RESEARCH doi: 10.1111/nicc.12032
Caring and technology in an intensive care unit: an ethnographic study Ann M Price ABSTRACT Background: Critical care practice is a mixture of caring and technological activities. There is debate about whether the balance between these two elements is correct and a concern that critical care units can dehumanize the patient. This research sought to examine aspects that might affect this balance between the caring and technology within the critical care setting. Aim: What aspects affect registered health care professionals’ ability to care for patients within the technological environment of a critical care unit? Methodology: A qualitative approach using ethnography was utilized as this methodology focuses on the cultural elements within a situation. Data collection involved participant observation, document review and semi-structured interviews to triangulate methods as this aids rigour for this approach. A purposeful sample to examine registered health care professionals currently working within the study area was used. A total of 19 participants took part in the study; 8 nurses were observed and 16 health care professionals were interviewed, including nurses, a doctor and 2 physiotherapists. The study took place on a District General Hospital intensive care unit and ethical approval was gained. Findings: An overarching theme of the ‘Crafting process’ was developed with sub themes of ‘vigilance’, ‘focus of attention, ‘being present’ and ‘expectations’ with the ultimate goal of achieving the best interests for the individual patient. Conclusion: The areas reflected in this study coincide with the care, compassion, competency, commitment, communication and courage ideas detailed by the Department of Health (2012). Thus, further research to detail more specifically how these areas are measured within critical care may be useful. Relevance to practice: Caring is a complex concept that is difficult to outline but this article can inform practitioners about the aspects that help and hinder caring in the technical setting to inform training. Key words: Adult intensive care • Critical care nursing • Fieldwork • Person-centered nursing • Qualitative research • Technology
INTRODUCTION Historically, nurses have been viewed as the ‘caring’ profession within health care which involved ensuring patient comfort and support (Coombs and Ersser, 2004), whereas medicine was seen as the more technical focused profession (Rust, 2010). In the last few decades, there has been an explosion of technological advances within society and health care (Moratti, 2009), which has impacted on the ability of practitioners to assess and treat a variety of patient conditions. This huge leap is often most apparent in critical care areas Author: AM Price, MA, MSc, BSc (Hons), PGCE, RN, Senior Lecturer, Department of Nursing and Applied Clinical Studies, Canterbury Christ Church University, North Holmes Road, Canterbury, Kent CT1 1QU, UK Address for correspondence: AM Price, MA, MSc, BSc (Hons), PGCE, RN, Senior Lecturer, Department of Nursing and Applied Clinical Studies, Canterbury Christ Church University, North Holmes Road, Canterbury, Kent CT1 1QU, UK E-mail: [email protected]
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where machines (such as for mechanical ventilation and dialysis) are becoming more sophisticated and are being more uniquely developed to meet critical care needs (Crocker, 2007). However, within the United Kingdom this has resulted in ethical and economic debates about the appropriateness and cost of some interventions (Moratti, 2009). A desire to explore how caring and technology related to the critical care setting led to the development of the research project. Elements that might be important to explore were based around the contextual and cultural issues affecting health care professionals within the setting as well as the patient illness acuity. Thus, the purpose of this study was to explore the following question: What aspects affect registered health care professionals’ ability to care for patients within the technological environment of a critical care unit? © 2013 British Association of Critical Care Nurses • Vol 18 No 6
Caring and technology in an intensive care unit
THE CONCEPT OF CARING The majority of the literature around the concept of caring within health care is framed within the context of nursing practice (Clifford, 1995; Kyle, 1995; Lea and Watson, 1996; Brilowski and Wendler, 2005). The term ‘caring’ is often used interchangeably with ‘nursing care’, and ‘care plans’ according to Lea and Watson (1996) and Ousey and Johnson (2007) felt that nursing and caring were still viewed as synonymous. Watson (1988) and Ousey and Johnson (2007) emphasis the difference between nursing and medicine as care and cure perspectives respectively; however, Clifford (1995) notes that ‘caring’ is not unique to nursing and other professions would describe themselves as caring. This highlights the confusion and ambiguity surrounding the term ‘caring’ (Kyle, 1995; Brilowski and Wendler, 2005). Kyle (1995) said that: ‘caring as a complex phenomenon involving more than a set of caring behaviours. It is a process including moral, cognitive and emotional components which is culturally derived.’ (p.512) A concept analysis by Brilowski and Wendler (2005) identified five key areas within the caring concept as ‘relationship’, ‘action’, ‘attitude’, ‘acceptance’ and ‘variability’ and, although this was related to nursing practice, it could be applied to other health care professionals. The broad concepts of caring remain similar today although there is more emphasis on caring as part of person centred care (NHS Education for Scotland – NMAHP Quality Council, 2011).
THE CONCEPT OF TECHNOLOGY Technology has revolutionized health care in the last 50 years (Moratti, 2009) and the Internet has exploded the information available to society at an unprecedented rate. Norman (1993) asks whether the technological advances are outstripping our ability to understand them and suggests that it potentially has a lot of power over us. The expansion of computer technology has changed societal norms (Rutsky, 1999) and is thought to promote a distancing from other people. Heidegger (1952/1993) is a seminal writer and discussed the ‘question of technology’ and the impression that it makes on the human condition. He suggests that technology could overtake humans in intellectual capability and notes its ability to be used for good and evil. Heidegger does not offer a definition of technology (Dreyfus, 2006) but unveils the power of technology within our society. He suggests that technology is more than just something that we use but has an ability to ‘enframe’ or challenge beings © 2013 British Association of Critical Care Nurses
(1952/1993). Heidegger (1962) talks about technology being ‘ready to hand’ meaning that equipment should be utilized within the context intended. Another key writing is Ihde’s ‘philosophy of technology’ (1993), which has a differing perspective in that it focuses on the ‘technoscience’ perception, particularly around the artificial nature of technology. The relationship of technology to the culture and science is evident in Ihde’s ideas (1993) and Rutsky (1999) notes that technology has a strong socialcultural effect as technological societies are seen as more ‘advanced’.
CARING AND TECHNOLOGY IN CRITICAL CARE Historically, critically ill patients were grouped together to facilitate the development of knowledge and skill in the technology used to treat them (Fairman, 1992). However, the broad concepts of caring and technology, as outlined above, have been applied to nursing and critical care practice by a number of authors (Locsin, 1995; Walters, 1995b; Beeby, 2000a; Burnard and Sandelowski, 2001; Coombs, 2001). Searching the literature on ‘caring’ usually leads to articles around the practicalities of looking after particular types of patients rather than the concepts that underpin practice. This leads to a complex and confusing picture between the aesthetic and practical elements that entwine caring and technology within critical care practice (Burnard and Sandelowski, 2001). Carnevale (1991) notes that caring is an invisible activity that is difficult to quantify and Funk (2011) says that technology now permeates critical care and wonders if it is always used appropriately. Research into the interchange of technology and caring within the intensive care setting has been evident in the literature since the 1980s. CINHAL and MEDLINE database searches using the terms ‘technology’, ‘caring’ and ‘critical care’ produced a range of material from across the globe. Several recurrent themes emerged from this literature search which will be detailed below. Technical competency was seen as vital to caring within critical care by Ray (1987), Burfitt et al. (1993), Bush and Barr (1997), Alasad (2002) and Almerud et al. (2008); this was reflected both in patients and staff perspectives. However, technology was not viewed as separate to caring by many authors (Bush and Barr, 1997; Mullen, 2002; Wilkin and Slevin, 2004; Bull and Fitzgerald, 2006) and the importance of holism was emphasized by others (Burfitt et al., 1993; Beeby, 2000b; Wilkin and Slevin, 2004; McGrath, 2008). However, none of the authors clarified their 279
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underpinning philosophy of ‘technology’ but seemed to rely on participants views. Integral to these broad concepts was the more personal relationship issues around practice such as communication (Ray, 1987), making the alien more humane (Hawley and Jensen, 2007; McGrath, 2008), individualization (O’Connell and Landers, 2008; Nascimento and Erdmann, 2009) and commitment (Zalumas, 1989). Other authors note the effect of technology more specifically such as technology being more objective because it records factual information (Cooper, 1993), that technology was part of caring (Walters, 1995a; Mullen, 2002), the complexity of technology in caring (Wikstrom and Larsson, 2004) which can create ¨ dilemmas (Wikstrom ¨ et al., 2007; Philpin, 2007) and the relationship between technology and its use by staff (Crocker, 2006; Kiekkas et al., 2006). The idea that technology blocks interactions was suggested by Alliex and Irurita (2004) although McGrath (2008) found that the opposite could be true because of the close nature of the work. Other authors talk about the demanding nature of technology (Alasad, 2002) and detail the complex world of intensive care which differs depending on patient or staff perspective (Kongsuwan and Locsin, 2011). Thus, the best way to offer patients complex treatment in a humane and individualized way is difficult to delineate. Many of the more recent studies above were performed outside the UK (O’Connell and Landers, 2008; Nascimento and Erdmann, 2009; Kongsuwan and Locsin, 2011) and there seemed to be a changing emphasis from technology being a negative influence on caring practice towards a more positive holistic view. The literature highlights a wide range of views and emphasis on caring and technology within critical care but most are small studies that draw of a qualitative research approach particularly phenomenology. The available evidence lacked detail about aspects that impacted on the ability to care effectively within the critical care setting; thus, this study was developed to examine this area. The literature did not address the cultural and societal aspects affecting caring within a technological setting that might be important in the process; thus the research aim was developed.
AIM What aspects affect registered health care professionals’ ability to care for patients within the technological environment of a critical care unit? The objectives of the study were to identify and explore the factors that enhance or inhibit participants’ ability to integrate caring with technology in practice, 280
the influence of social/cultural context and the impact of severity of illness on the process.
METHODOLOGY A qualitative methodology was chosen as the aspects to be explored would involve individual perceptions and beliefs about the world of critical care. Ethnography is described as exploring ‘the norms, values, beliefs, practices, custom, rituals, language, health behaviours and interactions of a group sharing a common culture’ (McCallin, 2002 p.26). Ethnography aims to examine human behaviours in their cultural context utilizing a range of data sources (Hammersley and Atkinson, 1983) and was originally used for large groups of people. However, Fetterman (1989) noted its’ usefulness for smaller cultural settings such as workrelated activities. This research aimed to examine these type of issues and ethnography was viewed as a relevant methodological approach. Townsend (1996) suggested that observation, interviews and document reviews are possible data sources in ethnographic research and these three data sources were used as a form of triangulation to increase research rigour (Savage, 2000). Brewer’s (2000) process of ethnographic research was used as a basis to structure the approach (Box 1). Fieldwork observation involves the researcher watching, recording and analysing events (Blaxter et al., 2008). Study participants were observed whilst undertaking practice activities with individual patients. Interactions, activities, distractions and interruptions were recorded to enlighten the relationship between caring and technology in practice. The context of the unit on the day of the observations was also recorded, such as whether it was short-staffed or had new admissions. The researcher was an observer participant so that she participated in activities and shared the study participants world to became an insignificant variable within the research setting (Kemp, 2001). Moule and Goodman (2009) explain the relevance of qualitative interviewing strategies when the participants’ opinions, experiences and perceptions are needed. Semi-structured interviews are usually most appropriate in ethnographic work as it enables the researcher to explore and clarify issues from other data sources to heighten reliability (Erlandson et al., 1993). Individual interviews were undertaken, recorded and transcribed for analysis. Documents are usually viewed as a static entity and containers of content (Prior, 2008) but give another source of evidence and alternative view (Alaszewski, 2007). Erlandson et al. (1993) suggests that researchers need to be discerning when collecting documentary © 2013 British Association of Critical Care Nurses
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BOX 1 BREWER’S PROCESS OF ETHNOGRAPHIC RESEARCH • • • • • • • • • •
Identify topic and aims of research Think about choice of field site Identify resources available (e.g. money and time) Sampling process Consider method/s of data collection Negotiate access and identify ‘gatekeepers’ Think about fieldwork role (participant-observer) and developing trust Consider ethics and Recording data Identify form of analysis Withdrawal from field and report writing
evidence so that relevant data is acquired. Thus, documents were examined to substantiate or refute interpretations that were being developed during the data gathering process and to identify similarities and gaps between practice and documentation recorded.
Ethical approval This research was approved by the NHS research ethics committee and the Trust Research and Governance Department. Data collection within health care is complicated by ensuring the safety of patients within the process and particularly relevant for critical care where the patients are vulnerable (Moule and Goodman, 2009). Thus the study was focused on staff participants who received information sheets prior to consenting to take part in the study. Participants could opt to be observed, interviewed or both and had the option to withdraw at any point. Patient consent was also gained formally during the observation periods, either from patients directly or their next of kin. The treatment of the patients would not change because of the observations taking place on the staff but consent was gained to ensure that patients, and their relatives, were informed of the research process.
Sample The sampling strategy for this study was purposeful (Erlandson et al., 1993) in nature as it aimed to incorporate staff with the knowledge and experience to enlighten the research aims. The criteria for participation was that they had to be a registered health care professional that worked as a permanent member of the intensive care team. These criteria could include doctors, physiotherapists and nurses (amongst others) and aimed to enable a broad spectrum of the culture to be viewed. Participants were recruited on a voluntary basis to allow individuals to maintain their autonomy. A total of 19 participants took part in the study; 8 nurses were observed and 16 health care professionals © 2013 British Association of Critical Care Nurses
were interviewed, including 13 nurses, 1 doctor and 2 physiotherapists. Three nurses who took part in the observations were unavailable for the interviews. The participants experience ranged from 5 months to 20 years within the intensive care setting. Only two of the participants were male. Data observations (including review of documents) were collected over a range of day and night shifts and interviews conducted in a private room during 2008–2009.
DATA ANALYSIS Constant comparative analysis, as developed by Glaser and Stauss (1967 cited in Annells, 2003) was consistent with the ethnographic approach of this study. The constant comparison approach advocates the ‘back and forth’ process as understanding of ideas develops and is facilitated by pauses in data collection before refocusing new data collection. Erlandson et al. (1993) expound the interpretative nature of the constant comparative method and the need to develop categories from the data. The fieldwork observations initially provided ideas that were examined and refined further using the documents and interviewing strategies. Moule and Goodman (2009) suggest triangulation of methods to aid completeness in data collection although suggests that this may complicate analysis as different methods may enlightened different aspects within the study; this was true for this study which found some contradictions in different data sources but this was useful for the development of categories completeness.
FINDINGS During the analysis, it was difficult to separate the caring and technology elements from the cultural influences as they were often intertwined. Thus, the themes developed to demonstrate the linking of the caring and technological aspects. This led to the 281
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identification of an overarching theme of the ‘Crafting process’ with sub themes of ‘vigilance’, ‘focus of attention, ‘being present’ and ‘expectations’ with the ultimate goal of achieving the best interests for the individual patient – this is represented in Figure 1 and will be explore further below.
Vigilance Vigilance involved aspects that enabled the patient to progress towards recovery and stabilization. This involved practical and decision-making skills involving assessing the patient, physically, psychologically and in technical areas. This was linked with maintaining safety and responding to warnings, such as alarms, appropriately. An aspect of safety was ‘keeping an eye’ on patients which referred to observing the patient, or other staffs’ patient, when no activities needed doing. ‘The main thing is you’re optimising their function, so make sure the ventilation is . . . all set to the correct settings, you’ll check the arterial line, everything, and your CVP line, make sure there safe’ Participant 2 interview (82–84) nurse The areas of prioritizing developed from the assessment and safety areas and included developing plans of action for particular patients and informing others to influence treatment. This included relaying abnormalities to other members of the health care team or referring to policies for guidance.
‘if you’re allocated say two patients and one goes very, very sick then it is the other one that’s not so sick that kind of gets neglected, it’s not that you want to neglect them it’s a case of prioritising the care.’ Participant 4 interview (185–189) nurse Vigilance incorporated the skills to identify and decide the priorities within the patients’ management. This was often reliant on an individual’s knowledge and skills and ability to apply this to the practice setting.
Focus of attention The focus of attention usually revolved around ensuring the physical stability of the patient and saving life. The focus shifted as patients physical condition improved towards enabling recovery or peaceful death. There were several elements that affected the staff’s ability to focus on the patients’ individual needs or vied for attention. Staff noted that there was a balancing between promoting physical recovery and the need for psychological and social support. Dealing with the technology could take up a lot of time, such as to it set up, but was generally viewed as useful to enable close monitoring of the patient. However, it was interesting to note that alarms appeared to be silenced or ‘ignored’ as participant 8 noted during an observation period: [if a machine alarms you tend to go and silence it first and see what problem is. Participant
Figure 1 The crafting of critical care practice.
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says that usually it is an error so often ignore them. Participant noted that they silence alarms and then look at patient to check they are alright] Participant 8 observation period 1·2 – nurse This demonstrated the links between focusing on the patients’ stability and the skills of vigilance to make decisions, thus it was difficult to separate the themes. Sometimes other issues moved the focus of attention away from the individual patient. Staff might have to move their attention away from their allocated patient to assist with a more unstable one; this could include helping more inexperienced members of staff. ‘the skill mix, coz sometimes you end up with lots of junior staff on one day, how are you going to support them and the patient who you have, the kind of patients affect the day you have, if you’ve got patients highly confused and or really very, very sick’ Participant 13 interview (275–278) – nurse Also, some patients might require more support because of anxiety or confusion; although they were not the most physically unstable patient they demanded additional staff input and changed the focus. The machines could become the focus of attention if they were not working smoothly which was observed as follows: [Participant talking about CVVH machine says it is ‘craving all my attention’ and might have to ‘bring it down’. Another nurse comes over – participant tells her problem and nurse says ‘oh its gone’]. Participant 7 observation 1·3 – nurse The focus might be affected by the professional priorities also: the doctor made this comment:
Being present Being present involved the participants communication, liaison and personal traits. It was about commitment and compassion for and building a relationship with the critically ill person and their family. The responsiveness of the patient seemed to affect the communication style and approach taken as is outlined in the two examples which were observed below [Participant is putting sedation lines onto central line so she can remove peripheral cannula. She talked to the patient while she did this even though the patient is sedated and not responding. Fairly directive – ‘I am going to do this now’]. Participant 3 observation 1·1 – nurse More awake patients tended to get much more reassurance and explanation: [Patient restless – Participant talks to her explains why she needs to be in bed and that it is night. Participant asks if she wants a sleeping tablet or pain killer. Patient admits she has pain] Participant 7 observation 2·5 – nurse The presence of the staff seemed to instil confidence and enabled the development of trust and rapport. Aspects of care were seen as providing comfort, whether physical, emotional or spiritual, and little touches were viewed as individualizing activity and important in making a difference to the patient or their family: ‘P – it’s the nurse that just does that extra little thing or says some kind work or basically even if it’s just being in the right place at the right time, all these things can make a bad experience a better experience for patients and their relatives.’ Participant 14 interview (59–62) nurse
‘they (nurses) are constantly by the bedspace whereas we have to deal with all of the patients and all the other patients on the ward in the hospital so we don’t have the luxury of just staying with one patient’. Participant 17 interview (121–125) doctor
Seeing the patient as a person was viewed as important to aid holistic and individualized therapy. A physiotherapist highlighted the importance of this in aiding treatment:
Thus, there were many elements that could draw the staff away from their patient that included the needs of colleagues, other patients or families. This could become a balancing act and sometimes led to frustration if the participant could not maintain their own workload and priorities.
‘P - we do get involved in the sort of psychological side as well, definitely, you get to know these patients very well and quite often we might be the one that they open up to about fears and phobias, we do spend a lot of time talking to patients.’ Participant 16 interview (109–113) physiotherapist
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This theme seems to enable the staff to interact with the patient on a one-to-one basis but was vital to hone interventions to the patients’ specific needs. An emphasis was on communication, both verbal and picking up non-verbal, but it was also about the skills of empathy and relationship building. The psychosocial elements were clearly articulated in this area but only two participants talked explicitly about the spiritual needs of patients.
‘The crafting process’ Craft (used as a verb) is defined as ‘to make or manufacture (an object, objects, product, etc.) with skill and careful attention to detail.’ (dictionary.com 2013). The themes above demonstrate the many skills and attention to detail needed to reach the goal for the patient within the intensive care setting using the technology appropriately. This crafting process is set within the economic, socio-cultural, political and technological considerations of the setting and was described by a senior nurse:
Expectations These were often unspoken elements that affected the working practices of critical care staff. Elements that were so ingrained within the setting but could affect the individualized patient and staff experience. This was where the cultural expectations within the unit could particular affect staff and patients. It was interesting to note that staff felt pressure to achieve tasks on-time and wanted to be seen to be busy, whether with routines or documentation. The organizational requirements, such as audit, were sometimes viewed as detracting the staff from the patient: ‘and auditing also, just pop in at anytime, just scribble something there . . . they will really get your name and you will be suspended if you won’t do this policy, if you don’t adhere, scary!’ Participant 7 interview (369–372) nurse Team functioning was affected by the dynamics of the staff and the people in charge and could fluctuate on a daily basis depending who was working the shift. There still seemed to be power relationships that affected the effective functioning as a whole: ‘ you got the dynamics of the people you’re working with, the dynamics of the team, the skill mix of the team, the personalities of the team, of nurses and, obviously it depends on the medical staff and medical cover’ Participant 11 interview (183–187) nurse The intensive care was seen as a place of learning but staff noted that personal issues could affect motivation and support for staff seemed variable. There was an expectation to contribute to the team proactively and be enthusiastic. Demanding patients/families could be seen as affecting morale and lead to avoidance tactics. Thus, the organization, professional and team expectations could place additional demands on the staff to act and prioritize in a set format. 284
‘there are mechanics and gardeners , there are nurses who attend to much to the psychological element and the physiological element gets neglected and that ends up having a psychological knock on effect, you have to balance them.’ Participant 9 interview (154–155) nurse The crafting process, combining all the elements above, meant that the individual best interests for each patient could be met. Critical care was viewed by participants as combining the aspects of caring with technology and they were not viewed as separate entities. Factors affecting health care professionals, whilst caring for patients within the technical setting of critical care unit, was multi-faceted and complex. It involved personal traits of staff/patients/family, teamworking dynamics, cultural norms of the setting and organizational priorities and the crafting enabled these to work cohesively to achieve the best outcome for the patient.
DISCUSSION This study has highlighted that the concepts around ‘caring’ and ‘technology’ cannot be separated into distinct segments which agrees with Bull and Fitzgerald (2006), but the way in which this is delivered is key. The themes identified above reinforce previous research but highlight the external aspects that impact on the activities. The importance of being safe and in control was noted by Alasad (2002) and Kiekkas et al. (2006), which links with the theme of vigilance; Burfitt et al. (1993) also identified this as important from the patients’ perspective as they wanted to feel safe and observed. Using technology to closely observe the patient is still evident today but recognizes that a balance is needed (Funk, 2011). The role of prioritization and decision-making as part of vigilance is not evident within the caring and technology literature but this may reflect the growing complexity of critical care practice where there is more focus on evidence-based approaches. © 2013 British Association of Critical Care Nurses
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The ‘focus of attention’ theme is not explicitly evident in other literature, however, the issues of competency Ray (1987), healing Burfitt et al. (1993), balancing (Walters, 1995a), making the life threatening life sustaining (Hawley and Jensen, 2007) and the essence of life (Nascimento and Erdmann, 2009) are areas that were identified as similar to this theme. This element is not static and the focus changes continually, not only for the individual patient but also for the team, unit and organization depending on wider pressures and aspects taking precedence. This may have become more evident as the economic and political drivers to ensure quality and costeffectiveness mean that the critical care landscape is shifting constantly to meet changing demands (Scholes, 2012). Although the theme could be seen as related to the physical condition of the patient, the reality is that many external issues, such as staff skill mix, impacted on the delivery of patient care. Other authors spoke about the frustrations (Beeby, 2000b) and the importance of the team pulling together (McGrath, 2008). The relevance of the practitioner presence and interaction specifically has been evident in other research such as McGrath (2008), Nascimento and Erdmann (2009), Kongsuwan and Locsin (2011) and Bridges et al. (2013). However, it was interesting to note that O’Connell and Landers (2008) saw that relatives were more concerned about the competency of the nurses although meeting the individual needs of patients was felt to be important too. The aspect of instilling trust has not been evident before and this study also emphasized that individualized and interpersonal care was relevant to other health care professionals and not just nurses. There has been an assumption in the literature that nurses ‘care’ and this study suggests that all health professionals see themselves as striving for holism in their approaches. Performing the little things (Hawley and Jensen, 2007) is also seen in this study as recognizing the uniqueness of the person during a time of crisis. What I have termed ‘expectations’ has little emphasis in other studies. Philpin (2007) talked about the values of ITU nurses, Beeby (2000b) noted the frustrations and Kiekkas et al. (2006) found increased stress, however, the health care environment has changed since these studies were published and the requirements to meet numerous standards increased. This area of culture may require further investigation to really understand the impact this has on the critical care setting and patient experience. Bridges et al. (2013) particularly note the importance of organizational conditions to enable practitioners to engage with © 2013 British Association of Critical Care Nurses
patients, if this is poor then staff may withdraw emotionally. The ability to integrate the caring of ‘head, hand & heart’ (Galvin, 2010) within my study is the ability to focus on the priorities to save life (head) ‘Focus of Attention’, ability to attend to practicalities such as dealing with machines and involving others (hand) ‘Vigilance’, and the ability to contribute to the uniqueness of the individual through refining the process (heart) ‘being present’. Galvin (2010) does not detail the external and internal factors, that I termed ‘expectations’, that might affect the integration of care within practice. The reality of practice is getting more target and cost driven and the potential impact of this on the ideal of the ‘head, hand, heart’ needs consideration. I would argue that these cannot be seen as separate entities and drawing them together is the ‘crafting process’ that combines all the external and internal issues whilst still striving for the best outcome for the individual patient. This links with Bridges et al. (2013) ideas around the importance of optimizing the organizational conditions to support this process. The ‘crafting process’ reflects the complexity of caring within a technological setting and this was detailed in Nascimento and Erdmann’s (2009) study that was based in Brazil. The dimensions of care that they revealed were similar to many properties that I discuss; that care is not purely physical, relational or professional but includes attitudes, reciprocity and exchange between unique human beings. Although their study was small it benefited from including a range of health care professionals, patients and relatives experiences. This seems to relate to the six ‘C’s of ‘Compassion in Practice’ document (Department of Health, 2012). The elements discussed in the themes above demonstrate that critical care practitioners incorporate aspects of caring, compassion, commitment, competence, courage and communication into their practice. For example, Vigilance relates to competence; Focus of Attention to commitment; compassion and communication to Being Present; courage is needed to deal with Expectations and the Crafting Process melds the care. This would need further research and exploration to identify whether there are measurable areas that would help to define the six ‘C’s for critical care practice. Watson (1988b) seems to commence the exploration of human caring theory showing how the whole is more than the sum of parts and there is so much interrelatedness within the caring-healing continuum. Within my study, the emphasis was on the ‘best interests’ of the patient which is the relationship 285
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between physical, psychological and social on an individual level. Today, there is growing recognition about the individual and organizations’ effect and influence on caring practice (Bridges et al., 2013).
Limitations There are several limitations of this study including that data collection was undertaken in 2008/2009 and critical care practice and pressures have already changed. The researcher, being a critical care nurse, may not have noticed aspects within the research process. Olson (2001) felt that it could be difficult to step-back and be objective, this may have been a particular issue as the researcher was a novice to fieldwork. The study was limited to one district general hospital and the findings in other units may be different. Issues of trustworthiness (Topping, 2010) for qualitative data, therefore, are not fully addressed.
CONCLUSIONS The findings of this study give a different perspective to the ideas of caring in critical care related to technology. It is not just nurses who ‘care’ but all health care professionals although their emphasis may be different. Further research into the ideas of care, compassion, competency, communication, commitment and courage as detailed by Department of Health (2012) related to critical care may be needed. All these aspects were evident within this study and may inform future work that can detail how to measure these within critical care to demonstrate quality.
ACKNOWLEDGEMENTS The author thanks Dr Catherine Caballero and Dr Caroline Williams for their supervision and advice during the research process and also to the participants for their contributions.
WHAT IS KNOWN ABOUT THIS TOPIC • Caring is a complex topic which is difficult to define. • Technological competency is seen as integral to caring in critical care practice. • Caring has been viewed as mainly a nursing issue. WHAT THIS PAPER ADDS • Caring is affected by the culture of the unit and pressures that staff work under. • Caring takes many forms and its expression is influenced by professional and personal attributes • The crafting process is a holistic way to view the complex nature of critical care practice.
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Moratti S. (2009). The development of ‘medical futility’: towards a procedural approach based on the role of the medical profession. Journal of Medical Ethics; 35: 369–372. Moule P, Goodman M. (2009). Nursing Research: An Introduction. London: Sage Publications. Mullen CK. (2002) Nursing, technology, and knowing the patient. Unpublished PhD thesis, University of North Carolina, Chaep Hill. Nascimento KC, Erdmann AL. (2009). Understanding the dimensions of intensive care: transpersonal caring and complexity theories. Revista Latino-Americana de Enfermagem; 17: 215–221. NHS Education for Scotland - Quality Council. (2011). The NMAHP Contribution to Quality Caring – The Concept, Behaviours, Influences and Impact. http://www.knowledge. scot.nhs.uk/media/CLT/ResourceUploads/1012888/Caring, %20concept,%20behaviours,%20influences%20and%20impact 26.pdf (accessed 25/03/13). Norman DA. (1993). Things that Make us Smart: Defending Human Attributes in the Age of the Machine. Massachusetts: Perseus Books. O’Connell E, Landers M. (2008). The importance of critical care nurses’ caring behaviours as perceived by nurses and relatives. Intensive & Critical Care Nursing; 24: 349–358. Olson K. (2001). Using qualitative research in clinical practice. In: Morse JM, Swanson JM, Kuzel AJ, (eds), The Nature of Qualitative Evidence. London: Sage Publications. Ousey K, Johnson M. (2007). Being a real nurse – concepts of caring and culture in the clinical areas. Nurse Education in Practice; 7: 150–155. Philpin S. (2007). Managing ambiguity and danger in an intensive therapy unit: ritual practices and sequestration. Nursing Inquiry; 14: 51–59. Prior L. (2008). Documents and Action. In: Alasuutari P, Bickman L, Brannen J, (eds), The SAGE Handbook of Social Research Methods. London: Sage publications. Ray MA. (1987). Technological Caring: a new model in critical care. Dimensions of Critical Care Nursing; 6: 166–173. Rust LA. (2010). The continuing importance of the art of medicine in modern-day practice. American Journal of Obstetrics and Gynecology; 202: 604–607. Rutsky RL. (1999). High Techn´e: Art and Technology from the Machine Aesthetic to the Post-human. Minneapolis: University of Minnesota Press. Savage J. (2000). Ethnography and health care. British Medical Journal; 321: 1400–1402. Scholes J. (2012). Editorial: time to care. Nursing in Critical Care; 17: 60–61. Topping A. (2010). The quantitative-qualitative continuum. In: Gerrish K, Lacey A, (eds), The Research Process in Nursing. 6 edn. Oxford: Blackwell publishing Ltd; 129–141. Townsend E. (1996). Institutional ethnography: a method for showing how the context shapes practice. Occupational Therapy Journal of research; 16: 179–199. Walters AJ. (1995a). A Heideggerian hermeneutic study of the practice of critical care nurses. Journal of Advanced Nursing; 21: 492–497. Walters AJ. (1995b). Technology and the lifeworld of critical care nursing. Journal of Advanced Nursing; 22: 338–346. Watson J. (1988). Nursing: Human Science and Human Care. USA: National League for Nursing. Sudbury, MA: Jones & Bartlett. Wikstrom ¨ AC, Larsson US. (2004). Technology – an actor in the ICU: a study in workplace research tradition. Journal of Clinical Nursing; 13: 555–561.
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Wilkin K, Slevin E. (2004). The meaning of caring to nurses; an investigation into the nature of caring in an intensive care unit. Journal of Clinical Nursing; 13: 50–59. Wikstrom ¨ AC, Cederborg A, Johanson M. (2007). The meaning of technology in an intensive care unit – an interview study. Intensive & Critical Care Nursing; 23: 187–195.
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Zalumas JC. (1989) Critically Ill and Intensively Monitored: patient, nurse and machine – the evolution of critical care nursing. Unpublished PhD Thesis. Emery University, USA.
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Caring and technology in an intensive care unit: an ethnographic study Ann M Price ABSTRACT Background: Critical care practice is a mixture of caring and technological activities. There is debate about whether the balance between these two elements is correct and a concern that critical care units can dehumanize the patient. This research sought to examine aspects that might affect this balance between the caring and technology within the critical care setting. Aim: What aspects affect registered health care professionals’ ability to care for patients within the technological environment of a critical care unit? Methodology: A qualitative approach using ethnography was utilized as this methodology focuses on the cultural elements within a situation. Data collection involved participant observation, document review and semi-structured interviews to triangulate methods as this aids rigour for this approach. A purposeful sample to examine registered health care professionals currently working within the study area was used. A total of 19 participants took part in the study; 8 nurses were observed and 16 health care professionals were interviewed, including nurses, a doctor and 2 physiotherapists. The study took place on a District General Hospital intensive care unit and ethical approval was gained. Findings: An overarching theme of the ‘Crafting process’ was developed with sub themes of ‘vigilance’, ‘focus of attention, ‘being present’ and ‘expectations’ with the ultimate goal of achieving the best interests for the individual patient. Conclusion: The areas reflected in this study coincide with the care, compassion, competency, commitment, communication and courage ideas detailed by the Department of Health (2012). Thus, further research to detail more specifically how these areas are measured within critical care may be useful. Relevance to practice: Caring is a complex concept that is difficult to outline but this article can inform practitioners about the aspects that help and hinder caring in the technical setting to inform training. Key words: Adult intensive care • Critical care nursing • Fieldwork • Person-centered nursing • Qualitative research • Technology
INTRODUCTION Historically, nurses have been viewed as the ‘caring’ profession within health care which involved ensuring patient comfort and support (Coombs and Ersser, 2004), whereas medicine was seen as the more technical focused profession (Rust, 2010). In the last few decades, there has been an explosion of technological advances within society and health care (Moratti, 2009), which has impacted on the ability of practitioners to assess and treat a variety of patient conditions. This huge leap is often most apparent in critical care areas Author: AM Price, MA, MSc, BSc (Hons), PGCE, RN, Senior Lecturer, Department of Nursing and Applied Clinical Studies, Canterbury Christ Church University, North Holmes Road, Canterbury, Kent CT1 1QU, UK Address for correspondence: AM Price, MA, MSc, BSc (Hons), PGCE, RN, Senior Lecturer, Department of Nursing and Applied Clinical Studies, Canterbury Christ Church University, North Holmes Road, Canterbury, Kent CT1 1QU, UK E-mail: [email protected]
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where machines (such as for mechanical ventilation and dialysis) are becoming more sophisticated and are being more uniquely developed to meet critical care needs (Crocker, 2007). However, within the United Kingdom this has resulted in ethical and economic debates about the appropriateness and cost of some interventions (Moratti, 2009). A desire to explore how caring and technology related to the critical care setting led to the development of the research project. Elements that might be important to explore were based around the contextual and cultural issues affecting health care professionals within the setting as well as the patient illness acuity. Thus, the purpose of this study was to explore the following question: What aspects affect registered health care professionals’ ability to care for patients within the technological environment of a critical care unit? © 2013 British Association of Critical Care Nurses • Vol 18 No 6
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THE CONCEPT OF CARING The majority of the literature around the concept of caring within health care is framed within the context of nursing practice (Clifford, 1995; Kyle, 1995; Lea and Watson, 1996; Brilowski and Wendler, 2005). The term ‘caring’ is often used interchangeably with ‘nursing care’, and ‘care plans’ according to Lea and Watson (1996) and Ousey and Johnson (2007) felt that nursing and caring were still viewed as synonymous. Watson (1988) and Ousey and Johnson (2007) emphasis the difference between nursing and medicine as care and cure perspectives respectively; however, Clifford (1995) notes that ‘caring’ is not unique to nursing and other professions would describe themselves as caring. This highlights the confusion and ambiguity surrounding the term ‘caring’ (Kyle, 1995; Brilowski and Wendler, 2005). Kyle (1995) said that: ‘caring as a complex phenomenon involving more than a set of caring behaviours. It is a process including moral, cognitive and emotional components which is culturally derived.’ (p.512) A concept analysis by Brilowski and Wendler (2005) identified five key areas within the caring concept as ‘relationship’, ‘action’, ‘attitude’, ‘acceptance’ and ‘variability’ and, although this was related to nursing practice, it could be applied to other health care professionals. The broad concepts of caring remain similar today although there is more emphasis on caring as part of person centred care (NHS Education for Scotland – NMAHP Quality Council, 2011).
THE CONCEPT OF TECHNOLOGY Technology has revolutionized health care in the last 50 years (Moratti, 2009) and the Internet has exploded the information available to society at an unprecedented rate. Norman (1993) asks whether the technological advances are outstripping our ability to understand them and suggests that it potentially has a lot of power over us. The expansion of computer technology has changed societal norms (Rutsky, 1999) and is thought to promote a distancing from other people. Heidegger (1952/1993) is a seminal writer and discussed the ‘question of technology’ and the impression that it makes on the human condition. He suggests that technology could overtake humans in intellectual capability and notes its ability to be used for good and evil. Heidegger does not offer a definition of technology (Dreyfus, 2006) but unveils the power of technology within our society. He suggests that technology is more than just something that we use but has an ability to ‘enframe’ or challenge beings © 2013 British Association of Critical Care Nurses
(1952/1993). Heidegger (1962) talks about technology being ‘ready to hand’ meaning that equipment should be utilized within the context intended. Another key writing is Ihde’s ‘philosophy of technology’ (1993), which has a differing perspective in that it focuses on the ‘technoscience’ perception, particularly around the artificial nature of technology. The relationship of technology to the culture and science is evident in Ihde’s ideas (1993) and Rutsky (1999) notes that technology has a strong socialcultural effect as technological societies are seen as more ‘advanced’.
CARING AND TECHNOLOGY IN CRITICAL CARE Historically, critically ill patients were grouped together to facilitate the development of knowledge and skill in the technology used to treat them (Fairman, 1992). However, the broad concepts of caring and technology, as outlined above, have been applied to nursing and critical care practice by a number of authors (Locsin, 1995; Walters, 1995b; Beeby, 2000a; Burnard and Sandelowski, 2001; Coombs, 2001). Searching the literature on ‘caring’ usually leads to articles around the practicalities of looking after particular types of patients rather than the concepts that underpin practice. This leads to a complex and confusing picture between the aesthetic and practical elements that entwine caring and technology within critical care practice (Burnard and Sandelowski, 2001). Carnevale (1991) notes that caring is an invisible activity that is difficult to quantify and Funk (2011) says that technology now permeates critical care and wonders if it is always used appropriately. Research into the interchange of technology and caring within the intensive care setting has been evident in the literature since the 1980s. CINHAL and MEDLINE database searches using the terms ‘technology’, ‘caring’ and ‘critical care’ produced a range of material from across the globe. Several recurrent themes emerged from this literature search which will be detailed below. Technical competency was seen as vital to caring within critical care by Ray (1987), Burfitt et al. (1993), Bush and Barr (1997), Alasad (2002) and Almerud et al. (2008); this was reflected both in patients and staff perspectives. However, technology was not viewed as separate to caring by many authors (Bush and Barr, 1997; Mullen, 2002; Wilkin and Slevin, 2004; Bull and Fitzgerald, 2006) and the importance of holism was emphasized by others (Burfitt et al., 1993; Beeby, 2000b; Wilkin and Slevin, 2004; McGrath, 2008). However, none of the authors clarified their 279
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underpinning philosophy of ‘technology’ but seemed to rely on participants views. Integral to these broad concepts was the more personal relationship issues around practice such as communication (Ray, 1987), making the alien more humane (Hawley and Jensen, 2007; McGrath, 2008), individualization (O’Connell and Landers, 2008; Nascimento and Erdmann, 2009) and commitment (Zalumas, 1989). Other authors note the effect of technology more specifically such as technology being more objective because it records factual information (Cooper, 1993), that technology was part of caring (Walters, 1995a; Mullen, 2002), the complexity of technology in caring (Wikstrom and Larsson, 2004) which can create ¨ dilemmas (Wikstrom ¨ et al., 2007; Philpin, 2007) and the relationship between technology and its use by staff (Crocker, 2006; Kiekkas et al., 2006). The idea that technology blocks interactions was suggested by Alliex and Irurita (2004) although McGrath (2008) found that the opposite could be true because of the close nature of the work. Other authors talk about the demanding nature of technology (Alasad, 2002) and detail the complex world of intensive care which differs depending on patient or staff perspective (Kongsuwan and Locsin, 2011). Thus, the best way to offer patients complex treatment in a humane and individualized way is difficult to delineate. Many of the more recent studies above were performed outside the UK (O’Connell and Landers, 2008; Nascimento and Erdmann, 2009; Kongsuwan and Locsin, 2011) and there seemed to be a changing emphasis from technology being a negative influence on caring practice towards a more positive holistic view. The literature highlights a wide range of views and emphasis on caring and technology within critical care but most are small studies that draw of a qualitative research approach particularly phenomenology. The available evidence lacked detail about aspects that impacted on the ability to care effectively within the critical care setting; thus, this study was developed to examine this area. The literature did not address the cultural and societal aspects affecting caring within a technological setting that might be important in the process; thus the research aim was developed.
AIM What aspects affect registered health care professionals’ ability to care for patients within the technological environment of a critical care unit? The objectives of the study were to identify and explore the factors that enhance or inhibit participants’ ability to integrate caring with technology in practice, 280
the influence of social/cultural context and the impact of severity of illness on the process.
METHODOLOGY A qualitative methodology was chosen as the aspects to be explored would involve individual perceptions and beliefs about the world of critical care. Ethnography is described as exploring ‘the norms, values, beliefs, practices, custom, rituals, language, health behaviours and interactions of a group sharing a common culture’ (McCallin, 2002 p.26). Ethnography aims to examine human behaviours in their cultural context utilizing a range of data sources (Hammersley and Atkinson, 1983) and was originally used for large groups of people. However, Fetterman (1989) noted its’ usefulness for smaller cultural settings such as workrelated activities. This research aimed to examine these type of issues and ethnography was viewed as a relevant methodological approach. Townsend (1996) suggested that observation, interviews and document reviews are possible data sources in ethnographic research and these three data sources were used as a form of triangulation to increase research rigour (Savage, 2000). Brewer’s (2000) process of ethnographic research was used as a basis to structure the approach (Box 1). Fieldwork observation involves the researcher watching, recording and analysing events (Blaxter et al., 2008). Study participants were observed whilst undertaking practice activities with individual patients. Interactions, activities, distractions and interruptions were recorded to enlighten the relationship between caring and technology in practice. The context of the unit on the day of the observations was also recorded, such as whether it was short-staffed or had new admissions. The researcher was an observer participant so that she participated in activities and shared the study participants world to became an insignificant variable within the research setting (Kemp, 2001). Moule and Goodman (2009) explain the relevance of qualitative interviewing strategies when the participants’ opinions, experiences and perceptions are needed. Semi-structured interviews are usually most appropriate in ethnographic work as it enables the researcher to explore and clarify issues from other data sources to heighten reliability (Erlandson et al., 1993). Individual interviews were undertaken, recorded and transcribed for analysis. Documents are usually viewed as a static entity and containers of content (Prior, 2008) but give another source of evidence and alternative view (Alaszewski, 2007). Erlandson et al. (1993) suggests that researchers need to be discerning when collecting documentary © 2013 British Association of Critical Care Nurses
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BOX 1 BREWER’S PROCESS OF ETHNOGRAPHIC RESEARCH • • • • • • • • • •
Identify topic and aims of research Think about choice of field site Identify resources available (e.g. money and time) Sampling process Consider method/s of data collection Negotiate access and identify ‘gatekeepers’ Think about fieldwork role (participant-observer) and developing trust Consider ethics and Recording data Identify form of analysis Withdrawal from field and report writing
evidence so that relevant data is acquired. Thus, documents were examined to substantiate or refute interpretations that were being developed during the data gathering process and to identify similarities and gaps between practice and documentation recorded.
Ethical approval This research was approved by the NHS research ethics committee and the Trust Research and Governance Department. Data collection within health care is complicated by ensuring the safety of patients within the process and particularly relevant for critical care where the patients are vulnerable (Moule and Goodman, 2009). Thus the study was focused on staff participants who received information sheets prior to consenting to take part in the study. Participants could opt to be observed, interviewed or both and had the option to withdraw at any point. Patient consent was also gained formally during the observation periods, either from patients directly or their next of kin. The treatment of the patients would not change because of the observations taking place on the staff but consent was gained to ensure that patients, and their relatives, were informed of the research process.
Sample The sampling strategy for this study was purposeful (Erlandson et al., 1993) in nature as it aimed to incorporate staff with the knowledge and experience to enlighten the research aims. The criteria for participation was that they had to be a registered health care professional that worked as a permanent member of the intensive care team. These criteria could include doctors, physiotherapists and nurses (amongst others) and aimed to enable a broad spectrum of the culture to be viewed. Participants were recruited on a voluntary basis to allow individuals to maintain their autonomy. A total of 19 participants took part in the study; 8 nurses were observed and 16 health care professionals © 2013 British Association of Critical Care Nurses
were interviewed, including 13 nurses, 1 doctor and 2 physiotherapists. Three nurses who took part in the observations were unavailable for the interviews. The participants experience ranged from 5 months to 20 years within the intensive care setting. Only two of the participants were male. Data observations (including review of documents) were collected over a range of day and night shifts and interviews conducted in a private room during 2008–2009.
DATA ANALYSIS Constant comparative analysis, as developed by Glaser and Stauss (1967 cited in Annells, 2003) was consistent with the ethnographic approach of this study. The constant comparison approach advocates the ‘back and forth’ process as understanding of ideas develops and is facilitated by pauses in data collection before refocusing new data collection. Erlandson et al. (1993) expound the interpretative nature of the constant comparative method and the need to develop categories from the data. The fieldwork observations initially provided ideas that were examined and refined further using the documents and interviewing strategies. Moule and Goodman (2009) suggest triangulation of methods to aid completeness in data collection although suggests that this may complicate analysis as different methods may enlightened different aspects within the study; this was true for this study which found some contradictions in different data sources but this was useful for the development of categories completeness.
FINDINGS During the analysis, it was difficult to separate the caring and technology elements from the cultural influences as they were often intertwined. Thus, the themes developed to demonstrate the linking of the caring and technological aspects. This led to the 281
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identification of an overarching theme of the ‘Crafting process’ with sub themes of ‘vigilance’, ‘focus of attention, ‘being present’ and ‘expectations’ with the ultimate goal of achieving the best interests for the individual patient – this is represented in Figure 1 and will be explore further below.
Vigilance Vigilance involved aspects that enabled the patient to progress towards recovery and stabilization. This involved practical and decision-making skills involving assessing the patient, physically, psychologically and in technical areas. This was linked with maintaining safety and responding to warnings, such as alarms, appropriately. An aspect of safety was ‘keeping an eye’ on patients which referred to observing the patient, or other staffs’ patient, when no activities needed doing. ‘The main thing is you’re optimising their function, so make sure the ventilation is . . . all set to the correct settings, you’ll check the arterial line, everything, and your CVP line, make sure there safe’ Participant 2 interview (82–84) nurse The areas of prioritizing developed from the assessment and safety areas and included developing plans of action for particular patients and informing others to influence treatment. This included relaying abnormalities to other members of the health care team or referring to policies for guidance.
‘if you’re allocated say two patients and one goes very, very sick then it is the other one that’s not so sick that kind of gets neglected, it’s not that you want to neglect them it’s a case of prioritising the care.’ Participant 4 interview (185–189) nurse Vigilance incorporated the skills to identify and decide the priorities within the patients’ management. This was often reliant on an individual’s knowledge and skills and ability to apply this to the practice setting.
Focus of attention The focus of attention usually revolved around ensuring the physical stability of the patient and saving life. The focus shifted as patients physical condition improved towards enabling recovery or peaceful death. There were several elements that affected the staff’s ability to focus on the patients’ individual needs or vied for attention. Staff noted that there was a balancing between promoting physical recovery and the need for psychological and social support. Dealing with the technology could take up a lot of time, such as to it set up, but was generally viewed as useful to enable close monitoring of the patient. However, it was interesting to note that alarms appeared to be silenced or ‘ignored’ as participant 8 noted during an observation period: [if a machine alarms you tend to go and silence it first and see what problem is. Participant
Figure 1 The crafting of critical care practice.
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says that usually it is an error so often ignore them. Participant noted that they silence alarms and then look at patient to check they are alright] Participant 8 observation period 1·2 – nurse This demonstrated the links between focusing on the patients’ stability and the skills of vigilance to make decisions, thus it was difficult to separate the themes. Sometimes other issues moved the focus of attention away from the individual patient. Staff might have to move their attention away from their allocated patient to assist with a more unstable one; this could include helping more inexperienced members of staff. ‘the skill mix, coz sometimes you end up with lots of junior staff on one day, how are you going to support them and the patient who you have, the kind of patients affect the day you have, if you’ve got patients highly confused and or really very, very sick’ Participant 13 interview (275–278) – nurse Also, some patients might require more support because of anxiety or confusion; although they were not the most physically unstable patient they demanded additional staff input and changed the focus. The machines could become the focus of attention if they were not working smoothly which was observed as follows: [Participant talking about CVVH machine says it is ‘craving all my attention’ and might have to ‘bring it down’. Another nurse comes over – participant tells her problem and nurse says ‘oh its gone’]. Participant 7 observation 1·3 – nurse The focus might be affected by the professional priorities also: the doctor made this comment:
Being present Being present involved the participants communication, liaison and personal traits. It was about commitment and compassion for and building a relationship with the critically ill person and their family. The responsiveness of the patient seemed to affect the communication style and approach taken as is outlined in the two examples which were observed below [Participant is putting sedation lines onto central line so she can remove peripheral cannula. She talked to the patient while she did this even though the patient is sedated and not responding. Fairly directive – ‘I am going to do this now’]. Participant 3 observation 1·1 – nurse More awake patients tended to get much more reassurance and explanation: [Patient restless – Participant talks to her explains why she needs to be in bed and that it is night. Participant asks if she wants a sleeping tablet or pain killer. Patient admits she has pain] Participant 7 observation 2·5 – nurse The presence of the staff seemed to instil confidence and enabled the development of trust and rapport. Aspects of care were seen as providing comfort, whether physical, emotional or spiritual, and little touches were viewed as individualizing activity and important in making a difference to the patient or their family: ‘P – it’s the nurse that just does that extra little thing or says some kind work or basically even if it’s just being in the right place at the right time, all these things can make a bad experience a better experience for patients and their relatives.’ Participant 14 interview (59–62) nurse
‘they (nurses) are constantly by the bedspace whereas we have to deal with all of the patients and all the other patients on the ward in the hospital so we don’t have the luxury of just staying with one patient’. Participant 17 interview (121–125) doctor
Seeing the patient as a person was viewed as important to aid holistic and individualized therapy. A physiotherapist highlighted the importance of this in aiding treatment:
Thus, there were many elements that could draw the staff away from their patient that included the needs of colleagues, other patients or families. This could become a balancing act and sometimes led to frustration if the participant could not maintain their own workload and priorities.
‘P - we do get involved in the sort of psychological side as well, definitely, you get to know these patients very well and quite often we might be the one that they open up to about fears and phobias, we do spend a lot of time talking to patients.’ Participant 16 interview (109–113) physiotherapist
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This theme seems to enable the staff to interact with the patient on a one-to-one basis but was vital to hone interventions to the patients’ specific needs. An emphasis was on communication, both verbal and picking up non-verbal, but it was also about the skills of empathy and relationship building. The psychosocial elements were clearly articulated in this area but only two participants talked explicitly about the spiritual needs of patients.
‘The crafting process’ Craft (used as a verb) is defined as ‘to make or manufacture (an object, objects, product, etc.) with skill and careful attention to detail.’ (dictionary.com 2013). The themes above demonstrate the many skills and attention to detail needed to reach the goal for the patient within the intensive care setting using the technology appropriately. This crafting process is set within the economic, socio-cultural, political and technological considerations of the setting and was described by a senior nurse:
Expectations These were often unspoken elements that affected the working practices of critical care staff. Elements that were so ingrained within the setting but could affect the individualized patient and staff experience. This was where the cultural expectations within the unit could particular affect staff and patients. It was interesting to note that staff felt pressure to achieve tasks on-time and wanted to be seen to be busy, whether with routines or documentation. The organizational requirements, such as audit, were sometimes viewed as detracting the staff from the patient: ‘and auditing also, just pop in at anytime, just scribble something there . . . they will really get your name and you will be suspended if you won’t do this policy, if you don’t adhere, scary!’ Participant 7 interview (369–372) nurse Team functioning was affected by the dynamics of the staff and the people in charge and could fluctuate on a daily basis depending who was working the shift. There still seemed to be power relationships that affected the effective functioning as a whole: ‘ you got the dynamics of the people you’re working with, the dynamics of the team, the skill mix of the team, the personalities of the team, of nurses and, obviously it depends on the medical staff and medical cover’ Participant 11 interview (183–187) nurse The intensive care was seen as a place of learning but staff noted that personal issues could affect motivation and support for staff seemed variable. There was an expectation to contribute to the team proactively and be enthusiastic. Demanding patients/families could be seen as affecting morale and lead to avoidance tactics. Thus, the organization, professional and team expectations could place additional demands on the staff to act and prioritize in a set format. 284
‘there are mechanics and gardeners , there are nurses who attend to much to the psychological element and the physiological element gets neglected and that ends up having a psychological knock on effect, you have to balance them.’ Participant 9 interview (154–155) nurse The crafting process, combining all the elements above, meant that the individual best interests for each patient could be met. Critical care was viewed by participants as combining the aspects of caring with technology and they were not viewed as separate entities. Factors affecting health care professionals, whilst caring for patients within the technical setting of critical care unit, was multi-faceted and complex. It involved personal traits of staff/patients/family, teamworking dynamics, cultural norms of the setting and organizational priorities and the crafting enabled these to work cohesively to achieve the best outcome for the patient.
DISCUSSION This study has highlighted that the concepts around ‘caring’ and ‘technology’ cannot be separated into distinct segments which agrees with Bull and Fitzgerald (2006), but the way in which this is delivered is key. The themes identified above reinforce previous research but highlight the external aspects that impact on the activities. The importance of being safe and in control was noted by Alasad (2002) and Kiekkas et al. (2006), which links with the theme of vigilance; Burfitt et al. (1993) also identified this as important from the patients’ perspective as they wanted to feel safe and observed. Using technology to closely observe the patient is still evident today but recognizes that a balance is needed (Funk, 2011). The role of prioritization and decision-making as part of vigilance is not evident within the caring and technology literature but this may reflect the growing complexity of critical care practice where there is more focus on evidence-based approaches. © 2013 British Association of Critical Care Nurses
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The ‘focus of attention’ theme is not explicitly evident in other literature, however, the issues of competency Ray (1987), healing Burfitt et al. (1993), balancing (Walters, 1995a), making the life threatening life sustaining (Hawley and Jensen, 2007) and the essence of life (Nascimento and Erdmann, 2009) are areas that were identified as similar to this theme. This element is not static and the focus changes continually, not only for the individual patient but also for the team, unit and organization depending on wider pressures and aspects taking precedence. This may have become more evident as the economic and political drivers to ensure quality and costeffectiveness mean that the critical care landscape is shifting constantly to meet changing demands (Scholes, 2012). Although the theme could be seen as related to the physical condition of the patient, the reality is that many external issues, such as staff skill mix, impacted on the delivery of patient care. Other authors spoke about the frustrations (Beeby, 2000b) and the importance of the team pulling together (McGrath, 2008). The relevance of the practitioner presence and interaction specifically has been evident in other research such as McGrath (2008), Nascimento and Erdmann (2009), Kongsuwan and Locsin (2011) and Bridges et al. (2013). However, it was interesting to note that O’Connell and Landers (2008) saw that relatives were more concerned about the competency of the nurses although meeting the individual needs of patients was felt to be important too. The aspect of instilling trust has not been evident before and this study also emphasized that individualized and interpersonal care was relevant to other health care professionals and not just nurses. There has been an assumption in the literature that nurses ‘care’ and this study suggests that all health professionals see themselves as striving for holism in their approaches. Performing the little things (Hawley and Jensen, 2007) is also seen in this study as recognizing the uniqueness of the person during a time of crisis. What I have termed ‘expectations’ has little emphasis in other studies. Philpin (2007) talked about the values of ITU nurses, Beeby (2000b) noted the frustrations and Kiekkas et al. (2006) found increased stress, however, the health care environment has changed since these studies were published and the requirements to meet numerous standards increased. This area of culture may require further investigation to really understand the impact this has on the critical care setting and patient experience. Bridges et al. (2013) particularly note the importance of organizational conditions to enable practitioners to engage with © 2013 British Association of Critical Care Nurses
patients, if this is poor then staff may withdraw emotionally. The ability to integrate the caring of ‘head, hand & heart’ (Galvin, 2010) within my study is the ability to focus on the priorities to save life (head) ‘Focus of Attention’, ability to attend to practicalities such as dealing with machines and involving others (hand) ‘Vigilance’, and the ability to contribute to the uniqueness of the individual through refining the process (heart) ‘being present’. Galvin (2010) does not detail the external and internal factors, that I termed ‘expectations’, that might affect the integration of care within practice. The reality of practice is getting more target and cost driven and the potential impact of this on the ideal of the ‘head, hand, heart’ needs consideration. I would argue that these cannot be seen as separate entities and drawing them together is the ‘crafting process’ that combines all the external and internal issues whilst still striving for the best outcome for the individual patient. This links with Bridges et al. (2013) ideas around the importance of optimizing the organizational conditions to support this process. The ‘crafting process’ reflects the complexity of caring within a technological setting and this was detailed in Nascimento and Erdmann’s (2009) study that was based in Brazil. The dimensions of care that they revealed were similar to many properties that I discuss; that care is not purely physical, relational or professional but includes attitudes, reciprocity and exchange between unique human beings. Although their study was small it benefited from including a range of health care professionals, patients and relatives experiences. This seems to relate to the six ‘C’s of ‘Compassion in Practice’ document (Department of Health, 2012). The elements discussed in the themes above demonstrate that critical care practitioners incorporate aspects of caring, compassion, commitment, competence, courage and communication into their practice. For example, Vigilance relates to competence; Focus of Attention to commitment; compassion and communication to Being Present; courage is needed to deal with Expectations and the Crafting Process melds the care. This would need further research and exploration to identify whether there are measurable areas that would help to define the six ‘C’s for critical care practice. Watson (1988b) seems to commence the exploration of human caring theory showing how the whole is more than the sum of parts and there is so much interrelatedness within the caring-healing continuum. Within my study, the emphasis was on the ‘best interests’ of the patient which is the relationship 285
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between physical, psychological and social on an individual level. Today, there is growing recognition about the individual and organizations’ effect and influence on caring practice (Bridges et al., 2013).
Limitations There are several limitations of this study including that data collection was undertaken in 2008/2009 and critical care practice and pressures have already changed. The researcher, being a critical care nurse, may not have noticed aspects within the research process. Olson (2001) felt that it could be difficult to step-back and be objective, this may have been a particular issue as the researcher was a novice to fieldwork. The study was limited to one district general hospital and the findings in other units may be different. Issues of trustworthiness (Topping, 2010) for qualitative data, therefore, are not fully addressed.
CONCLUSIONS The findings of this study give a different perspective to the ideas of caring in critical care related to technology. It is not just nurses who ‘care’ but all health care professionals although their emphasis may be different. Further research into the ideas of care, compassion, competency, communication, commitment and courage as detailed by Department of Health (2012) related to critical care may be needed. All these aspects were evident within this study and may inform future work that can detail how to measure these within critical care to demonstrate quality.
ACKNOWLEDGEMENTS The author thanks Dr Catherine Caballero and Dr Caroline Williams for their supervision and advice during the research process and also to the participants for their contributions.
WHAT IS KNOWN ABOUT THIS TOPIC • Caring is a complex topic which is difficult to define. • Technological competency is seen as integral to caring in critical care practice. • Caring has been viewed as mainly a nursing issue. WHAT THIS PAPER ADDS • Caring is affected by the culture of the unit and pressures that staff work under. • Caring takes many forms and its expression is influenced by professional and personal attributes • The crafting process is a holistic way to view the complex nature of critical care practice.
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