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Who does what in critical care?
EDITORIAL
Who does what in critical care?
It is sometimes said that when the United States (USA) sneezes the United Kingdom (UK) catches a cold, and certainly ideas cross the Atlantic. Now in the USA nurse practitioners are increasingly beginning to appear in critical care; with the definition: ‘The critical care nurse practitioner is a masters prepared nurse who has primary responsibility for advanced assessment and management of patients throughout the illness, with specialised skills in critical care’ (Keane & Kaiser 1994). According to the same source their responsibilities include intensive care unit admission and discharge, undertaking histories and physical examinations, evaluating clinical data and prescribing treatment, and using invasive procedures, as well as those more traditionally within nursing such as work with families and coordination. The impetus for this innovation comes from the need for costcutting in health care and the reduced availability ofjunior doctors due to cuts in their numbers and hours of work. Sounds familiar? So far the focus in the UK has been on changing the skill mix by introducing health care assistants and reducing the numbers of nurses, and encouraging nurses to take on some tasks previously done by doctors. In critical care areas sometimes numbers have been reduced, but sometimes the skill mix (not grade mix) has been changed less obviously by deliberately filling vacancies with inexperienced nurses - because they are cheaper (or appear so unless effectiveness of care is considered), and at the same time nurses are expected to take on more tasks. Nurse practitioners are increasingly appearing in some other areas of nursing in the UK and no doubt before long someone will want to have them in critical care, and as in the USA this will cause considerable debate. But the time for debate is now, so that any changes can be envisioned, deliberately planned
and prepared for - rather than just coping with them when they happen. It is important for experienced critical care nurses to free their minds from rigid constraints of what has been and is, and to envision what might be in a service designed to respond to patients’ needs. Who should do what, and why, and what are the implications? What should be the skill mix, and why? It is also important to discuss these visions with nonnursing colleagues, since collaboration and acceptance of some flexibility of the boundaries of professional function will always be essential for good patient care. Critical care nurses have long been accustomed to taking on new functions and responsibilities, for various reasons, and many no doubt have the potential to do much more (if time allows). The crucial question is whether to do so and why, and with what benefit and for whom; and equally important, how to achieve any necessary changes. It is fortunate that a number of nurses are now armed, usually with the benefit of higher education, with the intellectual skills to gather, analyse, evaluate and synthesise relevant information to develop an informed viewpoint; and to make a strong case well supported by available evidence to those who hold power over resources and have alternative points of view. They can help other nurses to do so. Years of seeing qualified, and not always young, nurses blossom when challenged by well-focused higher education have convinced me that this is often the key to unlocking the huge potential that many nurses have to improve not only their practice but also decision-making about the nature and scope of it, and how to work towards making their visions reality in times of turbulent change. Health professionals who work in critical care should be best fitted to decide who should do what in it, and how to achieve high quality care 163
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INTENSIVE AND CRITICAL CARE NURSING
within available resources, and nurses must play their full part in the decisions and implementation. But the ‘powers-that-be’ who want more costeffectiveness from nurses must remember the saying ‘Give us the tools and we’ll finish the job’ (and the tools include intellectual skills as well as psy-
chomotor ones), and offer more educational opportunities to qualified nurses as well as preregistration students. In the meantime the debate must go on. PAT ASHWORTH
Who does what in critical care?
It is sometimes said that when the United States (USA) sneezes the United Kingdom (UK) catches a cold, and certainly ideas cross the Atlantic. Now in the USA nurse practitioners are increasingly beginning to appear in critical care; with the definition: ‘The critical care nurse practitioner is a masters prepared nurse who has primary responsibility for advanced assessment and management of patients throughout the illness, with specialised skills in critical care’ (Keane & Kaiser 1994). According to the same source their responsibilities include intensive care unit admission and discharge, undertaking histories and physical examinations, evaluating clinical data and prescribing treatment, and using invasive procedures, as well as those more traditionally within nursing such as work with families and coordination. The impetus for this innovation comes from the need for costcutting in health care and the reduced availability ofjunior doctors due to cuts in their numbers and hours of work. Sounds familiar? So far the focus in the UK has been on changing the skill mix by introducing health care assistants and reducing the numbers of nurses, and encouraging nurses to take on some tasks previously done by doctors. In critical care areas sometimes numbers have been reduced, but sometimes the skill mix (not grade mix) has been changed less obviously by deliberately filling vacancies with inexperienced nurses - because they are cheaper (or appear so unless effectiveness of care is considered), and at the same time nurses are expected to take on more tasks. Nurse practitioners are increasingly appearing in some other areas of nursing in the UK and no doubt before long someone will want to have them in critical care, and as in the USA this will cause considerable debate. But the time for debate is now, so that any changes can be envisioned, deliberately planned
and prepared for - rather than just coping with them when they happen. It is important for experienced critical care nurses to free their minds from rigid constraints of what has been and is, and to envision what might be in a service designed to respond to patients’ needs. Who should do what, and why, and what are the implications? What should be the skill mix, and why? It is also important to discuss these visions with nonnursing colleagues, since collaboration and acceptance of some flexibility of the boundaries of professional function will always be essential for good patient care. Critical care nurses have long been accustomed to taking on new functions and responsibilities, for various reasons, and many no doubt have the potential to do much more (if time allows). The crucial question is whether to do so and why, and with what benefit and for whom; and equally important, how to achieve any necessary changes. It is fortunate that a number of nurses are now armed, usually with the benefit of higher education, with the intellectual skills to gather, analyse, evaluate and synthesise relevant information to develop an informed viewpoint; and to make a strong case well supported by available evidence to those who hold power over resources and have alternative points of view. They can help other nurses to do so. Years of seeing qualified, and not always young, nurses blossom when challenged by well-focused higher education have convinced me that this is often the key to unlocking the huge potential that many nurses have to improve not only their practice but also decision-making about the nature and scope of it, and how to work towards making their visions reality in times of turbulent change. Health professionals who work in critical care should be best fitted to decide who should do what in it, and how to achieve high quality care 163
164
INTENSIVE AND CRITICAL CARE NURSING
within available resources, and nurses must play their full part in the decisions and implementation. But the ‘powers-that-be’ who want more costeffectiveness from nurses must remember the saying ‘Give us the tools and we’ll finish the job’ (and the tools include intellectual skills as well as psy-
chomotor ones), and offer more educational opportunities to qualified nurses as well as preregistration students. In the meantime the debate must go on. PAT ASHWORTH