Intensive and Critical Care Nursing (2015) 31, 196—204

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ORIGINAL ARTICLE

Nurses’ experiences of caring for critically

ill, non-sedated, mechanically ventilated
patients in the Intensive Care Unit:
A qualitative study
Eva Laerkner a,b,∗, Ingrid Egerod c, Helle Ploug Hansen a

a
Faculty of Health, Department of Public Health, University of Southern Denmark, Denmark
b
Dept. of Anesthesiology and Intensive Care, Odense University Hospital, Denmark
c
University of Copenhagen, Copenhagen University Hospital Rigshospitalet, Trauma Centre, Denmark

Accepted 29 January 2015

KEYWORDS Summary
Critical illness; Objective: The objective was to explore nurses’ experiences of caring for non-sedated, critically
Fieldwork; ill patients requiring mechanical ventilation.
Intensive care; Design and setting: The study had a qualitative explorative design and was based on 13 months
Interpretive of fieldwork in two intensive care units in Denmark where a protocol of no sedation is imple-
description; mented. Data were generated during participant observation in practice and by interviews with
Interview; 16 nurses. Data were analysed using thematic interpretive description.
Mechanical Findings: An overall theme emerged: ‘‘Demanding, yet rewarding’’. The demanding aspects
ventilation; of caring for more awake intubated patients included unpredictability, ambiguous needs and
No sedation; complex actions, while the rewarding aspects included personal interaction. Three sub-themes
Nursing were identified: (i) caring for and with the patient, (ii) negotiating relational and instrumental
care and (iii) managing physical and emotional closeness.
Conclusion: Despite the complexity of care, nurses preferred to care for more awake rather
than sedated patients and appreciated caring for just one patient at a time. The importance of
close collaboration between nurses and doctors to ensure patient comfort during mechanical
ventilation was valued. Caring for more awake non-sedated patients required the nurses to
act at the interface between ambiguous possibilities and needs, which was perceived as both
demanding and rewarding.
© 2015 Elsevier Ltd. All rights reserved.

∗ Corresponding author at: Dept. of Anesthesiology and Intensive Care, Odense University Hospital, Sdr. Boulevard, 5000 Odense C,

Denmark. Tel.: +45 6541 5174.

E-mail addresses: elaerkner@health.sdu.dk, eva.laerkner@rsyd.dk (E. Laerkner).

http://dx.doi.org/10.1016/j.iccn.2015.01.005
0964-3397/© 2015 Elsevier Ltd. All rights reserved.
Nurses’ experiences of caring for patients in the ICU: A qualitative study
Implications for Clinical Practice
• Caring for more awake, non-sedated patients during mechanical ventilation requires a new set of competencies for
ICU nurses.
• Pay attention to and develop working conditions that incorporate a balance between closeness and distance in
everyday clinical practice to counter emotional burnout.
• Support and educate nurses to act as moral agents in the interface of complexity in the ICU, to preserve patients as
persons at the centre of nursing practice.
Introduction
Recent changes in the sedation management of critically
ill, mechanically ventilated (MV) patients in intensive care
(ICU) have been described as constituting a paradigm shift
(Mehta et al., 2011; Roberts et al., 2012). The evolution of
this new paradigm includes analgosedation, where pain is
treated first and sedation is administered only when neces-
sary (Devabhakthuni et al., 2012). The change in sedation
management may affect patients as well as the practice
of health care professionals, which makes it important to
explore nursing practice within this developing paradigm.
This article is part of a broader study exploring patients’
and nurses’ experiences, actions and interactions in the con-
text of a no-sedation strategy in ICU. This article focuses on
nurses’ experiences of caring for non-sedated and awake MV
patients.
Sedation has been considered to be an integral aspect
of the treatment of patients requiring intubation and MV
in ICU (Moore, 2011). In recent years, however, the disad-
vantages of sedation have become apparent and practice
has changed towards lighter sedation (Barr et al., 2013;
Egerod et al., 2013b; Egerod, 2009; Kress and Hall, 2012).
The new sedation paradigm enables better monitoring of
cerebral functioning and improves long-term patient out-
come (Wunsch and Kress, 2009). A randomized clinical trial
in Denmark demonstrated the feasibility of a protocol of
no sedation leading to significantly shorter duration of MV,
shorter ICU stay and shorter length of hospital stay, com-
pared to a group of patients receiving light sedation with
daily wake-up calls (Strom et al., 2010). A follow-up study
showed that a protocol of no sedation did not increase long-
term psychological sequelae after intensive care (Strøm
et al., 2011), suggesting that MV patients do well without
sedation (Strøm and Toft, 2011).
A cross-sectional survey of sedation practice in Nordic
and non-Nordic European countries, concluded that Nordic
countries come closer to applying a strategy of lighter
sedation (Egerod et al., 2013a). The study highlights that
organisational and contextual factors, such as ICU size,
staffing ratio and inter-professional collaboration affect
sedation practice. Not all studies however, support the goal
of less or no sedation. A Swedish study exploring ethi-
cal issues, argued that non-sedated patients might suffer
and stated that disagreement persists regarding sedation
practice (Nortvedt et al., 2005). This is consistent with a US
survey which demonstrated that most nurses consider MV to
be stressful and that sedation is required to ensure patient
comfort (Guttormson et al., 2010).
197
While research has focused on conscious MV patients
and their relatives (Karlsson et al., 2012a,b,c; Karlsson
and Forsberg, 2008), less attention has been given to the
experiences of ICU nurses. A recent qualitative study explor-
ing the perspective of experienced ICU nurses concluded
that lighter sedation enabled the provision of individual-
ized care, better communication and the establishment of a
nurse—patient relation (Tingsvik et al., 2013), while another
study highlighted the nurses’ experience of caring for less
sedated patients was more demanding and increased nursing
workload (Everingham et al., 2014).
Being awake implies that patients are alert and con-
scious, corresponding to a score of 0 on the Richmond
Agitation and Sedation Scale (RASS) (Sessler et al., 2002).
Change in medical practice may have some derived implica-
tions for everyday nursing practice, which will continue to be
silent, tacit and remain as ‘‘invisible work’’, if unexplored
(Mesman, 2008). Therefore, more knowledge is needed to
describe and understand how less or no sedation may influ-
ence nursing practice in the ICU. Our study attempts to
explore the nurses’ perspective in order to provide per-
ceptive knowledge of care in the ICU, embracing a new
paradigm of no-sedation.
Methods
Objective
The aim of the study was to explore nurses’ experiences
of, and attitudes towards, caring for non-sedated, awake,
critically ill MV patients in ICU.
Design
A qualitative approach, using participant observation and
interviews, was chosen to enable an in-depth enquiry into
everyday practice in ICU from the nurses’ perspective. The
study was conducted as part of an ethnographic fieldwork
(Emerson et al., 2011; Ybema, 2009) and our data were gen-
erated by the first author over 13 months in two ICU units
during the period 2011—2013 (August 2011 to March 2012
and September 2012 to March 2013).
Setting
The context of the study was two level three adult ICUs
(units A and B) in a University Hospital in Denmark. The units
198
Figure 1 Protocol of no sedation.
Source: Strom et al., 2010; Strøm and Toft, 2011.
were purposively selected as they had implemented a proto-
col of no sedation (Fig. 1) (Strom et al., 2010). A description
of the patients at the two study ICUs is provided in Fig. 2.
Nurses worked closely with the patients and used computer
work stations by the patients’ bedsides. The nurse—patient
ratio was 1:1 24 hours a day.
Participants
The participants were ICU nurses who were experienced
in caring for non-sedated and awake patients during MV.
The nurses followed during participant observation were
selected pragmatically according to those who cared for
non-sedated MV patients. During the fieldwork, different
nurses were observed in their daily work. This provided the
opportunity to observe a variety of situations and interac-
tions, leading to rich descriptions of everyday practice.
Nurses participating in the interviews were purposively
sampled; we looked for variation in age, gender and ICU-
experience. Eight nurses from each unit participated in the
interviews. To generate rich data about everyday practice,
a total of 16 nurses was considered to provide an adequate
sample to derive significant knowledge to fulfil the purpose
of the study (Sandelowski, 1995).
Figure 2 Patients at the two study units.
E. Laerkner et al.
Ethical approval
The study was conducted according to the principles of
the Declaration of Helsinki (WMA, 2013) and the ethical
guidelines for nursing research in Scandinavia (SSN, 2003).
The study was reviewed by the Scientific Committee in the
Region of Southern Denmark (Project-ID:S-20110012). Per-
mission to produce and store personal data was obtained
from the Danish Data Protection Agency (J.nr.2011-41-5724).
Permission to conduct the study was obtained from the
ICU management. All participating nurses and patients con-
sented to participant observation in clinical practice after
receiving written and verbal information about the study.
Written consent was further obtained from nurses who were
interviewed. To protect informants’ privacy and anonymity,
the nurses are referred to as N1 to N16 or pseudonyms. All
the participants were informed of the voluntary nature of
the study and the option to withdraw their consent at any
time.
Data generation
Participant observation was conducted by the first author,
who is an experienced ICU nurse and who works on the
department, although not in the units studied. Participant
observation was conducted for 102 days, between 2 and
12 hours a day, usually 4—5 hours at a time; most often in the
morning between 7 and 12 am or in the afternoon between 3
and 8 pm. Some observations were held in the late evenings
and during the nights. Most observations took place on week-
days and some on weekends and during public holidays.
Brief field notes were taken during observations and more
detailed descriptions were recorded immediately following
each observation.
The first author conducted individual, in-depth, semi-
structured interviews with the nurses (Holstein and
Gubrium, 1995). The interview guide (Table 1) was informed
by previous research and covered topics such as the partic-
ipants’ previous experience with non-sedated MV patients,
decisions regarding sedation, nurses’ attitudes towards the
no-sedation strategy and competencies nurses considered
were important. Interviews were conducted as open conver-
sations, using the interview guide as a loose structure; this
allowed for questions arising from the participant observa-
tion to be addressed. In this way the data generated during
participant observation and interviews mutually informed
each other (Tjørnhøj-Thomsen and Whyte, 2008). All the
interviews were conducted during the fieldwork at the hos-
pital, which was the participants’ preference, and at times
of their choosing. The interviews lasted between 41 and
87 minutes and were digitally recorded and transcribed ver-
batim by the first author.
Data analysis
Data from participant observation and interviews were
analysed using a qualitative, descriptive and interpretive
thematic analysis (Thorne, 2008), to produce knowledge
about everyday practice in accordance with the aim of
our study. Interpretive description is grounded in an inter-
pretive orientation that acknowledges the constructed and
Nurses’ experiences of caring for patients in the ICU: A qualitative study 199

Table 1 Interview guide.

Theme Exploring questions In-depth questions

Experience with using a
protocol of no sedation
The encounter with more
awake critically ill patients
during ventilator treatment
Difference between sedated
and non-sedated patients
Attitude towards patients
being awake during
ventilator treatment
Sedation decision-making
Collaboration
Competencies
Working conditions
How do you experience caring for
non-sedated and more awake patients in
need of mechanical ventilation?
How do you experience the encounter with
the patient?
Do you experience that there is a
difference in caring for non-sedated
patients as opposed to sedated patients?
Do you have an opinion about the no
sedation strategy?
Who makes the decision to sedate or not to
sedate?
How do you experience the collaboration
with other health care professionals
regarding the no-sedation strategy?
What competencies do you consider
important in caring for more awake,
non-sedated patients in need of mechanical
ventilation in ICU?
How do you experience your working
conditions in relation to caring for more
awake, non-sedated ventilated patients?
Could you give me examples from
your practice?
Could you give examples from
specific patient situations?
Could you tell me more about your
experience?
Can you elaborate more on your
opinion?
Try to tell me more about your role
as a nurse in this regard?
Can you describe some actual
situations that illustrate your views?
Why are these competences
important for you?
In what (if any) ways do personal,
physical and spatial conditions
influence your practice regarding
caring for non-sedated patients?

contextual nature of human experience (Thorne et al.,
1997, p. 172). This approach takes a stance in the partic-
ular and practical everyday life, and attempts to grasp,
describe and interpret the complexity of practice for the
purpose of developing meaningful and essentially useful
nursing knowledge (Thorne, 2008). The analytical process
is a reflective and dialectical, hermeneutical process that
moves between parts and the whole, between practice con-
text and abstraction, from data generation and through
the inquiry of data. The analytical process we followed is
described by Thorne (2008): First we immersed ourselves
in the data to comprehend its richness and integrity and
to sort out and deconstruct the data across the material in
entities. By continually challenging and refining the enquiry,
inductively we created a coherent whole from the basis of
generated data and re-contextualized patterns. In reflec-
tive and meaningful analytical interpretation, thematic
concepts and subthemes were developed (Thorne, 2008,
p. 163—176).
To ensure trustworthiness, we applied Lincoln & Guba’s
criteria of credibility, dependability, confirmability and
transferability (Lincoln and Guba, 1985; Tobin and Begley,
2004). Credibility was sought through a prolonged engage-
ment in a real-life context of an ICU that embraces a strategy
of no sedation, using acknowledged research methods
and triangulating observation and interviews. Dependabil-
ity was increased by generating thick descriptions of the
nurses’ experiences and everyday life in the ICU and
through the interpretation of these data by using a dialec-
tical, hermeneutical, analytical process in the genesis of
thematic concepts and subthemes. The transcripts were an
integrated part of data analysis. Quotations are presented
to provide evidence that the findings were grounded in data.
Triangulation of investigators and mutual intellectual reflec-
tivity through the research process enhanced confirmability.
By exploring an evolving ICU practice concerning a no-
sedation strategy from the nurses’ perspective, we have the
opportunity to inform other ICUs of challenges and consid-
erations, and this could support the transferability of our
study.
Findings
During the fieldwork, 70 different nurses were observed in
their daily practice, representing about half of the nurses
employed at the two units. In total, 16 nurses participated
in the interviews: 14 female and two male nurses, with a
median (range) age of 40 (27—49) years, median nursing
experience of 12 (1—25) years, median ICU experience of
eight (0.5—21) years, and median experience in current ICU
of six (0.5—18) years. Seventy-five percent of the nurses
were ICU certified (Table 2).
The findings are captured in the overarching theme
‘‘Demanding, yet rewarding’’. This theme, describing
nurses’ experiences of caring for non-sedated critically ill,
MV ICU patients, was further unfolded in three subthemes:
(i) caring for and with the patient, (ii) negotiating relational
and instrumental care and (iii) managing physical and emo-
tional closeness.
200 E. Laerkner et al.

Caring for and with the patient

Table 2 Informant characteristics.
In their everyday practice, nurses showed how their
Informant Unit ICU experience ICU work was influenced by interactions with more awake MV
number in years certification patients. The nurses were attentive and responsive to
patients’ wishes, and tried to comply with their preferences
N1 A 11 Yes in daily care. The situation was, at the same time, bound
N2 A 0.5 No by the patients’ critical illness and bodily dependence on
N3 A 3 No nursing care. Nurses performed their tasks, while at the
N4 A 3.5 Yes same time trying to integrate the particular needs of the
N5 A 12 Yes individual patient.
N6 A 9 Yes
N7 A 11 Yes ‘‘It is morning and I am with John, the nurse caring for a
N8 A 3 No young ventilated patient with a tracheostomy. The venti-
N9 B 18 Yes lator is in supporting mode, still with 60% oxygen and 12
N10 B 1 No in PEEP. The patient has an infection, is on dialysis, and
N11 B 21 Yes has a number of central intravenous and arterial lines,
N12 B 5 Yes a feeding tube and several abdominal drains. John has a
N13 B 8 Yes tray with meds for the patient. Before giving the meds he
N14 B 8 Yes asks the patient if he wants to be bathed after medica-
N15 B 9 Yes tion. The patient nods and finds a notepad on the bedside
N16 B 11 Yes table and slowly writes ‘‘water’’ and ‘‘soap’’ with cap-
ital letters. ‘‘Yes’’ says John ‘‘you want a proper bed
bath—not just warm washcloths?’’ The patient nods. John
Demanding, yet rewarding offers to help the patient wash after giving the meds. The
patient shakes his head and writes ‘‘not now’’. John nods
Non-sedated patients’ ability to interact and express sub- and starts to give the IV medications’’. (field note unit A)
jective and personal needs and wishes and at the same
time being critically ill, dependent of care and technologi- This observation illuminates how the nurse adapts care
cal devices to support vital body functions, were perceived to the preferences of the patient while performing nursing
by the nurses as simultaneously demanding and rewarding. care tasks. The nurses stress that caring for conscious and
‘‘It is at one and the same time exciting, but also awake patients requires patience, situational grasp and an
demanding. It is exciting because the patient is able to awareness that differs from caring for a sedated patient.
make requests and choices, which makes it possible to The nurse does not make all the decisions, but waits for
provide the best nursing care. But it is also very demand- cues from the patient. One nurse explains:
ing; because the nurse is so exposed when the patient is
awake’’. (N13) ‘‘With sedated patients, I follow a daily schedule, but
when they are awake I try to collaborate with the patients
The demanding aspects related to constant awareness and follow their wishes. It takes more time because it
of the patients’ condition, expressions, actions and needs, follows the rhythm of the patient’’. (N11)
while trying to comfort and manage care in relation to
severe bodily dysfunctions in a life-threatening situation. Nurses’ felt it was rewarding to collaborate with the
At the same time, it was emphasized that the opportunity patient and they often encouraged the patients to express
to interact, get feedback and adapt care to the benefit of their feelings and wishes, even though it sometimes was
the individual patient, was perceived as rewarding. more time consuming to involve the critically ill patient in
‘‘I really feel that the patients should be awake so they the care. At the same time, this interactive cooperation was
have the option of knowing what is going on’’. (N5) experienced as demanding by decreasing the nurse’s ability
to control and plan ahead. Attempting to handle the situa-
Although it was demanding, nurses preferred to inter- tion in the best interests of the patient may enhance nurses’
act with awake and conscious patients rather than sedated experiences of inadequacy and highlight the unpredictability
patients. However, they also expressed the importance of of caring for more awake MV patients.
caring for just one patient at a time.
‘‘Although it is a challenge, it is also encouraging to care
‘‘It is important to be one-on-one with a more awake
for a more awake patient. I get an impression of the per-
ventilated patient, because it requires constant nursing
son . . . and I also get something else . . . I get a response.
presence’’. (N3)
The patient reacts to what I do. It can be a challenge,
The demanding, yet rewarding aspects of caring were when the patient says not to do it this or that way. How
perceived as ambiguous, rather than dichotomous, in the should I do it then? It gives me a feeling of inadequacy’’.
nurse—patient encounter. Although ambiguity is inherently (N11)
stressful (Lindberg et al., 2008), the nurses valued the inter-
action and the increased patient control and promoted the Another aspect of increased nurse—patient interaction
integrity and person-centred care of the patient. This is was the nurses’ desire for more continuity after they had
elaborated further in the following three sub-themes. gotten to know the patient. One nurse explains:
Nurses’ experiences of caring for patients in the ICU: A qualitative study
‘‘On the first day, it is important to get at grasp of the
situation, to understand what kind of person I am dealing
with, and to know their preferences. It is great when I get
to care for the same patient for longer, so I know what the
patient wants and I understand their small expressions’’.
(N9)
Greater continuity helped the nurse to familiarise herself
with the patient’s expressions and gestures, enhancing the
patient’s opportunity to be seen and involved in the care.
More experienced nurses claimed however, that knowing the
patient was less important.
Negotiating relational and instrumental care
Another aspect of caring for more awake patients was
negotiating simultaneous attention to relational and instru-
mental aspects of care. This is illuminated in the following
example with Kim, a severely ill patient with abdominal
infection, multi-organ failure and high ventilator depend-
ency with 50% oxygen support.
‘‘Kim is in a semi-sitting position in bed and is wearing
glasses. He looks up and waves at us when we enter.
Camilla (the nurse I am following) goes immediately to
the bed. ‘‘Hi Kim’’ she says and takes his hand in both of
hers. Kim smiles and looks at Camilla. He clearly recog-
nizes her. ‘‘Yes, I will be with you today’’ says Camilla.
‘‘Did you sleep during the night?’’ Kim nods and lifts the
other hand and shows a small gap between thumb and
index finger [meaning ‘a little’]. ‘‘Not so much?’’ says
Camilla. Kim shrugs his shoulders. ‘‘I had planned for
you to sit in a chair this morning. How would that be?’’
Kim shrugs his shoulders again. Then the dialysis machine
starts to alarm. Camilla takes one hand and pushes the
button on the dialysis machine to silence the alarm, while
she holds Kim’s hand in the other. ‘‘Try to turn your head
toward the left, Kim. It [dialysis machine] is indicating
resistance at the inlet. I think it will help if you turn your
head a bit’’ says Camilla. Kim turns his head toward the
left and Camilla looks at the machine and back to Kim.
‘‘Yes, that’s better. Is it uncomfortable for you to sit like
this?’’ Kim shakes his head and gives a thumbs-up’’. (field
note unit A)
Being able to negotiate relational and instrumental care
was perceived as a valued skill by the nurses, where the
ability to maintain contact with the patient while perform-
ing technical tasks was regarded as rewarding. However, the
situation became demanding, when life-threatening situa-
tions arose. Managing the equipment without unsettling the
patient was indeed a challenge. In these situations, good
technical skills enabled the nurse to keep a focus on the
patient.
‘‘For me it is important to be good at handling the equip-
ment. If I know the machines, I am able to pay attention
to the patient, because I know what to do if the alarm
goes off on one of the machines’’. (N7)
Nurses with five or more years of critical care experience
stressed the importance of technical proficiency in order to
communicate with the patient while performing other tasks.
Surprisingly, the less experienced nurses perceived the
201
ability to perform simultaneous, but diverse, care activities
as merely a practical issue.
‘‘I have not thought that it could be different, because
the patients have been awake as long as I have worked
here. This is what we are trained to do, to talk to the
patient and try to understand what the patient is saying
while dealing with the equipment. I practice this every
day’’. (N2)
Managing physical and emotional closeness
The workstation in the patient’s room enabled the nurses to
be physically close to the patients during their shift. The
nurses stated that their physical presence was essential,
because they could observe the patient and immediately
react to changes. Moreover, the proximity to the patient
enabled continuous attention to the patient’s bodily and
facial expressions.
‘‘If I take my time with the patients I can get them to
relax. This is often what is most important . . . to be there
. . . and provide safety and closeness . . . to be around them
and explain what is going on’’. (N14)
It was rewarding for the nurses to be close to the
patients; the physical proximity enabled nurses to provide
attention and offer reassurance. The continuous presence
provided more time for the patient and encouraged com-
munication, touch and empathy.
‘‘I have experienced patients that were very anxious.
This also makes it difficult. There is a risk of self-
extubation, which can have fatal consequences. So I am
right by the bedside all the time’’. (N10)
The physical presence was also challenging; it was not
always possible for nurses to calm and reassure restless or
agitated patients. Some nurses were torn as they tried to
avoid sedation while trying to maintain patient comfort.
These difficult situations required good interdisciplinary
collaboration with physicians, who had the mandate to
sedate the patient, if necessary. Although not in charge
of sedation, the nurses exerted an influence in the situa-
tion and were able to negotiate with the physicians if they
believed sedation could be avoided without compromising
safety.
‘‘My experience is that the nurses’ arguments are heard
when the physicians assess the patient to decide if seda-
tion is necessary’’. (N16)
The physical proximity often led to a closer personal rela-
tionship with the patient. The patient’s ability to interact
made it easier to get an impression of the patient’s per-
sonality. The nurses stressed the importance of seeing the
patient as a unique individual with a personal life and his-
tory, despite critical illness, organ failure, technical support
and surveillance.
‘‘I get a better impression of the person I am caring for
when the patient is awake. The patients can demonstrate
who they are and what they want. Sedated patients need
others to explain who they are’’. (N7)
202
The physical proximity and personal nurse—patient rela-
tionship might affect the nurses emotionally. Caring for
non-sedated patients led to more patient involvement than
caring for sedated patients. ‘‘I take the awake patients with
me more . . . I am affected by their situation’’ (N12). The
physical proximity and emotional closeness represent both
demanding and rewarding aspects of critical care nursing.
Physical proximity to the patient at the bedside encourages
a personal relationship, while also making it more difficult to
maintain a professional distance; thus creating more emo-
tional involvement.
Discussion
The ICU nurses’ experience of caring for non-sedated and
awake MV patients was found to be both demanding and
rewarding. The demanding, yet rewarding aspects of care
were reflected in caring for and interacting with the patient,
negotiating relational and instrumental care and managing
physical and emotional closeness. In our study the nurses’
attitude towards caring for more awake MV patients was
positive; they preferred patients to be awake, as it enabled
more interactive nursing care. Our finding corresponds to a
study showing that caring for lightly sedated patients can
increase nurses’ work satisfaction (Tingsvik et al., 2013).
To our knowledge, this is the first study to focus solely on
nurses’ experiences of caring for non-sedated MV patients
in ICU. Karlsson and Bergbom (2015) have investigated
anaesthetists, nurses’ and nurses’ assistants experiences
of caring for conscious patients in the ICU (Karlsson and
Bergbom, 2015). They emphasized that the staff experi-
enced it as difficult, because patients’ suffering was so
visible. But some participants also found it more chal-
lenging and inspiring to care for conscious patients, while
they could establish communication with them. Karlsson
and Bergbom’s study highlights staff members’ ethical con-
cerns and their feelings about patients being insufficiently
sedated. Our study highlights to a greater extent the impor-
tance for nurses to deal with ambiguity and complexity in
ICU practice.
Our findings support the presumption that nurse-patient
interaction is essential when caring for more conscious MV
patients (Alasad and Ahmad, 2005; Karlsson et al., 2012b;
Patak et al., 2004). We demonstrated the significance of
attentiveness, empathy, patience and ability to improvize
while gaining a grasp of the situation. Caring for more awake
MV patients may increase uncertainty as it is less predictable
and controllable than caring for sedated patients. Acting
in accordance with, and integrating, patient preferences
may be captured by the concept of ‘‘following the patient’s
lead’’ (Benner et al., 2011, p. 473), and this highlights the
importance of patient involvement.
Nurses in our study stressed the importance of con-
tinuity. Knowing the patient is a key concept in nursing
(Tanner et al., 1993; Zolnierek, 2014) and particularly in
intensive care (Crocker and Scholes, 2009). Some of the
less experienced nurses highlighted the value of knowing
the patient and continuity of care, while the more experi-
enced nurses were less dependent on detailed knowledge
of the patient. According to Benner et al. (1996), know-
ing the patient is essential to intensive care nursing and is
E. Laerkner et al.
a sign of expertise. A study of ventilator weaning showed
that the process of weaning was more successful when an
experienced nurse cared for the patient, rather than a
less experienced nurse with more knowledge of the patient
(Egerod, 2003). One explanation could be that experienced
nurses are more expedient in acquiring knowledge of the
patient than novices (Benner et al., 1996, p. 145). These
findings throw light on important aspects relating to alloca-
tion of nurses to patients in clinical practice.
Our findings demonstrated that nurses were simulta-
neously able to negotiate relational and instrumental issues.
Other studies have questioned nurses’ ability to meet
patients’ personal and psychosocial needs during critical ill-
ness (Kongsuwan and Locsin, 2011; Mcgrath, 2008; Schulz
and Hounsgaard, 2011). The technological environment has
been described as powerful and the strongest reference
point in ICU (O’keefe-Mccarthy, 2009), leaving patients’ per-
sonal and communicative needs unmet and invisible to the
nurses. Nurses’ ability to negotiate relational and instru-
mental issues has been described as the ability to balance
care and technology in the ICU (Almerud et al., 2008; Price,
2013). Mitchell (2001) describes how the caring encounter
can be perceived as a picture of paradox, where either
instrumental or relational care is in the foreground, but
this metaphor could also emphasize nurses’ ability to shift
between different perspectives simultaneously (Mitchell,
2001). This has been described as the ‘‘double gaze’’,
illuminating the interface between the typical and unique
in nursing, where the nurse must act in accordance with
both well-known tasks and procedures and situated indi-
vidual patients (Hansen, 2008). Our findings show nurses’
ability to perform a complementary practice of integrat-
ing care and technology; when nurses paid attention to
both the patient and the equipment at the same time,
the importance of technical proficiency as the key to act-
ing in the interface between instrumental and relational
care was demonstrated. Other studies have described how
nurses’ technical knowledge enhanced vigilance in caring
situations in the ICU (Crocker and Timmons, 2009; Locsin,
2005; Wikstrom and Larsson, 2004). Nurses are in a unique
position to act as moral agents in the interface between
technology and humanity, showing the importance of crit-
ical and embodied reflectivity by placing the patient at
the centre of nursing practice (O’keefe-Mccarthy, 2009). We
found that younger nurses considered it usual practice that
the MV patients were awake. Learning to provide complex
care supports the need for situational practice-learning from
mentors skilled in ICU practice, who demonstrate holistic
nursing care while maintaining the double gaze.
Our findings illustrated the consequences of physical and
emotional closeness for the nurses. The need for physi-
cal closeness for patient observation has been described
in other studies (Tingsvik et al., 2013; Wilkin and Slevin,
2004). Patients who are lightly sedated may even require
closer surveillance than conscious and more awake patients,
because their semi-conscious state presents a greater safety
risk than being alert and able to collaborate.
The interaction with a non-sedated and more awake
patient created considerable emotional involvement for the
nurses in our study. Other studies have shown how nurses
view patients as companions, as they help the patients
through tough times in ICU (Mcgrath, 2008; Vouzavali
Nurses’ experiences of caring for patients in the ICU: A qualitative study
et al., 2011). This emotional closeness may result in
over-involvement and emotional exhaustion and eventu-
ally psychological burnout (Myhren et al., 2013). Balancing
nearness and distance might necessitate the provision of
supervision, collegial reflection and time-out for nurses
working with non-sedated MV patients, in order to enhance
nurses’ resilience.
Our findings support a 1:1 nurse—patient ratio when car-
ing for more awake MV patients. A strategy of no sedation
has been implemented in some Danish ICUs, where staffing is
adequate to support this practice (Strom et al., 2010). Bet-
ter staffing and lack of physical restraints is more common
in Nordic than non-Nordic European countries (Egerod et al.,
2013a), contrasting to ICU settings in Europe and the United
States (De Jonghe et al., 2013; Hofso and Coyer, 2007).
In our study, nurses were able to influence decisions
regarding sedation; the nurses stressed the importance of
close nurse—physician collaboration. This is consistent with
other studies that emphasize how culture and management
influence sedation practice (Egerod et al., 2013a; Egerod,
2009). Our study explored the complexity of caring for
more awake MV patients and supports the presumption that
change in sedation practice may influence the competencies
that nurses need to possess or develop.
Study limitations
Limitations of the study were the unique Danish context with
1:1 nurse—patient staffing and the cultural characteristics
of work relations in Nordic countries, such as greater inter-
professional collaborative decision-making (Egerod et al.,
2013a). We are aware that this limits transferability, but
serves to illustrate what is possible in clinical ICU practice.
Other limitations were participants’ positive view towards
the issue of more awake MV patients. This was probably
unavoidable, since nurses that hold a negative view of this
regard are unlikely to work for long in a unit with a strat-
egy of no sedation. Limitations and opportunities involved
in investigating the clinical practice in which the researcher
work must also be mentioned (Dobson, 2009). Knowing the
field may enhance access, but at the same time limit the
broadness of perspective during data generation and analy-
sis.
Conclusion
Caring for non-sedated and more awake MV patients is found
by the nurses to be demanding, yet rewarding. It enables
patient interaction, promotes a person-centred approach
and integrates patient preferences in daily care. However,
nurses must be able to negotiate relational and instru-
mental aspects of care as well as manage their physical
and emotional closeness to the patient. Care becomes
less predictable as nurses face multiple ambiguities in
caring for interactive, critically ill MV patients with indi-
vidual needs and preferences. One implication of this study
is that introducing a protocol of no sedation must be
seen as an interdisciplinary responsibility, requiring a car-
ing perspective, sufficient nursing staffing, supervision and
interdisciplinary education and collaboration.
203
Acknowledgements
The authors express a special thanks to all the nurses who
so willingly shared their experiences and their everyday
practice during the study.
Funding: The study received funding from the University
of Southern Denmark, Odense University Hospital and the
Danish Nursing Research Society.
Conflict of interest: No conflict of interest has been
declared by the authors.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.iccn.2015.01.005.
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