O Connell 2008 Nursing in Critical Care

7/23/2019 O Connell 2008 Nursing in Critical Care

http://slidepdf.com/reader/full/o-connell-2008-nursing-in-critical-care 1/6

Therapeutic relationships in criticalcare nursing: a reflection on practiceElizabeth O’Connell

ABSTRACTAims: The aim of this paper is to gain a greater understanding of the emotional intelligence required to form therapeutic nurse-patientrelationships in the context of critical care nursing.Context: There is currently a demand for patient-centred nursing in all aspects of health care to improve both quality of care andconsumer satisfaction. Central to patient-centred care is the presence of a therapeutic nurse-patient relationships, but the developmentof these relationships present a challenge in the acute and technological world of critical care nursing.Theoretical Framework: Using Titchen’s Skilled Companionship Model as a guide as well as empirical and theoreticalknowledge on nurse-patient relationships, this paper presents a reflection on a relationship that the author developed with a patient andhis family encountered in her practice as a critical care nurse.

Reflective Conclusions: Engaging in therapeutic nurse-patient relationships can expose nurses to emotional pain in the contextof critical care nursing. The process of reflection can facilitate critical care nurses in the development of the emotional intelligencerequired to develop and maintain these relationships and this enhances the care of critically ill patients and their families.

Key words: Critical care • Emotional intelligence • Therapeutic relationships

INTRODUCTIONThere is currently a considerable emphasis on the

provision of patient-centred care in all aspects of health

care in order to improve quality and increase consumer

satisfaction (Michie et al., 2003). Patient-centred care

has been defined as a system of delivery of care to

patients that incorporates both the lived experience of

illness (values) and the scientific knowledge (facts) inevery aspect of health care (Fulford, 1996) while

respecting the patients right to self determination

based on mutual trust, understanding and sharing of

knowledge (McCormack, 2003). The ability to deliver

patient-centred care has been described as one of the

characteristics of expert nursing (McCormack and

Titchen, 2001), and several frameworks can be found

in the nursing literature to guide nurses in achieving

this approach to nursing care. They include the Skilled

Companionship Model (Titchen, 2001), Authentic

Consciousness (Ford and McCormack, 2000), Tidal

Model (Barker, 2001) and the Senses Framework(Nolan et al., 2004). Central to all these models is the

presence of a therapeutic nurse-patient relationship

(McCormack, 2004), and Titchen (2001) proposes that

the presence of this therapeutic relationship lies at

the heart of patient-centred nursing. However, the

nature of nurse-patient relationships is very dependent

on the context in which nursing care is delivered

(McCormack, 2004).

This paper is a reflective analysis on the nature of

nurse-patient relationships in critical care nursing.

Following an introduction to the definitions and thecentral concepts of therapeutic nurse-patient relation-

ships, I will reflect on a relationship that I developed

with a patient and his family I encountered while

working as a staff nurse in an intensive care unit (ICU).

Sam’s story is presented in Box 1.

Using the Relationship Domain of the Skilled

Companionship Model of Titchen (2001) as well as

empirical and theoretical knowledge of nurse-patient

relationships, I hope to gain a greater insight into the

nature of nurse-patient relationships in the context of

critical care nursing and, in particular, the importance

of setting appropriate boundaries.

WHAT IS A THERAPEUTIC NURSE-PATIENT RELATIONSHIP?The therapeutic relationship is a central feature of many

health-related disciplines (Freshwater, 2002), and in

psychotherapy, Rodgers (1999) has described it as one in

which the therapist keeps himself out of the relationship

as a separate person so that his whole endeavour is an

understanding of the other so complete that he is almost

an alter ego of the client. However, Clarkson (2003)

Authors: E O’Connell, RGN, HDip (Crit. Care), MSc, Lec turer/Practitioner

in Critical Care Nursing at Catherine McAuley School of Nursing and

Midwifery, University College Cork, Ireland

Address for correspondence: Catherine McAuley School of Nursing

and Midwifery, Brookfield Health Sciences Complex, University College

Cork, Ireland

E-mail: [email protected]

REFLECTIVE ANALYSIS

138 ª 2008 The Author. Journal Compilation ª 2008 British Association of Critical Care Nurses, Nursing in Critical Care 2008 • Vol 13 No 3



Box 1 Sam*’s story

Sam, an 11-year-old boy, was admitted to the intensive care unit with

severe head injuries following a bicycle accident. He had sustained

a severe traumatic brain injury when he crashed his brother’s bicycle

into a wall at the end of a steep hill. On admission, he was intubated

and ventilated and on huge amounts of inotropes to sustain his blood

pressure. A brain scan showed multiple contusions and anintracerebral haemorrhage with mid-line shift. The neurosurgeons

had inserted an intracranial pressure (ICP) monitor but had informed

Sam’s parents and his older brother that he was unlikely to recover.

I was assigned to care for him. I knew from his history and the level of

support that he required that he was gravely ill. Within 2 h of

admission, Sam became more unstable; his ICP was very high and

was not responding to treatment. Although I was very busy with the

technical aspects of his care, I had time to talk to his parents and

learnt that he was their much loved youngest son. Despite the fact

that the neurosurgeons had spoken to them regarding his prognosis,

they were desperately hoping that Sam would recover. As the day

progressed, his condition stabilized somewhat and I too began to

hope that he would pull through as I also had a son his age and could

not even contemplate the awfulness of losing him.

I came on duty the following day, and although at report the nurse in

charge stated that Sam had deteriorated overnight, I asked to be

assigned to him again as I had built up a very good rapport with his

parents and felt that they would benefit from this continuity of care.

However, when I went in to his room, I could see his condition was

much worse and my heart sank as I knew intuitively that he was not

going to survive. I was close to tears when answering his parents’

questions about his condition as I felt I had nothing positive to report

and I was taking away the hope they were desperately looking for.

Sam continued to deteriorate despite my efforts and those of the

other team members of the multidisciplinary team. Eventually, his ICP

became uncontrollably elevated and he developed the classic

Cushing’s triad and pupillary signs of brain stem death. I kept hisparents fully informed of what was happening in order to prepare

them for his death, but each time I spoke to them, I found it more

difficult to control my own emotions. Finally, following a brain scan

and two sets of brain stem tests, Sam’s death was confirmed. I sat

down with Mary*, his mother and held her hand as the neurosurgeon

informed his parents and I had to fight back my tears.

I spent that evening with Sam’s parents. I explained brain stem death

to them in terms they could understand and took the opportunity to

discuss the question of organ donation with them. It was evident that

they did not want to donate Sam’s organs. They felt he had ‘been

through enough’. Following discussion with the medical team later

that evening, Sam’s life support was discontinued and he died in his

mother’s arms. As I write this, I can again feel the intense pain and

sadness I felt that evening at not being able to ‘save’ Sam for his

mother. I can still recall how, when she left the unit that evening, she

hugged me and thanked me for being with her and for ‘all I’d done for

Sam’. Later, as I prepared Sam’s body for transfer to the morgue with

one of my more experienced colleagues, I cried openly. She advised

me not to become so involved with a patient again or I would never

‘survive this place’.

*Sam and Mary are pseudo names.

proposes that there are five facets of a therapeutic

relationship ranging from a working alliance through

to a truly transpersonal healing relationship. In

nursing, a therapeutic nurse-patient relationship has

been described as one that allows for the meeting of

nursing needs to the mutual satisfaction of nurse and

patient (McQueen, 2000). There are a range of nurse

theories coming from a humanistic perspective (Wat-

son, 1985; Boykin and Schoenhofer, 2001; Leininger,2001), which propose that such relationships are

essential to the delivery of individualized and holistic

nursing care. Therefore, it is the nurse’s responsibility

to encourage the development of therapeutic relation-

ships (McQueen, 2000) with her patients if she is also

working from a humanistic philosophy. This is not easy

and has been described as ‘the emotional work of

nursing’ (McQueen, 2000). In order to enter into

a therapeutic relationship with a patient, the nurse

must first develop an understanding of her own beliefs

and values and her ability to create relationships or

‘personal knowing’ (Chinn and Kramer, 1999) before

she can respond to the needs of her patients. Fresh-

water and Stickley (2004) refer to this as ‘emotional

intelligence’. But the emotionally intelligent nurse

must, through open communication with the patient,

also demonstrate trust and commitment (Morse, 1991)

as well as a genuine concern (Freshwater, 2002) and an

unconditional positive regard (Rodgers, 1999) for the

patient to enable the development of a relationship

that is therapeutic rather than superficial in nature.

Feelings of empathy and compassion (McQueen, 2000)

will then motivate the nurse to develop practical

strategies in order to come to know the patient as an

individual with his/her own set of beliefs and values(McCormack, 2004). Through setting appropriate

boundaries (Briant and Freshwater, 1998), the nurse

and patient enter into a mutual and reciprocal relation-

ship that enables the provision of nursing care that is

individually tailored to meet the patient’s needs

(Freshwater, 2002) as well maintain the professional

satisfaction of the nurse (McQueen, 2000). However,

both Freshwater (2002) and Down (2002) argue that

clinical supervision and reflective practice are neces-

sary to support nurses in the development and main-

tenance of therapeutic relationships with their patients.

The nature of nurse-patient relationship is very

dependent on the context in which nursing care is

delivered (McCormack, 2004). In critical care nursing,

where technology can act as a barrier (Johns, 2005) and

compromise nurse-patient communication, it can be

very difficult to develop therapeutic relationships.

Down (2002) warns that without these, nurses are

reduced to objective technologists, while patients be-

come objects to be examined and evaluated. However,

critical care nurses are very creative in overcoming the

barriers to communication (Bergbom-Enberg and

Therapeutic relationships in critical care nursing

ª 2008 The Author. Journal Compilation ª 2008 British Association of Critical Care Nurses 139



Haljamae, 1993) as well as minimizing the negative

effects of the technological environment (Dyer, 1995;

Dyson, 1999; Granberg et al., 2001) in order to engage

in relationships with critically ill patients and their

families. Because of physiological instability, it is not

always possible to facilitate the patient’s active

engagement in the management of his/her illness(Michie et al., 2003), but through communication with

the patient’s family, the ICU nurse can act as advocate

to ensure the patient receives care that respects his

choices and culture (Beeby, 2000).

A REFLECTION ON THE NATURE OF ANURSE-PATIENT RELATIONSHIP INTHE ICUI will now reflect on the relationship I developed with

Sam and his family as I facilitated their journey from

loss to adjustment (Binnie and Titchen, 1999). The rela-

tionship domain of the Skilled Companionship Model

of Titchen (2001) will be used to guide this reflection

as it has been empirically derived (McCormack, 2004),

and Titchen (2001) suggests that it can be used in a

variety of healthcare settings. I will examine theconcepts

of particularity, reciprocity, mutuality and graceful care

within the context of my relationship with Sam and his

family. Thus, I hope to gain a greater understanding of

my own experience within this relationship, and by

comparing my individual experience with empirical

evidence of nurse-patient relationships within critical

care nursing, I hope to gain insight into the challenges

presented by therapeutic nurse-patient relationships inthis highly technological and specialized setting.

Particularity: knowing the patientParticularity according to Titchen (2001) is getting to

know the patient within the context of their specific

illness and the context of their lives. It consists of two

categories of knowing:

• the patient’s responses, physical functioning and

body typology;

• the patient’s feelings, perceptions, beliefs, imagin-

ings, expectations, memories, attitudes, meanings,

self-knowledge, knowledge about and interpreta-tions of health and illness, experience of illness

and what is happening, responses to illness,

concerns and significant social relationships, life

events and experiences (Titchen, 2001 p. 71).

There is no doubt that in ICU, technology has a

significant influence on the practice of caring (Locsin,

1998), and ICU nurses use data gathered from a range

of monitors to gain knowledge about the physiological

well-being of their patients as well as their response to

treatments (Villanueva, 1999). Thus, when I first

approached Sam, technology provided me with the

knowledge needed for the first category of knowing.

This guided my initial caring for Sam, which required

giving priority to technological aspects in order to

maintain his physiological stability and optimize his

chances of recovery. Technological mastery is essentialto provide effective nursing care in ICU (Little, 2000)

but can dehumanize the patient (Beeby, 2000; Wilkin

and Slevin, 2004), and I needed to move beyond

technology in order to seek answers to the second

category of knowing.

The one-to-one nurse-patient ratio in critical care

nursing enables nurses to get to know their patients

and families (Walters, 1995; Beeby, 2000; Wilkin and

Slevin, 2004), and this allows them access to knowledge

about their patient’s cultures, values and beliefs.

However, this demands that the nurse needs to engage

very closely with the patient and family in order to

fully understand where the patient is at (Titchen, 2001)

in regards to his/her illness and provide care tailored

to their specific needs (Freshwater, 2002). Many ICU

nurses experience difficulty in engaging meaningfully

with unresponsive patients and tend to concentrate on

the technological aspects of care (Villanueva, 1999), but

in Sam’s case, I became very closely engaged, and as I

reflect, I realize that I began to see Sam through his

mother’s eyes and through my own eyes as both

a nurse and a mother (Titchen, 2001). While it could be

argued that I was overidentifying with Sam and his

family and this could cause my cognitive reasoning to

be impaired by my emotions (Arnold and Boggs, 2003),I believe as does Benner (1984) that it actually

enhanced my clinical judgement and allowed me to

respond to very subtle changes in Sam’s condition and

respond more appropriately to his mother’s needs.

ReciprocityTitchen (2001) describes reciprocity as an exchange of

concern, knowledge and caring that occurs in a close

interpersonal nurse-patient relationship. I shared my

knowledge of the technical aspects of caring for Sam

with his parents by explaining each procedure and

Sam’s response to them. Thus, I was meeting their

needs for information and reassurance, which research

has shown to be the most important needs of relatives

of critically ill patients (Robb, 1998). According to

Soderstrom et al. (2003), a prerequisite to a positive

nurse-patient relationship is a medically and techni-

cally competent nurse. Research studies investigating

patients and relatives perceptions of nurses caring

behaviours have found that the technical and instru-

mental aspects of care are highly valued in acute care

settings (Cronin and Harrison, 1988; Balsdottir and


140 ª 2008 The Author. Journal Compilation ª 2008 British Association of Critical Care Nurses



Jonsdottir, 2002; Harbaugh et al., 2004). Because Sam’s

parents valued my technical expertise, I was confident

that I could meet Sam’s nursing needs to the

satisfaction of his parents. As it became clear that

Sam was not going to survive his injuries, the focus of

my care changed to ensuring a peaceful death for Sam

and minimizing the potential for future regret by hisfamily (McClement and Degner, 1995).

MutualityTitchen (2001) describes mutuality as patient and health

professional working together in a genuine relationship.

This could suggest that they enjoy an equal partnership

but this is not the case as the professional knowledge of

nurses gives them a position of power and control

(Henderson, 2003). Briant and Freshwater (1998) sug-

gest that nurse-patient relationships may never be equal

but within a therapeutic relationship are based on

mutuality, and thus, professional knowledge becomes

a negotiable resource for patients to be used by them in

the management of their illness (Titchen, 2001). This

particular facet of patient-centred care is rarely, if ever

achieved in ICU because of the acuity of illness within

this patient population. While Sam was unable to

participate in any aspect of his care, through sharing

my professional knowledge with his parents, they were

ableto become active participants in his care. By eliciting

their views on organ donation and answering their

questions, they were empowered to discussthis with the

medical team once it was confirmed that Sam had

suffered a brain stem death. Involving Mary in Sam’s

physical care also proved very beneficial for her as ithelped to demystify the technological environment

(Hammond, 1995) and enabled her to fulfil her role as

a mother, while it provided me with an opportunity to

develop my relationship with her as we worked

together in a mutual alliance.

Graceful careTitchen (2001) describes the concept of graceful care as

the nurse using all her physical, humanistic and

spiritual abilities to promote the patient’s healing and

personal growth. This is congruent with the complex

process of caring in ICU where nurses use affective,

cognitive, emotional and action processes (Bush and

Barr, 1997). While the reciprocal and mutual aspects of

my relationship with Sam and his family focused very

much on Sam’s parents, it was through ‘practical

caring’ (Titchen, 2001) that I engaged with Sam. As I

cared for his bruised body, I came to know him as the

much loved son of his parents. As Mary and I attended

to his hygiene needs, we spoke to him about soccer

teams, skateboarding and school friends. I was present

very much as my authentic self on these occasions and

my personal experiences with my own sons helped

facilitate closeness and connection between the three of

us. This self-disclosure helped to build trust and had

a very positive effect on my relationship with Mary

and Sam. However, nurses need to measure carefully

the amount of information that they disclose to their

patients as self-disclosure carries with it relational andpersonal risks (Dowling, 2006), and if self-disclosure is

fulfilling the nurses need to share rather than the

patient’s need to know the nurse, then it will have

a negative effect on the nurse-patient relationship

(Arnold and Boggs, 2003).

DISCUSSIONI believe the relationship that I developed with Sam

and his family was truly therapeutic in nature. I was

authentically present with Sam and his mother in

a mutual and reciprocal alliance motivated by feelings

of intense compassion and empathy. It is these

emotions that motivate ICU nurses to care for their

patients (Beeby, 2000). I used my professional craft

knowledge (Titchen, 2001) and personal knowing

(Chinn and Kramer, 1999) to care for Sam and his

family in an expert manner. According to Titchen

(2001), all parties experience personal growth from

a therapeutic relationship. Sam’s mother was genu-

inely thankful to me for facilitating her journey

through the critical care experience. My experience

within the relationship with Sam and his parents

should have enabled me to continue caring effectively

for critically ill patients and their families. Instead, itcaused me to avoid meaningful engagement with my

patients in order to protect myself from the emotional

pain I experienced when Sam died. As I reflect on this,

I now realize that I lacked awareness of my own

vulnerability within this relationship and did not set

appropriate boundaries. Many authors advocate the

importance of maintaining a professional distance

within the nurse-patient relationship (Arnold and

Boggs, 2003) as nurses are encouraged to care with

empathy and compassion while maintaining some

degree of emotional detachment (Dowling, 2006). Yet,

it was the sharing of my thoughts and feelings of my

experiences with my own sons or ‘therapeutic reci-

procity’ (Marck, 1990) that created boundaries, which

were sufficiently relaxed to allow Sam’s mother to be

open to my caring but left me vulnerable to emotional

hurt (Stickley and Freshwater, 2002). I now acknowl-

edge that my own self-awareness was not sufficiently

developed to alert me to my emotional vulnerability

within this relationship. Bunard (2002) suggests that as

self-awareness develops so too does the ability to

manage open interactions with others. I now realize





that increased self-understanding will enable me to set

appropriate boundaries and protect me from excessive

emotional vulnerability (Stickley and Freshwater,

2002). Perhaps, this was what my more experienced

colleague was alluding to when she advised me against

becoming overinvolved with my patients. The diffi-

culty is, however, knowing where to set these boundaries, particularly in critical care nursing where

so many patients, like Sam, die. This can lead to critical

care nurses concentrating on the technological aspects

of care (Villanueva, 1999) as a strategy to protect

themselves from the grief associated with losing their

patients. It can also lead to nurses experiencing

burnout and leaving the profession if they experience

repeated on-the-job trauma (Schwarz, 2005). However,

according to Freshwater (2002), it is only through the

experience of loving our patients within therapeutic

relationships that we learn where these boundaries are.

Clinical supervision and reflective practice have the

potential to support nurses in learning the art of thera-

peutic loving (Down, 2002; Stickley and Freshwater,

2002). However, clinical supervision has not yet be-

come a reality in critical care nursing in many hospi-

tals. While preceptorship is well established, in my

experience, preceptors tend to concentrate on support-

ing the acquisition of technical skills rather than the

development of nurse-patient relationships in the ICU.

Perhaps, this is because, according to Ray (1987) and

Beeby (2000), it is only when ICU nurses are confident

with the use of technology that emotional caring can

begin. Wilkin and Slevin (2004) believe that the support

of colleagues is very important to nurses when coping

with the emotions experienced in ICU, and unfortu-

nately, this support was not available to me. However,

through the process of reflection, I have become aware

of my own vulnerability and the importance of setting

appropriate boundaries within therapeutic relation-

ships. This knowing and recognizing of self is according

to Freshwater (2002) fundamental to the development of therapeutic alliances. While initially I felt that I

experienced professional regression as a result of my

relationship with Sam and his family, through the

process of reflection, I now realize that I have expe-

rienced professional growth. The emotional intelligence

(Stickley and Freshwater, 2002) that I have developed as

a result of this experience will enhance my ability to

form therapeutic relationships within appropriate

boundaries with the patients and families in my care.

CONCLUSIONTherapeutic nurse-patient relationships are central to

the delivery of patient-focused nursing, but the de-

velopment of these relationships depends upon the

context in which care is delivered. This paper, through

reflection on a personal experience and the presentation

of empirical evidence of nurse-patient relationships,

has demonstrated that in critical care nursing, engaging

in therapeutic nurse-patient relationships can expose

nurses to emotional pain if appropriate boundaries are

not set. However, reflective practice has the potential to

facilitate ICU nurses learning where to set these

boundaries to allow the development of relationships

that are mutually beneficial to both nurse and patient.

WHAT IS KNOWN ABOUT THIS TOPIC

• The presence of a therapeutic nurse-patient relationship is central to the delivery of patient-centred care.

• Emotional intelligence is required to develop therapeutic nurse-patient relationships.

• Nurse-patient relationships are dependent upon the context in which care is delivered.

WHAT THIS PAPER ADDS

• Engaging in therapeutic relationships with critically ill patients and their families can expose ICU nurses to emotional pain.

• Reflection can facilitate ICU nurses in the development of emotional intelligence and thus enhance their ability to engage in

therapeutic nurse-patient relationships.

REFERENCESArnold E, Boggs KU. (2003). Interpersonal Relationships: Pro-

fessional Communicatio n for Nurses, 4th edn. Missouri:

Saunders.

Balsdottir G, Jonsdottir H. (2002). The importance of nurse caring

behaviours as perceived by patients receiving care at an

emergency department. Heart and Lung: The Journal of Critical

Care; 31: 67–75.

Barker P. (2001). The tidal model: the lived – experience in

person-centered mental health nursing care. Nursing Philos-

ophy; 2: 213–223.

Beeby JP. (2000). Intensive care nurses’ experiences of caring Part

2. Intensive and Critical Care Nursing; 16: 151–163.

Benner P. (1984). From Novice to Expert. California: Addison-

Wesley.

Bergbom-Enberg I, Haljamae H. (1993). The communication

process with ventilator patients as perceived by nursing staff.

Intensive and Critical Care Nursing; 9: 40–47.

Binnie A, Titchen A. (1999). Background issues. In: Binnie A,

Titchen A, (eds), Freedom to Practice: The Development of

Patient-Centered Nursing. Oxford: Butterworth-Heinemann.


142 ª 2008 The Author. Journal Compilation ª 2008 British Association of Critical Care Nurses



Boykin A, Schoenhofer SO. (2001). Anna Boykin and Savina O.

Schoenhofer: nursing as caring. In: Parker M, (ed.), Nursing

Theories and Nursing Practice. Philadelphia: Davis.

Briant S, Freshwater D. (1998). Exploring mutuality within the

nurse-patient relationship. British Journal of Nursing; 7: 204–211.

Bunard P. (2002). Learning Human Skills: An Experiential Guide for

Nurses. Oxford: Heinemann.

Bush H, Barr W. (1997). Critical care nurses lived experience of

caring. Heart and Lung: The Journal of Acute and Critical Care ;

26: 387–398.

Chinn PL, Kramer MK. (1999). Theory and Nursing: Integrated

Knowledge Development, 5th edn. St. Louis: Mosby.

Clarkson P. (2003). The Therapeutic Relationship, 2nd edn. London:

Whurr.

Cronin SN, Harrison B. (1988). Importance of nurses’ caring

behaviours as perceived by patients after a myocardial

infarction. Heart and Lung; 17: 374–380.

Dowling M. (2006). The sociology of intimacy in the nurse-

patient relationship. Nursing Standard; 20: 48–54.

Down J. (2002). Therapeutic nursing and technology: clinical

supervision and reflective practice in a critical care setting.

In: Freshwater D, (ed.), Therapeutic Nursing; Improving Patient

Care through Self-awareness and Reflection. London: Sage.Dyer I. (1995). Preventing the ITU syndrome, or how not to

torture an ITU patient: part 1. Intensive and Critical Care

Nursing; 11: 130–139.

Dyson M. (1999). Intensive care psychosis, the therapeutic

nurse-patient relationship and the influence of the intensive

care setting: analyses of interrelating factors. Journal of Clinical

Nursing; 8: 284–290.

Ford P, McCormack B. (2000). Keeping the person in the centre

of nursing. Nursing Standard; 14: 40–44.

Freshwater D. (2002). The therapeutic use of self in nursing. In:

Freshwater D, (ed.), Therapeutic Nursing: Improving Patient

Care through Self-awareness and Reflection. London: Sage.

Freshwater D, Stickley T. (2004). The heart of the art: emotional

intelligence in nurse education. Nursing Inquiry; 11: 91–98.

Fulford KWM. (1996). Concepts of disease and the meaning of patient-centered care. In: Fulford KWM, Ersser S, Hope T,

(eds), Essential Practice in Patient-Centered Care. London:

Blackwell Science.

Granberg A, Bergbom I, Lundberg D. (2001). Clinical signs of

ICU syndrome/delirium: an observational study. Intensive

and Critical Care Nursing; 17: 72–93.

Hammond F. (1995). Involving families in care within the

intensive care environment: a descriptive survey. Intensive


Harbaugh BL, Tomlinson PS, Kirshbaum M. (2004). Parents

perceptions of nurses’ caregiving behaviours in the paediatric

intensive care unit. Issues in Comprehensive Paediatric Nursing;

27: 163–178.

Henderson S. (2003). Power imbalance between nurses and

patients: a potential inhibitor of partnership in care. Journal of Clinical Nursing; 12: 501–508.

Johns C. (2005). Reflection on the relationship between caring

and technology. Nursing in Critical Care; 10: 150–157.

Leininger MM. (2001). Madeleine M. Leininger: theory of culture

care diversity and universality. In: Parker M, (ed.), Nursing

Theories and Nursing Practice. Philadelphia: Davis.

Little CV. (2000). Technological competence as a fundamental

structure of learning in critical care nursing: a phenomeno-

logical study. Journal of Clinical Nursing; 9: 391–399.

Locsin RC. (1998). Technological competence as caring in critical

care nursing. Holistic Nurse Practitioner; 12: 50–56.

Marck P. (1990). Therapeutic reciprocity: a caring phenomenon.

Advances in Nursing Science; 13: 49–59.

McClement SE, Degner LF. (1995). Expert nursing behaviours in

care of the dying adult in the intensive care unit. Heart and

Lung: The Journal of Acute and Critical Care; 24: 408–419.

McCormack B. (2003). A conceptual framework for person-centered

practice with older people. International Journal of Nursing

Practice; 9: 202–209.

McCormack B. (2004). Person-centeredness in gerontological

nursing: an overview of the literature. International Journal of

Older People Nursing; 13: 31–38.

McCormack B, Titchen A. (2001). Patient-centered practice: an

emerging focus for nursing expertise. In: Higgs J, Titchen A,

(eds), Practice, Knowledge and Expertise in the Health Profession.

Oxford: Butterworth-Heinemann.

McQueen A. (2000). Nurse-patient relationships and partnership

in hospital care. Journal of Clinical Nursing; 9: 723–731.

Michie S, Miles J, Weinman J. (2003). Patient- centeredness inchronic illness: what is it and does it matter? Patient Education

and Counseling; 51: 197–206.

Morse JM. (1991). Negotiating commitment and involvement in

the nurse-patient relationship. Journal of Advanced Nursing;

17: 809–821.

Nolan M, Davies S, Brown J, Keady J, Nolan J. (2004). Beyond

‘person-centered’ care: a new vision for gerontological nurs-

ing. International Journal of Older People Nursing; 13: 45–53.

Ray MA. (1987). Technological caring: a new model in critical

care. Dimensions of Critical Care Nursing; 6: 166–173.

Robb YA. (1998). Family nursing in intensive care part two: the

needs of a family with a member in intensive care. Intensive


Rodgers CR. (1999). Client-Centered Therapy. London: Constable

and Company units.Schwarz T. (2005). PTSD in Nurses. American Journal of Nursing;

105: 13.

Soderstrom I, Benzein E, Saveman B. (2003). Nurses’ experiences

of interactions with nurses in intensive care. Scandinavian

Journal of Caring Sciences; 17: 185–195.

Stickley T, Freshwater D. (2002). The art of loving and the

therapeutic relationship. Nursing Inquiry; 9: 250–256.

Titchen A. (2001). Skilled companionship in professional practice.

In: Higgs J, Titchen A, (eds), Practice Knowledge and Expertise

in the Health Professions. Oxford: Butterworth Heinemann.

Villanueva N. (1999). Experiences of critical care nurses’ caring

for unresponsive patients. Journal of Neuroscience Nursing; 31:

216–223.

Walters AJ. (1995). A Heideggerian hermeneutic study of the

practice of critical care nurses. Journal of Advanced Nursing; 21:492–497.

Watson J. (1985). Nursing: Human Science and Human Care.

A theory of Nursing. New York: National League of Nursing.

Wilkin K, Slevin E. (2004). The meaning of caring to nurses: an

investigation into the nature of caring work in an intensive

care unit. Journal of Clinical Nursing; 13: 50–59.



O Connell 2008 Nursing in Critical Care

Documents

Transcript of O Connell 2008 Nursing in Critical Care