Different ways of thinking about patients in critical care

Chris McLean PhDLecturerUniversity of Southampton

Background and methods

• A 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)

Methods

Research 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:

1. As a valued individual

2. As a social being

3. As a set of needs

4. As routine work

5. As a body

6. As (un)stable

7. As a medical case

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Patient as Features Functions

Routine work Time dominates – ‘obs o’clock’

Habitual tidying

(Un)stable A focus on aims / targets / parameters

Precise and quantified

Body Focus on surface features

‘Prodding’ or ‘poking’

Medical case Understanding the significance of physiology

“So – the 5 o’clock obs, do the ward round and do some eye and mouth care”

She comments as the patient’s systolic blood pressure drops to 55 that even if the patient is lucid “I don’t like 55”

“The hip yesterday”

“I think with those things you probably have depersonalised …you’ve taken the person away”

Manages time

Ensures safety

Monitoring and supporting body systems

Assessment / examination

Understanding and communicating patterns.

Knowing how the patient is doing

Findings part 2

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“I don’t know if this is a really un-nursey thing to say ((laughter)) but I think the most important thing is making sure the patient’s safe“

“with the sickest ICU patients you are

unfortunately focusing more on their

observations”.

“It’s nice for us to see her as a

person as well as the patient in the

bed…but at the same time it’s

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. ..“It’s actually quite bad isn’t it ?”

Thinking in ‘impersonal’ ways was not consistent with being a nurse who cares for persons

Conclusions

•Nurses’ are socialised to believe it is ‘impersonal’ to think and talk about patients in certain ways

•Thinking about patients as ‘routine work’, as a ‘body’, as ‘(un)stable’ or as a ‘medical case’ is essential to critical care nursing practice

•Critical 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 practice

– It is a potential source of stress and distress to critical care nurses

– Disparity between nurses’ ideals and the realities of care can lead to emotional exhaustion and burnout (Maben et al. 2007)

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Recommendations

For 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 context

For education:

•Recognise that critical care nurses must gain skills in moving between different ways of thinking

– “Airway” or “person”?

– “Look at the patient”: Difficulty prioritising may reflect a failure to move between ways of thinking

For 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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ReferencesBenner P, Hooper-Kyriakidis P and Stannard D (1999) Clinical Wisdom and Interventions in Critical Care. A Thinking in Action Approach. Philadelphia: Saunders

Cronqvist A, Lützèn K and Nystrӧm, M. (2006) Nurses' lived experiences of moral stress support in the intensive care context. Journal of Nursing Management 14(5): pp. 405-413

Foucault M (1969) The Archeology of Knowledge. London: Routledge

Goffman E (1974) Frame Analysis: An essay on the organization of experience (1986 Edition). New York: Harper and Row

Lawrence L (2011) Work Engagement, Moral Distress, Education Level, and Critical Reflective Practice in Intensive Care Nurses. Nursing Forum 46(4): pp. 256-268

Maben J, Latter S and MacLeod-Clark J (2007) The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study. Nursing Inquiry 14(2): pp. 99-113

McAndrew N, Leske J and Garcia A (2011) Influence of Moral Distress on the Professional Practice Environment During Prognostic Conflict in Critical Care. Journal of Trauma Nursing 18(4): pp. 221-230

Menzies Lyth I (1959) Containing Anxiety in Institutions. London: Free Association Books

Royal College of Nursing (2004) The Future Nurse: the RCN vision. London: RCN

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