- Email: [email protected]
Securing the future of critical care nursing in Australia
Australian Critical Care (2007) 20, 3—5
GUEST EDITORIAL
Securing the future of critical care nursing in Australia Evidence from Australian studies indicates that the standard of patient care that we achieve in our intensive care units (ICUs) is as good or better than that in comparable developed countries. For example, patients of Australian ICUs rarely reported pain during their ICU stay when interviewed afterwards1,2 and were found to be optimally sedated most of the time during mechanical ventilation.3 Attempts to reduce length of ventilation with protocols that have achieved this abroad have been found not to do so in large Australian studies3—5 possibly because the length of ventilation is already shorter than in ICUs abroad6,7 as a result of the models of care we use in Australian ICUs, especially patient to nurse staffing ratios.3,4 It is cause for some satisfaction that much of what we do in our delivery of care is at the forefront by international standards. However, we need to be cognisant of areas where we can improve, especially in reducing variability in standards of care, and to grow our research and scholarship to support such care. It is imperative to maintain and adapt our standards in the face of changing social expectations, pervasive political challenges to critical care nursing as a profession and emerging worldwide threats to health that require the expertise of critical care nurses. Critical care nurses need to consider what changes may be necessary to maintain and improve these high standards of patient care in the future. Developments of our education and research activities will be key to both the individual critical care nurse and the specialty to have the knowledge, skills and capability to advance our practice. The Bachelor of Nursing degree became the standard for entry to practice in Australia in the
1980s—90s. Since then post-registration critical care nursing specialty courses have progressively become postgraduate tertiary courses offered at Graduate Certificate, Graduate Diploma and Master’s Degree levels, often in collaboration between universities and hospitals/health services. Many of the postgraduate courses are designed to meet the professional practice needs of individual nurses and the patients they care for, the health services’ needs for well prepared staff for critical care areas, and university requirements for academic awards. However, Aitken et al. found that the tertiary critical care courses available share little consistency in structure and content, the amount of clinical practice required in a course, or the qualifications and clinical currency of those assessing the competency of students.8 In subsequent work by the same authors there was mixed evidence of the importance assigned to practice, competence and problem-solving within the clinical environment. The first phase of this work, using a Delphi approach, sought to achieve consensus on the knowledge, skill and attitudes desired of graduates of critical care programs by Australian clinicians, educators, managers and students. Consensus was found about expectations across Graduate Certificate, Graduate Diploma and Master’s programs for learning outcomes in the areas of patient comfort and safety, professional responsibilities and ethical conduct. However, there was a notable lack of emphasis on advanced clinical practice, and little discrimination between the expectations of the three levels of programs. Extension of this work to refine and clarify these expectations through a stakeholder workshop found priority given to clinical competence, problem solving and decisionmaking abilities of graduates. There was also some
1036-7314/$ — see front matter © 2006 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.aucc.2006.11.004
4 discrimination evident between the three levels of education. These findings assist in planning for Australian critical care nursing education in the future. To maintain and increase our influence we need educational programs which meet local health service delivery needs, achieve consistent graduate attributes that the profession agrees are desirable, that prepare graduates to adapt to future challenges in critical care nursing and engage in life-long learning, and that are affordable and accessible to nurses in all geographic locations. The greatest challenge lies in achieving consistent standards in learning across programs, regardless of location and mode of delivery. Standardisation of educational programs, such as by accreditation of courses by professional nursing organisations, should be eschewed. However, there is a need to adopt consistent principles about what learning outcomes and practice roles should be demonstrated by graduates at the Graduate Certificate, Graduate Diploma and Master’s Degree levels, with an emphasis on competency in clinical practice and decision-making increasing to complex care, leadership, research and evidence-based policy in the higher level programs. Evidence-based practice and policy development are sophisticated scholarly endeavours that require critical care nurses educated in their execution and a body of knowledge derived from research to which Australian critical care nurses contribute, as is increasingly occurring. Critical care nursing research in Australia has mainly focussed on aspects of clinical practice and patient care, as exemplified by the work cited in the first paragraph above and in the recently published textbook, ACCCN’s Critical Care Nursing.9 There are three major areas of development to be addressed if we are to continue to progress as a research-based profession and achieve recognition for the difference we make to patient outcomes: publication of the critical care nursing research that is presently conducted in small investigatordriven projects and in higher degrees by research; progression from descriptive studies to larger interventional studies measuring meaningful outcomes for patients and families; and acknowledgment and reward amongst ourselves and promotion to others of our important research and scholarly achievements. It is essential that the Australian critical care nursing research that is abundantly in evidence every year amongst the free paper and poster presentations at our Annual Scientific Meeting (ASM) on Intensive Care is submitted for publication. The frequency with which the research in accepted abstracts appears in peer-reviewed journals is
S. McKinley, L.M. Aitken disappointing. For example, of the 30 abstracts published in the 2002 ASM proceedings, 10 have appeared as journal articles. Similarly, much of the research of students undertaking higher degrees by research that we see in university seminars and Master’s and Doctoral theses submitted for examination does not result in journal publications. This wasted effort cannot be justified, particularly the voluntary contributions of patients and others. Researchers have an ethical obligation to attempt to publish their research, making it available in the public domain for the benefit of those for whom it was intended. To build upon our contribution to knowledge on the impact of critical care nursing on patients outcomes, we must continue to progress from observational and descriptive studies to well designed studies that evaluate the effect of critical care nursing interventions on clinically meaningful patient outcomes, that is how patients feel, function and survive.10 While evidence of nursing influencing patient survival would be difficult to demonstrate, the effects of nursing care on patient comfort (e.g. reduction of pain and discomfort) and function (e.g. quality of life and psychological recovery) are amenable to clinical nursing interventions. This will require well coordinated, multicentre, and often multidisciplinary studies in order to enroll the numbers of patients necessary to validly test hypotheses on the effectiveness of interventions. Traditionally we have been part of a culture, which is reluctant to acknowledge and reward our research and scholarly achievements amongst ourselves or to promote to others our achievements that make a difference to patients; we have been socialised to under-rate and understate the impact of our work. The need to actively engage in peer recognition of achievements and to make this esteem evident to others, including interprofessional recognition, is especially important in the context of the Research Quality Framework exercise which will start in Australian universities in 2008. The RQF will contrast nursing research productivity with other academic disciplines and effect funding for nursing masters and doctoral research programs, government research grants for critical care nursing research and possibly the viability of critical care coursework programs in Australian universities. Education and scholarship provide a framework on which Australian critical care nursing in the future is heavily dependent. It is essential that the structure and processes we implement and refine now enable both the individual and the speciality to be appropriately prepared to function effectively in the future.
Guest editorial
References 1. Daffurn K, Bishop GF, Hillman KM, Bauman A. Problems following discharge after intensive care. Intensive Crit Care Nurs 1994;10:244—51. 2. McKinley S, Nagy S, Stein-Parbury J, Bramwell M, Hudson J. Vulnerability and security in seriously ill patients in intensive care. Intensive Crit Care Nurs 2002;18:27—36. 3. Elliott R, McKinley S, Aitken LM, Hendrikz J. The effect of an algorithm-based sedation guideline on the duration of mechanical ventilation in an Australian intensive care unit. Intensive Care Med 2006;32:1506—14. 4. Bucknall TK, Manias E, Presneill J, McEwen GC, Rose L. Comparing outcomes in sedation management methods. (Abstr) Program and Abstract Book, 29th Australian and New Zealand Annual Scientific Meeting on Intensive Care, Melbourne, Vic, 7—10 October, 2004. p 75. 5. Williams T, Martin S, Leslie G, Leen T, Thomas L, Tamaliunas S, Lee KY, Dobb G. Use of a sedation scoring tool and pain scale did not shorten duration of mechanical ventilation in a general intensive care unit (ICU). (Abstr) Program and Abstract Book, 31st Australian and New Zealand Annual Scientific Meeting on Intensive Care, Hobart, Tas, 12—15 October, 2006. p 173. 6. De Jonghe B, Bastuji-Garin S, Fangio P, Lacherade JC, Jabot J, Appere-De-Vecchi C, Rocha N, Outin H. Sedation algorithm in critically ill patients without acute brain injury. Crit Care Med 2005;33:120—7. 7. Brattebo G, Hofoss D, Flaatten H, Muri AK, Gjerde S, Plsek PE. Effect of a scoring system and protocol for seda-
5 tion on duration of patients’ need for ventilator support in a surgical intensive care unit. Qual Saf Health Care 2004;13:203—5. 8. Aitken LM, Currey J, Marshall A, Elliott D. The diversity of critical care nursing education in Australian universities. Aust Crit Care 2006;19:46—52. 9. Elliott D, Aitken LM, Chaboyer W. ACCCN’s critical care nursing. Sydney: Elsevier; 2007. 10. Bucher HC, Guyatt GH, Cook DJ, Holbrook A, McAlister FA. Users’ guides to the medical literature: XIX. Applying clinical trial results. How to use an article measuring the effect of an intervention on surrogate end points. Evidence-based medicine working group. JAMA 1999;282:771—8.
Sharon McKinley ∗ University of Technology Sydney and Northern Sydney Central Coast Area Health Service, Sydney, Australia Leanne M. Aitken Research Centre for Practice Innovation, Griffith University and Princess Alexandra Hospital, Brisbane, Australia ∗ Corresponding
author. Tel.: +61 299268281; fax: +61 294398418. E-mail address: [email protected] (S. McKinley)
GUEST EDITORIAL
Securing the future of critical care nursing in Australia Evidence from Australian studies indicates that the standard of patient care that we achieve in our intensive care units (ICUs) is as good or better than that in comparable developed countries. For example, patients of Australian ICUs rarely reported pain during their ICU stay when interviewed afterwards1,2 and were found to be optimally sedated most of the time during mechanical ventilation.3 Attempts to reduce length of ventilation with protocols that have achieved this abroad have been found not to do so in large Australian studies3—5 possibly because the length of ventilation is already shorter than in ICUs abroad6,7 as a result of the models of care we use in Australian ICUs, especially patient to nurse staffing ratios.3,4 It is cause for some satisfaction that much of what we do in our delivery of care is at the forefront by international standards. However, we need to be cognisant of areas where we can improve, especially in reducing variability in standards of care, and to grow our research and scholarship to support such care. It is imperative to maintain and adapt our standards in the face of changing social expectations, pervasive political challenges to critical care nursing as a profession and emerging worldwide threats to health that require the expertise of critical care nurses. Critical care nurses need to consider what changes may be necessary to maintain and improve these high standards of patient care in the future. Developments of our education and research activities will be key to both the individual critical care nurse and the specialty to have the knowledge, skills and capability to advance our practice. The Bachelor of Nursing degree became the standard for entry to practice in Australia in the
1980s—90s. Since then post-registration critical care nursing specialty courses have progressively become postgraduate tertiary courses offered at Graduate Certificate, Graduate Diploma and Master’s Degree levels, often in collaboration between universities and hospitals/health services. Many of the postgraduate courses are designed to meet the professional practice needs of individual nurses and the patients they care for, the health services’ needs for well prepared staff for critical care areas, and university requirements for academic awards. However, Aitken et al. found that the tertiary critical care courses available share little consistency in structure and content, the amount of clinical practice required in a course, or the qualifications and clinical currency of those assessing the competency of students.8 In subsequent work by the same authors there was mixed evidence of the importance assigned to practice, competence and problem-solving within the clinical environment. The first phase of this work, using a Delphi approach, sought to achieve consensus on the knowledge, skill and attitudes desired of graduates of critical care programs by Australian clinicians, educators, managers and students. Consensus was found about expectations across Graduate Certificate, Graduate Diploma and Master’s programs for learning outcomes in the areas of patient comfort and safety, professional responsibilities and ethical conduct. However, there was a notable lack of emphasis on advanced clinical practice, and little discrimination between the expectations of the three levels of programs. Extension of this work to refine and clarify these expectations through a stakeholder workshop found priority given to clinical competence, problem solving and decisionmaking abilities of graduates. There was also some
1036-7314/$ — see front matter © 2006 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.aucc.2006.11.004
4 discrimination evident between the three levels of education. These findings assist in planning for Australian critical care nursing education in the future. To maintain and increase our influence we need educational programs which meet local health service delivery needs, achieve consistent graduate attributes that the profession agrees are desirable, that prepare graduates to adapt to future challenges in critical care nursing and engage in life-long learning, and that are affordable and accessible to nurses in all geographic locations. The greatest challenge lies in achieving consistent standards in learning across programs, regardless of location and mode of delivery. Standardisation of educational programs, such as by accreditation of courses by professional nursing organisations, should be eschewed. However, there is a need to adopt consistent principles about what learning outcomes and practice roles should be demonstrated by graduates at the Graduate Certificate, Graduate Diploma and Master’s Degree levels, with an emphasis on competency in clinical practice and decision-making increasing to complex care, leadership, research and evidence-based policy in the higher level programs. Evidence-based practice and policy development are sophisticated scholarly endeavours that require critical care nurses educated in their execution and a body of knowledge derived from research to which Australian critical care nurses contribute, as is increasingly occurring. Critical care nursing research in Australia has mainly focussed on aspects of clinical practice and patient care, as exemplified by the work cited in the first paragraph above and in the recently published textbook, ACCCN’s Critical Care Nursing.9 There are three major areas of development to be addressed if we are to continue to progress as a research-based profession and achieve recognition for the difference we make to patient outcomes: publication of the critical care nursing research that is presently conducted in small investigatordriven projects and in higher degrees by research; progression from descriptive studies to larger interventional studies measuring meaningful outcomes for patients and families; and acknowledgment and reward amongst ourselves and promotion to others of our important research and scholarly achievements. It is essential that the Australian critical care nursing research that is abundantly in evidence every year amongst the free paper and poster presentations at our Annual Scientific Meeting (ASM) on Intensive Care is submitted for publication. The frequency with which the research in accepted abstracts appears in peer-reviewed journals is
S. McKinley, L.M. Aitken disappointing. For example, of the 30 abstracts published in the 2002 ASM proceedings, 10 have appeared as journal articles. Similarly, much of the research of students undertaking higher degrees by research that we see in university seminars and Master’s and Doctoral theses submitted for examination does not result in journal publications. This wasted effort cannot be justified, particularly the voluntary contributions of patients and others. Researchers have an ethical obligation to attempt to publish their research, making it available in the public domain for the benefit of those for whom it was intended. To build upon our contribution to knowledge on the impact of critical care nursing on patients outcomes, we must continue to progress from observational and descriptive studies to well designed studies that evaluate the effect of critical care nursing interventions on clinically meaningful patient outcomes, that is how patients feel, function and survive.10 While evidence of nursing influencing patient survival would be difficult to demonstrate, the effects of nursing care on patient comfort (e.g. reduction of pain and discomfort) and function (e.g. quality of life and psychological recovery) are amenable to clinical nursing interventions. This will require well coordinated, multicentre, and often multidisciplinary studies in order to enroll the numbers of patients necessary to validly test hypotheses on the effectiveness of interventions. Traditionally we have been part of a culture, which is reluctant to acknowledge and reward our research and scholarly achievements amongst ourselves or to promote to others our achievements that make a difference to patients; we have been socialised to under-rate and understate the impact of our work. The need to actively engage in peer recognition of achievements and to make this esteem evident to others, including interprofessional recognition, is especially important in the context of the Research Quality Framework exercise which will start in Australian universities in 2008. The RQF will contrast nursing research productivity with other academic disciplines and effect funding for nursing masters and doctoral research programs, government research grants for critical care nursing research and possibly the viability of critical care coursework programs in Australian universities. Education and scholarship provide a framework on which Australian critical care nursing in the future is heavily dependent. It is essential that the structure and processes we implement and refine now enable both the individual and the speciality to be appropriately prepared to function effectively in the future.
Guest editorial
References 1. Daffurn K, Bishop GF, Hillman KM, Bauman A. Problems following discharge after intensive care. Intensive Crit Care Nurs 1994;10:244—51. 2. McKinley S, Nagy S, Stein-Parbury J, Bramwell M, Hudson J. Vulnerability and security in seriously ill patients in intensive care. Intensive Crit Care Nurs 2002;18:27—36. 3. Elliott R, McKinley S, Aitken LM, Hendrikz J. The effect of an algorithm-based sedation guideline on the duration of mechanical ventilation in an Australian intensive care unit. Intensive Care Med 2006;32:1506—14. 4. Bucknall TK, Manias E, Presneill J, McEwen GC, Rose L. Comparing outcomes in sedation management methods. (Abstr) Program and Abstract Book, 29th Australian and New Zealand Annual Scientific Meeting on Intensive Care, Melbourne, Vic, 7—10 October, 2004. p 75. 5. Williams T, Martin S, Leslie G, Leen T, Thomas L, Tamaliunas S, Lee KY, Dobb G. Use of a sedation scoring tool and pain scale did not shorten duration of mechanical ventilation in a general intensive care unit (ICU). (Abstr) Program and Abstract Book, 31st Australian and New Zealand Annual Scientific Meeting on Intensive Care, Hobart, Tas, 12—15 October, 2006. p 173. 6. De Jonghe B, Bastuji-Garin S, Fangio P, Lacherade JC, Jabot J, Appere-De-Vecchi C, Rocha N, Outin H. Sedation algorithm in critically ill patients without acute brain injury. Crit Care Med 2005;33:120—7. 7. Brattebo G, Hofoss D, Flaatten H, Muri AK, Gjerde S, Plsek PE. Effect of a scoring system and protocol for seda-
5 tion on duration of patients’ need for ventilator support in a surgical intensive care unit. Qual Saf Health Care 2004;13:203—5. 8. Aitken LM, Currey J, Marshall A, Elliott D. The diversity of critical care nursing education in Australian universities. Aust Crit Care 2006;19:46—52. 9. Elliott D, Aitken LM, Chaboyer W. ACCCN’s critical care nursing. Sydney: Elsevier; 2007. 10. Bucher HC, Guyatt GH, Cook DJ, Holbrook A, McAlister FA. Users’ guides to the medical literature: XIX. Applying clinical trial results. How to use an article measuring the effect of an intervention on surrogate end points. Evidence-based medicine working group. JAMA 1999;282:771—8.
Sharon McKinley ∗ University of Technology Sydney and Northern Sydney Central Coast Area Health Service, Sydney, Australia Leanne M. Aitken Research Centre for Practice Innovation, Griffith University and Princess Alexandra Hospital, Brisbane, Australia ∗ Corresponding
author. Tel.: +61 299268281; fax: +61 294398418. E-mail address: [email protected] (S. McKinley)