Implementing integrative therapies in adult critical care: Barriers and strategies.

BACKGROUND: Critically ill patients experience intense physical and psychological stressors in the intensive care unit (ICU). More than half of ICU survivors report overwhelming mental health symptoms after ICU discharge, such as post-traumatic stress symptoms, anxiety, and depression. Relaxation-inducing integrative therapies such as guided imagery, massage, therapeutic touch, music therapy, and spirituality-based healing practices have the potential to promote comfort and relaxation and improve patient outcomes. OBJECTIVES: The aim of this study was to explore the attitudes of healthcare professionals towards the implementation of relaxation-inducing integrative therapies in critical care, barriers to implementation, and potential strategies to overcome them. METHODS: We conducted seven focus group interviews with 23 critical care clinicians (70% nurses, 17% allied health professionals, 13% physicians). Interviews were audiotaped and transcribed verbatim. Data were thematically analysed using an inductive content analysis approach. FINDINGS: Results reveal a constant interplay between mostly positive personal attitudes towards implementation of integrative therapies and the perceived culture and priorities of the unit. The main benefits for critically ill patients as perceived by participants were promotion of comfort, sleep, and coping, increase of trust, and decrease of pain and stress. As for barriers, dominant themes were a perceived lack of evidence, cost, and time constraints and the fear of loss of professional credibility. Participants related nurses' education and training, family involvement, and leadership were seen as main strategies for implementation. CONCLUSIONS: The dominant ICU culture needs to be considered when implementing integrative therapies. Education, access to evidence, and role modelling are proposed as means to shift the ICU culture towards utilisation of integrative therapies in critical care.

A Neurobiological Framework for the Therapeutic Potential of Music and Sound Interventions for Post-Traumatic Stress Symptoms in Critical Illness Survivors.

OVERVIEW: Post traumatic stress disorder (PTSD) has emerged as a severely debilitating psychiatric disorder associated with critical illness. Little progress has been made in the treatment of post-intensive care unit (ICU) PTSD. AIM: To synthesize neurobiological evidence on the pathophysiology of PTSD and the brain areas involved, and to highlight the potential of music to treat post-ICU PTSD. METHODS: Critical narrative review to elucidate an evidence-based neurobiological framework to inform the study of music interventions for PTSD post-ICU. Literature searches were performed in PubMed and CINAHL. The Scale for the Assessment of Narrative Review Articles (SANRA) guided reporting. RESULTS: A dysfunctional HPA axis feedback loop, an increased amygdalic response, hippocampal atrophy, and a hypoactive prefrontal cortex contribute to PTSD symptoms. Playing or listening to music can stimulate neurogenesis and neuroplasticity, enhance brain recovery, and normalize stress response. Additionally, evidence supports effectiveness of music to improve coping and emotional regulation, decrease dissociation symptoms, reduce depression and anxiety levels, and overall reduce severity of PTSD symptoms. CONCLUSIONS: Despite the lack of music interventions for ICU survivors, music has the potential to help people suffering from PTSD by decreasing amygdala activity, improving hippocampal and prefrontal brain function, and balancing the HPA-axis.

Working at the Intersection of Palliative End-of-Life and Mental Health Care: Provider Perspectives.

Objective: Palliative, end-of-life care (PEOLC) providers are poorly resourced in addressing the needs of patients with mental health challenges, and the dying experiences of this cohort-particularly those with a comorbid, chronic and persistent mental illness (CPMI)-are poorly documented. We sought to explore the experiences of PEOLC providers with regard to caring for patients with mental health challenges, and gather insights into ways of improving accessibility and quality of PEOLC for these patients. Method: Twenty providers of PEOLC, from different disciplines, took part in semi structured interviews. The data were coded and analyzed using a reflexive, inductive-deductive process of thematic analysis. Results: The most prominent issues pertained to assessment of patients and differential diagnosis of CPMI, and preparedness of caregivers to deliver mental health interventions, given the isolation of palliative care from other agencies. Among the assets mentioned, informal relationships with frontline caregivers were seen as the main support structure, rather than the formal policies and procedures of the practice settings. Strategies to improve mental health care in PEOLC centered on holistic roles and interventions benefiting the entire palliative population, illustrating the participants saw little point in compartmentalizing mental illness, whether diagnosed or not. Conclusions: Continuity of care and personal advocacy can significantly improve quality of life for end-of-life patients with mental health challenges, but bureaucracy and disciplinary siloing tend to isolate these patients and their caregivers. Improved interdisciplinary connectivity and innovative, hybridized roles encompassing palliation and psychiatry are 2 strategies to address this disconnect, as well as enhanced training in core mental health care competencies for PEOLC providers.

Effects of massage on outcomes of adult intensive care unit patients: a systematic review.

BACKGROUND: The critical care experience is particularly stressful for patients, which can result in a number of physiological and psychological consequences, including haemodynamic instability, increased pain, agitation and delirium, leading to prolonged mechanical ventilation, length of stay and subsequent complications. Massage therapy encompasses different techniques to promote relaxation and to counter stress, therefore potentially affecting several patients' outcomes. AIMS: To systematically review evidence on the effects of massage on outcomes of adult critically ill patients. The outcome measures included pain, vital signs (VS), haemodynamic measurements, level of consciousness, sleep quality, muscle tension, anxiety, feelings of calm and relaxation, coping, arterial blood gases and serum biomarkers. METHOD: This was a systematic review based on focused literature searches (PubMed, CINAHL, Scopus, EMBASE-Ovid databases, Google Scholar). The Cochrane Collaboration's tool was used to assess the risk of bias. Eligibility criteria included published experimental and quasi-experimental studies reporting on the physiological and psychological outcomes of critically ill patients. RESULTS: Based on the selection criteria, 12 studies were included in the review. The main findings are as follows: 8 of 12 studies used randomized control designs with high internal validity, and there was a high level of evidence of favourable effects with respect to improvements in VS and a reduction in pain and anxiety. Outcomes that need to be more rigorously pursued include quality of sleep, analgesic and sedative dosages and level of consciousness. CONCLUSION: The results suggest that massage interventions can have positive effects on critically ill patients' outcomes. However, there are several gaps in the literature, along with methodological limitations, that require further consideration in critical care settings. RELEVANCE TO CLINICAL PRACTICE: The results of this systematic review can inform implementation of massage interventions in critical care, which can be challenging as a result of several barriers.

Relaxation for Critically ill Patient Outcomes and Stress-coping Enhancement (REPOSE): a protocol for a pilot randomised trial of an integrative intervention to improve critically ill patients' delirium and related outcomes.

INTRODUCTION: Delirium is a common complication of critical illness, associated with negative patient outcomes. Preventive or therapeutic interventions are mostly ineffective. Although relaxation-inducing approaches may benefit critically ill patients, no well-designed studies target delirium prevention as a primary outcome. The objective of this study is to assess feasibility and treatment effect estimates of a multimodal integrative intervention incorporating relaxation, guided imagery and moderate pressure touch massage for prevention of critical illness delirium and for related outcomes. METHODS AND ANALYSIS: Randomised, controlled, single-blinded trial with two parallel groups (1:1 allocation: intervention and standard care) and stratified randomisation (age (18-64 years and ≥65 years) and presence of trauma) with blocking, involving 104 patients with Intensive Care Delirium Screening Checklist (ICDSC): 0-3 recruited from two academic intensive care units (ICUs). Intervention group participants receive the intervention in addition to standard care for up to five consecutive days (or until transfer/discharge); control group participants receive standard care and a sham intervention. We will assess predefined feasibility outcomes, that is, recruitment rates and protocol adherence. The primary clinical outcome is incidence of delirium (ICDSC ≥4). Secondary outcomes include pain scores, inflammatory biomarkers, heart rate variability, stress and quality of life (6 weeks and 4 months) post-ICU discharge. Feasibility measures will be analysed descriptively, and outcomes will be analysed longitudinally. Estimates of effects will be calculated. ETHICS AND DISSEMINATION: The study has received approval from the Human Research Ethics Board, University of Alberta. Results will inform the design of a future multicentre trial. TRIAL REGISTRATION NUMBER: NCT02905812; Pre-results.

Discharge planning in mental health care: an integrative review of the literature.

AIMS AND OBJECTIVES: To identify the evidence base related to discharge planning in the context of acute and community mental healthcare service provision to ascertain the need for future research. BACKGROUND: Discharge planning is an important activity when preparing consumers to transition from hospital to home. The efficiency of discharge planning for consumers living with a mental health issue can influence both the number of future readmissions to acute-care facilities and their quality of life at home. DESIGN: An integrative review of the peer-reviewed literature. METHOD: This review uses specific search terms and a 21-year time frame to search two key nursing databases CINAHL (Cinahl Information Systems, Glendale, CA, USA) and PSYCHINFO (American Psychological Association, Washington, DC, USA) for research reports investigating the substantive area of enquiry. Hand searches of reference lists and author searches were also conducted. Nineteen peer-reviewed journal articles met the inclusion criteria for this review. RESULTS: Research findings about discharge planning for people living with a mental health issue identify the importance of communication between health professionals, consumers and their families to maximise the effectiveness of this process. The complexity of consumer's healthcare needs influences the discharge planning process and impacts on aftercare compliance and readmission rates. There is a limited amount of research findings relating to differences between health professionals and families' perceptions of the level of information required for effective discharge planning, and the appropriate level of involvement of individuals living with a mental health issue in their own discharge planning. Results from this integrative review will inform future research related to this topic. CONCLUSION: Discharge planning for consumers living with a mental health issue involves many stakeholders who have different expectations regarding the type of information required and the necessary level of involvement of people living with a mental health issue in this process. RELEVANCE TO CLINICAL PRACTICE: Comprehensive discharge planning can result in reduced readmissions to both acute and community mental health services. Understanding the impact of effective communication on the outcomes of discharge planning is an important step in promoting success.

Irukandji Syndrome: what nurses need to know.

Irukandji Syndrome can be frightening for the patient and make care delivery difficult for the nurse. Nurses' knowledge of Irukandji Syndrome has been limited to information provided by marine biologists, doctors, and tropical medicine specialists. This paper proposes to assist with the evolution of nursing knowledge for the care of the patient with Irukandji Syndrome. An algorithm of nursing management is presented that has been derived from the continuing debate among scientists about the etiology of signs, symptoms, and treatment rationales. Community safety and education surrounding Irukandji Syndrome requires concurrent progression of nursing knowledge and scientific inquiry.