Category: Critical Care

The four core principles of biomedical ethics are non-maleficence, justice, beneficence, and patient autonomy. Respect for autonomy means that doctor has to make decisions based on the patients moral and ethical values because the one is legally competent to make individual health choices. This principle involves a range of practices, from protecting patient information privacy to accepting do-not-resuscitate orders. However, ethical issues, especially in emergencies, are not straightforward, requiring physicians to be guided by the other three principles of medical ethics. For example, the provided scenario tells the patients story of being admitted to the Intensive Care Unit (ICU) after attempting suicide. The patient requires intubation because his respiration is deteriorating rapidly. However, the mans relative brought the patients advance healthcare directive that states his refusal to be placed on a ventilator or any other artificial life support. This complex case requires respecting patient autonomy, but beneficence and non-maleficence should also be considered before the final decision.

The ethical issue for the psychologist who needs to consult the ICU team about the patients will is patient autonomy. The suicide attempt, in this case, indicates the fact that the patient was not capable of rational decisions. Therefore, the principle of beneficence dictates that he should be intubated. Still, the mans advance directive states that he would not want to be placed on a ventilator. The meaning of his last words was ambivalent because it may either mean that the patient did not plan to be hospitalized or did not expect the overdose. Since the advance directive was written in the past year, the possible course of action for the doctors to provide oxygen and intravenous fluids, but not intubation. However, it is crucial to discuss this issue with the relative to investigate the reasons for suicide. If the patient had a terminal illness, then the terms of the advance directive should be followed. Conversely, this document cannot be accepted if the man was clinically depressed when his will was created, then this document cannot be valid.

If I were a psychologist, in this case, I would recommend disregarding the advance directive and introducing intubation to the patient. I think this document cannot be followed in this scenario because the patient tried to commit suicide, but his final words appeared to express his regret about this event. The advance directive should be considered when external factors cause health damage, but suicide cases should be carefully evaluated. In this scenario, the patients final words were: This wasnt supposed to have happened, which may mean that he did not wish to die. Therefore, his written refusal to be on a ventilator can be disregarded. If no advance healthcare directive were provided, I would immediately suggest the ICU team intubate this man. People who attempt killing themselves cannot often make informed decisions about their health because of a potential psychiatric condition such as major depression or schizophrenia. Thus, it is critical to provide immediate help to these patients during such emergencies and offer treatment for the underlying cause later.

To sum up, this scenario involved a complex case of a patient admitted to the ICU after a suicide attempt. The team is hesitant to perform intubation due to the mans advance directive that expresses his wish to refuse any form of artificial life support. However, the patients last words suggest that this document can be ignored in this particular case, and all the necessary procedures should be done to save the mans life, placing beneficence and non-maleficence above autonomy.

For new graduate nurses working in Intensive Care Units, does the application of the social representation approach compared to no intervention lead to the reduction of stress levels during the first six months of their practice?

• P (population)  new graduate nurses working in Intensive Care Units
• I (intervention)  the application of the social representation approach
• C (comparison)  no intervention
• O (outcome)  reduction of stress levels
• T (time)  the first six months of practice

Description of the Clinical Issue of Interest

The work at the Intensive Care Unit (ICU) is never simple because nurses should take multiple responsibilities for patients, manage life-threatening health problems, and professionally cooperate with other employees. When graduate students join the ICU, it is hard for some of them to recognize the number of existing obligations and deal with stressors. A new environment, real-life situations, and the direct connection to life-quality issues challenge students confidence and competence (DeGrande et al., 2018). Many researchers admit that nursing remains one of the most stressful professions across the globe because of constant exposure to different events and factors when people suffer from pain and complications (Feddeh & Darawad, 2020; Hattingh & Downing, 2020). Creating a safe clinical environment is a significant task for employees, and new graduate nurses need to feel support and understanding. Sometimes, it does not take much time for a new nurse to establish trustful relationships with a team and patients. However, professional care and treatment require integrating various skills and knowledge.

Nursing stressors vary, depending on job circumstances, management, and leadership. Nurses may report poor awareness of care fundamentals and a lack of experience in communication (Almeida et al., 2020). Young people need to demonstrate their readiness to work and participate in all clinical experiences, which contributes to their understanding of real social interactions. Social representations introduce a unique system of values and ideas to promote social order and define appropriate communication methods. This approach was firstly developed in the middle of the 20^th century, but its implementation and progress are regularly discussed today. My interest is to understand if the application of social representation could minimize stressors in new graduate nurses who have to work in ICUs.

The first database I used was CINAHL & Medline Combined search and the Boolean/phrase used was intensive care and new graduate nurses, this search resulted in 185 articles. Next, I used the filters to limit results by limiting information to peer-reviewed, full-text resources published between 2017-2022. This resulted in 63 resources. With filters still activated I also used the Boolean, intensive care and new graduate nurses and stress, this further reduced findings to 6 results.

The second database I used was PubMed. I used the same Boolean words, intensive care, and new graduate nurses which resulted in 60 articles. One thing I really enjoyed about PubMed filters is that you can checkmark the randomized control trial. After I filtered the PubMed database to the randomized control trial information, I had 9 results. A randomized controlled trial is a type of clinical trial that randomly assigned participants to one of two groups, and this method helps to minimize the possibility of selection bias and makes the trial a high-quality study (Walden University Library, n.d.-i).

Strategies one may use to increase the rigor and effectiveness of a database search is to search for evidence by the level of evidence, for example, the best evidence design is a systematic review that includes a randomized control trial (McGonigle & Mastrian, 2022). An example of lower-level evidence would be a descriptive study (i.e., a qualitative study). Another strategy that can help improve the effectiveness of a database search in the MEDLINE database is to use the subject set box and select systematic reviews; this method allows the researcher to find unbiased and credible studies (Walden University Library, n.d.-e).

References

Almeida, R. D. O., Ferreira, M. D. A., & Silva, R. C. D. (2020). Intensive care in non-critical units: Representations and practices of novice graduate nurses. Texto & Contexto-Enfermagem, 29. Web.

DeGrande, H., Liu, F., Greene, P., & Stankus, J. A. (2018). The experiences of new graduate nurses hired and retained in adult intensive care units. Intensive and Critical Care Nursing, 49, 72-78. Web.

Feddeh, S. A., & Darawad, M. W. (2020). Correlates to work-related stress of newly-graduated nurses in critical care units. International Journal of Caring Sciences, 13(1), 507-516.

Hattingh, H., & Downing, C. (2020). Clinical learning environment: Lived experiences of post-basic critical care nursing students. International Journal of Africa Nursing Sciences, 13. Web.

McGonigle, D., & Mastrian, K. G. (2022). Nursing informatics and the foundation of knowledge (5th ed.). Jones & Bartlett Learning.

Walden University Library. (n.d.-e). Evidence-based practice research: MEDLINE search help. Web.

Walden University Library. (n.d.-i). Systematic review. Web.

Introduction

The use of physical and chemical restraints in acute and intensive care began ages ago. Of these two restraint methods, physical restraint has attracted the most negative attention and criticism from both the health care sector and the human rights organizations. However, both chemical and physical restraints continue to be used to a certain extent in countries across the globe. In the United States, for instance, acute and intensive care units use restraints as a therapeutic and moral method of minimizing accidents and injuries to both the patients and healthcare providers (Hamers, Gulpers, and Strik, 2004).

This is because the majority of patients in acute and intensive care settings may be emotionally, psychologically, or mentally unstable and are therefore in a position to inflict harm not only to themselves but also to others. Restraints have turned into a legal concern and some countries like the United States and England have laws that govern the extent and circumstances of their use. For instance, the Mental Health Act of 1983 identifies five circumstances under which restraints can be used.

These circumstances include: noncompliance with treatment, self-harm, and risk of a physical injury by an accident were the most relevant in critical care settings. Such legislation, in conjunction with advocacy from human rights organizations, has forced nurses and other healthcare providers to use the restraints taking into consideration the patients rights, potential complications, and ethical considerations. This paper aims to review several studies that discuss the use of chemical and physical restraints and the ethical issues that affect them.

Review of Literature

Physical restraints

A considerable number of patients in acute and intensive care settings are normally subjected to physical restraints. This number is said to range between 7% and 17% according to a research study done by Akansel (2007). Common types of physical restraints include wrist restraint, ankle restraint, chest restraint, chest and leg restraint, and whole-body restraints. Materials used to physically restrain patients include sheets, belts, and gloves.

The use of physical restraint on patients is associated with harm not only to the patients but also to their families. The harm done is not only physical but also emotional and psychological. The Food and Drug Administration estimates that the number of deaths resulting from physical restraint is at least 100. Other studies show that physical restraints cause skin trauma, pressure sores, muscular atrophy, nosocomial infection, constipation, incontinence, limb injury, contractures, depression, anger, a decline in functional and cognitive state and increasing agitation, (Cheney, Gossett, Fullerton-Gleason, Weiss, Ernst and Sklar, 2006, p.211).

The ratio of nurse to the patient increases the understanding of the utilization of physical restraint and the development of complications from the use of such restraints. A study conducted by Demir (2007) indicated that some intensive care units are understaffed. This limits the abilities of the nurses to pay close attention to the patients or to reassess the restraints. This occurred especially if the nurse in charge of a restrained patient has to leave the patient to attend to other patients. The absence of the nurse in the restrained patients room provides the patient with the opportunity to harm themselves as they try to free themselves from the restraints.

The researchers gave a good illustration of how patients can be harmed by physical restraints as a result of a low nurse: patient ratio. In one case observed by Demir (2007), a patient suffered from arm paralysis after being restrained. In this particular case, the nurse, being busy with other patients, had requested an inexperienced aide to restrain the patient in question but the nurse forgot to assess the patient for a whole weekend. When the nurse returned to work after the weekend she found the patient still restrained and suffering from paralysis. Besides this case, nurses in the study also admitted to finding patients suffering from armpit and chest ulcers due to prolonged restraints.

Complications resulting from physical restraints have also been reported by other researchers. Cheney et al. (2006) found that limb and vest restraints used on elderly patients caused atrioventricular irregularities. In addition, prolonged agitation resulted in tachycardia and deaths among patients. Mott et al. (2005) also found that physical restraints fail to completely play their purpose but instead enhance the risk of agitation.

Physically restrained patients are more likely than non-restrained patients to suffer from falls and strangulation. They are more likely to spend more time in hospitals, less likely to be discharged, and have higher risks of complications and death. Like Mott et al. (2005), Zun and Downey (2008) also found that patients who are physically restrained are normally agitated, acquire more complications, and fall more often as they try to free themselves from the restraints. The complications that arise from physical restraints may be grave and life-threatening. Most of the studies above found that hospitals and healthcare units that physically restrain patients lack standard material that is distinctively designed for physical restraint.

In the study by Demir (2007), for instance, the materials used for wrist and ankle restraint were produced by nurses themselves by making use of a roll of gauze directly or after placing some cotton in between the layers of the gauze. Only a handful of intensive care units studied above used standard restraint materials. Interestingly, none of the hospitals used in the above-mentioned studies had guidelines for the use of physical restraint on their patients.

The complications resulting from physical restraints are also linked to the lack of adequate care of the patients by the nurses in charge of them. The U.S. Center of Medicare and Medicaid Services states that the maximum number of hours that a restrained patient should go unobserved is two hours (cited in Moore and Haralambous, 2007). That is, restrained patients should not be left on their own for more than two hours without being reassessed or observed.

Unfortunately, most acute and intensive care settings do not comply with this rule. The majority of the studies mentioned above showed that restrained patients go for more than three hours  and in some extreme cases for days  without being reexamined and reevaluated. It is therefore important for nurses to continually observe and monitor restrained patients to ensure that self-inflicted harm and complications arising from the restraints are minimized as much as possible (Moore and Haralambous, 2007).

Chemical Restraints

Chemical restraints used in critical care are of three main types: sedation; neuromuscular or paralyzing agents, and anxiolytics drugs (Zun and Downey, 2008). Anxiolytics drugs are used purposely to manage nervous, highly confused, and delirious patients. These drugs include sedation and antipsychotic medications. Sedation is most used in critical care for mechanically ventilated patients. Sedation helps to relieve anxiety, give comfort and facilitate care such as ventilation. Sedation is a widely accepted restraint method but there are claims that some nurses tend to over-sedate patients.

Over-sedation can have substantial negative effects on patients that include: hypotension, pulmonary vasculature, reduced rapid eye movement sleep, and reduced intestinal motility, (Zun and Downey, 2008, p.62). Over-sedation is more likely to occur especially if the sedation is followed by pain relief therapy. The most favorable level of sedation for patients depends on the patients illness and the supportive therapies they need. The majority of the sedation examination tools strive for a sedation level that provides the patient with the least amount of sedation which makes it possible for the patient to be aware but also to be calm and tolerant of required treatments like mechanical ventilation (Happ, Tuite, Dobbin, DiVirgilio-Thomas and Kitutu, 2004).

Neuromuscular blocking agents are used to paralyze patients and are considered to be the most dangerous chemical restraints used in critical care. Because of their potential harm, neuromuscular blocking agents ought to be used as the last resort and in certain conditions such as: increased intracranial pressure, muscle spasms, and to decrease oxygen consumption, (Mott, Poole and Kenrick, 2005, p.98). However, other treatment options should be used before the neuromuscular blocking agents are used on the patients.

The second condition of the use of neuromuscular blocking agents is that they should be halted daily and only re-used when the patients condition needs it. Third, when infusing neuromuscular blocking agents in patients, nurses should make sure that the patients are well sedated to minimize the risk of awareness and paralysis of patient.

Ethical Considerations

Seriously ill patients rely on nurses and other healthcare professionals to care for their fundamental and complex needs. When patients become delirious, they may unintentionally interfere with their treatment and therapy devices thus endangering their lives. Protecting patients from dangers is one of the most essential responsibilities of nurses. The use of physical and chemical restraints is considered to be one of the simplest solutions to this challenge. However, the use of restraints is linked with potential and actual harm and hence the ability of the nurses to obtain consent from the patients is a requirement.

However, consent is rarely obtained by nurses when administering physical or chemical restraints on patients. This violates the Human Rights Act which states that human beings have the right to be free from unconstitutional force to limit their mobility unless they are subject to lawful imprisonment. Additionally, people should not be put through affliction or undignified treatment (Kielb, Hurlock-Chorostecki, and Sipprell, 2005).

Despite the human rights concerns, patients suffering from critical conditions may experience changes to their bodies and normal behavior as a result of their health conditions. Nurses and other healthcare providers in the critical care settings, therefore, face difficult decisions concerning the identification of the most effective tactics of preventing patients from inflicting harm on themselves and others. The quagmire faced by healthcare professionals in critical care units can be solved by following the United States Department of Health guidelines as well as the Nurses Code of Professional Conduct (Kielb, Hurlock-Chorostecki, and Sipprell, 2005).

The U.S. Department of Health guidelines stresses that consent is not a one-off procedure but rather is a continuous process that covers treatment, physical examination, and individualized care for patients. The need to respect patient freedom is generally supported as a determinant of professional practice. Nonetheless, it means that the patient should be competent enough to make such as decision. When competence on the part of the patient is lacking, nurses are allowed to follow the reasonable person rule in which the nurse can take actions that are in the best interest of the patient by the socially and legally accepted standards (Kielb, Hurlock-Chorostecki, and Sipprell, 2005).

Conclusion

Restraint in critical and intensive care units is used to prevent patients from inflicting harm on themselves and others and also to enable the nurses to administer treatment to the patients. Whereas physical restraint is widely used, chemical restraint is less common and is only used when all other methods have failed. The grave complications that arise from the use of physical restraint on patients can be minimized by increasing the ratio of nurses to patients.

This will increase the frequency with which the restrained patients are assessed and monitored. Legal and ethical issues about restraint use arise from the need to obtain consent from patients before such methods are used on them. Unfortunately, the majority of patients in critical care units are not competent enough to give such consent. Nurses can address this challenge by following professional guidelines and code of conduct which will ensure that they act to serve the best interests of the patients while maintaining their professional standards.

There is also a need for healthcare organizations to train their nurses and other concerned healthcare professionals on the use of restraint, different types of restraint, complications resulting from their use as well as their ethical and legal considerations. This will minimize the cases of death or serious injuries that result from the use of restraint.

References

Akansel, N. (2007). Physical restraint practices among ICU nurses in one university hospital in Western Turkey. Health Science Journal 4, 1-8.

Cheney, P., Gossett, L., Fullerton-Gleason, L., Weiss, S.J., Ernst, A. & Sklar, D. (2006). Relationship of restraint use, patient injury, and assaults on EMS personnel. Pre-hospital Emergency Care 10(2), 207-212.

Demir, A. (2007). Nurses use of physical restraints in four Turkish hospitals. Journal of Nursing Scholarship, 39(1), 38-45.

Evans, D., Wood, J., & Lambert, L. (2003). Patient injury and physical restraint devices: A systematic review. Journal of Advanced Nursing, 41(3), 274-282.

Hamers, J.P.H., Gulpers, M.J.M. & Strik, W. (2004). Use of physical restraints with cognitively impaired nursing home residents. Journal of Advanced Nursing 45(3), 246-251.

Happ, M.B., Tuite, P., Dobbin, K., DiVirgilio-Thomas, D. & Kitutu, J. (2004). Communication ability, Method, and content among non-speaking non-surviving patients treated with mechanical ventilation in the intensive care unit. American Journal of Critical Care 13(3), 210-220.

Kielb, C., Hurlock-Chorostecki, C. & Sipprell, D. (2005). Can minimal patient restraint be safely implemented in the intensive care unit? Canadian Association of Critical Care Nurses 16(1), 16-19.

Moore, K. & Haralambous, B. (2007). Barriers to reducing the use of restraints in residential elder care facilities. Journal of Advanced Nursing 58(6), 532-540.

Mott, S., Poole, J. &. Kenrick, M. (2005). Physical and chemical restraints in acute care: Their potential impact on the rehabilitation of older people. International Journal of Nursing Practice, 11, 95-101.

Zun, L.S. & Downey, L. (2008). Level of agitation of psychiatric patients presenting to an Emergency Department. Primary Psychiatry 15(2), 59-65.

The Strategy for Disseminating the Results

The first strategy of disseminating the results will entail the use of brochures and newsletters. These periodic publications (quarterly) will serve the purpose of informing the nurses and other stakeholders about the progress of the project. The data will also highlight the areas of achievement, which will motivate the nurses to improve their performance. ONeal and Manley (2007) have underscored the significance of developing brochures and newsletters professionally. The essence of this activity is to ensure that the brochures and newsletters are presentable to the hospital administrators and other external parties. In addition, Gale and Schaffer (2009) have noted that these documents lay the foundation for developing the final report.

Secondly, the hospital should also use its website to inform the staff and members of the public about the new guidelines. According to Titler (2007), it is easy to update and access the information located on web pages. Nonetheless, the target audience should be aware of this information and motivated to visit the website (Gale & Schaffer, 2009). The brochures and newsletters will contain the hospitals web address to inform the critical care nurses about the presence of additional information. On the other hand, the website should also have hyperlinks, which will direct the visitors to other sources of similar information. The hospital can also include downloadable documents and reports on the website to facilitate the distribution of the information.

Third, workshops, seminars, and conferences will be other critical techniques of disseminating the results. The primary advantage of these approaches is that they will allow the hospital administrators and change agents to consult with the target audiences (Acheterberg, Schoonhoven, & Grol, 2008). Further, the face-to-face interactions will be significant to provide feedback about the performance of the new guidelines and protocols. In addition, these forums will allow the audience to make proposals for quality improvement based on the current evidence and challenges (Oman, Duran, & Fink, 2008).

The Evaluation Plan

Methods for Evaluating the Effectiveness of the Project

The implementation of this pilot project will employ a phased-out approach. First, it will not be financially feasible to introduce antimicrobial uniforms in all the hospital units at once. Second, this project requires complex logistics in terms of procurement, production, and supply. The initial stage of this program will entail the introduction of this attire in the ICU and postoperative recovery units. Thus, it will be essential to conduct a randomized control trial (RCT) to validate the clinical efficacy of the new interventions. The data from this research design will ascertain the clinical efficacy of introducing antimicrobial uniforms to the other hospital units. According to Oman, Duran, and Fink (2008), RCTs constitute the gold standard for evaluating the effectiveness of health projects.

Variables for Assessment

The evaluation process will measure the following variables. First, the nurses behavior regarding the use of microbial uniforms will be imperative to assess the level of compliance. Second, the nurses knowledge of the new protocols and guidelines will determine the need for further education and training. Third, it is essential to evaluate the nurses self-confidence in incorporating the new guidelines into the nursing practice. Fourth, the nurses perceptions and attitudes will determine their adaptation to the implemented changes. Finally, the level of staff turnover and absenteeism will ascertain if the nurses are satisfied with the new guidelines.

Tools for Educating the Participants

The proposed solution will involve the replacement of the standard nursing uniforms with antimicrobial clothing. In addition, this strategy will complement the existing hand hygiene guidelines and protocols. The purpose of these strategies is to reduce the prevalence and incidences of hospital-acquired infections among ICU patients. Thus, it is essential to educate the critical care nurses about these new interventions. The first strategy for accomplishing this goal will entail the development of brochures and fliers. These documents will contain a summary of the new procedures and protocols. The information will also include the rationale for introducing the new policies, including the perceived benefits and outcomes.

Secondly, the use of questionnaires will be essential to collect raw data from the participants (Oman et al., 2008). The primary objective of this survey will be to assess the critical nurses attitudes and beliefs about the new processes. The information gathered from these procedures will identify gaps in knowledge and possible barriers to effectual implementation. The hospital administrators will use the analyzed data to develop teaching materials to address the issues. For example, a PowerPoint presentation during workshops and regular meetings will provide more information about the project. In addition, the use of simulators will play an important role in modeling the optimal nursing practice. The simulation and other multimedia tools will illustrate the optimal nursing practices.

Tools for Evaluating the Outcomes of the Project

The use of the focus group discussions will be useful in measuring the outcomes of the solutions. A focus group is a qualitative approach that collects data about an explicit and concrete goal. According to Oman et al. (2008), the focus group discussions will provide crucial information about the success or failure of the project. The nurses will use the comments and reactions of their colleagues to develop a synergy of discussions. Conversely, some of the nurses may not feel comfortable contributing in a group setting. In addition, the groupthink phenomenon may lead to the collection of biased information (Acheterberg et al., 2008). As such, it will be critical to triangulate the information generated from the focus group with other sources.

Another technique for evaluating the effectiveness of the new policies and protocols will be the analysis of tasks. Task analysis is a quantitative tool that describes, analyzes, and documents the procedures used by employees to achieve organizational goals (Schifalacqua, Costello, & Denman, 2009). This approach will diagnose the current needs and detect the potential for making quality improvements. The task analysis process will precede the assessment of performance indicators. The former technique will focus on examining the effectiveness of the new systems. By contrast, the latter approach will pay more attention to the achievement of results. The risk of using this tool is that it requires resources and time that may not have been included in initial plans (Gale & Schaffer, 2009).

The performance observations will be extremely necessary to document the current procedures and systems. External reviewers will gather first-hand information regarding the performance of the newly introduced antimicrobial techniques. For instance, the assessors will observe if the nurses are sanitizing their hands before handling patients. Thus, the performance observations will form the basis for determining the practicability and feasibility of these procedures (Titler, 2007). On the other hand, this technique will enable the hospital administrators to identify the barriers to effectual implementation. The reviewers will have a chance to get practical experience by interacting with the nurses as they provide care (Gale & Schaffer, 2009).

References

Acheterberg, T., Schoonhoven, L., & Grol, R. (2008). Nursing implementation science: How evidence based nursing requires evidence based implementation. Journal of Nursing Scholarship, 40, 302310.

Gale, B., & Schaffer, M. (2009). Organizational readiness for evidence-based practice. The Journal of Nursing Administration, 39(2), 9197.

ONeal, H., & Manley, K. (2007). Action planning: Making change happen in clinical practice. Nursing Standard, 21(35), 35-39.

Oman, K. S., Duran, C., & Fink, R. M. (2008). Evidence-based policies and procedures: An algorithm for success. Journal of Nursing Administration, 38(1), 4751.

Schifalacqua, M., Costello, C., & Denman, W. (2009). Roadmap for planned change: Part 1: Change leadership and project management. Nurse Leader, 7(2), 26-29.

Titler, M.G. (2007). Translating research into practice. American Journal of Nursing, 107(6), 2633.