Critical care nursing in Northern Ireland: A rich history with a future of opportunity
Article Outline
- Northern Ireland: the backdrop to the region
- Beginnings in the Mid Ulster Hospital
- Early developments in Belfast
- Training and education
- Professional and educational developments
- Acknowledgements
- References
- Copyright
Keywords: Critical care, Nursing history, Northern Ireland
The story of intensive care and more recently critical care nursing in Northern Ireland is an absorbing one. As is the case with most countries, the early days of intensive care were challenging and required innovation and creativity by nurses supported by their medical colleagues. Such practitioners had an obvious vision of saving lives and improving the condition of critically ill patients through a continuous drive for improved care. Despite having to operate for many decades in an environment of civil disturbance and political conflict, critical care nurses in Northern Ireland are now in a strong position to seize whatever opportunities are presented for healthcare in a post-conflict situation. This editorial focuses on the historical context in which critical care nursing in Northern Ireland emerged and provides an overview of the possible areas for future development.
The poet Seamus Heaney (Nobel Laureate, 1995) in ‘The Bogland’ illustrates how we have to explore the layers of history as a way of seeing who we are now. The renowned singer/songwriter Van Morrison reminds us in ‘These are the days’ that there is no past there's only future. However during the conversations with Noelle Gormley (nee Gibson) MBE, the first Intensive Care Unit (ICU) Sister in the Royal Victoria Hospital, Belfast; Dr. Dennis Coppel retired Consultant Anaesthetist from the same hospital and Dorothy Fleming retired Clinical Teacher from the Mid Ulster Hospital, Magherfelt we realised that the past is alive and is very relevant to modern-day critical care nurses. It provides us with the required identity to reflect on where we are at in the present but remains secondary to striving for a brighter future.
The stories from the early days of Intensive Care provision in Northern Ireland were not only inspiring but entertaining. Noelle Gormley who later became sister of the intensive care at the Royal Victoria Hospital, tells the story of how an injury to her knee resulted in her first encounter with an intensive care patient. Due to her restricted movement, she was allocated to ‘special’ a patient who had poliomyelitis and required ventilatory support. Dr. Dennis Coppel tells his story about writing directly to the Prime Minister of the United Kingdom (UK), Margaret Thatcher seeking additional funding for security in the ICU in an attempt to improve safety for patients, families and staff from bullets and bombs during the ‘troubles’. It was one of Dorothy Fleming's stories about the initiation of Progressive Patient Care at the Mid Ulster Hospital, Magherafelt that led us to the probable origins of critical care nursing in Northern Ireland.
Northern Ireland: the backdrop to the region
As a place, Northern Ireland was created in 1921 from six of the nine counties of Ulster, the northern province and ancient Celtic kingdom of the island of Ireland. It was recently estimated that Northern Ireland has a population of 1,741,619 people (Northern Ireland Statistics and Research Agency, 2008) consisting of mostly white Caucasians of Irish, Scottish or English ancestry. These groups make up what has been defined as the ‘divided society’, a negative but unfortunately real descriptor of the political and religious divisions that are perceived to exist. Whatever the cause of the division, and there are many (see Cain Project, 2008), Northern Ireland has been at the forefront of the world media in relation to civil disturbance and political conflict since the late 1960s. The ‘troubles’ as they are known claimed the lives of over 3500 people between 1969 and 1994. Many times this number were injured and/or psychologically scarred (Fay et al., 1997). Many of the atrocities have never been resolved, with victims groups on both sides of the conflict seeking resolution and sometimes atonement. For a total population of just over 1.7 million people, the impact of the ‘troubles’ on the history and culture of Northern Ireland has to be seen as central to its current state.
While the civil disturbances caused havoc within communities across Northern Ireland, often disrupting day to day living, those involved in healthcare delivery maintained a service not only for those directly affected by the violence but also for all individuals requiring standard healthcare input. McKenna (2004) described how nursing staff and healthcare workers often had to ‘run the gauntlet of barricades and security searches on the way to and from work’ (p. 231). Medical colleagues developed skills in areas such as blast and gunshot injuries, especially within the speciality of vascular trauma surgery (Barros D'Sa, 1995). Intensive care and more recently critical care maintained and developed this service throughout this difficult time, while also remaining at the forefront of advances in clinical treatments and therapeutics.
Many positive things have emerged from the ‘troubles’, none less important than the Good Friday or Belfast Agreement of 10th April 1998 which established an arrangement for devolved government in Northern Ireland within the UK. This Belfast Agreement sets out far reaching proposals for a shared future in relation to human rights, cultural diversity and equality for all communities (see Northern Ireland Office, 2008). The Belfast Agreement is generally viewed as a valuable template for conflict resolution and has been considered in other conflict areas across the world. The current political landscape now provides a backdrop for locally elected politicians to make decisions relating to health and social care provision.
Northern Ireland is now experiencing a period where the ‘troubles’ and the ‘divided society’ are being replaced by a growing sense of optimism and a renaissance of tolerance. The rich tapestry that is the growing cultural diversity of Northern Ireland coupled with a mostly rural environment of outstanding natural beauty and plethora of tourist attractions, augers well for the future of the new power sharing executive established in 2007.
Beginnings in the Mid Ulster Hospital
The history of intensive care in Northern Ireland is intriguing. There are records of Intensive Care Nursing existing in May 1961 at the Mid Ulster Hospital, Magherfelt, County Derry. This 8-bedded Unit was created as part of a UK Pilot Project on Progressive Patient Care by the Matron Mrs. Sarah Mooney (nee Cameron), Mr. Brennan, Consultant Surgeon and Ms. Anne White, Nursing Officer with the Northern Ireland Hospital Authority. A collaborative approach between nursing and medical staff resulted in the implementation of the Progressive Patient Care initiative at the Mid Ulster Hospital with Ms. Anne White, Mrs. Sarah Mooney and Mr. Brennan as key players. It is interesting to note that The Really Useful Book on Intensive Care refers to this development as being among the first in the world to promote the concept of intensive care (Jones et al., 1998). Progressive Patient Care was a system of placing patients into one of three distinct levels of care—intensive, intermediate and self care. Interestingly, these levels of care could be compared to our current levels of critical care as defined by the Intensive Care Society (ICS, 2002). This early ICU grouped the sickest medical and surgical patients together and provided one-to-one nursing by State Registered Nurses (SRNs). Much of the care within this unit focused on the on-going assessment and observation of the patient, a skill which remains at the forefront of critical care nursing today. While Irwine (1968) provides a comprehensive analysis of the advantages and disadvantages of the Progressive Patient Care system at the Mid Ulster, there is little detail on the ICU or the Nurses who staffed it. However, there is evidence to note that nurses from Northern Ireland were engaged in intensive care developments at a UK wide level. We discovered that Ms. McCrory a Sister in the Mid Ulster Hospital Intensive Care Unit, attended an ICU Ward Sister's Discussion Group at the King Edward's Hospital Fund for London on Wednesday 15 December 1965 (Minutes of Ward Sisters Discussion Group 1965). The developments of Progressive Patient Care at the Mid Ulster Hospital reflect the views of the UK Intensive Care Society (2003) document ‘The Evolution of the Intensive Care Unit in the UK’ which notes that,
‘Nurses embraced the idea of intensive care earlier and more enthusiastically than their medical colleagues. This may reflect the nursing profession's focus on the patient rather than disease. Treating patients according to their dependency seemed obvious. From a nursing perspective the development of intensive care seems to be driven by the concentration of human resources and expertise’ (p. 3).
Early developments in Belfast
As was the case throughout the Western World in the late 1950s, the polio epidemic also existed in Northern Ireland and with this the normal treatments (iron lung; tracheotomy; ventilation) for patients with bulbar polio developed. The combination of caring for the needs of individuals with tetanus and bulbar polio was the stimulus for developments in general respiratory support. While Progressive Patient Care was being initiated at the Mid Ulster Hospital, developments in anaesthesia were afoot in Belfast. Coppel (2007) states that the establishment of an academic department of anaesthesia in 1958 at Queen's University, Belfast (5th one in the UK) was a key factor in improving the care and treatment of patients with respiratory insufficiency in Northern Ireland. He attributes the establishment of the concept of Intensive Care Medicine in Northern Ireland to Dr. John W. Dundee a Senior Lecturer in Anaesthetics at Queen's University, Belfast in 1958. Dr. Robert Gray, another pioneer and Consultant Anaesthetist was appointed as the first Director of Intensive Care Medicine at the Royal Victoria Hospital, Belfast in 1961. The ICU or RICU (Respiratory Intensive Care Unit) consisted of 6 beds in Quinn House, Ward 22, Royal Victoria Hospital. The Sister in this Unit was Noelle Gibson who supervised a system of care similar to the Progressive Patient Care system at the Mid Ulster Hospital. Each patient was allocated to a SRN who had additional training. Sister Gormley (nee Gibson) describes how challenging it was to work in the RICU and how she worked alongside the anaesthetists in the early training of nurses in intensive care therapy. She reflects upon the challenges associated with having to learn about Intermittent Positive Pressure Ventilation (IPPV), giving intravenous drugs and stresses in dealing with a death rate of almost 35%. Nevertheless, she points out that the challenge of the work and caring for the many patients who did survive was rewarding. In August–September 1970, a larger Unit comprising of 12 beds was opened. The term RICU was retained but now referred to the Regional Intensive Care Unit, as it was the largest unit in Northern Ireland. McAllister (1972) emphasising the importance of nursing in the new RICU states.
“it must be remembered that monitoring equipment can never replace the bedside observation of the nurse. This personal observation can often mean the difference between life and death” (p. 204).
Again, almost three decades ago, the importance of assessment and continual observation is highlighted as an integral component of critical care nursing. Throughout the early period of Intensive Care it is apparent that great value was placed on the quality and effectiveness of nursing both by the medical teams and the nurses themselves. In 1971, McAllister (1972) notes that the mortality rate had dropped to 31%.
Training and education
In the early 1970s the ‘troubles’ were at their worst in Northern Ireland and the need for intensive care grew. This growth was not necessarily in response to the troubles, but reflected the developments in this speciality and the subsequent increase in demand for access to ICU beds. The model of RICU was replicated albeit on a smaller scale in most district general hospitals across Northern Ireland. The first ICU Nursing course, combining training in general ICU, Coronary Care and Cardiac Surgery was offered at the Royal Victoria Hospital in the early 1970s and this provided training for nurses in all units. The developments in ventilation and surgery served as a driver for a country-wide network of ICUs and a growing interest in the field of intensive care and trauma management by anaesthetists and nurses.
Today, most critical care nurses in Northern Ireland hold a minimum of a Diploma in Higher Education or Bachelors degree, with many others attaining a Masters degree or PhD. Some post registration qualifications can be combined with a Specialist Nursing Course in Critical Care which is recordable with the Nursing and Midwifery Council (NMC) of the UK. Access to critical care courses is available through programmes offered at the two main universities (Ulster and Queens) and through in-service training (Educare).
Professional and educational developments
Although there were close ties between all units across Northern Ireland, no formal clinical network existed until 2007. The formal network, Critical Care Network Northern Ireland (CCaNNI) was developed to,
“improve access, experience and outcome for patients in Northern Ireland with potential or actual need for critical care by providing a service that is high quality coordinated, timely, and unrestricted by clinical or organisational boundaries” (CCaNNI, 2006, p. 9).
This formal network mirrors those which are already operational in other parts of the UK. This group has a Lead Clinician and a Lead Nurse. The present Critical Care Nurse Consultant (Ms. Joanna McCormack) is the Lead Nurse on this network. Of particular interest is the proposed development of a system for monitoring the ‘live bed state’ which will assist healthcare staff identify critical care bed availability throughout Northern Ireland and assist in the timely allocation of critically ill patients to appropriate units. Due to the need for access to critical care beds and the need for specialist treatments, patients are often transferred between the ICUs of different hospitals throughout Northern Ireland. To promote patient safety, the Northern Ireland Critical Care Transfer Service has been established through nursing and anaesthetic collaboration. While based at the Royal Victoria Hospital, this transfer service is available to all hospitals throughout Northern Ireland.
Today, as well as the support for Nursing developments from within critical care units and from CCaNNI, nurses will benefit from the monitoring and support systems offered by the Northern Ireland Practice and Education Council (NIPEC). NIPEC aims to improve the quality of health and care by supporting the practice, education and performance of nurses and midwives (NIPEC, 2008). This organisation has many excellent initiatives such as the ‘Development Framework’, the ‘Clinical Supervision Project’ and the ‘Nurse Prescribing Project’ that critical care nurses are encouraged to engage in. The Development Framework Project is an innovative system for all registered Nurses, providing them with an opportunity to develop a competency portfolio, reflection skills and career plans. This framework will support nurses working within Level Two and Three critical care settings to identify their professional learning needs and in collaboration with others, create individual development plans.
Pre-registration nursing education within Northern Ireland facilitates all nurses to achieve a degree-level qualification within a three-year period. While it is often difficult, placement of undergraduate nursing students in critical care settings remains an important part of nurse education in Northern Ireland. Such opportunities are seen as central to the future nursing workforce having the skills and knowledge to care for critically patients within and outside the intensive care setting. As part of the NMC Review of Pre-registration Nurse Education practitioners have the opportunity to provide opinions on the future of nursing for 2015. It could be proposed that the outcomes of such consultations will in some way impact upon the future shape of critical care nursing.
Research in Critical Care Nursing in Northern Ireland is embryonic. Our Emeritus Editor Pat Ashworth launched the first intensive care nursing journal in the UK in 1985 (then known as Intensive Care Nursing). This was a significant contribution to Intensive Care Nursing in the United Kingdom, but within Northern Ireland, critical care nurses had the added benefit of having Pat close at hand to encourage them to begin writing and sharing knowledge. Pat was a Senior Lecturer in Nursing at the University of Ulster at Coleraine on the north coast of Northern Ireland. Critical care nurses in Northern Ireland have published on many topics (see Box One) that contributed to knowledge development at a national and international level.
Reflecting the general trend in nursing literature the number of publications from critical nurses in Northern Ireland has increased since 1999. This work lays foundations for continuing development of the evidence base for critical care nursing. However both universities and the healthcare trusts must work together to in a multi-professional arena to further improve the output of quality research. To assist achievement of this goal recent support has been offered to a Northern Ireland Clinical Research Network (Critical Care). The Royal College of Nursing Northern Ireland Critical Care Nursing Forum and the British Association of Critical Care Nursing also remain as an ongoing support for nurses throughout the region. Both groups organise study days and conferences to assist critical care nurses in being kept informed of recent advances in critical care therapies and also keeping abreast of critical care developments both within Northern Ireland and at a national level.
From the beginnings of critical care nursing in 1961 at the Mid Ulster Hospital until now, critical care nurses in Northern Ireland have been on a journey of professional growth, keeping abreast of national and international developments. The story we have told illustrates how practice, knowledge and research have all developed despite the ‘troubles’ and are now poised to advance even further. Having just emerged from a difficult period in its history, Northern Ireland society has much to look forward to. Critical Care Nursing must be part of this to ensure the population of Northern Ireland has equity of access to quality critical care services. New opportunities in the form of clinical and research networks alongside support with individual development plans provides critical care practitioners in Northern Ireland with the prospect of building on their rich history and shaping their own future.
N.B.: As regards the history on Intensive Care Nursing in Northern Ireland this is only part of the story and we are sure much more insightful and interesting information and anecdotes exist. We would invite readers to share with us their accounts and anecdotes so that we can draw together the history of intensive and critical care nursing in Northern Ireland.
Acknowledgements
We are grateful to the following people for their help and guidance in writing this editorial.
References
- . Twenty five years of vascular trauma in Northern Ireland. Brit Med J. 1995;310:1–2
- . Sensoristrain: an exploration of nursing interventions in the context of the Neuman systems theory. Intensive Crit Care Nurs. 1997;13(5):249–258
- . A concept analysis of the sensoristrain experienced by intensive care patients. Intensive Crit Care Nurs. 1997;13(4):209–215
- . The effect of air fluidised bed therapy on hypermetabolism in intensive care unit patients. Intensive Crit Care Nurs. 1996;12(4):200–206
- . The practice and perception of intensive care staff using the closed suctioning system. J Adv Nurs. 1998;28(5):1020–1029
- . Closed tracheal suctioning systems and infection control in the intensive care unit. J Hospital Infect. 1998;39(4):315–322
- . Normal saline instillation with endotracheal suctioning: primum non nocere (first do no harm). J Adv Nurs. 1999;29(4):928–934
- . The art and science of predicting patient readiness for weaning from mechanical ventilation. Int J Nurs Stud. 2000;37(2):145–151
- . Can protocolised-weaning developed in the United States transfer to the United Kingdom context: a discussion. Intensive Crit Care Nurs. 2003;19(4):215–225
- . Protocolized weaning from mechanical ventilation: ICU physicians’ views. J Adv Nurs. 2004;48(1):26–34
- . An evaluation of protocolised weaning on the duration of mechanical ventilation. Anaesthesia. 2006;61(11):1079–1086
- . The impact of nurse-directed protocolised-weaning from mechanical ventilation on nursing practice: a quasi-experimental study. Int J Nurs Stud. 2007;44(2):209–226
- . Family needs in critical care settings: a comparison of the perceptions of nurses and family members. All Ireland J Nurs Midwifery. 2000;1(3):108–115
- Cain Project. Background material on the Northern Ireland conflict. University of Ulster. http://cain.ulst.ac.uk/index.html, 2008 [accessed 24th January 2008].
- . Recognising post-traumatic stress in intensive care patients. Intensive Crit Care Nurs. 1995;11(2):60–65
- . Respiratory care in spinal cord injury with associated traumatic brain injury: bridging the gap in critical care nursing interventions. Intensive Crit Care Nurs. 2003;19(3):143–153
- Coppel D. History of Development of Intensive Care at the Royal Victoria Hospital. Belfast; 2007 [unpublished].
- . Meeting the needs of the family: the role of the specialist nurse in the management of brain death. Intensive Crit Care Nurs. 2000;16(1):45–50
- . Transfer anxiety: preparing to leave intensive care. Intensive Crit Care Nurs. 2002;17(3):138–143
- Critical Care Network Northern Ireland (CCaNNI). Application for DHSSPS approval to launch a fully operational Managed Clinical Network (Draft). Belfast, CCaNNI; 2006.
- . Psychological experience of older people who have major surgery (elective repair of aneurysm involving intensive care. Nurs Crit Care. 2001;6(1):75–82
- . The Cost of the Troubles Study; mapping troubles-related deaths in Northern Ireland 1969–1994. Derry-Londonderry: Derry-Londonderry: INCORE University of Ulster; 1997;
- . Potential hazards of tracheobronchial suctioning. Intensive Crit Care Nurs. 1992;8(4):217–226
- . Perceptions and experiences of primary nursing in an ICU: a combined methods approach. Intensive Crit Care Nurs. 2001;17(5):294–303
- . Clinical governance and intensive care: what does it mean?. Intensive Crit Care Nurs. 1999;15(4):210–213
- Intensive Care Society. Levels of Critical Care for Adult Patients. London: ICS; 2002.
- Intensive Care Society. Evolution of Intensive Care in the UK. London: ICS; 2003.
- . Progressive patient Care in Northern Ireland. Nurs Times Occas Pap. 1968;64(48):185–186
- . The really useful book on intensive care. Carnforth, UK: Martin Lister Publishing; 1998;
- King Edwards Fund for London. Minutes of Ward Sister's Discussion Group Wednesday 15 December 1965. King Edwards Fund for London: unpublished; 1965.
- . A respiratory and intensive care unit. Nurs Times. 1972;68(7):203–204
- . Nursing the ARDS patient in the prone position: the experience of qualified ICU nurses. Intensive Crit Care Nurs. 2001;17(6):331–340
- . Nursing care of the general paediatric surgical patient. Intensive Crit Care Nurs. 2000;16(6):405
- . An exploration of the handover process of critically ill patients between nursing staff from the emergency department and the intensive care unit. Nurs Crit Care. 2007;12(6):261–269
- . The use of case studies as a learning method during pre-registration critical care placements. Nurse Educ Pract. 2004;4:208–215
- . Developing an information booklet to meet the needs of intensive care patients and relatives. Intensive Crit Care Nurs. 1994;10(4):271–277
- . Standardizing the assessment of clinical competence: an overview of intensive care course design. Nurs Crit Care. 2004;9(5):238–246
- . Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev. 2007;(3):CD005529
- . Supernumerary status: definition, operationalisation and its effect in practice. Intensive Crit Care Nurs. 2003;19(5):308–317
- . Editorial. Trouble with the troubles: a reflection on nursing and politics in Northern Ireland. J Nurs Manage. 2004;12:231–232
- . Leaving the intensive care unit: a phenomenological study of the patients’ experience. Intensive Crit Care Nurs. 2002;18(6):320–331
- Northern Ireland Office. The Agreement. Northern Ireland Office. http://www.nio.gov.uk/the-agreement, 2008 [accessed on 24th January 2008].
- Northern Ireland Practice and Education Council (NIPEC). http://www.nipec.n-i.nhs.uk [accessed on 17 January 2008].
- Northern Ireland Statistics and Research Agency. http://www.nisra.gov.uk [accessed on 17 January 2008].
- . Immediate follow-up after ICU discharge: establishment of a service and initial experiences. Nurs Crit Care. 2003;8(2):49–55
- . Investigating nurses’ perceptions of their role in managing sedation in intensive care: an exploratory study. Intensive Crit Care Nurs. 2006;22(6):338–345
PII: S0964-3397(08)00033-5
doi:10.1016/j.iccn.2008.03.005
© 2008 Elsevier Ltd. All rights reserved.
