receiving no-sedation were more awake with a RASS score close to zero, compared with patients receiving sedation and daily wake up. Nurses reported no difference in self-assessed workload between the no-sedation and sedated group of patients. RELEVANCE TO CLINICAL PRACTICE: Patients receiving no-sedation are more awake during their stay in ICU. There might be a potential economical saving with the use of a 1:1 nurse-patient ratio and no-sedation compared with sedation and a 1:2 nurse-patient ratio.

Experience and usability of a website containing research-based knowledge and tools for pain self-management: a mixed-method study in people with high-impact chronic pain.

OBJECTIVES: Smerteinfo.dk is a freely accessible Danish website containing research-based, up-to-date knowledge on chronic pain, written in lay language, with a focus on information, guidance and self-management tools, developed in collaboration between health professionals and persons with high-impact chronic pain. This mixed-method study explored experiences, perceived usability, and challenges of Smerteinfo among patients with high-impact chronic pain. METHODS: Semi-structured interviews enabling thinking-aloud and participant observation while using Smerteinfo were performed in 11 patients with high-impact chronic pain. Survey data were collected three months after being invited to use Smerteinfo among 200 patients on waiting-list at a Pain Center in Denmark. RESULTS: Three themes captured the depth and variation in patterns of experiences, usability and challenges using Smerteinfo during interviews: 1) Appreciated easy access to new knowledge yet strived for more personalized information, 2) Experienced incentives as well as challenges when navigating the website, and 3) Suggested earlier introduction to the website. Challenges concerned the unknown update frequency of the website, information consisting of mostly text and many links, lack of material to improve self-management and too general information. Survey data revealed that 87 % found the language in the articles easy to understand and 73 % could recognize themselves and their challenges in the articles. A proportion of the respondents reported improved understanding of their pain condition (56 %), improved coping (33 %), and that they had made changes in their everyday life after reading on the website (33 %). CONCLUSIONS: Patients with high-impact chronic pain found Smerteinfo valuable. The results suggest attention towards spreading knowledge of the website to general practitioners, who could introduce the site at an earlier stage of illness. Continuously improving the site and expand the applicable tools based on scientific evidence and in collaboration with end-users are crucial to ensure the usability of the website in the future.

Professional prehospital clinicians' experiences of ethical challenges associated with the collaboration with organised voluntary first responders: a qualitative study.

BACKGROUND: Volunteer First Responders are used worldwide. In the Region of Southern Denmark, two types of programs have been established. One of these programs consists of voluntary responders without any requirements of education or training who are summoned to prehospital cardiac arrests. The other type of program is established primarily in the rural areas of the region and consists of volunteers with some mandatory education in first aid. These volunteers are summoned to all urgent cases along with the ambulances. Cooperation between professional healthcare workers and nonprofessionals summoned through official channels may be challenging. This study aimed to explore prehospital clinicians' experiences of ethical challenges in cooperation with volunteer first responders. METHODS: We conducted 16 semi-structured interviews at four different ambulance stations in the Region of Southern Denmark. Five emergency physicians and 11 emergency medical technicians/paramedics were interviewed. The interviews were transcribed, and the data were analysed using systematic text condensation. RESULTS: The study's 16 interviews resulted in the identification of some specific categories that challenged the cooperation between the two parties. We identified three main categories: 1. Beneficence, the act of doing good, 2. The risk of harming patients' autonomy 3. Non-maleficence, which is the obligation not to inflict harm on others. CONCLUSION: This study provides an in-depth insight into the ethical challenges between prehospital clinicians and voluntary first responders from the perspective of the prehospital clinicians. Both programs are considered to have value but only when treating patients with cardiac arrest. Our study highlights potential areas of improvement in the two Danish voluntary programs in their current form.

Getting the body back on track - Understanding the phenomenon of mobilisation when conscious and mechanically ventilated patients are mobilised in the intensive care unit.

OBJECTIVE: To gain an in-depth understanding of the phenomenon of mobilisation when conscious and mechanically ventilated patients are mobilised in the intensive care unit. DESIGN: A qualitative study with a phenomenological-hermeneutic approach. Data were generated in three intensive care units from September 2019 to March 2020. Participant observations of twelve conscious mechanically ventilated patients, thirty-five nurses and four physiotherapists were performed. Furthermore, seven semi-structured patient interviews were conducted, both on the ward and after discharge. FINDINGS: Mobilisation during mechanical ventilation in the intensive care unit followed a trajectory from a failing body to a growing sense of independence in getting the body back on track. Three themes were revealed: 'Challenging to move a failing body', 'Ambiguity of both resistance and willingness in the process of strengthen the body', and 'An ongoing effort in getting the body back on track'. CONCLUSIONS: Mobilisation when conscious and mechanically ventilated included support of the living body by physical prompts and ongoing bodily guidance. Resistance and willingness regarding mobilisation were found to be a way of coping with bodily reactions of comfort or discomfort, embedded in a need to feel bodily control. The trajectory of mobilisation promoted a sense of agency, as mobilisation activities at different stages during the intensive care unit stay supported the patients in becoming more active collaborators in getting the body back on track. IMPLICATIONS FOR CLINICAL PRACTICE: Ongoing bodily guidance provided by healthcare professionals can promote bodily control and support conscious and mechanically ventilated patients in active participation in mobilisation. Furthermore, understanding the ambiguity of patients' reactions caused by loss of bodily control provides a potential to prepare mechanically ventilated patients for and assist them with mobilisation. In particular, the first mobilisation in the intensive care unit seems to influence the success of future mobilisation, as the body remembers negative experiences.

Writing a Diary for "You" - Intensive care nurses' narrative practices in diaries for patients: A qualitative study.

BACKGROUND: Diaries written by nurses for critically ill patients have been implemented in some intensive care units as an intervention to construct patients' "lost time" and fill in their gaps in memory. Studies have shown that diaries have an impact on patients' psychological recovery after intensive care. However, little is known about how nurses view and carry out the process of writing a diary on behalf of a patient. OBJECTIVE: To investigate the choices nurses make in content and language, the rationale by which they make them, and how these narrative aspects shape the story of critical care that is constructed in the diary. DESIGN: The study was conducted using a qualitative approach informed by narrative methodology. SETTING: Three intensive care units at a university hospital in Denmark. PARTICIPANTS: Nine nurses with experience in diary writing. Each of the participants handed in five anonymized diary notes written for different patients they had cared for. METHODS: The study combined textual analysis of the diary notes and a thematic analysis of individual interviews with nurses about their narrative choices when writing the diary. FINDINGS: Three prominent strategies that characterize nurses' choices of content and language were identified: 1) Making the situation of intensive care more manageable, 2) Showing acts of perceiving the patient, and 3) Constituting relations through actions and interactions. The study showed that on one hand these strategies engage the patient and depict nurses' care, empathy and support, yet on the other, reveal the nurses' power to interpret, passivize and downplay the patient's experiences. CONCLUSION: It was demonstrated that although the diary narrative is written about and for the patient, who is referred to and addressed as you, the nurse's interpretations, evaluations, perceptions, and actions figure prominently throughout the diary. Narrating for a you to some degree relegates the patients to a secondary position in their own diary. With the power to control the diary narrative, nurses' linguistic choices may either narrow down or expand possibilities for the patient's own understanding when reading the diary after intensive care. Permission to produce and store all data was obtained from the Danish Data Protection Agency (no. 18/60944).

Parents' experiences during and after their child's stay in the paediatric intensive care unit - A qualitative interview study.

BACKGROUND: Having a child admitted to the paediatric intensive care unit (PICU) is often an emotional and stressful experience for parents. AIM: The aim of the study was to explore parents' experiences during and after their child's hospitalization in the PICU and to investigate whether parents have a need for post-PICU follow-up. MATERIAL AND METHODS: The research design was a qualitative study inspired by Ricoeur's phenomenological-hermeneutic approach. The context of the study was a six-bed PICU in a university hospital in Denmark. In 2017, semi-structured interviews were conducted with four couples and three mothers six to 14 weeks after their child had been discharged from the PICU. The data were analysed and interpreted through Ricoeur's three analytical levels and presented in themes and subthemes. FINDINGS: Three themes were identified in the analytical process: "The challenging PICU stay", "The value of a network" and "The uncertain post-PICU trajectory". CONCLUSION: Information, dialogue and interaction with familiar health professionals, the diary written by PICU nurses, the parents' personal network and social media supported the parents during and after the PICU stay. The parents expressed that post-PICU follow-up was not the most essential but that follow-up initiatives may be arranged individually.

Noise in the operating room--what do we know? A review of the literature.

Because noise is a general stressor, noise in the OR should be avoided whenever possible. This article presents the results of a review of the research literature on the topic of noise in the OR. A systematic literature search was conducted. Eighteen relevant articles were identified and categorized as follows: noise levels, noise sources, staff performances, and patient's perception of noise. Each study was assessed according to the strength of the evidence and the quality of the study. Noise levels in the OR in general exceed recommended levels, and the noise sources are related to equipment and staff behavior. The main effect of noise on staff performances is related to impaired communication, resulting in a negative effect on patient safety. The literature on patients' perception of noise is both limited and inconsistent, and more research on this topic is needed.

The extent and application of patient diaries in Danish ICUs in 2006.

The aim of this study was to describe the extent and application of patient diaries in Danish intensive care units (ICUs) in 2006. Following critical illness, many patients experience disturbed and disconnected memories. Patient diaries in the ICU have been introduced locally by nurses in the Scandinavian countries and the UK as a means to improve cognitive recovery and prevent psychological trauma following critical illness. Descriptive design, using qualitative key informant telephone interviews (n= 19) was used as the source of data. A semi-structured interview guide was used and field notes from the interviews were mailed to the informants for verification and additional information. Nineteen out of 48 Danish ICUs use patient diaries. Patient diaries are mainly used for sedated, ventilated patients during critical illness. The purpose of diaries was mainly to assist memory due to post-ICU amnesia. There was no systematic follow-up after the ICU stay. The study showed a number of legal and ethical issues that still need to be resolved. Patient diaries are ambiguous documents that are neither the property of the hospital nor the patient. The diaries have been implemented at Danish ICUs without a plan for the assessment of their effect, thus bypassing established control mechanisms that evaluate the usefulness of an intervention, such as Health Technology Assessment or nursing research.

Sedation versus no sedation: Are there differences in relatives' satisfaction with the Intensive Care Unit? A survey study based on data from a randomised controlled trial.

BACKGROUND: Currently there is a trend towards less or no use of sedation of mechanically ventilated patients. Still, little is known about how different sedation strategies affect relatives' satisfaction with the Intensive Care Unit (ICU). AIM: To explore if there was a difference in relatives' personal reactions and the degree of satisfaction with information, communication, surroundings, care and treatment in the ICU between relatives of patients who receive no sedation compared with relatives of patients receiving sedation during mechanical ventilation in the ICU. METHOD: A survey study using a questionnaire with 39 questions was distributed to relatives of mechanically ventilated patients, who had been randomised to either sedation with daily wake up or no sedation. RESULTS: Forty-nine questionnaires were sent out and 36 relatives answered. The response rate was 73%. We found no differences in relatives' personal reactions or in the degree of satisfaction with information, communication, care and treatment in the ICU between relatives of patients in the two groups. Relatives of patients treated with no sedation felt more bothered by disturbances in the surroundings compared with relatives of patients who were sedated (p=0.03). CONCLUSION: Treating the patient during mechanical ventilation with no sedation does not affect relatives' satisfaction adversely.

A sense of agency: An ethnographic exploration of being awake during mechanical ventilation in the intensive care unit.

BACKGROUND: There is a current trend towards lighter or no sedation of mechanically ventilated patients in the intensive care unit. The advantages of less sedation have been demonstrated as shorter duration of mechanical ventilation and reduced length of stay in the intensive care unit and hospital. Non-sedated patients are more awake during mechanical ventilation, but little is known about how this affects the intensive care patient. AIM: To explore patients' experiences of being awake during critical illness and mechanical ventilation in the intensive care unit. DESIGN & METHODS: The study was based on Interpretive Description, an applied inductive, qualitative approach with an ethnographic exploration of the patient experience. A longitudinal perspective was obtained through 13 months of fieldwork followed by two patient interviews after intensive care and after hospital discharge. Data were analyzed using thematic analysis. SETTING & PARTICIPANTS: The fieldwork was conducted in two intensive care units at a university hospital in Denmark, where the no sedation strategy for mechanically ventilated patients was implemented. Twenty-eight patients were observed in the intensive care unit. Twenty patients, who had been awake for most of the time on mechanical ventilation, were interviewed during the first week after discharge from intensive care. Thirteen of these patients were interviewed again two to four months after discharge. FINDINGS: Three themes were identified: "A sense of agency", "The familiar in the unfamiliar situation" and "Awareness of surrounding activities". Patients had the ability to interact from the first days of critical illness and a sense of agency was expressed through initiating, directing and participating in communication and other activities. Patients appreciated competent and compassionate nurses who were attentive and involved them as individual persons. Initiatives to enhance familiar aspects such as relatives, personal items and care, continuity and closeness of nurses contributed to the patients' experience of feeling safe and secure in the unfamiliar setting. Patients were aware of the surrounding activities and felt powerless when ignored by the staff and were affected when witnessing fellow patients' suffering. CONCLUSION: Being awake during mechanical ventilation entailed new opportunities and challenges for critically ill patients. Patients found themselves at the interface between agency and powerlessness as they were able to interact, yet were bound by contextual factors such as bodily weakness, technology, spatial position and relational aspects. This knowledge is important to develop patient-centered nursing practice in the context of lighter sedation.

Parents' experience of a follow-up meeting after a child's death in the Paediatric Intensive Care Unit.

OBJECTIVE: 'To identify parents' experience of a follow up meeting and to explore whether the conversation was adequate to meet the needs of parents for a follow-up after their child's death in the Paediatric Intensive Care Unit (PICU). DESIGN AND SETTING: Qualitative method utilising semi-structured interviews with six pairs of parents 2-12 weeks after the follow-up conversation. The interviews were held in the parents' homes at their request. Data were analysed using a qualitative, descriptive approach and thematic analysis. FINDINGS: Four main themes emerged: (i) the way back to the PICU; (ii) framework; (iii) relations and (iv) closure. CONCLUSION: The parents expressed nervousness before the meeting, but were all pleased to have participated in these follow-up meetings. The parents found it meaningful that the follow-up meeting was interdisciplinary, since the parents could have answers to their questions both about treatment and care. It was important that the staff involved in the follow-up meeting were those who had been present through the hospitalisation and at the time of the child's death. Parents experienced the follow-up meeting as being a closure of the course in the PICU, regardless the length of the hospitalisation.

Nurses' experiences of caring for critically ill, non-sedated, mechanically ventilated patients in the Intensive Care Unit: a qualitative study.

OBJECTIVE: The objective was to explore nurses' experiences of caring for non-sedated, critically ill patients requiring mechanical ventilation. DESIGN AND SETTING: The study had a qualitative explorative design and was based on 13 months of fieldwork in two intensive care units in Denmark where a protocol of no sedation is implemented. Data were generated during participant observation in practice and by interviews with 16 nurses. Data were analysed using thematic interpretive description. FINDINGS: An overall theme emerged: "Demanding, yet rewarding". The demanding aspects of caring for more awake intubated patients included unpredictability, ambiguous needs and complex actions, while the rewarding aspects included personal interaction. Three sub-themes were identified: (i) caring for and with the patient, (ii) negotiating relational and instrumental care and (iii) managing physical and emotional closeness. CONCLUSION: Despite the complexity of care, nurses preferred to care for more awake rather than sedated patients and appreciated caring for just one patient at a time. The importance of close collaboration between nurses and doctors to ensure patient comfort during mechanical ventilation was valued. Caring for more awake non-sedated patients required the nurses to act at the interface between ambiguous possibilities and needs, which was perceived as both demanding and rewarding.