Similarities and differences in critical care nursing

Article Outline

• Challenges
• Copyright

In its 23rd year this journal celebrates its international nature. One of the major beneficial changes in nursing over the last 40 years is the increase in communication between nurses in different countries, and in particular through such journals as this, and e-mail. But while appreciating the increasingly high quality papers published, it is important to remember the countries from which we read little; where satisfactions may be similar, but some of the challenges are different and perhaps greater. This editorial combines two perspectives. One author (M.B.) is Romanian and has been the senior nurse in the Intensive Therapy Unit (ITU) at the big Military Hospital in Bucharest for more than 10 years, as well as being a wife, mother and past President of the Romanian Nursing Association (ANR). The other (P.A.), after a career which included helping to develop critical care nursing in the United Kingdom (UK), has learned a lot while assisting development of nursing in Romania since 1991, mainly through three to five weekly visits twice a year working with hospitals, schools of nursing, the Romanian Nursing Association and others; in addition to some other involvement with nursing in parts of Central and Eastern Europe. Although the focus here is on Romania, some of what is written would be similar for other countries in that area.

First a consideration of factors which may be similar in most countries anywhere. Why do nurses choose to work in ITUs or other critical care units? The reasons are probably complex, but as summarised from discussion with colleagues in Bucharest they are:

One of these colleagues (Cristina Toma) presented a paper at the 2005 ANR Conference, entitled ‘Nursing—the motivation hidden behind the choice.’ Most of those she asked had chosen nursing with a desire to help people in pain and relieve their suffering, and nurse–patient and nurse–team relationships were also identified as sources of satisfaction. “In conclusion, the motivation sustaining nurses’ choice is an emotional one, which can provide them with the energy required for considerable physical and psychological effort during their activity in ITU.”

As regards patients’ views, some are unhappy about admission to such a unit since it indicates their critical condition and uncertain survival. But most of them change their first impression, feel safe, and ask to stay until full recovery. Others want to leave the unit as soon as they feel better, seeing this as a big step towards recovery. The majority of patients see the staff as ‘phenomenal’, saying they could never do this kind of work.

It is interesting that these views of nurses and patients are so similar to those which might be found around the world, given the different historical context in Romania and its legacy of challenges which affect the development of nursing, critical care and the knowledgeable, decision-making, accountable, and compassionate nurses it requires.

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Challenges 

In Romania, nursing schools were closed from around 1978 to1990, and 14–18-year-olds were trained in high schools, learning technical procedures to be medical assistants. Their official function was just to follow orders, which was not so unusual in a society where the consequences of independent thought and action were likely to be unpleasant, and there was little trust. (Of course as everywhere, even under these circumstances some human spirits triumphed.) When the ending of Ceausescu's regime in 1989 brought freedom and open communication with other countries, efforts began to re-develop nursing, with help from international agencies and individuals. Three-year nursing courses at post-high school level (age >18) were re-started, and in 1992 a new curriculum with more nursing content was introduced nationally. More recently, several university courses at first-degree level have started. But these (like most nursing schools) have doctors of medicine in charge, and in at least some places supervising clinical practice, with nurses just teaching some parts of the course. Until 2004, the law stated that work of an ‘asistent medical’ (still the official title on qualification) was derived from doctors’ orders and routine. Despite some changes in education and the continued efforts of some nurses, only since 2004 does the relevant law include identification of health needs, and provision of preventive, curative and rehabilitative care. So it is often still hard for nurses to gain respect from doctors and others as a separate and complementary profession, though there is now a system of registration and regulation.

The economic consequences of history also present challenges. Although some Romanian critical care units have some relatively sophisticated equipment (often donated) maintenance systems are not always good, and more basic necessities may be lacking. There were (and probably still are) units without waterproof mattresses and pillow covers, and autoclaved drums of dressings are still in use. When I (P.A.) recently asked a nurse in the only ITU in Kosova (a place still under United Nations Administration since the 1999 war) what was the most stressful, he took from the wall a list of supplies the unit lacked, including suction and urinary catheters, some sizes of endotracheal and tracheostomy tubes, and medications including insulin and adrenaline. (Relatives may go out and buy them.) The response would probably be similar in at least some Romanian ITUs. It is true that some patients who are in Romanian ITUs would be in high dependency units (HDUs) or ordinary hospital units in places like the UK. But this is understandable when HDUs are missing, and ordinary units have few staff (e.g. 1 asistenta and 1 unqualified auxiliary on afternoon shift for 50 neurology patients), few nursing records other than temperature charts, and little individualised patient observation and care.

However, lives are saved, patients often appreciate their care in ITUs, and despite the challenges good, thoughtful, and committed ITU nurses, supported by a few good doctors, are helping to lead the way to a better future. It takes a long time and much sustained effort to change from a medical system based on regimentation, following orders and technical procedures, often with little consideration for individual humans, to a modern healthcare system in which nurses provide professional support and assistance to patients and their families through the process of illness, regaining and maintaining health – or coping with dying and death. It is more difficult to develop professional nursing when salaries are low (around £100 per month) causing many able people to emigrate, when there is no national system of post-basic education for nursing specialties like critical care, and when resources for learning, such as specialist nursing journals and on-line courses, are foreign and too expensive as well as requiring foreign language ability. (Though many Romanian nurses now understand English.) It is difficult to convince those who control limited resources that good nursing is essential to healthcare, is cost-effective and should be supported in development, when resources and opportunity to practise professional nursing and to demonstrate its effectiveness by research are very limited. But there are nurses in Romania working on it.

Changes for the better are visible over the last 15 years, much to the credit of those who have worked for them, and we hope that progress will increase with accession of Romania to the European Union, and that nurses and patients in Romania will benefit from what has already been achieved in Western Europe. Communication, collaboration and partnerships can bring mutual benefits, not least a fresh look at what we take for granted. These nurses are mostly in the relatively early stages of academic writing and research, and many of us worldwide know that it takes time, effort and resources to develop high quality activity in such areas, as well as clinical expertise. But we hope that they will make an increasing contribution to the world of critical care nursing. Wisdom is often born and matured in difficult circumstances. Mirela commented that “Intensive care is the nearest place to the border between life and death, but at the same time our souls flicker between light and darkness. It is hard and impressive at the same time. You learn to value life's small pleasures, never to give up the fight and more important, to love people with all their qualities and flaws.” Those are lessons which can help us not only in nursing critically ill individuals, but also in developing high quality critical care nursing, wherever we are.