Volume 22, Issue 6 , Pages 313-314, December 2006
The art of nursing: A hidden science?
Article Outline
As a consultant nurse, I am frequently asked to discuss the role of nurses and nursing in intensive care. Often this is to justify the number of nurses required or the large amount of study time provided to ensure safe delivery of care to critically ill patients. However, recently I was invited by a medical colleague to present a lecture on nursing responsibility in the intensive care unit. This provided me with an opportunity to think about the responsibility placed on nurses and nursing in critical care and what expectations the critical care population of patients and professionals might have of us.
In identifying the role of the critical care nurse, The World Federation of Critical Care Nurses (2005) state:
‘The role of the critical care nurse is essential to the multidisciplinary team needed to provide specialist knowledge and skill when caring for critically ill patients. The critical care nurse, which enhances delivery of a holistic, patient centred approach in a high tech environment, brings to this team a unique combination of knowledge and caring. In order to fulfil their role, nurses require appropriate specialised knowledge and skills not typically included in the basic nursing programs of most countries.’
This suggests that in order to provide effective care at the bedside, the critical care nurse is required to be technologically competent whilst providing compassionate nursing care. Implicit within this statement is the need for the nurse to be educated and subsequently an educator.
Nurses choose to work in critical care to provide high quality care to patients and their families, to maintain direct patient contact (Heskins, 1997) and to gain knowledge and skills (Farnell and Dawson, 2006). It is suggested that as knowledge improves and experience increases, risk to the patient reduces due to timely patient progression (Ball and McElligott, 2003). Interestingly, it is suggested that mastering the technology also enables the caring aspects of nursing (Wilkin and Slevin, 2004). Therefore developing skills and retaining experienced staff is not a luxury but a necessity in order to ensure appropriate decision-making and care for the critically ill patient.
As the role of the critical care nurse has developed, the differences between nursing and medicine have become blurred; many factors have influenced this development. Critical care nurses work in an ever more autonomous manner, with the nursing role expanding to include the management of highly technical equipment and the resultant decision-making based on the data produced by these advances. Nurses have embraced changing patterns of work among their nursing and medical colleagues, often being required to extend their nursing practice into areas that were previously identified as medical roles. Indeed, the contemporary role of the nurse within critical care may include making differential diagnosis and prescribing, once the sole remit of medicine.
The patient population is changing with a dramatic worldwide increase in the number of people who live to old age. This has resulted in an increased critical care population of elderly patients who often have complex co-morbidity. Increased technical and patient complexity requires greater education in order to maintain and develop skill, with an increasing awareness that basic nurse education does not develop the requisite level of specialised skills and knowledge to practice safely within critical care. This skills deficiency is exacerbated by a shortage of nurses, resulting in many critical care units employing nursing staff who have need of education to develop the skills to practice effectively. To provide effective education, the educator must interrogate the evidence, however the research to steer nursing care is often lacking. Consequently, there is a need for nurses to be researchers to establish an appropriate evidence base.
These changing practices have had a profound impact on the workload of the critical care nurse. The bedside nurse, faced with a variety of demands on their time is left to solve the dilemma of managing and co-ordinating the very visible science of critical care technology versus the often invisible art of nursing care.
As a professional, the nurse has the legitimate freedom to choose one course of action or intervention over another, combined with the responsibility for making correct choices in each clinical situation (Holden, 1991). The responsibility for the decisions a nurse might make, is demonstrated through the nurses’ legal liability in four areas. Criminal: The nurse is accountable to the public. Civil: The nurse is accountable to the patient (or relatives). Professional: The nurse is accountable through their code of conduct. Contractual: The nurse is accountable to their employer and so long as they meet their criminal, civil, professional and contractual obligations, then the employer provides for vicarious liability.
Despite these competing demands and responsibilities, nurses are in a unique position to influence the way in which care is delivered and thus the patients’ and relatives’ experiences of critical care. It is often the art of nursing, the invisible care that is remembered by the patient or their family. The time taken to explain procedures to a patient with little ability to communicate; the organisation of care so that the patient is in control; providing individualised care, knowing when and how to ‘break the rules’.
‘those who look at only the surface level, at what is very obvious, see some equipment and activities which are different from elsewhere. But they completely miss the essence of what is really happening, the skills and knowledge in use, the joys and achievements and the actual or potential dangers’ (Ashworth, 1992).
The art of nursing can easily be hidden by the science of technical healthcare and because of that, perhaps the wide-ranging responsibilities nurses have are often forgotten. Nursing responsibility is complex, it requires the nurse to be conscientious, listening to the patient while responding to the needs of other professionals, being innovative in their care and often working across boundaries, whilst developing and constantly updating their skills and knowledge. Nurses are the invisible co-ordinators of care. In the hands of experts, the untrained eye may even think the art of nursing is simple.
References
- . Nursing is not just the tasks nurses do. Intens Crit Care Nurs. 1992;8(3):129
- . Realising the potential of critical care nursing. An exploration of the factors that affect and comprise the nursing contribution to the recovery of critically ill patients. Intens Crit Care Nurs. 2003;19(4):226–238
- . ’It's not like the wards’. Experiences of nurses new to critical care: a qualitative study. Int J Nurs Stud. 2006, March;43(3):319–331
- . Exploring dichotomies of caring, gender and technology in intensive care nursing: a qualitative approach. Intens Crit Care Nurs. 1997;13(2):65–71Apr
- . Responsibility and autonomous nursing practice. J Adv Nurs. 1991;16(4):398–403
- The World Federation of Critical Care Nurses (WFCCN).(2005). Position statement on the provision of critical care nursing education http://www.wfccn.org/webdocs/Education_May_05.doc last accessed 29th August, 2006.
- . The meaning of caring to nurses: an investigation into the nature of caring work in an intensive care unit. J Clin Nurs. 2004;13(1):50–59
PII: S0964-3397(06)00113-3
doi:10.1016/j.iccn.2006.09.001
© 2006 Elsevier Ltd. All rights reserved.
Volume 22, Issue 6 , Pages 313-314, December 2006
