The power of one
Article Outline
Late last year I received a book from the European Society of Intensive Care Medicine (ESICM) that charts the progress intensive care has made over the past 25 years (Kuhlen et al., 2007). I commenced my nurse training in 1982 and moved into critical care nursing as soon as I qualified, so can remember the introduction of many of these developments. These include the intensive care nurse being responsible for delivering continuous renal replacement therapy without the support of a dialysis nurse; caring for patients who are lightly sedated rather than fully sedated and paralysed, and delivering a vast array of spontaneous modes of ventilation including non-invasive.
As medical knowledge has progressed, so have nurses developed the care they provide to their patient. When new practices are introduced it is frequently the nurse who is required to implement the change as the clinician closest to the patient. In fact, recent changes in practice such as the use of weaning and sedation protocols and the ventilator care bundle (Crocker, 2002, Crunden et al., 2005) have been championed by nursing staff. Aside from the moment of nostalgia, browsing through this book did make me think about the events that have influenced my patient care during the last 25 years. Despite the technical developments and the vast number of research papers produced over this time, the most powerful memories I have are those related to individual patients. These patients or the care they received, have prompted me to stop and question and frequently they have been the catalysts for change. Early in my career when it was more common for children to be treated in an adult intensive care unit (ICU), I nursed a small boy following a serious head injury. I found it difficult caring for a child as all my post-registration experience was with adults, and his mother found it distressing that he was cared for in an adult environment. As a result of this experience, I spent some time working in a paediatric ICU and developed with them, guidelines to help provide care to children in the adult ICU. During this time I met his mother to identify practical solutions to her distress about the adult environment. At the end of this we simply put together a box of toys, mobiles and posters that could be easily placed in a bed space to provide a child friendly environment. Hopefully we both felt that we had ‘improved’ future care and that our individual concerns had been listened to and acted upon.
The ‘power of one’ event to highlight deficits or to instigate innovative means of caring can apply in many situations from the unusual to the everyday. It should inspire individuals to query practice, prompting the question ‘why do (or don’t) we do that?’ and is then the catalyst to investigate further and perhaps bring about change. Recently our ICU team transferred a relatively dependant but terminally ill patient home. This was prompted following a comment by a member of the family and was the trigger to rethink how the patients care might be provided at home. The process clearly required some thought and planning; nevertheless bureaucracy was not allowed to over ride the family's wish that this patient should die at home. Community and hospital services galvanised to do the right thing, at the right time; surely this is what nursing and individualised patient care is about. More importantly it provides an important message to colleagues to encourage them to question the care they are providing and nurse patients as individuals which sometimes means doing things differently.
Likewise case studies are a valuable tool to learn from an individual patient or situation. By publishing unusual cases, clinicians not involved with the original patient or situation can learn from them. Recently two interesting cases have been offered in the critical care press, Coombs (2007) presented a case of cocaine-induced myocardial infarction and Creagh-Brown and Ball (2008) a case of salbutomol-induced lactic acidosis. However, a look at the wider nursing press demonstrates how rarely nurses report on individual patients. I think this is a deficit and agree with Coombs (2007) that this is something we should support and encourage. A suggested format might be as follows:
However, it is important to use single case experiences and interpret single centre or one off research reports with caution. The ability for one study to alter practice has been impressively demonstrated by the surge towards and subsequent move away from tight glycaemic control (van den Berghe et al., 2001). Successive research groups have failed to achieve the outcomes reported in the original study; however, there is no doubt that there has been a world wide shift in practice. Similarly, Annane et al. (2002) published their paper identifying a benefit of steroids in the septic patient. Despite the evidence being from a single report the results were included in the sepsis guidelines (Dellinger et al., 2004) which have been latterly removed following a subsequent trial demonstrating no difference in survival in patient who received steroids in septic shock (Sprung et al., 2008).
So what does this tell us? Great ideas can grow from single events, but the ‘power of one’ is just the conception of an idea, the early presentation of a problem or perhaps even the early shoots of a solution, but it is not the end in itself. A solution for one patient may not be the solution for another, however sharing that information in a publishable form enables us, as a wider body of nurses to develop the initial ideas, perhaps improve on them but certainly to discuss and debate them. If we do not publish or present our findings or put our thoughts forward for debate we are in danger of loosing a part of the complex picture that is intensive care. Knowledge is power and multiple pieces of information are the way this speciality will grow and develop. However, like all things the initial concept commonly originates from something very small and can be the ‘the power of one’.
References
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- In: Kuhlen R, Mereno R, Ranieri M, Rhodes A editor. 25 years of progress and innovation in intensive care medicine. Berlin: Meddiizinisch Wissenschaftliche Verlagsgesellschaft; 2007;
- Hydrocortisone therapy for patients with septic shock. New England Journal of Medicine. 2008;358:111–124
- Intensive insulin therapy in the critically ill patients. New England Journal Medicine. 2001;345(19):1359–1367
PII: S0964-3397(08)00073-6
doi:10.1016/j.iccn.2008.07.002
© 2008 Published by Elsevier Inc.
