Intensive and Critical Care Nursing

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This editorial will describe some current issues and concerns in Swedish intensive care. In Sweden there are three types of hospital levels; regional, county and district hospitals. All levels have intensive care units (ICU). There are about 70 county and district hospitals. The nine regional hospitals are University hospitals and referral hospitals providing care for the most severely injured or ill patients. The regional hospitals have different specialised ICUs such as medical, neurosurgical, cardiac, infection and general ICUs for adults and paediatrics. The number of beds in ICU usually ranges from 8 to 10 beds. In some ICUs the nursing staff are practical nurses/enrolled nurses and registered nurses (RN). Usually one registered nurse and one practical nurse are responsible for the care of one or two patients in the unit during their shift. The patient is never left alone and unattended. No registered nurses with a general nurse education (BScN) from the university are allowed to work in ICUs. Registered nurses must have a one-year specialist university education course in intensive care following their RN certification and BScN.

The most significant changes that have occurred over the last few years are that the patients in the ICUs, especially in the regional hospitals, are more severely ill or injured and older than previously. The use of technical equipment in the treatment of patients has also become more advanced and intensive, which has consequences for the nurses and the care they provide, how they use their time and attention. Even if the advanced technical equipment is necessary and lifesaving for the patients, the technical treatment seems to more or less dominate the nurses’ time and attention. This might mean that the nurses “freedom” to give priority to different aspects of caring have become more limited and the nurses express that there is lack of time to perform care.

Both the patients’ severe condition and the increase in advanced technical devices in ICU thus affect the nurses’ workload. The technical development of equipment and devices and an increased monitoring and controls of the equipment as well as the patients’ responses to care and treatment result in a greater need for effective documentation and information to patients and their relatives. An increased awareness and knowledge among nurses about patients’ and relatives’ needs and experiences may lead to inner demands on the quality of nursing care which should be performed. When it is, due to many reasons, impossible to develop the care and work in accordance with this new knowledge moral stress can be experienced. Thus, the quality of nursing care is affected due to “lack of time” to care for the patient and their relatives, but it may also cause stress because nurses may experience a lack of fulfilment in their work. It may also be due to another type of stress caused by uncertainty and insecurity related to the technical devices and equipment. Nurses are obliged to continuously update and learn about new medical treatment, technical equipment, organisational and administrative issues and new findings in caring research. However, they are seldom given time or opportunity for study as organisations seldom provide the necessary support to meet these expectations.

The intensive use and occurrence of technical equipment in nurses’ working environment may also affect their health and well-being. For example, many nurses express that their work makes them very sensitive to noise. Such issues must be considered seriously and research about nurses working environment is needed, as we do not know which types of noise cause the greatest problems. We must also know more about the consequences of being confronted with suffering and tragic circumstances almost each day. Therefore, we must ask ourselves whether the ICU environment is caring for all who stay or work there.

There are also other challenges for ICU nurses in Sweden to face. The first is the need to develop more family focused care for patients and their families. Patients spend a relatively short time in ICU and in hospital. In fact the majority of the patients’ recovery period usually takes place in their home with family members as caregivers. However, performing family centred care is a great challenge for nurses because family relationships and dynamics are often complicated and difficult to assess. If possible, we should involve the family members and regard them as contributors in the care and caring process, and prepare them for the recovery period in different ways.

Research has shown that the patients’ recovery time and life quality are influenced by discomforting recollections of the ICU period. This highlights the ICU nurses’ most significant part in co-ordinating with other health care workers and family members, as the nurse has knowledge about the patients’ responses to life-threatening experiences such as trauma and severe, critical illness. Here, I believe that ICU nurses have a significant role in sharing their knowledge with colleagues in other health care settings. We need to take actions to improve the quality of care for patients and their families following critical illness/injury during the recovery period. In many cases the patient after discharge from hospital is in need of nursing care but not always in need of medical treatment. Therefore, I believe that nurses have to discuss their responsibilities and obligations to patients and society with health care politicians and the public. At the same time they should work for the development of health care organisations, which means a more “modern” perspective on patient and family focused care. This might mean that after discharge from ICU, the ICU nurse in conjunction with other members of the ICU team can work as counsellor and contact person with the surgical/medical ward team, and again after discharge from the hospital with the primary/recovery health care team. Knowledge about the phenomenon of being severely ill or injured includes the whole process from the initial illness or injury through to the recovery period at home. This view of patients and their families challenges not only hospital organisations and traditions but also the nurses’ professional role and assignments. It is promising that several ICUs in Sweden have started out-patient clinics where they can follow up and care for discharged patients and their families.

In several ICUs new types of ICU teams have been developed and are developing. For example, in Malmö, Lund, Stockholm and Göteborg so called MIG teams have been developed. In Great Britain they are often identified as CCOT (Critical Care Outreach Team) and in Australia as MET (Medical Emergency Team). The purpose is to stop patients’ gradual deterioration and to support the staff in the ward where the patient is being cared for. The goal is to prevent the development of critical conditions among patients and thus prevent admission to ICU. It will be interesting to study how this development of intensive care affects nurses’ role and function.

However, the nurses’ expanded role and function does not mean that nurses should not continue to pay attention to the period of ICU care and treatment. We still have to study and discuss care and treatment, what and how it is provided and within which environment and organisation the care should be provided. I was the first nurse in Sweden who defended a doctoral thesis in intensive care in 1989. Today, about 15 nurses have defended their doctoral thesis in intensive care and about 40 nurses are PhD students. Research is mainly focused on the following areas: (1) Research about ICU delirium, the recollection of becoming severely ill, being cared for and treated in the ICU including follow up studies. (2) Ethical dilemmas and moral stress among nurses. (3) Relatives’, families’ including small children's experiences and needs in conjunction with patients’ severe illness or injury, or when they are dying, and the patients’ need for their families during their ICU stay. (4) Intensive care in different contexts and patients’ need and dependence of high tech equipment for their survival. (5) The consequences for patients, families and staff of the high-tech ICU environment, and finally (6) research about the phenomena of being severely and critically ill or injured. In a few years or in coming years I hope that we can present theories about being severely ill or injured and this knowledge will change and challenge the way of caring and treating the critically ill or injured patient, not only in the ICU but also in emergency units and during the patients’ process of recovery, i.e after the discharge from the hospital. The network NOFI (Nordic Association For nursing research in Intensive care) became an association in 2004 with about 80 Danish, Norwegian and Swedish researchers, PhD students and nurses with a masters degree. Our ambition is to recruit Icelandic and Finnish researchers too (see www.nofi.info). We conduct fellow research projects and meetings are held each spring and autumn for all members.

In many Swedish ICUs, action has been taken to encourage nurses to conduct and participate in research and to develop nursing care. Many colleagues are making a wonderful contribution, collecting data, providing access to information and “opening doors” for nursing care researchers. ICU nurses are continuously improving the quality of nursing care and this must be further supported by society and the public.