Intensive care survivors’ experiences of ward-based care: Meleis’ theory of nursing transitions and role development among critical care outreach services.

Aims and objectives. To explore the psychosocial needs of patients discharged from intensive care, the extent to which they are captured using existing theory on transitions in care and the potential role development of critical care outreach, follow-up and liaison services. Background. Intensive care patients are at an increased risk of adverse events, deterioration or death following ward transfer. Nurse-led critical care outreach, follow-up or liaison services have been adopted internationally to prevent these potentially avoidable sequelae. The need to provide patients with psychosocial support during the transition to ward-based care has also been identified, but the evidence base for role development is currently limited. Design and methods. Twenty participants were invited to discuss their experiences of ward-based care as part of a broader study on recovery following prolonged critical illness. Psychosocial distress was a prominent feature of their accounts, prompting secondary data analysis using Meleis et al.’s mid-range theory on experiencing transitions. Results. Participants described a sense of disconnection in relation to profound debilitation and dependency and were often distressed by a perceived lack of understanding, indifference or insensitivity among ward staff to their basic care needs. Negotiating the transition between dependence and independence was identified as a significant source of distress following ward transfer. Participants varied in the extent to which they were able to express their needs and negotiate recovery within professionally mediated boundaries. Conclusion. These data provide new insights into the putative origins of the psychosocial distress that patients experience following ward transfer. Relevance to clinical practice. Meleis et al.’s work has resonance in terms of explicating intensive care patients’ experiences of psychosocial distress throughout the transition to general ward–based care, such that the future role development of critical care outreach, follow-up and liaison services may be more theoretically informed.

Understanding nurses’ decision-making when managing weaning from mechanical ventilation: a study of novice and experienced critical care nurses in Scotland and Greece.

Aim and objectives To examine how nurses collect and use cues from respiratory assessment to inform their decisions as they wean patients from ventilatory support. Background Prompt and accurate identification of the patient's ability to sustain reduction of ventilatory support has the potential to increase the likelihood of successful weaning. Nurses' information processing during the weaning from mechanical ventilation has not been well-described. Design A descriptive ethnographic study exploring critical care nurses' decision-making processes when weaning mechanically ventilated patients from ventilatory support in the real setting. Methods Novice and expert Scottish and Greek nurses from two tertiary intensive care units were observed in real practice of weaning mechanical ventilation and were invited to participate in reflective interviews near the end of their shift. Data were analysed thematically using concept maps based on information processing theory. Ethics approval and informed consent were obtained. Results Scottish and Greek critical care nurses acquired patient-centred objective physiological and subjective information from respiratory assessment and previous knowledge of the patient, which they clustered around seven concepts descriptive of the patient's ability to wean. Less experienced nurses required more encounters of cues to attain the concepts with certainty. Subjective criteria were intuitively derived from previous knowledge of patients' responses to changes of ventilatory support. All nurses used focusing decision-making strategies to select and group cues in order to categorise information with certainty and reduce the mental strain of the decision task. Conclusions Nurses used patient-centred information to make a judgment about the patients' ability to wean. Decision-making strategies that involve categorisation of patient-centred information can be taught in bespoke educational programmes for mechanical ventilation and weaning. Relevance to clinical practice Advanced clinical reasoning skills and accurate detection of cues in respiratory assessment by critical care nurses will ensure optimum patient management in weaning mechanical ventilation

Supporting the case for “progressive universalism” in health visiting: Scottish mothers and health visitors’ perspectives on targeting and rationing health visiting services, with a focus on the Lothian Child Concern Model.

Aims. To explore parents and professionals’ experience of family assessment in health visiting (public health nursing), with a focus on the Lothian Child Concern Model (LCCM). Background. Health visitors (HVs) currently assess families as requiring core, additional or intensive support, and offer support at a corresponding level. The majority of families are assessed as core and receive no pro-active support beyond the early days. Previous assessment tools, consisting of checklists, have been criticised as being ineffective in identifying a range of health needs and unacceptable to parents and HVs. The LCCM model was developed and introduced in the study area to promote a partnership approach with parents and assess strengths as well as difficulties in parents’ capacity to care for their child. Methods. Qualitative methods were used. Ten mothers and twelve HVs took part in individual semi-structured interviews. Results. Most mothers were aware of the assessment process but some felt that they were not involved in the decision making process. Explaining the assessment process to parents is problematic and not all HVs do so. The assessment process was stressful for some mothers. HVs find the model useful for structuring and documenting the assessment process. Many believe that most families benefit from some support, using public health approaches. Families are often assessed as core because there are insufficient resources to support all those who meet the criteria of the additional category, and managers assess caseloads in terms of families with child protection concerns. Conclusions. The study findings support the concept of “progressive universalism” which provides a continuum of intensity of support to families, depending on need. Mothers would like better partnership working with HVs. Relevance to clinical practice. The study endorses proposed policy changes to re-establish the public health role of HVs and to lower the threshold for families to qualify for support.