Comforting the Patient Speeds Nasogastric Tube Insertion
January 1, 2001 3 minutes read
Comforting the Patient Speeds Nasogastric Tube Insertion
Abstract & Commentary
Numerous invasive and discomforting procedures are performed almost routinely in the critical care setting. Clinicians are advised to use comforting strategies during such procedures. However, little is known about how such strategies impact clinician effectiveness or efficiency. To evaluate the effect of clinician approach, Morse and colleagues analyzed 32 cases of nasogastric (NG) tube insertion that occurred during trauma care in conscious patients. The cases were identified from a review of 193 trauma cases videotaped in three Level 1 trauma centers (among which 32 involved NG tube insertion in conscious patients). The 49 clinicians inserting NG tubes included nurses (55%), physicians (37%), and students (8%).
Insertion attempts in each patient ranged from 1-5. To categorize clinician behavior, Morse et al viewed the videotapes, defined patterns of behavior, and developed codes that reliably categorized these behaviors (> 80% agreement among multiple raters). The categories were: 1) technical (priority given to procedure, limited communication with patient beyond commands); 2) affective (priority given to minimizing patient discomfort); 3) blended (primary focus on procedure but attentive to patient comfort); and 4) mixed (several different approaches).
Most (53%) clinicians used the technical approach and interacted minimally with the patient except to give instructions. Mean total time for NG tube insertion, sorted by approach used on the last trial, was: technical 108.1 ± 12.8 seconds, affective 70.1 ± 53.0 seconds, mixed 61.4 ± 23.6 seconds, and blended 53.0 ± 17.6 seconds. Clinicians who used the technical approach on the first trial took more time to complete the task than clinicians who used the blended approach, for both the subsample of successful insertions (P = 0.009) and the full sample (P = 0.022). Clinicians who used the technical approach on the last trial fared similarly. They required more time to complete the task, both overall (P = 0.05), and when the number of trials was controlled for by analysis of covariance (P = 0.03), compared to the blended group. (Morse JK, et al. Am J Crit Care 2000;9:325-333.)
Comment by Leslie A. Hoffman, PhD, RN
This study used an innovative approach to document, define, and categorize behavioral styles of providing care and differences in the effectiveness of these behavioral styles. The technique used to record clinician behavior was unobtrusive. Video cameras were mounted on the walls of trauma rooms and taping was done on a continuous basis throughout the patient’s treatment. Operators and monitors were not present in the room. Four patterns of clinician behavior toward the patient during the procedure were identified. Overall, clinicians who balanced the technical aspects of the procedure with use of comforting strategies (blended approach) were the most efficient and most effective in completing the procedure. Clinicians who were most attentive to procedural technique with little respect to the patient’s discomfort (technical approach) or were overly attentive to comforting strategies (affective approach) took longer and/or were less successful in completing the procedure.
This study is one of the first to provide objective documentation of the value of comforting strategies during invasive procedures in critically ill patients. As such, study findings provide strong support for a need to balance technologic expertise with actions that consider patient needs. We are frequently reminded of the importance of comforting strategies. However, it is easy to omit such strategies in the fast paced critical care environment. Findings of this study provide strong support for including such actions, as a means to increase patient comfort and, thereby, the efficiency and effectiveness of care.
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