VOL: 98, ISSUE: 40, PAGE NO: 32
Philip Woodrow, MA, CertEd, DipN, RGN, is practice development nurse, critical care, East Kent Hospitals NHS Trust, CanterburyIf you work on an acute ward your handover notes may be made up mainly of: lists of intravenous infusions and drugs being administered through syringe drivers and infusion pumps; continuous oxygen; hourly urines; and two-hourly observations for critically ill patients. If this sounds familiar, you are probably one of many nurses struggling to provide the best care you can for patients who should ideally be in intensive or high-dependency care.
If you work on an acute ward your handover notes may be made up mainly of: lists of intravenous infusions and drugs being administered through syringe drivers and infusion pumps; continuous oxygen; hourly urines; and two-hourly observations for critically ill patients. If this sounds familiar, you are probably one of many nurses struggling to provide the best care you can for patients who should ideally be in intensive or high-dependency care.
Over the past decade increasing numbers of critically ill patients have been cared for on acute wards (Haines and Coad, 2001). This is the result of a number of factors, including:
- An increasing emphasis on NHS productivity;
- Advances in drug therapies and other treatments enabling more patients to survive previously fatal illnesses;
- An ageing population;
- The limited availability of critical care facilities forcing acute wards to manage critically ill patients.
While politicians clash over crises in health care, staff on acute wards quietly try to provide quality care. Government funding and initiatives relieve some of the worst pressures, but the solution lies in longer-term strategies.
The UK has the worst provision of intensive care unit beds in Europe (Daly et al, 2001), so critically ill patients are being cared for on acute wards (Miranda and Nap, 2001).
Vincent et al (2001) found that more than 10% of inpatients experienced adverse events while in hospital, half of which were preventable. The costs of such events, whether measured in a patient's reduced quality of life or an increased workload for staff, are high. Research shows that poor outcomes and some deaths are potentially avoidable (McGloin et al, 1999).
Ward nurses are best placed to identify early indications of complications and initiate appropriate interventions (Gibson, 1997). However, preregistration education does not adequately prepare most of them to provide the level of care needed by many patients.
Welch (2000) says nurses need to be empowered by knowledge provided through education and professional development. They should be allowed to initiate more interventions without waiting for medical staff, for example through the use of patient group directions.
Critical care reviewed
Comprehensive Critical Care: Review of Adult Critical Care Services (Department of Health, 2000), recommended some radical changes which could significantly alter acute care services and the workload of staff on acute wards. However, few staff working in this area have heard of the document.
The report recognises that critically ill patients are being nursed on acute wards and that this situation is not likely to change. It recommends 'replacing the existing division into high dependency and intensive care based on beds by a classification that focuses on the level of care that individual patients need, regardless of location'. In other words, developing critical care without walls.
To achieve this, wards caring for critically ill patients must have the necessary resources to provide appropriate care, and these resources must include funds for staff development. The report recommends providing education on high dependency care for all ward staff in acute hospitals. It sets targets for half of ward staff to receive this by March this year, with the rest doing so by March 2004.
Although the report's recommendations could significantly improve patient care, and the working conditions and job satisfaction of staff, expectations of what can be delivered need to be realistic. It will not reverse the root causes of critically ill patients being cared for on acute wards, such as chronic NHS underfunding, low staffing levels, pay and morale, and the pressure of excessive workloads.
The Comprehensive Critical Care review (Department of Health, 2000) suggests that critical care exists wherever there are critically ill patients. Therefore, the recent position statement from the British Association of Critical Care Nurses (Pilcher and Odell, 2000), which defends nurse-patient ratios of 1:2 for highly dependent patients in critical care, should lead to increased staffing levels on wards caring for this patient group.
However, nurse recruitment and retention is a problem and is likely to remain one for the foreseeable future.
Before the publication of the Comprehensive Critical Care review (Department of Health, 2000), East Kent Hospitals NHS Trust and the Kent Education Consortium decided to address the issue of critical care education for ward staff by funding a trust-wide five-day course. I was appointed in February last year to facilitate it and further developed it after consultation with senior staff and evaluations from those who completed it.
The course is divided into five themed days (Box 1), which are delivered one day a week on each of the trust's three main sites. Whenever possible, specialist speakers are invited to lead relevant sessions. The aim of the course is to:
- Provide knowledge and resources to support the care of highly dependent patients;
- Support evidence-based practice;
- Encourage continuing professional development;
- Challenge rituals of practice.
There are a maximum of 12 places on each course, and 20 courses were run during the last financial year.
On the first day of the course staff are encouraged to view care from the perspective of acutely ill patients and their relatives. The importance of assessment and prioritising, particularly respiratory assessment and monitoring, are emphasised (McQuillan et al, 1998; Kenward et al, 2001).
On the second day a range of respiratory problems, treatments and aspects of care are explored, while on the third day the focus is on cardiac problems and care.
On the fourth day of the course experts explore how the failure of various body systems can complicate critical illnesses and show what types of care can limit complications. To emphasise holistic nursing, this session concludes with the focus on the needs of patients and relatives rather than on diseases.
How to apply these lessons in practice is dealt with on the final day. Time is also allocated for a negotiated session. Topics in this session have included: blood results; pancreatitis; head injury; diabetes and diabetic emergencies; and Guillain-Barre syndrome. Staff are also invited to describe how they have been able to use the course in clinical practice.
Although practice is expected to be evidence-based (Department of Health, 1999), in clinical practice nurses tend to rely on trusted individuals to provide reliable information rather than on texts and electronic sources (Thompson et al, 2001). The course, therefore, aims to provide evidence for use in clinical practice.
There is a danger that such evidence can be applied uncritically (Ballinger and Wiles, 2001) and staff are encouraged to reflect both on the course and on how it applies to clinical practice.
To support this, the course handbook includes recommended further reading and resources, together with portfolio-style pages to reflect on study days, clinical practice and career development after the course has been completed.
To encourage evidence-based practice, most sessions are supported by recent evidence and recommended further reading, as well as printouts for staff.
For a long time, nursing has been disadvantaged by a gap between theory and practice (Cook, 1991; Conway, 1994). To prevent this from occurring in my work I spend one day a week giving direct patient care. I also support individuals and staff in the environment of their own wards.
Anecdotal evidence from staff on recent courses suggests that those from earlier intakes have used the knowledge gained to challenge and change practice. For example, fan therapy is no longer used on patients with pyrexia.
Staff are also asked to evaluate each session individually, as well as the course as a whole. The feedback has been strongly positive and has helped to develop the course to meet the needs of staff.
The most common concern is the pace at which the material is presented and many ward staff have suggested that the course should be extended. This is not practical but those who are interested are advised to sign up for further specialist courses.
The Department of Health has acknowledged that critically ill patients are being cared for in various ward areas, creating staff development needs that are often not met. Its recommendation to provide modules on high dependency care for all acute hospital staff coincided with East Kent Hospitals NHS Trust's plan to provide a five-day course on this area of care.
Staff on acute wards face many problems, but courses such as this improve patient care, providing incentives and resources to improve morale, recruitment and retention.