Maintaining patient endurance: the comfort work of trauma nurses.

Seriously injured patients frequently arrive at the Emergency Department (ED) conscious or partly conscious yet still aware of the serious nature of their injuries. They may be vocalizing their distress, responsive to pain, withdrawing from painful stimuli, or combative and fighting staff. Despite these patients' obvious distress, analgesics are frequently delayed until their condition is assessed. Furthermore, analgesics are often ineffective for the amount of pain experienced. Pain is frequently overwhelming.

In this life-threatening situation, the goal of medical care is to assess the patient and to provide treatments as quickly as possible to stabilize the patient, to ensure patient survival, or to minimize the effects of injury. Although nursing staff share these goals, they report that "they do not have time to comfort." However, when care cannot be administered to patients who resist caregivers and who are combative, abusive, uncooperative, or out of control, these patients are often pharmaceutically paralyzed so that care essential for the maintenance of life may proceed as rapidly and as efficiently as possible.

Nevertheless, previous research using participant observation showed that, despite nurses' claims to the contrary, ED nurses do, indeed, provide comfort to these patients, thus helping patients to endure extraordinarily painful procedures. Nurses use particular patterns of touch, eye contact, and talking patients through painful procedures or helping patients to "hold on" (Morse, 1992), thus enabling patients to endure. From this preliminary participant observational research conducted in a Canadian ED for a period of 7 months, it was noted that nurses used a style of speech that was patterned and rhythmic, "sing song," and pragmatically appropriate. Nurses would encourage patients by repeating such phrases as "Good, good, good." "We're nearly finished." "A little longer, OK? and so forth. Elsewhere we have identified this pattern of speech as the Comfort Talk Register (CTR) and described its linguistic features (Proctor, Morse, & Khonsari, 1996). In this article, we will describe the comforting function of comfort and the concomitant comforting behaviors of the trauma room nurse that enable the patient to endure the extreme pain of procedures and major trauma when analgesics are ineffective or delayed.

In the context of providing trauma care, nurse comfort behaviors are not extraneous, trivial tasks, such as pillow-fluffing or soothing the brow. Rather, the comforting behaviors that nurses use to maintain patient endurance have been described in patient interviews as their "lifeline." We suggest that these behaviors assist the patient to remain psychologically intact, thereby reducing shock and physical stress and minimizing the post-traumatic stress of the resuscitation. For the trauma team, these nurse comforting behaviors enable the patient to keep still and to cooperate with care so that essential assessment and treatment procedures may be administered more quickly and safely. If patients are not resisting care or "fighting" the caregiver, physical injury from the provision of care is minimized.

The purpose of this article, therefore, is to describe these nurse comforting behaviors that co-occur with the CTR, which assist the seriously injured patient to endure the pain of injury and subsequent treatments and to remain in control. We will also differentiate comfort talk from other types of interaction between the trauma team and the patient, and describe the patient's response when these comforting behaviors are not provided.

METHOD

SETTING

In this study, data were collected using videotapes of patient care in the trauma rooms of two certified Level 1 trauma centers. Both trauma centers were equipped with medevac air ambulances and served as regional trauma centers, receiving between 500 and 1,200 trauma patients per year. Both centers provided medical and nursing educational programs. Data were collected for 1 month at Site 1, and for 3 weeks at Site 2, by taping all patients who were admitted to the trauma room.

DATA COLLECTION

The video cameras were mounted on the wall of the treatment room. Videotaping commenced as soon as the patient entered the rooms and continued until the patient left the room (usually to go for a CAT scan or X ray). As the cameras were fixed (i.e., were not remotely operated with a pan control and zoom lens), the view of the patient and/or the nurse was frequently obscured by other caregivers or X-ray equipment. Audio recording was achieved by using the microphones attached to the cameras, and in this setting, the excessive noise and multiple simultaneous dialogues sometimes obscured the sound of the nurses' or the patient's voice. Furthermore, the patient's voice was often muffled because of dryness of the mouth or the presence of a facial oxygen mask. Instances where the nurse-patient dialogue could not be heard or the camera view was obscured were considered missing data. Such problems are unavoidable in settings where patient care takes priority and is a limitation of data collected in this setting.

Ethical Considerations

The patient was informed that the videotaping was in process or had been completed as soon as the patient's condition permitted and the patient was able to comprehend and consent to the study. Sometimes consent was obtained before the patient left the ED, other times it was obtained in the intensive care unit (ICU), and on some occasions it was obtained several days after data had been collected. In the latter case, tapes were secured with the quality assurance (QA) data(1) until the necessary consents were obtained. Parental consent was obtained for minors, and if the child was able to comprehend, verbal assent was obtained from the child.

The patient was asked to provide two types of consent: to have the cleaned tape (i.e., one with the patient's identifiers removed) included in the research data set, and to allow the researchers to use the cleaned tape for educational or publication purposes. If the participant declined to participate in the study, the tape was immediately erased. If the patient agreed to have the tape included in the data set, then, using a video editing system, tapes were "cleaned" by erasing all patient names and concealing the patient's face by using a mosaic patch. The original tapes were then erased.

Written consents were also obtained from all nursing staff who provided care to the trauma patient--nurses who did not wish to participate in the study were assigned to other areas in the ED during the study. Releases for the taping were obtained from all medical and technical personnel providing care. Relatives were informed about the study before they entered the room and, if they so desired, told that the tape would be turned off while …