Intensive Care Med (1997) 23:1282-1285

Springer-Verlag 1997

M. A . E P. N o v a e s Stressors in ICU: patients' evaluation

A. Aronovich
M. B. Ferraz
E. K n o b e l

Abstract Objective: To study the physical stressors. Loss of self con-

Received: 1 April 1997
Accepted: 24 September 1997
Hospital Israelita Albert Einstein,
Centro de Terapia Intensiva,
Av. Albert Einstein 627,
05651-901 Sao Paulo - SE Brazil
FAX: +55 (11) 846 9411 and 845 1500
e-mail: novaes@ibm.net
physical and psychological stressors
in the intensive care unit (ICU) and
to correlate stressors with different
d e m o g r a p h i c variables.
Design: Cross-sectional analytical
survey.
Setting: Intensive care unit of a pri-
vate hospital.
Patients and participants: 50 ran-
domly selected I C U patients during
the first week of their I C U stay.
Measurements and results: The In-
tensive Care Unit E n v i r o n m e n t a l
Stressor Scale was administered to
50 patients. Pain and the impossibil-
ity of sleeping due to noise and hav-
ing tubes in the nose and m o u t h
were considered the most i m p o r t a n t
trol and lack of understanding about
the attitudes and procedures were
the main psychological stressors.
Conclusions: Interventions should
be a i m e d at relieving the patient's
pain and at controlling the level of
noise to m a k e sleep possible. F r o m
the psychological standpoint, the in-
d e p e n d e n c e of the patient should be
e n c o u r a g e d , thus stimulating the re-
c o v e r y of self-control. The team
should also inform the patient a b o u t
the p r o c e d u r e s which will be carried
out.
Key words Stress Intensive care
unit P s y c h o l o g y . E n v i r o n m e n t -
Stress assessment Critical care

found that being away f r o m h o m e / w o r k , restrictions as

Introduction
The p r e s e n c e of strange machinery, endless alarms, un-
familiar people, u n p l e a s a n t smells, and bright lights are
factors that c o n t r i b u t e to the physical and psychological
stress o f patients a d m i t t e d to intensive care units (ICUs)
[1, 2].
Several studies have d o c u m e n t e d the impact of the
stress e x p e r i e n c e d by patients in I C U s [3]. In p i o n e e r
work, D e M e y e r [4] describes h o w the patient in the I C U
feels tied down by the e q u i p m e n t , complains o f noise
and disturbance and of loss of sense of time, and of not
being included in the conversations taking place around
them. Ballard [5] studied 22 patients, who p o i n t e d out re-
striction of m o v e m e n t and the p r e s e n c e of tubes in the
nose and m o u t h as the principal stressors factors in the
ICU. M o r e recently, Yarcheski & K n a p p - S p o o n e r [6],
studying patients who had u n d e r g o n e cardiac surgery,
to previous lifestyle, pain, and physical discomfort were
classified as the biggest stressors b y the patients.
This study a i m e d to identify the main physical and
psychological stressors for patients in general ICUs.
Materials and methods
Sample
Fifty patients randomly selected from a general ICU at Hospital Is-
raelita Albert Einstein (S~o Paulo, Brazil) who fulfilled the eli-
gibility criteria, were invited to participate in this study. The inclu-
sion criteria were the following: (a) patients who were conscious
and well-informed, having no neurological or psychological distur-
bances; (b) patients admitted to the ICU for more than 24 h, but
less than 1 week; (c) age greater than 18 years; (d) patients who
consented to participate in the survey.
 1283

Table 1 Ranking of stressors

Ranking Description Mean Standard
deviation
01 Have pain 3.36 1.01
02 Not being able to sleep 3.34 0.98
03 Having tubes in your nose or mouth 3.26 1.01
04 Not being in control of yourself 3.10 1.11
05 Being tied down by tubes 3.02 1.12
06 Not having treatments explained to you 3.02 1.22
07 Not being able to move your hands because of i. v. line 2.90 1.15
08 Not knowing when to expect things will be done to you 2.84 1.06
09 Being stuck with needles 2.80 1.18
10 Being thirsty 2.76 1.22
11 Having lights on constantly 2.72 1.25
12 Seeing family and friends for only a few minutes each day 2.66 1.22
13 Uncomfortable bed and/or pillow 2.64 1.26
14 Having no privacy 2.64 1.24
15 Nurses and doctors talking too loudly 2.54 1.15
16 Being bothered 2.52 1.15
17 Having to wear oxygen 2.50 1.20
18 Hearing other patients cry out 2.46 1.23
19 Being in a room that is too hot or too cold 2.46 1.05
20 Not knowing where you are 2.46 1.33
21 Not knowing what time it is 2.44 1.18
22 Unfamiliar and unusual noises 2.40 1.11
23 Having nurses be in too much of a hurry 2.40 1.14
24 Missing your husband or wife 2.34 1.19
25 Hearing the heart monitor alarm go off 2.26 1.16
26 Not knowing what day it is 2.20 1.21
27 Having the team use words you cannot understand 2.20 1.20
28 Being awakened by nurses 2.14 1.13
29 Having to look at the pattern of holes in the ceiling 2.14 1.25
30 Feeling the nurses are watching the machines closer than 2.08 1.08
they are watching you
31 Having nurses constantly doing things around your bed 2.06 1.08
32 Hearing buzzers and alarms from machinery 2.02 0.91
33 Being cared for by unfamiliar doctors 1.96 1.18
34 Constantly being examined by doctors and nurses 1.96 1.11
35 Hearing the telephone ring 1.92 1.12
36 Being aware of unusual smells around you 1.92 1.07
37 Having strange machines around you 1.90 1.16
38 Having your blood pressure taken often each day 1.74 0.90
39 Not having the nurses introduce themselves 1.64 0.88
40 Seeing i. v. bags hanging over your head 1.58 0.91

Instrument
The Intensive Care Unit Environmental Stressor Scale (ICUESS)
was administered to all patients after being translated into Portu-
guese and culturally adapted. This scale contains 40 items scored
from (1) not stressful to (4) very stressful. This scale has been vali-
dated by Ballard [5] and Nastasy [7]. The clinical and demographic
characteristics of the patients were recorded using a standard form.
tal stress score with severity of illness [Acute Physiology and
Chronic Health Evaluation (APACHE) II] and age. Student's t-
test was used to compare the total stress score between the clinical
and surgical treatment groups, between males and females, and be-
tween levels of education. The level of statistical significance was
set as 5 % (a = 0.05).

Analysis of results
Descriptive statistical analysis was used to characterize the clinical
and demographic variables. The mean score was reported for each
of the 40 stressors and ranked from most stressful to least stressful.
The total stress score for each patient was calculated by the sum of
ICUESS answers. The Spearman test was used to correlate the to-
Results
T w o p a t i e n t s d i d n o t a g r e e t o t a k e p a r t in t h e study, a n d
one was found to be confused and consequently ineligi-
b l e . O f t h e p a t i e n t s i n t e r v i e w e d , 36 (72 % ) w e r e m a l e .
T h e l e v e l o f e d u c a t i o n o f t h e s t u d y p o p u l a t i o n w a s as
f o l l o w s : t h e m a j o r i t y (n = 3 1 , 6 2 % ) h a d g r a d u a t e d
f r o m c o l l e g e , 13 ( 2 6 % ) f i n i s h e d e l e m e n t a r y h i g h
1284
school, and 6 (12 %) had completed only elementary
school.
The mean (SD) age was 52.9 years (15.5), ranging
from 18 to 83; 33 (66 %) were married, 9 (18 %) were
single, and 4 (8 %) were widowed.
The mean length of stay in the ICU was 2.7 days,
ranging from 1 to 7 days; 76 % (n = 38) of the intervie-
wees were in the ICU following surgery and the remain-
ing 24% (n = 12) for medical treatment. Thirteen
(26 %) patients received psychotropic medication dur-
ing hospitalization, such as anxiolytics and benzodiaze-
pine.
Table 1 presents the ranking of the stressors as de-
fined by the mean score obtained from the patient's
evaluation. It was observed that the five most important
stressors were: have pain, not being able to sleep, having
tubes in your nose/mouth, not being in control of your-
self, and being tied down by tubes. Several other items
were classified as non-stressing by the patients, such as
having blood pressure measurements taken many times
a day, not having the nurses introduce themselves by
name, or seeing i.v. bags hanging overhead.
There was no statistically significant correlation be-
tween the total stress score for each patient and the se-
verity of illness (determined by A P A C H E II score)
(r--0.12) or age (r = 0.06). No statistically significant
correlation was observed between the total stress score
for each patient and type of treatment, either clinical
or surgical (p = 0.25), sex (p = 0.29), or level of educa-
tion (p = 0.65).
Discussion
Having pain was classified as the principal stressor in
this study. This corroborates findings from other re-
searchers [1, 6, 8]. The presence of pain is something so
uncomfortable that it surpasses other inconveniences
experienced in the ICU. When patients reply that pain
is the principal physical stressor, it may be that the pa-
tient is being subjected to the complete set of physical
and psychological discomforts inherent in ICU treat-
ment.
The second stressor factor mentioned was being un-
able to sleep. The difficulty of sleeping in the ICU is re-
ferred to by Nastasy [7] as one of the principal stressors
for the patient. Other surveys discuss the existence of a
sleep disturbance specific to ICUs. It would seem that
all these factors, added to the presence of pain and
tubes, combine to make normal sleep difficult. These
factors progressively stress patients to a point where
the capacity to rest is affected and, in some cases, made
impossible.
Having tubes in the nose or mouth was classified as
the third most stressful item. The presence of either na-
sal or oral tubes is invasive which, apart from being un-
comfortable, limits communication and eating, and in
general adds stress to the privations already experi-
enced by the patient in the ICU.
The feeling of not having control of oneself was the
fourth stressor and the first from the psychological point
of view. This lack of control has also been mentioned by
Carr and Powers [9]. While in an ICU, the patient re-
gresses to infantile standards of behavior and a state of
dependency, having to rely on strangers to perform for-
merly simple tasks like hygiene, feeding, or even chang-
ing position in bed. The loss of independence can gener-
ate anguish and a sensation of helplessness, the principal
cause of psychological instability in this context.
The fifth most important stressor mentioned by pa-
tients was the state of being tied down by tubes. To feel
restrained by tubes is contrary to the natural state of lib-
erty and freedom of movement. When the individual en-
ters the ICU, he or she may feel further oppressed by the
equipment, which is reinforced in this specific situation.
One of the patient's prime needs is to know what is
happening; many consider not being given explanations
about the treatment and not knowing what is going to
be done a stressor. When conscious and well-adjusted,
patients prefer to know all the medical team's decisions
and participate in discussions even when dealing with
difficult situations.
It was found that most patients considered lack of
privacy as not very stressful, this being ranked as stres-
sor 14. It should be noted that 72 % of the sample were
in six-bed units, which have movable partitions and not
private cubicles, where privacy is maintained. Accord-
ing to Elpern et al. [3], patients accept the ICU stay as
a means of restoring their health; privacy is not consid-
ered a priority, especially by male patients.
As regards the distance from family and friends, the
interviewees did not consider this aspect as one of the
top ten stressors. It is possible that the routine in this
ICU, which has flexible visiting hours permitting the
family to be present in accordance with the patient's
needs, effectively removes this particular problem.
The perception of the family and medical team about
the stressor factors is often seen to be different from the
patient's point of view. This aspect should be better
studied so that intervention can be specific for each
group.
It should be emphasized there was no statistically sig-
nificant correlation between the total stress score for
each patient and the severity of the illness (APA-
CHE II), treatment (clinical or surgical), sex, or level
of education.
In conclusion, the five greatest stressors detected
were: to have pain, to be unable to sleep, to have tubes
in the nose and/or mouth, not to be in control of oneself,
and to be tied down by tubes. Interventions should be
aimed at relieving the patient's pain, providing an atmo-
sphere in which rest is possible, with less light, noise,
 1285

and the fewest possible interruptions. Unfortunately, lit-
tle can be d o n e a b o u t the n u m b e r of tubes required for
I C U patients. A s for not having control of oneself, one
of the principal psychological stressors, psychological
assistance should be offered and m o r e information
about t r e a t m e n t should be given by the multidisciplin-
ary team. The patients have to participate in their own
clinical t r e a t m e n t and, most importantly, feel involved
in the process.
It should be n o t e d that the first three stressors men-
tioned are physical and susceptible to intervention by
the I C U team. Physical c o m f o r t , sleep, and b r e a t h i n g
are basic n e e d s and, w h e n affected, b e c o m e priority
causes of w o r r y for the patient. Pain s h o u l d be m e a -
sured and c o n t r o l l e d in the ICU, as a r o u t i n e b y the nur-
ses team, like h e a r t rate, b l o o d pressure, and t e m p e r a -
ture.
The I C U stay is a difficult experience in the life of a
patient. Stress m a n a g e m e n t m i g h t allow for b e t t e r phys-
ical and psychological conditions for the p a t i e n t ' s re-
covery, providing as far as possible a m o r e h u m a n e
ICU environment.

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S. A . L o e r Interaction between haematocrit

T. W. L. S c h e e r e n
J. Peters and pulmonary blood volume
on pulmonary vascular flow resistance
and pressure-flow relationships

D u e to an u n f o r t u n a t e error, the a u t h o r s ' addresses for the a b o v e Experimental article, published in v o l u m e 23:
1082-1088 ( O c t o b e r 1997), have b e e n missprinted. The study has b e e n carried out at the Institute of E x p e r i m e n t a l
A n a e s t h e s i o l o g y and the correct addresses should have read:

S. A. L o e r ( ~ ) T . W . L . S c h e e r e n J. Peters
Institut for E x p e r i m e n t e l l e Anaesthesiologie,
Heinrich-Heine-Universit/it,
M o o r e n s t r a s s e 5, D-40225 DiJsseldorf, G e r m a n y
F A X : +49 (211) 811 3954
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