BACKGROUND: Use of lower backrest positions occurs frequently and is a factor in the development of ventilator-associated pneumonia. OBJECTIVES: To determine the usual bed elevation and backrest position in a medical intensive care unit and their relationship to hemodynamic status and enteral feeding. METHODS: Data were collected in a 12-bed medical respiratory intensive care unit for 2 months. A protractor was used to measure the elevation of the head of the bed. Hemodynamic status was defined by systolic, diastolic, and mean arterial blood pressure measurements retrieved from each patient's flow sheet. RESULTS: The sample included 347 measurements of 52 patients. Mean backrest elevation was 22.9 degrees, and 86% of patients were supine. Backrest position differed significantly (P = .005) among nursing shifts (days, evenings, nights) but not for systolic (r = -0.04, P = .49), diastolic (r = 0.01, P = .83), or mean arterial blood pressure (r = -0.01, P = .84). Backrest elevation did not differ significantly between patients who were receiving enteral feedings and patients who were not (P = .23) or between patients receiving intermittent versus continuous nutrition (P = .22). CONCLUSIONS: Use of higher levels of backrest elevation (> or = 30 degrees) is minimal and is not related to use of enteral feeding or to hemodynamic status. The rationale for using lower backrest positions for critically ill patients may be based on convenience, the patient's comfort, or usual patterns in the unit. However, the dangers of supine positioning and its relationship to aspiration and ventilator-associated pneumonia should not be minimized.
BACKGROUND: Constraint of nurses by healthcare organizations, from actions the nurses believe are appropriate, may lead to moral distress. OBJECTIVE: To present findings on moral distress of critical care nurses, using an investigator-developed instrument. METHODS: An instrument development design using consensus by three expert judges, test-retest reliability, and factor analysis was used. Study participants (N = 111) were members of a chapter of the American Association of Critical-Care Nurses, critical care nurses employed in a large medical center, and critical care nurses from a private hospital. A 32-item instrument included items on prolonging life, performing unnecessary tests and treatments, lying to patients, and incompetent or inadequate treatment by physicians. RESULTS: Three factors were identified using factor analysis after expert consensus on the items: aggressive care, honesty, and action response. Nurses in the private hospital reported significantly greater moral distress on the aggressive care factor than did nurses in the medical center. Nurses not working in intensive care experienced higher levels of moral distress on the aggressive care factor than did nurses working in intensive care. Of the 111 nurses, 12% had left a nursing position primarily because of moral distress. CONCLUSIONS: Although the mean scores showed somewhat low levels of moral distress, the range of responses revealed that some nurses experienced high levels of moral distress with the issues. Research is needed on conditions organizations must provide to support the moral integrity of critical care nurses.