Psychosocial and Spiritual Alterations and Management
Patients are admitted to critical care units because they need physiologic rescue. Life or death depends on restoring physiologic homeostasis through the use of highly technical interventions carried out by a competent critical care team. When a person is seriously ill or injured, however, it is not just the body that suffers. An experience of critical illness impacts the whole person—body, mind, and spirit. While not as readily measured as physical parameters, psychologic and spiritual variables significantly impact outcomes in physically compromised and vulnerable patients. Psychologic and spiritual interventions have the power to engage a patient’s hope, energy, will to survive, and his or her ability to meet life’s challenges.1 This chapter provides a discussion of the psychosocial-spiritual challenges encountered by critically ill patients and offers holistic nursing interventions for helping patients and family members cope effectively and thrive during a stressful experience.
Nursing diagnoses related to psychologic, social, and spiritual health are discussed. Relevant nursing diagnoses include stress overload, risk for post-trauma syndrome, anxiety, compromised individual or family coping, disturbed body image, situational low self-esteem, hopelessness, powerlessness, risk for compromised human dignity, and spiritual distress.2 The chapter also provides an overview of holistic nursing responses to the psychosocial and spiritual needs of critically ill patients. Critical care nurses provide psychosocial-spiritual care by communicating with compassion and understanding, practicing dignity-enhancing care, supporting patient coping, using a family-centered focus, and engaging spiritual resources. In a problem-oriented environment like a critical care unit, nurses should remember that acute events also have the potential to surface patient strengths and trigger a readiness for spiritual well-being and enhanced hope. Finally, providing meaningful person-to-person psychologic and spiritual care also depends, in part, on the nurse’s own psychologic health and spiritual well-being. It is not possible to give what one does not have. A discussion of critical care nurses’ self-care concludes the chapter.
Stress and Psychoneuroimmunology
The term “stress” is often used to indicate a negative experience or internal tension. While living with chronic stress can contribute to numerous health problems over time,3,4,5 an acute stress response is an essential, protective, inherent reaction to a stressor, designed to mobilize the body’s response to threats, actual or perceived, for purposes of survival. Stress is a non-specific response to any demand placed on a person to adapt or change, and can come from physical, emotional, social, spiritual, cultural, chemical, or environmental sources.6,7
The nursing diagnosis “stress overload” refers to excessive amounts and types of demands that require action. The stressors are experienced as a problem and contribute to the development of other problems.8 Stress overload should be differentiated from other stress-related nursing diagnoses discussed in this chapter—anxiety, fear, low self-esteem, hopelessness, powerlessness, spiritual distress, or ineffective coping. Stress overload does not occur because the patient or family members have coping deficits or psychologic disorders. Rather, the stressors of critical illness are so numerous and severe, people become overwhelmed. The appropriate nursing response to patients at risk for stress overload is to reduce the number or types of stressors that patients experience.
To respond appropriately to patients at risk for stress overload, nurses must first become aware of the many stressors faced by critical care patients (Box 6-1). Normal life patterns are disrupted and patients experience alterations in their bodily functions, social roles, job status, and finances. They are in strange, frightening, and restrictive environments. Critically ill patients report distressing bodily reactions, deprivation of control, fear of medical equipment, loss of meaning, and relationship disturbances during and after treatment in a critical care unit.9 They are subjected to painful procedures, abrupt or continual noises, loss of privacy, sleep interruptions, pain, medications, isolation, and minimal contact with loved ones.10,11 Lack of sleep and interrupted sleep-wake cycles depress mood and immune functions.12 Sources of stress overload described in the literature include worry about life events, illness, social factors, low educational level or lack of education, poverty, severe emotional responses, lack of resources, and environmental threats.8
Stress Response
Stress of any type—whether positive or negative, biologic, psychologic, spiritual, or social—elicits the same physical responses.7 Classic stress theorists describe stress as a stimulus, a response, and a transaction.13–16 Selye, in his pioneering work,13 described the body’s responses to a stressor the “general adaptation syndrome” (GAS), characterized by three stages: alarm reaction, resistance, and exhaustion. An alarm reaction is initiated by the hypothalamus, which upon receiving sensory and chemical information regarding the presence of a stressor signals the release of corticotrophin-releasing factor (CRF). The pituitary gland, signaled by CRF, releases stress hormones: cortisol and aldosterone. The sympathetic nervous division of the autonomic nervous system (ANS) releases neurotransmitters and endocrine hormones associated with an acute stress response. Known as the “fight or flight” response, an alarm reaction triggers highly integrated cardiovascular and endocrine changes, evidenced by elevations in blood pressure, respiratory rate, heart rate, systemic vascular resistance, and glucose production, sweating, tremors, and nausea. During the resistance stage, the person’s systems fight back, leading to adaptation and a return of normal functioning. If the stressors continue, exhaustion occurs, a stage in which reserves have been depleted. Reversal of stress exhaustion can be accomplished by restoration of one’s reserves through the use of medications, nutrition, and other stress-reduction measures.
Nuerberger16 first described the process of “shutting down,” a person’s eventual emotional response to a stressor that results from overstimulation of the parasympathetic nervous system. He labeled this survival tactic the general inhibition syndrome (GIS), or the “possum response.” Defense mechanisms such as withdrawal, avoidance, and detachment are typical behaviors associated with this type of response.14,17 Both sympathetic and parasympathetic nervous system responses are innate and protective, but prolonged stimulation or imbalances in either response can be detrimental. Sustained or frequent sympathetic nervous system arousal places added physiologic burdens on a compromised critical care patient. Similarly, an exhausted patient lacks the reserves necessary to recover from the demands of illness or injury.
Psychoneuroimmunology
The idea of complex, multifactorial interactions between persons and their internal and external environments first described by stress theorists has led to an area of multidisciplinary study known as psychoneuroimmunology (PNI). PNI research verifies, measures, and explicates the intricate interactions between a person’s psyche, and his or her neural, endocrine, and immune systems.18,19,20 PNI is based on the understanding that health and well-being are not simply physiologic processes, but rather are expressions of a person’s emotions, personality traits, social connections, health behaviors, social environments, and spiritual life. Instead of thinking of the mind being located in the brain, PNI theory posits that the whole human organism “knows,” has a memory, and reacts to sensory input and interpretations of life in every cell of the body. Psychologic stressors and emotional states, experienced in the mind (consciousness), trigger a series of physiologic reactions. Sensory input and environmental cues are interpreted and appraised in the prefrontal cortex of the brain, association areas, and the hippocampus. The content of the appraisal of the threat generates specific emotional states, which initiate autonomic and endocrine responses and outflow. The autonomic responses also send feedback to the cortex and limbic systems.6
Behavior and emotions profoundly impact the immune system. Negative psychologic states are associated with decreased lymphocyte proliferation, natural killer cell activity, and the number of white blood cells, and change the amount of antibodies in circulation and antibody produced after exposure to a harmful substance.21 The multiple stressors faced by critical care patients become bodily chemistry, impacting their cardiovascular, neurologic, endocrine, and immune systems. An interpretation of words a patient hears, or the anticipation of a procedure can generate a stress response as if it were actually happening. PNI theory posits that actions to promote psychologic and spiritual well-being have healing potential and profoundly impact a person’s immune system.19,22 PNI posits a world view that serves as a foundation for holistic critical care nursing based on interpersonal connection, empathy, and compassion.
Post-Traumatic Stress Reactions
Increasingly, clinicians and researchers have begun to describe the frequency and nature of acute stress reactions, panic attacks, or post-traumatic stress disorder (PTSD) experienced by patients after discharge from critical care units.23,24,25 Even though post-traumatic reactions occur from several weeks to years after an event, critical care nurses should be aware of the possibility of PTSD reactions after critical care for purposes of recognizing and reducing all unnecessary stressors during a patient’s stay, being alert to patients at higher risk for developing PTSD, and by using psychosocial-spiritual interventions to reduce the occurrence of PTSD in the critical care patient population. A patient may survive a critical illness, only to face an even greater challenge on the road to recovery after leaving the critical care unit.
The actual incidence and nature of PTSD symptoms in the critical care population has not yet been fully determined. The problem is serious enough, however, to demand the attention of critical care professionals. Published studies report a wide range, from 5%-63%, of critical care patients experiencing PTSD symptoms of varying degrees.26 Numerous studies indicate that patients with PTSD are at risk for developing other mental health problems and physical illnesses.26,27
Classified often as an anxiety disorder, post-traumatic stress reactions involve a wide range of cardiovascular, neuromuscular, gastrointestinal, cognitive, emotional, mood, and memory responses.25,28 After an exposure to a traumatic event of any sort, people may experience unbidden, intrusive recall of the distressing event often triggered by a noise, sound, sight, smell, event, or memory that produces an acute stress response. Nightmares and delusional memories, during which a trauma is re-experienced, provoke intense psychologic and physiologic distress. People with PTSD can also exhibit numbing responses, including detachment, isolation, restricted affect, and depression. States of hyperactivity lead to sleep disturbances, hypervigilance, nervous, and repetitive behaviors. Cognitively, stress reactions lead to difficulty concentrating, poor executive function, and impaired decision making.
Griffiths and Jones, summarizing 20 years of follow-up with critical care unit survivors, discuss the importance of the quality and types of patients’ memories of their critical care experience.28 Even though most critical care patients have poor factual recall or amnesia related to their stay, they often live with delusional, paranoid, or nonfactual memories or create false substitute interpretations and experiences. Nightmares and delusional recall result in PTSD symptoms for a significant number of patients and can cause problems as they attempt to construct a realistic understanding of their recovery.29
Family members are also at risk for developing post-traumatic stress reactions30–31 related to prolonged periods of uncertainty, anxious waiting, disrupted sleep patterns, financial concerns, witnessing emergency interventions, and confronting fears of loss and death. Koss et al32 report both depression and higher rates of PTSD in family members of patients who die during a critical care admission. Also at higher risk are family members of younger patients and those for whom mechanical ventilation is not withdrawn.
Critical care nurses can engage in health-promotion activities related to preventing post-traumatic stress reactions in patients and family members. Being aware of the possibility for stress overload in critical care settings is the first step. Care providers should then take steps to manage or eliminate as many of those stressors as possible. Often patients are unaware or uncertain of what has happened to them and their bodily function. Nurses should engage in encouraging but realistic discussions of the patient’s experiences, explain events carefully, and talk openly about recovery timelines and the gradual process of regaining strength. Certain populations are at greater risk for developing PTSD. Independent of case mix or illness severity, researchers identify patients of younger age, those with delusional memories, pre-existing mental health problems, and physical restraints without sedation as conditions known to increase risk for PTSD symptoms.25,28 While inconclusive, research into the relationship between PTSD symptoms and the duration and degree of sedation used in critical care highlights the need to consider the impact of all critical care practices on long-term outcomes.33,34 Another study notes that pessimism is a predictor of post-discharge stress reactions.35 Although the process of identifying PTSD risk and symptoms is complex and multidimensional, screening questionnaires have been developed and tested for initially evaluating risk for PTSD soon after discharge.36
Patient and family members usually recall and interpret the events, decisions, and time sequences involved in a critical care stay differently. Keeping a diary with photographs taken during a patient’s stay in the critical care unit can help patients and family members reach a degree of shared common ownership of the experience. Journal review helps patients understand what happened so they can better come to terms with their illness and their recovery process.37,38 In learning to live with the memories of critical care, patients benefit when they can construct a meaningful story.39 The interventions described in this chapter not only support patients while they are in the unit, they are also designed to support patients’ well-being over time, preparing them for the challenges of rehabilitation and recovery.
Anxiety
Anxiety is a normal and common subjective human response to a perceived or actual threat, which can range from a vague, generalized feeling of discomfort to a state of panic and loss of control. Feelings of anxiety are common in critically ill patients but are often undetected by care providers.40 In a study of 171 patients with high risk for dying in critical care units, 58% reported feeling anxiety of a moderate level of intensity.41 Anxiety and agitation in critical care patients can complicate patient recovery due to unplanned extubations,42 shortness of breath episodes, and behavioral changes.
The physiologic effects of anxiety can produce negative effects in critically ill patients by activating the sympathetic nervous system and hypothalamic-pituitary-adrenal axis. Anxiety elicits changes in the neurohumoral release patterns involving the neurotransmitters in the brain that regulate mood—including acetylcholine, norepinephrine, dopamine, and serotonin and gamma-aminobutyric acid (GABA)—and their corresponding receptors. The neurotransmitters’ complex and elusive integration of these responses within the central nervous system relies on communication among the cerebral cortex, limbic system, thalamus, hypothalamus, pituitary gland, and the reticular activating system. The cortex is involved with cognition, attention, and alertness, whereas emotional responses to stress are located in the limbic system. Corticotropin-releasing factor (CRF) controls the endocrine response and the norepinephrine pathway that is active in regulating the sympathetic branch of the ANS. A positive feedback loop between the CRF and the ANS occurs when increased activation in one system influences the other system. It is also proposed that large amounts of circulating CRF can accelerate behavioral responses (i.e., anxiety and hypersensitivity) to stressful stimuli.17 As anxiety levels increase, a patient experiences the physiologic effects of sympathetic nervous system stimulation with feelings of excitement and heightened awareness, followed by a diminishment of his or her perceptual field, problem-solving abilities, and coping skills. Panic attacks, a manifestation of severe anxiety not uncommon in critical care patients, can produce an acute stress response with tachycardia, hyperventilation, and dyspnea. Pharmacologic interventions for acute anxiety include the use of benzodiazepines, antihistamines, noradrenergic agents, antidepressants, and anxiolytics.17
The stressful experiences of having an acute or chronic illness, facing a real or anticipated loss, being admitted or discharged from a critical care unit, or requiring mechanical ventilation can trigger high degrees of patient anxiety.43,44,45 Research also suggests that women, patients with less social support, and those with longer critical care length of stay are at higher risk for developing anxiety upon transfer out of the unit to a less intense level of care.45,46 Whether the causes of anxiety are biochemical, genetic, emotional, or driven by the threats inherent in the situation, the critical care nurse should consider all contributing factors if interventions are to be effective.
Although rates of moderate to high anxiety exist in critical care patients, leading to higher complication rates,47 valid and reliable methods to assess anxiety have not been put into practice. Critical care nurses most often rely on behavioral indicators such as agitation and restlessness and physiologic parameters such as increased heart rate and blood pressure.48 Behavioral or vital sign changes do not provide consistently reliable indicators of anxiety and may lead to underestimation of the extent of anxiety in critical care patients.46 The literature on anxiety in critical care patients cites over 50 clinical indicators, many of which are nonspecific or can be associated with multiple causes.48 Using valid scales for evaluating patients’ self-perceived anxiety levels can be helpful in determining the level and extent of anxiety.40,47,48 See also Appendix A, Nursing Management Plan: Anxiety.
Anxiety and Pain
Of particular importance in the critical care setting is the cyclic relationship between levels of anxiety and perceptions and tolerance of pain. Pain triggers anxiety, and increased anxiety intensifies pain experiences. This reciprocal relationship varies, depending on whether pain is produced by disease processes or invasive procedures, is acute or chronic in nature, or if the pain is anticipated. In critical care, pain experiences arise from many sources, including injured tissues, immobility, pre-existing and chronic pain conditions, intubation, diagnostic or treatment procedures, bright lights, excessive noise, and interrupted sleep. When pain or a discomfort such as nausea is severe enough, patients try to conserve energy and focus inwardly to gain control of their pain and anxiety. They may startle easily, become irritable, display anger, be vigilant and wary of caregivers, or may be perceived as demanding. An overwhelmed patient often withdraws from interpersonal contact.17,49 In situations of pain-induced anxiety, the nurse must identify the source of the pain, validate observations with the patient, and initiate pain-management strategies. Medications such as theophylline, anticholinergics, dopamine, levodopa, salicylates, and steroids can also contribute to feelings of anxiety49,50 (see Chapter 9).
Alterations in Self-Concept
The stressors imposed by serious illness, trauma, and surgical procedures can cause disturbances in the self-concept. Self-concept can be defined as the values, beliefs, and ideas that form a person’s self-knowledge and influence relationships with others. One’s self-concept is unique to the individual and is developed through perceptions of his or her own characteristics and abilities, goals, and ideals, interactions with others and the environment, and how those interactions are valued. One’s self-concept also includes body image, self-esteem, and self-identity.17,51
People must make adjustments to their self-concept or role limitations when life circumstances necessitate change. Patients admitted to critical care settings may experience self-concept challenges, perceiving themselves to be viewed by others as a problem, as only their disease, or as a patient instead of as a person.51 Patients in critical care units usually do not have time to adjust to their altered health status. They may exhibit early signs of a response to loss or disability, including shock, numbness, and avoidance of reality and they may be unable to clearly understand the implications of the situation.17,52 Self-concept constructs of particular relevance for critical care patients include body image, self-esteem, and identity disturbance.
Body Image
One’s body is central to self-concept. Body image is the mental picture an individual has of his or her body and its physical functioning at a given time. Body image includes attitudes and feelings about one’s appearance, body build, health, performance, ability, and gender. A person’s body image develops over time, influenced by contact with people and the environment, emotional experiences, and fantasies. Body image is dynamic and changes based on present and past perceptions and experiences.17,53
When ill, inevitably a person knows that experience as a body. In their classic description of the impact of stress and coping on health and illness, Benner and Wrubel54 note that a person does not just have a body; rather he or she is a body. The experiences of being ill are “embodied” and are stored in bodily memory. Often bodily sensations in a state of illness do not make sense to the patient, which creates a cascade of stress responses.9 Patients in critical care units are subjected to prolonged periods of lying in bed, position disorientation, sensory deprivation, muscle atrophy, changed metabolic patterns, mechanical ventilation, pain, profound weakness,28 nutritional alterations, and medication-induced physical symptoms. Disturbances in body image in critical care arise when the person fails to perceive or adapt to the changes that are imposed by the situation. In some instances, the person may feel betrayed by his or her body, which no longer seems normal. Body image issues, of course, often emerge and resolve over time, but critical care nurses begin the process of helping the patient live with a change in bodily appearance or function. A more keen awareness of the embodied nature of a patient’s experiences will help nurses attune to the patient’s bodily perceptions of all nursing activities. See Appendix A, Nursing Management Plan: Disturbed Body Image.
Self-Esteem
Self-esteem refers to how well one’s behavior correlates with a sense of the ideal self and is most closely linked to one’s sense of self-worth.17 Maslow, one early theorist of human flourishing, identified self-esteem and actualization as an important component in his hierarchy of human needs.55 Having high self-esteem helps a person deal with maturational and situational life crises more easily.
Self-esteem has been studied in a variety of contexts. Because nurses interact with patients so intimately and frequently, it is important that nurses develop a deeper appreciation of the impact of self-esteem on a patient’s energy, recovery, and sense of self-efficacy. Illness robs a person of perspective, often leading to low self-esteem and feelings of powerlessness, helplessness, and depression.56 Low self-esteem impairs one’s ability to adapt. A patient may refuse to participate in self-care, exhibit self-destructive behavior, or become too compliant—asking no questions and permitting others to make all decisions.52,56 A comprehensive approach to recovery includes the provision of ongoing supportive measures designed to help patients maintain self-esteem and a healthy body image. See Appendix A, Nursing Management Plan: Situational Low Self-Esteem.
Identity Disturbance
A personal identity disturbance, as a type of altered self-concept, is defined as an inability of a person to differentiate the self as a unique and separate human being from others within a social environment. The sense of depersonalization that accompanies identity disturbance engenders a high level of anxiety. Personal identity disturbance can result from the effects of psychoactive medications, biochemical imbalances in the brain, and organic brain disorders, dementia, traumatic brain injury, amnesia, or delirium (see Chapter 10). A careful nursing assessment, including the use of psychiatric or neurologic consultation, is essential in cases of identity disturbance. Disorientation and confusion, common in patients in critical care settings, are influenced by several factors, including the severity of the physical problem, chemical imbalances, sensory overload or deprivation, and previous illness or health care experiences.
Risk for Compromised Human Dignity
A sense of the dignity of the person underlies considerations of self-concept, body image, and self-esteem. The underlying purpose of all interactions with patients and family members is to bring them to restored health. When people are treated with dignity and respect, they are put in the best position to recover their health and well-being.57
Lazare’s58 insightful description of the shame and humiliation patients experience in medical encounters has provoked an analysis of health care culture. Moral philosophers point to the “rules of cultural systems” as a source for the unintended but distressing experiences of shame, embarrassment, and humiliation experienced by patients and providers when giving and receiving medical care. The rules of cultural systems are notably present in critical care environments: objectification of the person (for more precise physiologic management), disempowerment, distancing the self from the experience of others, indifference, and dissociation. The authority of the medical model supersedes patient experiences, interpretations, and meanings.59 The rules of cultural systems determine, in part, the behaviors of the people within a culture. Although health care providers do not intend to humiliate patients, they become accustomed to the cultural attitudes and circumstances that diminish patients’ dignity on a daily basis.
A sense of dignity includes a person’s positive self-regard, an ability to invest in and gain strength from one’s own meaning in life, feeling valued by others, and how one is treated by caregivers. Chochinov’s60 model for dignity-conserving care identifies sources of threats to dignity inherent in health care contexts, including the level of a person’s independence and his or her symptom distress. Patients in most acute care settings, especially critical care, must by necessity give up those things that give them a sense of self: clothing, daily habits, and privacy. Their bodies are frequently exposed to people who inspect them for their pathology and irregularities. Often patients cannot communicate their preferences, or give permission for assessments, tests, or interventions. Family members and friends have restricted access to patients due to environmental constraints. Stripped of everything that communicates personal identity, patients are known as their pathologies instead of as a person with a history and hopes for a future. When caregivers become more aware of their own feelings and humanity in an exchange, they are less often to unintentionally minimize patients’ emotions and experiences.59
Spiritual Challenges in Critical Care
Many of the psychosocial issues already discussed—stress, anxiety, self-concept, body image, self-esteem, coping, dignity, and relationships with others—are rooted in the spiritual dimension of life, the seat of a person’s deepest meanings and ground of being. One’s spiritual dimension encompasses those elements of life that provide meaning, purpose, hope, and connectedness to others and a higher power.56,61,62 Providing spiritual care is essential for patient recovery in critical care units.
Spiritual Distress
Spiritual distress has been defined as a disruption in the life principle that pervades a person’s entire being and that integrates and transcends one’s biologic and psychosocial nature.56 Threats of physiologic or psychologic illness, prolonged pain, and suffering can challenge a person’s spirituality. Separation from one’s meaningful religious or spiritual practices and rituals, coupled with intense suffering, can induce spiritual distress for patients and their families. Patients experiencing spiritual distress may question the meaning of suffering and death in relation to their personal belief system. They may wonder why the illness or injury has happened to them or may fear that what they have believed in has failed them in the time of greatest need. Some individuals in spiritual despair may question their existence, verbalize their wish to die, or display anger toward religious traditions. Unresolved spiritual distress is interpreted in the body as a stressor. Prolonged spiritual distress may lead to a sense of hopelessness, unwillingness to seek further treatment, or consent to therapeutic interventions or regimens.56
Hope and Hopelessness
Hope is a subjective, dynamic internal process essential to life. Considered to be a spiritual process, hope is an energy that arises out of a sense of being meaningfully connected to one’s self, others, and powers greater than the self. With hope, a person is able to transition from a state of vulnerability to a point of being able to live as fully as possible.63 The need for hope is stimulated by a demand to adapt or change in unexpected situations, as is the case for people who are critical ill. The desire to maintain hope underlies many coping mechanisms. When people have hope and belief in their goals, they are empowered to engage in their own recovery with a sense of internal peace and freedom. While hope has a future orientation, it also has a present orientation that impacts people in the here and now.64 We have come to understand, through observations of people in extreme circumstances, that an element of hope must be maintained for survival65 and is an essential component in the successful treatment of illness.66
By contrast, hopelessness is a subjective state in which an individual sees extremely limited or no alternatives and is unable to mobilize energy on his or her own behalf.49,56 Feelings of hopelessness can greatly hinder recovery. Conditions that increase a person’s risk for feeling hopeless include a loss of dignity, long-term stress, loss of self-esteem, spiritual distress, and isolation, all of which can be present in a critical care experience. Patients who feel hopeless may be less involved in their recovery, may withdraw from the support of others, and lack the energy and initiative to engage in increasing degrees of self-care.56
Loss of Control and Powerlessness
Rotter’s early research67 on human behavior and perception of control has been helpful in explaining the wide range of responses people have in situations in which they must give up control. Rotter suggests that a person’s locus of control is internally or externally focused. Individuals who have an internal locus of control perceive themselves to be responsible for the outcome of events. Individuals with an external locus of control believe that their actions will have no effect on the outcome of a situation. Furthermore, as with any highly individualized concept, people vary in the amount of control they prefer.
Patients who have a pervasive sense that they can do nothing to change or control their circumstances are at risk for feeling powerless.52,56 Critically ill people can experience powerlessness due to the constraints of their health and the care environment, a loss of meaningful interpersonal interactions with their usual support system, inability to maintain cultural or religious beliefs and practices, or by adopting a helpless coping style. The degree of powerlessness a person experiences depends on his or her perceived sense of control, the type of loss that was experienced, and the availability of social support. Powerlessness can be manifested by a refusal to participate in decision making, disengagement from plan of care, expressions of self-doubt, or a seeming lack of interest in recovery. Frustration, anger, and resentment over being dependent on others often occur and are exhibited in verbal expressions regarding dissatisfaction with care.56 Poor interactions with health care providers who are perceived as imposing restrictions can make the situation worse. Patients may react aggressively, may try bargaining, or may refuse to comply with diagnostic and treatment regimens. Patients may lose sight of those areas of life over which they still maintain some influence because so much control has been taken from them. See Appendix A, Nursing Management Plan: Powerlessness.
Coping with Stress and Illness
Coping mechanisms are intentional processes used to adjust, adapt, and successfully meet life stressors. Each patient’s response to stress is unique and depends on a variety of environmental factors and individual differences, including cognitive variables, one’s place in the life cycle, degree of social support, and the person’s perception of the nature of the stressor or loss.17
If a patient is coping effectively, he or she appears relatively comfortable with self and others, is able to form a valid appraisal of stressors, makes decisions consistent with his or her own preferences and values, and has access to needed resources. Effective coping mechanisms help a person maintain a perception of an acceptable degree of control, empower him or her to take necessary actions, share concerns, use healthy denial, and manage troublesome life challenges and uncertainties (see Chapter 11). Most people have a repertoire of coping mechanisms to manage stressful situations and life challenges. Coping mechanisms are learned and practiced over a lifetime and are based on the person’s sense of the effectiveness of any given strategy for adapting to the stressor.53
A person’s coping mechanisms may or may not be effective, depending on the nature and seriousness of the challenge being faced, his or her prior experience with a similar situation, or the extent to which the coping mechanism can be used in given situation. For example, a person may ordinarily cope with a distressing situation by careful problem analysis, information gathering, talking things over, and getting some refreshing sleep. That person will likely have a sense of ineffective coping when facing the lack of control characteristic of acute illness and critical care environments: inability to speak or process information, sleep interruptions, diminished access to resources, or limited time to make careful deliberations. Common effective coping responses can be problem focused, cognitively focused, or emotionally focused. Coping methods include physical exercise, meditation, prayer, healthful foods, social support, positive self-talk, reframing, time management, counseling, new skill-building, and the use of spiritual and religious rituals.17,53
Use of Psychologic Defense Mechanisms
The overuse of psychologic defense mechanisms may give evidence of ineffective patient or family coping. Defense mechanisms are automatic self-protective measures developed in response to an internal or external stressor and may be evident when patients or family members feel out of control and unable to cope.64 Unrelenting anger, excessive protectiveness, distrust of others, extreme dependence or regression, psychologic withdrawal, denial, or apathy concerning treatment goals may suggest that the stressors of the critical care experience have outstripped a person’s coping abilities. Use of maladaptive measures may temporarily minimize anxiety but does not effectively or permanently resolve the conflict. Two common defense mechanisms especially evident in critical care settings include regression and denial.
Regression
Regression is an unconscious defense mechanism characterized by a retreat, in the face of stress, to behaviors characteristic of an earlier developmental level.17 Regression allows a patient to give up his or her usual role, autonomy, and privacy to become the passive recipient of medical and nursing care. Admittedly, patients in critical care settings are expected to relinquish control and rely on others for even the most basic needs. To resist the care that others provide can jeopardize a patient’s outcome. On the other hand, favorable patient outcomes and a speedy recovery can be threatened when patients regress to the point of relinquishing all control and responsibility for themselves to others and become excessively dependent on others. Behaviors such as whining, clinging to staff, needing the nurse constantly at the bedside, and giving evidence of an inability to self-modulate feelings of anxiety or fear can interfere with patient recovery and negatively affect nurse-patient relationships.
Denial
Denial is defined as the “conscious and unconscious attempts to disavow knowledge or the meaning of an event to reduce anxiety and fear.”2 Critically ill patients or their family members may use denial as a defense mechanism to protect against and manage an overwhelming sense of threat brought on by illness, injury, or impending death. As Weisman69 notes in his classic work denial has both protective and potentially detrimental functions.
Witnessing or responding therapeutically to problematic behavior can be challenging and uncomfortable, especially when the behavior seems to be directed at the caregiver. Critical care nurses should carefully evaluate their own response to what seems to be maladaptive behavior. Patients and family members are usually doing the best they can, under very stressful circumstances, and rely on the insight and understanding of caregivers who appreciate the complexities of stress, coping styles, and use of defensive mechanisms. A patient’s stay in the critical care unit is only one phase in an often long journey to recovery from a serious health threat. Patients and family members need time to work through their experiences and often do so more effectively when they are given the support and encouragement they need during the acutely stressful events of being in a critical care unit. See Appendix A, Nursing Management Plan: Compromised Family Coping.
Holistic Psychosocial-Spiritual Care
In addition to having sophisticated knowledge of anatomy and physiology, the pathophysiology of disease processes, and appropriate nursing interventions, the holistic critical care nurse also needs the knowledge, wisdom, and skills to interpret the internal human responses to experiences of serious illness or injury. Attention to the whole patient is the ultimate goal of nursing care, and is vitally important for critical care patients, families, and nurses. Nightingale believed that it was “unthinkable to consider sick humans as mere bodies who could be treated in isolation from their minds and spirits.”70 Essential skills that underlie nursing interventions for psychosocial-spiritual care include using communication patterns based on compassion and care, practicing dignity-enhancing care, supporting patient coping, using a family-centered focus, and engaging spiritual resources.
Communicate with Compassion and Care
Caring, compassionate verbal and nonverbal communication patterns give substance to nursing activities that promote expert psychosocial-spiritual care interventions. Nelson et al71 describe the top challenges to providing care in the critical areas, especially for the very seriously ill. None of the top challenges had to do with technical issues of medical management. Instead, the top challenges include inadequate patterns of communication between the critical care team and family members, insufficient staff knowledge of effective communication, unrealistic family and provider expectations, family disagreements, lack of advance directives, voiceless patients, and suboptimal space for having meaningful conversations. Patients and family members rank their needs for communication with health care providers as one of the most important aspects of feeling cared for in the critical care setting,72 especially in nonspeaking patients.73,74 Interviews with patients after critical care revealed that they believed that a nurse’s caring attitude led to more positive memories of their experience. Patients also reported less stress when they perceived nurses to be caring, warm, and competent, and when they communicated respect.75 Many patients interpret a nurse’s expressions of empathy and physical contact as evidence of caring and support.76
Many times sharing concerns with a caring and understanding listener can relieve emotional or spiritual distress. Patients are consoled knowing that they are not alone and when they sense that someone knows and cares about their feelings and experiences. Although the patient may share concerns with family members, she or he may be reluctant to upset loved ones and find that talking to a nurse seems more appropriate and emotionally safer. A patient who copes by talking to others will benefit from a nurse who recognizes when the patient needs to talk and who knows how to listen.57,77
Nurses should not avoid difficult conversations. Many patients need to talk about their fears and prefer conversations that balance their needs for honesty with their need to maintain hope.76,78 It is also important to remember cultural differences in communicating with patients and family members. Many people in Western and American culture expect and value honesty and truth-telling in difficult situations. Patients and family members from other cultures may have taboos surrounding what should be discussed regarding the diagnosis and prognosis in serious illness.79,80 Careful medical and nursing assessments, use of family and team conferences to foster communication, and enlisting the assistance of a spiritual counselor lead to more fruitful, understanding conversations in crisis and decision-making situations. Patients and family members in critical care areas need careful nurse-patient communication strategies (Box 6-2).
Trust
Effective verbal and nonverbal communication is essential for the development of trust in a nurse-patient relationship.57 Trust manifests itself in critical care patients’ belief that the people they depend on will get them through the illness and will be able to manage any untoward event that might occur. A patient needs to trust the nurse’s competence in the physical and technical aspects of care and rely on what the nurse says. Patients are keen observers of their caregivers and read them well. Trust and hope are easily lessened when inappropriate information is given or nurses do not follow through on what they say. See also Appendix A, Nursing Management Plan: Impaired Verbal Communication.
Practice Dignity-Enhancing Care
“The capacity to give one’s attention to a sufferer is a very rare and difficult thing; it is almost a miracle; it is a miracle.”81 The practice of dignity-enhancing care is anchored in authentic human presence, the giving of one’s whole attention and being to another person in a given moment. When authentically present, the nurse is able to go beyond relying only on scientific information and attunes him- or herself to patient needs, experiences, and emotions in a way that facilitates the patient’s healing.82
Dignity-enhancing perspectives include the need a person has to maintain a continuity of the self, one’s roles and legacy, and a sense of pride, hopefulness, control, acceptance, and resiliency. Dignity-enhancing care has four components: attitude, behaviors, compassion, and dialogue.84 Caregivers’ first step in providing dignity-conserving care involves reflecting on the attitudes and assumptions they hold about other people and their situations. The nurse’s attitudes, worldviews, and beliefs about a patient or family member influence his or her openness and ability to develop a trusting relationship.
Compassion refers to the awareness of another person’s suffering, coupled with a sincere intention to alleviate the suffering. In compassion, caregivers are able to identify with another person and recognize a shared humanity. Showing compassion can be quite simple, in acts of consideration, kindness, or a simple touch. Critical care nurses frequently touch people in the completion of procedures and caregiving activities. Keeping in mind individual and cultural differences, nurses should include nonprocedural touch in their care. The use of touch intended to communicate care and comfort can be an important part of patient healing and interpersonal connection. Compassion is also evidenced in dialogue, the fourth element of dignity conserving care. At the most basic level, patients and family members need timely updates, explanations, repetition of unfamiliar information, and thorough information sharing. At a deeper level, patients need to feel that they are heard by their caregivers and know that their personhood is valued and respected.84
Support Patient Coping
Helping Patients Maintain Control
Research suggests that one of the most effective ways to decrease the stress of being in a critical environment is give patients as much control over their care and the environment as possible.75 Allow patients to make decisions as they are able, such as how and when to administer personal hygiene, diet preferences, and the timing of nursing interventions. Inform patients and family members about daily activities, tests, or therapies, their purpose, and anticipated effects. Critical care patients are often unable to see or turn around to witness what is going on in their environments. During treatments and procedures, provide the patient with explanations, brief discussions on what to expect, the anticipated time of a procedure, and descriptions of what is happening during an intervention. The patient for whom control is important should be helped to maintain control in as many areas of his or her life as possible. On the other hand, a patient must be given the opportunity to not exercise control if having too many choices provokes even greater stress.
Support Patient Preferred Complementary Therapies
Patients and families enter health care settings with well-established practices and beliefs about managing stress, maintaining wellness, balance, and harmony in their lives, and knowing what methods best facilitate their bodies’ own healing responses. Integrative health care practices involve a blending of allopathic medical health care methods with patient-identified complementary therapies.86
The type of complementary or integrative therapies used depends on a patient’s preferences, coping style, physical capabilities, and personality type. Music therapy, relaxation, guided imagery, therapeutic massage, visualization, prayer, biofeedback, and mindfulness meditation are potentially useful for critical ill patients.21,87 Significant decreases in anxiety and symptom distress have been attributed to tactile touch. Although more research is needed to support the value of complementary therapies on selected outcomes in critically ill hospitalized patients, early studies support their potential as therapeutic nursing interventions (see Chapter 1).
Creating Healing Environments
People are continuous with their environments. Alterations in the physical environment of critical care units can provide a sense of calm, enhance patient coping, and facilitate healing.88 Nurses can make changes in care environments to give patients a greater sense of comfort and familiarity while they are in the unit.
Visiting Policies
While practices vary among critical care units, a more relaxed visitation policy humanizes the environment and facilitates healing. The American Association of Critical-Care Nurses’ AACN Practice Alert89 recommends giving unrestricted access of hospitalized patients to a chosen support person. Giving family members access to their loved ones enhances patient and family satisfaction and improves safety of care. Family members have insight into the patient’s behaviors and preferences, especially with patients who are unable to communicate. Interactions with family members reduces patient anxiety and enhances a sense of control.90 Including patients and family members in critical care interdisciplinary rounds has been shown to improve perceptions of accessibility and communication.91
Physical Environment
Critical care areas are bright, loud, and busy. Close patient doors to adjacent areas, use sound dampening panels, turn off unnecessary noisy equipment, and decrease noise at workstations. Nurse call interruptions can be minimized with the use of smart phones. Music can be used to produce therapeutic sound in critical care areas. Control lighting for individual patient preference, allow for natural sunlight if possible, and position patients so that they can see out of windows.88 Within the limits of unit policy, familiarize patient rooms by displaying photographs, cards, drawings, and favored items. Sleep deprivation is a serious concern in critical care environments. To prevent light exposures that awaken patients, nurses should group care activities to limit nighttime interruptions and collaborate with lab personnel to decrease sleep interruptions.75,92
Provide Family-Centered Care
Family-centered care, endorsed by the AACN as a practice standard for critical care, formalizes the patient and family as the unit of care. Family-centered care is based on the belief that patients and families should participate in decisions together and that patients need their families for love, understanding, and support while coping with critical illness.93 The nurse’s observable support of family members at the bedside gives the patient comfort.
The elements essential to family-centered care include respect, collaboration, and support. Research had demonstrated that family members of critical care patients want information, reassurance, and proximity to their loved ones. They also want accurate information, communicated in an understandable manner, and they need room for hope.78 A majority of family members who helped in acts of caregiving had a more positive outlook.
Family members, themselves in a time of crisis, are particularly sensitive to a nurse’s words and actions, making it essential that the nurse convey understanding and acceptance. Although the critical care nurse rarely has the time or opportunity to perform a full family assessment or give ongoing support to all family members, he or she can observe the quality of the patient-family interaction and formulate interventions that will aid the family in supporting the patient.84 The patient determines who counts as “family.” Regard non-biologic or non-legal partners as full members of the patient’s family or support system if that is the nature of the patient’s relationships. The critical care nurse provides interventions aimed at supporting family members throughout the patient’s stay in the unit (Box 6-3).
Box 6-3
NIC
Family Support
Assure family that best care possible is being given to patient
Appraise family’s emotional reaction to patient’s condition
Determine the psychological burden of prognosis for family
Listen to family concerns, feelings, and questions
Facilitate communication of concerns/feelings between patient and family or between family members
Promote trusting relationship with family
Accept the family’s values in a nonjudgmental manner
Answer all questions of family members or assist them to get answers
Orient family to the health care setting, such as hospital unit or clinic
Provide assistance in meeting basic needs for family, such as shelter, food, and clothing
Identify nature of spiritual support for family
Identify congruence between patient, family, and health professional expectations
Reduce discrepancies in patient, family, and health professional expectations through use of communication skills
Assist family members in identifying and resolving a conflict in values
Respect and support adaptive coping mechanisms used by family
Provide feedback for family regarding their coping
Counsel family members on additional effective coping skills for their own use
Provide spiritual resources for family, as appropriate
Provide the family with information about the patient’s progress frequently, according to the patient preference
Teach the medical and nursing plans of care to family
Provide necessary knowledge of options to family that will assist them to make decisions about patient care
Include family members with patient in decision making about care, when appropriate
Encourage family decision making in planning long-term patient care affecting family structure and finances
Acknowledge understanding of family decision about postdischarge care
Assist family to acquire necessary knowledge, skills, and equipment to sustain their decision about patient care
Advocate for family, as appropriate
Foster family assertiveness in information seeking, as appropriate
Provide opportunities for visitation by extended family members, as appropriate
Introduce family to other families undergoing similar experiences, as appropriate
Give care to patient in lieu of family to relieve them and/or when family is unable to give care
Arrange for ongoing respite care, when indicated and desired
Provide opportunities for peer group support
Refer for family therapy, as appropriate
Tell family members how to reach the nurse
Assist family members through the death and grief processes, as appropriate
From Bulechek GM, et al, eds. Nursing Interventions Classification (NIC). 6th ed. St. Louis: Mosby; 2013.
Engage Spiritual Resources
Transformative spiritual care strategies are particularly helpful in times of crisis and uncertainty. When faced with significant life challenges, people need resources to transcend their circumstances and know that no matter what happens, they will endure. Spiritual resources include faith in a higher power, support communities, a sense of hope and meaning in life, and religious practices. Patient and family spirituality affects their ability to cope with loss.94
Cutcliffe’s95 qualitative research on critically ill patients’ perspective on hope reveals that hope is perceived as being directly related to help. That is, when patients know there is help, they feel more hopeful. They also described hope as closely interwoven with care. To feel cared for and cared about brings hope to critically ill patients. Hope was related to patients’ sense of their personal future and was used as a coping resource. In each patient description of hope in Cutcliffe’s study, the nurse plays a pivotal, potentially inspirational role. Nursing interventions that engender hope can be quite simple, quiet, and informal. Listening to patients’ concerns, offering support, being present, enhancing dignity, and developing caring, trusting relationships with patients gives hope.96 People hope for different things over the course of an illness. Listen for shifts in what patients hope for and find ways to help them meet their desired goals.60
While distinctions between spiritual and religious concerns are important to highlight,62 many people find spiritual strength in their adherence to a particular religious tradition. They get inspiration to endure, hope, comfort, assurance, and confidence from the texts, rituals, and beliefs of their faith communities. Facilitate patient access to religious rituals, prayer, and scripture reading as hope-sustaining activities and help patients make connections to their spiritual or cultural communities. Collaborate with the hospital’s spiritual care department when you sense that a person has unmet or unaddressed spiritual questions or needs. Often a professional spiritual care provider is the best person to assess spiritual needs and plan helpful interventions. Spiritual and religious leaders can also provide valuable insights when discussing ethical decisions that may have implications for the person’s values and beliefs. Religious, spiritual, or philosophical practices can also directly inform diet, hygiene practices, and rituals surrounding birth, death, and medical interventions.
Patients with Mental Health Co-Morbidities
Alcohol Withdrawal in Critical Care Settings
Nurses in any acute care setting must be alert to the symptoms of withdrawal from chemical substances, including alcohol, which can complicate recovery from the admitting diagnosis. Not infrequently, in emergency admissions to a critical care unit, a full patient history of substance use has not been elicited. Investigators estimate that 1 in 4 patients admitted to general hospitals meet criteria for alcohol dependence.97 Withdrawal progresses to delirium tremens without treatment and can occur from three hours up to 7 days after the last alcohol consumption. Peak withdrawal time is 48-72 hours after last alcohol consumption in a person with alcohol addiction.98
The signs and symptoms of alcohol withdrawal syndrome (AWS) are easily confused with other conditions. Patient with AWS exhibit altered concentration, tremulousness, autonomic hyperarousal, hallucinations, disorientation, psychosis, tachycardia, hypertension, low-grade fever, agitation, diaphoresis, and delirium tremens.99 Critical care nurses can quickly and accurately assess a patient’s risk for AWS by using the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar).100 This 10-item scale assesses for nausea and vomiting, tremors, paroxysmal sweats, anxiety, agitation, tactile, auditory, and visual disturbances, headache, and orientation. Treatment protocols for AWS depend on the severity of the patient’s symptoms. Commonly used medications include chlordiazepoxide and lorazepam for withdrawal symptoms, and ondansetron and promethazine for nausea. Thiamine, folic acid, and multivitamins should be added to intravenous fluids.99 (See also Chapter 34, Alcohol Screening Questionnaire, Box 34-1.)
Caring for Patients After Attempted Suicide
Nurses in critical care settings not infrequently care for patients who have attempted suicide. It is especially important to practice dignity-enhancing care in these situations. Nurses should carefully consider their own attitudes concerning self-destructive behaviors. Patients who have attempted suicide are often stigmatized, and caregivers can resent caring for a person whose critical condition is self-inflicted. A suicide attempt indicates, however, that the patient was experiencing personal and spiritual distress to the point of wanting to end his or her life. A suicidal behavior resides at the extreme, maladaptive end of a continuum of self-protective responses to life’s challenges.17 Usually a person who has attempted suicide is quickly transferred out of the unit for further evaluation and mental health care when they are medically stable. While the patient is in the unit, however, primary nursing interventions include validating the patient’s worth and self-esteem, helping him or her regulate emotional states and behaviors, and mobilizing the patient’s social support, necessary for long-term recovery.17,53
Nurses also care for family members of persons who have attempted suicide. They are often undergoing a significant family crisis and can have feelings of shame, guilt, or anger concerning the suicide attempt. Talk to family members in a private setting, and establish an atmosphere of interested concern for their loved one. Before the patient is discharged from the unit or hospital, gather assessment data from family members, including information about the patient’s medical and psychiatric history, history of previous suicide attempts, presence of a trigger for self-destructive behavior (recent disagreement with someone, or anniversary of a loss), presence of acute stressors, and availability of support systems. Family members should be encouraged to inform health care providers if the patient has stopped taking prescribed psychotropic medications or seeing a mental health provider and begin to make a plan for immediate follow-up care after discharge from the unit.101
Nurse Self-Care
Critical care nurses do amazing, life-giving work. In the words of poet John O’Donohue, nurses “stand like a secret angel between the bleak despair of illness and the unquenchable light of spirit that can turn the darkest destiny towards dawn.”102 Critical care nurses possess the knowledge, wisdom, and power to help others in situations of uncertainty and suffering.
Remembering always critical care nurses’ life-giving work, it is also important to recognize the need for consistent, intentional self-care. A nurse cannot give fully engaged, compassionate care to others when he or she feels depleted or does not feel cared for him- or herself. In critical care settings, nurses rarely have time to recover from one emotionally draining situation before they are called upon to respond to another. They often witness prolonged, concentrated suffering on a daily basis, leading to feelings of frustration, anger, guilt, sadness, or anxiety. Frequent, intense, or prolonged exposure to grief and loss places nurses at risk for developing compassion fatigue, a physical, emotional and spiritual exhaustion accompanied by emotional pain. The stressors of caregiving can lead to a decreased capacity to show compassion or empathize with suffering people.103 Nurses, too, are at risk for developing PTSD reactions to the relentless stress and psychologically difficult work of caring for others in extreme situations.104,105
To avoid the extremes of either becoming overly involved in patients’ suffering or detaching from them, nurses can use self-care activities to maintain balance. Nurses should first use self-reflection when they feel overwhelmed, considering the possible reasons for their feelings. There are often multiple causes for feeling overwhelmed: sadness about a particular patient, overwork, lateral hostility at work,106 and disruptions in one’s personal life. Reflection is an important first step because without awareness, it is difficult to identify possible solutions. Talking with friends, a spiritual care provider, or a close colleague can help the nurse recognize his or her own grief and reflect on the meaning of work.
Stress-management techniques help to restore energy and enjoyment in caring for patients. In some instances, nurses choose to work temporarily in less emotionally stressful settings. Nurses who practice self-care are more likely to experience professional and personal growth and find much meaning in their work. Maintain physical health by eating well, exercising, engaging in relaxing activities, laughing, and by getting enough sleep. Promote emotional health by participating in calming activities such as meditation, daily gratitude reflections, deep breathing, walking, or listening to music.107,108 Use self-transcendence (spiritual awareness) activities, such as journal writing, sharing stories, recognizing one’s own positive contributions and unique gifts, and connecting with one’s self.109 Given the ongoing demands of critical care nursing, balance time at work with time for recreation and relaxation. Invest time in those people and activities that nurture the spirit. Learn from the courage exhibited by patients and family members, and with good self-care, find joy and fulfillment in being a critical care nurse.
Summary
• Critical care nurses consider connections between the body, mind, and spirit in providing holistic nursing care to critically ill patients.
• Patients in critical care settings must cope with many stressors. Each patient’s response is unique and depends on a variety of environmental factors and individual differences.
• A person’s perceptions of self and relationships with others, of spiritual values, and of self-competency in social roles play a role in how he or she responds to stress or illness.
• Anxiety is a normal subjective response to a perceived or actual threat to self-integrity, which can range from a vague, generalized feeling of discomfort to a state of panic and loss of control.
• Disturbances in self-concept, body image, and self-esteem often accompany experiences of critical illness or injury.
• Spiritual distress, hopelessness, and powerlessness in critically ill patients can complicate recovery and should be addressed by critical care nurses.
• Each person has a preferred set of coping strategies for meeting life stressors.
• Dignity-enhancing care includes elements of attitude, behaviors, compassion, and dialogue.
• Supportive family members and friends provide a source of strength and hope for patients facing the stressors of a critical illness or injury.
• Spirituality provides patients with transcending practices for accepting what cannot be changed, and for fostering hope and trust in self, others, and the transcendent.
• Critical care nurses should engage in self-care practices for their own wellness and to sustain meaning in their work with critically ill people and their families.
