Abstract
The critical care environment is a complex arena in which clinical judgements of the ventilated patients pain state are made over the course of their surgical trajectory. The presence of the critical care nurse at the bedside is the key to informed judgement in this unpredictable and fragile situation. This study sought to capture the judgement process of thirty critical care nurses in the context of the ventilated patient in pain in the immediate phase after cardiac surgery i.e. six-hours. Evidence of the judgement process was sought using the Lens Model as a framework, utilising the cognitive side of the model. Moreover, in order to capture this phenomenon of interest, the researcher observed the pain behaviours of thirty ventilated patients in the immediate phase post cardiac surgery. Within-methods triangulation was employed as an approach for justifying and underpinning knowledge by acquiring additional knowledge, which was seen as pertinent to this naturalistic case study.The data collection approach included think-aloud by thirty critical care nurses and simultaneous researcher observation over a six-hour period in the natural habitat of the ventilated patient post cardiac surgery. The findings give tentative support for the hypothesis that critical care nurses use a pattern of cues to make a judgement of ventilated patients' pain state in the immediate phase post cardiac surgery. Conversely, there was tentative support for the hypothesis that ventilated patients convey a pattern of cues to the critical care nurse in the immediate phase post cardiac surgery. Moreover, tentative conclusions are afforded which are as follows: a judgement structure is employed by critical care nurses which is comprised of two stages. The initial stage involves a pattern of physiological, behavioural general, covert behaviour, physical, overt motor pain behaviour, mechanical, technical, paraclinical, knowledge and pain descriptor cues. These aforesaid cues are utilised and integrated into a small number of intermediate judgements which operate as second order cues. Consequently the second order cues are combined in order to make a final judgement of the ventilated patient's pain state in the immediate phase post cardiac surgery: '(s)he is in acute pain' or '(s)he is not in acute pain'. In addition, critically ill ventilated patients convey a pattern of pain cues to the critical care nurses which comprises of physiological, behavioural general, overt motor pain behaviour cues, patient ventilator dysynchrony cues and verbal subjective pain behaviour cues. The pattern of cues conveyed by the ventilated patient may be influenced by many factors in an unpredictable and delicate surgical trajectory and chief among these factors is haemodynamic instability. The critical care nurse must make sense of all of this to gain access to the pattern of cues.