EDITORIAL doi: 10.1111/nicc.12061
What’s in this issue? This issue brings together a group of papers that explore aspects of caring. In my editorial I examine the issues associated with resilient practice. Much is written about resilience, especially in the light of criticisms over standards of care. I argue to sustain practice of the highest standards, fostering compassion and care and we have to take care of colleagues and ourselves. In the past responsibility for resilient practice has been left to the individual. However, I argue we should pay more attention to arrest stress and burnout experienced by our colleagues and offer some small changes that can make a big difference. This includes measures that build towards a collective responsibility to nurture resilient characteristics. Lin and Ringdal’s editorial argues for building a Community of Practice (CoP) in critical care nursing to facilitate the translation of research evidence into clinical practice. Communities of Practice are non-hierarchical groups who come together specifically to learn from one another. Learning and working together through challenges is one of the key characteristics of a resilient team. It counters isolation, ensures we can enlist help from others and celebrates the practice and academic knowledge that resides in our colleagues. The first paper demonstrates the use of the British Medical Research Council’s (MRC) framework by which a complex intervention can be evaluated. In this paper touch massage is the subject of evaluation. Lindgren et al. demonstrate how they generated a hypothesis out of a clinical understanding that touch massage could reduce stress, anxiety, lower blood pressure and heart rate. They describe how the MRC framework enables researchers to isolate the impact of a complex intervention. There are four stages to the process: development/feasibility, piloting,
evaluation and implementation. Their design included randomization of 20 patients postelective aortic surgery into an intervention (10) and a control arm (10). Practitioners trained in the art of massage undertook the intervention and pressure monitoring ensured consistency in the depth of touch applied to the intervention group. The patients in the control arm rested in the presence of a health care professional who was instructed not to speak to them. Feasibility and isolation of the outcome measures were undertaken on a group of healthy volunteers prior to the pilot study. From this they determined the following outcome measures: selfreported anxiety levels and biological markers of stress [time intervals between heart beats, heart rate variability (HRV), blood pressure, respiratory rate, oxygen saturation and serum levels of cortisol, insulin and glucose]. Their results upheld what clinicians had observed: that massage did significantly reduce self reported anxiety. However, the intervention group had significantly lower levels of stress than the control group prior to the intervention. The researchers concluded that this might be because they were positively anticipating the impact of massage. The biological markers showed no significant difference between the control and the intervention group. The researchers accounted for this by suggesting that massage dampens the physiological response to stress. What the researchers do not indicate was how much this evaluation cost, especially where this evaluation consolidated a previous study that included magnetic resonance imaging (MRI) of the brain to determine which regions were activated by massage. All good, robust science, but is this economically justifiable? Patient and public involvement in the steerage of such an evaluation would help to confirm the investment
© 2013 British Association of Critical Care Nurses • Vol 18 No 6
is considered worthwhile, timely and provide long-term benefits to patients. Price’s paper summarizes the findings of an ethnographic study that revisits the impact of technology on caring in critical care. This is a timely paper that corresponds with the new initiative launched by the Chief Nurse in the United Kingdom in response to high profile cases reporting poor standards of care in the heath and social care sector. This has resulted in the British media being openly critical of nurses. Cummings (2013) remedy are the six Cs: care, compassion, competence, courage, communication and commitment, core values and behaviours that she feels will help with the re-examination of practice and as a consequence the restoration of consistent high quality care. Price concludes that caring and technology are inextricably linked and that the culture of the unit frames the way in which competence is performed. The limits of the literature search are not included in her paper and that may account for why some of her claims do not fully take into account research that precedes her own, notably the ‘focus of attention’ and how this corresponds to the concept of ‘noticing’ made explicit in the seminal work of Martha McLeod (1994) and Christine Tanner’s (2006), alongside the research undertaken by Benner and her colleagues. The next three papers pull together a sub-theme of exploring patients’ and relatives’ experiences and perspectives. The first of these by Cullinane and Plowright is a summary of the literature on patients’ and relatives’ experiences of transfer from ICUs (intensive care units) to the wards. Further, the insecurity patients’ and relatives’ experience when they leave ICU and step down from one to one nursing is only minimally offset by the relief and hope signalled by that step down and 261
Editorial
indication that they are on the road to recovery. The time for patients and relatives to adjust to these changes is often short exacerbating the feelings of anxiety. Cullinane and Plowright suggest the use of patient diaries, information leaflets explaining the procedure and links to others’ experiencing similar events through websites run by ICU steps and the Intensive Care Society. These suggestions are practical and helpful but can only support the presence of the nurse who co-ordinates the transfer and the genuine warmth and assurance of competence provided by the nurse receiving the patent and their relatives. James et al. provide us with important insight into the staff’s experience of transferring patients from ICU. Importantly, they highlight the criticality of timing a transfer, and the disparity in what ward staff want to know about a patient and what ICU nurses feel they should communicate. Practice in the different environments means the landscape of risk about what needs to be known and the priorities for certain information are distinct. The example the authors cite is the ward staff’s need to know the extent to which a patient can self-care while the ICU nurse is interested in communicating the severity of illness and any indicators of deterioration. Clearly, there is a need to ensure the time of a patient’s discharge allows for effective communication, but as we are all aware, the urgency of transferring a patient can be dictated by demands for an ICU bed or the business of the ward. With this in mind effective mechanisms for hand over need to be devised in collaboration with both ward and ICU
262
staff engaging in the development of efficient and effective materials to supplement a verbal handover. All this is critical to ensure patient safety and to enhance the well-being of the patients and their relatives. The final paper by Gelinas et al. explores patients’ and ICU nurses’ perceptions of non-medication pain management strategies. These strategies focus on the cognitive, emotional and physical interventions that can enhance comfort and well-being of the patient. The list of 33 alternatives to drug treatment is creative and draws upon diverse techniques and therapies. Once again the difference in the priorities given to the various alternative treatments stated by patients and ICU nurses differed. Patients and their relatives talked of active listening, reality orientation and help with communicating while ICU nurses highlighted positioning and the acquisition of new competencies to enable them to provide a wider range of options. One of the recommendations was the importance of massage and the impact on relief of anxiety. This brings us full circle back to the first paper and Lindgren et al.’s quest to determine the efficacy of massage to relive anxiety and stress. The papers in this issue celebrate what nurses do best, that is to translate their considerable knowledge and expertise into care that is delivered with compassion and concern to ensure the best outcome for our critical care patients and their relatives.
REFERENCES Cummings J. (2013). 6 C’s http://www.engl and.nhs.Uk/tag/6cs/ (accessed 18/09/13). Benner P, Tanner C, Chesla C. (2009). Expertise in Nursing Practice, Second Edition: Caring, Clinical Judgment, and Ethics (2nd Edition) New York: Springer Publishing. Cullinane JP, Plowright CI. (2013). Patients’ & relatives’ experiences of transfer from ICU to wards. Nursing in Critical Care; 18: 289–296. Gelinas C, Arbour C, Michaud C, Robar L, Cote J. (2013). Patients and ICU nurses’ perspectives of non-pharmacological interventions for pain management. Nursing in Critical Care; 18: 307–318. James S, Quirke S, McBride-Henry K. (2013). Staff perception of patient discharge from ICU to Ward-based care. Nursing in Critical Care; 18: 297–306. Lin F, Ringdal M. (2013). Building a community of practice in critical care nursing. Nursing in Critical Care; 18: 266–268. Lindgren L, Lehtipalo S, Winso O, Karlsson M, Wiklund U, Brulin C. (2013). Touch massage: a pilot study of a complex intervention. Nursing in Critical Care; 18: 269–277. Mcleod M. (1994). ‘It’s the little things that count’: the hidden complexity of everyday clinical nursing practice. Journal of Clinical Nursing; 3: 361–368. DOI: 10.1111/j.13652702.1994.tb00413.x. Price AM. (2013). Caring and technology in an intensive care unit: an ethnographic study. Nursing in Critical Care; 18: 278–288. Richardson A. (2013). A newly elected BACCN Chair. Nursing in Critical Care; 18: 319–322. Scholes J. (2013). Building emotional resilience: small steps towards big change. Nursing in Critical Care; 18: 263–265. Tanner C. (2006). Thinking like a nurse: a research-based model of clinical judgment in nursing. Journal of Nursing Education 45, 204–211. http://jxzy.smu. edu.cn/jkpg/UploadFiles/file/TF_069281 0354_thinking%20like%20a%20nurse.pdf (accessed 18/09/13).
Julie Scholes Co-editor, Nursing in Critical Care
© 2013 British Association of Critical Care Nurses
What’s in this issue? This issue brings together a group of papers that explore aspects of caring. In my editorial I examine the issues associated with resilient practice. Much is written about resilience, especially in the light of criticisms over standards of care. I argue to sustain practice of the highest standards, fostering compassion and care and we have to take care of colleagues and ourselves. In the past responsibility for resilient practice has been left to the individual. However, I argue we should pay more attention to arrest stress and burnout experienced by our colleagues and offer some small changes that can make a big difference. This includes measures that build towards a collective responsibility to nurture resilient characteristics. Lin and Ringdal’s editorial argues for building a Community of Practice (CoP) in critical care nursing to facilitate the translation of research evidence into clinical practice. Communities of Practice are non-hierarchical groups who come together specifically to learn from one another. Learning and working together through challenges is one of the key characteristics of a resilient team. It counters isolation, ensures we can enlist help from others and celebrates the practice and academic knowledge that resides in our colleagues. The first paper demonstrates the use of the British Medical Research Council’s (MRC) framework by which a complex intervention can be evaluated. In this paper touch massage is the subject of evaluation. Lindgren et al. demonstrate how they generated a hypothesis out of a clinical understanding that touch massage could reduce stress, anxiety, lower blood pressure and heart rate. They describe how the MRC framework enables researchers to isolate the impact of a complex intervention. There are four stages to the process: development/feasibility, piloting,
evaluation and implementation. Their design included randomization of 20 patients postelective aortic surgery into an intervention (10) and a control arm (10). Practitioners trained in the art of massage undertook the intervention and pressure monitoring ensured consistency in the depth of touch applied to the intervention group. The patients in the control arm rested in the presence of a health care professional who was instructed not to speak to them. Feasibility and isolation of the outcome measures were undertaken on a group of healthy volunteers prior to the pilot study. From this they determined the following outcome measures: selfreported anxiety levels and biological markers of stress [time intervals between heart beats, heart rate variability (HRV), blood pressure, respiratory rate, oxygen saturation and serum levels of cortisol, insulin and glucose]. Their results upheld what clinicians had observed: that massage did significantly reduce self reported anxiety. However, the intervention group had significantly lower levels of stress than the control group prior to the intervention. The researchers concluded that this might be because they were positively anticipating the impact of massage. The biological markers showed no significant difference between the control and the intervention group. The researchers accounted for this by suggesting that massage dampens the physiological response to stress. What the researchers do not indicate was how much this evaluation cost, especially where this evaluation consolidated a previous study that included magnetic resonance imaging (MRI) of the brain to determine which regions were activated by massage. All good, robust science, but is this economically justifiable? Patient and public involvement in the steerage of such an evaluation would help to confirm the investment
© 2013 British Association of Critical Care Nurses • Vol 18 No 6
is considered worthwhile, timely and provide long-term benefits to patients. Price’s paper summarizes the findings of an ethnographic study that revisits the impact of technology on caring in critical care. This is a timely paper that corresponds with the new initiative launched by the Chief Nurse in the United Kingdom in response to high profile cases reporting poor standards of care in the heath and social care sector. This has resulted in the British media being openly critical of nurses. Cummings (2013) remedy are the six Cs: care, compassion, competence, courage, communication and commitment, core values and behaviours that she feels will help with the re-examination of practice and as a consequence the restoration of consistent high quality care. Price concludes that caring and technology are inextricably linked and that the culture of the unit frames the way in which competence is performed. The limits of the literature search are not included in her paper and that may account for why some of her claims do not fully take into account research that precedes her own, notably the ‘focus of attention’ and how this corresponds to the concept of ‘noticing’ made explicit in the seminal work of Martha McLeod (1994) and Christine Tanner’s (2006), alongside the research undertaken by Benner and her colleagues. The next three papers pull together a sub-theme of exploring patients’ and relatives’ experiences and perspectives. The first of these by Cullinane and Plowright is a summary of the literature on patients’ and relatives’ experiences of transfer from ICUs (intensive care units) to the wards. Further, the insecurity patients’ and relatives’ experience when they leave ICU and step down from one to one nursing is only minimally offset by the relief and hope signalled by that step down and 261
Editorial
indication that they are on the road to recovery. The time for patients and relatives to adjust to these changes is often short exacerbating the feelings of anxiety. Cullinane and Plowright suggest the use of patient diaries, information leaflets explaining the procedure and links to others’ experiencing similar events through websites run by ICU steps and the Intensive Care Society. These suggestions are practical and helpful but can only support the presence of the nurse who co-ordinates the transfer and the genuine warmth and assurance of competence provided by the nurse receiving the patent and their relatives. James et al. provide us with important insight into the staff’s experience of transferring patients from ICU. Importantly, they highlight the criticality of timing a transfer, and the disparity in what ward staff want to know about a patient and what ICU nurses feel they should communicate. Practice in the different environments means the landscape of risk about what needs to be known and the priorities for certain information are distinct. The example the authors cite is the ward staff’s need to know the extent to which a patient can self-care while the ICU nurse is interested in communicating the severity of illness and any indicators of deterioration. Clearly, there is a need to ensure the time of a patient’s discharge allows for effective communication, but as we are all aware, the urgency of transferring a patient can be dictated by demands for an ICU bed or the business of the ward. With this in mind effective mechanisms for hand over need to be devised in collaboration with both ward and ICU
262
staff engaging in the development of efficient and effective materials to supplement a verbal handover. All this is critical to ensure patient safety and to enhance the well-being of the patients and their relatives. The final paper by Gelinas et al. explores patients’ and ICU nurses’ perceptions of non-medication pain management strategies. These strategies focus on the cognitive, emotional and physical interventions that can enhance comfort and well-being of the patient. The list of 33 alternatives to drug treatment is creative and draws upon diverse techniques and therapies. Once again the difference in the priorities given to the various alternative treatments stated by patients and ICU nurses differed. Patients and their relatives talked of active listening, reality orientation and help with communicating while ICU nurses highlighted positioning and the acquisition of new competencies to enable them to provide a wider range of options. One of the recommendations was the importance of massage and the impact on relief of anxiety. This brings us full circle back to the first paper and Lindgren et al.’s quest to determine the efficacy of massage to relive anxiety and stress. The papers in this issue celebrate what nurses do best, that is to translate their considerable knowledge and expertise into care that is delivered with compassion and concern to ensure the best outcome for our critical care patients and their relatives.
REFERENCES Cummings J. (2013). 6 C’s http://www.engl and.nhs.Uk/tag/6cs/ (accessed 18/09/13). Benner P, Tanner C, Chesla C. (2009). Expertise in Nursing Practice, Second Edition: Caring, Clinical Judgment, and Ethics (2nd Edition) New York: Springer Publishing. Cullinane JP, Plowright CI. (2013). Patients’ & relatives’ experiences of transfer from ICU to wards. Nursing in Critical Care; 18: 289–296. Gelinas C, Arbour C, Michaud C, Robar L, Cote J. (2013). Patients and ICU nurses’ perspectives of non-pharmacological interventions for pain management. Nursing in Critical Care; 18: 307–318. James S, Quirke S, McBride-Henry K. (2013). Staff perception of patient discharge from ICU to Ward-based care. Nursing in Critical Care; 18: 297–306. Lin F, Ringdal M. (2013). Building a community of practice in critical care nursing. Nursing in Critical Care; 18: 266–268. Lindgren L, Lehtipalo S, Winso O, Karlsson M, Wiklund U, Brulin C. (2013). Touch massage: a pilot study of a complex intervention. Nursing in Critical Care; 18: 269–277. Mcleod M. (1994). ‘It’s the little things that count’: the hidden complexity of everyday clinical nursing practice. Journal of Clinical Nursing; 3: 361–368. DOI: 10.1111/j.13652702.1994.tb00413.x. Price AM. (2013). Caring and technology in an intensive care unit: an ethnographic study. Nursing in Critical Care; 18: 278–288. Richardson A. (2013). A newly elected BACCN Chair. Nursing in Critical Care; 18: 319–322. Scholes J. (2013). Building emotional resilience: small steps towards big change. Nursing in Critical Care; 18: 263–265. Tanner C. (2006). Thinking like a nurse: a research-based model of clinical judgment in nursing. Journal of Nursing Education 45, 204–211. http://jxzy.smu. edu.cn/jkpg/UploadFiles/file/TF_069281 0354_thinking%20like%20a%20nurse.pdf (accessed 18/09/13).
Julie Scholes Co-editor, Nursing in Critical Care
© 2013 British Association of Critical Care Nurses
