Critical Reflection in the Critical Care Unit- Part 2

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As I get closer towards finishing my four-year nursing degree, I have begun to make some reflections on the various placements I have had. I have been very fortunate in having received two critical care placements to summarize my final year of the program and have been immensely grateful for the opportunities they have both brought forward in allowing me to find my passion within this area of nursing. I believe one of the areas that has stood out most for me has been the work environments I have been exposed to. Working at some of the smaller, regional hospitals provided me insight into how sometimes nurses can exhibit more autonomy in their decision-making processes compared to working at a large urban centre such as at SickKids. Working at the smaller hospitals, which were often underfunded and short-staffed, I have now realized how this may impacts and influence health outcomes for patients. 

For the purposes of this reflection, I will be using John’s Model of Structured Reflection. to briefly compare the care provided for patients at both my placement at SickKids and Brantford General Hospital. I have had phenomenal experiences at both centres, but have recently wondered how care in smaller and more local hospitals can be improved for those who are in a critical care environment. Namely, I had one patient last term who was nearing the end of their life, having suffered with COPD and had experienced a steady decline cognitively, to the point they were no longer deemed competent to make their own healthcare decisions. While the patient had verbalized to the nurses they wished to pass peacefully, family refused to withdraw care and instead the patient would sit helpless in bed. Conversely, the hospital had experienced a shortfall in the budget and was unable to fund additional services such as music/art therapy or run a large volunteer program to keep patients company at the bedside and stimulate them. I have also been curious how we as nurses can make the hospital environment more humanistic, in the sense that hospital can often trigger increased anxiety, isolation/loneliness, and PTSD amongst patients.

In comparison, while I understand working at a world renowned urban paediatric can provide many more services, it has been astounding to see the level of interprofessional care that goes into helping children grow physically, mentally, and cognitively. The patients I have cared for often receive an assortment of complementary therapies during the day and for example I have witnessed the benefits that music therapy provides in reducing patient anxiety, express emotions and stimulate creativity, and improve their overall mood (SickKids, n.d.). A whole assortment of health professionals, child life therapists, music therapists, physiotherapists, therapeutic clowns, art therapists, and therapy dogs are used to promote and stimulate growth among these patients. I was curious to see what the literature had to say about this and how it can influence patient care. It is well known that the risks of developing delirium amongst ICU patients is high, and often has long-term impacts on patients mental, cognitive, and functional status (Tobar, Alvarex, & Garrido, 2017). I was curious how I as a nursing student moving into professional practice can be an advocate for my patients and perhaps look in how I can influence patient outcomes in this regard, particularly if I were to work in a smaller community setting where there is often a lack of funding to hire such professionals (ex. art or music therapists).

The literature also points out how patients that are critically ill are in a state of sensory deprivation and that cognitive stimulation has been shown to enhance cognitive function and decrease the emergence of neurocognitive impairments (Turon, Fernandex-Gonzalo, Comex-Simon, Blanch, & Jodar, 2013). Over the last decade, there has been increasing researchexploring the roles that multidisciplinary rehabilitation strategies for early intervention can have on patients who are in the ICU. While many studies have focused on the benefits of physical therapy protocols and the benefits of early mobilization there has yet to be substantial research focusing on other professions. However, preliminary research has indicated the benefits of non-pharmacological strategies to prevent cognitive decline and delirium in critically ill patients. However, preliminary research has indicated for example that music therapy has shown drastic decreases in heart rates, systolic blood pressure and noise annoyance. 

In terms of providing a more humanistic environment for patients, one study looked at the design of critical care units in improving the physical and emotional tone of the unit. For example, artwork was one method to bring together the aspects of light, colour and nature in helping to promote a more calming and restful environment (Fontaine, Briggs, Pope-Smith, & 2001).  Lack of colour has often been noted to facilitate distress amongst individuals who have had prolonged stays in the ICU (Fontaine, Briggs, Pope-Smith, & 2001).  In my personal experience, I have often found patient rooms to have little colour and at SickKids, little privacy due to how small the rooms are, with often the floor having tape on it to indicate a “patient space”. Walking into “patient spaces” filled with artwork seems to promote a more mentally stimulating environment, compared to the often pale and muted colours that are used in the initial design of hospital rooms.  In reducing noise, it was found headsets and periodic assessments using monitors of ICU noise levels was another way to reduce unnecessary environmental stressors (Fontaine, Briggs, Pope-Smith, & 2001).  While the benefits towards the use of essential oils often brings up debate amongst healthcare providers, one hospital which seeks to promote holistic care found that nurses who used a 15-minute holistic intervention such as essential oils saw improved moods and decreased anxiety amongst ICU patients (Dunn, Sleep, & Collett, 1995).

 As healthcare professionals, we need to take every opportunity we can get to help optimize patients’ quality of life. Simple measures to achieve this include ensuring the patient has decreased exposure to noxious stimuli (ex. bright lights, lack of privacy, loud noises, and exposure to disagreeable odours), which can promote a sense of well-being, relaxation, and adequate sleep (Fontaine, Briggs, Pope-Smith, & 2001).  Over time, I have seen how isolating being in hospital can be for many patients, with not all families and loved ones having the ability to be at the bedside 24/7. It has often been eye-opening to see patients sit solemnly in bed or in a chair staring into the abyss due to lack of stimulation and over time I have wondered how I as a healthcare professional can help be an advocate for these patients. Through this reflection, I have learned some basic strategies to help reduce noxious stimuli and advocate for complementary therapies due to the benefits they exhibit, however I recognize not all hospital are able to offer such services and I would hope that there may be other ways we can help support patients’ well-being and improve health outcomes to promote system efficiencies.  Potential aspects I could implement as a nurse include the ability to access a radio, ensuring routine and multidisciplinary care promotes an optimal sleep-wake cycle, to play music or advocating for the purchase of art supplies or games to help promote cognitive stimulation amongst my patients (permitted spread of infection could be kept at the forefront).

References

Dunn, C., Sleep, J. & Collett, D. (1995). Sensing an improvement: An experimental study to evaluate the use of aroma therapy, massage, and periods of rest in intensive care  units. J Adv Nurs. 1995;21:34-40.

SickKids. (n.d.). Music Therapy. Retrieved February 18, 2020, from,            http://www.sickkids.ca/patient-family-resources/Creative-Arts-Therapy/MusicTherapy/Music-Therapy.html

Tobar, E., Alvarez, E., & Garrido, M. (2017). Cognitive stimulation and occupational therapy for  delirium prevention. Estimulação cognitiva e terapia ocupacional para prevenção de delirium. Revista Brasileira de terapia intensiva29(2), 248–252.   https://doi.org/10.5935/0103-507X.20170034

Turon, M., Fernandez-Gonzalo, S., Gomez-Simon, V. et al. Cognitive stimulation in ICU patients: should we pay more attention?. Crit Care 17, 158 (2013).   https://doi.org/10.1186/cc12719

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