Maureen Coombs

Power and conflict in intensive care clinical decision making.

It is clear that current government policy places increasing emphasis on the need for flexible team working. This requires a shared understanding of roles and working practices. However, review of the current literature reveals that such a collaborative working environment has not as yet, been fully achieved. Role definitions and power bases based on traditional and historical boundaries continue to exist. This ethnographic study explores decision making between doctors and nurses in the intensive care environment in order to examine contemporary clinical roles in this clinical specialty. Three intensive care units were selected as field sites and data was collected through participant observation, ethnographic interviews and documentation. A key issue arising in this study is that whilst the nursing role in intensive care has changed, this has had little impact on how clinical decisions are made. Both medical and nursing staff identify conflict during patient management discussions. However, it is predominantly nurses who seek to redress this conflict area through developing specific behaviours for this clinical forum. Using this approach to resolve such team issues has grave implications if the government vision of interdisciplinary team working is to be realised.

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.

Objective: To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. Methods: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development. Results: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice. Conclusions: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.

Crossing boundaries, re‐defining care: the role of the critical care outreach team

• There is clear indication that both government and professional policy in the United Kingdom supports a radical change in the role of healthcare practitioners, with a move towards a patient-focused service delivered by clinical teams working effectively together. • Recent health service imperatives driving the agenda for flexible clinical teams have occurred simultaneously with an increased public and political awareness of deficits in availability of critical care services. • Against this policy backdrop, working across professional and organizational boundaries is fundamental to supporting quality service improvements. In the acute care sector, the development of critical care outreach teams is an innovation that seeks to challenge the traditional support available for sick ward patients. • Activity data and observations from the first 6-month evaluation of two critical care outreach teams identify the need for clinical support and education offered by critical care practitioners to ward-based teams. • The experiences from such flexible clinical teams provides a foundation from which to explore key issues for intradisciplinary and interdisciplinary working across clinical areas and organizational boundaries. • Adopting innovative approaches to care delivery, such as critical care outreach teams, can enable clinical teams and NHS trusts to work together to improve the quality of care for acutely ill patients, support clinical practitioners working with this client group, and develop proactive service planning.

Challenges in transition from intervention to end of life care in intensive care: a qualitative study

BACKGROUND Providing quality end of life care is a challenging area in intensive care practice. The most demanding aspect for doctors and nurses in this setting is not the management of care at end of life per se, but facilitating the transition from active intervention to palliation and finally, end of life care. Whilst there is understanding about some aspects of this transition, recognition of the complex and inter-related processes that work to shift the patients trajectory from cure to end of life care is required. This is important in order to work towards solutions for issues that continue to pose problems for health care professionals. OBJECTIVES To identify the challenges for health care professionals when moving from a recovery trajectory to an end of life trajectory in intensive care. DESIGN Qualitative methods of enquiry. METHODS AND SETTING Single semi-structured interviews with 13 medical staff and 13 nurses associated with 17 decedents who underwent treatment withdrawal in intensive care were carried out. Participants were drawn from two Intensive Care Units in a large university-affiliated hospital in England. FINDINGS Patients who died in intensive care appeared to follow a three-stage end of life trajectory: admission with hope of recovery; transition from intervention to end of life care; a controlled death. The transition from intervention to end of life care was reported as being the most problematic and ambiguous stage in the end of life trajectory, with potential for conflict between medical teams, as well as between doctors and nurses. CONCLUSIONS End of life care policy emphasises the importance of end of life care for all patients regardless of setting. These findings demonstrate that in intensive care, there is need to focus on transition from curative intervention to end of life care, rather than end of life care itself so that effective and timely decision making underpins the care of the 20% of intensive care patients who die in this setting each year.

Conversations in end-of-life care: communication tools for critical care practitioners

BACKGROUND Communication skills are the key for quality end-of-life care including in the critical care setting. While learning general, transferable communication skills, such as therapeutic listening, has been common in nursing education, learning specific communication tools, such as breaking bad news, has been the norm for medical education. Critical care nurses may also benefit from learning communication tools that are more specific to end-of-life care. STRATEGY We conducted a 90-min interactive workshop at a national conference for a group of 78 experienced critical care nurses where we presented three communication tools using short didactics. We utilized theatre style and paired role play simulation. The Ask-Tell-Ask, Tell Me More and Situation-Background-Assessment-Recommendation (SBAR) tools were demonstrated or practiced using a case of a family member who feels that treatment is being withdrawn prematurely for the patient. The audience actively participated in debriefing the role play to maximize learning. The final communication tool, SBAR, was practiced using an approach of pairing with another member of the audience. At the end of the session, a brief evaluation was completed by 59 nurses (80%) of the audience. SUMMARY These communication tools offer nurses new strategies for approaching potentially difficult and emotionally charged conversations. A case example illustrated strategies for applying these skills to clinical situations. The three tools assist critical care nurses to move beyond compassionate listening to knowing what to say. Ask-Tell-Ask reminds nurses to carefully assess concerns before imparting information. Tell Me More provides a tool for encouraging dialogue in challenging situations. Finally, SBAR can assist nurses to distill complex and often long conversations into concise and informative reports for colleagues.

Physical assessment skills: a developing dimension of clinical nursing practice.

This paper proposes that the current use of physical assessment skills within critical care nursing practice is part of a on-going nursing role development process. A review of the critical care nursing role highlights how nurses in this setting have always been responsive to patient management needs. In exploring one recent nursing role development, the critical care outreach nurse, it is suggested that enhanced assessment skills enable these practitioners to safely and competently assess critically ill patients out of the intensive care environment. The use of patient case studies in this paper, demonstrate how the theory of a more intensive physical assessment knowledge base can be applied in the everyday practice of an critical care outreach nurse. Through such systematic patient review, patient management plans can be agreed and ward based practitioners can be supported in the on-going treatment of sick ward patients. The use of the cases presented also highlights the complexity of the outreach nurses practice in addressing clinical management and team management issues.

Managing a good death in critical care: can health policy help?

AIM This paper discusses end-of-life care (EoLC) in critical care through exploration of what is known from the international literature and what is currently presented within UK policy. BACKGROUND AND CONTEXT EoLC is an important international critical care issue, and currently provides a key focus for health care policy in the UK. While society holds that critical care is delivered in a highly technical area with a strong focus on cure and recovery, mortality rates in this speciality remain at approximately 20%. When patient recovery is not an outcome, discussions with patient, family and extended care teams turn towards futility of treatment and end-of-life management. However, there are specific barriers to overcome in EoLC for the critically ill. CONCLUSION A key issue for EoLC in critical care is a lack of robust systems to prospectively identify individuals who are most at risk of dying. A further challenge is divergent perspectives within and across clinical teams on treatment withdrawal and limitation practices. To streamline patient management and underpin a hospice approach to care, EoLC policies are currently being used within the UK. While this provides a national framework to address some key critical care clinical issues in the UK, there is a need for further refinement of the tool to reflect the reality of EoLC for the critically ill. It is important that international best practice exemplars are examined and clinicians actively engage and contribute to ensure that any local EoLC frameworks are fit for purpose.

International dialogue on end of life: challenges in the UK and USA

AIM The aim of this paper was to increase international collaboration on end of life care (EoLC) in critical care. Objectives included highlighting key challenges for critical care nurses in EoLC through a transcribed interview between a clinician, an educationalist and a researcher who all hold an EoLC focus. BACKGROUND EoLC continues to hold high profile within international health care arenas, including critical care units. Whilst end of life care remains well debated, it still presents many challenges for everyday practitioners. Dialogue with international colleagues and disciplines may provide opportunity for further understanding of this complex and sensitive area. CONCLUSIONS A key issues to arise from this venture of shared learning was that futility of treatment is problematic for all. This is further complicated in the USA where the concept of (family) autonomy strongly shapes EoLC decision making. RELEVANCE TO CLINICAL PRACTICE This paper demonstrates that there are opportunities for nurses within health care teams which could be addressed through education and professional development initiatives. Furthermore, knowledge from other disciplines can provide a useful lens through which to improve our understanding of EoLC.

Doctors’ and nurses’ views and experience of transferring patients from critical care home to die: A qualitative exploratory study

Background: Dying patients would prefer to die at home, and therefore a goal of end-of-life care is to offer choice regarding where patients die. However, whether it is feasible to offer this option to patients within critical care units and whether teams are willing to consider this option has gained limited exploration internationally. Aim: To examine current experiences of, practices in and views towards transferring patients in critical care settings home to die. Design: Exploratory two-stage qualitative study Setting/participants: Six focus groups were held with doctors and nurses from four intensive care units across two large hospital sites in England, general practitioners and community nurses from one community service in the south of England and members of a Patient and Public Forum. A further 15 nurses and 6 consultants from critical care units across the United Kingdom participated in follow-on telephone interviews. Findings: The practice of transferring critically ill patients home to die is a rare event in the United Kingdom, despite the positive view of health care professionals. Challenges to service provision include patient care needs, uncertain time to death and the view that transfer to community services is a complex, highly time-dependent undertaking. Conclusion: There are evidenced individual and policy drivers promoting high-quality care for all adults approaching the end of life encompassing preferred place of death. While there is evidence of this choice being honoured and delivered for some of the critical care population, it remains debatable whether this will become a conventional practice in end of life in this setting.

The current role of the consultant nurse in critical care: consolidation or consternation?

BACKGROUND The consultant nurse role emerged into the National Health Service in 1999, presented against a backdrop of practice and service modernisation. As with any innovative development, the role was originally subject to much scrutiny with regards to impact and outcome. However, six years after its initial introduction, continued focus and support on this role is less visible. This paper presents a follow-up review of the role and function of consultant nurses in critical care, using an original survey tool that underpinned Dawson and McEwens work in 2003. From the results of the current study, key changes in role are identified and areas for further development are highlighted. AIMS To provide a contemporary profile of the consultant nurse in critical care. To identify changes in the consultant nurse role from 2003 to 2006. METHOD A national email survey of all known critical care nurse consultants in post in the United Kingdom was undertaken in October 2006. Using a validated survey tool originally used in 2003, a return rate of 73% (n = 47) was yielded. RESULTS Biographics of this survey reveal a static consultant nurse population with increasing length of tenure in post (mean = 60.2 months). There is no substantial increase in the size of the cohort since 2003. Postholders demonstrate advanced academic skills through higher degrees (94%) and carry a national and international profile through presentation and publication portfolios (92% national and 53% international presentation, 62% multi-authored publication, 47% single authored publication). The core role that consultant nurses in critical care engaged in is practice and service development (mean involvement score = 3.65), with expert practice holding least mean involvement scores (mean involvement score = 2.67). There is evidence of increasing use by these posts for strategic input at organisational/trust level. CONCLUSIONS This paper has identified ongoing strengths and limited developments of the consultant nurse in critical care role. Whilst it is clear that core role functions have not dramatically changed, there are demonstrable shifts towards more strategic engagement within Acute Care Trusts. This has brought about concerns regarding overall management of the role, and sustainability of postholders to balance this ever-increasing portfolio. It is also clear that there has been little new investment in this key leadership role, and this raises concerns as to the perceived contribution that experienced clinical nurses bring to a currently financially and operationally driven health service agenda.