changes in a patient’ clinical conditions — Perspectives of intensive care nurses

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Paper I

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Availableonlineatwww.sciencedirect.com

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j ou rn a l h o m e p a g e :w w w . e l s e v i e r . c o m / i c c n

ORIGINAL ARTICLE

Foresight and awareness of incipient

changes in a patient’ clinical conditions — Perspectives of intensive care nurses

Monica Kvande

^a,∗

, Charlotte Delmar

^b

, Else Lykkeslet

^c

, Sissel Lisa Storli

^a

aDepartmentofHealthandCareSciences,FacultyofHealthSciences,UniversityofTromsø,TheArctic UniversityofNorway,N-9037Tromsø,Norway

bSectionforNursing,DepartmentofPublicHealth,HealthFacultyAarhusUniversity,DK&Facultyof HealthScience,AalborgUniversity,DK&UniversityCollegeDiakonova,Oslo,Norway

cFacultyofHealthandSocialCare,MoldeUniversityCollege,Molde,Norway

Accepted12June2015

KEYWORDS Hermeneutics— phenomenological;

ICU;

Intensivecarenurse;

Patientconditions;

Sensation;

Sign

Summary

Objectives:Theaimofthisstudywastoexplorethephenomenonofbecomingawareofincipient changesinpatientconditionfromtheperspectivesandexperiencesofintensivecarenurses.

Researchmethodology:Thisstudyinvolvedcloseobservationsofandin-depthinterviewswith 11experiencedintensivecarenurses.Thetextwasanalysedusingahermeneuticphenomeno- logicalmethodthatwasinspiredbyvanManen.

Setting:Thisstudywasundertakenattwodifferenthigh-technologyintensivecareunits(ICUs) inNorwegianuniversityhospitals.

Findings: Nurses formed images of individual patients composed ofsigns (of changes in a patient’scondition)thatweresensory,measurable,andmanifestedasthemoodofthenurse.

Thesignsmay beviewedasseparatefromandopposedtooneanother,buttheyaretightly interwovenandinteractwithoneanother.Caresituationsarepowerfulstimuliforthepatient, anditisofgreatimportancefornursestobecomeawareofsignsinthesesituations.Nurses alsoascribethatfollowingthepatientovertimeisimportantforbecomingawareofsigns.

Conclusion:Anawarenessofincipientchangesinpatientclinicalconditionrequiresunderstand- ingtheever-changingdynamicsofpatientconditionanddialogicimagescomposedofsigns.Care situationsandthefollowingofpatientsthroughshiftsareessentialinenablingnursestodetect thesesigns.

∗Correspondingauthor.Tel.:+4777660659.

E-mailaddresses:Monica.kvande@uit.no(M.Kvande),cd@ph.au.dk(C.Delmar),Else.Lykkeslet@hiMolde.no(E.Lykkeslet), sissel.l.storli@uit.no(S.L.Storli).

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262 M.Kvandeetal.

Implicationsforclinicalpractice

• Adeeperinsightintotheprocessofbecomingawareofincipientchangesinpatientsclinicalconditionfromintensive carenursesperspective.

• Payattentiontoanddevelopworkingroutinesthatenablenursestofollowingpatientsthroughshifts.

• Increasedemphasisneedtobeplacedontheprocessofrecognisingincipientchangesinapatient’sclinicalcondition ineducationsystemandnursingpractice.

Introduction

Intensive care patients have life-threatening conditions andrequireclosemonitoringoftheirvitalfunctions along withsupportfromadvancedequipmentandmedicationsto maintain bodily functions. The clinical scenario involving intensivecarepatientsiscomplex.Suchpatientshaveunsta- blemedicalandsurgicalconditionsthatexhibithighlevels ofambiguity, uncertainty andunpredictability. The condi- tionofanintensivecarepatientcanoscillatebetweengood conditionandever-increasingdeterioration(Klepstad,2010;

Lakanmaaetal.,2012;Rothschildetal.,2005).

In the new millennium, the context of intensive care hasevolvedtowardsaparadigmoflightersedation(Egerod et al., 2013; Strom and Toft, 2014). Despite being more awakeunder thislightersedation, intensivecare patients areoftenunabletoexpressthemselvesverballyduetotheir useofaventilatorandbecausenurseshavefewcommuni- cationtechniques(ortools)thatallowconsciouspatientsto communicatetheirfeelingsandneeds(Guttormsonetal., 2015;Karlssonetal.,2012).Intensivecarenursesworkina highlytechnicalenvironmentandmustbeabletocopewith stressfulwork conditions;moreover,theirwork hasahigh level of unpredictability andrequires theability to accu- ratelydeﬁne andrapidlychange priorities (Benneretal., 2011;Swinny,2010).

AstudybyBringsvoretal.(2014)exploredthesourcesof knowledgethatintensivecarenursesuseintheirdailynurs- ingpracticeanddescribedthevarietyandcomplexityofthe knowledgebaseofintensivecarenurses.Experience-based knowledgeisonesourceofknowledgeandisoftenlinkedto exercisingjudgement,tacitknowledgeandtheclinicalgaze.

RandenandBjørk(2010)foundthatpersonalexperienceand intuition areconsidered by intensive care nurses asmore importantthanresearch-basedknowledgeinassessingseda- tionneeds.Theyalsofound thatformalassessmenttools, suchassedationorweaningprotocolsandobjectivescoring systems are rarely used in the intensive care unit (ICU) inrelation tosedation practice. Additionally,Dykes etal.

(2010)reportedthatcriticalcarenursesidentify,intercept, andcorrectseveralmedicalerrorsthatmayotherwiselead toseriousandpotentiallylethaladverseevents.Theirstudy demonstratestheimportanceofcriticalcarenursesinpro- motingpatientsafety.However,Randenetal.(2013)found that nurses underestimate unpleasant symptoms, such as pain, anxiety and delirium, in mechanically ventilated adult ICU patients.A deeper understanding of unpleasant symptomsandsignsmayaidnursesintheearlyrecognition ofpatientproblemsandinprovidingimprovedcare.

Thedeteriorationofwardpatientsandtheuseofarapid responsesystem (RRS) teamtoimprovepatient outcomes

have been the subjects of several studies (Howell et al., 2012;Jäderlingetal.,2011;Rothschildetal.,2010).Early warningscores(EWSs) areusedtoactivatethe RRSteam, andthecriteriaforsummoningtheteamaretypicallybased onthedeteriorationofthepatient’svitalsigns(Rothschild etal.,2010).Clinicalstaffalsousethe‘‘worriedcriterion’’

(intuition),whichisbasedonclinicaljudgement,toactivate theRRSteam,regardlessofwhetherthepatient’scondition satisﬁesanyof theformalcriteria(Jäderling etal.,2011;

Rothschildetal.,2010).

Awareness of incipient changes in a patient’s condi- tionandtheabilitytoforeseepotentialcomplicationsare viewedasimportantinpreventingcomplicationsandinsafe- guarding the lives of critically illpatients (Benner et al., 2011; Dykes etal.,2010; Hennemanetal.,2012; Swinny, 2010).

However, few studies have examined the actual pro- cessofbecomingawareofincipientchangesinapatient’s condition from the perspective of intensive care nurses.

Therefore, the aim of the present study was to explore the phenomenon of becoming aware of incipient changes inpatientclinicalconditionfromtheperspectivesofexpe- riencedintensivecarenurses.

Methods

Studydesign

This study was qualitative and used the hermeneutic phenomenological approach (van Manen, 2007, 2014).

This approach is considered phenomenological (descriptive)becauseitconsidershowthephenomenoninquestion appears, and this approach is hermeneutic (interpretive) becauseuninterpretedphenomenadonotexist(vanManen, 2007).

Theaimofthisapproachistodescribeandinterpretthe wayinwhichweexperiencetheworldineverydaysituations andrelations(vanManen,2007,2014).Inthepresentstudy, the experiences were the experiences of intensive care nursesofthephenomenonofrecognisingincipientchanges inpatientconditions.Thegeneralapproachinvolvesgather- ingadescriptionofthestructureofthelivedexperiencesof aspeciﬁcphenomenon,wherethestructureoflivedexpe- rienceisunderstoodasadescriptionoftheessence,which refersto‘‘thatwhatmakesathingwhatitis’’(vanManen, 2007).

Inthissearchformeaning,theresearcher’sattitudeof opennessandsensitivitytotheunpredictedandunexpected isimportant(Dahlberg,2006;Dahlbergetal.,2008).Inthe present study,the researcher, an intensive care nurse no

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longerworkingbed-side,practicedopennessbyaskingopen- ended questions, asking follow-up questions and pausing sothatthenursecouldcommunicateher/hisexperiences.

Furthermore,self-reflectionandself-awarenessareimpor- tantattitudesforthephenomenologicalresearcherandare called for in all phases of the researchprocess. Reflexiv- ity can make the researcher sensitive to his or her own roleandcultivateapre-understandingofthephenomenon in the form of experiences, personal beliefs and theories (Dahlberg,2006;Dahlbergetal.,2008).Inthepresentstudy, theresearcherrecordeddailyfieldnotesincludingherown thoughts, reflectionsand emotions.By recording her personal experiences, she became more aware of her own preconceptionsandpotentialprejudices.

Settingandparticipants

This studywaspartof alargerqualitativeinvestigationof theexperiencesofintensivecarenursesofbecomingaware of changes in patient conditions and of how changes are communicatedintheICUteam.Aﬁeldstudywasconducted involvingcloseobservationsofbedsidenursingandin-depth interviewswithnursesaftertheirshifts.

This study was conducted at two ICUs in two Norwe- gian universityhospitals, each with 8—10 activeintensive care beds.OneICU treatedpaediatric andadultintensive carepatientswithmedicalandsurgicalconditionsaswellas trauma(general),andtheothertreatedadultintensivecare patientswithneurosurgicalconditions.Theinclusioncrite- riafornursesinthestudywerehavingadiplomainintensive carenursing(90credits)andaminimumof5yearsofexpe- riencein actual ICU.In addition,thenurses hadtobeon shiftscaringforadultICUpatientswhoweremechanically ventilatedandwith an expectedlength ofstay of several days.The headofeach ICUselectednursesfromtheirICU basedontheinclusioncriteria.Elevennurseswereincluded inthestudy.

Datacollection

Closeobservationenablestheresearcher tocloselyfollow theeveryday experiencesof thesubjectwhileretaining a hermeneutic alertness to situations. A researcher who is closely observing situations is both a participant and an observeratthesametime(Dahlbergetal.,2008;vanManen, 2007).

In-depthinterviewsserve thepurposeof exploringand gathering experiential narrative material in the form of stories,anecdotesandexamplesofexperiences,whichmay serve as a resource for developing a richer and deeper understandingofthephenomenonunderinvestigation(van Manen, 2007). In the present study, the researcher conducted close observations and in-depth interviews of 11 intensive care nurses (4 males and 7 females) during a 10-monthperiodfromDecember2012toSeptember2013.

Seven nurses were fromthe general unit and four nurses werefromtheneurosurgicalunit.Thenursesworkexperi- enceinactualICUrangedfrom7—28years(mean18).The ﬁndingsinthispaperaremainlybasedonthein-depthinterviews,buttheﬁeldnotesrecordedduringtheshiftsformed thebasisfortheinterviews.

Closeobservations

Thenurseswereaccompaniedfor2—3shiftseach.Duringa shift,thenursewasobservedinhis/herwork andinterac- tionswiththeICUpatientforwhomhe/shewasresponsible.

TheresearcherwasanexperiencedICU nursewhopartici- patedbyassistinginsimplenursingcare.Theresearcheralso participatedinformalsettings,suchasin nursingreports, pre-rounds,androunds,aswellasininterdisciplinarymeet- ings. Therewas alsoinformal dialogue with the intensive care nurses.The focus of observation wasonthe partici- pantnurses’verbalorphysicalinteractionswithpatientsor regardingpatientswithintheICUenvironment.Fieldobser- vations were written in a notebook during the shift and includedinthedataanalysis.

In-depthinterviews

Attheendofthedaybeforetheshiftchangeandreport,the nurseswereinterviewedregardingthesituations thathad occurredduringtheirshift.Theinterviewssought toelicit theintensivecarenurses’accountsoftheobservedepisodes ofcareandtheirrecallofeventsbyaskingthemtodiscuss extractsfromtheﬁeldnotes.Thenurseswereinterviewed intheICU onetothreetimeseach for 20—70minutesper interview,resultingin atotalof 24interviews. The work- ingdayin theICU isunpredictable, andpatientcondition canquicklydeteriorate.Therefore,aftersomeshifts,itwas notpossibletoconducttheinterviewortheinterviewwas interrupted.All ofthe interviews wereconducted,audio- recorded,andtranscribedverbatimbytheresearchertoaid recallandensureclarityoftranscription.

Tofacilitatethenurses’recallofemotionsandthoughts, theinterviewhadanarrativeformandusedthefollowing openingquestion:‘‘Couldyoutellme...?’’(Dahlbergetal., 2008).Thefollowingquestionsareexamplesofotherques- tionsaskedintheinterview:‘‘Whatdidyousee?’’,‘‘What did you hear?’’, ‘‘Could you tell me what happened?’’,

‘‘Couldyoutellmealittlemore?’’,and‘‘Canyougive an example?’’.In narrative interviewing,the goal is to gen- erate detailed descriptions rather than short answers or generalstatements(Riessman,2008).Detailsareimportant tofacilitateacompleteunderstandingofexperiencesinall theircomplexityandtoinclude‘‘speciﬁcincidentsandtur- ningpoints, notsimplygeneral evaluations’’ (p. 24).It is oftennotnecessarytoaskmanyquestions.Theresearcher refrainedfrominterruptingthenursesduringtheinterview toallowthenursestospeakintheirownwords.Althoughit mayappeartobeahindrance,patienceandsilencecanaid nursesin rememberingevents, enablingthem tocontinue theirstory(vanManen,2007).

Dataanalysis

Analysiswasperformedusingthereﬂectivemethodsofvan Manen(2007),includingthematicandlinguisticreﬂections.

The purposeof phenomenological reflection is toidentify and reflect on the various aspects and meanings of the nurses’ experiences with the phenomenon of recognising earlychangesinapatient’scondition.Thematicreflection refersto the process of recovering meaningful structures

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264 M.Kvandeetal.

thatareembodiedinnurses’experiencesasrepresentedina text.Graspingandformulatingathematicunderstandingisa complexandcreativeprocess,anditisnotarule-boundpro- cessbutratherafreeactof‘‘seeing’’meaning(vanManen, 2007,2014).

First,weconcentratedonthetextasawhole.Thetran- scriptionswererepeatedlyreadtoenabletheresearchersto gainanopenandimmediateimpressionofeachdescription.

Thetextwasthenre-readandline-by-linereadingsofthe transcriptswereemployedforthematicexplorationofexpe- riential descriptions. We carefully read each sentence or sentenceclustertoobtainaninitialunderstandingofwhat wassaidinthenurses’ownwords.Theﬁrstphaseresultedin apreliminaryandopensystematisationoftheinterviewtext thatdisclosedsomethingaboutthenurses’experiencesof becomingawareofearlychangesin apatient’scondition.

The next phaseledto a morefocused interpretation and wascharacterisedbyadialoguewiththetextthatincluded movingbetweentheinterviewtextsthemselvesandthedif- ferentthematicmeaningsthatbegan toemerge. Wethen asked the following questions: ‘‘What does this mean?’’

and ‘‘How is it said?’’. In this phase,emerging meanings thatappearedtobelinkedwereclusteredintoatemporary pattern of meanings, which wasfollowed by a processof reﬂectionwiththeaimofsynthesizingtheclusteredmean- ingunitsintoanewwhole.Inthediscussion,weusedthe phenomenologyofsensationoftheDanishphilosopher,Knud Ejler Løgstrup, the thinking of the Norwegian nurse and philosopher,KariMartinsenandthethinkingofLøgstrupin aclinicalnursingcontexttoreﬂectonthethemeswiththe goalofinterpretingthetextasawholeandarrivingatacom- prehensiveunderstandingoftheawarenessoftheincipient changesinpatients’conditions.

Pre-understandingwaschallengedindiscourseswithone anotherandwith othernursesinclinicalpractice. Wedis- cussed the emerging understanding of the experience of early signs of changes in a patient’s condition and asked critical,reﬂectivequestionssuchas:‘‘Isthisthemeaning orcanthismeansomethingelse?’’.

Ethicalconsiderations

The study was approvedby the Norwegian Social Science Data Services (NSD). Close observation of intensive care nursesinICUsimpliedthatthepatientsbecameindirectly involvedpartieswithnorealright torefuse.The Regional Committee for Medical and Health Research Ethics (REK) granteddispensation tothe project regardinghealth per- sonnel’sconﬁdentialityofpatientswhowerepresentduring theobservationbasedontheﬁrstparagraphsofTheHealth ResearchAct29andAdministrationAct13(REK2012/622- 4).OnthebasisoftherecommendationsmadebytheREK, the patients’ families received written and oral informa- tionontheresearchprojectandtherighttomakerequests on behalf of their relatives. Information was also posted onthewallintheunits’corridor.Topreserveparticipants’

andpatients’completeconﬁdentiality,informationfromthe ﬁeldnotesandinterviewswasanonymised.Allofthepar- ticipantnursesprovidedtheirwritten,voluntary,informed consent.

Duringthe observations, the researcher paid attention tothepatientsandtheirfamiliesandfocusedonpreserving patientconﬁdentialityandpersonalintegrity.

Findings

Anoveralltheme,‘‘Livingimagetakesform’’,wasapparent inalloftheinterviewsandwasdescribedbythefollowing twomainthemes:‘‘interwovenandinteractingsigns’’and

‘‘awarenessofsigns’’.

The essential meaning of the phenomenon of becom- ingawareofincipientchangesinpatientclinicalcondition encompasses the ever-changing dynamics of patient condition and dialogic images that are composed of signs.

Sensorialsignsexistinanintenseinterplaywithsignsthat are measurable and manifest as the mood of the nurse.

An awareness of these signs is obtained by nurses mainly throughcaresituationsandshifts.

Theseexperiencesareilluminatedinthefollowingtext by quotations from the intensive care nurses (ICNs) in this study; these nurses are identiﬁed by numbers (e.g., ICN1—ICN11).

Interwovenandinteractingsigns

Signsthataresensory

The manner in which anurse perceives events is through her/hisnaturalsenses, suchasvision, hearing,smell,and touch,allowing thenursetobecomeawareof smallsigns that may indicate changes in a patient’s condition. The patient’sface,eyes,bodymovements,breath,responseto contactandanxietylevelsaresignstowhichnursesascribe signiﬁcance:

‘‘Ifhe were moreawake today, I would look for more facialmimicry,perhapshewouldhavetriedtoopenhis eyes,perhapstriedtoopenhismouth,buthedoesnot, orwhetherhehadmorepurposefulmovements.Thereis nothing,nomovementagainstthefaceornormalmove- ments.Hehastheselittletwitches...Therearenosigns ofawakening,butthepatientisbreathingandthatisa smallsignthen,butIhadhopedfromthereportthathe would have hadmore gesturesand movedmore ...he doesnot,sowithout anymovement asfarasIcansee, [hiscondition]isnotgood...’’(ICN6)

Movementofthebodycanbemovementthatisnormalor pathological,andtheremaybesomequiveringorpurposeful movementsagainstatrachealtube:

‘‘Heisnotmarkedbyspasms.Hehasanabnormalflex- ionpatternmixedwithnormalflexion,maybesometimes extensionandthatisabadsign,butit’samixtureofdif- ferentmovementsanditisformeagoodsign,becauseit ismovementandthereisnormalflexionpresent.’’(ICN 7)

‘‘Therearesmallmovementsthatseemnormalandade- quate. Fine, smallflexion. Fine,smallmovements that seemveryappropriate.Thereismoremovementofthe body, moretone, moremovement in thefingers, more purposefulmovementandhetriestofightthetracheal tube.’’(ICN5)

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Bodymovementsthatareotherwisenearlyundetectable areoftenimmediatelyvisibletonurses:

‘‘Smallsigns,changesmaybeashoulderthatmoves,a footthatmoves,anarmorﬁnger,ahand...(...)some signs of life (...) There may be a little sign that the patientisawake,perhapswhetherthepatientmoveshis headslightly...’’(ICN3)

Nurses areaware of changes in skin condition, muscle toneandresponsetostimulusandperceivethemassignsof negativeorpositivedevelopmentinthepatient’scondition:

‘‘Ifyouhaveapatientwholooksabitsallowintheskin.

Youseethatheisabitpale,coldperipheral.It’sthatkind ofsignsthatmayindicatethatthereissomethingunder development...Orifthepatientiswarmandﬂushesor hasverylargerosycheeks.’’(ICN5)

‘‘Apatientwhohasbeenveryﬂaccid,butwhostartsto getalittlemorenormalmuscletone...smallmovements thatseemnormalandadequate,anicebitofﬂexion,the patientrespondsadequatelyinrelationtothestimuliyou give,thosekindofsmall,smallsigns.’’(ICN5)

Signsthataremeasurable

The nurses monitor measurable parameters suchasblood pressure,pulse,temperature,heartrate,intracranialpres- sureandsecretionsfromsurgicaldrains.Datafrombedside monitorsandcomputerisedinformationsystems,suchasthe ventilator,complexinvasivehaemodynamicmonitoringand thedialysismachine,aremonitoredandassembledwiththe othermeasurableparametersintoaschema:

‘‘I sawthat she was tired today and influenced by all medicinesshegotlatelastnight,butshehadstillabetter dayinrelationtothepain.Respiratoryfunctionwasfine eventhoughshehadquiteabitofpleuraleffusion.She gotonelitreofoxygenandshehad14inPO2and98—99 insaturationdespiteherbreathingonherownwasonly fiveperminute,butyoulookedatherandsawthatshe hadnicecolorinthefaceandlips.Shewasnotcyanotic, therewerenosignsofoxygendeficiency,noflaringofthe nostrilsandshebreatheddeeplyandwell...’’(ICN4)

Signsthatmanifestasamoodintheintensivecarenurse Theparticipantsdescribedthattheyareimpactedbysome aspects of the situation andthey can sense that thereis a fluctuation in the patient’s condition. There is some- thingabout thepatient andthe situationthat creates an impression.However,she/hemayfinditdifficulttointerpret sensorialinputortostateinwordswhatthechangeentails.

This impression foreshadows a speciﬁc mood that can be positive,wherein thenursefeelsthatthepatient’scondi- tionis improving,or negative, whereinthenursebelieves thatsomethingisnotright orthatthepatientisatriskof suddendeclineinhis/hercondition:

‘‘IthinkthatwhenIgothatwayandwalkaroundthebed itissomethingthatmakesmelikealert...stressedorI seethatthepatientisstressedorthatsomethingisnot right.SometimesIhavenoideawhatitis,butIjustfeel thatImustassessverywellandIbecomeverystringent.

Itmakesmeveryrule-governedandIthinkthatIneedto properlygothroughthechecklist...’’(ICN8)

‘‘Icangetasensethatthereisachangeinthesituation andIstartlookingforwhatcouldpotentiallybetheprob- lem. Sometimes I findsomething,other times Icannot findanything.Inthosecases[that]Icannotfindanything, Idon’tstoptolooking,Ihaveanincreasedawarenessand follow[up]withthepatient...’’(ICN2)

Awarenesstosigns

Caresituations

Duringcaresituations,suchasoral hygiene,tracheal suction,mobilisationtothebedsideandchangingthepatient’s positionin bed, nurses sense signs, suchas muscle tone, movementofthebody,skincondition,coughandwakeful- ness.Thefollowingstatementsexemplifythisassertion:

‘‘Therewasnosignofbloodpressureorpulserisewhen changingthepatient’spositioninbed.Heliesthereand hislipsaremoving,buthedoesthatallthetime.Hedid notcoughwhenweturnedhimover.Itremainstobeseen ifherespondstotrachealsuction...’’(ICN6)

‘‘That’showherespondstooralhygiene,todayitwasno problembrushingtheinsideofhisteethorthechewing surfaces ofhisteeth,whereitcanoftenbeaproblem, therearespasms inthe jawandone cannotget inside themouthwiththetoothbrush.Hereitwentﬁneandit isformeagoodsign...’’(ICN7)

Caresituationsarepowerfulstimuliforthepatientand areofgreatimportanceforthenurseinenablingthemto developanimpressionofthepatient:

‘‘Heisveryheavyandtired,butwhenweputhimupon the bed side,we get acompletely differentpicture of him.Itisagreatstimulusandthenwecouldseehowhe reacts...’’(ICN7)

Shifts

Apatient’sconditioncandevelopandchangewithinashift orbetweenshifts.Thenurseformsanimageofthepatientat thebeginningoftheshiftasastartingpoint,whichenables her/himtobecomeawareofchangesinthepatient’scondition.Oneparticipantdescribedthisbyreferringtoher/his experienceswithapatientinwhomsepsiswasdeveloping:

‘‘Itwassostrangehowshechangedappearance,hernose becameslightlypointedandhercheeksweresunken,and thecheekbonesbecameveryvisible,bluishinskincolor.

I turned onmore light to see ifit was true, Ithought it wasa changeinface shape...Itwasnotlikethata fewhoursbefore...Wehadbasicmonitoringofher,but itwasnothingspecial[regardingtheparameters]’’(ICN 11)

Nurses follow patients from one shift to another, and impressionsfromtheprevious shiftarecomparedtothose formedatthebeginningofthenextshift.Thenurseislook- ingforsignsofchange, suchaswakefulness,eye contact, bodymovement,andresponsetocareactivities:

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‘‘IthoughthewasalittlemoreawakethelasttimeIwas withhim ...Alittlemorespontaneouseyeopening, he lookedalittleout,althoughhelookedatmeanddidnot giveeyecontact.Hehuggedmyhandtwiceonrequest, anditseemedlikeitwasadequatebecauseherepeated it...TodayIaskedhim toclaspmyhand,but hedoes not.Todayheseemsmoretired,liewithhiseyesclosed, andheopensthemonlyuponstimulation...’’(ICN5)

Discussion

The main ﬁnding of this study was that nurses develop foresightandawarenessofincipientchangesinapatient’s conditionthroughimagesorimpressionsthatarecomposed ofsigns.Throughbodilysenses(i.e.,vision,hearing,smell, andtouch), nurses sense signsof changes in patientcon- dition, such as wakefulness, response to contact, body movements,eye contact,facialexpression, andthesmell and colour of secretions. According to Løgstrup (1995a), weexistemplacedintheworldwithoursenses.Martinsen (2012)explains thatwhen nursesin a clinicalcontext are sensitive and attentive, they are receptive, touched and movedtorespondtotheappealsandneedsofthepatient.In relationtoourﬁndings,thisstatementmeansthatnursesare receptivetopatients’bodilyexpressions,suchaseyecon- tact,facialexpression,bodymovement,wakefulness,and anxiety.

Initspurestform,sensation comesentirelystrippedof any interpretation or conscious understanding (Løgstrup, 1995b). The nurse is touched and moved by something in his/her situational encounter; i.e., there is something occurring with the patient that makes an impression and hasthepowertoattunethenursetoapositiveornegative mood. Løgstrup’s (Løgstrup,1995b, 2013) phenomenology ofsensationdescribesanimpressionasalwaysbeingsense- basedandtuned.Inrelation toourfindings,thecorrelate isthatwhenevernursessee,hear,touch,orsmell,she/he alwaysacquiresanimpressionofwhatshe/hesees,hears, touches,orsmells.Animpressionmovesandaffectsanurse, anditleadstoanattunedawarenessdirectedtowardsthe patient.Nurses ascribe significance toimpressions and to beingmovedbyfollowingandrecognisingearlychangesin apatient’scondition.Thisobservationissimilartothefind- ings of Randen and Bjørk (2010), whodemonstrated that personal experiences and intuition are considered impor- tantbynursesinassessingsedationneeds.Thisobservation mayalsobecongruentwiththefindingsofJäderlingetal.

(2011) and Rothschild et al. (2010), in which staff mem- bers used the ‘‘worried criterion’’ as an early warning criterion (intuition); this ﬁnding is also similarto that of Howelletal.(2012),inwhich‘‘nursingconcern’’wasacri- terion for activatingthe RRS in the absence of vital sign criteria. Benner et al. (2011) used the term ‘‘intuitive’’

to refer to a sense of salience and a sense of atten- tiveness based on nurses’ experiences in past concrete situations.

AccordingtoLøgstrup(1995b),wesenseimpressionsas thoughtheyarespeech;theseattunedimpressionscarrya prelinguistic meaning that will eventually be articulated.

Martinsen(2008a) explainedthattoreceivean impression istobesensitivelymoved.Knowledgeisobtainedwhenthe

impressionisexpressed.Ininterpretingtheimpression,the nurse is open in the present situation to perceiving sev- eralsidesofthepatientandtoobtainingamoreaccurate overallimpression,asnurseshaveexpressed.Inrelationto our study, nurses attempt to understand what has made an impression and begin to examine the patient through her/hissensesandbymonitoring.Insomecases,thenurse is attentive tosignsof change in the patient’scondition, whereas in other cases,she/he is unabletoidentify any- thing.However,she/hedoesnotstop‘‘searching’’because she/hehasbeentouchedbytheattunedimpression,which leadstoincreasedattentiontowardsthepatientandbedside monitoring.

AsLøgstrup(2013)explains,withoutdistance,wewould be lost in sensation and unable to understand. With language, understanding creates distance from what we understand and creates a space for thinking and action.

AccordingtoMartinsen(2008a),understandinggivesusdis- tancesothatwecanstructurethesensualimpressionthat nature and people give us and express it so that others understand it. In relation toour findings,the corollary is thatthenurseentersintoadialoguewiththesituationand dwells ontheimpression that hasmovedher/him. In this space,or whatLøgstrup(1995c)calls‘‘thefictional space ofunderstanding’’,nursesarebeingremindedofsomething inaspontaneous,intuitiveflashofinsight.Løgstrup(2013) stressesthatwemustpursueaspontaneousflashofinsight immediatelywhenandwhereitoccursbecauseitisaunique andaonetimeconstellation;otherwise,wemayloseit.In thecontextofthepresentstudy,thisinsightcouldarisefrom achangeintheshapeoftheface,achangeintheskincon- dition,abriefmomentofeyecontact,orthemovementof aneyelid,finger,orshoulder.

Sensation has an analogue character that brings out variations andcontexts of the situation,thereby allowing the situation to be considered from several perspectives (Martinsen,2008a,2008b).Withregardtoourﬁndings,the corollaryisthatthroughlivingimages,thenurseisreminded of something else that evokes something inside her/him basedonthenurse’spastexperiencesandknowledge.The nurseissuddenlyabletoenvisionnewanalogies,andshe/he perceiveslikenessinthedifference.AccordingtoLøgstrup (1995b), there is something that is the same in the dif- ference, and we may consider something else under the impressionofoneortheother.

The nurses follow measurable parameters, such as intracranialpressure,temperature,heartrhythm,andres- piration values, and they consider these parameters in relation tosensorysigns,suchasawakening, contactwith thepatient,skincolourandpatientmanagementofrespira- toryeffort.Theseviewsaresimilartonurses’viewsinother studies(Hennemanetal.,2012;Randenetal.,2013).

Signsthataresensorialandsignsthataremeasurablemay beviewedasseparatefromandopposedtooneanother,but theyaredependentononeanother. Innurses’dailyprac- tices,sensorysignsaretightlyinterwovenandareincluded intheinteractionwithsignsthatcanbemeasuredandwith signsthatmanifest asamoodinthenurse.Weconsidered thisphenomenonaswhatLøgstrup(2013)described‘‘united opposites’’,i.e.,phenomenathataredifferent,thatcannot existwithoutoneanother,andthatstrengthenoneanother mutuallyintheirdiversity.

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Caresituations,suchasbodyhygiene,skincare,mouth care, changing position in bed and tracheal suction, are ascribed special meaning as signs of incipient changes in apatient’scondition.Throughcaresituations,nursesform an impression of thepatientand cansense signs,suchas responsetostimuli,wakefulness,eyecontact,bodystrength and body movements. This observation is consistent with thatofMartinsen(2008a),whostatedthat‘‘wegraspsome- thingthroughourpracticaldealingswiththings,peopleand nature’’.

Studylimitations

Onelimitation ofthe present study wasthesmallsample size. However, ouraim wasnot togeneraliseour ﬁndings buttopresentrichdescriptionsofthephenomenoninques- tioninawaythatenablesthereadertoevaluatepossible transferabilitytoothercontexts.Wearguethattheinsights andknowledgegainedfromthisstudymaybeofbeneﬁtto nursingpractice,educationandfutureresearch.Thenurses’

lengthofcriticalcareexperienceandtotalnursingexperi- encewasnotconsideredin evaluatingtheresponses.Itis possible that the findings evaluated here varyamongdif- ferent subgroups. Other limitations of the present study were that the number of interviews and the time frame oftheinterviewsdifferedamongtheparticipantsandmay haveinfluencedthefindings.Limitationsandopportunities involvedininvestigatingclinicalpracticeinone’sownfield mustalsobeacknowledged.Asaresearcher,beinganexpe- riencedICUnurseandknowingthefieldmayfacilitateaccess toinsights,butitmight alsolimitperspectiveduringdata collectionandanalysis.

Conclusion

This study offersinsights intothe phenomenonof becom- ingawareofincipientchangesinpatientclinicalcondition from the perspectives and experiences of intensive care nurses. Nurses foresee andare awareof early changesin patients’clinicalconditionsthroughlivingimagescomposed ofsignsthatmaybeviewedasseparatefromandopposed to one anotherbut that are interdependent. In a nurse’s dailypractice,sensorysignsaretightlyinterwovenandare included intheinteractionwith signsthataremeasurable andwithsignsthatmanifestasamoodinthenurse.Ourﬁnd- ingsalsorevealedthatcaresituations,suchasbodyhygiene, mouthcare,changingpositioninbedandtrachealsuction, aswellasfollowingpatientsthroughshiftsareessentialfor nursestoperceivethesesigns.

Conﬂict of interest

Theauthorshavenoconﬂictofinteresttodeclare.

Ethical statements

Nonedeclared.

Acknowledgements

We aregrateful tothe intensive care nurses who partici- pated in this study and the ward managers for giving us accesstothestudylocations.Financialsupportwasobtained from the University of Tromsø, The Arctic University of Norway,andTheNorwegianNursesOrganisation.

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