Nursing perspectives for intensive care

Nursing perspectives for intensive care

debate, confusion often remains about the role of nurses both generally and in specific areas; confusion which is seldom clarified by vague, open-ended job descriptions. This article explores the role of nurses in one speciality, intensive care.

A C H O I C E O F ROLES

A Strategy for Nursing (Department of Health

Philip Woodrow Within health care, market forces increasingly determine what services have economic value. For nursing to survive this economic onslaught, nurses must clarify their values and roles. While nurses working in intensive care develop useful technical skills and normally work within a constructive multi-disciplinary team framework, they have a potentially unique contribution to care, focusing on the patient as a whole person rather than intervening to solve a problem. The need for both physiological and psychological care creates a need for holistic values, best achieved through humanistic perspectives. Humanistic nursing places patients as people at the centre of nursing care, as illustrated by the limitations of reality orientation compared with the potentials of validation therapy. Intensive care nurses asserting and developing such patientcentred roles offer a valuable way forward for nursing to develop into the 21 st century.

INTRODUCTION

Philip Woodrow MA, RGN, DipN, Grad Cert Ed, ENB 100 Senior Lecturer, Middlesex University, Whittington Education Centre, Highgate Hill, London NI9 5NF, UK Correspondence to: 30 York Street, Broadstairs, Kent CTI0 IPB, UK (Requests for offprints to

pw) Manuscript accepted 13 March 1997

As health care is increasingly placed under the economic microscope, progressively thorough re-examinations are being made of expenses in healthcare. One of the largest areas of expense for the National Health Service (NHS) has always been the nursing budget; Endacott (1996) estimated that the nursing budget accounted for three quarters of Intensive Care Unit (ICU) costs. This has forced nurses to clarify their roles in order to justify their value in the healthcare market. Reminiscences by former nurses provide interesting insights into how roles have changed over the years. Yet despite wide

Intensiveand Critical Care Nursing(1997) 13, 151-155 © 1997PearsonProfessionalLtd

1989) identified four possible roles for nurses: (i) surrogate parent; (ii) technician; (iii) contracted clinician; and (iv) advocate. The obvious implication of this document was that nurses and nursing should adopt the last of these four roles. However, a similar conflict of roles within intensive care had already been identified by Ashworth. • technician • doctor's assistant • carer for patient while others deal with technical treatment and maintenance • a 'prickly' professional (Ashworth 1985). What nursing increasingly needs, whether in intensive care or in other areas, is nurses who are actively involved in their practice, thinking about and questioning what they are doing. Such involvement brings individual values into question. It is hypocritical, and potentially dangerous, to deny that we each have values, beliefs and prejudices. They are a part of being human. Such values need to be acknowledged and continually re-evaluated. The values and beliefs inherent in intensive care nursing can be re-evaluated through the work of Ashworth (1985) and A Strategy for Nu~'sin2 (Department of Health 1989). Essentially, this is working out a nursing philosophy; however, the words 'nursing philosophy' too often conjure up images of some esoteric message found somewhere on the unit wall-space, ornately framed but seldom read or practised. So rather than claim that 'man is a bio-psycho-social being', a simple message like 'remember our patients are human' might be more meaningful. The issue o f values is illustrated by the semantic dilemma of whether to call the speciality units 'Intensive Therapy' (ITU) or 'Intensive Care' (ICU). The terms are in practice often interchangeable, but there is an important philosophical distinction. While care can, and should be, therapeutic, therapy without care is almost an oxymoron. So, to emphasize the caring, human role of critical care nurses (and other staff) this article refers to I C U rather than ITU. To explore individual nursing values, a values exercise can be beneficial. There are a number of published values exercises, a particularly

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useful one was devised for intensive care by Manley (1994). Fundamentally though, values will be clarified by exploring how we as nurses see our role. After all, regardless of individual nursing beliefs, nurses will be replaced by cheaper commodities if the cheaper commodities can be shown to be as effective in the healthcare market. As Wilkinson (1992) states, 'nurses working in intensive care units need to clarify their role and 'articulate the importance of their role in caring for patients and relatives'.

TECHNOLOGY To explore concepts of I C U nursing, it is useful to explore the history of the speciality itself. Intensive care is a young speciality. Respiratory units offering mechanical ventilation developed following the poliomyelitis epidemic of 1952-53 (Edwards 1994), although the first purpose-built intensive care unit in the U K did not follow until 1964 (Broadgreen Hospital, Liverpool). With an emphasis on medical need and availability of technology, ICUs were able to offer potentially life-saving intervention during acute physiological crises. As technology and medical skills proliferated, so the speciality grew. The role of doctors and technology in ICUs justified the growth of the speciality. In the UK, where I C U patients are generally sicker than elsewhere in Europe (Silvester 1994), physiological health needs are especially acute. So if the role of technology is justified, technicians are needed to maintain and operate the machines. Many ICUs employ a technician, yet many technology-related tasks are delegated to nurses: managing machines at the bedside, recording obselwations from them, and making changes in regimes as prescribed by the doctor. The technical role of nurses in intensive care is undeniable. Technologies provide useful means to monitor and treat critically-ill patients; however, technology should not become a substitute for care. For nursing to achieve a patientcentred focus, patients, not machines, must remain central to each nurse's role. Technology should not, therefore, be seen as justification of the role or presence of the nurse. Health-care assistants (and, potentially, robots) could be trained to perform such tasks, and would be cheaper to employ. So, while acknowledging the need for a technical role, an I C U nurse needs to be more than just a technician.

DOCTOR-NURSE RELATIONSHIPS Ford and Walsh (1994) observed that nurses working in high-dependency areas often have

an especially good relationship with medical staff. Most I C U nurses would agree with, and value, this. But the cost o f this, Ford and Walsh suggest, is that the relationship is on the terms of the medical staff This clearly implies that I C U nurses take on a doctor's assistant role. There are clearly times when I C U nurses do need to assist doctors, but if this were all that is required of an I C U nurse, then again, trained health care assistants (HCAs) would be a cheaper, more cost-effective, option. Nurses should collaborate with doctors (and other members o f the health-care team, U K C C 1992). H o w this collaboration is achieved will vary from unit to unit, and from person to person, but while recognizing and respecting the valuable and unique role of doctors, collaboration by nurses should not mean subservience to medicine. I C U nurses need to define actively and positively their unique role and their contribution within the speciality, and genuine respect should be a two-way process. Neither the technician nor the doctor's/ contracted assistant role should fully encompass the role of an I C U nurse. Rather than look for partial answers to questions about nurses' roles in the medically/technologically-led history of ICU, more comprehensive answers can be gleaned from exploring nursing values.

PSYCHOLOGY In recent years, the nursing profession has placed increasing emphasis on psychology and the psychological needs of patients. This psychological approach to care has been noticeably absent in the medical and technological perspectives above. Increasingly, nursing (and other professions) has recognized the psychological needs of patients, whether conscious or unconscious. Indeed, Parfitt (1988) claims that I C U nurses emphasize psychological needs, an emphasis that caused Cochran and Ganong (1989) to conclude that I C U nurses were more concerned with psychosocial stressors while their patients were more concerned with physical care. The implication that I C U nurses overemphasize psychological needs should be approached cautiously, as patient needs and nursing care will vary between units and individuals. However, if both Parfitt and Cochran and Ganong are right, then cognitive dissonance exists between I C U nurses and their patients. As patients are admitted to I C U with acute physiological crises, intervention for those crises necessarily focuses care on physical needs. It would be obviously inappropriate during a cardiac arrest to consider on bow

Nursing perspectives for intensive care

many pillows the patient normally sleeps. But psychology and physiology are not the two distinct pigeon-holes that some nursing (and other) course timetables might suggest. The very real homoeostatic imbalances caused by psychological distress have been well described by Ashworth (1980), or may be found in any respectable anatomy and physiology textbook. Examples familiar to I C U nurses will be the fight/flight response, and the metabolic response to trauma. Rather than ritualistically following a list ofpre-ordained cues (such as an assessment form), nurses need to evaluate actively the holistic needs of their patients. So questions about the number of pillows used at home will be appropriate to some patients, but not others. By acknowledging the psychological as well as physiological needs of their patients, I C U nurses can complement the valuable physiological care that is offered by other professions. In caring for both physical and psychological needs, nurses can add a humane, holistic perspective into patient care.

CARE OR TORTURE? The psychological stresses specific to, or accentuated by, intensive care have been widely discussed in the nursing literature since Ashworth's seminal study (1980). The most poignant exploration is arguably made by Dyer (1995), who compares intensive care practices to torture. Deprived of the ability to speak, make decisions, or alter their environment, patients in I C U are confronted with a barrage of unusual, and deficit of usual, sensory inputs. Some of the most basic human physiological functions are replaced (breathing, movement). The I C U environment clearIy has the ingredients for successful psychological (and physical) torture. The difference between deliberate torture and a patient's experience in I C U is in the intention of the inflictor of suffering. Torture aims to make its victim serve the torturer (such as through confession); intensive care is intended to overcome physiological disease and restore health. To achieve this end suffering is often knowingly inflicted or is an unrecognized side effect of treatment. The cost of critical illness to the patient is this suffering (Carnevale 1991). However, this suffering may be reduced or made more bearable through a number of nursing strategies. This makes the role of I C U nurses (and other staff) diametrically opposed to that of the torturer; an I C U nurse should try to humanize the environment for each patient. But the almost inevitable suffering also means that admission of any patient unlikely to survive

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is inappropriate, as that patient will effectively be tortured to death. Attempts to minimize suffering for patients who need to be admitted to I C U can be offered through intrinsic and extrinsic means.

N U R S I N G CARE Intrinsic needs derive from the patient's own physiological and functional deficits, including many 'activities of living', such as the need to be comfortable and pain-flee. Nurses should try and ensure patients receive appropriate analgesia and sedation, and that fundamental aspects of care are promoted (hygiene, including eye and mouth care; pressure area care). This care includes not only ensuring that patients receive appropriate drugs (such as analgesia and sedatives), but observing patients, and monitoring the effectiveness of drugs used (such as through pain and sedation scoring). Stereotypically an I C U patient is unconscious, intubated and sedated. But Monger (1995) questions the value of sedating all patients, as has been the practice in many units; depriving them of consciousness can replace autonomy with paternalism. ICUs in the U K increasingly care for more conscious and semiconscious patients. However, while Monger's article may reflect a significant change in philosophy of care, it also raises worrying issues about physical restraint. Nurses in the U K (although not in all other countries) view physical restraint as barbaric, although they accept widespread use of chemical restraint (sedation). Development of more sophisticated ventilatory modes has enabled patients to breathe comfortably while being partly supported by ventilation. This has reduced needs for sedation. Sedation has a useful place in practice as long as it promotes patient comfort; used as a chemical restraint, its value is more questionable. For comfort, sedation is still often necessary; and the need for analgesia is unlikely to be superseded. In addition to their intrinsic physiological functions, people (and animals) are influenced by, and interact with, their environment. Extrinsic factors are aspects from the environment which by promoting dignity, respecting privacy, and offering psychological and spiritual support, make people individual humans rather than just biologically functioning organisms. For instance, the depressive state caused by short winter days, called Seasonally Affective Disorder (SAD) (Ford 1992), may be experienced by nurses going to and returning from work in the dark during winter months. For I C U patients other natural body rhythms, par-

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ticularly the circadian rhythm, are probably more significant. Valuable nursing literature explores such aspects as day/night orientation and sleep (Bartie-Shevlin 1987, Moore 1989). Patients who are unable to communicate verbally need nurses to promote a therapeutic environment proactively and creatively. Waldman (1996) describes one patient feeling tortured by hearing a can being opened, while unable to drink. Such a simple thing as opening a can of naso-gastric feed away from the patient's hearing may reduce unintentional, but unnecessary, suffering. Another important extrinsic factor is the role (and care) of relatives, friends and other significant people in each patient's life. While intensive care staff still have much to learn here from other specialities (in particular, paediattics), some useful recent studies, such as Jones and Gtiffiths (1995) and Plowright (1995) have focused on this aspect of care. Psychological approaches to nursing should be planned and implemented individually according to each patient's needs. These needs can be assessed through patients themselves, augmented by infonnation from families and friends. Different nurses will feel comfortable with different approaches, but there is a fundamental need to recognize the individual, the human being, inside each patient. Calne (1994) suggests patients are dehumanized by admission to intensive care; Sawyer's (1997) account ofexpetiences as a patient in I C U makes salutory reading. This revives the thigh tech versus high touch' debate; too often communication and touch are task-orientated. So patients are given information about imminent procedures, but there is little sense of human or humane conversation. Relatives may sit silently at the bedside, afraid to touch their loved ones in case they interfere with some machine. Nurses can help to restore the sense of humanity to intensive care (Ball 1990, Mann 1992). But this does require nurses to think actively about the nursing care they offer. Probably few I C U nurses would willingly sleep naked (with only a single sheet) in a mixed ward, yet many I C U nurses subject their patients to this potentially degrading experience. Nurses need to question proactively every nursing action, no matter how small and insignificant that action may initially appear. So much valuable literature has been written on many aspects of psychological care that this article can do little more than acknowledge some key texts. However, one area that has been poorly explored in intensive care nursing is reality orientation. This is often glibly offered as a means to offer psychological care. There will be times when reality orientation is appropriate and valuable. But ira patient's perception of reality differs from the nurse's ('ICU syn-

drome'), i.e. the nurse continually contradicting what the patient thinks, this may cause psychological pain, distress and aggression. These effects are undesirable from a humane perspecfive; they may also cause a number of potenfially undesirable physiological consequences (such as adrenaline release causing hypertension, tachycardia and hyperglycaemia). Far from being a panacea for all acute states of confusion, reality orientation can be psychologically cruel and physiologically counter-producfive. Rather than attempt to orientate patients to the nurses' reality, it may be more therapeutic to try and orientate the nurse to the patient's reality or perspective. Apart from reducing the patient's aggression, this approach may help nurses to empathize more with their patients, promoting patient-centred, rather than regimefocused, care. Working with elderly (conscious) people Fell (1993) found this approach of validating the patient's perception ('validation therapy'), more useful than reality orientation. Readers familiar with the work of Rogers and Maslow will recognize the strong influence of" humanistic psychology on Feil's work. Impaired consciousness and intubation may make application o f Feil's work to intensive care problematic, but validation therapy is potentially a valuable area of psychological care for I C U nurses to explore further. Unlike all other medical and para-medical professions, hospital nurses do not just visit to treat a problem or set of problems. Unique among health-care workers, nurses are with the patient throughout his/her hospital stay. A fundamental role of each nurse therefore is to be with, and be for, the patient. This is compatible with the advocacy role promoted by A Strategy for Nursing (Department of Health 1989). This role is facilitated by making patients the focus of organization of care (such as through primary/named nursing). As a member of the one group in the muki-disciplinary team which is continuously present in the patient's environment, a nurse is ideally placed to put the patient (as a person) first. The role of intensive care nurses in the U K is highlighted by the 1 : 1 nurse-patient ratio of most units (Appleyard & Langan 1997, Endacott 1996, Hinds & Watson 1996). Although an ideal (most I C U nurses will have experienced caring for more than one ventilated patient at the same time), the overall nurse:patient ratio in the U K is 0.85 (Ryan 1997). This ratio, better than all other countries identified by R.yan, should be considered against the greater severity of illness (and so dependency) among I C U patients in the UK. Nevertheless, the constant presence of nurses at 'their' patient's bedside should promote more holistic, patient-centred, care.

Nursing perspectives for intensive care

CONCLUSION T h e r e are clearly needs for t e c h n i c a l expertise to m a n a g e e q u i p m e n t safely a n d m a i n t a i n a safe e n v i r o n m e n t for each patient. I f n u r s i n g w e r e j u s t a series o f t e c h n i c a l tasks, h e a l t h - c a r e assistants or r o b o t s w o u l d m a k e a m o r e e c o n o m i c o p t i o n t h a n e m p l o y i n g nurses. T o restore t h e acute physiological imbalances that h a v e caused patients' admissions to the I C U , t h e r e is also clearly a n e e d for nurses to assist doctors a n d o t h e r professionals w h e n appropriate. B u t t h e role o f any nurse, a n d especially t h e role o f an I C U nurse, extends b e y o n d these v e r y l i m i t e d parameters. G i v e n the i n t e r a c t i o n b e t w e e n physiological a n d psychological homeostasis, r e p l a c e m e n t o f n u r s i n g ' s holistic role b y t e c h n i c i a n s or assistants w o u l d almost certainly b e reflected in increased m o r t a l i t y a n d m o r b i d i t y , a n d p r e s u m a b l y b y increased average l e n g t h o f stay (and thus soaring costs). O f course, the costb e n e f i t ratio o f h a v i n g nurses i n 1CUs will n o t b e fuIly p r o v e n unless a trust decides to m a n a g e w i t h o u t t h e m ; b u t g i v e n t h e likely cost i n terms o f h u m a n i t y , mortality, a n d budgets, it is to b e h o p e d n o trust wiI1 ever b e f o o l h a r d y e n o u g h to a t t e m p t this e x p e r i m e n t . I C U nursing, m e a n w h i l e , needs to assert itself b y r e c o g n i z i n g its o w n k n o w l e d g e , valuing its skills, a n d offering holistic p a t i e n t / p e r s o n centred care. P e r s o n - c e n t r e d care involves each nurse b e i n g there for the patient, rather t h a n the institution. H a v i n g r e c o g n i z e d the primacy o f the patient, nurses can t h e n develop their valuable technological skills, t o g e t h e r w i t h o t h e r resources, to fulfil their u n i q u e role in the m u l t i disciplinary t e a m for the benefit o f patients. I C U nurses o f the 21st c e n t u r y should value I C U nursing o n its o w n terms to h u m a n i z e the e n v i r o n m e n t for their patients, n o t b e c o m e merely facilitators o f t e c h n o l o g y or the subordinates o f doctors, accountants or others w i t h power-bases w i t h i n health care. It is the beliet~, attitudes and philosophical values o f nurses that will ultimately d e t e r m i n e the e c o n o m i c value o f n u r s i n g in the health-care market.

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Textbook of Intensive Care. Chapman and Hall Medical, London, 761-766 Ashworth P 1985 Editorial. Intensive Care Nursing 1 (1): 1-2 Bail C 1990 Humanity in intensive care. Intensive Care Nursing 6 (1): 12-16 Barrie-Shevlln P 1987 Maintaining sensory balance for the critically ill patient. Nursing 3 (16): 597-60I Calne S 1994 Dehumanisation in intensive care. Nursing Times 90 (17): 31-33 Carnevale F 1991 High technology and humanity in intensive care: finding a balance. Intensive Care Nursing 7 (1): 23-27 CochranJ, Ganong L 1989 A comparison of nurses and patients perceptions oflCU stressors.Journal of Advanced Nursing 14 (12): 1038-1043 Department of Health 1989 A Strategy for Nursing. Department of Health, London Dootson S 1990 Sensory imbalance and sleep loss. Nursing Times 86 (35): 26-29 Edwards D 1994 Technology responds to the challenge. International Journal of Intensive Care 1 (3): 77 Endacott R 1996 Staffing intensive care units: a consideranon of contemporary issues. Intensive and Critical Care Nursing 12 (4): 193-199 Feil N 1993 The Validation Breakthrough. Health Professionals Press, Baltimore, USA Ford K 1992 A seasonal depression: management ofseasonaI affecrive disorder. Professional Nurse 8 (2): 94-98 Ford P, Walsh M 1994 New Rituals for Old. Butterworth Heinemann, Oxford Hinds C, Watson D 1996 Intensive Care: A Concise Textbook. WB Saunders Company, London Jones C, Griffiths R 1995 Social support and anxiety levels in relatives of critically ill patients. British Journal of Intensive Care 5 (2): 44-47 Manley K 1994 Primary nursing and critical care. In: Millar B, Burnard P (eds) Critical Care Nursing. Bailliere Tindall, London 41-73 Mann R •992 Preserving humanity in an age oftechnologT. Intensive and Critical Care Nursing 8 (1): 54--59 Monger E 1995 Sn'ategies for nursing conscious mechanically ventilated patients in Southampton and Amsterdam. Intensive and Critical Care Nursing 11 (3): 140-147 Moore T 1989 Sensory deprivation in the ICU. Nursing 31 (36): 44-47 Parfitt B 1988 Cultural assessment of the ITU. Intensive Care Nursing 4 (3): 124-127 Plownght C 1995 Needs of visitors in the intensive care unit. British Journal of Nursing 4 (18): 1081-1083 Ryan D 1997 Euricus-1. Care of the Critically Ill 13 (1): 4 Sawyer N 1997 Back from the twilight zone. Nursing Times 93 (7): 28-29 Silvester W 1994 Outcome in temas of quality of life. International Journal of Intensive Care 1 (3): 105-106 UKCC 1992 Code of Professional Conduct for the Nurse, Midwife and Health Visitor. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London Waldmann C 1996 The intensive care follow-up clinic. Care of the Critically Ill 12 (4): 118 121 Wilkinson P 1992 The influence of high technology care on patients, their relatives and nurses. Intensive and Critical Care Nursing 8 (4): 194-198