EDITORIAL doi: 10.1111/nicc.12099
What’s in this issue? The selection of papers within this issue explores a number of important issues which, regardless of whether working either with adults or in paediatrics, are very much at the heart of nursing practice and which transcend cultural barriers. Some subjects covered may be deemed controversial, while others introduce a fresh perspective, yet they will provoke important and searching questions of how critical care nurses can develop their practice. In particular, a thread that appears to connect the papers is around providing respectful, thoughtful and conscientious person-centred nursing, something that is often demonstrated by the ‘little things’ (Macleod, 1994) nurses do that make a real and meaningful difference to the patients’ experience of care. The assessment and effective management of an individual’s pain is at the core of a nurse’s role and this is a particular challenge when caring for unconscious and critically ill patients in an intensive care unit (ICU). In her editorial, Papathanassoglou (2014) reviews current scientific advances in the understanding of pain and its interaction with emotional and social elements that appear to offer new directions in preventing risks of pain persistence and reduce the onset of potential chronic problems. Research into pain conducting pathways has identified that this symptom has sensory and effective components, which can produce similar levels of pain intensity. Indeed, experiences of grief, feeling excluded and isolation can trigger affective pathway nociception, resulting in intense pain sensations. Being aware of this is important in caring for the critically ill as for a variety of reasons patients may feel lonely, fearful and socially isolated and as such are at greater risk for pain intensity. Likewise, it is also vital to recognize that physiological disturbances such as systemic
inflammatory responses can augment feelings of isolation and/or social pain which may aggravate physical pain. In addition, research into physical pain is opening new horizons in beginning to explain some of the behaviours individuals such as patients in ICU may exhibit in certain situations. For example, the presence of poor pain relief can augment feelings of irritability, hostility and aggressiveness; however, within the ICU, this may precipitate delirium onset in some patients. Having an appreciation of developments in how pain is mediated is core to Papathanassoglou’s (2014) argument. She observes that nurses can employ a number of non-pharmacological interventions that complement standard measures to help attenuate physiological responses to social exclusion and distress. This can include frequent nurse-patient interactions, displaying family pictures at the bedside, open visiting and encouraging emotional support from relatives. These ideas are neither unique nor expensive to implement, but could be deemed to be the substance of the ‘little things’ (Macleod 1994); nurses must be mindful and attentive to the needs of individuals and recognize that pain symptoms have many causes. Undoubtedly, the importance of assessing and managing pain which is underpinned by appropriate evidence is vital to the long-term recovery of patients, as delayed recognition and negative experiences from ineffective pain relief can later translate into catalysts for the persistence and chronic nature of the symptoms. In contrast, Timmins et al.’s (2014) editorial describes a disturbing situation of an elderly family member spending 4 h on a hospital trolley after admission to a busy emergency department (ED) late one evening. However, when the lady was placed on the trolley there were no pillows provided because
© 2014 British Association of Critical Care Nurses • Vol 19 No 3
apparently there was a shortage as they were often stolen. It was only at the request of the relatives that a pillow was made available. What is alarming about this incident, as suggested by Timmins et al. (2014), is the acceptance or ‘acculturation’ by nursing staff and the lack of concern for patient comfort. The point here is that these issues are becoming common place, partly due to workload demands of busy clinicians who maybe weary as a result of organizational inaction and so eventually become acclimatized and accept the situation. However, changing such a culture and a ‘not my responsibility’ mindset, demands concerted effort, courage and commitment of individuals or groups in articulating falling standards and service inadequacies on behalf of vulnerable patients and populations. Strong nursing leadership is pivotal too in shaping workplace cultures. Timmins et al.’s account serves as a reminder that compassion and patient dignity can be violated in simple ways; however, these situations can be avoided by a culture that embraces and pledges the promotion of comfort, respect for individuals needs, being present and communication as often it is the little things rather than grand gestures that are remembered. The first study in this compilation arose from Iranian ICU policies of restricted visiting hours which were recognized to be incongruent with patient-centred care ideals. Tayebi et al. (2014) therefore conducted a qualitative study to explore the reasons and justifications that nurses (n = 9), family visitors (n = 4) and patients (n = 2) had for this practice. Analysis of data revealed three themes, namely ‘promoting safety’, ‘protecting patient health’ and ‘preserving privacy’, which on the surface appear appropriate and relevant. However, responses made by 107
Editorial
participants could be regarded as controversial and in some cases, inconsistent with the international philosophy of nursing. Yet, this work does provide an insight into critical care nursing and cultural issues in Iran which frame these findings that are likely to invoke much discussion internationally. It is interesting to see how nurses from different cultures construct and frame values and beliefs that reflect their custom and practice. This paper also serves as a timely contrast to the editorial by Papathanassoglou (2004), who frames her argument for visiting, largely on the physiology of trauma and critical illness. Papathanassoglou (2004) advances that it is the duty of critical care nurses to work hard to reduce any risk associated with visiting rather than generate blanket restrictions that prohibit close relatives from visiting family members, especially when we have evidence that this has a therapeutic value. Olausson et al.’s (2014) findings likewise dwell on safety and patient privacy issues but are examined from a very different perspective. The aim of this study was to explore the lived experiences of 13 Swedish nurses in relation to the physical bed spaces where nursing care takes place. Data collection included interviews and digital photographs taken by participants of bed spaces which were used to aid reflections and depth of dialogue on the phenomena of inquiry. The authors observe that the space where critical care nursing occurs is often a privileged area. A world inhabited mainly by patients, relatives and nurses, where intimacy, suffering and loss may occur. Analysis of data suggests that nurses viewed themselves as guardians of patient well-being, welfare and recovery, often employing technology to aid security and safety of individuals under their care. Yet, nurses also reported struggling to overcome structural adversities of ICU bed space and lacking control in managing external noises that often interfered with creating a therapeutic calming and healing environment. Nurses were 108
also challenged and ethically compromised in trying to observe and monitor patients while at the same time maintain their privacy and confidentiality, particularly if the units were busy. Yet, despite this, nurses sought to humanize the environment often through the use of personal items and family photographs, by reducing alarm volumes while performing specific tasks and more importantly placing technology at the periphery so as to ensure the patient was centre stage within the confines of the bed space. Open visiting and contributions of families were also part of reframing the bed-space area. Getting patients to sit by a balcony or a window and feel fresh and having open visiting were employed to instil hope, reduce social isolation and promote well-being; clearly all are examples of low cost ‘little things’. The findings of this study are valuable as they challenge and prompt critical care nurses to critically examine the layout of ICU bed-space environments in facilitating individualized person-centred care and to reflect how the needs of patients and relatives can be supported within current and future architectural designs. The issue of the ICU environment and needs of families is identified in the next paper as well. The study by Al-Mutair et al. (2014) using a descriptive qualitative design aimed to explore the experiences of 12 family members whose loved one was admitted to one of eight ICUs in Saudi Arabia. Unremarkably, the themes emerging from data analysis are all too familiar and included problems with obtaining information about the patient progress, being reassured about a loved one’s recovery, being at the bedside of a patient and having support from staff for physical and emotional needs. The role of spiritual healing within Muslim communities was very evident and families used prayer as a powerful source of comfort, as a means of meditation and to seek the patient’s speedy recovery. However, it is unclear whether this was facilitated and enabled by nursing staff or whether
this was undertaken in corridors or in private. An issue that stands out is the continued practice of restricted visiting of relatives that pervades many countries including parts of Europe. As Papathanassoglou (2014) describes, limiting visitors is detrimental to patient recovery and precipitates a number of physiological changes that can culminate in further pain and disorientation. Arguably, isolating patients from loved ones can have deleterious physical and psychological effects on relatives, such as exacerbating their anxiety, reducing trust in health care professionals, increasing uncertainty and disconnecting lifetime family bonds. If there is a takeaway message here, it is that nurses must begin to challenge traditional and outdated harmful practices, for example by drawing on position statements and international guidelines such as those developed by BACCN (2012), which are underpinned by a critical review of existing evidence. The final paper, a fascinating qualitative systematic review of the literature, investigated the psychosocial impact on children and adolescents who survived a critical illness (Manning et al., 2014). Following a comprehensive search of the literature in a number of databases, three papers meeting predetermined criteria were selected for inclusion. The research team were interested on the psychological and social impact among children who had survived critical illness by examining their understanding, experiences, views, perceptions and needs following discharge. Analysis of published studies resulted in five descriptive themes, which on subsequent analysis resulted in three analytical themes capturing the experiences of study participants. The analysis of data characterizes a journey in which survivors of critical illness are initially confronted by uncertainty, discomfiture and confusion in recollecting and in disclosing the period of critical illness to others. In the early stages, children and adolescent survivors reported incomplete and disrupted understanding of events, which had © 2014 British Association of Critical Care Nurses
Editorial
adverse psychosocial effects on them. Drawing on parental and other narratives, however, helped them to gain clarity and meaning about their illness experience. Holding on to their former persona, coping with an emerging identity and the loss of peer relationship meant that often they struggled to adjust, feeling isolated and marginalized. Acceptance, rationalizing and coming to terms with the limitations of critical illness became a complex process for survivors, becoming part of a dynamic transformational continuum. The implications from this paper, albeit confined to a review of three published qualitative studies would suggest that survivors of childhood critical illness undergo a complex journey of recovery, which hitherto has not been comprehensively investigated and further work is required. From a practice perspective, it seems reasonable to suggest that clinicians need to develop and implement policies for supporting parents of survivors of childhood illness; this arguably might start from admission. For example, there is a wealth of growing evidence in the UK and abroad, in relation to adults, that the use of patient diaries is helpful in making sense of the illness experience, to capture missing moments and to reduce symptoms of post-traumatic stress disorder (Jones et al. 2008). In addition, the role of paediatric intensive care nurses will be vital in supporting and preparing parents to the stages that accompany the survival recovery
© 2014 British Association of Critical Care Nurses
phase following a period of childhood critical illness. After discharge, support for child and parents will also be pivotal as this should enable survivors to progress in their adjustment with minimal psychological and social impact.
INVITATION We hope that you agree, that the editorials and studies in this issue are thought-provoking, engaging, stimulating and have provided relevant takeaway messages around the challenges and at times complexities in providing high-quality, evidence-based and person-centred care. The papers have particularly stressed that as professionals, nurses must not become complacent about their knowledge base, their workplace culture and caring values, but must continuously question and re-examine the evidence that underpins their care, and in answer to Timmins et al. (2014), do a great deal more. It is also clear from this collection, that there are many examples of the ‘little things’ that nurses do for their patients and families, that arguably seem to matter most to those receiving our care. Finally, if you have a comment or view about this ‘What is in the Journal,’ the editorials or any of the studies appearing in the journal, please write to us, share your thoughts and engage and open up a debate; this is after all a sign of a mature profession.
REFERENCES Al-Mutair A, Plummer V, Clereham R, O’Brien A. (2014). Needs and experiences of intensive care patients’ families: a Saudi qualitative study. Nursing in Critical Care; 13: 135–144. British Association of Critical Care Nurses (BACCN). (2012). Position statement on visiting in adult intensive care units https:// www.baccn.org.uk/news/120403.asp (accessed 15/03/14). Jones C, Capuzzo M, Flaatten H, Backman C, Rylander C, Griffiths RD. (2008). ICU diaries may reduce symptoms of posttraumatic stress disorder. Intensive Care Medicine; 32(Suppl 1): S144. Macleod M. (1994). ‘It’s the little things that count’: the hidden complexity of everyday practice. Journal of Clinical Nursing; 3: 361–368. Manning J, Hemingway P, Redsell SA. (2014). Long-term psychosocial impact reported by childhood critical illness survivors: a systematic review. Nursing in Critical Care; 19: 145–156. Olausson S, Ekebergh M, Osterberg SA. (2014). Nurses’ lived experiences of ICU bed spaces as a place of care: a phenomenological study. Nursing in Critical Care; 19: 126–134. Papathanassoglou ED. (2014). Recent advances in understanding pain: what lies ahead for critical care? Nursing in Critical Care; 19: 110–113. Tayebi Z, Borimnejad L, Dehghan-Nayeri N, Kohan M. (2014). Rationales of restricted visiting hour in Iranian intensive care units: a qualitative study. Nursing in Critical Care; 19: 117–125. Timmins F, Bennett P, Norton C. (2014). Providing compassionate care to patients on Emergency Department trolleys: can we do more? Nursing in Critical Care; 19: 114–116.
Dr John Albarran Co-Editor
109
What’s in this issue? The selection of papers within this issue explores a number of important issues which, regardless of whether working either with adults or in paediatrics, are very much at the heart of nursing practice and which transcend cultural barriers. Some subjects covered may be deemed controversial, while others introduce a fresh perspective, yet they will provoke important and searching questions of how critical care nurses can develop their practice. In particular, a thread that appears to connect the papers is around providing respectful, thoughtful and conscientious person-centred nursing, something that is often demonstrated by the ‘little things’ (Macleod, 1994) nurses do that make a real and meaningful difference to the patients’ experience of care. The assessment and effective management of an individual’s pain is at the core of a nurse’s role and this is a particular challenge when caring for unconscious and critically ill patients in an intensive care unit (ICU). In her editorial, Papathanassoglou (2014) reviews current scientific advances in the understanding of pain and its interaction with emotional and social elements that appear to offer new directions in preventing risks of pain persistence and reduce the onset of potential chronic problems. Research into pain conducting pathways has identified that this symptom has sensory and effective components, which can produce similar levels of pain intensity. Indeed, experiences of grief, feeling excluded and isolation can trigger affective pathway nociception, resulting in intense pain sensations. Being aware of this is important in caring for the critically ill as for a variety of reasons patients may feel lonely, fearful and socially isolated and as such are at greater risk for pain intensity. Likewise, it is also vital to recognize that physiological disturbances such as systemic
inflammatory responses can augment feelings of isolation and/or social pain which may aggravate physical pain. In addition, research into physical pain is opening new horizons in beginning to explain some of the behaviours individuals such as patients in ICU may exhibit in certain situations. For example, the presence of poor pain relief can augment feelings of irritability, hostility and aggressiveness; however, within the ICU, this may precipitate delirium onset in some patients. Having an appreciation of developments in how pain is mediated is core to Papathanassoglou’s (2014) argument. She observes that nurses can employ a number of non-pharmacological interventions that complement standard measures to help attenuate physiological responses to social exclusion and distress. This can include frequent nurse-patient interactions, displaying family pictures at the bedside, open visiting and encouraging emotional support from relatives. These ideas are neither unique nor expensive to implement, but could be deemed to be the substance of the ‘little things’ (Macleod 1994); nurses must be mindful and attentive to the needs of individuals and recognize that pain symptoms have many causes. Undoubtedly, the importance of assessing and managing pain which is underpinned by appropriate evidence is vital to the long-term recovery of patients, as delayed recognition and negative experiences from ineffective pain relief can later translate into catalysts for the persistence and chronic nature of the symptoms. In contrast, Timmins et al.’s (2014) editorial describes a disturbing situation of an elderly family member spending 4 h on a hospital trolley after admission to a busy emergency department (ED) late one evening. However, when the lady was placed on the trolley there were no pillows provided because
© 2014 British Association of Critical Care Nurses • Vol 19 No 3
apparently there was a shortage as they were often stolen. It was only at the request of the relatives that a pillow was made available. What is alarming about this incident, as suggested by Timmins et al. (2014), is the acceptance or ‘acculturation’ by nursing staff and the lack of concern for patient comfort. The point here is that these issues are becoming common place, partly due to workload demands of busy clinicians who maybe weary as a result of organizational inaction and so eventually become acclimatized and accept the situation. However, changing such a culture and a ‘not my responsibility’ mindset, demands concerted effort, courage and commitment of individuals or groups in articulating falling standards and service inadequacies on behalf of vulnerable patients and populations. Strong nursing leadership is pivotal too in shaping workplace cultures. Timmins et al.’s account serves as a reminder that compassion and patient dignity can be violated in simple ways; however, these situations can be avoided by a culture that embraces and pledges the promotion of comfort, respect for individuals needs, being present and communication as often it is the little things rather than grand gestures that are remembered. The first study in this compilation arose from Iranian ICU policies of restricted visiting hours which were recognized to be incongruent with patient-centred care ideals. Tayebi et al. (2014) therefore conducted a qualitative study to explore the reasons and justifications that nurses (n = 9), family visitors (n = 4) and patients (n = 2) had for this practice. Analysis of data revealed three themes, namely ‘promoting safety’, ‘protecting patient health’ and ‘preserving privacy’, which on the surface appear appropriate and relevant. However, responses made by 107
Editorial
participants could be regarded as controversial and in some cases, inconsistent with the international philosophy of nursing. Yet, this work does provide an insight into critical care nursing and cultural issues in Iran which frame these findings that are likely to invoke much discussion internationally. It is interesting to see how nurses from different cultures construct and frame values and beliefs that reflect their custom and practice. This paper also serves as a timely contrast to the editorial by Papathanassoglou (2004), who frames her argument for visiting, largely on the physiology of trauma and critical illness. Papathanassoglou (2004) advances that it is the duty of critical care nurses to work hard to reduce any risk associated with visiting rather than generate blanket restrictions that prohibit close relatives from visiting family members, especially when we have evidence that this has a therapeutic value. Olausson et al.’s (2014) findings likewise dwell on safety and patient privacy issues but are examined from a very different perspective. The aim of this study was to explore the lived experiences of 13 Swedish nurses in relation to the physical bed spaces where nursing care takes place. Data collection included interviews and digital photographs taken by participants of bed spaces which were used to aid reflections and depth of dialogue on the phenomena of inquiry. The authors observe that the space where critical care nursing occurs is often a privileged area. A world inhabited mainly by patients, relatives and nurses, where intimacy, suffering and loss may occur. Analysis of data suggests that nurses viewed themselves as guardians of patient well-being, welfare and recovery, often employing technology to aid security and safety of individuals under their care. Yet, nurses also reported struggling to overcome structural adversities of ICU bed space and lacking control in managing external noises that often interfered with creating a therapeutic calming and healing environment. Nurses were 108
also challenged and ethically compromised in trying to observe and monitor patients while at the same time maintain their privacy and confidentiality, particularly if the units were busy. Yet, despite this, nurses sought to humanize the environment often through the use of personal items and family photographs, by reducing alarm volumes while performing specific tasks and more importantly placing technology at the periphery so as to ensure the patient was centre stage within the confines of the bed space. Open visiting and contributions of families were also part of reframing the bed-space area. Getting patients to sit by a balcony or a window and feel fresh and having open visiting were employed to instil hope, reduce social isolation and promote well-being; clearly all are examples of low cost ‘little things’. The findings of this study are valuable as they challenge and prompt critical care nurses to critically examine the layout of ICU bed-space environments in facilitating individualized person-centred care and to reflect how the needs of patients and relatives can be supported within current and future architectural designs. The issue of the ICU environment and needs of families is identified in the next paper as well. The study by Al-Mutair et al. (2014) using a descriptive qualitative design aimed to explore the experiences of 12 family members whose loved one was admitted to one of eight ICUs in Saudi Arabia. Unremarkably, the themes emerging from data analysis are all too familiar and included problems with obtaining information about the patient progress, being reassured about a loved one’s recovery, being at the bedside of a patient and having support from staff for physical and emotional needs. The role of spiritual healing within Muslim communities was very evident and families used prayer as a powerful source of comfort, as a means of meditation and to seek the patient’s speedy recovery. However, it is unclear whether this was facilitated and enabled by nursing staff or whether
this was undertaken in corridors or in private. An issue that stands out is the continued practice of restricted visiting of relatives that pervades many countries including parts of Europe. As Papathanassoglou (2014) describes, limiting visitors is detrimental to patient recovery and precipitates a number of physiological changes that can culminate in further pain and disorientation. Arguably, isolating patients from loved ones can have deleterious physical and psychological effects on relatives, such as exacerbating their anxiety, reducing trust in health care professionals, increasing uncertainty and disconnecting lifetime family bonds. If there is a takeaway message here, it is that nurses must begin to challenge traditional and outdated harmful practices, for example by drawing on position statements and international guidelines such as those developed by BACCN (2012), which are underpinned by a critical review of existing evidence. The final paper, a fascinating qualitative systematic review of the literature, investigated the psychosocial impact on children and adolescents who survived a critical illness (Manning et al., 2014). Following a comprehensive search of the literature in a number of databases, three papers meeting predetermined criteria were selected for inclusion. The research team were interested on the psychological and social impact among children who had survived critical illness by examining their understanding, experiences, views, perceptions and needs following discharge. Analysis of published studies resulted in five descriptive themes, which on subsequent analysis resulted in three analytical themes capturing the experiences of study participants. The analysis of data characterizes a journey in which survivors of critical illness are initially confronted by uncertainty, discomfiture and confusion in recollecting and in disclosing the period of critical illness to others. In the early stages, children and adolescent survivors reported incomplete and disrupted understanding of events, which had © 2014 British Association of Critical Care Nurses
Editorial
adverse psychosocial effects on them. Drawing on parental and other narratives, however, helped them to gain clarity and meaning about their illness experience. Holding on to their former persona, coping with an emerging identity and the loss of peer relationship meant that often they struggled to adjust, feeling isolated and marginalized. Acceptance, rationalizing and coming to terms with the limitations of critical illness became a complex process for survivors, becoming part of a dynamic transformational continuum. The implications from this paper, albeit confined to a review of three published qualitative studies would suggest that survivors of childhood critical illness undergo a complex journey of recovery, which hitherto has not been comprehensively investigated and further work is required. From a practice perspective, it seems reasonable to suggest that clinicians need to develop and implement policies for supporting parents of survivors of childhood illness; this arguably might start from admission. For example, there is a wealth of growing evidence in the UK and abroad, in relation to adults, that the use of patient diaries is helpful in making sense of the illness experience, to capture missing moments and to reduce symptoms of post-traumatic stress disorder (Jones et al. 2008). In addition, the role of paediatric intensive care nurses will be vital in supporting and preparing parents to the stages that accompany the survival recovery
© 2014 British Association of Critical Care Nurses
phase following a period of childhood critical illness. After discharge, support for child and parents will also be pivotal as this should enable survivors to progress in their adjustment with minimal psychological and social impact.
INVITATION We hope that you agree, that the editorials and studies in this issue are thought-provoking, engaging, stimulating and have provided relevant takeaway messages around the challenges and at times complexities in providing high-quality, evidence-based and person-centred care. The papers have particularly stressed that as professionals, nurses must not become complacent about their knowledge base, their workplace culture and caring values, but must continuously question and re-examine the evidence that underpins their care, and in answer to Timmins et al. (2014), do a great deal more. It is also clear from this collection, that there are many examples of the ‘little things’ that nurses do for their patients and families, that arguably seem to matter most to those receiving our care. Finally, if you have a comment or view about this ‘What is in the Journal,’ the editorials or any of the studies appearing in the journal, please write to us, share your thoughts and engage and open up a debate; this is after all a sign of a mature profession.
REFERENCES Al-Mutair A, Plummer V, Clereham R, O’Brien A. (2014). Needs and experiences of intensive care patients’ families: a Saudi qualitative study. Nursing in Critical Care; 13: 135–144. British Association of Critical Care Nurses (BACCN). (2012). Position statement on visiting in adult intensive care units https:// www.baccn.org.uk/news/120403.asp (accessed 15/03/14). Jones C, Capuzzo M, Flaatten H, Backman C, Rylander C, Griffiths RD. (2008). ICU diaries may reduce symptoms of posttraumatic stress disorder. Intensive Care Medicine; 32(Suppl 1): S144. Macleod M. (1994). ‘It’s the little things that count’: the hidden complexity of everyday practice. Journal of Clinical Nursing; 3: 361–368. Manning J, Hemingway P, Redsell SA. (2014). Long-term psychosocial impact reported by childhood critical illness survivors: a systematic review. Nursing in Critical Care; 19: 145–156. Olausson S, Ekebergh M, Osterberg SA. (2014). Nurses’ lived experiences of ICU bed spaces as a place of care: a phenomenological study. Nursing in Critical Care; 19: 126–134. Papathanassoglou ED. (2014). Recent advances in understanding pain: what lies ahead for critical care? Nursing in Critical Care; 19: 110–113. Tayebi Z, Borimnejad L, Dehghan-Nayeri N, Kohan M. (2014). Rationales of restricted visiting hour in Iranian intensive care units: a qualitative study. Nursing in Critical Care; 19: 117–125. Timmins F, Bennett P, Norton C. (2014). Providing compassionate care to patients on Emergency Department trolleys: can we do more? Nursing in Critical Care; 19: 114–116.
Dr John Albarran Co-Editor
109
