EDITORIAL doi: 10.1111/nicc.12109
What’s in this issue? The opening editorial by Heyns and McCormack (2014) describes an exciting international collaboration aimed at restoring high quality nursing care professional moral, integrity and quality for the citizens of South Africa. The challenges facing South Africa are exacerbated by demographic transitions and politics, but the concern for a shortage of nurses, a crisis in the public perception of the quality of nursing, shifting health care cultures, increasing acute and chronic health care demand are shared by nurses across the globe. The response to resolve the problem through traditional pedagogic strategy and evidence-based protocols was shown to be uninspired and was not making the difference that practice needed. Heyns and McCormack argue for change through practice development methodology. This includes evidence informed practice, person-centred approaches, team collaboration, shared decision-making and dispersed responsibility throughout the team for achieving quality outcomes. Although working in a different culture, the core uniting ingredients are critical care nurses wishing to reclaim high quality care. Inspiration can be taken from the determination to improve things for patients and their families with staff rather than imposing quality compliance through managed systems on staff. The second editorial by McCormack (2014) explores a problem we experienced while attempting to generate a special issue on older people in critical care. The demographic of intensive care unit (ICU) is that nearly 50% of the patient population is over the age of 65. Has this rendered the older person invisible in ICU? Or is it that we take little account of the age of our patients in critical care practice and research? If so, why? Are we nervous because this touches on sensitive
ethical and resource issues? McCormack challenges us all to reflect and consider these points. He goes further and advocates for a sub-speciality within critical care nursing. That would extend beyond a named patient champion and take us into a realm that gives priority to generating new knowledge to inform our practice to serve the needs of older people in ICU, be they patients or their relatives. de Boer et al.’s (2014) paper reviews the causes and self management of stressful and emotionally challenging incidents. The authors examined the experiences of a diverse (age, gender and experience) sample of 12 ICU nurses within one unit. Semi-structured interviews were thematically analysed to label four themes. Stressful events were constructed when there was ‘high emotional involvement’ where there was an ‘avoidable incident’ or ‘sub optimal care (e.g. error or missed cues), and finally, where the nurses experienced intimidation (e.g. verbal abuse). The concern of the authors was how long these critical incidents were “held” by the nurses and the impact this had on the nurses’ longer-term emotional welfare. Most of the nurses managed the stress they experienced following a critical incident by talking with colleagues and/or family and this helped them cope. Some were left avoiding comparable situations and the authors suggested this could represent ‘ineffective coping’. This paper focuses on ‘one off’ incidents. Largely events labelled ‘critical incidents’ are acknowledged, discussed and managed. This can range from a concern expressed by a colleague at the end of a shift, a focused debrief or in some cases an incident analysis through facilitated team review. All these require an acknowledgement and collective agreement about the
© 2014 British Association of Critical Care Nurses • Vol 19 No 4
severity of an event which in itself legitimizes the potential for distress and reduces any sense of isolation. However, many ICU nurses talk about the insidious creep of stress brought on by cumulative smaller events, exposure to suffering, challenges to competence, poor communication, breaches in peer relationships and frustrations that build into distress that might not be recognized by others but can lead to depleted caring, withdrawal and burn out (Skovholt and Trotter-Mathison, 2011). de Boer et al. (2014) remind us that this can lead to poor psychological health outcomes, absenteeism and wastage. Therefore, formalized debriefing at the end of shifts along with focused, facilitated reflection on a stressor is a good supportive and responsive practice. Embedding resilience focused training for practitioners (throughout initial training and continuing professional development) is becoming a topic of both research and educational practice to ascertain the protective impact of such an intervention (e.g. Hudson, 2014, http://www. boingboing.org.uk/). This is an important investment as staff well-being is considered an ‘antecedent to patient care experience’ (Maben et al., 2012). Building capacity to cope with critical incidents and manage the everyday pressures of critical care practice is seen as a fundamental competence and one inextricably linked to compassionate care. Ballangrud et al. (2014) examine how simulation can be used for team training and the prevention of incidents arising from poor team communication. Simulation, for the express purpose of enhancing patient safety, has often been used to assess individual’s competence to make decisions and respond to deterioration in skills development and reaction (Buykx et al., 2011). Simulation has been found to impact on skills 159
Editorial
retention and changes in practice (Kinsman et al., 2012) but can be unpopular among some practitioners as it leads to performance anxiety. Where the simulation has low fidelity, low confidence in the training potential of the event has been reported (Kinsman et al., 2012). Ballangrund’s Norwegian study recruited 63 Registered Nurses to evaluate their satisfaction and confidence in their learning experiences and score the simulation design and development using validated Likert scales. These tools did provide evidence that the structure of the programme helped practitioners learn from the experience. However, the potential for the retention of that learning is in doubt as the tool to evaluate the experience was distal to the emotional component of the experiential learning. The authors advocate for qualitative studies to help understand the learning process and experience. Reflective review of team performance demands debriefing and potential for remediation of any shortfall in knowledge or skill that emerges during the exercise. High impact learning that arises from self-review of performance and identification of potential limitations can serve as a critical learning incident. This has the potential for learning leaps if handled sensitively, but can be extremely damaging, leading to aversive reaction if the participant has a bad experience. This is one example of when research can serve as an educative opportunity. The participant learns from facilitated self-review and the researcher gains a richer understanding of the practitioners’ decision-making. Al-Mutair et al. (2014) look at the support Muslim families in Saudi Arabia seek when a family member is admitted to critical care. Using a cross-sectional design, a translated questionnaire (based on Molter’s 1979, Critical Care Family Need Inventory, CCFNI), was completed by 176 family members and 497 health care providers. The disproportionate loading towards health care providers is accounted for by a convenience sample. The researchers 160
reported little difference in the perception of needs prioritizing assurance and information as important dimensions reported by staff and family members. This is particularly important in the early phases of an admission where the differences in Saudi critical care culture (e.g. restricted visiting and the nurses’ not being sanctioned to report information directly to a family) exacerbate the need to know the patient is receiving the best possible treatment. Later, in the patient’s stay, Saudi family members identified a need for more patient- and family-centred practice that respected the Muslim culture and potential for spiritual healing. Despite the introduction of paediatric early warning scores (PEWS), there remains a failure to recognize and manage the deteriorating child. Tume et al. (2014) provide us with a review of a 1-day course aimed to redress sub optimal care in this area. Evaluated by 65 participants who attended the training on four separate occasions, one of the key benefits cited was enhanced communication arising from the interdisciplinary training and the use of the SBAR (Situation, Background, Assessment Recommendation) tool that guides escalation and referral with an intention to assure a timely response from appropriate people. The course includes a lecture and paper exercise for groups to work through information from a handout that also enabled access to DVD prompts. The training included simulation of working together but not with a mannequin or patient actor. Participant evaluations were positive and combined with a reduction in the number of hospital cardiac arrest rates post the inception of the course, were provided as good impact indicators of the course. Data to support the retention of this learning was weakened by a poor response rate of 18%. However, all but one respondent identified that the RESPOND course had enabled them to deal with a paediatric emergency. Clearly, one outcome from this project was to help practitioners identify what to report,
how to convey that information and to whom in order to get a rapid response. An apparently easy set of outcomes that remains uncannily challenging to achieve. The final paper from Friesecke et al. (2014) report on an initiative to improve caloric targets for critical care patients. A nurse-led protocol on enteral feeding and an education programme empowered nurses to initiate enteral feeding sooner and escalate the enteral nutrition programme to meet the caloric targets. The research was conducted prospectively and the outcomes compared with 6 months retrospective data and these data enabled the researchers to state, with confidence, that when nurses were positioned to drive enteral nutrition within a protocol this contributed to improving patient outcomes. All the papers illustrate a rich variety of approaches to quality initiatives to improve patient safety (previously known as practice development). Some are delivered through more traditional pedagogic approaches, others explicitly empower critical care practitioners with knowledge, evidence informed practices and improved communication, shared decision-making and distributed responsibility arising from practice for practice. A clear message is when critical care nurses are engaged and inspired they will rise to meet a variety of challenges especially where patient care triggers the need for change. The link between the well-being of professional staff and the quality of care they deliver and how improved outcomes feed back into professional empowerment and well-being is an indelible conjunction that should not be forgotten. Language might change to describe this process but the power of practice development through emancipation stays the same and is, for it, the more potent. Julie Scholes Professor of Nursing and Co-Editor, Nursing in Critical Care
© 2014 British Association of Critical Care Nurses
Editorial
REFERENCES Al-Mutair AS, Plummer V, Clerehan R, O’Brien A. (2014). Families’ needs of critical care Muslim patients in Saudi Arabia: a quantitative study. Nursing in Critical Care; 19: 185–195. Ballangrud R, Hall-Lord ML, Hedelin B, Persenius M. (2014). Intensive care unit nurses’ evaluation of simulation used for team training. Nursing in Critical Care; 19: 175–184. Buykx P, Kinsman L, Cooper S, McConnell-Henry T, Cant R, Endacott R, Scholes J. (2011). First2act: educating nurses to identify patient deterioration - a theory-based model for best practice simulation education. Nurse Education Today; 31: 687–693. de Boer J, van Rikxoort S, Bakker AB, Smit BJ. (2014). Critical incidents among intensive
© 2014 British Association of Critical Care Nurses
care unit nurses and their need for support: explorative interviews. Nursing in Critical Care; 19: 166–174. Friesecke S, Schwabet A, Stechart S-S, Abel P. (2014). Improvement of enteral nutrition in intensive care unit patients by a nurse-driven feeding protocol. Nursing in Critical Care; 19: 204–210. Heyns T, McCormack B. (2014). Moving from crisis intervention towards person-centredness. Nursing in Critical Care; 19: 162–163. Kinsman L, Buykx P, Champion R, Cant R, Cooper S, Endacott S, Enadcaott R, McConnell-Henry SJ. (2012). The first2act simulation program improves nursing practice in a rural Australian hospital. Australian Journal of Rural Health; 20: 270–274. Maben, J., Morrow, E., Ball, J., Robert, G., and Griffiths, P. (2012). High Quality Care
Metrics for Nursing. National Nursing Research Unit. King’s College London. http://eprints.soton.ac.uk/346019/1/ High-Quality-Care-Metrics-for-Nursing – Nov-2012.pdf (accessed 17/05/14). McCormack B. (2014). Critical care nursing and older people – is there an issue? Nursing in Critical Care; 19: 164–165. Molter N. (1979). Needs of relatives of critically ill patients; a descriptive study. Heart and Lung; 2: 332–339. Skovholt T, Trotter-Mathison M. (2011). The Resilient Practitioner: Burnout Prevention and Self-Care Strategies for Counselors, Therapists, Teachers, and Health Professionals, Second Edition … Historical, and Cultural Perspectives). New York: Routledge. Tume LN, Sefton G, Arrowsmith P. (2014). Teaching paediatric ward teams to recognise and manage the deteriorating child. Nursing in Critical Care.; 19: 196–203.
161
What’s in this issue? The opening editorial by Heyns and McCormack (2014) describes an exciting international collaboration aimed at restoring high quality nursing care professional moral, integrity and quality for the citizens of South Africa. The challenges facing South Africa are exacerbated by demographic transitions and politics, but the concern for a shortage of nurses, a crisis in the public perception of the quality of nursing, shifting health care cultures, increasing acute and chronic health care demand are shared by nurses across the globe. The response to resolve the problem through traditional pedagogic strategy and evidence-based protocols was shown to be uninspired and was not making the difference that practice needed. Heyns and McCormack argue for change through practice development methodology. This includes evidence informed practice, person-centred approaches, team collaboration, shared decision-making and dispersed responsibility throughout the team for achieving quality outcomes. Although working in a different culture, the core uniting ingredients are critical care nurses wishing to reclaim high quality care. Inspiration can be taken from the determination to improve things for patients and their families with staff rather than imposing quality compliance through managed systems on staff. The second editorial by McCormack (2014) explores a problem we experienced while attempting to generate a special issue on older people in critical care. The demographic of intensive care unit (ICU) is that nearly 50% of the patient population is over the age of 65. Has this rendered the older person invisible in ICU? Or is it that we take little account of the age of our patients in critical care practice and research? If so, why? Are we nervous because this touches on sensitive
ethical and resource issues? McCormack challenges us all to reflect and consider these points. He goes further and advocates for a sub-speciality within critical care nursing. That would extend beyond a named patient champion and take us into a realm that gives priority to generating new knowledge to inform our practice to serve the needs of older people in ICU, be they patients or their relatives. de Boer et al.’s (2014) paper reviews the causes and self management of stressful and emotionally challenging incidents. The authors examined the experiences of a diverse (age, gender and experience) sample of 12 ICU nurses within one unit. Semi-structured interviews were thematically analysed to label four themes. Stressful events were constructed when there was ‘high emotional involvement’ where there was an ‘avoidable incident’ or ‘sub optimal care (e.g. error or missed cues), and finally, where the nurses experienced intimidation (e.g. verbal abuse). The concern of the authors was how long these critical incidents were “held” by the nurses and the impact this had on the nurses’ longer-term emotional welfare. Most of the nurses managed the stress they experienced following a critical incident by talking with colleagues and/or family and this helped them cope. Some were left avoiding comparable situations and the authors suggested this could represent ‘ineffective coping’. This paper focuses on ‘one off’ incidents. Largely events labelled ‘critical incidents’ are acknowledged, discussed and managed. This can range from a concern expressed by a colleague at the end of a shift, a focused debrief or in some cases an incident analysis through facilitated team review. All these require an acknowledgement and collective agreement about the
© 2014 British Association of Critical Care Nurses • Vol 19 No 4
severity of an event which in itself legitimizes the potential for distress and reduces any sense of isolation. However, many ICU nurses talk about the insidious creep of stress brought on by cumulative smaller events, exposure to suffering, challenges to competence, poor communication, breaches in peer relationships and frustrations that build into distress that might not be recognized by others but can lead to depleted caring, withdrawal and burn out (Skovholt and Trotter-Mathison, 2011). de Boer et al. (2014) remind us that this can lead to poor psychological health outcomes, absenteeism and wastage. Therefore, formalized debriefing at the end of shifts along with focused, facilitated reflection on a stressor is a good supportive and responsive practice. Embedding resilience focused training for practitioners (throughout initial training and continuing professional development) is becoming a topic of both research and educational practice to ascertain the protective impact of such an intervention (e.g. Hudson, 2014, http://www. boingboing.org.uk/). This is an important investment as staff well-being is considered an ‘antecedent to patient care experience’ (Maben et al., 2012). Building capacity to cope with critical incidents and manage the everyday pressures of critical care practice is seen as a fundamental competence and one inextricably linked to compassionate care. Ballangrud et al. (2014) examine how simulation can be used for team training and the prevention of incidents arising from poor team communication. Simulation, for the express purpose of enhancing patient safety, has often been used to assess individual’s competence to make decisions and respond to deterioration in skills development and reaction (Buykx et al., 2011). Simulation has been found to impact on skills 159
Editorial
retention and changes in practice (Kinsman et al., 2012) but can be unpopular among some practitioners as it leads to performance anxiety. Where the simulation has low fidelity, low confidence in the training potential of the event has been reported (Kinsman et al., 2012). Ballangrund’s Norwegian study recruited 63 Registered Nurses to evaluate their satisfaction and confidence in their learning experiences and score the simulation design and development using validated Likert scales. These tools did provide evidence that the structure of the programme helped practitioners learn from the experience. However, the potential for the retention of that learning is in doubt as the tool to evaluate the experience was distal to the emotional component of the experiential learning. The authors advocate for qualitative studies to help understand the learning process and experience. Reflective review of team performance demands debriefing and potential for remediation of any shortfall in knowledge or skill that emerges during the exercise. High impact learning that arises from self-review of performance and identification of potential limitations can serve as a critical learning incident. This has the potential for learning leaps if handled sensitively, but can be extremely damaging, leading to aversive reaction if the participant has a bad experience. This is one example of when research can serve as an educative opportunity. The participant learns from facilitated self-review and the researcher gains a richer understanding of the practitioners’ decision-making. Al-Mutair et al. (2014) look at the support Muslim families in Saudi Arabia seek when a family member is admitted to critical care. Using a cross-sectional design, a translated questionnaire (based on Molter’s 1979, Critical Care Family Need Inventory, CCFNI), was completed by 176 family members and 497 health care providers. The disproportionate loading towards health care providers is accounted for by a convenience sample. The researchers 160
reported little difference in the perception of needs prioritizing assurance and information as important dimensions reported by staff and family members. This is particularly important in the early phases of an admission where the differences in Saudi critical care culture (e.g. restricted visiting and the nurses’ not being sanctioned to report information directly to a family) exacerbate the need to know the patient is receiving the best possible treatment. Later, in the patient’s stay, Saudi family members identified a need for more patient- and family-centred practice that respected the Muslim culture and potential for spiritual healing. Despite the introduction of paediatric early warning scores (PEWS), there remains a failure to recognize and manage the deteriorating child. Tume et al. (2014) provide us with a review of a 1-day course aimed to redress sub optimal care in this area. Evaluated by 65 participants who attended the training on four separate occasions, one of the key benefits cited was enhanced communication arising from the interdisciplinary training and the use of the SBAR (Situation, Background, Assessment Recommendation) tool that guides escalation and referral with an intention to assure a timely response from appropriate people. The course includes a lecture and paper exercise for groups to work through information from a handout that also enabled access to DVD prompts. The training included simulation of working together but not with a mannequin or patient actor. Participant evaluations were positive and combined with a reduction in the number of hospital cardiac arrest rates post the inception of the course, were provided as good impact indicators of the course. Data to support the retention of this learning was weakened by a poor response rate of 18%. However, all but one respondent identified that the RESPOND course had enabled them to deal with a paediatric emergency. Clearly, one outcome from this project was to help practitioners identify what to report,
how to convey that information and to whom in order to get a rapid response. An apparently easy set of outcomes that remains uncannily challenging to achieve. The final paper from Friesecke et al. (2014) report on an initiative to improve caloric targets for critical care patients. A nurse-led protocol on enteral feeding and an education programme empowered nurses to initiate enteral feeding sooner and escalate the enteral nutrition programme to meet the caloric targets. The research was conducted prospectively and the outcomes compared with 6 months retrospective data and these data enabled the researchers to state, with confidence, that when nurses were positioned to drive enteral nutrition within a protocol this contributed to improving patient outcomes. All the papers illustrate a rich variety of approaches to quality initiatives to improve patient safety (previously known as practice development). Some are delivered through more traditional pedagogic approaches, others explicitly empower critical care practitioners with knowledge, evidence informed practices and improved communication, shared decision-making and distributed responsibility arising from practice for practice. A clear message is when critical care nurses are engaged and inspired they will rise to meet a variety of challenges especially where patient care triggers the need for change. The link between the well-being of professional staff and the quality of care they deliver and how improved outcomes feed back into professional empowerment and well-being is an indelible conjunction that should not be forgotten. Language might change to describe this process but the power of practice development through emancipation stays the same and is, for it, the more potent. Julie Scholes Professor of Nursing and Co-Editor, Nursing in Critical Care
© 2014 British Association of Critical Care Nurses
Editorial
REFERENCES Al-Mutair AS, Plummer V, Clerehan R, O’Brien A. (2014). Families’ needs of critical care Muslim patients in Saudi Arabia: a quantitative study. Nursing in Critical Care; 19: 185–195. Ballangrud R, Hall-Lord ML, Hedelin B, Persenius M. (2014). Intensive care unit nurses’ evaluation of simulation used for team training. Nursing in Critical Care; 19: 175–184. Buykx P, Kinsman L, Cooper S, McConnell-Henry T, Cant R, Endacott R, Scholes J. (2011). First2act: educating nurses to identify patient deterioration - a theory-based model for best practice simulation education. Nurse Education Today; 31: 687–693. de Boer J, van Rikxoort S, Bakker AB, Smit BJ. (2014). Critical incidents among intensive
© 2014 British Association of Critical Care Nurses
care unit nurses and their need for support: explorative interviews. Nursing in Critical Care; 19: 166–174. Friesecke S, Schwabet A, Stechart S-S, Abel P. (2014). Improvement of enteral nutrition in intensive care unit patients by a nurse-driven feeding protocol. Nursing in Critical Care; 19: 204–210. Heyns T, McCormack B. (2014). Moving from crisis intervention towards person-centredness. Nursing in Critical Care; 19: 162–163. Kinsman L, Buykx P, Champion R, Cant R, Cooper S, Endacott S, Enadcaott R, McConnell-Henry SJ. (2012). The first2act simulation program improves nursing practice in a rural Australian hospital. Australian Journal of Rural Health; 20: 270–274. Maben, J., Morrow, E., Ball, J., Robert, G., and Griffiths, P. (2012). High Quality Care
Metrics for Nursing. National Nursing Research Unit. King’s College London. http://eprints.soton.ac.uk/346019/1/ High-Quality-Care-Metrics-for-Nursing – Nov-2012.pdf (accessed 17/05/14). McCormack B. (2014). Critical care nursing and older people – is there an issue? Nursing in Critical Care; 19: 164–165. Molter N. (1979). Needs of relatives of critically ill patients; a descriptive study. Heart and Lung; 2: 332–339. Skovholt T, Trotter-Mathison M. (2011). The Resilient Practitioner: Burnout Prevention and Self-Care Strategies for Counselors, Therapists, Teachers, and Health Professionals, Second Edition … Historical, and Cultural Perspectives). New York: Routledge. Tume LN, Sefton G, Arrowsmith P. (2014). Teaching paediatric ward teams to recognise and manage the deteriorating child. Nursing in Critical Care.; 19: 196–203.
161
