HOW MUCH DOES THE ART AFFECT THE SCIENCE OF CRITICAL CARE?
Nursing practice is described by what we know, what we do, and how we care. Although there is a shared a common foundation for each of these domains, they differ widely depending on the nursing specialty. Each of our fields has developed tools to evaluate the specific knowledge and skills required. In addition, we have developed tools to evaluate our caring practices and the art of nursing. These tools are widely applicable to all areas of practice and focus on communication skills, on relationships with patients and their families, on the ability to identify and meet an individual patient's needs, on moral and ethical behaviors, and on empathy and compassion. Watson and Sitzman1 recently published a book describing a wide range of tools that have been developed and validated for measuring caring practices. However, these tools require patients to be relatively aware and able to express themselves.1,2
In the intensive care unit (ICU), this is not always the case. Patients often lack the ability to identify or express the causes of their distress. The severity of illness as well as the multitude of interventions, drugs, and devices required for intensive care often decrease patients' level of consciousness while increasing their level of discomfort. Therefore, the need for physical comfort and stress reduction may be all they are aware of. In these conditions, meeting those needs often becomes a therapeutic intervention.
During my 50 years of critical care nursing practice, I taught, followed students, and made rounds in dozens of critical care units around the United States and other countries. I observed thousands of nurses in action. I became aware of the wide gap between those who gave the comforting arts of critical care nursing a high priority and those who only completed their list of tasks. I talked to many nurses who have made the same observation.
Some ICU nurses seem to give little attention to the comforting arts of nursing. They enter the patient's room, turn on the lights, concentrate on devices, fulfill the necessary tasks, and leave with little interaction or acknowledgment of the person in the bed. On the other hand, there are nurses who place a higher value on comforting and caring practices. They maintain focus on the patient, give eye contact, touch to reassure, ask patients how they are and what they need, tell them what they are doing and what is planned even when the patient's awareness level is questionable, and gently touch or move the patient when performing their tasks. Before they leave, they assess the patient from head to toe for sources of physical discomfort and address them. They adjust the room environment to meet the patient's comfort and needs.
Another way of demonstrating the wide breadth of approaches is to look at it from the patient's perspective. Take a typical patient we will call Fred.
Fred has been in the ICU for 5 days, and he is becoming more alert. It is 6 am, and he is once again awakened by loud noises outside his room. Immediately, he wonders, should I drool or swallow? The tube in his wind pipe is irritating, and when he swallows, it really hurts his throat. When he doesn't, the puddle of mucus on his pillow under his cheek grows. Also, right now, his tongue is caught between the tube and his teeth, but when he tries to move it, he tastes blood so he abandons the effort. Next, he becomes aware of the hair in his eye that has been there for hours, causing an awful one-sided headache. He can't reach up to flick it away because his arms are restrained by the tubes and lines draped over and around them. Once earlier he did manage to get his hand up to his face, but his nurse ran in, told him to stop thinking that he was going to pull out the tube, and further restrained him. Now, in addition, he feels something hard imprinted under the right hip. By the size, shape, and feel, he thinks it is a syringe someone left there and hopes whoever finally finds it will show him what it is. As he squirms, his foot catches and pulls on his Foley catheter only amplifying his struggling.
Just after the change of shift, his new nurse walks in, sees his agitation, frowns, turns up his sedation, and walks out. What if instead Fred had a nurse who practiced these unique arts of critical care nursing? This nurse would walk in, hold Fred's hand, look into his eyes, and, speaking slowly and softly, would tell Fred the plan. “I can see that you're having a bad time this morning. Here's what I want to do. I am going to assess you for all the things that are making you uncomfortable. As I run my hand down slowly from head to toe, I want you to move your hand up when I reach some place that is bothering you. I will stop, figure out what it is, and fix it. Next, I will free your arms so you can move them around and point to any areas I have missed. After we have done all that, I will change your position, make you as comfortable as I can, and fix the lighting and temperature so that you can get some rest. Then, I will go out to the waiting room and bring your wife in. I know she has been very concerned because she can see that you haven't been resting well so she would probably like to hold your hand while you fall asleep. How does that sound Fred?”
It is not hard to imagine how different the patient's experience and response would be. During a pandemic with visitors banned and patient-family interactions relegated to virtual tools, the impact is even more intense. Family members are often more sensitive to the patient's basic needs and, under more normal circumstances, can even be taught to tend to them. The COVID crisis has nurses struggling to act as both the patient's nurse and his or her family surrogate. These struggles are hampered further by the need for nurses to wear protective gear that interferes with the sense of touch, hide facial and eye expressions, and may add to the patient's sense of fright and confusion. Nurses are coached to enter the room only when necessary and limit physical contact. At the same time, there are many dying patients who need comforting and should not be left alone. In addition, there are often periods when ICUs are overwhelmed with increased numbers of high-acuity patients, which require nurses to carry a higher patient load and work longer hours under tremendous duress. All these conditions interfere with the nurses' ability to practice the art of nursing at a time when patients may need them most.
These observations would be important for humane reasons alone, but there are other concerns as well. Although communication, caring, and interpersonal relationships between the critical care team and the patient or family have been fairly well researched, these more basic comforting practices have not been well defined or studied.1-5 What if they are important? What if, operating in the background of many studies in the field of critical care, these caring practices are having a significant impact on results? It seems obvious that the presence or absence of attention to these patient needs could dramatically impact many outcomes and variables commonly studied. Wouldn't the level of these arts a nurse practiced affect the patient's blood pressure, heart rate, respiratory rate, level of pain or anxiety, and need for narcotics or sedatives; the incidence of delirium or sleep disturbances; the level and adverse effects of stress; the length of stay; long-term outcomes; or the incidence of post–intensive care syndrome?
Critically ill patients are most vulnerable to the adverse effects of physical and emotional discomfort and cannot always give voice to their feelings or needs. The impact of these caring practices should have the most profound effect in the ICU, but it is probably also important in other specialties such as hospice and palliative care.
We do not know how much these differences confound critical care study results primarily because we have no tool to measure the level of these unique arts of critical care nursing practiced by individual nurses. What is lacking is identification and recognition of the broad range of physically comforting practices that address the potential causes of discomfort and stress caused by critical illness and our interventions. Once they are recognized and a measurement tool is developed, their impact on patient outcomes can be studied.
Granted, developing such a tool would not be easy, but it is possible. A workgroup of expert clinicians and researchers could be convened to review what little research has been done, conduct observational studies of relevant nursing practices, and compile a list of possible key elements. The list would be composed of behaviors that nurses use to address the basic human needs and physical discomforts in ICU patients who have limited ability to communicate. This list of elements could be developed into a tool that would then be piloted and modified as necessary.
This new instrument could eventually be used to measure this variable's impact in relevant studies of the critically ill.4 For example, research questions could explore whether or not the level of these behaviors practiced by the ICU patient's nurse affects the incidence of delirium, the need for sedatives or narcotics, the length of stay, or the incidence of postdischarge posttraumatic stress disorder.
If found to be significant, there would be even more reasons beyond those dictated by ethics, compassion, and professional responsibility to explore ways to foster these higher arts of ICU nursing practice. We would also have to determine whether and how such care can be effectively fostered if it is not already part of a nurse's basic personality, value system, and practice.6-8
Beyond the impact on patient outcomes, does the degree of comforting caring arts practiced by ICU team members affect job satisfaction, unit culture, or the incidence of burnout?9-13 There are clearly some clinicians whose mere caring presence has a calming and positive effect on a chaotic critical care environment. There are others whose presence tends to rev things up and add to the stress in the unit. Should caring and comforting practices be given a higher priority in hiring and recruiting new team members? The COVID crisis has highlighted how much the ICU team members turn to each other for support and comfort.
I have been raising these issues for the last few decades in various ICU circles to little avail thus far. Critical care clinicians quickly recognize and relate to the description of this wide variation in the practice of these caring practices. However, I have not been able to motivate them to form a work group and begin to address this issue. With the outpouring of compassion and concern the COVID crisis had caused for both ICU patients and staff, now the time may be right.
Major roadblocks include the difficulties of developing a measurement tool, the desire of many researchers to conduct studies in hard science, and the fear that raising the possibility that some clinicians need to be more caring in their practice may have professional or social consequences. As the complexity of critical care nursing has increased and the demands placed on our time and attentions have intensified, the art of nursing may be endangered in the environment in which patients may need it most. I am convinced that it is far too important a factor in ICU patient care to remain unstudied, unrevealed, unrecognized, and uncelebrated. It is time to address the issue and determine its relevance. The question deserves an answer.
The public has always ranked nurses as one of the most highly respected and trusted professions. During the COVID crisis, the world has been in awe of what they saw critical care nurses doing to meet incredible demands with great humanity and compassion. We have been repeatedly referred to as heroes. I have never been prouder to be a nurse, and I am even more convinced that the art of nursing is at the core of our essence.
We are critical care nurses for what we know, what we do, and how we care. Our education and technical skills are valued and can be documented. Our art of comforting practices is valued but not well documented. How can such an important deficit not stimulate a cry for action? I look forward to the day when critical care nurses clamor for recognition of this key aspect of their practice.
Maurene A. Harvey, MPH, MCCM
Glenbrook, Nevada Maurene46@gmail.com
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