The nurse on the intensive care unit

INTENSIVE

C:ARE NURSING,

c Lunqmn

1986, 1, 181 186

Croup 198h

The nurse on the intensive

care unit

C. Shuldham

Nursing

has undergone

great

changes

times and it seems likely that during years

it will

continue

increasingly fc)r nurses (ICU).

demanding,

in the

Intensive

serves

being

comprises

namely

functions wrote

that

definition

the nurse is to assist the individual, the performance health

ofthose

or its recovery

he would

perform

will or knowledge.

unaided

critical

contributing

often

nurse

compensates

perform tenet unique

more

of’ the definition, function

ofthe

which

initiates

that,

than

illness,

nursing

assistance

in question. however,

as the

inability The

holds

nurse comprises controls.

on to

general true.

The

those areas

It involves

practiher in

other

members

the doctor,

others. drugs

are to be administered.

happens

The

doctor

patient.

is therefore

The

the doctor

nurse

for the prescription,

in his turn, fulfillment

is dependent

upon

of that prescription

1984).

patient.

They

On paper in reality,

however,

that

have found

themselves

but the doctor, treatment.

upon

the doctor,

the nurse

collaborate

It is likely

in

for the & Vaug-

treating

the

very straightfor-

there can be difficulties.

many

knew for example,

dependent while (Pearson

this appears

experienced

ICU

in the situation

what drugs

knowing

better,

Frustration

the patient would

and conflict

nurses

when

they

needed

not initiate can so easily

arise, particularly

if the doctor

is dismissive

of the

nurse’s

knowledge,

and

nurse

skill

and

if the

becomes aggressive in defence of her position. Thus it can be seen that collaboration has to be upon

mutual

Caroline Shuldham SRN, RCNT, RNT, TutorContinuing Education, Guildford Nurse Education Centre, Guildford, Surrey.

phere where every for the contribution

7986

of the role

what

diagnosis and prescribes certhe nurse then gives to the

founded

16 Jan

or dietitian

of this aspect

by examining

willingness

accepted

hand,

co-opera-

of the multidisciplin-

physiotherapist

The nature

For convenience the female gender is applied throughout to the nurse and the male genderto the patient and doctor.

Manuscript

on the other

the nurse works

makes the medical tain drugs which

ward;

of the

element, when

be illustrated

han,

as rapidly

she, as an independent

and

that

because

for the patient’s

the activities

of her work tioner,

entails

to

death)

And to do this in such

of the person’s

ICU

of

if he had the necessary

It can be argued

nature

when

Hender-

a way as to help him gain independence as possible’.

and

sick or well, in

activities

strength,

can

function

(or to peaceful

evident

with

among

of nursing by a problem-

approach.

becomes

role

1980). In

the prescription

The collaborative tively

to

and

and may be facilitated

orientated

ary team;

the unique

‘the unique

intervention

of the

nursing

(McFarlane,

decision-making

of the

role

many

The

and well received

son (1979:4)

Unit

as well as those specific

two elements,

her famous

of the

examined.

the collaborative

become not least

Care

to highlight

issues in nursing

topic

and

and

an exploration

in ICU

current the

working

Thus

nurse

to develop

complex

in recent

the next few

person’s

to listen expertise.

respect and

This

between

parties,

to acknowledge helps

create

a

each

an atmos-

member of the team is valued he makes. True collaboration

on TCU may necessitate a re-examination of the changing relationship between both nurses and

182

INTENSIVE

doctors,

and

health

CARE.

nurses

NURSING

with

other

members

of the

namic

care team.

monitoring,

Ganz catheter,

for example

at least one nurse, him.

THE ROLE OF THE NURSE IN ICU

He

minute

has

in ICU

it soon becomes

not all nurses

perform

this

elements,

common

exclusive

ones,

clinical,

can

teaching

of these

aspects

time

spent

in pursuit

Thus

a sister,

and

of the

clinical

not performing

fact

each

teacher.

Similarly,

role, for example

people

own interpretation

upon

role despite and

occupying

two sisters,

elsewhere,

a

receive

ledge

and

neglect

one aspect

effective

or frankly

The critically

and experience.

place,

upon professiojust

The care should are,

by the very

ill. They

rather

than

nature

fall into three

their medical

have One

invasive

two such patients gory of patient

may

depen-

diagnosis.

Using

be able

concurrently. is likely

is one who

from

the

ventilator.

He

infusions,

thesia.

He requires

a nurse

which

renders

unavailable

her

of

nursing,

cate-

with

an

have

or epidural

multiple anaes-

to care for him alone, to help

her col-

leagues. The final group includes those people who are dependent upon life support systems, notably ventilators. They may be sedated and have muscle relaxants or be unconscious. Infusions of positive inotropic drugs (ie ‘support’ drugs) may be in progress and invasive haemody-

less

who

giver

occur. Many

of

physically

dependent distorted

patients perception, is also likely

and

of

and

charged of life or

has

and humane

person.

and a lack of control

highly

on the edge

time

the

flash-

ventilators

of this

expert

kindly

sounds

of equipmen--intrave-

nurse

skilled,

at the same

of alarms,

monitors,

ICU

whole

environ-

An all perva-

shriek

nurse’s

overload

care

ICU

this while

care, a competent

and the

patient

for as to

by the relentless

midst

an

about

of nursing,

important.

pumps,

the

psychological warm

against

the

for the

the facility

The

is the patient

and

comfort

needs care ofhis

recovery.

is created

knowledgeable,

upon

The second

might

dialysis,

environment

or complex

to be intubated

In

intricate

dangerous.

and a plethora

like.

to look after

endotracheal tube or have a tracheostomy. He may be breathing spontaneously or being weaned intravenous

the

recog-

manage

provide

the sudden

nous infusions,

death

by their

monitoring

nurse

of the

categories

the first type of patient

sive atmosphere

is

Among

she has to observe

science

it vitality

of ventilators,

some

elsewhere

and make decisions

ill patient

can mitigate

time making

nurse

her findings,

is to render

to enhance

ing lights

fashion.

et al., 1983) determined

not

on intuition be carried

on ICU

treatment.

on know-

then

this criterion, does

than

as

in a kind and humanitarian

critically

(Phillips dency

ment on ICU,

and

the art and

their

is founded

hours

She has to have

same

be based

rather

care.

the

person

that

research

out skilfully Patients

should

judgement

support

will each place

that patients

than

exhausting.

in detail

and his relatives

combining

their job.

intervention

nal nursing

patient

the ICU

standard

over many

appropriate

The Nurse as Clinician The nursing

needs

emotionally

record

equipment,

are

for every the clinical

1984) in an area of work which

and

things

observed

patients

requires

two, to care for

To provide

nise early signs of complications,

activities.

a manager

& Daze,

the patient,

a Swan-

a high level of competence,

a higher

physically other

placed

the proportional

the same

of these

say

(Roth

the

and staff nurse

is a clinician,

would

components

relevant

teacher

to be closely

has to maintain

mutually

namely

does vary is the emphasis

each

manifestly

not

identified;

and

that

role. Despite

although be

upon

the

an identical

management

of the role. What

apparent

and sometimes

of the 24 h span.

care each Working

with

may be used. This patient

to

be

a

practitioner physical

technician,

and and a

Conflicting

demands

attention

obviously

compromised

and

may also be experiencing limited understanding of, over their situation. (Lindenmuth

Sensory

et al., 1980).

Imagine for example a man who, on his way to work, suffers a myocardial infarction and consequent ventricular fibrillation. He is resuscitated and admitted to ICU where he awakens to find he is flat in bed, looking at a well-lit ceiling. The last thing he remembers is being on the station platform. Now there is something uncomfortable in his throat, his breathing is beyond his control.

INTENSIVE

He tries

to speak

reaction?

Perhaps

which

the

about

not

might

secure

‘reassuring’ cited,

the

Ashworth

(1980)

was of the short-term

recipients

unable

informative

manner.

physical,

are

met.

technical

Indeed

and

‘the

the manner

found

that

Yet

influencing the

the deal

who are passive

the relationship

art

and

so

needs

of continuous

science

the essence

of nursing

of patient

on ICU

ratio readily tion

aspects

can

and

role

be

demands

placed

upon

by the example oirerdose and

care the patient

is aggressive

survived.

and

patient,

angry

frustrated

patients

whom

and unused

she perceives

The final elements the clinical

functions

morbidity

and

which

that

ofstress

come spent weeks

nursed

or tragic

for a

to cope or away

from

sick.

in the context

of

nurse are those of

of patients,

both

It is generally

acknow-

an enormous

amount

this can create

for the nurses,

they have difficult

as more

of the ICU high.

an and

he has

to caring

taken

to consider

mortality

are obviously

ledged

that

she may feel unable at being

of

nurse

who may have

lived or died in

circumstances.

They

is involved

may have

for them.

in

the

management

might

to give

be primary

of

a patient,

skills ofthe

as

to

necessity or which

upon,

bedside

giving

of nurse

her a prime

of

individualised

nursing

responsibility

his stay.

This

essential

to establish

relevant

alleviate

nett,

1984:8).

At present a system off-duty,

whereby

one

a continuity

rapport

and

nursing

‘which

is of

to provide company

i W'ilson-Bar-

stress’.

is generally

nurse

knowledge

for him, to provide

unnecessary

based

throughout

is feeling and thinking,

information

and

care

for a patient

provides

how that person

causes

The Nurse as Manager The

which

two, eg the administration

be capitalised

organised

using

of shared responsibility so that holidays, sickness and the like can be accommo-

This also gives the opportunity

to be relieved

who may grieve for patients

caring

eg turning

The management

assumes

dated.

to know the person and his family well and many hours, sometimes over a period of or months,

tasks

a way

upon a cycle of assessment, planning, implementation and evaluation. A natural extension to this

the

consciousness

to find

those

nurse alloca-

such

it and has taken

regains

in

opportunity

of observation

angry

Unprepared

psychiatric and

who

After hours

a 1 : I nurse/patient

this. Further,

the nurse’s

her. This can be illustrated

of a patient

of drugs.

supportive

perceives

age than The type

organised

two nurses,

can then

also between

as she

require drugs.

of them.

can be conflict

interests

while concentrat-

of

Henderson

characteristic’.

requiring

policy states requires

this often in difficult

nursing.

in a technological

facilitates

1984). She has to accomplish

There

it.

of the dual aspects

of

administrative

accommodate

ing on several

she performs

( 1980 : 250) argues that patient-assignment rather than task assignment ‘would do more to preserve any other

the situation

psychological

circumstances,

in which

Management of Patient Care The organisation of patient care can be a factor

psychological care during illness or critical events’ is a key function in nursing (Wilson-Barnett, and demanding

eg of she is and

cardiac

a great

provision

she occupies,

experience

she

in a conventional

She has to manipulate

that

that

time

to lie flat

type.

to patients

to respond

the team

machine

from nurse to patient

nurse often has to communicate

more than information

care and of the unit itself. It is likely that

the role within

sister or staff nurse, determines which aspect most concerned with and her personality

his

him

in her study

communication

patient

183

NURSING

that he does

observe

encourages

at

him that all is well. As in the example

most verbal ICU

and

At the same

and

then

is his

information

line, ensure

himself

as she

What

to sit up,

him

tube

for him.

the arterial

extubate

rhythm

give

endotracheal

is breathing

might

has no voice.

he will attempt

nurse

the

that

but

CARE

particular

from

looking

after

for a nurse a patient

stress. This is especially

who

relevant

as stress is a well recognised phenomenon among nurses (Hay & Oken, 1972; Cassem & Hackett, 1975)

as

well

as

patients

on

ICU.

Nursing

management to help reduce or cope with this is an individual and a collective responsibility.

Management of the Unit This encompasses many factors

including

staff:

184

INTENSIVE

other

resources,

patients, the

of stress

rather

and

and

innovation

help from senior assistance provision

morale

ICU,

unlike patients

evidence

where

many ward

nurses,

in whom

there This,

mortality

and on

long hours

is little

tangible

in addition

nurses

for

alike.

For

are the impact

threatening plexity

nature

that

sick,

orientation,

education

tion of work

with

to meet

accept

her

ofsome

and

the stress.

responsibility

with

A cohesive

are

and

support

to ICU

and

many

can

Accomplished

of

team, alloca-

supervision

needs

for caring

and

nurses

during

emerges

It is important involved

in the

sented or

that, wider

are kept

ofgive

and take

on planning

clinical

involved

teams

nurse in

and

decisions policy,

to this nurses

organisation,

are

by experienced

about and

sisters and

equipment,

forward

are

repre-

specialists/managers,

unit

planning

of

care facilities (Schultz, 1980). This, not as ‘sleeping partners’, but as an equal with

doctors,

administrators

and other

members

of the

team.

nurse can also suffer stress and

consideration

that

ability.

Accountability

1982). The

to be cognisant

to crisis

staff are

they

of the unit,

without

exposure

cited periods

complementary

management

on

precipitate

quiescent

situation

vation might

staff.

are given the opportunity

Accountability A discussion such as this would

needs

to be

of the

as to whether

long exposure can lead to ‘burn-out’. This is characterized by disillusionment and loss of motiICU

has

with peaks already

(ensuring

A flexible

day-to-day

patient merely

must

calls

adaptability

elsewhere

unexpected

workload

the pressures

and

A variable

additional

is to be recommended.

planning

(Orlowski,

the

organisation

itself.

requires

or, alternatively,

design

for their less expert

the

periods

on relief

help

colleagues. The experienced

who have

& Eisendrath,

as resuscitation

encountered,

suffiall

involves

with

the vexed question

the lifethe rom-

appropriate

nurse’s

busy

to recuperate.

working

to a ward

can help improve

The erratic

troughs

busy)

procedures,

in communicating

to consider.

alleviate

illnesses,

of

or from

to full life. In

(Dunkel

of the unit

work

such

on ICU

new

also

accommodated.

inexper-

of the environment, of people’s

the patients

cient

and

the nurse

and unfamiliarity

the difficulties

the work

experienced

of

demands

sent

stress

a span

patient,

past patients

nurse

administration

During

to the

critically

during

and return

about

of the ICU

Management pattern

spends

feedback

she

1983).

the

nurse

when

for example

progress

their usual lifestyle

morale

stress include of stress

breaks

of

level of

in the form of

a particular

environment,

resumed

and

The

from

patients

can

of the

It has to be recognised ienced

ICU

which

of duty-.

acknowledging

additional

any event

before

stress.

promotes there

factors

at times

spans

and

are well

recognised

and reduce

of progress.

morbidity causes

the

by

allocation

to the nurse’s

relief. This may be provided

where

they need it. Furtherare

breaks

prolonged

with

removal

decision-making

Additional

of extra

during

help,

duty,

care are easily able to ask for

is sought.

help promote

extra

indi-

by sensitive

attention

and

experience,

style is likely to

is promoted

of staff

can be reduced paying

needs

and change

staff when

needs

problems patients

a

Thus

1980).

an atmosphere

nurses giving bedside the

an effect

staff.

group

(Henderson,

In this climate

more

among

of

style of

care as well as encourage

initiative staff

received

of groups

so on. The

than autocratic

patient

among

and

in the unit may well have

democratic vidual

organisation

policies

levels

facilitate

NURSING

the

setting

management on

CARE

this. and

These death,

manager

nurse

of the factors include fatigue

constant caused

by

overwork, the technological enviroment of ICU and the situations that threaten the nurse’s feelings of competence (Phillips et al., 1983). The nurse manager can help reduce this by ensuring that staffing levels are adequate to meet the demands of the workload. Some of the nurse’s

work

and/or

decisions

of the is being about

not be complete issue

of account-

answerable work

and

for being

professionally responsible for the standard of practice in relation to relevant advances in nursing and research (RCN, 198 1). Therefore, to be accountable the nurse has to have authority to act, at least a degree ofautonomy, and knowledge on which to base her decisions and exercise discretion.

The

nurse

owes accountability

to her

INTENSIVE

patients,

to her colleagues,

to the profession

and to

Similarly

the nurse

assists

the public.

understanding information,

for example

The Nurse as Teacher

observations,

can be given

The

nurse

relation

has

to patient

Following ment

each

every

and

qualified

reasonable

improve

responsibilities staff

in

development.

nurse

ability

as she should

opportunity

professional

and vigilance

presence

and

com-

Patient Care one basis,

is a component

role

in respect

Mention

non-formal

has already

munication

and

with

and

been

patients.

an ENB

clinical

their

made

relatives.

of nurse’s

com-

Communication

with

learners

ICU

life, likes and dislikes,

1983).

This,

hurt

should

nurse

care

relatives role

for

the

her clinical by meeting information,

their

needs

support

problems

member

is reduced and

the

and giving

care

therapy,

(2)

and

nurse,

assistance

by using this

anxiety, with

any

ofco-operation

relatives,

providing

repeating

also

have

them the freedom

to

express their feelings of shock and grief. Relatives need to learn from nurses how to develop their skills, for example in communicating ventilated patient. The nurse is involved

with a in giving

relatives an opportunity to understand what is happening, to know what they can do for the patient, and in helping them to accomplish it.

of design

intensive these,

relationships

and

with

with

colleagues.

understanding

organisation

and

unit,

‘At

the

end

and

teaching

is of

of the

the nurse will have an understanding of learning

the

apprecia-

an

The fifth and final ob.jective here:

the She

of the

of the

of an ITU,

relevance

methods

and

(3 J in communication

(4) an

and

on

total

observations,

interpreting

should

a

of com-

(1 in giving

undergoing

good

as

of the nurse

clinical

his family

to all

well

the areas

to patients making

perma-

The objectives

in

and

tion of research.

The as

required

in establishing

particular

nurses

commitment

100 illustrate

action,

course

Care.

colleagues

measurements,

ofthe and will

be able to pass on skills and knowledge

effectively

to staff (ENB, undated). responsibility to teach

ICX

members

it as

her

patient

basic

1983). The

to

appropriate

principles

also be

pupil

of the Professional

that she be skilled

nursing

taking

and/or

for parts

knowledge

namely

may

& Gibbons,

information,

and nurses and the

in Intensive

Course

management

facilitates

with

often as necessary,

towards

from

by meeting

and relatives,

such as the avail-

for her own learning.

and

they are able

expertise,

an atmosphere

often

The

for relief

nurse can generate them with up-to-date

The

petence

taking

the

of helplessness

care.

and

(Bozett

help

as a person.

feelings

and teaching

to greater

also

can play a sigificant

support

their

her

can

family

in physical

or a

& Eisendrath,

expose die,

patient

psychological

to reduce

to intubation

in ICU

their

at a time when

(Dunkel

it can

patient

If their anxiety

participating

family

while the

in assisting

to give

state.

of a patient

recovery. able

to do so due

in an reassur-

equipment.

nurse has a teaching

responsibility

personality,

physical

of

1983), and may also be used for for qualified nurses following

Course and

for ENB

he is unable

ofdoctors

training

nent ICU

relativ,es is vital. They can help the nurse get to know the patient by giving a picture of him, his

weakened

aspects

Staff Development Some units have student Register (UKCC, clinical experience

on a one-to-

of the nurse’s

of patients

is givren

environment

for patients

of monitoring

undertaking usually

the frequency

to maintain

knowledge

petenc,e’.

Teaching,

hostile positive

an

Specific

to try to allay miscon-

the ICU

than

to gain

care.

information

to render

ing rather

has a commit-

learning

Detailed

attempt

and

about

18.5

NURSING

the patient

of his illness

by emphasising

(1984: 2) Code of Professio-

to her own continued

‘take and

care

the UKCC

nal Conduct

ceptions.

wide-ranging

CARE

who

of those

might

The nurse on all staff that

disciplines

not normally

expect

such

has a includes

as medicine

to learn

from

a

nurse.

The Nurse’s Extended Role The

nurse’s

role is continuously

developing

and

new skills, which might more conveniently be performed by nurses, are constantly added to her normal ranges of duties. The lines between medi-

186

INTENSIVE

CARE

NURSING

tine and nursing

can thus become

blurred

these

as often

established extending

medical

functions.

In

role is very apparent

such as the administration venepuncture

and

These functions

increasingly

tasks are derived

from

ICU

this

with examples

of intra-venous

emergency

drugs,

defibrillation.

are not incorporated

into basic

nurse training and therefore the nurse cannot as a matter of course undertake can be extended

them. The nurse’s role

however if:

the nurse has been specifically

and adequately

trained to perform the new task and agrees to undertake

it

this training has been recognised as satisfactory by the employing the

new

task

authority by

the

professions and by the employing authority

as a

task which

has

been

recognised

may be properly

delegated

to a

nurse the delegating competence

doctor had been assured of the

of the individual

nurse concerned

(Young, In response locally

to these needs,

organised

by experience

training

there

1981: 167) is usually

programme

a

followed

and assessment of competence.

CONCLUSION In conclusion, ICU

it can be stated that the nurse on

functions

independently

and interdepen-

dently. She manipulates the diverse elements of her role, working within a difficult and complex environment

in order to provide the best possible

care for the critically sick, their relatives and friends. These people are, after all, her ‘raison d’etre’.

References Ashworth P M 1980 Care of Nursing, London

to Communicate,

Royal

College

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