The Domain of Nursing: Developing Practice Through Action Research in the Intensive Care Unit

In the intensive care unit (ICU) the bedside nurse is the person who carries out the fundamental care to sustain life and comfort for that patient and is the conduit between the patient, their family/whanau, the doctors and the multi disciplinary team. Nursing practice has an indelible impact on that patient's life and future and for their family. This thesis presents a project on the reconnaissance phase of a future critical action research project. The project involved ICU nurses collectively defining their practice within the context of ICU and identifying aspects which needed development and change. As this was the first time that the nurses had met to define and discuss their practice it was essential for them to take this time in order to focus on the reconnaissance phase as this will guide and inform all future action. The study is informed by Habermas' Theory of Communicative Action which has an emancipatory focus. The action research approach enabled the nurses to reach mutual understanding of their practice and reach consensus on areas of practice they wish to develop to enhance their care of the patient. Mutual understanding and consensus have been achieved using focus groups and interviews involving self reflection as well as collective reflection. The reconnaissance phase as described in this thesis involves the nurse participants collectively identifying their ideals of ICU nursing, then defining where they are unable to meet these ideals in the reality of every day practice. The themes emerging from the discussions are defined in terms of relationships; nurse to patient, nurse to family/whanau, nurse to doctor and nurse to nurse. These relationships are interconnected and all occur within the overarching theme of professional standards of care. Through the process of discussion and consensus the nurses identified nurse to nurse communication and support as the most important aspect of practice needing development. Reconnaissance in this research defines the beginning of the change process as the transformation begins with the creation of the communicative space enabling the nurses to connect and together to look ahead at what changes might now be possible

Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.

BACKGROUND: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months. METHODS: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed. FINDINGS: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed. INTERPRETATION: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. FUNDING: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden

The Domain of Nursing: Developing Practice Through Action Research in the Intensive Care Unit

In the intensive care unit (ICU) the bedside nurse is the person who carries out the fundamental care to sustain life and comfort for that patient and is the conduit between the patient, their family/whanau, the doctors and the multi disciplinary team. Nursing practice has an indelible impact on that patient's life and future and for their family. This thesis presents a project on the reconnaissance phase of a future critical action research project. The project involved ICU nurses collectively defining their practice within the context of ICU and identifying aspects which needed development and change. As this was the first time that the nurses had met to define and discuss their practice it was essential for them to take this time in order to focus on the reconnaissance phase as this will guide and inform all future action. The study is informed by Habermas' Theory of Communicative Action which has an emancipatory focus. The action research approach enabled the nurses to reach mutual understanding of their practice and reach consensus on areas of practice they wish to develop to enhance their care of the patient. Mutual understanding and consensus have been achieved using focus groups and interviews involving self reflection as well as collective reflection. The reconnaissance phase as described in this thesis involves the nurse participants collectively identifying their ideals of ICU nursing, then defining where they are unable to meet these ideals in the reality of every day practice. The themes emerging from the discussions are defined in terms of relationships; nurse to patient, nurse to family/whanau, nurse to doctor and nurse to nurse. These relationships are interconnected and all occur within the overarching theme of professional standards of care. Through the process of discussion and consensus the nurses identified nurse to nurse communication and support as the most important aspect of practice needing development. Reconnaissance in this research defines the beginning of the change process as the transformation begins with the creation of the communicative space enabling the nurses to connect and together to look ahead at what changes might now be possible

The Domain of Nursing: Developing Practice Through Action Research in the Intensive Care Unit

In the intensive care unit (ICU) the bedside nurse is the person who carries out the fundamental care to sustain life and comfort for that patient and is the conduit between the patient, their family/whanau, the doctors and the multi disciplinary team. Nursing practice has an indelible impact on that patient's life and future and for their family. This thesis presents a project on the reconnaissance phase of a future critical action research project. The project involved ICU nurses collectively defining their practice within the context of ICU and identifying aspects which needed development and change. As this was the first time that the nurses had met to define and discuss their practice it was essential for them to take this time in order to focus on the  reconnaissance phase as this will guide and inform all future action. The study is informed by Habermas' Theory of Communicative Action which has an emancipatory focus. The action research approach enabled the nurses to reach mutual understanding of their practice and reach consensus on areas of practice they wish to develop to enhance their care of the patient. Mutual understanding and consensus have been achieved using focus groups and interviews involving self reflection as well as collective reflection. The reconnaissance phase as described in this thesis involves the nurse participants collectively identifying their ideals of ICU nursing, then defining where they are unable to meet these ideals in the reality of every day practice. The themes emerging from the discussions are defined in terms of relationships; nurse to patient, nurse to family/whanau, nurse to doctor and nurse to nurse. These relationships are interconnected and all occur within the overarching theme of professional standards of care. Through the process of discussion and consensus the nurses identified nurse to nurse communication and support as the most important aspect of practice needing development. Reconnaissance in this research defines the beginning of the change process as the transformation begins with the creation of the communicative space enabling the nurses to connect and together to look ahead at what changes might now be possible.</p

Night Shift: Can a Homeopathic Remedy Alleviate Shift Lag?

Night shift nurses are subject to shift lag or circadian dysrhythmia, which may result in physical and mental symptoms ranging from fatigue, irritability, depression, and apathy to gastrointestinal, cardiovascular, and sleep disorders. This study investigated the effect a homeopathic remedy No-Shift-Lag had on the night shift nurses in an intensive care unit. The study was a randomized, double-blind, placebo-controlled, crossover trial. The measures included an objective computer-based vigilance test and a series of subjective questionnaires

Evolution over Time of Ventilatory Management and Outcome of Patients with Neurologic Disease∗

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p &lt; 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p &lt; 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p &lt; 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease