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CURRENT CONTROVERSIES IN CRITICAL CARE |
A fellow healthcare worker was recently hospitalized for eye surgery. For 24 hours following the surgery and anesthesia, she experienced extreme nausea and dizziness. Her husband stayed with her for assistance, but her problem was complicated by the fact that she had to keep her head in a prone position because of the eye surgery. Despite pain and nausea medications, any head movement could cause dizziness and vomiting. At 3 AM, her husband had fallen asleep, so she called for a nurse to help her get to the bedside commode. The nurse quietly and gently assisted her, trying not to wake the patient’s husband, as this was his first time sleeping since the surgery.
Upon moving back to bed, my colleague again experienced vomiting and extreme dizziness. She had been given anti-emetic medication before getting up, so the nurse gave her a cool cloth and sat holding her steady in a sitting, head-down position. She had muscle spasms in the neck from the extended time lying in a prone position, and she was discouraged and distressed by the vomiting and dizziness. The nurse rubbed her shoulders to relieve the strain until the dizziness and nausea subsided enough for her to return to a prone position. My colleague, knowing that I am a nurse educator, recounted this experience to me, explaining that it was the first time during this hospitalization that anyone had offered anything other than medications to soothe or comfort her. She greatly appreciated what she considered to be a central nursing art and asked me if nursing students were no longer taught how to comfort with touch and presence.
I believe that we still do teach the arts of gentle touch and comfort measures, such as being present in a reassuring manner as was this nurse. However, there are many threats to this central nursing practice. First, it is invisible, rarely charted, and almost never suggested in a nursing care plan. Comforting touch, solace, and presencing (ie, being present and available to the patient) are left in the region of the art of nursing practice, yet few would deny their importance when confronted with a situation like the one just described.
With culturally diverse patient and nurse populations, there can be cultural confusion and even barriers to the nursing tradition of comforting practices such as touch and presencing. Touch itself may be endangered by concern for crossing cultural boundaries of either the patient or the nurse. There is also the technological imperative of providing more technical interventions such as medications for pain and nausea or tranquilizers. Such "ordered" and charted interventions remain expected and highly visible therapies.
Despite the endangerment of comforting touch and solace, my colleagues and I found many examples of comfort measures in a recent study of critical care nursing.1,2 The goal is to articulate these marginalized, invisible practices in order to make their crucial contributions to critical caring evident and open for discussion and renewal. An example is given in the following observational interview:
Nurse J. was taking care of a 55-year-old man. He told me immediately that the main problem was the man’s psychological condition, and that he had taken steps to deal with that at the beginning of the shift. Before going into detail about those steps, he gave me details of the man’s medical history and current hospitalization. (NB, this was 45 minutes into the shift.)... "But now we know the anatomy," Nurse J. said. The patient had just returned from an emergency cardiac catheterization. The 3 grafts from his previous coronary artery bypass graft (CABG) surgery plus 2 of his major arteries were completely occluded. The third was barely perfusing. Nurse J. told me that the attending physician had talked with the patient about the results of the catheterization, telling him that he was getting all the medications available for his disease, and that the medical staff would be talking with him over the next couple of days about a heart transplant. Nurse J. saw the patient take off his oxygen mask in his sleep a few times. He would go into the room and tell the patient directly that he was putting his "oxygen back on," and that he should try to keep it on because it was good for his heart. Nurse J. said to me that if he were "going by the book," he’d tape the mask to the patient’s face, or maybe restrain him. In this case that didn’t make any sense and it would just backfire making the patient angry and upset. After a few attempts to keep the mask on, Nurse J. mentioned to the resident that he was going to try a nasal cannula. This would deliver less oxygen per minute, but the patient would get more oxygen with the cannula because it would be more comfortable and the patient would leave it on. He did this, explaining to the patient that it would be a lot more comfortable, and that "we’ll try this to see if you get enough oxygen this way." The patient agreed.2
This kind of accommodation and comfort measure is common practice, but invisible unless the nurse does "go by the book" and inappropriately uses physical restraints. In this example, the nurse uses good judgment and ethically chooses the least necessary restraint. This is the ethically demanded care in this situation. It is not clear what the nurse has in mind when he mentions "going by the book," but presumably, he believes that restraints and taping of the mask could be done in following the mandated therapy. This common practice of adjusting therapies for the patient’s comfort and well-being remains invisible, unless it is not used and the patient’s condition deteriorates as a result. In the following observation in a recovery room, the nurse makes a similarly judicious withholding of restraints, and uses touch and comfort measures instead:
Nurse: I was taking care of an elderly woman in her late 80s. She had a femoral popliteal bypass and she was intubated. We needed to restrain her because she was very active, and there was a possibility of extubation. We restrained her and we then extubated her. She remained restrained in the bed for a little while, but she was clearly very uncomfortable. I gave her pain medicine, which helped for a little while, but she really seemed like she wanted to be in a fetal position, and restraints disallow that. I said, "I’m just going to take the restraints off and see what happens" (whispers this last line). So I took them off and she tried to get out of bed, so I calmed her and patted her back. I told her she had to stay in bed, and if she stayed in bed I wouldn’t have to put any restraints on her, but she was nonverbal. Even though she probably was capable of speaking, she couldn’t speak postoperatively. I could see that she couldn’t take being restrained. She was petite and not thrashing too badly, so I elected to leave the restraints off, even though it was a little bit difficult for me to manage her with them off. I just felt that freedom of her extremities was more important to her well-being than it was to restrain her. All I needed to do was put her down in the bed every 5 minutes, or she would try to get out of the bed. I didn’t feel that she was in any clinical danger, that she could move about in the bed as she felt she needed to, and I thought that a lack of movement would be to her detriment. She clearly wanted to be in a fetal position. I was not going to restrain her hands in that sidelying position, and because she was dysphoric and confused, it was making her worse to be restrained. I very rarely feel it’s necessary to restrain people. Usually kind, gentle words, and caresses, and giving them the understanding that they’re safe and healing seem to work a lot when they are not in danger of actually altering their clinical course by extubating themselves and endangering their lives.2
Interviewer: You seem to put a lot of emphasis on the fact that she wanted to be in a prenatal position. What’s your understanding of this?2Nurse: I’m sure she felt very threatened, and she wanted to be in a safe position. I didn’t want to take that away from her. That was her way of comforting herself. And, she’s like a primate after all, right? (chuckles) In a way, she was acting that way. [Referring to the early stages of waking from anesthesia.] I didn’t want to take away her natural instincts to protect and comfort herself. I know my colleagues were looking at me, saying (whispers), "What is she doing? She took the restraints off, you know."2
It is evident that the nurse is breaking informal rules about using restraints in the recovery room, but this is an ethical stance. She rarely finds it necessary to use physical restraints. Instead, she relies on touch and verbal reassurance. She can do this in the recovery room where the patient-to-nurse ratios are small and the physical space allows for constant patient observation. The nurse astutely refers to the "animal" side of our embodied instincts that the patient uses to guard her very being. The patient is seeking a position of comfort and protection, because she is not yet in command of her usual powers. The nurse observes the patient and allows her to seek safety by drawing up into a guarded fetal position. The nurse’s soothing touch and calming voice provide solace and reassurance, replacing the need for restraints in these 2 common situations.
It is evident in observing nurses in critical care and recovery rooms that the use of voice and touch is central during recovery from anesthesia:
Nurse 1: When the patients come in, I usually touch them and say, "Mr X., your surgery is over. You’re in the recovery room now, things are going well, you’re just waking up. You may be experiencing some very different sensations, but they will go away as you wake up. I’m going to take your blood pressure now, and the doctor is going to give me report." The next question is whether he is having any pain.2Nurse 2: Then you have to go over nonverbal cues. Are they thrashing around? Is their bladder full? Are they uncomfortable? You decide whether you’re going to give them pain medicine first, before you take report, or ask the anesthesiologist whether you should go and get something right away. With kids, you say, "Oh, surgery is over, oh, you’ve been so good, and you’ve been so brave, you did a great job. Do you want your mommy? I’ll get your mommy for you." 2
Comforting a patient includes providing social, emotional, physical, and spiritual support for the patient. While these terms sound soft and tend to get trivialized in a setting focused on highly technical curative techniques, they are life giving and valuable in their own right. Providing comfort measures requires astute judgment and skill, can be life saving in fragile patients, and is always a basic notion of good care. It almost always requires detective work and problem solving.
Observational field note: While the nurse was talking with me, the patient became restless [I don’t think he could hear us]. She tried to determine why he was upset. She asked if he could write and said it was worth a try. She got the paper and pen, but he couldn’t coordinate his hand movements to write legibly. Without finding out specifically what his restlessness is about, she repositions pillows and says, "Let’s get you more comfortable here." He seems to settle down. The nurse doesn’t seem satisfied. She’s still trying to figure out what’s going on. She suctions him intermittently when he coughs, and says she’s trying to get him more comfortable. She pulls him up in bed. She seems to still be trying to get a sense of him and how to get him comfortable. She hasn’t worked with him before, she tells me.2
This active problem solving may seem mundane compared with titrating vasoactive drugs, but without addressing physical comfort, one cannot rule out the need for pain medication, or the beginning of agitation caused by changes in level of consciousness, or even prodromal signs of sepsis.
Infants need to learn to be comforted by human touch and physical comfort measures. The absence of soothing touch causes sensory deprivation when the infant is old enough to tolerate soothing touch. The absence of soothing touch, change in position, swaddling, or a decrease in stimulation can also inappropriately increase the need for pain and sedation medications. This kind of problem solving related to comfort measures for premature infants is demonstrated in the following observational interview:
Nurse: We do try to get sort of a rhythm so that we’re not constantly handling the babies. In other words, every hour (or 2, or 3, depending on the condition of the baby) you do all of the tasks that need to be done and the rest of the time you try to keep your hands off the baby and let the baby rest. We try to coordinate this with the physicians and with respiratory therapy and blood gas draws and with everyone who needs to handle the baby, so that the baby is not being disturbed every 15 minutes. Sometimes with the really sick babies you can’t help it, you have to be constantly handling them, but we try to use our monitors as much as possible.2Interviewer: How was your care of this baby different from a baby that isn’t paralyzed? I’m wondering about comfort procedures, and you’re talking about having a hands off approach with this baby, and I’m wondering about other babies. You don’t think about being hands off with babies, you think of comforting them. It seems to be a very different framework you’re working with.2
Nurse: It depends on the level of illness of the baby. A lot of times we’ll turn babies who have an illness, or who maybe had surgery. We’ll be hands on with them and they find it comforting when they’re crying or making crying faces or whatever. You can pat them and give them a pacifier, put them in a comfortable position, get them flexed and things like that, and those interventions do help. With very fragile babies or small preemies, they appreciate it more if you keep your hands off them; they don’t like the comforting, it agitates them.2
Interviewer: Does that cause problems with the parents?2
Nurse: It can. We do try to explain to them, particularly with the preemies, that there are touch times and non-touch times, and you have to try to explain to them it’s not that the baby doesn’t like them, but that preemies aren’t sufficiently developed neurologically to be able to process the handling and it can cause them a lot of autonomic instability. We watch the monitors and teach the parents to watch the monitors, to know when the baby has reached his or her limit and when it’s time to leave him or her alone.2
The relational ethics of touch for premature infants, infants, young children, adolescents, and adults vary, just as they vary with the patient’s condition, preferences, and needs. Intrusive, boundary-crossing, inappropriate, and unwanted touch must be avoided, but the dangers of inappropriate touch must not prevent comforting touch and human comfort measures.
The relationship between healthcare providers and patients creates a "disclosive" space, where solace, trust, and reassurance can occur. By disclosive space, I mean the social space created by human relationship and interaction that makes it possible to disclose and notice some things and not others. Suspicion and fear create a constricted disclosive space focused by fear and suspicion. Touch and other physical and emotional comforting measures are central to creating safe disclosive spaces. This involves good relational ethics and skillful ethical comportment. Such skillful comportment is evident in the following observational note:
Nurse A. drew up the medication and mixed in the intravenous solution for the infusion pump. She was quite unobtrusive in her work. She eased in quietly, looked at them [the husband and wife] so that if they wanted anything she would recognize it, but did not make distracting conversation. I got the sense she had a deep respect for them both and for their need for privacy. In an unusual way, she helped maintain their privacy and preserved their dignity. She conveyed a different message from most healthcare providers. The way in which most nurses go about their work conveys that this is their room in a very subtle way. I had the distinct impression that Nurse A. felt more as if it was the patient’s room. That difference in understanding changed her way of being in the room. One could see respect, honor, and humility. The only times her way of being changed back to the typical perspective was when she had to do a procedure, which required her direct interaction with them. Then she entered and initiated communication in a very confident and knowledgeable manner. Otherwise, she took her cues for psychosocial intervention from them.2
The nurse-patient relationship sets up the conditions of possibility for patients to disclose their concerns, fears, and discomforts. If the nurse is too hurried or too task-oriented to notice the patient’s and family’s experience, then the level of disclosure on the part of the patient or family will be constrained. Likewise, the nurse’s attunement and engagement with the patient allows the nurse to notice subtle changes. Caregiving relationships may open up possibilities or close them down. But even with the best intentions and ethical comportment, the one being cared for may not be able to respond to care.
Outcomes in caregiving relationships are necessarily interdependent and mutual. Some types of influence are morally unacceptable such as manipulation, coercion, or misuse of professional influence in persuading a patient to accept a treatment. When things go well and the patient or family is able to respond to caring practices, the practitioner cannot attribute the good outcome solely to the efficacy of some technique he or she may have used. The current focus on "prespecified outcomes" and identifying and evaluating nursing outcomes in case management is based on the premise that only technique is involved in healthcare, that one knows the outcomes to expect, and that all things can be fixed. Herein lies the fallacy of thinking that what can’t be counted doesn’t count. The problem is further complicated by institutional constraints to good caregiving. Meeting and responding to the other may clash with the bureaucratic goals of care for the many in the most cost-efficient manner. All of these aspects of rationalizing practices within an organizational setting push comforting practices to the margins, devaluing them and rendering them invisible.
We can make comforting touch and human solace more visible by observing and articulating the skillfulness of comforting measures. Endangered arts of comforting, reassuring, and providing solace in the midst of human distress are too life giving and restorative to be squandered by inattention and lack of visibility. How do we teach them? By noticing and valuing them, acknowledging them, and providing examples of excellent comforting practices. The examples cited in this article are given in the hope that they will be extended and valued by others, bringing the artful practices of comfort, presence, touch, and solace back from their precarious position of invisibility and endangerment.
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This article has been cited by other articles:
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  F. Strzempko Butt and C. Chesla Relational Patterns of Couples Living With Chronic Pelvic Pain From Endometriosis Qual Health Res, May 1, 2007; 17(5): 571 - 585. [Abstract] [PDF]
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