NATURE AND FUNCTION OF CRITICAL CARE NURSING

Nurses are the one round-the-clock constant for critically ill patients and their families, acting as the ‘glue’ that holds the critical care service together. Nurses ensure safety and provide continuity and fine-tuning, coordinating and communicating all the elements of treatment and care needed by the patient.

Skilled critical care nurses provide:

Nursing in critical care is influenced by both the essential nature of nursing and the specific characteristics of the field. Fundamental concerns for all nurses are said to take in:

There is inevitably an emphasis on technology in the intensive care unit (ICU), and nurses must be technically competent. However, treatments should be administered with an understanding of the essential human elements of care. ICU patients report that such care is often missing: one described his experience as ‘rooted in the minute analysis of charts and the balancing of chemicals, not so much in the warmth of human contact’.³

Patients are not usually able to control what happens to them during the first phases of critical illness, but seek to reassert their autonomy as they begin to recover, e.g. when weaning from ventilation or with the transition to lower levels of care. Critical care nurses can enable patients to have a say in the management of these processes while still ensuring safe progression through different stages of treatment. Studies highlight the value of connecting with patients both psychologically and physically,⁴ and that patient-centred care and emotional support can be lost when the nursing resource is reduced.⁵ Fundamental care (e.g. personal cleansing, protection of tissue integrity, prevention of infection) is also generally undertaken or supervised by nurses. Other important functions (e.g. chest physiotherapy, mobilisation, delivery of nutrition) may be managed by other specialists, but it is nurses who integrate these treatments into a complete package of care.

A SYSTEMATIC APPROACH TO CARE

Nursing the critically ill patient is highly complex. It is vital to structure the patient review in order to clarify and prioritise patient needs, so that the whole range of patient function – and dysfunction – is addressed. In acute situations, assessment in turn of the fundamental A–B–C–D–E aspects of physiology is a useful method:

Appropriate treatment strategies can be prioritised using this schema, which has the additional benefit that it will be familiar to colleagues trained in advanced life support and similar systems.

Further detail may then be gained from review of:

More sophisticated models can be used to frame a wider impression of the patient and to reflect a particular philosophy or approach to nursing. For example, the Roy model⁷ expresses a view of nursing as a vehicle for enabling adaptive adjustments to any dysfunction. The model prompts analysis of both immediate and other contributing influences in a systematic consideration of oxygenation, nutrition, elimination, activity and rest, protective mechanisms, sensory function, fluid, electrolyte and acid–base balance, neurological and endocrine function, as well as the patient’s self-concept, role-mastery and psychosocial interdependence.⁷ Such an approach has a commendable breadth of vision, but may be too complex for the novice. Articulation of patient problems may be aided by the use of validated nursing diagnoses, as developed in North America. This system provides definitions and recommended nursing responses for many problems, and specifies appropriate outcome measures. What is most important is that any system used gives unambiguous definitions of patient problems and a clear statement of specific, measurable therapeutic goals.

NURSING AND PATIENT SAFETY

Inadequate nurse staffing is linked to increases in adverse events, patient morbidity and mortality. Significant numbers of patients suffer serious harm caused by errors in clinical practice, but nurses prevent many more incidents by intercepting and mitigating errors made by other professionals.⁸ Direct observation and patient care remain key to patient safety:⁹ it has been calculated that at least seven nurses need to be employed for each patient if a nursing presence is required continually 24 hours a day.¹ No particular system of critical care nursing has been shown to be definitively superior to others,⁹ but ensuring appropriate nursing numbers, skills and experience to meet patient need is a gold standard of care¹⁰ (see Staffing the critical care unit, below).

EVOLVING ROLES OF CRITICAL CARE NURSES

Critical care nurses’ range of practice has evolved rapidly with progress in technology and with changes in the working of interdisciplinary team colleagues. The benefits of developing new skills must be balanced against ensuring the maintenance of fundamental patient care.¹¹ There remains a large variation in the array of tasks undertaken by nurses in critical care, with invasive procedures and drug prescriptions still usually performed by doctors. However, from 2006 qualified nurse (and pharmacist) prescribers in the UK have been enabled – in theory at least – to prescribe licensed medicines for the whole range of medical conditions. Nurse prescribing is not as yet a widespread phenomenon in critical care, but may become a routine part of practice in the future.

Critical care nurses also have a large and developing role in decision-making regarding the ongoing adjustment, titration and troubleshooting of such key treatments as ventilation, fluid and inotrope administration, and renal replacement therapy. The use of less invasive techniques (e.g. transoesophageal Doppler ultrasonography for cardiac output estimation) means that it is possible for nurses to institute relatively sophisticated monitoring and administer appropriate therapies for restoration of homeostasis. There is evidence that nurses can achieve good outcomes in these areas, especially with the use of clinical guidelines and protocols; for example, by reducing the time to wean respiratory support.¹² This indicates that further development of protocols, guidelines, care pathways and the like can be used to enhance the nursing contribution to critical care.

NEW NURSING ROLES IN CRITICAL CARE

Medical and nursing staffing in the ICU is an ongoing problem in many countries. This has led to the development of various new ways of working to deliver both fundamental and more sophisticated modes of care.¹³ New nursing roles include those that essentially substitute for medical roles, as well as those that retain a nursing focus and aim to fill gaps in health care with nursing practice rather than medical care. For example, the UK has designated a relatively small number of nurse consultant posts in all areas of health care, with the largest proportion in critical care, particularly in outreach roles. These are advanced practitioners focusing primarily on clinical practice but also required to demonstrate professional leadership and consultancy, development of appropriate education and training, macrolevel practice and service development, research and evaluation.¹⁴

Other sorts of non-nursing staff are increasingly being used to deliver what has been seen as basic nursing care (e.g. oral and ocular care, recording of vital signs), in order to support trained nurses and enable them to concentrate on more advanced practices.¹⁵ Nursing shortages may make such developments inevitable in some areas, but it is imperative that nurses continue to ensure best outcomes for patients with proper arrangements for training, support and working systems.

CRITICAL CARE NURSING BEYOND THE ICU: CRITICAL CARE OUTREACH

Around the world, general wards are required to manage an increasing throughput of patients who are, on average, older than before, with more complex, chronic diseases, and more acute and critical illness. Review of admissions to ICU from general wards shows that many patients experience substandard care before transfer.¹⁶ Various factors are implicated, including lack of knowledge and failure to appreciate clinical urgency and to seek advice, compounded by poor organisation, breakdown in communication and inadequate supervision.

These issues are problems for the whole interdisciplinary team, but the nursing contribution is significant. It is nurses who record or supervise the recording of vital signs, suggesting that there is often poor understanding of the seriousness of such indicators, or failures to communicate effectively with medical staff, or difficulty in ensuring that appropriate treatment is prescribed and administered. Nurse-led outreach teams can support ward staff caring for at-risk and deteriorating patients, and facilitate transfer to intensive care when appropriate¹⁷ (see Chapter 2). They can also support the care of patients on wards after discharge from ICU, and after discharge from the hospital (see Chapter 8). Potential problems with these approaches include a loss of specialist critical care staff from the ICU, and being sure that outreach teams have the necessary skills to manage high-risk patients in less well-equipped areas, particularly when there are limitations placed on nurses prescribing and administering treatments.

NURSING IN THE INTERDISCIPLINARY TEAM

Effective critical care is based on interdisciplinary teamwork, with:

QUALITY OF CARE

Robust systems of audit are the foundation of quality care. Various measures have been suggested as indicators of the effectiveness of nursing structures, processes and outcomes, e.g. pressure ulcer prevalence, nosocomial infection rates and patient satisfaction. Although nurses should take responsibility for the care that they deliver, there are few, if any, nursing activities that can be considered entirely separately from other variables that influence patient outcomes. Furthermore, there are few, if any, medical interventions that are unaffected by nursing care. Rather, quality care depends on a collective interdisciplinary commitment to continuous improvement.¹⁹ This interdependence of different critical care personnel was illustrated in a multicentre investigation where interaction and communication between team members were more significant predictors of patient mortality than the therapies used or the status of the institution.²⁰