Concept Analysis

Running head: PSYCHOLOGICAL DISTRESS 1 Concept Analysis : Psychological Distress Maribeth L McCarthy Wilmington UniversityPSYCHOLOGICAL DISTRESS 2 Abstract The purpose of this paper is an attempt to examine the concept of psychological distress in the critically ill p atient and because this concept is not often identified nor adequately defined as a stand -alone illness but as rather both an obje ctive and subjective reaction to something uncomfortable that the patient struggles to understand . This is relevant to me as the RN Case Manager of the Medical and Surgical Intensive Care Units as a primary focus of my job is discharge planning and what factors cause a delay in a patient’s length of stay within those units. Psychological Distress has not been distinctly defined in thi s population and clearly needs to be examined more closely as providing better understanding of the correlation between lack of restful sleep and psychological distress will certainly assist the Advanced Practice Nurse in modifying factors that would impro ve patient outcomes. Using Walker and Avant’s Strategies for Theory Construction in Nursing 5th ed. (2011) and with following their eight -step method of conducting concept analysis, a thorough literature review was done using databases such as CINAHL, NCB I, EBSCO, MEDLINE and Google Scholar. The need to research interdisciplinary thoughts and research gives credence to the notion that nursing, and medicine are all a part of an interdisciplinary cohort in treating a complex, critically ill patient. All ar ticles were published within the last five years with the exception of the Walker and Avant book; and all articles were from multidisciplinary professional journals supporting peer review and evidence -based practice. Psychological Distress is defined by the Scandinavian Journal of Caring Science as “a state of emotional suffering associated with stressors and demands that are difficult to cope with in daily life. (Ar vidsdotter et al, 2016).”. In my infinite wisdom, I believe that there is aPSYCHOLOGICAL DISTRESS 3 causative agent, an event, that leads one to the state of psychological distress. In the Critical Care setting, there are certainly many signs that patients exhibit that compris e Arvidsdotter’s definition . The ‘causative agent’ and in this case , the concept, that I have chosen to delve into is one that is well known but yet not studied much and that is the relevance of sleep deprivation and the development of psychological distr ess; as most are aware, if you need restful sleep that the last place you are going to get it is as a patient in the hospita l. With patient’s having to listen to the never -ending sounds of call lights, overhead paging and then being subjected to nurses awakening them to take vital signs or give medications , its completely understandable why a patient cannot get uninterrupted sleep. In particular, I am directing this to patients in an intensive care unit as things happen quickly and are more intense due to the nature of the acuity of the patients there. It is difficult to achieve a steady state of restful sleep and is a complaint that I hear all of the time . In a newsletter originally published in J uly of 2 009 by Harvard Mental Health and was most recently updated June 19 of 2018 that speaks to the association between inadequate sleep and the effect on mental health as it reports that scientists have “discovered that sleep disruption — which affects levels o f neurotransmitters and stress hormones, among other things — wreaks havoc in the brain, impairing thinking and emotional regulation. ”. So, if psychological distress is a state of emotional suffering and sleep deprivation can cause an impairment in emotional regulation, does it stand to reason that being a patient in the hospital, specifically in an intensive care environment, that the sleep deprivation is a causative agent in psychological distress? A study was conducted by the Association of Anaesthetists (2014, May 11) that investigated whether or not implementing non -pharmaco logical interventions during an intensive care stay would improve a patients’ sleep pattern and reduce the chances of delirium. PreviousPSYCHOLOGICAL DISTRESS 4 studies that challenged the use of non -phar macological interventions outside of the ICU environment had proven that said interventions do have a direct effect on the reduction of del irium. Some of the non -pharmacological interventions were to reduce the amount of light exposure to the patient by shutting curtains and doors, turning down the volume on the staff’s phones prior to entering the room, scheduling of the medication times to midnight and six o’clock in the morning and attaching an electronic listening and video device to the patient’s electronic monitoring board to limit the staff interaction with the patient. The data retrieved showed significant improvement in the hours of restful sleep, a reported decrease in daytime sleepiness and a reduction of restlessness both during sleep and during the day . It also showed a reduction of cases of sleep delirium in comparison to those patients not in the study. The measures represented a significant improvement in patients’ perception of sleep as well (Patel et al.). There is a growing concern regarding the adverse effects of interruptions in the circadian rhythm in the patient whom is critically ill. The concern is that the se interruptions “may impair recovery by obstructing the coordinated activity of normal physiologic processes” (Pisani, et al.). So, if it is ascertained to be detrimental for a patient in need of recovery and healing if they do not achieve an adequate am ount of restful sleep, why has none of this been evaluated in depth before as there is very little in the literature regarding this subject? Furthermore, if the research correlates the fact that there is seemingly a direct link between sleep deprivation a nd the symptoms of psychological distress, why are institutions not looking at the non -pharmacological interventions that can reduce the negating of the healing process and implementing them as policy? Especially when given the fact that the interventions are all modifiable. Model CasePSYCHOLOGICAL DISTRESS 5 John Jones (name has been changed to protect the privacy of the patient), age 74 has been admitted to the ICU with a Right MCA Occlusion. He has a past medical history of Hy perten sion and Diabetes Mellitus II. He was also a two and a half pack per day smoker up until two years ago. Patient complaints at the time of arrival to the ED were left hemiparesis, expressive aphasia, and dysarthria. His blood pressure upon admission was 198/ 110. Mr. Jones was administered tPA at 3 PM on the day of admission. Policy is that a patient must stay in the ICU twenty -four hours after administration of the tPA for monitoring. His presenting S/S are dissipating, and his vital signs are stable. Througho ut the night, patient reports that he was awoken at r egular intervals to obtain vital signs and perform neurological chec ks and complains about feeling tired, overwhelmed and depressed. Reports at 0600 that he has a headache and rates the pain to be at a 7. A STAT CT Scan of Head is ordered but no interval changes are noted. Throughout the day, patient is observed with daytime sleepiness, he is irritable and his spouse reports that the patient seems sa d and that all he wants to do is be left alone. Under normal circumstances, patient would have transfers orders to go to the stroke unit but because of his mental and personality changes, his complaint of headaches and his wanting to sleep the majority of the time, the treating team decides to keep him in the ICU despite the fact that he meets criteria to transfer out. During his s econd night in the ICU, the patient experiences the same interruptions, but this time is worse because the woman in the room next to him coded at 0200. Mr. Jones hears and sees everything given the dynamics of the step -up in the critical care environment. He pleads with his doctors the next morning to discharge him as he felt that he would heal much more quickly at home and al though the patients presenting symptoms had dissipated, he felt worse from a different perspective. He explained to the doctors that he really felt that all he needed was a good nights’ sleep and that he would wake up feeling like a millionPSYCHOLOGICAL DISTRESS 6 dollars. His team was not ready to discharge him home at that juncture, but they were willing to transfer him out of the ICU. Interestingly enough, Case Managers talk with patients on a daily basis, constantly assessing the appropriateness of the discharge plan, updating it, changing it completely or not at all. We a re expected to see a patient for their initial assessment withi n 24 -48 hours of admission to ascertain information regarding their level of functionality prior to the event that brought them in, their financial status, their support system, layout of their primary residence in order to better understand what their ant icipated discharge needs might be. I decided to begin asking my patients about their sleep habits prior to admission and how their quality of sleep had been since they were admitted to the intensive care unit. I asked the patients to rate their quality of sleep on a scale similar to the pain scale giving a number of 0 to equate to the poorest quality of sleep they have ever had all the way he way up to ten. I also asked the patient to identify what they felt was the factor that was associated with a poor nights’ rest. Overall, I interviewed 14 patients over the course of a week’s period. Nine of those patients I spoke with were in the SICU (surgical intensive care unit) and the remainder of those nine were in the CVICU (cardiovascular intensive care uni t). I concluded that the patients in SICU reported approximately a 20 percent better quality of sleep than did the patients in the CVIC U. The major contributing factor for sleeplessness in the SICU were the staff interruptions while the CVICU reported that light and noise keep them awake the majority of the time. When the layout of both units was studied, the CVICU did not have separate rooms but the beds were separated by curtains that there was no ability to block our sound nor light while t he SICU patients had rooms with doors on them that could be shut.PSYCHOLOGICAL DISTRESS 7 The patients in the CVICU also exhibited signs of psychological distress that were much more prevalent than those patients in the SICU. One woman in particular on her fifth day post CABG was confused, crying and restless to the point that she tried to get out of bed and fell to the floor, hitting her head. She believed that the hospital police were there to kill her and that all of the nurses were on a witch hunt. During interdiscipl inary rounds that morning, not one physician could be heard questioning her wake -sleep cycle and whether or not the imbalance in her circadian rhythm was the reason for her emotional lability and change in mental status. In conclusion, the evidence cert ainly presents itself enough of times for practitioners to give pause to the correlation between sleep deprivation, or poor sleep quality, and psychological distress. Furthermore , the factors that can lead to an imbalanced wake -sleep cycle causing a profound imbalance in a patient’s circadian rhythm, are modifiable. Nurses specifically have the ability over any other discipline in the critical care units to a) address the issue, b) be the strong advocate for their patients, and c) implement the necessary changes to assist in alleviating, if not irradiating this issue. Transforming the environment in which our patients initially are placed in following a catastrophic event can hav e a radical effect on the patient’s ability to heal itself, assist in maintaining a positive and productive mental state. All of this would prove to be evident as it would result in a decrease in a patient’s length of stay, less hospital -based infections and more expedient recovery times.PSYCHOLOGICAL DISTRESS 8 References Arvidsdotter, T., Markind, B., Kylen, S., Taft, C. & Ekman, I. (2015). Understanding persons with psychological distress in primary healthcare. Scandinavian Journal of Caring Sciences, 30 (4). doi.org/10.1111/scs.12289 . Patel, J., Baldwin, J., Bunting, P. & Laha, S. (2014, May). The effects of a multicomponent multidisciplinary bundle of interventions on sleep and delirium on medical and surgical intensive care patients. Presented in part at the Intensive Care Society State of the Art meeting, London, UK. Pisani, M.A., Gehlbach, B.K., Schwab, R.J., Weinhouse, G.L. & Jones, S.F. (2015). Sleep in the intensive care unit. American Journal of Respiratory and Critical Care, 191 (7). doi.org/10.1164/rccm.201411 -2099Cl. Sleep deprivation can affect your mental health (2009; 2018). Harvard Medical School, Bosto n, MA. Harvard Health Publishing.PSYCHOLOGICAL DISTRESS 9 Walker, L.O. & Avant, K.C. (2011). Strategies for the theory construction in nursing (6th ed.). Scandinavian Journal of Caring Sciences, 30 (4). doi.org/10.1111/scs.12289PSYCHOLOGICAL DISTRESS 10

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