Nick Bakalis

Fever effects and treatment in critical care: Literature review

Considering that the incidence of fever may reach up to 75% among critically ill adults, healthcare professionals employed in the Intensive Care Unit (ICU) are called to evaluate and manage patient temperature elevation on a daily basis. This literature review synthesizes the evidence about the effects of fever and antipyretic treatment in ICU patients. Although the febrile response acts protectively against infections, noxious effects are possible for patients with cerebral damage, neuropsychiatric disorders or limited cardiorespiratory reserve. Observational studies on ICU populations have reported associations between fever magnitude and patient mortality. Especially recent findings indicated that infected patients may significantly benefit from temperature elevation, while high fever may be maladaptive for non-infected ones. Aggressive antipyretic treatment of ICU patients has not been followed by decreased mortality in randomized trials. However, fever suppression and return to normothermia improved outcomes of septic shock patients. Antipyretic treatment should begin with drug administration and proceed with external cooling in case of refractory fever, but adverse effects of both antipyretic methods should always be considered. This article concludes by providing implications for antipyretic treatment of critically ill adults and suggesting areas for future research.

Knowledge of pulse oximetry: comparison among intensive care, anesthesiology and emergency nurses.

AIMS AND OBJECTIVES To evaluate pulse oximetry knowledge of nurses employed in the Intensive Care Unit (ICU), Anesthesiology Department (AD) and Emergency Department (ED) and to compare knowledge among these departments/units. BACKGROUND Although pulse oximetry has been widely used in clinical practice, previous studies have reported knowledge deficits among nurses, which may adversely affect patient outcomes. DESIGN   Prospective, cross-sectional, multicentre study. METHODS All nurses employed in the ICU, AD and ED of six hospitals were asked to complete in private a 21-item, knowledge-evaluating questionnaire, which was evaluated for content-related validity and reliability. RESULTS Two hundred and seven questionnaires were completed (a response rate of 74·5%). Mean pulse oximetry knowledge score was 12·8 ± 3·2, with ICU nurses having significantly higher scores than ED nurses (p = 0·001) and those with more than 10 years of experience having significantly higher scores than less experienced ones (p = 0·015). Correct responses did not exceed 50% for six questionnaire items, five of which covered principles of pulse oximetry function. ICU nurses had significantly more correct responses in five items compared to ED nurses, and in two of them compared to AD nurses. CONCLUSIONS Longer professional experience and being employed in the ICU were associated with higher pulse oximetry knowledge of Greek nurses. Considering knowledge deficits and differences among nurses, pulse oximetry knowledge seems to mainly develop through clinical experience. RELEVANCE TO CLINICAL PRACTICE These findings highlight the need for pregraduate education to follow clinical advances, and especially for the implementation of high-quality, continuing education programmes to provide systematic learning and support professional development of nurses.

Perioperative Adverse Respiratory Events in Overweight/Obese Children: Systematic Review

Childhood obesity is associated with numerous respiratory disorders, which may be aggravated when general anesthesia is administered. This systematic review aimed to investigate and synthesize the published literature on the associations between childhood obesity and perioperative adverse respiratory events (PAREs). By using key terms, observational studies published between 1990 and 2014 in English-language journals indexed by Cumulative Index for Nursing and Allied Health Literature, PubMed, Web of Science, Cochrane Database, and EMBASE were searched for reports of relevant associations. Nine articles were considered eligible for inclusion. In all studies, significant univariate and multivariate associations were reported between obesity and increased risk for PAREs in pediatric patients, mainly for hypoxemia, upper airway obstruction, and difficult mask ventilation. Appropriate strategies for preventing PAREs in obese children need to be followed by health care professionals. Multicenter studies are also recommended for ensuring high generalizability of reported associations and elucidating underlying mechanisms that link obesity to PAREs.

The Image and Profile of the Nursing Profession in Greece: Attitudes of High School Students, Nursing Students and Nurses

To identify and compare the attitude of high school students, nursing students and nurses regarding the image and profile of the nursing profession in Greece.

Commentary on Cao Y, Davidson P & DiGiacomo M (2009) Cardiovascular disease in China: an urgent need to enhance the nursing role to improve health outcomes Journal of Clinical Nursing18, 687–693

This is a very interesting paper because it reveals important information regarding cardiac nursing in China (Cao et al. 2009). The paper describes adequately the advantages of specialised nursing knowledge in the cardiac area, especially in cardiac rehabilitation. In general, review papers have mainly two aims, first to describe and/or analyse a situation and second, to recommend ideas and propose ways for such change to occur in different areas of nursing science (education, clinical practice, research and management). The paper describes and analyses nursing practice in China and the need for change in cardiac nursing practice. Although the authors analyse the obstacles for changes in cardiac nursing (shortage of nursing staff, language problems, low prestige for nurses and the low number of nurse researchers engaged in research) they do not propose how these changes will occur in China. It is true that most countries have changed nursing education and practice due to inadequate outcomes in patient care. Nevertheless, it is not an easy task to change something; it is rather more complicated than it sounds. For example, the authors propose that the introduction of a doctoral programme, through collaboration with other universities, is a positive sign. This might help to engage more Chinese nurses in research, minimise the international isolation of Chinese nurses, promote nursing science in China and also recommend areas of research that Chinese nurses need to be involved with more in the future. However, there is a direct and positive interaction between nursing education and clinical practice (Bakalis et al. 2004). In other words, the purpose of nursing education, worldwide, is to prepare student nurses for profession clinical practice (Little et al. 1996). In China, the authors describe nursing as ‘an adjunct profession’, nurses are the ‘doctors’ legs’ and nursing, as a profession, does not enjoy high prestige. Probably most hospitals in China are physician-run and nurses are subordinated to doctors. This philosophy towards the organisation of nursing clinical practice is not uncommon, as the authors point out. Many countries operate nursing under the ‘biomedical model’ of clinical practice (Heater et al. 2006). It seems that, to change something, it is necessary to view several areas of change and not a particular one. In other words, to change nursing education does not mean that clinical practice will change, especially when clinical practice is influenced by many factors. The nursing philosophy in any country is the most important issue that usually guides the other areas of nursing (McSherry et al. 1997). For example, the authors mentioned that, although cardiac rehabilitation programmes were established in China in 1991, nurses played a limited role. Why did this happen? It appears that Chinese doctors have introduced and are in charge of these programmes. Furthermore, the title of the paper mentions that nurses need to enhance the nursing role to improve health outcomes. How will Chinese nurses achieve this? Chinese nurses may need to examine more carefully the factors (nurses’ prestige, preregistration education, postgraduate education, role, authority, autonomy, research) that influence the nursing philosophy in other countries and researchers should try to investigate altering some of the above factors. The interventions should rely not only on management and educational level (hospitals – universities) but also at the political level. Nurses, worldwide, must not forget how Florence Nightingale achieved the development of nursing science. She had the potential to change things but she also maintained correspondence with the politicians of her time.

Commentary on Wilson B (2007) Nurses' knowledge of pain. Journal of Clinical Nursing 16, 1012-1020.

which were meeting already e.g. a managers meeting or course. The two small ward based groups comprised people who happened to be on duty that day. Third, it is highlighted that we did not discuss the study limitations. We acknowledge this deficit. However, it should be noted that this was not a research project. Rather the aim was to conduct a service review and provide insight into the topic in the light of existing literature. Whilst the project as conducted systematically and rigorously, it was limited in scope. It merely provided a snapshot of views of a limited number of staff. Clearly no claims of generalisability can be made. However, the authors do maintain that it provides insight and raises valuable issues in relation to the development, implementation and evaluation of the Clinical Librarian role. We agree with Bakalis that there is a need for clinical managers to try and find the resources to develop the role of the Clinical Librarian. However, considering the existing financial pressures within the NHS in the UK, the necessary investment for Clinical Librarian services will be even more difficult to acquire and justify. There is still a need to develop robust evaluations of the Clinical Librarian.

Commentary on Tod A, Bond B, Leonard N, Gilsenan I & Palfreyman S (2007) Exploring the contribution of the Clinical Librarian to facilitating evidence-based nursing. Journal of Clinical Nursing 16, 621-629.

that they are not ‘accountable’ and when enter to clinical practice, as a nurse, the ‘whole scene’ is changed? The author reports that patients and their relatives, doctors and even staff nurses, behave completely different; probably because student nurses are not considered important to patients’ care. They are ‘the eyes’ and ‘ears’ of staff nurses. They are not accountable for their practice and their knowledge and skills need to be improved. It will be interested to search the reasons of this different behaviour in such short period of time. Finally, nursing, as a science, has tried over the years to ‘update’ its social prestige. Moving to this philosophy, nurses extend their clinical roles, introduce guidelines and protocols, change nursing curricula and emphasise clinical research. All these have established to make nurses autonomous decision-maker and thus increase authority in their actions. Nevertheless, if student nurses realise that the clinical environment is not appropriate for learning and are discouraged from improving skills such as clinical decision making, reflection and critical thinking, then nursing, as a science, needs to re-consider issues that are significant to nursing as an art but, most important, as a science.

Commentary on Mooney M (2007) Newly qualified Irish nurses’ interpretation of their preparation and experiences of registration. Journal of Clinical Nursing,16, 1610–1617

For over 30 years the experiences of newly qualified nurses have received considerable attention in research studies. One of the first papers published by Kramer (1974) identified the ‘reality shock’ of newly registered nursing graduates. This was followed by several studies looking at their career pathways, attrition, the acquisition and application of skills and knowledge and influences on their practice. The introduction of Project 2000 heralded the integration of nurse education within higher education institutions. There was a radical shift from an apprenticeship, industrial model, where the demands of the service were a predominant factor in allocation of student placements, to awarding students’ supernumerary status and an emphasis on designing the students’ placement learning experiences to meet the curriculum themes and their own learning needs. Fuelled by concerns that these nurses would not be fit for practice and purpose there was a plethora of studies exploring their experiences. The UKCC Fitness to Practice Report 1999 and NMC Fitness for Practice and NMC Assuring Fitness for Practice (2005) drew on such research evidence. The study is based on the premise that ‘the clinical learning environment is a powerful catalyst that influences students’ learning’ and by implication being in this environment ‘should prepare them for transition to registered nurse’. The aim of the study was to contrast the participants’ preand postregistration perceptions and experiences in relation to the extent to which they felt they were prepared for their role as a staff nurse. This is presented as a study using ‘qualitative methodology’. The author felt that as this topic had not been previously studied in relation to newly qualified Irish nurses an exploratory study based on the tenets of naturalistic enquiry and using qualitative methodology was most appropriate. The claim was that a modified grounded theory approach was adopted. Semi-structured interviews were recorded, transcribed and then analysed to generate themes. The study was carried out with 12 nurses in an Irish acute general hospital. It is unclear how many potential participants there were and how may declined to take part because there are few details about how the ‘purposive sample’ of 12 was chosen and the criteria used to determine who would be ‘good sources of information’. They were interviewed after they had been qualified for between 6–10 months. Mooney maintains that because the ‘stories were told retrospectively’ this strengthens the data. However, it could be argued that the nurses had to rely on recall and furthermore difference in length of time in service may have affected what the nurses remembered. Recognising time constraints may have been difficult to gain the views of these nurses concurrently with their emergence as registered nurses but, because of this challenge, Correspondence: Annette K Dearmun, WhitleSeam, Wainhill, Chinnor, Oxon OX39 4AB, UK. E-mail: nettie.dearmun@orh.nhs.uk