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Macau Polytechnic Institute

School of Health Sciences


Bachelor of Science in Nursing Program
2016 / 2017
4 Year
Intensive Care Unit

General Care Assignment I


Experience Report / The Units Shift Change

Teacher: Dr. Leong Sin U, Cindy


Student: Andr Assuno Alves
Student ID: P1609356
Number of Words: 2302
Date of Submission: 10th September 2016

General Care Assignment Experience Report / The Units Shift Change

I would like to thank to the staff of the Intensive Care Unit


for guiding me in my practice in this internship of three
weeks, always showing availability, promoting a friendly
environment in a professional way, dignifying the profession
of a nurse.

Andr Assuno Alves, 2016

General Care Assignment Experience Report / The Units Shift Change

1. Summary and Reflection


Different cultures, divergent views, new approaches. A new world in a career that dubs itself
challenging, encouraging, innovative and above all, rewarding.
Despite these dichotomies, I consider that the adaptation to the unit was fairly easy. The staff
were very accommodating in a way that it was possible to create an environment of thrust and
mutual aid, aiming to provide the best of cares to the patients. The language barrier was the
main hurdle. However, all members of the nursing team shown availability to clarify doubts as
well as an encouraging attitude in the management of the tasks. Almost all the nurses could
speak English fluently so the comprehension and the interpretation of the information was
eased.
One of my main goals in this internship was to comprehend what was a nurse purpose in an
Intensive Care Unit [ICU], and how it managed the care provided to the patients. I can see
clearly now that it is not an easy job. From medication interactions, to constant surveillance of
a patient clinical status, a nurse is almost responsible for all the factors that influence a patients
condition.
In regards of learning during these three weeks, I believe that it completely exceeded
expectations. The diversity of contents lectured, allied to the range of different clinical
situations, promoted not only the attainment of new knowledge but also, and more importantly,
the demand for new approaches. Not for one moment my curiosity wavered and I always tried
to search for more information, not only with the nurses but also with the medical team.
To be more precise, one of the goals I consider I was able to achieve is the effectiveness in the
management of patients with respiratory issues namely situations like pneumonia and cancer.
These patients are commonly monitored with mechanical ventilation [MV] since they cant
breathe on their own. Interpreting the factors that influence breathing and link them to the type
of MV that is being used is rather relevant point. A patient can be monitored by pressure, by
volume or both (in short). The most commonly used mode is Synchronized Intermittent
Mandatory Ventilation [SIMV], in which the patient can breathe spontaneously at any time
(trigger), but the number of mandatory breaths is specified. This way the patient has a free
breathing ability during the complete breathing cycle. This is just one of the thing that Ive
learned in this matter and I find it quite interesting working with patients with this clinical
situation.
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General Care Assignment Experience Report / The Units Shift Change

Another aspect that it is extremely important for me is the knowledge of the wide range of
medication that is used in the unit. From antibiotics to corticosteroids, the knowledge of the
mechanisms and interactions is a high-priority aspect whenever a nurse is administrating a drug.
Moreover, a lot of medication is diluted in fluids such as dextrose, and the hydric balance is
one of the most relevant aspects when taking care of a patient in this unit. Being so, it is
extremely important that we make sure that the medication is administrated and that the dilution
is done correctly to prevent renal, cardiac and pressure issues and, of course, overdoses.
Lastly, I was astonished by the variety of oncological problems that I got to know and
experience. Cancers affected mostly the digestive system such as esophagus, tongue,
duodenum, among others. This is due to a cultural aspect according to researchers, since the
local food is served very hot and with a lot of condiments which damages the digestive tract. It
was rather interesting to understand the different surgical procedures to treat each type of
cancer, being that I never had experience in this area.
I conclusion, and regarding the professional and personal growth, I consider it was a very
ambitious and rewarding experience although I think three weeks is a very short period to an
internship like this one. It is not an easy area and it is most certainly one of the most challenging.
I think that now that we are finally speeding up the pace, it would be the best time to dive
deeper in the unit since that is so much more to learn. However, one positive aspect, is that
Im strongly thinking in specializing in this area. The learning never stops and it is undoubtedly
one of the best career paths to follow in my opinion.

General Care Assignment Experience Report / The Units Shift Change

2. The Units Shift Change


For the second half of the assignment, I was asked to focus a discussion on a problem that I
identified in the unit throughout my practice of three weeks. Being so, for my experience in the
unit, I say that one of the main issues I identified was the communication in the shift change.
Therefore, my goal is to state the problem as clearly as possible and develop a solution based
in a comprehensive, scientific and rational way.

2.1. The Problem


The nursing change of shift report is a communication which occurs between two shifts of
nurses, where the purpose is thought specifically to be communicating information about
patients under the nurses' care. The shift report occurs on many hospital wards up to three
times a day, and it is claimed that it is central for maintaining the continuity and quality of
care which patients receive (Clair & Trussell 1969, Georgopoulos & Sana 1971, Feeley
1973, Kilpack & Dobson-Brassard 1987, McMahon 1990, Kihlgren et al. 1992)

Since the first day one of my main hurdles was the comprehension of the clinical information
exchanged in the shift change. However, this is not an astonishment since Im unable to
comprehend cantonese or mandarin, only speaking Portuguese and English. However, when I
decided to approach this problematic, my focus was the communication between the staff
nurses.
The shift change happens in a small table in the centre of the unit, in the same space as patients
are. At this moment, the information passed is mainly about changes in the unit, the arrival of
materials, changes in medical prescriptions, surgeries timetable, among others. When it comes
to describing the patients condition, the nurses go next to the beds and explain to the other
nurses what happened during the shift, namely: changes in the vital patterns, adjustments in the
medication or if the patient needed SOS drugs, state of consciousness, new diagnostics, clinical
evolution or regression etc. This follows the total of 12 beds of the unit. Therefore, in my
opinion, this brings the following problems:
First of all, the noise. An ICU is a place of constant movement being this amplified by the
sounds of monitor alarms, ventilators, infusion alarms, telephones, doors, among others. It is
certainly not the quietest place to do the shift change as it hinders the transmission of
information between the nurses. Moreover, as the nurses talk and discus a patients clinical
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General Care Assignment Experience Report / The Units Shift Change

status, the noise in the room is only amplified. This disturbs the patient, the staff and the shift
change itself. A study made by Dr. Richard Pugh supports this perspective:
Noise causes stress to patients. Among patients recovering from acute coronary syndrome,
adverse coronary care acoustics were associated with increased markers of cardiovascular
stress as well as an increased readmission rate. Noise is also associated with greater
requirements for sedation and analgesia among ICU patients. () The volume of noise in
ICUs frequently exceeds the recommended limits for hospitals, with significant implications
for the psychological and physiological health of patients and staff. (Puth, 2007)

Another issue is that all the information exchange occurs next to the patients putting at stake
ethical issues in the privacy and intimacy sphere, being that the unit is an open space and other
patients can clearly hear what is being transmitted. Moreover, since the average of nurses per
shift is seven, usually all those nurses are entering the patients space, which is in my
perspective, unnecessary.
The shift change is par excellence a moment of exchange the important information to
insure the continuity of care. Whether it take place in the room along with the patient or
supplied in the nursing retreat, who is essential to respect the condentiality of information
and the right to privacy which assists the patient, so that nurses are an important piece of
knowledge to pass on their users, passing the most insightful information and relevant.
(Teixeira et al, 2013)

This subject must not be devalued just because most of the patients are sedated or in coma.
Research has found that patients in a coma or in an unconsciousness state may hear and they
are aware of their surroundings. They can distinguish voices, noises and can associate
conversations and actions, even though they dont make it consciously.
Evidence (Walker, Eakes and Siebelink, 1998) suggests that the majority of comatose
patients have normal brainstem auditory evoked responses and indicates that they may hear.
Indeed, LaPuma et al. (1990) have gone so far as to suggest that talking to comatose patients
may have considerable therapeutic value. (Simes et al, 2014)

Finally, the place for the shift change is not suitable for the nurses needs; most of the nurses
arent sat or even are too far from the table because of the spaces limitations. This hinders the
transmission of information as well as it doesnt promote the nurses comfort. Moreover, the
disposition of the nurses promotes the noise and the decentralization of the content, allowing
parallel conversations.
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General Care Assignment Experience Report / The Units Shift Change

I understand that one of the goals of this type of shift change is to be nearer the patient. To
describe the clinical status and the nursing interventions next to the subject. However, because
the space is limited and the number of nurses disproportional to the previously stated, in my
opinion it doesnt achieve its objectives as a working method. Besides, from what Ive
experienced, this method requires more time.

2.2. The Solutions


For me, most of the solutions follow up the traditional method of shift change. First of all:

The shift change should be done in a separate room with all the conditions necessary.
The noise is isolated, the nurses are comfortable and everyone is in the reach of
information. This would require a table and the necessary number of chairs for all the
nurses to be sat and available to discussion. Moreover, materials like pens, paper,
clinical documents and at least one computer (for consultation of computerized data)
would be indispensable.

However, I recognize that a patient in ICU requires constant surveillance. Being so, I suggest
two more points to resolve this matter:

For a short term solution, I consider having one or two (depending on the resources)
back-up nurse in the unit would be beneficial as well. While the other nurses are
meeting in another room there was always a nurse in the room to watch the patient and,
if necessary, develop emergency interventions;

The construction of a room in the middle of the units space. This room would have to
isolate noise as well as gather the right temperature for the comfort of the nurses.
Moreover, the building of glass windows would allow the nurses to meet in quiet as
well as be able to watch their patients from behind the glass. This is a long term solution
and it is, of course, very expensive. Still, it would bring other benefits such as enable
the families to have a quiet room to talk to the clinical staff about delicate subjects in
the matter of the patients clinical status.

Another aspect I find improvable is the content of the information that is transmitted in the shift
change. Sometimes, most of the information becomes repetitive and some aspects lose focus.
For this, I recommend the elaboration of a document for the nurses to write their notes with
blank spaces for the nurse to fulfil so that nothing gets missed or forgotten. This would include
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General Care Assignment Experience Report / The Units Shift Change

vital patterns changes, SOS medication, hydric balance, wounds treatment, surgery plans,
appointments with families, clinical evolution, consciousness observation, communicative
state, among others. This way, essential and crucial information passes on and subjects of minor
matters lose focus. As the nurses are all in the same room and at the reach of information,
parallel conversations would lose relevance and all the nurses would know the clinical status of
all patients in the unit. This reduces the time implied in the shift change and the decentralization
of content.
To conclude I find that managing a matter like this is no easy. The solutions are scarce due to
the use of resources but can be applied. Moreover, I completely understand what are the main
goals of bedside shift change but I find the theoretical and practical components incompatible.
Moreover, accordingly to Press Gainey Associates the following article, one of the main
positive aspects of this shift change is the participation of the patient in the information
exchange which does not apply in most of the cases in an ICU unit since the patients are either
in a coma or in a sedated state.
This meeting is intended to engage patients in exchange of real-time information at shift
change, giving both the oncoming nurse and patient the opportunity to ask questions and
verify important information about the patients history and care plan before the outgoing
nurse leaves. (PGA, u.d.)

Finally, I think that the units environment and space doesnt gather the needs for such
methodology as the space between the beds is too short for all the nurses to concentrate and see
the patient.
In conclusion, I look forward for changes in the shift change. I understand that the present
document doesnt contain any investigative work in the field but the main goal of the previous
was to identify the problem and report it with theoretical bases and critique thinking. Still, I
hope further investigation is done to improve the units development and rectify the problems
stated in here.

General Care Assignment Experience Report / The Units Shift Change

References
Simes et al, 2014. The effects of acoustic stimulation on comatose patients In University of
Aveiro, Institute of Sound and Vibration Research, Portugal. Consulted on 8
September

2016.

https://www.researchgate.net/publication/236175603_The_effects_of_acoustic_stim
ulation_on_comatose_patients

Puth, 2007. The impact of noise in the Intensive Care Unit In University Hospital Aintree,
Merseyside, United Kingdom. Consulted on 8 September 2016. http://iheonline.com/fileadmin/artimg/the-impact-of-noise-in-the-intensive-care-unit.pdf

Teixeira et al, 2013. Questes ticas Inerentes Passagem de Turno Junto dos Doentes In
Revista de Enfermagem Sinais Vitais, Portugal. Consulted on 8 September 2016.
https://www.academia.edu/10982065/PASSAGEM_DE_TURNO_EM_ENFERMA
GEM_uma_reflex%C3%A3

Douglas et al, 2012. Making the Transition to Nursing Bedside Shift Reports In The Joint
Comission Journal on Quality and Patient Safety, United Kingdom. Consulted on 8
September 2016. http://www.jcrinc.com/assets/1/14/S1-JQPS-0612_wakefield.pdf