#ICUrestraint study: using audio-visual vignettes

Using audio-visual vignettes to explore how nurses make the decision to restraint delirious patients on the critical care unit

How do nurses make the decision to restrain a delirious patient? What influences their decision? Do they follow protocols or base their decision on an individual assessment of the patient? If they assess the patient, what impacts on this process: the nurse’s experience, the acuity of the unit, or perhaps just how they felt that day? These are some of the questions I am seeking to answer through my PhD research.

My background research showed that nurses were the main decision makers when managing patient agitation and lacked support from medical colleagues. The literature suggests that nurses found caring for agitated and delirious patients physically and emotionally challenging. Nurses used negative subjective terms such as ‘mad’ and ‘poorly behaved’ to describe patient behaviours associated with hyperactive delirium despite the existence of objective, validated tools such as RASS and CAM-ICU. This can lead to the sharing of judgements of dysfunctional or deviant patient behaviour (Carveth, 1995). Wide variations in restraint use appear to be influenced by previous adverse clinical experiences and unit custom rather than evidence based practice.

What is delirium? Delirium is a rapid onset, reversible, fluctuating condition characterised by inattention, changes in cognition, disordered sleep-wake cycle and increased or decreased psychomotor activity (American Psychiatric Association, 2013). It affects approximately 20-50% of mechanically ventilated patients in critical care (Krewulak et al., 2018).  Hyperactive delirium presents as psychomotor agitation, which is often cited as a rationale for initiating chemical and physical restraint in critical care despite a poor evidence base (Ai et al., 2018).

Think aloud

To answer these questions, I wanted to develop a data collection method which would help me to understand how nurses make the decision to restrain a patient, and identify potential modifiable factors. I rejected direct observation because it risked disrupting clinical care and I decided against written scenarios as i doubted these could convey the clinical urgency of caring for an agitated patient. Together with my supervisors, I chose audio-visual vignettes, or short films with ‘Think Aloud’ as the data collection method. ‘Think Aloud’ aims to reveal the thought processes involved in making decisions by encouraging participants to vocalise their thoughts.

Developing the method

I began by writing scenarios based on my reflections on practice and cues identified from my background research. I asked a clinical expert (an Advanced Critical Care Practitioner) to check the scenarios before I developed illustrated storyboards that detailed the patient behaviours I wanted to ask participants about. An enthusiastic group of colleagues agreed to simulate these patient behaviours, and I filmed and edited the audio-visual vignettes early this year. The vignettes depict a range of delirious critical care patients with varying levels of potential risk inference, such as agitated or combative behaviour or the presence of medical devices. Each film is preceded by a verbal handover, which provides an opportunity to explore whether subjective descriptors influence how the participants perceived the patient and if this affected their decision-making.

I piloted the vignettes with three participants. The method works well and simulates decision-making under time-pressure in the critical care environment. Early data suggests variations in practice, and a focus on short-term management over a consideration of the long-term impact of restraint use.

For more information about my PhD research please visit my study page. Data collection is ongoing and the study is actively recruiting new participants.

Would you like to take part?

please see the Participant Information Sheet

Your can contact me at a.m.teece@leeds.ac.uk. You can also follow me on Twitter @AngelaTeece

References

AI, Z.-P., GAO, X.-L. & ZHAO, X.-L. 2018. Factors associated with unplanned extubation in the Intensive Care Unit for adult patients: A systematic review and meta-analysis. Intensive & Critical Care Nursing, 47, 62-68.

AMERICAN PSYCHIATRIC ASSOCIATION, D. S. M. T. F. 2013. Diagnostic and statistical manual of mental disorders: DSM-5, Arlington, Va;London;, American Psychiatric Association.

CARVETH, J. A. 1995. Perceived Patient Deviance And Avoidance by Nurses. Nursing Research, 44, 173-178.

KREWULAK, K. D., STELFOX, H. T., LEIGH, J. P., ELY, E. W. & FIEST, K. M. 2018. Incidence and Prevalence of Delirium Subtypes in an Adult ICU: A Systematic Review and Meta-Analysis. Critical Care Medicine, 46, 2029-2035. 3

Delusions in intensive care: How can healthcare professionals help?

BBC Radio 4 recently aired the series The History of Delusions. One episode focused on delusions specific to people who had been patients on intensive care units.

An intensive care unit (ICU) is a highly specialised area of secondary care. They provide technology-driven treatment for patients in multi-organ failure. Until recently, little attention was paid to the psychological impact of admission to ICU. Delirium, previously referred to as ICU Syndrome or ICU Psychosis, affects around 60% of ICU patients (Brummel and Girard, 2013). Delirium is thought to be caused by critical illness, sleep deprivation, and sedative drugs such as Benzodiazepines. Delirious patients may appear agitated or withdrawn; or display both states alternately. The syndrome is associated with poor post-discharge outcomes, including anxiety and depression (Salluh et al., 2015) and reduced socio-economic function (Griffiths et al., 2013).

“Delusions are false beliefs stemming from an incorrect perception of reality.”

Delusions are one element of delirium and are false beliefs stemming from an incorrect perception of reality. Delusions can also be experienced by non-delirious patients. Post-discharge, former ICU patients report vivid memories of their delusions, often over-powering actual ‘factual’ memories of intensive care. These ‘false’ memories have been linked to the development of post-traumatic stress disorder (Jones, 2010).

Patients report experiencing feelings of motion and of being moved (Svenningsen et al., 2016), which can perhaps be linked to the use of pressure-relieving air mattresses together with the way patients are frequently moved around the unit to accommodate new admissions. As a former ICU sister, I heard numerous beliefs and stories from my patients. One lady accused staff of stealing her organs, one by one, night after night. Another was convinced her sons had left her in intensive care so we could murder her and they could receive their inheritance. Another patient wrote to staff to tell them about his delusions, the memory of which persisted a year after his discharge. He recalled how ‘Satan and his helpers’ visited each patient. I interpreted this as a reference to the consultants’ ward round.

“One lady accused staff of stealing her organs, one by one, night after night.”

The journalist David Aaronovitch reportedly fought off nurses who he believed were using oxygen to tenderise his flesh prior to eating him. Many patients report believing that they are involved in games or challenges, where they feel compelled to do certain tasks ‘or else’.  Such delusions may explain some of the agitation and hypervigilance seen amongst ICU patients. Not all delusions are persecutory, however: one patient told me that he was on a cruise with the greats of Formula 1 motor racing and asked his bemused relatives to bring in his passport and dinner jacket.

“Not all delusions are persecutory, however: one patient told me that he was on a cruise with the greats of Formula 1 motor racing…”

So how can healthcare professionals help?

We have written about how discharged patients value diaries written by their family and ICU staff. The diaries help patients reclaim ownership of lost time and reconstruct their illness narrative. Such diaries should be used alongside multi-disciplinary follow-up support (Teece and Baker, 2017). The recent POPPI Trial explored the use of nurse-led interventions to provide a calm environment and detect signs of psychological distress in patients, and future phases will trial the effectiveness of other interventions. The bedside nurse has an important role to play in screening for delirium, re-orientating, reassuring, and comforting frightened and vulnerable patients.

Do you have any experience of caring for delirious patients, or supporting discharged patients who have experienced delirium whilst in hospital? Comments and questions are very welcome. You can
contact Angela Teece directly or use the comments form below.

References

BRUMMEL, N. E. & GIRARD, T. D. 2013. Preventing delirium in the intensive care unit. Critical Care Clinics, 29, 51-65.

GRIFFITHS, J., HATCH, R. A., BISHOP, J., MORGAN, K., JENKINSON, C., CUTHBERTSON, B. H. & BRETT, S. J. 2013. An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study. Critical Care, 17, 1-12.

JONES, C. 2010. Post-traumatic stress disorder in ICU survivors. Journal of the Intensive Care Society, 11, 12-14.

SALLUH, J. I. F., WANG, H., SCHNEIDER, E. B., NAGARAJA, N., YENOKYAN, G., DAMLUJI, A., SERAFIM, R. B. & STEVENS, R. D. 2015. Outcome of delirium in critically ill patients: systematic review and meta-analysis. British Medical Journal, 350.

SVENNINGSEN, H., EGEROD, I. & DREYER, P. 2016. Strange and scary memories of the intensive care unit: a qualitative, longitudinal study inspired by Ricoeur’s interpretation theory. Journal of Clinical Nursing, 25, 2807-2815. h

TEECE, A. & BAKER, J. 2017. Thematic Analysis: How do patient diaries affect survivors’ psychological recovery? Intensive and Critical Care Nursing, 41, 50-56.

Artwork credit: original artist unknown, but sourced from the Delirium Care Network @deliriumcare