EDITORIAL doi: 10.1111/nicc.12079

What’s in this issue? This issue welcomes in 2014 and the 19th volume of Nursing in Critical Care. The journal has moved significantly over the years to embrace international papers comparing practice in the UK with caring practices from around the globe. This issue has papers that explore quality initiatives, research and education that challenges our notions of care and technology, and raises questions about the ethics of innovation. Pattison and O’Gara’s (2014) editorial explores a complex and sensitive area of practice for the critical care outreach team: supporting patients who are suffering from long-term chronic illness and when, in the face of further acute deterioration, decisions need to be made as to the benefit an admission to the critical care unit. The challenge of a decision for further aggressive life support or deliberative palliation on an end of life care pathway has to involve the parent medical team, the family and where ever possible respect the wishes of the patient. However, circumstances that affect a call out by the critical care outreach team often militate against an extensive consultation. Therefore, patient directives in which the family and the patient determine a course of action in the event of sudden decline empower the health care team to make sensitive decisions and take appropriate action. The editorial by Dr Kiekkas (2014) opens by reviewing the hypnotic draw of technology. Technology, can potentially, reduce the patient to ‘measurable objects’ on whom medicine is titrated and against which, equipment is calibrated. The critical care nurses’ presence has always been one to mitigate the extremes of physical and psychological alienation and iatrogenic harm that technology and life support can induce. Dr Kiekkas reminds us that as equipment becomes more complex

and intricate we should receive frequent updates and training to ensure we can competently manage this technology to reduce risk to patients and to ensure the machinery of medicine does not dehumanize the patient but remains a tool with which to assist critical nursing care. The first paper by Langley et al. (2014) provides an illuminative comparison between End-of-Life Care (EOL) practices in Europe with those of Critical Care Nurses’ (CCNs) practice in South Africa. These data were gathered through a replication survey of the original Views of European Nurses in Intensive Care on End of Life Care (VENICE) tool, modified for use in the South African context to take account of the diversity of religion and culture. The response rate was 67%, but 42% of that sample did not have intensive care unit (ICU) experience but worked in specialist critical care settings. The key findings were that nurses did not feel they had early involvement in EOL discussions and decisions. The main conclusion from the study was that due consideration should be given to strategies to improve interprofessional and family communication. The authors indicate that further research was needed to nuance the context, conditions and relationships that shape how EOL discussions are handled and when they are conducted. The ethical complexities that would need to be addressed to conduct research into such a sensitive topic would require careful consideration and would essentially require us to involve patients and their families in the design, but the outcome would ultimately be to improve care for patients at the end of their life. Haughdahl et al. (2014) undertook a survey to examine the way Medical Directors and Nurse Managers perceived nurses’ clinical responsibility for decisions on managing mechanical

© 2014 British Association of Critical Care Nurses • Vol 19 No 1

ventilation and weaning. Nurse managers rated nurses influence on ventilation decisions and actions to change ventilator settings according to the patient’s clinical acuity higher than their medical colleagues. Medical directors reported less collaboration in the decisions made on readiness to wean, weaning method and the patient’s readiness for extubation than the nurse managers. The research did identify that both nurse managers and medical directors were in agreement that nurses were key to assessing and changing ventilation settings in response to the patient’s weaning tolerance and that ‘knowing the patient’ was critical to individualize care and to manage the process. With this knowledge, the authors concluded that increased awareness and acknowledgement of the role of the nurse may promote interprofessional collaboration and improve patient care. However, this is a big claim to make on the basis of the data collated through a survey completed by nursing and medical managers who were not directly involved in clinical care. Greater confidence in such a suggestion would arise from data that addressed the rich moments of professional interaction in the real world of intensive care practice, the intentionality of the practitioners to refer, confer or act independently and the parameters that determine discrete and specific areas of practice within the management of a patient’s ventilation. The real world might reveal that inter-professional collaboration is effective at the clinical interface and that subjecting inter-professional communication to the interference of management’s engineering, however well meaning, could impede rather than improve patient outcome especially if that intervention is taken out to the classroom. We need to understand the nuances of clinical interaction and 1

Editorial

the meaning that is ascribed to that by the clinicians themselves before we can confidently prescribe what needs to change and how. Korhan et al. (2014) report on a cross-sectional study to assess Turkish Nurses knowledge of guideline on the prevention of ventilator-associated pneumonia (VAP). This is an important topic as it is estimated that 80% of the pneumonias in ICU are VAP. Korhan et al. used validated multiple-choice questionnaires translated to Turkish and these data were supplemented by interviews. Data were gathered from intensive care nurses of four hospitals. Participation was high with 92% of the potential sample of 150 nurses from the four ICUs taking part in the study. The authors reported that the knowledge of VAP guidelines was poor and that the nurses’ theoretical and practical knowledge of VAP was also weak. The authors attributed this to the lack of evidence-based protocols being available within the intensive care units in which the nurses worked. Of note, unlike studies conducted elsewhere in Europe using the same instrument, knowledge levels did not increase with the length of the nurses’ experience in intensive care. This the authors attributed to the working practices in Turkey whereby with increasing years of experience the practitioners assume different roles in practice and tend to participate less frequently in professional development opportunities. The authors’ solution to this problem is to suggest the use of written protocols and monitoring to ensure adherence to them. In-service training programmes to support the implementation of the protocol are advocated alongside education to raise awareness and knowledge of infection control. Although the suggested solutions are intended to be developmental, a key contextual factor that may have impacted on these data are embedded in the limitations section. Multi choice questionnaires may provide convenient data for researchers that can be analysed rapidly through computer systems, but can only gather 2

one type of knowledge from respondents that is very specific and either right or wrong. This seems even more unfair on the subjects of study when the questionnaire was designed to test knowledge specifically framed by evidence guidelines that might not have been available to the nurses who were asked to complete the test. This challenges the ethical principle of justice: whereby all participants in research should be treated with dignity, equality and fairness. One way to redress this would to remediate any shortfall in knowledge, debrief and empower those who answered incorrectly. That intervention needs to be facilitative and immediate and designed into the study rather than a recommendation arising from it. Akerman et al.’s (2014) paper compares the use of closed and open suction systems in the prophylaxis of VAP. Swedish best practice, as advocated in the prophylactic care bundle, was supplemented with the addition of closed suction system (CSS) to identify if this had any impact on patient outcomes. Using an observational cohort design, the authors compared the outcomes of open suction systems (OSS) and CSS in a 12 bedded ICU. The design did not include randomization, rather, OSS or CSS was used exclusively during two of the four 1-month study periods. Data were gathered on the rates of contamination of the CSS units, desaturation following episodes of suctioning along with a record of adverse incidents during the use of CSS and OSS on a total population of 126 patients (sample: 61 OSS, 65 CSS). The results showed no beneficial effect from using a CSS over OSS, but a high incidence of circuit contamination was identified in the CSS and staff experienced problems using the CSS to clear secretions. The authors concluded that their findings and those of studies that included larger populations indicate that generalized use of CSS is debatable. The study was framed as a quality improvement initiative as both the CSS and OSS units were commercially available and

the introduction of the CSS was supplementary to the existing guidelines for best practice to reduce VAP. Other than to change the suction device, practice did not differ. On this basis, the authors did not submit their protocol for institutional ethical review nor did they seek patient consent. This raises an important issue: did the fact that patient data were being collected, although not randomly assigned to a study arm and using two different suction devices that were commercially available and therefore approved for clinical use, need consent? Was the autonomy of the patient compromised because it was assumed, without third party review, not to compromise ‘best practice’? This is challenging especially when we read that other ‘extensive studies’ indicate that the incidence of circuit contamination increased when using CSS (Sic). Therefore, if there is a risk, however small, and even if the design is framed as a quality initiative or an evaluation, the patient and their family has a right to know and be given opportunity to opt in or out of the study. What we do not know from this paper was the way in which this project was communicated to patients and whether an informal agreement was secured. Due regard to the autonomy of the individual should be respected in all circumstances and professional decisions about risk to that autonomy at the very least, peer reviewed by the patients’ advocate. The final paper by Alinier and Platt (2014) provides an opinion on the place of simulation as a training strategy to improve patient safety and quality of care. The review examines the work of societies that support the pedagogic practice of simulation at international and national level and compares practices that can optimize the impact of training in the simulated environment. Recently research studies have demonstrated the impact of learning through simulation. However, simulation is resource and labour intensive and often relies on expensive technology. Alinier and Platt (2014) argue that © 2014 British Association of Critical Care Nurses

Editorial

investment should be balanced with sound pedagogic principle and appropriate, expert support. They argue for compulsory training and monitoring of competence to demonstrate the value of any investment. This argument can be taken further to develop research that demonstrates the outcomes of learning through simulation and the impact that this might have on improved patient outcomes (Kinsman et al., 2012). The more we know the more we want to know and realize how much there is to learn. Often the conclusion of papers is a call for more research or evidence to draw safe conclusions about ‘best practice’. Sometimes the changes we propose may seem so minimal that we label the project evaluation and or quality enhancement. As such, the investigators assume they do not require full ethical review. Review should always be proportionate to the risk. However, if a study is worthy of reporting because the findings are significant, we should take measures to ensure that the ‘subjects’ of that study were fully aware of the project and agreed to take part.

© 2014 British Association of Critical Care Nurses

Each one of the papers in this issue has in some way touched on the central principle of respect for autonomy implicitly or explicitly. The take home message being: involve the patients and their families in decisions be that in the design and conduct of research or in the treatment options a patient is to receive. Autonomy is intercultural, relative and core to beneficence, non-maleficence and justice (the four pillars of ethics). Respect for autonomy is, and should remain, a core value for all critical care practitioners, researchers, managers and educators. We hope for it, we teach and write about it but we sometimes we need peer review to check that we embody it. Julie Scholes Co-Editor, Nursing in Critical Care

REFERENCES Akerman E, Larsson C, Ersson A. (2014). Clinical experience and incidence of ventilatorassociated pneumonia using closed versus open suction-system. Nursing in Critical Care; 19: 34–41.

Alinier G, Platt A. (2014). International overview of high-level simulation education initiatives in relation to critical care. Nursing in Critical Care; 19: 42–49. Haughdahl HS, Storli S, Rose L, Romild U, Engerod I. (2014). Perceived decisional responsibility for mechanical ventilation and weaning: a Norwegian survey. Nursing in Critical Care; 19: 18–25. Kiekkas P. (2014). Technological equipment in critical care: the cost of progress. Nursing in Critical Care; 19: 7–8. Kinsman L, Buykx P, Champion R, Cant R, Cooper S, Enadcaott R, McConnell-Henry T, Scholes J. (2012). The first2act simulation program improves nursing practice in a rural Australian hospital. Australian Journal of Rural Health; 20: 270–274. Korhan EA, Hakverdioglu Yont G, Kilic SP, Uzelli D. (2014). Knowledge levels of intensive care nurses on prevention of ventilator-associated pneumonia. Nursing in Critical Care; 19: 26–33. Langley G, Schmollgruber S, Fulbrook P, Albarran JW, Latour JM. (2014). South African critical care nurses’ views on end-of-life decision-making and practices. Nursing in Critical Care; 19: 9–17. Pattison N, O’Gara G. (2014). Making appropriate decisions about admission to critical care: the role of critical care outreach and medical emergency teams. Nursing in Critical Care; 19: 4–6.

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