EDITORIAL doi: 10.1111/nicc.12086
What’s in this issue? Welcome to the second issue of this volume. The papers explore topics familiar to everyday critical care practice and illuminate new insights. The first editorial is a paper by Vandijck and Hellings (2014), which explores innovation in education and challenges us to think about what that really means. They argue that innovative methods to facilitate teaching and learning should be distinguished from new content. What is taught has to be dynamic as we fit practitioners for their changing role and societies’ expectations of how the profession will function. They offer an interesting insight into how technology may be the medium through which new pedagogies are realized. The second editorial offers a critical dialogue on these issues (Scholes, 2014). The editorial questions whether we can truly be innovative given the statutory and regulatory requirements for nursing practice. How can we enable transformative learning experiences that are sustainable and genuinely make a difference to the clinician as well as the patient for whom they care? Are computers along with other digital learning tools the answer? Will the expert mentor of tomorrow be a 3D virtual world avatar? How do we financially sustain the interactive and technically well-equipped classrooms? Professional learning is highly complex and capturing the sustainable impact of a single pedagogic intervention is methodologically very challenging. That does not mean we should not do it, but certainly we should be very cautious about claims we make that lay claim to the certainty of a single teaching and learning tool, intervention or approach. Deborah Dawson (2014) has written an essential guide to the care of patients
with a tracheostomy. She has undertaken an extensive search of the literature and based her guide on the best evidence available. In this instance often, expert opinion. This has been distilled into 12 essential principles to guide clinical practice and shape how this might be taught to junior colleagues. Dawson has assimilated all her clinical wisdom, teaching and research experience to generate this invaluable tool kit. We are indebted to Deborah for undertaking this task, and thank the British Association of Critical Care Nurses (BACCN), who commissioned this paper. This essential guide was commissioned in response to requests made by the journal’s readership and the BACCN membership for guidelines for essential clinical care. We would encourage our readers to make known to us, either by emailing the editors directly or via members of the Regional BACCN Committees, the topics that you feel would make useful, essential guides. The second paper by Masoudi Alavi et al. (2014) reports an audit undertaken of eye dryness and corneal abrasion among intensive care patients in Iran. Drawing on the expertise of an opthalmologist to assess patients on the day of admission and on day 5 for corneal abrasions, their audit included 87 patients who met their inclusion criteria. Their data reminds us of the importance of frequent attention to eye care and the use of eye lubricants to avoid corneal abrasions. They concluded that taping eyes alone was inadequate and twice as likely to cause corneal abrasions. The background literature review situates their findings and provides a comprehensive summary of the types and causes of corneal damage and eye dryness among critical care patients. Once again this paper is a useful guide for staff and students new to critical care as well as a reference to support teaching. It also serves to compare
© 2014 British Association of Critical Care Nurses • Vol 19 No 2
eye care practices in Iran with those of our own country. It serves to shrink the world and show how all critical care nurses need to pay attention to fundamental nursing care practices as much as complex technological challenges. ¨ The third paper by Ozden et al. (2014) turns to a quasi-randomized control trial to determine which of three available solutions was most effective in mouth care. The researchers recruited 60 patients to their study and randomly assigned 20 patients to receive one of the three solutions. The researchers found no difference in the oral mucosa of patients if they were treated with either saline solution, sodium bicarbonate or 0.2% chlorehexidine. The presence of bacterial colonization was found in all three groups. The researchers recommended that a larger randomized control trial be conducted to evaluate the numbers of bacteria that form in the mouths of patients relative to the solution used for mouth care. The one solution they did not trial was the patient’s own toothpaste solution and gauge any data on patient preference for either one of the three solutions. This serves as a timely reminder of how important the patient voice is to help us design research that is robust and provides sound evidence, but also illuminates what makes the experience of mouth care more comforting to the patients who receive the care. The paper by Karra et al. (2014) reports a study of self-reported clinical decisions made by 23 critical care nurses working in three different centres in Greece. Through content analysis, eight types of clinical decisions were identified. Capturing clinical decisions as they happen is a complex process and is methodologically challenging. To design some of these methodological issues, Karra et al (2014) generated a log sheet designed by experts and through pilot testing. The 57
Editorial
participants were allowed to free text an account of their decision and this text was subsequently categorized during the analytical process. To situate the nurses’ experience, additional sociodemographic data were recorded along with a summary of the context and conditions that surrounded the clinical shifts. The participants then provided a self-reported post hoc account of their clinical decisions. This reflective summary of the clinical decisions might contribute to the difference in the frequency of decisions reported to have been made by the Greek nurses (56 decisions per 8 hour shift) compared with those of Australian nurses who were observed to make a clinical decision every 30 seconds (Bucknall, 2000). In the Bucknall study, the nurses were observed for a 2-h period and the researcher made a commentary of actions as they happened and recorded into a digital recorder. This was interesting as such an approach although taking place in real time did include the researcher’s own judgement of the clinician’s decision. When analysed, Bucknall reported three categories of decision, while Karra et al (2014) report eight different categories. What is also important to note is the different types of clinical decisions that are self-recorded; of note, few entries relating to the emotional and psychosocial well-being of patients and those entries relating to physical assessment findings were linked to medical diagnoses. The authors conclude that this might have something to do with the dominant biomedical paradigm in the ICU. However, medical diagnoses are labels made through observation, samples and measurement. Inherently they hold an element of ‘objective observed truth’ validated by a report, test or
58
record. Making clinical decisions relating to emotional and psychosocial wellbeing relies on less tangible accounts of feelings and experience that under the scrutiny of a researcher, a nurse may feel less confident to report. One of the concluding comments made by the authors is the need for comparative data surveying the types of decisions made by critical care nurses in different clinical settings and countries. Before such a survey is undertaken, it is important to discover if it is intentional, and if so why, to under-report the emotional and psychosocial aspects of a clinical decision. The final paper by Tume et al. (2014) reports on the sensitivity and specificity of a pressure ulcer (PU) assessment tool (The Braden Q Tool) to predict PU risk in children admitted to a Paediatric intensive Care Unit (PICU). A retrospective audit of 891 critically ill children was undertaken. Braden Q scores made 24 h after admission were downloaded from the electronic nursing documentation. Other key patient data, including demographics, were downloaded from the Paediatric Intensive Care Audit Network (PICANET) database. All data were exported into an Excel spreadsheet and analysed using IBM SPSS and the subject of statistical analysis. This analysis allowed the audit team to report that the Braden Q tool performed well for the children for whom it had been validated and moderately well for children up to the age of 14 years and moderately well in predicting the pressure risk for children with congenital heart disease. The authors concluded that the Braden Q tool might be used for the wider PIC population until a more robustly validated tool was made available. This audit demonstrates the value of
large databases that can download vast quantities of information that can be subjected to statistical analysis. However, conclusions made from this analysis remain cautious. When, we might ask ourselves, can we ever be certain? Validation is the reply: more research, more data and more specificity. In short: observe, sample and measure. Julie Scholes Professor of Nursing and Co-Editor, Nursing in Critical Care
REFERENCES Bucknall TK. (2000). Critical care nurses’ decision making activities in the natural clinical setting. Journal of Clinical Nursing; 9: 25–36. Dawson D. (2014). Essential principles: tracheostomy care in the adult patient. Nursing in Critical Care 19: 63–72. Karra V, Papathanassoglou ED, Lemonidou C, Sourtiz P, Ginannakopoulou M. (2014). Exploration and classification of intensive care nurses’ clinical decisions: a Greek perspective. Nursing in Critical Care 19: 87–97. Masoudi Alavi N, Sharifitabar Z, Shaeri M, Adib Hajbaghery M. (2014). An audit of eye dryness and corneal abrasion in ICU patients in Iran. Nursing in Critical Care 19: 73–77. ¨ Ozden D, Turk C, Guler EK, Tok F, ¨ G, Duger ¨ ¨ Gulsoy Z. (2014). Effects of oral care solu¨ tions on mucous membrane integrity and bacterial colonization. Nursing in Critical Care 19: 78–86. Scholes J. (2014). Innovation in critical care nursing education: a reply. Nursing in Critical Care 19: 61–62. Tume LN, Siner S, Scott E, Lane S. (2014). The prognostic ability of early Braden Q Scores in critically ill children. Nursing in Critical Care 19: 98–103. Vandijck D, Hellings J. (2014). Innovation in critical care nursing education. Nursing in Critical Care 19: 59–60.
© 2014 British Association of Critical Care Nurses
What’s in this issue? Welcome to the second issue of this volume. The papers explore topics familiar to everyday critical care practice and illuminate new insights. The first editorial is a paper by Vandijck and Hellings (2014), which explores innovation in education and challenges us to think about what that really means. They argue that innovative methods to facilitate teaching and learning should be distinguished from new content. What is taught has to be dynamic as we fit practitioners for their changing role and societies’ expectations of how the profession will function. They offer an interesting insight into how technology may be the medium through which new pedagogies are realized. The second editorial offers a critical dialogue on these issues (Scholes, 2014). The editorial questions whether we can truly be innovative given the statutory and regulatory requirements for nursing practice. How can we enable transformative learning experiences that are sustainable and genuinely make a difference to the clinician as well as the patient for whom they care? Are computers along with other digital learning tools the answer? Will the expert mentor of tomorrow be a 3D virtual world avatar? How do we financially sustain the interactive and technically well-equipped classrooms? Professional learning is highly complex and capturing the sustainable impact of a single pedagogic intervention is methodologically very challenging. That does not mean we should not do it, but certainly we should be very cautious about claims we make that lay claim to the certainty of a single teaching and learning tool, intervention or approach. Deborah Dawson (2014) has written an essential guide to the care of patients
with a tracheostomy. She has undertaken an extensive search of the literature and based her guide on the best evidence available. In this instance often, expert opinion. This has been distilled into 12 essential principles to guide clinical practice and shape how this might be taught to junior colleagues. Dawson has assimilated all her clinical wisdom, teaching and research experience to generate this invaluable tool kit. We are indebted to Deborah for undertaking this task, and thank the British Association of Critical Care Nurses (BACCN), who commissioned this paper. This essential guide was commissioned in response to requests made by the journal’s readership and the BACCN membership for guidelines for essential clinical care. We would encourage our readers to make known to us, either by emailing the editors directly or via members of the Regional BACCN Committees, the topics that you feel would make useful, essential guides. The second paper by Masoudi Alavi et al. (2014) reports an audit undertaken of eye dryness and corneal abrasion among intensive care patients in Iran. Drawing on the expertise of an opthalmologist to assess patients on the day of admission and on day 5 for corneal abrasions, their audit included 87 patients who met their inclusion criteria. Their data reminds us of the importance of frequent attention to eye care and the use of eye lubricants to avoid corneal abrasions. They concluded that taping eyes alone was inadequate and twice as likely to cause corneal abrasions. The background literature review situates their findings and provides a comprehensive summary of the types and causes of corneal damage and eye dryness among critical care patients. Once again this paper is a useful guide for staff and students new to critical care as well as a reference to support teaching. It also serves to compare
© 2014 British Association of Critical Care Nurses • Vol 19 No 2
eye care practices in Iran with those of our own country. It serves to shrink the world and show how all critical care nurses need to pay attention to fundamental nursing care practices as much as complex technological challenges. ¨ The third paper by Ozden et al. (2014) turns to a quasi-randomized control trial to determine which of three available solutions was most effective in mouth care. The researchers recruited 60 patients to their study and randomly assigned 20 patients to receive one of the three solutions. The researchers found no difference in the oral mucosa of patients if they were treated with either saline solution, sodium bicarbonate or 0.2% chlorehexidine. The presence of bacterial colonization was found in all three groups. The researchers recommended that a larger randomized control trial be conducted to evaluate the numbers of bacteria that form in the mouths of patients relative to the solution used for mouth care. The one solution they did not trial was the patient’s own toothpaste solution and gauge any data on patient preference for either one of the three solutions. This serves as a timely reminder of how important the patient voice is to help us design research that is robust and provides sound evidence, but also illuminates what makes the experience of mouth care more comforting to the patients who receive the care. The paper by Karra et al. (2014) reports a study of self-reported clinical decisions made by 23 critical care nurses working in three different centres in Greece. Through content analysis, eight types of clinical decisions were identified. Capturing clinical decisions as they happen is a complex process and is methodologically challenging. To design some of these methodological issues, Karra et al (2014) generated a log sheet designed by experts and through pilot testing. The 57
Editorial
participants were allowed to free text an account of their decision and this text was subsequently categorized during the analytical process. To situate the nurses’ experience, additional sociodemographic data were recorded along with a summary of the context and conditions that surrounded the clinical shifts. The participants then provided a self-reported post hoc account of their clinical decisions. This reflective summary of the clinical decisions might contribute to the difference in the frequency of decisions reported to have been made by the Greek nurses (56 decisions per 8 hour shift) compared with those of Australian nurses who were observed to make a clinical decision every 30 seconds (Bucknall, 2000). In the Bucknall study, the nurses were observed for a 2-h period and the researcher made a commentary of actions as they happened and recorded into a digital recorder. This was interesting as such an approach although taking place in real time did include the researcher’s own judgement of the clinician’s decision. When analysed, Bucknall reported three categories of decision, while Karra et al (2014) report eight different categories. What is also important to note is the different types of clinical decisions that are self-recorded; of note, few entries relating to the emotional and psychosocial well-being of patients and those entries relating to physical assessment findings were linked to medical diagnoses. The authors conclude that this might have something to do with the dominant biomedical paradigm in the ICU. However, medical diagnoses are labels made through observation, samples and measurement. Inherently they hold an element of ‘objective observed truth’ validated by a report, test or
58
record. Making clinical decisions relating to emotional and psychosocial wellbeing relies on less tangible accounts of feelings and experience that under the scrutiny of a researcher, a nurse may feel less confident to report. One of the concluding comments made by the authors is the need for comparative data surveying the types of decisions made by critical care nurses in different clinical settings and countries. Before such a survey is undertaken, it is important to discover if it is intentional, and if so why, to under-report the emotional and psychosocial aspects of a clinical decision. The final paper by Tume et al. (2014) reports on the sensitivity and specificity of a pressure ulcer (PU) assessment tool (The Braden Q Tool) to predict PU risk in children admitted to a Paediatric intensive Care Unit (PICU). A retrospective audit of 891 critically ill children was undertaken. Braden Q scores made 24 h after admission were downloaded from the electronic nursing documentation. Other key patient data, including demographics, were downloaded from the Paediatric Intensive Care Audit Network (PICANET) database. All data were exported into an Excel spreadsheet and analysed using IBM SPSS and the subject of statistical analysis. This analysis allowed the audit team to report that the Braden Q tool performed well for the children for whom it had been validated and moderately well for children up to the age of 14 years and moderately well in predicting the pressure risk for children with congenital heart disease. The authors concluded that the Braden Q tool might be used for the wider PIC population until a more robustly validated tool was made available. This audit demonstrates the value of
large databases that can download vast quantities of information that can be subjected to statistical analysis. However, conclusions made from this analysis remain cautious. When, we might ask ourselves, can we ever be certain? Validation is the reply: more research, more data and more specificity. In short: observe, sample and measure. Julie Scholes Professor of Nursing and Co-Editor, Nursing in Critical Care
REFERENCES Bucknall TK. (2000). Critical care nurses’ decision making activities in the natural clinical setting. Journal of Clinical Nursing; 9: 25–36. Dawson D. (2014). Essential principles: tracheostomy care in the adult patient. Nursing in Critical Care 19: 63–72. Karra V, Papathanassoglou ED, Lemonidou C, Sourtiz P, Ginannakopoulou M. (2014). Exploration and classification of intensive care nurses’ clinical decisions: a Greek perspective. Nursing in Critical Care 19: 87–97. Masoudi Alavi N, Sharifitabar Z, Shaeri M, Adib Hajbaghery M. (2014). An audit of eye dryness and corneal abrasion in ICU patients in Iran. Nursing in Critical Care 19: 73–77. ¨ Ozden D, Turk C, Guler EK, Tok F, ¨ G, Duger ¨ ¨ Gulsoy Z. (2014). Effects of oral care solu¨ tions on mucous membrane integrity and bacterial colonization. Nursing in Critical Care 19: 78–86. Scholes J. (2014). Innovation in critical care nursing education: a reply. Nursing in Critical Care 19: 61–62. Tume LN, Siner S, Scott E, Lane S. (2014). The prognostic ability of early Braden Q Scores in critically ill children. Nursing in Critical Care 19: 98–103. Vandijck D, Hellings J. (2014). Innovation in critical care nursing education. Nursing in Critical Care 19: 59–60.
© 2014 British Association of Critical Care Nurses
