Pulmonary Critical Care
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ISCOVERY OF
UNEXPECTED PAIN IN INTUBATED AND SEDATED PATIENTS By Lory Clukey, RN, PhD, PsyD, CNS, Ruth A. Weyant, RN, MSN, CCRN-CMC, Melanie Roberts, MS, APRN, CCRN, CCNS, and Ann Henderson, PhD, APRN, CNS
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Background The perceptions of patients who are restrained and sedated while being treated with mechanical ventilation in the intensive care unit are not well understood. The effectiveness of sedation used to aid in recovery and enhance comfort during intubation is unknown. Objective To explore the perceptions of patients who were intubated and receiving pain medication while sedated and restrained in the intensive care unit, in particular, their experience and their memories of the experience. Methods In a phenomenological study, 14 patients who were intubated and receiving pain medication while sedated and restrained were interviewed at the bedside. A semistructured interview guide was used. Data were analyzed by using an inductive method consistent with qualitative research. Results Three major themes were identified from the data: lack of memory of being restrained; a perception of being intubated as horrific; nursing behaviors that were helpful and comforting. An unexpected discovery was that sedation may be interfering with pain assessment and management. Conclusion Being intubated can be painful and traumatic despite administration of sedatives and analgesics. Sedation may mask uncontrolled pain for intubated patients and prevent them from communicating this condition to a nurse. Nurses may need to evaluate current interventions in order to provide maximum comfort and promote optimal positive outcomes for intensive care patients who are intubated. (American Journal of Critical Care. 2014;23:216-220)
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atients are often sedated and restrained during intubation in the intensive care unit (ICU). The perceptions and experiences of these patients are not fully known. The purpose of this phenomenological study was to explore the experience of patients and patients’ families in the ICU when the patients were physically restrained and sedated for treatment with mechanical ventilation. In this article, we present the patients’ perceptions. The results related to the families’ perceptions will be presented in a separate article.
Method The sample consisted of ICU patients who were physically restrained and sedated for intubation and mechanical ventilation. They were receiving pain medication routinely in conjunction with the sedation. Each patient was interviewed at the bedside after he or she was transferred from the ICU and before being discharged from the hospital. Written informed consent was obtained before the interview was conducted. Each patient was interviewed by the primary investigator (R.A.W.) and was asked a series of open-ended questions (Table 1) about the experience of being restrained while intubated and treated with mechanical ventilation. During the interviews with the first 2 patients, a coinvestigator (L.C.) was present to validate the interview process and ensure lack of bias. The study was approved by the institutional review board of a regional level II trauma center, where the interviews were conducted. Data were collected until saturation was reached. The audiorecorded interviews were transcribed verbatim, and data were entered into NVivo 9 qualitative research software (QSR International Inc) to aid in data management. Transcriptions, codes, and themes were reviewed by members of the research team, and agreement was reached on the themes that emerged from the data.
Results A total of 11 men and 3 women were interviewed. Of the 14, 8 had planned intubations and 6
About the Authors Lory Clukey is an associate professor, University of Northern Colorado, Greeley, Colorado. Ruth A. Weyant is a staff nurse in the cardiac intensive care unit, Melanie Roberts is a critical care clinical nurse specialist, and Ann Henderson is an education nurse specialist, Medical Center of the Rockies, Loveland, Colorado. Corresponding author: Lory Clukey, RN, PhD, PsyD, CNS, 501 20th St, Gunter Box 125, University of Northern Colorado, School of Nursing, Greeley, CO (e-mail: Lory.clukey@ unco.edu).
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Table 1 Interview guide for the qualitative study on restrained patients receiving mechanical ventilation Questions for the patient: 1. In the intensive care unit (ICU), we restrain patients who are on the ventilator with soft wrist restraints. What was it like for you being restrained in the ICU? 2. What do you remember being said to you while you were on the ventilator? Who was talking with you? 3. How do you remember feeling and what did you think? Tell me more about that. 4. What seemed to help you or provide comfort while you were restrained and on the ventilator? 5. What did not help you while you were restrained and on the ventilator?
had emergent intubations. All 14 were adult patients in the cardiac ICU, and all 14 spoke English. The 3 primary themes identified were a lack of memory of the restraints (14 patients), a perception that being intubated was horrific (8 patients), and nurses’ behaviors that were deemed helpful and provided reassurance and comfort (12 patients). These themes were consistent throughout the interviews and are reported as noted by patients (Table 2). Lack of Memory All of the patients noted some lack of memory of the restraints. Several patients noted that they did not remember the restraints at all. Most patients said that the lack of memory was due to the heavy sedation. Of note, during the time of the study, patients were routinely given medications to induce a light or moderate level of sedation. Patients reported that they did not remember the restraints specifically and that the memories they did have were fragmented: “I do remember bits and pieces. I don’t remember the restraints” (F). (Letters following quotes are pseudonyms for participants’ names.) Patients’ family members, if present during the interview, would fill in events and descriptions for the patients.
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Table 2 Core themes Examplea
Theme Lack of memory
It’s blank. They told me they were there to keep me from pulling hoses out. (N)
Intubation as torture
You know it is essentially breathing for you, you know it is saving your life. On the other hand it is a horrific experience. . . . So you are constantly fighting against this tube, gasping and so forth. It was probably the closest feeling to drowning that you could ever experience . . . the anxiety levels at that point are extremely high. (K)
Nurses’ interventions
a
Well, whoever the nurse was had a very pleasant voice, a very calming effect, and she was in control. I knew she was working for me. I think that was comforting. (A)
Letters in parentheses after quotes are pseudonyms for participants’ names.
Intubation as Torture Despite not remembering the restraints specifically, patients remembered the experience in general. Patients had strong and graphic words to describe their experiences once they became aware of having the breathing tube in place. You know, if you need it, and it does a good job and it helps you, I suppose the misery is worth it. But I would offer this as a good torture for Guantanamo. (A) You can’t take any air in or anything. So you are constantly fighting against this tube, gasping and so forth. It was probably the closest feeling to drowning that you could ever experience . . . It is a rather intimidating device. (K) Nurses’ Interventions Patients said that being told what was happening even while under sedation was important. Having a nurse provide information and anticipatory guidance helped relieve anxiety for both patients and the patients’ family members: “When they talked to me and told me what to do, I would calm down and do what I needed to do.” (E) Patients noted that having restraints was not a problem when they knew the restraints were there to prevent pulling the tubes out. Several noted that without restraints they would have pulled at the tubes because they felt as if they were choking. The perception was that the restraints were there for a patient’s “own good.” (A) Patients felt comforted and less anxious when nurses communicated what the nurses were doing. Actions that seemed to help included informing patients and patients’ family members what was
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going to happen, speaking in a calm but confident voice, providing information, explaining what was happening, and answering questions. Coaching patients was also helpful. Just that calming, kindly reassurance and the explanation that when I could control my breathing and I could relax. (A) Well, if I even thought I had a pain, they were right there with pain pills or whatever and they were really good about wetting my mouth with water. (G)
Discussion Our results included an unanticipated and unexpected finding. We discovered that even though patients may appear relaxed and pain-free while receiving sedation and pain medication, often they are not. Lack of Memory Although patients may be adequately sedated and not pulling against the restraints, one should not assume that the patients are comfortable. Our patients described having fragmented memories of the restraints and were not distressed about them. The lack of memory associated with restraints when intubated has been documented.1,2 Our findings support the contention that adequate sedation is being achieved. However, if sedation is adequate, are the results of assessments accurate for addressing a patient’s needs? Are adequate assessments possible without input from the patient? Intubation as Torture As noted, patients reported marked discomfort despite sedation. They had vivid memories and descriptions of what it was like to be intubated. The words used to describe intubation were words of distress. Sedation may interfere with the ability of patients to express themselves, especially about the discomfort they are experiencing. These descriptions led to the awareness that despite sedation and pain medication, the lived experience of intubation is quite intense and profoundly severe. Words used to describe the experience are listed in Table 3. Words such as drowning, gasping, and choking invoke feelings of helplessness and vulnerability as well as fear. Words such as horrific, misery, and torture provide insight into how extreme and traumatic the experience of being intubated can be. Jones et al2 hypothesized that use of sedation and restraints might have a marked impact on the psychological effects of perceived trauma during ICU experiences. Our patients definitively described
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the perceived trauma associated with intubation. This result most likely is related to the potency of the experience of being intubated in contrast to that of the experience of being restrained. Being sedated did not seem to mitigate the intubation experience. The descriptions of our patients suggest that sedation and administration of pain medications may not always be adequate. Just because patients are sedated and quiet does not mean they are not experiencing pain or anxiety. Sedation may be interfering with a patient’s ability to communicate discomfort. On the basis of this finding, less sedation or periods of sedation interruption may be useful to obtain patients’ feedback. Dotson1 noted that daily interruption of sedation is slow in being adopted and that fears of an increase in self-extubations when sedation is decreased have not been supported by research. More research is needed on sedation and pain management during intubation. Better pain control might be preferable to heavier sedation. Pain management, while providing some sedative effects, could also decrease the perception that being intubated is like being tortured. Research2-4 suggests that intubation is uncomfortable at best and torturous in many circumstances and may lead to a lingering posttraumatic stress response. Kress et al4 examined the effect of daily interruption of sedation on psychological outcomes and concluded that this procedure may reduce trauma symptoms and decrease the incidence of posttraumatic stress disorder after intubation in the ICU. Perhaps with less sedation, patients recover more quickly and have less trauma than they do with more sedation. Nurses’ Interventions Providing information and anticipatory guidance is central when interacting with patients who may appear unconscious. Nurses often do not consider the simple things they do as interventions. Our data indicate that those actions often taken for granted, such as explaining what one is doing and speaking in a calm but reassuring voice, remain vital and important to patients. Clinical Implications Our results have several clinical implications. Our initial intent was to understand the lived experience of being physically restrained; however our patients did not focus on the restraints. Rather, they focused on the experience of intubation and the associated pain and anxiety caused by this procedure. During the study, standard sedation in the ICU was light to moderate, meaning that patients
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Table 3 Words used to describe the experience of being intubated Torture
Agitated
Constantly fighting
Misery
Panic
Angry
Pain
Uncomfortable
Hurt
Choking
Unhappy
Aggravated
Gasping
Scared
Wore out
Drowning
Gagging
Anxiety
Horrific
Frustrated
Ripping
responded to verbal and light tactile stimulation and thus could follow commands. Patients were kept at lighter sedation levels on the basis of the compelling evidence of patients’ need for factual memory2,5,6 to decrease anxiety, depression, and posttraumatic stress syndrome. According to our results, even light to moderate levels of sedation felt like heavy sedation to patients and resulted in a lack of memory, yet pain was still perceived. Pain management was the key issue in each patient’s lived experience. All of the patients used graphic language to describe the experience of intubation and the associated pain and discomfort. Improved pain management is required so that patients’ can tolerate the endotracheal tube and require less sedation. The literature supports analgosedation,7 which is using pain medication before providing sedative therapy. Once pain is controlled, sedatives can be used to treat anxiety. Nurses must be able to assess a patient to determine if the patient’s pain is controlled. They must observe the patient, and determining the status of a patient’s pain is highly inaccurate when the patient is sedated. Although more research is needed to support the efficacy of analgosedation, especially in the ICU, our results suggest that analgosedation might be a reasonable practice change in the ICU. The nurses on the cardiac ICU at Medical Center of the Rockies have changed their professional practice to use analgosedation as the first and primary intervention. They now use a sedative-hypnotic regimen only if a patient requests or physiologically requires sedation. Initial observations indicate that patients’ experiences are more positive than before. Research is currently planned to evaluate the effects and efficacy of these practice changes. The final clinical implication is the importance and value of nurses’ caring behaviors. Patients and
Despite sedation and pain medication, the lived experience is quite intense and profoundly severe.
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patients’ families repeatedly discussed how important these behaviors were to them, helping them through the ICU experience. Caring behaviors are what defines nursing, the foundation of the profession. Examples of caring behaviors from the study include touching, coaching patients through breathing with the mechanical ventilator, providing reassurance, orienting patients, speaking in a pleasant and calm voice, and providing information. These seemingly small acts that nurses perform while constantly assessing and monitoring patients are the most memorable to the patients. Further descriptions of nurses’ caring behaviors related to this study will be presented in a subsequent article. The experience of being in an ICU can be traumatic and frightening to both patients and patients’ family members. Being intubated can be painful and torturous, thus minimizing patients’ realization and concern over being restrained to prevent extubation. The sedation typically used during intubation may mask the discomfort patients feel when the tube is in place, leaving caregivers unaware of the need for better pain management and less sedation. The best way to evaluate pain is to have patients self-report. Patients are not able to communicate their needs or experiences when sedated and intubated. When patients are more awake and able to nod yes or no to queries about pain, pain management can be optimized. More research is needed in this area. Nurses can assess, monitor, and intervene in ways that enhance comfort for both patients and patients’ family members, thus improving outcomes and supporting healing. Evaluating the effectiveness of practice changes and the potential increase in positive outcomes due to the changes will help build evidence for nursing interventions. Patients and their families are the experts in the ICU experience. Continuing to evaluate the effectiveness of practices by asking patients and their families for their perceptions helps nurses determine how effective interventions are and learn what is helpful and what is not.
Caring behaviors are the most memorable to the patients.
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ACKNOWLEDGMENTS This study was conducted at Medical Center of the Rockies and was a collaborative effort with the University of Northern Colorado, School of Nursing. We thank Nancy Reno, RN, BSN, for transcribing our interviews. FINANCIAL DISCLOSURES None reported.
SEE ALSO For more about the experience of intubation, visit the Critical Care Nurse Web site, www.ccnonline .org, and read the article by Jenabzadeh and Chlan, “A Nurse’s Experience Being Intubated and Receiving Mechanical Ventilation” (December 2011).
eLetters Now that you’ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click “Responses” in the second column of either the full-text or PDF view of the article.
REFERENCES 1. Dotson B. Daily Interruption of sedation in patients treated with mechanical ventilation. Am J Health Syst Pharm. 2010; 67(12):1002-1006. doi:10.2146/ajhp090134. 2. Jones C, Bäckman C, Capuzzo M, Flaatten H, Rylander C, Griffiths RD. Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care. Intensive Care Med. 2007;33(6):970-985. doi:10.1007/s00134-007-0600-8. 3. Grap MJ, Blecha T, Munro C. A description of patients’ report of endotracheal tube discomfort. Intensive Crit Care Nurs. 2002;18(4):244-249. doi:10.1016/S0964339702000654. 4. Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168:1457-1461. doi:10.1164/rccm.200303-455OC. 5. Kinrade T, Jackson AC, Tomnay JE. The psychosocial needs of families during critical illness: comparison of nurses’ and family members’ perspectives. Aust J Adv Nurs. 2009;27(1):82-88. 6. Ethier C, Burry L, Martinez-Motta C, et al. Recall of intensive care unit stay in patients managed with a sedation protocol or a sedation protocol with daily sedative interruption: a pilot study. J Crit Care. 2011;26(2):127-132. doi:10.1016/j.jcrc.2010.08.003. 7. Devabhakthuni S, Armahizer MJ, Dasta JF, Kane-Gill SL. Analgosedation: a paradigm shift in intensive care unit sedation practice. Ann Pharmacother. 2012;46(4):530-540. doi:10.1345/aph.1Q525.
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Evidence-Based Review and Discussion Points By Ronald L. Hickman, RN, PhD, ACNP-BC Evidence-Based Review (EBR) is the journal club feature in the American Journal of Critical Care. In a journal club, attendees review and critique published research articles: an important first step toward integrating evidence-based practice into patient care. General and specific questions such as those outlined in the “Discussion Points” box aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications of the article for clinical practice. When critically appraising this issue’s EBR article, found on pp 216-220, consider the questions and discussion points outlined in the “Discussion Points” box. Visit www.ajcconline.org to discuss the article online.
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ach year, thousands of Americans require mechanical ventilation in an intensive care unit (ICU). For patients receiving mechanical ventilation, the experience of being intubated typically entails the use of physical restraints, sedation, and analgesia to maintain patient safety and comfort. Because of the use of sedatives and analgesia, most patients using mechanical ventilation have difficulty expressing their level of discomfort to critical care clinicians.
This qualitative study was initially conducted to explore the perceptions of patients who were physically restrained and sedated for mechanical ventilation. A total of 14 adult patients were enrolled from a cardiac intensive care unit of a community hospital located in Northern Colorado. After ICU discharge, each of the participants underwent a semistructured interview at the bedside and were asked 5 open-ended questions that prompted them to reflect on how it felt to be restrained, recall any conversations they had with clinicians or relatives, and any emotions Investigator Spotlight they may have experienced while receiving mechanical ventilation. This feature briefly describes the personal journey and background story of Participant recruitment was conthe EBR article’s lead investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article cluded once the investigators identifeatured in this issue. fied thematic saturation. Data analysis consisted of reviewing verbaory Clukey, RN, PhD, PsyD, CNS is currently tim transcripts of each participant to an associate professor at the University of assess codes and themes among parNorthern Colorado School of Nursing. She has ticipants using qualitative data anamore than 20 years of clinical nursing experilytic software. ence, which is uniquely blended with her academic preparation in counseling psychology. The study investigators identified Clukey has expertise in the conduct and dis3 major themes among participants semination of qualitative research. She and her who were restrained and sedated coauthors used qualitative methods to explore during an episode of mechanical the perceptions of patients who have been Lory Clukey ventilation. The first theme, “lack of restrained and sedated while on mechanical memory,” highlights that participants ventilation to reveal commonalities in their lived experiences. who were restrained and sedated Clukey says this study, which was proposed by a critical care staff during mechanical ventilation have nurse, was designed to evaluate how patients felt about being limited memory regarding physical restrained while receiving mechanical ventilation. She notes, “We were restraints. Despite receiving sedation surprised to hear how difficult it was to be intubated and receiving and analgesia during mechanical mechanical ventilation.” When the authors did an analysis of the words used to describe being intubated, “Terms like horrific, torture, ventilation, the second theme, “intuhurt, misery, and pain were used by patients to describe their intubabation as torture,” underscores that tion experience,” she says. the experience of intubation and Clukey and her coauthors note their research may shed light on the mechanical ventilation was uncompossibility that sedation may mask uncontrolled pain, hinder patient fortable and invoked feelings of communication, and limit the critical care clinician’s assessment of helplessness among participants. The the patient’s symptom burden while sedated and on mechanical ventithird theme, “nursing interventions,” lation. Their qualitative research provides supportive evidence that emphasizes the simple, but powerful, critically ill patients receiving mechanical ventilation have unmet acts of nurses that can effectively alleneeds for palliation of pain and psychological symptoms. viate the physical and psychological
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symptom burdens associated with mechanical ventilation. The results of this study reinforce the need for assistive communication technology to facilitate patient communication and proactive palliation of symptoms among critically ill patients who are sedated and using mechanical ventilation.
potential to change practice and improve the clinical outcomes of patients who are sedated and on mechanical ventilation,” she says. Clukey suspects that her research will be used to inform future studies that examine pain management strategies and support the need to address the symptom burden of patients who are sedated and using mechanical ventilation.
Information From the Authors Lory Clukey, RN, PhD, PsyD, CNS, lead author on this study says that her interest in qualitative research and her passion for exploring the “firsthand” experiences of patients and their family members motivated her to collaborate with critical care clinicians from the study site. She explains, “The phenomenological approach allows me to dip into the participants’ understandings of their experiences and learn what their experiences means to them.” When asked about the personal and professional experiences that led her to undertake this study, Clukey recalls, “Ruth Weyant, a critical care nurse and graduate student, initiated this study and is a principal investigator. Weyant had proposed a project for the completion of her master’s degree in nursing. I was initially approached by her to serve as a consultant and soon became a coinvestigator to supervise the initial interviews, safeguard introducing bias in the data collection and assist with data analysis.” Clukey further explains, “Although our original intent was to explore the experience of patients on mechanical ventilation who were restrained and sedated, it was clear that physical restraints were not the foremost concern among these patients. This has led to a new awareness for the investigative team and changes in clinical practice with regards to pain management at the study site.”
Implications for Practice Clukey and coauthors encourage the readers of the American Journal of Critical Care to work collaboratively to improve the clinical outcomes of patients who receive mechanical ventilation. She advises, “collaboration is key to the conduct of clinically relevant research and it facilitates the translation of research into practice.” This project was made possible by collaborations among nurses in clinical practice partnered with nurse scientists in academia. “The blended research and clinical expertise generated meaningful research findings that holds the
About the Author Ronald L. Hickman is an assistant professor, Case Western Reserve University, and an acute care nurse practitioner at University Hospitals Case Medical Center, Cleveland, Ohio.
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eLetters Now that you’ve read the EBR article and accompanying features, discuss them with colleagues. To begin an online discussion using eLetters, just visit www.ajcconline.org and click “Responses” in the second column of either the full-text or PDF view of the article. All eLetters must be approved by the journal’s coeditors prior to publication.
Discussion Points A. Description of the Study K What is known about the experiences of critically ill patients who were restrained, sedated, and required mechanical ventilation? K What is the purpose of this study? B. Literature Evaluation K What has been cited in the literature about the patient experience of being sedated while receiving mechanical ventilation? K What previous research did the authors discuss about symptom management among patients needing mechanical ventilation? C. Sample K What patients were eligible to participate in this study? K What are the characteristics of patients who participated in this study? D. Methods and Design K How did the investigators collect their data? K How did the investigators determine that they had sufficient data to conclude the recruitment of participants? E. Results K What were 3 major themes identified by the investigators? K What words did patients use to describe their intubation experience? F. Clinical Significance K What are the implications of this study for clinical practice? K What strategies can be used to identify symptoms and inform treatment for sedated patients who receive mechanical ventilation?
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Discovery of Unexpected Pain in Intubated and Sedated Patients By Lory Clukey, Ruth A. Weyant, Melanie Roberts and Ann Henderson Am J Crit Care 2014;23:216-220 doi: 10.4037/ajcc2014943 © 2014 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2014 by AACN. All rights reserved.
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ISCOVERY OF
UNEXPECTED PAIN IN INTUBATED AND SEDATED PATIENTS By Lory Clukey, RN, PhD, PsyD, CNS, Ruth A. Weyant, RN, MSN, CCRN-CMC, Melanie Roberts, MS, APRN, CCRN, CCNS, and Ann Henderson, PhD, APRN, CNS
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Background The perceptions of patients who are restrained and sedated while being treated with mechanical ventilation in the intensive care unit are not well understood. The effectiveness of sedation used to aid in recovery and enhance comfort during intubation is unknown. Objective To explore the perceptions of patients who were intubated and receiving pain medication while sedated and restrained in the intensive care unit, in particular, their experience and their memories of the experience. Methods In a phenomenological study, 14 patients who were intubated and receiving pain medication while sedated and restrained were interviewed at the bedside. A semistructured interview guide was used. Data were analyzed by using an inductive method consistent with qualitative research. Results Three major themes were identified from the data: lack of memory of being restrained; a perception of being intubated as horrific; nursing behaviors that were helpful and comforting. An unexpected discovery was that sedation may be interfering with pain assessment and management. Conclusion Being intubated can be painful and traumatic despite administration of sedatives and analgesics. Sedation may mask uncontrolled pain for intubated patients and prevent them from communicating this condition to a nurse. Nurses may need to evaluate current interventions in order to provide maximum comfort and promote optimal positive outcomes for intensive care patients who are intubated. (American Journal of Critical Care. 2014;23:216-220)
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atients are often sedated and restrained during intubation in the intensive care unit (ICU). The perceptions and experiences of these patients are not fully known. The purpose of this phenomenological study was to explore the experience of patients and patients’ families in the ICU when the patients were physically restrained and sedated for treatment with mechanical ventilation. In this article, we present the patients’ perceptions. The results related to the families’ perceptions will be presented in a separate article.
Method The sample consisted of ICU patients who were physically restrained and sedated for intubation and mechanical ventilation. They were receiving pain medication routinely in conjunction with the sedation. Each patient was interviewed at the bedside after he or she was transferred from the ICU and before being discharged from the hospital. Written informed consent was obtained before the interview was conducted. Each patient was interviewed by the primary investigator (R.A.W.) and was asked a series of open-ended questions (Table 1) about the experience of being restrained while intubated and treated with mechanical ventilation. During the interviews with the first 2 patients, a coinvestigator (L.C.) was present to validate the interview process and ensure lack of bias. The study was approved by the institutional review board of a regional level II trauma center, where the interviews were conducted. Data were collected until saturation was reached. The audiorecorded interviews were transcribed verbatim, and data were entered into NVivo 9 qualitative research software (QSR International Inc) to aid in data management. Transcriptions, codes, and themes were reviewed by members of the research team, and agreement was reached on the themes that emerged from the data.
Results A total of 11 men and 3 women were interviewed. Of the 14, 8 had planned intubations and 6
About the Authors Lory Clukey is an associate professor, University of Northern Colorado, Greeley, Colorado. Ruth A. Weyant is a staff nurse in the cardiac intensive care unit, Melanie Roberts is a critical care clinical nurse specialist, and Ann Henderson is an education nurse specialist, Medical Center of the Rockies, Loveland, Colorado. Corresponding author: Lory Clukey, RN, PhD, PsyD, CNS, 501 20th St, Gunter Box 125, University of Northern Colorado, School of Nursing, Greeley, CO (e-mail: Lory.clukey@ unco.edu).
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Table 1 Interview guide for the qualitative study on restrained patients receiving mechanical ventilation Questions for the patient: 1. In the intensive care unit (ICU), we restrain patients who are on the ventilator with soft wrist restraints. What was it like for you being restrained in the ICU? 2. What do you remember being said to you while you were on the ventilator? Who was talking with you? 3. How do you remember feeling and what did you think? Tell me more about that. 4. What seemed to help you or provide comfort while you were restrained and on the ventilator? 5. What did not help you while you were restrained and on the ventilator?
had emergent intubations. All 14 were adult patients in the cardiac ICU, and all 14 spoke English. The 3 primary themes identified were a lack of memory of the restraints (14 patients), a perception that being intubated was horrific (8 patients), and nurses’ behaviors that were deemed helpful and provided reassurance and comfort (12 patients). These themes were consistent throughout the interviews and are reported as noted by patients (Table 2). Lack of Memory All of the patients noted some lack of memory of the restraints. Several patients noted that they did not remember the restraints at all. Most patients said that the lack of memory was due to the heavy sedation. Of note, during the time of the study, patients were routinely given medications to induce a light or moderate level of sedation. Patients reported that they did not remember the restraints specifically and that the memories they did have were fragmented: “I do remember bits and pieces. I don’t remember the restraints” (F). (Letters following quotes are pseudonyms for participants’ names.) Patients’ family members, if present during the interview, would fill in events and descriptions for the patients.
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Table 2 Core themes Examplea
Theme Lack of memory
It’s blank. They told me they were there to keep me from pulling hoses out. (N)
Intubation as torture
You know it is essentially breathing for you, you know it is saving your life. On the other hand it is a horrific experience. . . . So you are constantly fighting against this tube, gasping and so forth. It was probably the closest feeling to drowning that you could ever experience . . . the anxiety levels at that point are extremely high. (K)
Nurses’ interventions
a
Well, whoever the nurse was had a very pleasant voice, a very calming effect, and she was in control. I knew she was working for me. I think that was comforting. (A)
Letters in parentheses after quotes are pseudonyms for participants’ names.
Intubation as Torture Despite not remembering the restraints specifically, patients remembered the experience in general. Patients had strong and graphic words to describe their experiences once they became aware of having the breathing tube in place. You know, if you need it, and it does a good job and it helps you, I suppose the misery is worth it. But I would offer this as a good torture for Guantanamo. (A) You can’t take any air in or anything. So you are constantly fighting against this tube, gasping and so forth. It was probably the closest feeling to drowning that you could ever experience . . . It is a rather intimidating device. (K) Nurses’ Interventions Patients said that being told what was happening even while under sedation was important. Having a nurse provide information and anticipatory guidance helped relieve anxiety for both patients and the patients’ family members: “When they talked to me and told me what to do, I would calm down and do what I needed to do.” (E) Patients noted that having restraints was not a problem when they knew the restraints were there to prevent pulling the tubes out. Several noted that without restraints they would have pulled at the tubes because they felt as if they were choking. The perception was that the restraints were there for a patient’s “own good.” (A) Patients felt comforted and less anxious when nurses communicated what the nurses were doing. Actions that seemed to help included informing patients and patients’ family members what was
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going to happen, speaking in a calm but confident voice, providing information, explaining what was happening, and answering questions. Coaching patients was also helpful. Just that calming, kindly reassurance and the explanation that when I could control my breathing and I could relax. (A) Well, if I even thought I had a pain, they were right there with pain pills or whatever and they were really good about wetting my mouth with water. (G)
Discussion Our results included an unanticipated and unexpected finding. We discovered that even though patients may appear relaxed and pain-free while receiving sedation and pain medication, often they are not. Lack of Memory Although patients may be adequately sedated and not pulling against the restraints, one should not assume that the patients are comfortable. Our patients described having fragmented memories of the restraints and were not distressed about them. The lack of memory associated with restraints when intubated has been documented.1,2 Our findings support the contention that adequate sedation is being achieved. However, if sedation is adequate, are the results of assessments accurate for addressing a patient’s needs? Are adequate assessments possible without input from the patient? Intubation as Torture As noted, patients reported marked discomfort despite sedation. They had vivid memories and descriptions of what it was like to be intubated. The words used to describe intubation were words of distress. Sedation may interfere with the ability of patients to express themselves, especially about the discomfort they are experiencing. These descriptions led to the awareness that despite sedation and pain medication, the lived experience of intubation is quite intense and profoundly severe. Words used to describe the experience are listed in Table 3. Words such as drowning, gasping, and choking invoke feelings of helplessness and vulnerability as well as fear. Words such as horrific, misery, and torture provide insight into how extreme and traumatic the experience of being intubated can be. Jones et al2 hypothesized that use of sedation and restraints might have a marked impact on the psychological effects of perceived trauma during ICU experiences. Our patients definitively described
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the perceived trauma associated with intubation. This result most likely is related to the potency of the experience of being intubated in contrast to that of the experience of being restrained. Being sedated did not seem to mitigate the intubation experience. The descriptions of our patients suggest that sedation and administration of pain medications may not always be adequate. Just because patients are sedated and quiet does not mean they are not experiencing pain or anxiety. Sedation may be interfering with a patient’s ability to communicate discomfort. On the basis of this finding, less sedation or periods of sedation interruption may be useful to obtain patients’ feedback. Dotson1 noted that daily interruption of sedation is slow in being adopted and that fears of an increase in self-extubations when sedation is decreased have not been supported by research. More research is needed on sedation and pain management during intubation. Better pain control might be preferable to heavier sedation. Pain management, while providing some sedative effects, could also decrease the perception that being intubated is like being tortured. Research2-4 suggests that intubation is uncomfortable at best and torturous in many circumstances and may lead to a lingering posttraumatic stress response. Kress et al4 examined the effect of daily interruption of sedation on psychological outcomes and concluded that this procedure may reduce trauma symptoms and decrease the incidence of posttraumatic stress disorder after intubation in the ICU. Perhaps with less sedation, patients recover more quickly and have less trauma than they do with more sedation. Nurses’ Interventions Providing information and anticipatory guidance is central when interacting with patients who may appear unconscious. Nurses often do not consider the simple things they do as interventions. Our data indicate that those actions often taken for granted, such as explaining what one is doing and speaking in a calm but reassuring voice, remain vital and important to patients. Clinical Implications Our results have several clinical implications. Our initial intent was to understand the lived experience of being physically restrained; however our patients did not focus on the restraints. Rather, they focused on the experience of intubation and the associated pain and anxiety caused by this procedure. During the study, standard sedation in the ICU was light to moderate, meaning that patients
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Table 3 Words used to describe the experience of being intubated Torture
Agitated
Constantly fighting
Misery
Panic
Angry
Pain
Uncomfortable
Hurt
Choking
Unhappy
Aggravated
Gasping
Scared
Wore out
Drowning
Gagging
Anxiety
Horrific
Frustrated
Ripping
responded to verbal and light tactile stimulation and thus could follow commands. Patients were kept at lighter sedation levels on the basis of the compelling evidence of patients’ need for factual memory2,5,6 to decrease anxiety, depression, and posttraumatic stress syndrome. According to our results, even light to moderate levels of sedation felt like heavy sedation to patients and resulted in a lack of memory, yet pain was still perceived. Pain management was the key issue in each patient’s lived experience. All of the patients used graphic language to describe the experience of intubation and the associated pain and discomfort. Improved pain management is required so that patients’ can tolerate the endotracheal tube and require less sedation. The literature supports analgosedation,7 which is using pain medication before providing sedative therapy. Once pain is controlled, sedatives can be used to treat anxiety. Nurses must be able to assess a patient to determine if the patient’s pain is controlled. They must observe the patient, and determining the status of a patient’s pain is highly inaccurate when the patient is sedated. Although more research is needed to support the efficacy of analgosedation, especially in the ICU, our results suggest that analgosedation might be a reasonable practice change in the ICU. The nurses on the cardiac ICU at Medical Center of the Rockies have changed their professional practice to use analgosedation as the first and primary intervention. They now use a sedative-hypnotic regimen only if a patient requests or physiologically requires sedation. Initial observations indicate that patients’ experiences are more positive than before. Research is currently planned to evaluate the effects and efficacy of these practice changes. The final clinical implication is the importance and value of nurses’ caring behaviors. Patients and
Despite sedation and pain medication, the lived experience is quite intense and profoundly severe.
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patients’ families repeatedly discussed how important these behaviors were to them, helping them through the ICU experience. Caring behaviors are what defines nursing, the foundation of the profession. Examples of caring behaviors from the study include touching, coaching patients through breathing with the mechanical ventilator, providing reassurance, orienting patients, speaking in a pleasant and calm voice, and providing information. These seemingly small acts that nurses perform while constantly assessing and monitoring patients are the most memorable to the patients. Further descriptions of nurses’ caring behaviors related to this study will be presented in a subsequent article. The experience of being in an ICU can be traumatic and frightening to both patients and patients’ family members. Being intubated can be painful and torturous, thus minimizing patients’ realization and concern over being restrained to prevent extubation. The sedation typically used during intubation may mask the discomfort patients feel when the tube is in place, leaving caregivers unaware of the need for better pain management and less sedation. The best way to evaluate pain is to have patients self-report. Patients are not able to communicate their needs or experiences when sedated and intubated. When patients are more awake and able to nod yes or no to queries about pain, pain management can be optimized. More research is needed in this area. Nurses can assess, monitor, and intervene in ways that enhance comfort for both patients and patients’ family members, thus improving outcomes and supporting healing. Evaluating the effectiveness of practice changes and the potential increase in positive outcomes due to the changes will help build evidence for nursing interventions. Patients and their families are the experts in the ICU experience. Continuing to evaluate the effectiveness of practices by asking patients and their families for their perceptions helps nurses determine how effective interventions are and learn what is helpful and what is not.
Caring behaviors are the most memorable to the patients.
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ACKNOWLEDGMENTS This study was conducted at Medical Center of the Rockies and was a collaborative effort with the University of Northern Colorado, School of Nursing. We thank Nancy Reno, RN, BSN, for transcribing our interviews. FINANCIAL DISCLOSURES None reported.
SEE ALSO For more about the experience of intubation, visit the Critical Care Nurse Web site, www.ccnonline .org, and read the article by Jenabzadeh and Chlan, “A Nurse’s Experience Being Intubated and Receiving Mechanical Ventilation” (December 2011).
eLetters Now that you’ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click “Responses” in the second column of either the full-text or PDF view of the article.
REFERENCES 1. Dotson B. Daily Interruption of sedation in patients treated with mechanical ventilation. Am J Health Syst Pharm. 2010; 67(12):1002-1006. doi:10.2146/ajhp090134. 2. Jones C, Bäckman C, Capuzzo M, Flaatten H, Rylander C, Griffiths RD. Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care. Intensive Care Med. 2007;33(6):970-985. doi:10.1007/s00134-007-0600-8. 3. Grap MJ, Blecha T, Munro C. A description of patients’ report of endotracheal tube discomfort. Intensive Crit Care Nurs. 2002;18(4):244-249. doi:10.1016/S0964339702000654. 4. Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168:1457-1461. doi:10.1164/rccm.200303-455OC. 5. Kinrade T, Jackson AC, Tomnay JE. The psychosocial needs of families during critical illness: comparison of nurses’ and family members’ perspectives. Aust J Adv Nurs. 2009;27(1):82-88. 6. Ethier C, Burry L, Martinez-Motta C, et al. Recall of intensive care unit stay in patients managed with a sedation protocol or a sedation protocol with daily sedative interruption: a pilot study. J Crit Care. 2011;26(2):127-132. doi:10.1016/j.jcrc.2010.08.003. 7. Devabhakthuni S, Armahizer MJ, Dasta JF, Kane-Gill SL. Analgosedation: a paradigm shift in intensive care unit sedation practice. Ann Pharmacother. 2012;46(4):530-540. doi:10.1345/aph.1Q525.
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Evidence-Based Review and Discussion Points By Ronald L. Hickman, RN, PhD, ACNP-BC Evidence-Based Review (EBR) is the journal club feature in the American Journal of Critical Care. In a journal club, attendees review and critique published research articles: an important first step toward integrating evidence-based practice into patient care. General and specific questions such as those outlined in the “Discussion Points” box aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications of the article for clinical practice. When critically appraising this issue’s EBR article, found on pp 216-220, consider the questions and discussion points outlined in the “Discussion Points” box. Visit www.ajcconline.org to discuss the article online.
E
ach year, thousands of Americans require mechanical ventilation in an intensive care unit (ICU). For patients receiving mechanical ventilation, the experience of being intubated typically entails the use of physical restraints, sedation, and analgesia to maintain patient safety and comfort. Because of the use of sedatives and analgesia, most patients using mechanical ventilation have difficulty expressing their level of discomfort to critical care clinicians.
This qualitative study was initially conducted to explore the perceptions of patients who were physically restrained and sedated for mechanical ventilation. A total of 14 adult patients were enrolled from a cardiac intensive care unit of a community hospital located in Northern Colorado. After ICU discharge, each of the participants underwent a semistructured interview at the bedside and were asked 5 open-ended questions that prompted them to reflect on how it felt to be restrained, recall any conversations they had with clinicians or relatives, and any emotions Investigator Spotlight they may have experienced while receiving mechanical ventilation. This feature briefly describes the personal journey and background story of Participant recruitment was conthe EBR article’s lead investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article cluded once the investigators identifeatured in this issue. fied thematic saturation. Data analysis consisted of reviewing verbaory Clukey, RN, PhD, PsyD, CNS is currently tim transcripts of each participant to an associate professor at the University of assess codes and themes among parNorthern Colorado School of Nursing. She has ticipants using qualitative data anamore than 20 years of clinical nursing experilytic software. ence, which is uniquely blended with her academic preparation in counseling psychology. The study investigators identified Clukey has expertise in the conduct and dis3 major themes among participants semination of qualitative research. She and her who were restrained and sedated coauthors used qualitative methods to explore during an episode of mechanical the perceptions of patients who have been Lory Clukey ventilation. The first theme, “lack of restrained and sedated while on mechanical memory,” highlights that participants ventilation to reveal commonalities in their lived experiences. who were restrained and sedated Clukey says this study, which was proposed by a critical care staff during mechanical ventilation have nurse, was designed to evaluate how patients felt about being limited memory regarding physical restrained while receiving mechanical ventilation. She notes, “We were restraints. Despite receiving sedation surprised to hear how difficult it was to be intubated and receiving and analgesia during mechanical mechanical ventilation.” When the authors did an analysis of the words used to describe being intubated, “Terms like horrific, torture, ventilation, the second theme, “intuhurt, misery, and pain were used by patients to describe their intubabation as torture,” underscores that tion experience,” she says. the experience of intubation and Clukey and her coauthors note their research may shed light on the mechanical ventilation was uncompossibility that sedation may mask uncontrolled pain, hinder patient fortable and invoked feelings of communication, and limit the critical care clinician’s assessment of helplessness among participants. The the patient’s symptom burden while sedated and on mechanical ventithird theme, “nursing interventions,” lation. Their qualitative research provides supportive evidence that emphasizes the simple, but powerful, critically ill patients receiving mechanical ventilation have unmet acts of nurses that can effectively alleneeds for palliation of pain and psychological symptoms. viate the physical and psychological
L
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symptom burdens associated with mechanical ventilation. The results of this study reinforce the need for assistive communication technology to facilitate patient communication and proactive palliation of symptoms among critically ill patients who are sedated and using mechanical ventilation.
potential to change practice and improve the clinical outcomes of patients who are sedated and on mechanical ventilation,” she says. Clukey suspects that her research will be used to inform future studies that examine pain management strategies and support the need to address the symptom burden of patients who are sedated and using mechanical ventilation.
Information From the Authors Lory Clukey, RN, PhD, PsyD, CNS, lead author on this study says that her interest in qualitative research and her passion for exploring the “firsthand” experiences of patients and their family members motivated her to collaborate with critical care clinicians from the study site. She explains, “The phenomenological approach allows me to dip into the participants’ understandings of their experiences and learn what their experiences means to them.” When asked about the personal and professional experiences that led her to undertake this study, Clukey recalls, “Ruth Weyant, a critical care nurse and graduate student, initiated this study and is a principal investigator. Weyant had proposed a project for the completion of her master’s degree in nursing. I was initially approached by her to serve as a consultant and soon became a coinvestigator to supervise the initial interviews, safeguard introducing bias in the data collection and assist with data analysis.” Clukey further explains, “Although our original intent was to explore the experience of patients on mechanical ventilation who were restrained and sedated, it was clear that physical restraints were not the foremost concern among these patients. This has led to a new awareness for the investigative team and changes in clinical practice with regards to pain management at the study site.”
Implications for Practice Clukey and coauthors encourage the readers of the American Journal of Critical Care to work collaboratively to improve the clinical outcomes of patients who receive mechanical ventilation. She advises, “collaboration is key to the conduct of clinically relevant research and it facilitates the translation of research into practice.” This project was made possible by collaborations among nurses in clinical practice partnered with nurse scientists in academia. “The blended research and clinical expertise generated meaningful research findings that holds the
About the Author Ronald L. Hickman is an assistant professor, Case Western Reserve University, and an acute care nurse practitioner at University Hospitals Case Medical Center, Cleveland, Ohio.
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eLetters Now that you’ve read the EBR article and accompanying features, discuss them with colleagues. To begin an online discussion using eLetters, just visit www.ajcconline.org and click “Responses” in the second column of either the full-text or PDF view of the article. All eLetters must be approved by the journal’s coeditors prior to publication.
Discussion Points A. Description of the Study K What is known about the experiences of critically ill patients who were restrained, sedated, and required mechanical ventilation? K What is the purpose of this study? B. Literature Evaluation K What has been cited in the literature about the patient experience of being sedated while receiving mechanical ventilation? K What previous research did the authors discuss about symptom management among patients needing mechanical ventilation? C. Sample K What patients were eligible to participate in this study? K What are the characteristics of patients who participated in this study? D. Methods and Design K How did the investigators collect their data? K How did the investigators determine that they had sufficient data to conclude the recruitment of participants? E. Results K What were 3 major themes identified by the investigators? K What words did patients use to describe their intubation experience? F. Clinical Significance K What are the implications of this study for clinical practice? K What strategies can be used to identify symptoms and inform treatment for sedated patients who receive mechanical ventilation?
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Discovery of Unexpected Pain in Intubated and Sedated Patients By Lory Clukey, Ruth A. Weyant, Melanie Roberts and Ann Henderson Am J Crit Care 2014;23:216-220 doi: 10.4037/ajcc2014943 © 2014 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2014 by AACN. All rights reserved.
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