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. 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 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. 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. 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 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. 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). 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. 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 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. 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. 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 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 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 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
Psychosocial and Spiritual Alterations and Management
Stress and Psychoneuroimmunology
Stress Response
Psychoneuroimmunology
Post-Traumatic Stress Reactions
Anxiety
Anxiety and Pain
Alterations in Self-Concept
Body Image
Self-Esteem
Identity Disturbance
Risk for Compromised Human Dignity
Spiritual Challenges in Critical Care
Spiritual Distress
Hope and Hopelessness
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