EDITORIAL doi: 10.1111/nicc.12156
What’s in this issue? On behalf of the editorial team we wish you a Happy New Year. For Nursing in Critical Care, 2015 marks the 20th anniversary of the journal’s existence, something that we as editors are proud to be leading, shaping and advancing on behalf of the British Association of Critical Care Nurses (BACCN). The landscape of critical care nursing practice, education and research has undergone major transformation in the past two decades and the journal has, through a wide range of published papers, captured the developments and challenges faced by critical care nurses. Through the pages in the journal, we have learned about the adaptability, creativity, innovation and strong leadership of nurses in developing practical solutions and evidence-based interventions in responding to a changing cultural climate, in supporting patients with increasingly complex needs and in advancing the provision of high quality care. The journal has sought and will continue to strive for excellence, embrace clinical practice as the core to our business, provide our readers with an evidence base to underpin their practice, and deliver patient care in a way that is person-centred and compassionate. The collection of articles in this issue are testament to the continued and enduring commitment of critical care nurses to foster innovation, raise standards of care and improve services that are the forefront of the discipline. The article by Richardson and Whatmore (2015), commissioned by BACCN, draws upon an appraisal of the literature to produce guidance for critical care nurses in relation to the care and management of patients receiving continuous renal replacement therapy (CRRT). The identification and diagnosis of acute kidney injury has undergone much refinement based on international consensus and research.
Likewise, the nomenclature of available renal replacement therapies has evolved rapidly and due to the highly specialized skills and complex work involved, a sound understanding and appreciation of the core principles behind care is vital to optimising the safe management of patients. Following an analysis of the literature, Richardson and Whatmore (2015) describe four principles of good practice. To begin with, continuously assessing the indications for CRRT means that nurses must understand the differences between the various modes available to treat underlying clinical problems. Vascular access is equally important in optimising the treatment and for maintaining blood flow; this requires that nurses are vigilant and apply technical know-how to avert problems. Minimizing interruptions during CRRT is another principle of good practice, as maintaining filter integrity and continuous blood flow are pivotal to improving the clinical status of the patient. A number of strategies are described which are informed by the literature and which if implemented can enhance the quality of treatment. Finally, caring for patients who are critically ill demands that nurses be proactive by instituting plans of care that include actions to prevent complications related to CRRT. A number of practical techniques are discussed that if implemented will ensure the safety of patients. The comprehensive overview by Richardson and Whatmore (2015) provides current and update guidance on an important area of nursing practice, and it importantly highlights the diverse skills and knowledge-base that is required to make informed judgements, and deliver safe and competent care to patients. Transporting critically ill patients by road is challenging and often a
© 2015 British Association of Critical Care Nurses • Vol 20 No 1
testing experience as the resources and equipment available in an ambulance is scaled down considerably compared to an intensive care unit (ICU). The study by Senften and Engström (2015) describes the experiences of seven Swedish nurses delivering care to critically ill patients being transported by helicopter. The confinement of space and cabin pressures requires nurses to effectively adapt to the situation and consider their environment in the context of the patient’s clinical status and use their expertize to make appropriate care and safety decisions. Thematic content analysis of data identified the core theme of ‘Safe nursing care, but sometimes feeling afraid’ which embraced six categories. One category concerned the problems with available space, the large area occupied by medical equipment and restricted ceiling height within the helicopter interfered with nurses ability to provide care, perform interventions such as cardiopulmonary resuscitation and control environmental temperature. However, despite these challenges, stabilising the patient, close proximity and monitoring ensured the safety of patients during transit. ‘A loud environment complicates communication’ was another category emerging from the data, in which nurses outlined how they overcame communication barriers amidst the noise arising from the helicopter engine. Nurses described using non-verbal communication techniques to maintain interactions with patients and increased use of monitoring resources to gauge the status of those under their care. ‘Planning and checking to minimize risks’ and ‘Previous experience and good co-operation’ capture the detailed actions that nurses undertook to ensure patient safety, which depended on strong and effective intra-professional working with the helicopter pilots and other 5
Editorial
clinicians. These two categories illustrate how nurses used human and other clinical resources to optimize the well-being of patients during airborne transport. At times nurses reported being confronted with ‘the dilemma of allowing relatives to accompany patient or not’. This category describes how participants had to juggle whether to allow relatives to fly with patients to their destination. However while decision was often determined by the pilot in terms of fuel and other parameters, nurses had to ensure that relatives had alternative and safe modes of transport to reach the hospital the patient had been transferred to. Finally, the last category relates to ‘Feeling the patient’s and their own fear’ this embraces participants’ awareness of the risks and hazards of transporting patients in difficult weather conditions, but were confident in the training they had received and pilot’s expertize. Managing patient anxieties associated with fears of flying was usually resolved by reassurance and frequent explanations during the journey. What the work of Senften and Engström (2015) highlights is the resourcefulness and proactivity that nurses demonstrated when transporting patients by helicopter. Additionally, the experience and skills of nurses in terms of inter-personal communication, team-working, adaptability and forward planning seem pivotal to the success of transporting patients by helicopter. The take-away message is that nurses will often work in varying and demanding environments; however, to be effective and competent they need to have a well-honed and developed range of clinical and professionals. Weaning patients from ventilation safely and effectively is a complex activity within ICUs and although guidelines and protocols are helpful in guiding decision making, their use varies from country to country. While much research has been undertaken in this area, the aim of Tingsvik et al.’s (2015) study was to describe the factors that influence 6
a nurse’s judgments when weaning patients as it is an area receiving little attention in the literature. Using a qualitative study design, Tingsvik et al. (2015) conducted semi-structured interviews with 22 ICU nurses in Sweden. The findings identified that decisions were largely determined by patient-centred factors and the nature of the care culture within the ICU. In terms of patient-related factors, the data reveal how nurses considered a range of clinical parameters which included reviewing respiratory status, level of effort made by individuals, response to a reduction in ventilation support, signs of stability and recovery. In addition, nurses also assessed other patient factors such as underlying disease processes, cardiovascular signs, cognitive functioning, ability to communicate and receptiveness or motivation to wean. Each of these variables was instrumental in guiding and informing nurses’ judgements about whether weaning was appropriate. Aside from this, participants’ responses suggest that several cultural factors impact on how decisions are made and implemented. The culture of a unit is important in enabling or hindering innovation, staff proactivity, empowerment and ability to exercise discretionary judgments. In this study, factors such as team working conditions, collaborative practices, availability of guidelines, depth of experience and knowledge, use of structured weaning plans and staff attitudes to mechanical ventilation and weaning processes were highly relevant in how decision making was operationalized. Participants in this study appropriately considered a wide range of parameters to support decision making, and while psychological factors were acknowledged, the important issues that emerged were related to the rapport between the nurse and patient, as a way of promoting trust. Moreover, in ‘knowing the patient’ this enabled the weaning plan and decision making to be tailored to the individual’s needs. As in the study of Senften
and Engström (2015), the knowledge and expertize that nurses accrue is an essential component of excellence in critical care nursing. The article by Peart and Richardson (2015), reports on best practice for bowel care to generate a bowel management tool using a quality improvement methodology. The ultimate aim of the tool is to prevent skin injury and reduce harmful effects caused by faecal incontinence. The authors set out the four stages of a quality improvement program and the evidence on which their bowel assessment tool was based and the analytical framework with which they reviewed the data (the ‘fishbone’ analysis tool). From a methodological perspective this is an insightful and significantly important contribution to the journal that can serve as a framework for others wanting to report on quality initiative programs undertaken in their unit. The authors also contribute evidence on which fundamental care practice to prevent pressure ulceration and moisture lesions forming as a result of faecal incontinence can be based. Here is an article that clearly demonstrates how systematic and rigorous approaches contribute to the care and well-being of patients and how a quality initiative can impact on patient outcomes. The editors are proud to publish this article as we feel it will become a seminal paper that can guide other authors who wish to publish their own quality initiative interventions. Howes’ (2015) article examines end-of-life care in a paediatric intensive care unit. This systematic review draws together articles that examine practice when further treatment is considered to be futile. The sensitivity with which these papers are analysed and the core themes represented is a testament to this profoundly emotional and traumatic topic. Of note is the balance given to the trauma experienced by the families of children who are at the end of their life, and also to the impact this has on the staff. The impact of a transfer to a hospice or the child’s home is examined. The complexity that © 2015 British Association of Critical Care Nurses
Editorial
surrounds the withdrawal of treatment for a child leads Howes to conclude that each case needs to be considered within each individual circumstance. Guidelines and protocols can guide and facilitate practice but the context of each case will always require professional judgement of what is in the best interests of the child. This issue has published a series of articles that touch the essence of critical care practice in all its diversity. It situates clinical know-how and importantly provides evidence of the impact that high quality evidence has
© 2015 British Association of Critical Care Nurses
on clinical practice. These articles serve as a fitting celebration to launch the 20th volume of Nursing in Critical Care and demonstrate the philosophy and values that underpin the journal. John Albarran and Julie Scholes Co-editors
REFERENCES Howes C. (2015). Caring until the end: a systematic literature review exploring paediatric intensive care unit end-of-life care. Nursing in Critical Care; 20: 41–51.
Peart J, Richardson A. (2015). Developing a critical care bowel management assessment tool to manage faecal incontinence. Nursing in Critical Care; 20: 34–40. Richardson A, Whatmore J. (2015). Nursing essential principles: continuous renal replacement therapy. Nursing in Critical Care; 20: 8–15. Senften J, Engström A. (2015). Critical care nurses’ experiences of helicopter transfers. Nursing in Critical Care; 20: 25–33. Tingsvik C, Johansson K, Märtensson J. (2015). Weaning from mechanical ventilation: factors that influence intensive care nurses’ decision-making. Nursing in Critical Care; 20: 16–24.
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Copyright of Nursing in Critical Care is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
What’s in this issue? On behalf of the editorial team we wish you a Happy New Year. For Nursing in Critical Care, 2015 marks the 20th anniversary of the journal’s existence, something that we as editors are proud to be leading, shaping and advancing on behalf of the British Association of Critical Care Nurses (BACCN). The landscape of critical care nursing practice, education and research has undergone major transformation in the past two decades and the journal has, through a wide range of published papers, captured the developments and challenges faced by critical care nurses. Through the pages in the journal, we have learned about the adaptability, creativity, innovation and strong leadership of nurses in developing practical solutions and evidence-based interventions in responding to a changing cultural climate, in supporting patients with increasingly complex needs and in advancing the provision of high quality care. The journal has sought and will continue to strive for excellence, embrace clinical practice as the core to our business, provide our readers with an evidence base to underpin their practice, and deliver patient care in a way that is person-centred and compassionate. The collection of articles in this issue are testament to the continued and enduring commitment of critical care nurses to foster innovation, raise standards of care and improve services that are the forefront of the discipline. The article by Richardson and Whatmore (2015), commissioned by BACCN, draws upon an appraisal of the literature to produce guidance for critical care nurses in relation to the care and management of patients receiving continuous renal replacement therapy (CRRT). The identification and diagnosis of acute kidney injury has undergone much refinement based on international consensus and research.
Likewise, the nomenclature of available renal replacement therapies has evolved rapidly and due to the highly specialized skills and complex work involved, a sound understanding and appreciation of the core principles behind care is vital to optimising the safe management of patients. Following an analysis of the literature, Richardson and Whatmore (2015) describe four principles of good practice. To begin with, continuously assessing the indications for CRRT means that nurses must understand the differences between the various modes available to treat underlying clinical problems. Vascular access is equally important in optimising the treatment and for maintaining blood flow; this requires that nurses are vigilant and apply technical know-how to avert problems. Minimizing interruptions during CRRT is another principle of good practice, as maintaining filter integrity and continuous blood flow are pivotal to improving the clinical status of the patient. A number of strategies are described which are informed by the literature and which if implemented can enhance the quality of treatment. Finally, caring for patients who are critically ill demands that nurses be proactive by instituting plans of care that include actions to prevent complications related to CRRT. A number of practical techniques are discussed that if implemented will ensure the safety of patients. The comprehensive overview by Richardson and Whatmore (2015) provides current and update guidance on an important area of nursing practice, and it importantly highlights the diverse skills and knowledge-base that is required to make informed judgements, and deliver safe and competent care to patients. Transporting critically ill patients by road is challenging and often a
© 2015 British Association of Critical Care Nurses • Vol 20 No 1
testing experience as the resources and equipment available in an ambulance is scaled down considerably compared to an intensive care unit (ICU). The study by Senften and Engström (2015) describes the experiences of seven Swedish nurses delivering care to critically ill patients being transported by helicopter. The confinement of space and cabin pressures requires nurses to effectively adapt to the situation and consider their environment in the context of the patient’s clinical status and use their expertize to make appropriate care and safety decisions. Thematic content analysis of data identified the core theme of ‘Safe nursing care, but sometimes feeling afraid’ which embraced six categories. One category concerned the problems with available space, the large area occupied by medical equipment and restricted ceiling height within the helicopter interfered with nurses ability to provide care, perform interventions such as cardiopulmonary resuscitation and control environmental temperature. However, despite these challenges, stabilising the patient, close proximity and monitoring ensured the safety of patients during transit. ‘A loud environment complicates communication’ was another category emerging from the data, in which nurses outlined how they overcame communication barriers amidst the noise arising from the helicopter engine. Nurses described using non-verbal communication techniques to maintain interactions with patients and increased use of monitoring resources to gauge the status of those under their care. ‘Planning and checking to minimize risks’ and ‘Previous experience and good co-operation’ capture the detailed actions that nurses undertook to ensure patient safety, which depended on strong and effective intra-professional working with the helicopter pilots and other 5
Editorial
clinicians. These two categories illustrate how nurses used human and other clinical resources to optimize the well-being of patients during airborne transport. At times nurses reported being confronted with ‘the dilemma of allowing relatives to accompany patient or not’. This category describes how participants had to juggle whether to allow relatives to fly with patients to their destination. However while decision was often determined by the pilot in terms of fuel and other parameters, nurses had to ensure that relatives had alternative and safe modes of transport to reach the hospital the patient had been transferred to. Finally, the last category relates to ‘Feeling the patient’s and their own fear’ this embraces participants’ awareness of the risks and hazards of transporting patients in difficult weather conditions, but were confident in the training they had received and pilot’s expertize. Managing patient anxieties associated with fears of flying was usually resolved by reassurance and frequent explanations during the journey. What the work of Senften and Engström (2015) highlights is the resourcefulness and proactivity that nurses demonstrated when transporting patients by helicopter. Additionally, the experience and skills of nurses in terms of inter-personal communication, team-working, adaptability and forward planning seem pivotal to the success of transporting patients by helicopter. The take-away message is that nurses will often work in varying and demanding environments; however, to be effective and competent they need to have a well-honed and developed range of clinical and professionals. Weaning patients from ventilation safely and effectively is a complex activity within ICUs and although guidelines and protocols are helpful in guiding decision making, their use varies from country to country. While much research has been undertaken in this area, the aim of Tingsvik et al.’s (2015) study was to describe the factors that influence 6
a nurse’s judgments when weaning patients as it is an area receiving little attention in the literature. Using a qualitative study design, Tingsvik et al. (2015) conducted semi-structured interviews with 22 ICU nurses in Sweden. The findings identified that decisions were largely determined by patient-centred factors and the nature of the care culture within the ICU. In terms of patient-related factors, the data reveal how nurses considered a range of clinical parameters which included reviewing respiratory status, level of effort made by individuals, response to a reduction in ventilation support, signs of stability and recovery. In addition, nurses also assessed other patient factors such as underlying disease processes, cardiovascular signs, cognitive functioning, ability to communicate and receptiveness or motivation to wean. Each of these variables was instrumental in guiding and informing nurses’ judgements about whether weaning was appropriate. Aside from this, participants’ responses suggest that several cultural factors impact on how decisions are made and implemented. The culture of a unit is important in enabling or hindering innovation, staff proactivity, empowerment and ability to exercise discretionary judgments. In this study, factors such as team working conditions, collaborative practices, availability of guidelines, depth of experience and knowledge, use of structured weaning plans and staff attitudes to mechanical ventilation and weaning processes were highly relevant in how decision making was operationalized. Participants in this study appropriately considered a wide range of parameters to support decision making, and while psychological factors were acknowledged, the important issues that emerged were related to the rapport between the nurse and patient, as a way of promoting trust. Moreover, in ‘knowing the patient’ this enabled the weaning plan and decision making to be tailored to the individual’s needs. As in the study of Senften
and Engström (2015), the knowledge and expertize that nurses accrue is an essential component of excellence in critical care nursing. The article by Peart and Richardson (2015), reports on best practice for bowel care to generate a bowel management tool using a quality improvement methodology. The ultimate aim of the tool is to prevent skin injury and reduce harmful effects caused by faecal incontinence. The authors set out the four stages of a quality improvement program and the evidence on which their bowel assessment tool was based and the analytical framework with which they reviewed the data (the ‘fishbone’ analysis tool). From a methodological perspective this is an insightful and significantly important contribution to the journal that can serve as a framework for others wanting to report on quality initiative programs undertaken in their unit. The authors also contribute evidence on which fundamental care practice to prevent pressure ulceration and moisture lesions forming as a result of faecal incontinence can be based. Here is an article that clearly demonstrates how systematic and rigorous approaches contribute to the care and well-being of patients and how a quality initiative can impact on patient outcomes. The editors are proud to publish this article as we feel it will become a seminal paper that can guide other authors who wish to publish their own quality initiative interventions. Howes’ (2015) article examines end-of-life care in a paediatric intensive care unit. This systematic review draws together articles that examine practice when further treatment is considered to be futile. The sensitivity with which these papers are analysed and the core themes represented is a testament to this profoundly emotional and traumatic topic. Of note is the balance given to the trauma experienced by the families of children who are at the end of their life, and also to the impact this has on the staff. The impact of a transfer to a hospice or the child’s home is examined. The complexity that © 2015 British Association of Critical Care Nurses
Editorial
surrounds the withdrawal of treatment for a child leads Howes to conclude that each case needs to be considered within each individual circumstance. Guidelines and protocols can guide and facilitate practice but the context of each case will always require professional judgement of what is in the best interests of the child. This issue has published a series of articles that touch the essence of critical care practice in all its diversity. It situates clinical know-how and importantly provides evidence of the impact that high quality evidence has
© 2015 British Association of Critical Care Nurses
on clinical practice. These articles serve as a fitting celebration to launch the 20th volume of Nursing in Critical Care and demonstrate the philosophy and values that underpin the journal. John Albarran and Julie Scholes Co-editors
REFERENCES Howes C. (2015). Caring until the end: a systematic literature review exploring paediatric intensive care unit end-of-life care. Nursing in Critical Care; 20: 41–51.
Peart J, Richardson A. (2015). Developing a critical care bowel management assessment tool to manage faecal incontinence. Nursing in Critical Care; 20: 34–40. Richardson A, Whatmore J. (2015). Nursing essential principles: continuous renal replacement therapy. Nursing in Critical Care; 20: 8–15. Senften J, Engström A. (2015). Critical care nurses’ experiences of helicopter transfers. Nursing in Critical Care; 20: 25–33. Tingsvik C, Johansson K, Märtensson J. (2015). Weaning from mechanical ventilation: factors that influence intensive care nurses’ decision-making. Nursing in Critical Care; 20: 16–24.
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Copyright of Nursing in Critical Care is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
