Effets de la nitroglycérine intraveineuse sur la saturation cérébrale hémisphérique pendant la chirurgie cardiaque à haut risque

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal

Clinical Supervision and Learning in Acute Care Environments: A Multifaceted Relationship

ContextClinical supervision is intended to maintain a balance between a safe and timely provision of care to the patients and the creation of learning opportunities for the trainees. Many changes have recently affected the health care and medical education systems. The effects of these changes on current supervisory practices and on clinical learning are only partially understood. The objective of this program of research was therefore to explore the complex relationships between clinical supervision and learning in today's acute care environments.DesignTwo studies were combined: a mixed methods, simulation-based study, followed by an observational, naturalistic study. For the simulation study, 53 residents were randomized to one of three levels of clinical supervision and completed acute simulated scenarios. This study explored the impact of the level of clinical supervision on quantitative outcomes related to patient care and trainee learning, and on the learning processes involved in acute resuscitation. The second study, based on 350 hours of participant observation in real acute care environments, explored three aspects of the learning interactions among supervisors and trainees.ResultsThe simulation study indicated a benefit of direct supervision for patient care. Direct supervision had a neutral effect on learning, despite the creation of distinct learning opportunities. In real acute clinical environments, learning interactions between clinical supervisors and trainees facilitated trainee involvement in patient care and allowed supervisors to adjust the level of supervision. Factors related to the clinical case, the participants, and the broader context interacted to affect the occurrence of these learning interactions. In addition, the specific clinical situations in which participants interacted affected the nature and the educational potential of the learning interactions. ConclusionThis program of research revealed that direct supervision could improve patient care without compromising trainee learning. In-person interactions between clinical supervisors and trainees were commonly used to create learning opportunities in today's acute clinical environments. Clinical supervisors and trainees displayed different types of learning interactions in response to different clinical circumstances.Ph.D

Stressful intensive care unit medical crises : how individual responses impact on team performance

BACKGROUND: Intensive care units (ICUs) are recognized as stressful environments. However, the conditions in which stressors may affect health professionals' performance and well-being and the conditions that potentially lead to impaired performance and staff psychological distress are not well understood. OBJECTIVES: The purpose of this study was to determine healthcare professionals' perceptions regarding the factors that lead to stress responses and performance impairments during ICU medical crises. DESIGN: A qualitative study in a university-affiliated ICU in Canada. METHODOLOGY: We conducted 32 individual semistructured interviews of ICU nurses, staff physicians, residents, and respiratory therapists in a university-affiliated hospital. The transcripts of the audiotaped interviews were analyzed using an inductive thematic methodology. RESULTS: Increased workload, high stakes, and heavy weight of responsibility were recognized as common stressors during ICU crises. However, a high level of individual and team resources available to face such demands was also reported. When the patient's condition was changing or deteriorating unpredictably or when the expected resources were unavailable, crises were assessed by some team members as threatening, leading to individual distress. Once manifested, this emotional distress was strongly contagious to other team members. The ensuing collective anxiety was perceived as disruptive for teamwork and deleterious for individual and collective performance. CONCLUSIONS: Individual distress reactions to ICU crises occurred in the presence of unexpectedly high demands unmatched by appropriate resources and were contagious among other team members. Given the high uncertainty surrounding many ICU medical crises, strategies aimed at preventing distress contagion among ICU health professionals may improve team performance and individual well-being

Interprofessional intensive care unit team interactions and medical crises : a qualitative study

Research has suggested that interprofessional collaboration could improve patient outcomes in the intensive care unit (ICU). Maintaining optimal interprofessional interactions in a setting where unpredictable medical crises occur periodically is however challenging. Our study aimed to investigate the perceptions of ICU health care professionals regarding how acute medical crises affect their team interactions. We conducted 25 semi-structured interviews of ICU nurses, staff physicians, and respiratory therapists. All interviews were audio-taped and transcribed, and the analysis was undertaken using an inductive thematic approach. Our data indicated that the nature of interprofessional interactions changed as teams passed through three key temporal periods around medical crises. During the "pre-crisis period", interactions were based on the mutual respect of each other's expertise. During the "crisis period", hierarchical interactions were expected and a certain lack of civility was tolerated. During the "post-crisis period", divergent perceptions emerged amongst health professionals. Post-crisis team dispersion left the nurses with questions and emotions not expressed by other team members. Nurses believed that systematic interprofessional feedback sessions held immediately after a crisis could address some of their needs. Further research is needed to establish the possible benefits of strategies addressing ICU health care professionals' specific needs for interprofessional feedback after a medical crisis

“It’s better to have three brains working instead of one”: a qualitative study of building therapeutic alliance with family members of critically ill patients

Abstract Background Studies in the intensive care unit (ICU) suggest that better communication between families of critically ill patients and healthcare providers is needed; however, most randomized trials targeting interventions to improve communication have failed to achieve family-centered outcomes. We aim to offer a novel analysis of the complexities involved in building positive family-provider relationships in the ICU through the consideration of not only communication but other important aspects of family-provider interactions, including family integration, collaboration, and empowerment. Our goal is to explore family members’ perspectives on the enablers and challenges to establishing therapeutic alliance with ICU physicians and nurses. Methods We used the concept of therapeutic alliance as an organizational and analytic tool to conduct an interview-based qualitative study in a 20-bed adult medical-surgical ICU in an academic hospital in Toronto, Canada. Nineteen family members of critically ill patients who acted as substitute decision-makers and/or regularly interacted with ICU providers were interviewed. Participants were sampled purposefully to ensure maximum variation along predetermined criteria. A hybrid inductive-deductive approach to analysis was used. Results Participating family members highlighted the complementary roles and practices of ICU nurses and physicians in building therapeutic alliance. They reported how both provider groups had profession specific and shared contributions to foster family communication, integration, and collaboration, while physicians played a key role in family empowerment. Families’ lack of familiarity with ICU personnel and processes, physicians’ sporadic availability and use of medical jargon during rounds, however, reinforced long established power differences between lay families and expert physicians and challenged family integration. Family members also identified informal interactions as missed opportunities for relationship-building with physicians. While informal interactions with nurses at the bedside facilitated therapeutic alliance, inconsistent and ad-hoc interactions related to routine decision-making hindered family empowerment. Conclusions Multiple opportunities exist to improve family-provider relationships in the ICU. The four dimensions of therapeutic alliance prove analytically useful to highlight those aspects that work well and need improvement, such as in the areas of family integration and empowerment