Night has fallen in the intensive care unit, and the medical team is smaller. What do physicians, nurses and patients actually feel? An overview of the night falls in the ICU - from the perspective of an ICU team.
Brief Description and Comparison with the Day-Time Atmosphere
During the day and at night, intensive care units (ICU) have their own temporal rhythm. In our ICU, each day is divided into two sets of twelve hours, marked by a changeover in ICU teams, which changes patterns of care for patients and their relatives. The monitoring alarms, which are so specific to intensive care, ring out at different frequencies and with varying intensity, intertwining and combining in an unpredictable manner. The alarms come from the patients’ beds and the machines that they are attached to and on which their lives depend. They also come from the patients themselves, as they seek for medical and nursing attention. Nursing staff recognise the alarms and react to them in different ways, more or less quickly, more or less stressfully, depending on their meanings. "There are lots of alarms and you have to learn to identify them, but they are all important,” (verbatim account by a nurse responsible for general care). There seem to be fewer alarms at night, but they are still present and go off at irregular intervals. Late in the evening, the lights are dimmed, but never completely turned off, immersing the unit in murky atmosphere. The atmosphere becomes similar to that of a night-flight, with the same impression of confinement. The dimmed lights and gentle hum of machines encourage drowsiness. Time is suspended and the place soon induces a sense of time lag.
The atmosphere can be particularly challenging for the patients, who often suffer from some degree of delirium and very easily lose track of time. Caregivers themselves can be taken by surprise by the clock.The notion of space is also compromised by the limits of the rooms in the unit. Loss of spatial and temporal bearings is thus exacerbated by a claustrophobic atmosphere, in which a reduced team focuses on a common objective: patients’ well-being. The nursing staff try to give the patients context by regularly explaining to them the reason they are in the unit; giving them the date, year and time of day or night; and saying what visits they have had, thereby providing the information they need to understand their situation.
At the beginning of the evening, nurses on the day shift interact with the incoming night team, handing over all the information required to ensure continuity of care during the night and to bring everyone up to speed. The night shift then takes over. Compared to daytime, the number of staff is reduced. Lights are dimmed, conversations are hushed, and there is less dialogue. The throb of daytime activity, with its constant comings and goings, gradually fades into the singular night-time atmosphere. Everything seems to slow down, becomes calmer, and you can almost hear the silence.
An Oppressive Yet Calming Atmosphere
An endurance race for the ICU team
Night has fallen, and the medical team is smaller. In charge of the unit, there is one experienced “senior” physician, a resident in training, and a medical student. Nurses and nurse assistants provide the best standard of nursing care. The organisation and the pace of work change. For the nurses, the night is organised around the rounds of the patients carried out once every three hours. In addition to the patients already in the ICU, the 24-hour on-call doctors' night is also governed by emergencies. Sometimes rest is possible, but will always be incomplete, and disrupted. Being on duty for the entire nychthemeron is a real challenge for doctors. However, some do defend the pattern although it appears exhausting at first glance, insisting that this apparently stressful pace helps them acquire a better knowledge of the patients and consequently improves medical skills: "it is the idea that the person on call at night has already worked the day and knows the patients, which ensures a certain continuity of care,"(verbatim account by a doctor). This intense workload is also justified by the severity of the patients' conditions and the speed at which they can change. Of notice, a smaller number of people taking care of the patient during the day implies a decreased risk of attrition of knowledge concerning the patient.
At night, the smaller size of the ICU team generally results in a reduction of the number of urgent orders and tasks that are constant during the day: "the atmosphere is more relaxed at night, there are fewer people, and fewer urgent requests than during the day,"(nursing assistant's verbatim statement); "there is no-one to interfere with your night, while during the day, it's a mess all the time, it's bustling and noisy all day long,"(nurse's verbatim statement). Nurses are able to do their rounds in the unit at night without being interrupted, or at least less often, than during the day. This calm atmosphere is particularly appreciated by nursing staff, who feel they can better focus on their primary duties.
Moments of respite are rare during the day because there is always another task to attend to, duties being non-stop and continuously overlapping. At night, in the absence of emergencies, the workload may be lighter, making time seem longer. Concentration then becomes a real challenge for the nursing team, especially from 3 am onwards. Some nursing staff use power-nap strategies to help them stay responsive. Alternatively, others keep themselves constantly busy to stay alert. Speed becomes less important than the ability to keep going through the night while maintaining the same standard of performance and dynamism. Nurses and doctors have to tackle the issue of resisting how the night affects their physical and mental abilities.
As a result, throughout the night, the ICU team constantly makes compromises between the specific demands of the night and the unchanged demands of their work requiring that they provide the best care to their patients and the best information and comfort to their patients' relatives, who can nowadays be present during the night as during the day. These compromises result in strategies aimed to adapt care objectives, for example, when possible, minimising interventions during the night.
Adapting the ICU team’s objectives
At night, patients undergo less diagnostic procedures, doctors make fewer complex diagnoses and carry out fewer tests, which are usually limited to emergencies: "anything that can be performed later without damage is not done at night,"(verbatim account by a doctor). At night, non-urgent medical or nursing procedures are easily postponed.
Ensuring that the patient gets some sleep despite the environmental constraints of the unit is among the most important nursing roles. Bedridden, plugged into various machines and almost completely incapable of moving, ICU patients struggle to get rest. For them, night-time is not the calm resting time that it is supposed to be. The silence is systematically broken by alarms, caregivers’ work, and the other patients, all creating a permanent background noise. One night, a patient’s screams of pain in response to leg cramps kept all the other patients awake, fretful and worried. Another night, the simultaneous admission of several critically ill patients in the unit made it as busy as during the day and deprived all of any hope of rest.
Patients have to be given treatments during the night, further disrupting their sleep. To minimise the impact of sleep deprivation and to preserve the patient's circadian rhythm, nurses sometimes postpone certain procedures that can be put off until later to let the patient sleep (Toupin 2009). "Sometimes we skip certain procedures to avoid disturbing the patient and interrupting their sleep, as it is very difficult to get enough sleep in here,"(nursing assistant's verbatim statement).
The reduced number of visits and the calm atmosphere can, paradoxically, be oppressive for patients, who find themselves confronting existential questions and feelings of solitude.
The nocturnal anxiety of patients and their relatives
Death is a common event in ICU. The unit itself is associated with death, and night-time often accentuates the patient's fear of death. Feelings of loneliness, fear of abandonment, the inability to sleep, the administration of drugs that can provoke hallucinations, can all exacerbate nocturnal anxiety. Anxiety manifests itself in the excessive use of buzzers to call the nursing staff, escape attempts and violent behaviour: “they get up, they tear everything off, they get out of bed, they ring the alarm,"(verbatim account by a nursing assistant). At the start of the evening, while providing care and settling the patients for the night, nursing staff try to prevent anxiety attacks. Mouthwashes, eye care, massages and repositioning the patient in the bed are accompanied by the nurse's comforting words, explaining each gesture describing the patient's surveillance throughout the night, listing who will be present and in charge of what (Toupin 2005). The presence of loved ones can also help to prevent anxiety. If loved ones are present, nursing staff can include them in basic care. The nursing staff also reassures patients’ relatives, who can manifest their concern by staying through the night. In these cases, the nursing staff may alert patients’ loved ones to their own need for sleep, in order to avoid exhaustion and protect their mental health.
A Reduced Team: Between Solitude and Solidarity
The reduced size of the ICU team at night can induce a feeling of loneliness among the nursing staff, closely linked to their empowerment and accountability, together with more intense feelings of solidarity and complicity.
Increased autonomy and accountability of healthcare personnel
ICU physicians are used to emergencies and adopt a serene and stoic attitude, even at night, however serious the situation. Projecting confidence helps the doctors to insure against the risk of communicating their stress to the whole team: “you are like the conductor of an orchestra, if you can show that you are confident and relaxed, it calms everybody else,” (verbatim account by a doctor). The ICU duty doctor increased responsibility and accountability are both gratifying and stressful: "The most difficult aspect of working at night is that you are the only one to make some urgent decisions,"(doctor's verbatim statement).
The absence of interdisciplinary discussions at night does indeed make decision-making trickier. In difficult situations, nurses call the on-duty doctor who, in turn, can contact the on-call senior doctor. However, calling on someone is far from automatic, because no one wants to wake a colleague for no good reason: “at 4 am you ask yourself - should I really wake them for this?” (verbatim account by a doctor).
One of the most difficult decisions for physicians at night is whether to admit a new patient to the ICU. This decision involves ethical issues, as the physician must determine whether the patient's medical profile actually corresponds to intensive care, whether intensive care admission is truly indicated, or whether, on the contrary, intensive care admission would be medically futile: "but the problem is that you have no-one to talk to about how to limit therapeutic obstinacy, and these decisions must be team-based,"(doctor's verbatim statement).
Free and liberating time
In the absence of an emergency, the reduced number of medical procedures and the preservation of patients’ sleep free some time for the nursing team which can be used to rest, to get ahead with administrative tasks, to study, to think about a case, or simply to enjoy eating and talking to workmates: “sometimes we really are able to sit down and eat,"(verbatim account by a nursing assistant). Free time at night is much more conducive to informal discussions and forging closer ties with other members of the team: "You may be able to create stronger bonds; you have more time to establish a relationship with your colleagues,"(nurse's verbatim statement).
The peaceful aspect of the night shift also loosens patients’ tongues and make them more likely to confide in the nurses and forge ties with them: “often the night, before going to bed […] they need to talk about it” (verbatim account by a nursing assistant). The lack of physical availability of the nurses and the lack of psychological availability of the patients during the day tend to fade at night, and the time spent preparing the patient for the night may be conducive to more intimate conversations. Night nurses may therefore place more importance on care than on cure.
Free and liberating time during the night enables the nursing staff to forge ties, discuss professional practice, and talk over difficulties with a patient or his or her relatives, thereby finding support within the group. Mutual aid, a common feature in the ICU, is even more marked at night because it is expressed more spontaneously and more naturally. Nurses often don't even need to ask for help with a task, as all of the available staff are ready to join in. For example, when cleaning a room, the whole team focuses on this one task, which can then be performed very quickly: "team work is even more important due to the reduced number of staff. There are just as many patients, but fewer nurses, so we really need to be able to count on each other. It is that little bit of extra effort which is rewarding,"(nursing assistant's verbatim statement). Communication between nurses is more direct, as there are fewer people and no intermediaries.
At about 5 am, the night is nearly over. Soon the team working on the day shift will gradually arrive and take over, following a hand-over on the previous twelve hours from the team on the night shift. The lights in the unit start dazzling once again as does the bustle. The oppressive, yet calm atmosphere of the night leaves its place to the day-time rush. Reality changes again for the ICU team, the patients and the families and they all interact in a different way.
- Intensive care units have their own temporal rhythm during the day and at night.
- Monitoring alarms ring out at different frequencies.
- Number of staff is reduced, lights are dimmed, conversations are hushed and there is less dialogue during the night.
- Patients undergo less diagnostic procedures, doctors make fewer complex diagnoses and carry out fewer tests.
- Night-time often accentuates the patient's fear of death.
- The reduced size of the ICU team at night can induce a feeling of loneliness among the nursing staff.
- The oppressive, yet calm atmosphere of the night eventually leaves its place to the day-time rush.