EDITORIAL doi: 10.1111/nicc.12140
What’s in this issue? The first editorial by Maureen Coombs (2014) sets out an inspirational exploration of the importance of leadership and celebrates the fact that 80% of health care delivery is undertaken by those who follow. She describes the role everyone has to play in a successful organization, be they a leader or a follower. She applies this to the safe delivery of end-of-life care and how important the term ‘we’ is to take responsibility and centre our own contribution within the team. She celebrates good followership. This is not a passive response to a directive from a ‘leader’, but as an active partner in delivery of high quality care and support for those who deliver that care with us. The management of pain, delirium and the safe extubation of patients in critical care practice is an area for which many assessment tools and guidelines have been developed to support and inform the delivery of high-quality nursing care. However, despite their availability they may not always be consistently applied and it is this challenge that the first three papers in this issue examine. The next three papers explore very different aspects of practice: a case study on the protocolized care of a lady supported by extracorporeal membrane oxygenation (ECMO), the experience of preregistration students in intensive care and finally a deeply moving reflective account of the support of parents whose child is at the end of life. The regular assessment and management of patient pain in the intensive care unit (ICU) is recommended as good practice; however, this may in part depend on the relevance, flexibility and ease of use of existing tools. The Critical Care Pain Observation Tool (CPOT) is a behavioural pain scale which scores facial expression, body movements, muscle tension and
individuals’ interaction/compliance with their ventilator to inform pain assessments. While previous studies have highlighted that CPOT leads to improvements in terms of frequency of assessments, compliance among nurses has remained below 80%. Gélinas et al. (2014) conducted an evaluation on CPOT using a self-administered questionnaire with 38 ICU nurses to determine feasibility, clinical relevance and satisfaction. Socio-demographics were included in data collection. The data confirmed that nurses were satisfied with CPOT; moreover, the tool was seen as acceptable in terms of ease of use, simplicity and in completing. In addition, CPOT was reported to influence the practice of participants, but not in relation to communicating pain assessment findings with medical staff. The value of this study emphasizes the importance of engaging with frontline nurses to determine the acceptability, relevance and satisfaction of new innovations to staff prior to wholesale implementation. While participants had received educational CPOT training, medical staff had not been included; this led to confusion and problems in communicating the assessment scores. Clearly, an implementation strategy that includes staff most likely to be affected by a development in practice is essential in facilitating shared understanding, cooperation and in planning relevant interventions to meet patient needs. Identifying ICU patients most at risk of developing delirium is an ongoing clinical challenge, particularly as there are many variables that may precipitate cognitive problems within the setting. As delirium is not well defined it can be difficult to recognize and diagnose by inexperienced staff. To this end, Oh et al. (2014) developed the Automatic Prediction of Delirium in Intensive Care Units (APREDEL-ICU) to support
© 2014 British Association of Critical Care Nurses • Vol 19 No 6
identification of at-risk patients for delirium, particularly as this was not part of standard practice at the study centre. APREDEL-ICU is a predictive algorithm that contains a number of physiological, pharmacological and environmental high risk factors known to stimulate the onset of delirium in vulnerable populations. Parameters for each risk factor together with cut-off points were defined and any deviation would appear on a patient’s electronic records alerting staff to the risk and prompting a response with appropriate interventions. Like Gélinas et al. (2014), Oh et al. (2014) undertook their study to determine the impact of APREDEL-ICU on sensitive nurse measures, patient outcomes, and to evaluate its ease of use and satisfaction among ICU nurses. Prior to implementation, nurses were trained in using the tool and in appropriate interventions to minimize the incidence of delirium in at-risk patients. Results identified that post implementation of APREDEL-ICU, high-risk patients showed a slight decrease in the incidence of delirium. More positively, the data demonstrated that administration rates and duration of narcotic/sedation use fell following implementation of the tool. In-hospital mortality of high-risk patients also decreased. However, survey data on nurses’ views on the acceptability of APREDEL-ICU identified that they did not appreciate the need for delirium care, assessment for risk was not part of the usual and they perceived its use as adding substantially to their workload. Additionally 81% (n = 34) had not received continuing education on prevention of delirium in the ICU; however, post implementation of APREDEL-ICU means knowledge levels among the sample of nurses increased and this enhanced their practice. The message here is that 265
Editorial
when implementing new technologies such as computerized decision-making software, it is important to engage with end-users through feasibility studies in order to identify possible barriers to adoption and address these to support ease of implementation. Tume et al. (2014) describe a situation whereby despite being prepared to initiate nurse-led (protocol-directed) ventilation weaning (NLVW) and extubation in a paediatric ICU, some nurses showed some reluctance to undertake this specific role. To address the barriers in relation to NLVW, two self-administered online surveys were undertaken with the aim of uncovering the perspectives of PICU nurses (n = 36), advanced nurse practitioners and physicians (n = 20) in relation to this area of practice. For nurses who had been trained to undertake NLWV, their reasons for not instigating weaning often centred on the rigidity of the protocol, not being assigned a patient ready for weaning, running the unit or acting as ‘the runner’ on a shift, the demands of workload and a perceived lack of support from physicians and advanced nurse practitioners. In contrast, physicians considered themselves very positive and supportive of nurses undertaking NLVW roles. An explanation accounting for the perceived lack of support of physicians related to the fact that 94% of them were unaware that nurses were able to wean patients from ventilation. This one related to physicians not completing relevant weaning prescription forms. Undertaking advanced clinical roles is essential to the quality care patients receive, as often they expedite the urgent assessment and integration of appropriate clinical interventions to support well-being and health. This particular study of Tume et al. (2014) again reminds us that implementing a new service is challenging and that once introduced it is important to review how those who are operationalizing this are managing the processes. Another take-away learning point here 266
is that without effective interdisciplinary communication there is poor collaboration and this can affect the timeliness in which interventions are implemented for maximum effect. Evans’ (2014) account of the use of ECMO to support a lady who had experienced spontaneous coronary artery dissection early postpartum is a fascinating case study that describes an unusual event. Evans shares us with an excellent account of the pathophysiology of this rare condition and in her writing conveys the rapid onset and severity of this critical illness. She outlines the implications for managing the patient, notably the blood gases, blood assays (haematocrit, platelet and fibrinogen levels) and inotrope support. She identifies that the nursing care is heavily protocol driven but this allows for nursing decisions to be made. The reader is left without any information about the patient’s psychological well-being. These details may have been omitted to help protect the identity of the lady in question, but they are important elements of care in such a scenario. Often we under-report these aspects of critical care practice. This is unfortunate as it is these practices that significantly contribute to the well-being and rehabilitation of the patient. For example, how was the family enabled to cope with this situation and what was the implication of care for the 2-week infant throughout the episode of admission? Can the authors share with us their clinical acumen of how to deliver personal care when the patient is so unstable and in need of so much technical support? How did the nurses’ facilitate family visits and was there anything in particular that needed to be shared with the family to help them feel they are participants in the care delivery of the patient? Sharing experiential wisdom about these essential aspects of nursing practice requires a different language because it describes a different type of knowledge. However, that knowledge should be celebrated, and when it is absent we notice.
Williams and Palmer (2014) explore the ICU through the eyes of a student on placement. Their paper highlights the challenges of supervising preregistration students in critical care whilst maintaining high standards of patient care. Their paper outlines what we know about the experience of students: that it is stressful and anxiety provoking but provides students with opportunity to learn new skills, work closely with qualified specialist nurses and participate in care for patients who are critically unwell and who can develop rapid onset deterioration requiring complex and rapid intervention. However, meaningful learning is inhibited by anxiety and how that is managed is key to the creation of a positive learning experience. Understanding from students how we might best facilitate a placement in intensive care, acknowledging that the difference of this environment will make it stressful and demand a different modus operandi, requires further research that includes all disciplines, teaching and clinical staff in critical care as well as students who are placed there. O’Brien’s (2014) paper of the expressions of hope in paediatric intensive care is a powerful reflective account of one of the most difficult aspects of practice. Finding the equilibrium between parental hope for recovery and realistic expectation when the prognosis is poor has always been a difficult balance to strike. Intensive care staff need to find a way through the complex ethical and emotional issues this aspect raises. Mixing ideas of cure and care, ‘honesty’ and ‘protection’ compound this dissonance. When recognizing that the prospects of recovery are unrealistic, it is even more challenging for staff supporting relatives who cling to hope. O’Brien’s eloquent account of hope as an ‘innate component of the parenting role’ even when intellectually the parents understood this to conflict with their child’s prognosis gives insight into this dynamic of suffering. Further, O’Brien explores the difference in linguistic meaning to parents between © 2014 British Association of Critical Care Nurses
Editorial
the idea of treatment and care – and the importance for them to understand that although treatment may have been withdrawn, care is at its most active. For nurses this can exacerbate the distress they experience when working closely with parents who endure the end of life of their child. The nurse who bears witness to this suffering can provide care through genuine, therapeutic practice. The words used by O’Brien to describe this care are move, inspire and enable. Her paper teaches us how we can openly and honestly engage with the families. Through her words she expresses the importance of reflective narration to make sense of the saddest of experiences. Her writing brings hope into that most sorrowful component of our practice. The papers in this volume highlight the dynamic and complex nature of critical care practice. The authors provide insights that are evidence-based and reflective into how we might address these challenges. Of note, we
© 2014 British Association of Critical Care Nurses
distill a different authorial voice to describe different types of knowledge and know how: each voice holding a vibrancy and tenor consistent with the messages they depict. Finding an authorial voice is not easy and in the second editorial, Scholes and Albarran (2014) examine some of the issues that affect the writing process. We hope that the exploration of these different articles inspires you to write about your own practice development, research or reflection, and for those who feel they need some help to get started we hope you will enroll for the on-line writing workshop. Be inspired and get writing! John Albarran and Julie Scholes Co-editors, Nursing in Critical Care
REFERENCES Coombs M. (2014). Followership: the forgotten part of leadership in end-of-life care. Nursing in Critical Care; 19: 268–269.
Evans R. (2014). Post-partum spontaneous coronary artery dissection and the use of veno-arterial extra-corporeal membrane oxygenation. Nursing in Critical Care; 19: 304–309. Gélinas C, Ross M, Boitor M, Desjardins S, Vaillant F, Michaud C. (2014). Nurses’ evaluations of the CPOT use at 12-month post-implementation in the intensive care unit. Nursing in Critical Care; 19: 272–280. O’Brien R. (2014). Expressions of hope in paediatric intensive care: a reflection on their meaning. Nursing in Critical Care; 19: 316–321. Oh S-H, Park E-J, Jin Y, Piao J, Lee S-M. (2014). Automatic delirium prediction system in a Korean surgical intensive care unit. Nursing in Critical Care; 19: 281–291. Tume LN, Scally A, Carter B. (2014). Paediatric intensive care nurses’ and doctors’ perceptions on nurse-led protocol-directed ventilation weaning and extubation. Nursing in Critical Care; 19: 292–303. Williams E, Palmer C. (2014). Student nurses in critical care benefits and challenges of critical care as a learning environment for student nurses. Nursing in Critical Care; 19: 310–315. Scholes J, Albarran J. (eds.) (2014). Emotional aspects of writing. Nursing in Critical Care; 19: 270–271.
267
What’s in this issue? The first editorial by Maureen Coombs (2014) sets out an inspirational exploration of the importance of leadership and celebrates the fact that 80% of health care delivery is undertaken by those who follow. She describes the role everyone has to play in a successful organization, be they a leader or a follower. She applies this to the safe delivery of end-of-life care and how important the term ‘we’ is to take responsibility and centre our own contribution within the team. She celebrates good followership. This is not a passive response to a directive from a ‘leader’, but as an active partner in delivery of high quality care and support for those who deliver that care with us. The management of pain, delirium and the safe extubation of patients in critical care practice is an area for which many assessment tools and guidelines have been developed to support and inform the delivery of high-quality nursing care. However, despite their availability they may not always be consistently applied and it is this challenge that the first three papers in this issue examine. The next three papers explore very different aspects of practice: a case study on the protocolized care of a lady supported by extracorporeal membrane oxygenation (ECMO), the experience of preregistration students in intensive care and finally a deeply moving reflective account of the support of parents whose child is at the end of life. The regular assessment and management of patient pain in the intensive care unit (ICU) is recommended as good practice; however, this may in part depend on the relevance, flexibility and ease of use of existing tools. The Critical Care Pain Observation Tool (CPOT) is a behavioural pain scale which scores facial expression, body movements, muscle tension and
individuals’ interaction/compliance with their ventilator to inform pain assessments. While previous studies have highlighted that CPOT leads to improvements in terms of frequency of assessments, compliance among nurses has remained below 80%. Gélinas et al. (2014) conducted an evaluation on CPOT using a self-administered questionnaire with 38 ICU nurses to determine feasibility, clinical relevance and satisfaction. Socio-demographics were included in data collection. The data confirmed that nurses were satisfied with CPOT; moreover, the tool was seen as acceptable in terms of ease of use, simplicity and in completing. In addition, CPOT was reported to influence the practice of participants, but not in relation to communicating pain assessment findings with medical staff. The value of this study emphasizes the importance of engaging with frontline nurses to determine the acceptability, relevance and satisfaction of new innovations to staff prior to wholesale implementation. While participants had received educational CPOT training, medical staff had not been included; this led to confusion and problems in communicating the assessment scores. Clearly, an implementation strategy that includes staff most likely to be affected by a development in practice is essential in facilitating shared understanding, cooperation and in planning relevant interventions to meet patient needs. Identifying ICU patients most at risk of developing delirium is an ongoing clinical challenge, particularly as there are many variables that may precipitate cognitive problems within the setting. As delirium is not well defined it can be difficult to recognize and diagnose by inexperienced staff. To this end, Oh et al. (2014) developed the Automatic Prediction of Delirium in Intensive Care Units (APREDEL-ICU) to support
© 2014 British Association of Critical Care Nurses • Vol 19 No 6
identification of at-risk patients for delirium, particularly as this was not part of standard practice at the study centre. APREDEL-ICU is a predictive algorithm that contains a number of physiological, pharmacological and environmental high risk factors known to stimulate the onset of delirium in vulnerable populations. Parameters for each risk factor together with cut-off points were defined and any deviation would appear on a patient’s electronic records alerting staff to the risk and prompting a response with appropriate interventions. Like Gélinas et al. (2014), Oh et al. (2014) undertook their study to determine the impact of APREDEL-ICU on sensitive nurse measures, patient outcomes, and to evaluate its ease of use and satisfaction among ICU nurses. Prior to implementation, nurses were trained in using the tool and in appropriate interventions to minimize the incidence of delirium in at-risk patients. Results identified that post implementation of APREDEL-ICU, high-risk patients showed a slight decrease in the incidence of delirium. More positively, the data demonstrated that administration rates and duration of narcotic/sedation use fell following implementation of the tool. In-hospital mortality of high-risk patients also decreased. However, survey data on nurses’ views on the acceptability of APREDEL-ICU identified that they did not appreciate the need for delirium care, assessment for risk was not part of the usual and they perceived its use as adding substantially to their workload. Additionally 81% (n = 34) had not received continuing education on prevention of delirium in the ICU; however, post implementation of APREDEL-ICU means knowledge levels among the sample of nurses increased and this enhanced their practice. The message here is that 265
Editorial
when implementing new technologies such as computerized decision-making software, it is important to engage with end-users through feasibility studies in order to identify possible barriers to adoption and address these to support ease of implementation. Tume et al. (2014) describe a situation whereby despite being prepared to initiate nurse-led (protocol-directed) ventilation weaning (NLVW) and extubation in a paediatric ICU, some nurses showed some reluctance to undertake this specific role. To address the barriers in relation to NLVW, two self-administered online surveys were undertaken with the aim of uncovering the perspectives of PICU nurses (n = 36), advanced nurse practitioners and physicians (n = 20) in relation to this area of practice. For nurses who had been trained to undertake NLWV, their reasons for not instigating weaning often centred on the rigidity of the protocol, not being assigned a patient ready for weaning, running the unit or acting as ‘the runner’ on a shift, the demands of workload and a perceived lack of support from physicians and advanced nurse practitioners. In contrast, physicians considered themselves very positive and supportive of nurses undertaking NLVW roles. An explanation accounting for the perceived lack of support of physicians related to the fact that 94% of them were unaware that nurses were able to wean patients from ventilation. This one related to physicians not completing relevant weaning prescription forms. Undertaking advanced clinical roles is essential to the quality care patients receive, as often they expedite the urgent assessment and integration of appropriate clinical interventions to support well-being and health. This particular study of Tume et al. (2014) again reminds us that implementing a new service is challenging and that once introduced it is important to review how those who are operationalizing this are managing the processes. Another take-away learning point here 266
is that without effective interdisciplinary communication there is poor collaboration and this can affect the timeliness in which interventions are implemented for maximum effect. Evans’ (2014) account of the use of ECMO to support a lady who had experienced spontaneous coronary artery dissection early postpartum is a fascinating case study that describes an unusual event. Evans shares us with an excellent account of the pathophysiology of this rare condition and in her writing conveys the rapid onset and severity of this critical illness. She outlines the implications for managing the patient, notably the blood gases, blood assays (haematocrit, platelet and fibrinogen levels) and inotrope support. She identifies that the nursing care is heavily protocol driven but this allows for nursing decisions to be made. The reader is left without any information about the patient’s psychological well-being. These details may have been omitted to help protect the identity of the lady in question, but they are important elements of care in such a scenario. Often we under-report these aspects of critical care practice. This is unfortunate as it is these practices that significantly contribute to the well-being and rehabilitation of the patient. For example, how was the family enabled to cope with this situation and what was the implication of care for the 2-week infant throughout the episode of admission? Can the authors share with us their clinical acumen of how to deliver personal care when the patient is so unstable and in need of so much technical support? How did the nurses’ facilitate family visits and was there anything in particular that needed to be shared with the family to help them feel they are participants in the care delivery of the patient? Sharing experiential wisdom about these essential aspects of nursing practice requires a different language because it describes a different type of knowledge. However, that knowledge should be celebrated, and when it is absent we notice.
Williams and Palmer (2014) explore the ICU through the eyes of a student on placement. Their paper highlights the challenges of supervising preregistration students in critical care whilst maintaining high standards of patient care. Their paper outlines what we know about the experience of students: that it is stressful and anxiety provoking but provides students with opportunity to learn new skills, work closely with qualified specialist nurses and participate in care for patients who are critically unwell and who can develop rapid onset deterioration requiring complex and rapid intervention. However, meaningful learning is inhibited by anxiety and how that is managed is key to the creation of a positive learning experience. Understanding from students how we might best facilitate a placement in intensive care, acknowledging that the difference of this environment will make it stressful and demand a different modus operandi, requires further research that includes all disciplines, teaching and clinical staff in critical care as well as students who are placed there. O’Brien’s (2014) paper of the expressions of hope in paediatric intensive care is a powerful reflective account of one of the most difficult aspects of practice. Finding the equilibrium between parental hope for recovery and realistic expectation when the prognosis is poor has always been a difficult balance to strike. Intensive care staff need to find a way through the complex ethical and emotional issues this aspect raises. Mixing ideas of cure and care, ‘honesty’ and ‘protection’ compound this dissonance. When recognizing that the prospects of recovery are unrealistic, it is even more challenging for staff supporting relatives who cling to hope. O’Brien’s eloquent account of hope as an ‘innate component of the parenting role’ even when intellectually the parents understood this to conflict with their child’s prognosis gives insight into this dynamic of suffering. Further, O’Brien explores the difference in linguistic meaning to parents between © 2014 British Association of Critical Care Nurses
Editorial
the idea of treatment and care – and the importance for them to understand that although treatment may have been withdrawn, care is at its most active. For nurses this can exacerbate the distress they experience when working closely with parents who endure the end of life of their child. The nurse who bears witness to this suffering can provide care through genuine, therapeutic practice. The words used by O’Brien to describe this care are move, inspire and enable. Her paper teaches us how we can openly and honestly engage with the families. Through her words she expresses the importance of reflective narration to make sense of the saddest of experiences. Her writing brings hope into that most sorrowful component of our practice. The papers in this volume highlight the dynamic and complex nature of critical care practice. The authors provide insights that are evidence-based and reflective into how we might address these challenges. Of note, we
© 2014 British Association of Critical Care Nurses
distill a different authorial voice to describe different types of knowledge and know how: each voice holding a vibrancy and tenor consistent with the messages they depict. Finding an authorial voice is not easy and in the second editorial, Scholes and Albarran (2014) examine some of the issues that affect the writing process. We hope that the exploration of these different articles inspires you to write about your own practice development, research or reflection, and for those who feel they need some help to get started we hope you will enroll for the on-line writing workshop. Be inspired and get writing! John Albarran and Julie Scholes Co-editors, Nursing in Critical Care
REFERENCES Coombs M. (2014). Followership: the forgotten part of leadership in end-of-life care. Nursing in Critical Care; 19: 268–269.
Evans R. (2014). Post-partum spontaneous coronary artery dissection and the use of veno-arterial extra-corporeal membrane oxygenation. Nursing in Critical Care; 19: 304–309. Gélinas C, Ross M, Boitor M, Desjardins S, Vaillant F, Michaud C. (2014). Nurses’ evaluations of the CPOT use at 12-month post-implementation in the intensive care unit. Nursing in Critical Care; 19: 272–280. O’Brien R. (2014). Expressions of hope in paediatric intensive care: a reflection on their meaning. Nursing in Critical Care; 19: 316–321. Oh S-H, Park E-J, Jin Y, Piao J, Lee S-M. (2014). Automatic delirium prediction system in a Korean surgical intensive care unit. Nursing in Critical Care; 19: 281–291. Tume LN, Scally A, Carter B. (2014). Paediatric intensive care nurses’ and doctors’ perceptions on nurse-led protocol-directed ventilation weaning and extubation. Nursing in Critical Care; 19: 292–303. Williams E, Palmer C. (2014). Student nurses in critical care benefits and challenges of critical care as a learning environment for student nurses. Nursing in Critical Care; 19: 310–315. Scholes J, Albarran J. (eds.) (2014). Emotional aspects of writing. Nursing in Critical Care; 19: 270–271.
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