Guest editorial

itical | ' f r o "

care - sniT lng undaries and open ing the

_Jors

With 1999 comes an exciting new era: a formal link between the RCN Critical Care Nursing Forum and the Intensive and Critical Care Nursing journal. It is anticipated that this new partnership will have benefits for both parties (including, of course, reduced subscription to the journal for Forum members). This move provides an ideal opportunity to re-visit the arena of critical care nursing; what is it and where is it provided? The first of these questions is one we focus on from time to time at our Forum meetings. The Forum embraces all aspects of practice where nurses are caring for patients who are, or have potential to be, in a life-threatening condition but might recover with appropriate care. Our focus, however, is on the nursing aspects of critical care: that relationship between the nurse and the patient/family that is about so much more than physiological measurements. Some of the work undertaken by the Forum in recent years, often in conjunction with the British Association of Critical Care Nurses, has focused on articulating aspects of that relationship in order to inform, for example, work at the Department of Health (1996) and the Audit Commission. It is unfortunate (but perhaps inevitable) that such work has often had to focus on specific aspects of care, (for example the Critical Care Forum telephone survey; RCN 1997), rather than the totality of the nursing relationship. However, discussion across professional boundaries requires the use of a common language and currency; articulating some of the clinical decisions nurses make provides an area of shared understanding from which discussion and recommendations can move forward.

There is a tendency to use the terms 'critical care' and 'intensive care' interchangeably. Within

our own committee structure, we have encouraged members from non-ICU areas of critical care to stand for election, to broaden our outlook. As a result (see page ...), we have representation from coronary care and high- dependency care, as well as research, education and management. All committee members are elected by the membership, so it's in your hands!

Critical care has been high on the agenda in various quarters over the past few years. Three years ago, the Department of Heath published guidelines for admission and discharge for intensive care unit (ICU) and HDU patients (Doll 1996), the English National Board have commissioned a review of all critical care nursing courses (publication imminent) and the Audit Commission are exploring the overall configuration of critical care services. In addition, the media have highlighted deficiencies in the service.

This publicity prompts us to explore how and where critical care is provided. Contemporary definitions of intensive care and high- dependency care focus on levels of care rather than geographical location (Doll 1996). A feature of the Augmented Care Period (ACP) dataset (Doll 1997) is that it enables identification of critical care being provided in areas like recovery units and provides the opportunity for nurses to identify those coronary care patients who receive a level of organ support equating to intensive care. The current study being undertaken by the Audit Commission has similar threads. The acknowledgement of these periods of augmented care as 'levels of care' rather than locations emphasizes the potential need to provide critical care in ward settings. It also perhaps reflects a

4 Intensive and Critical Care Nursing (1999) 15, 4 -5 © 1999 H a r c o u r t Brace & C o m p a n y Ltd

Guest Editorial

wider trend; the Heathrow debate ( D o t 1994) suggested that hospitals of the future would become 'high technology centres offering intensive, and specialised, care'.

A key role of both medical and nursing staff in the general wards is the early recognition of deterioration in the patient 's condition ( D o t 1996); this appears to be one of the key missing links in the chain of 'seamless ' critical care. Data from a recent confidential inquiry highlight this as an area needing urgent attention, with patients frequently admitted too late and too sick to ICU (McQuillan et al 1998). From the nursing perspective, maybe we are reaping the effects of displacing ward staff in some aspects of their rote. One of the dangers of the ICU staff attending cardiac arrests in the wards (in addition to the cardiac arrest team) was the perception of 'here comes the cavalry' with ward staff moved to the sidelines. Wherever specialities develop, there is a danger of the 'specialists' taking the moral high ground and condemning (with varying degrees of subtlety) those without that knowledge and skill. But perhaps, in the past, we were also part ly to blame, as critical care practitioners, for not anticipating need and providing support. There is sometimes an issue with work carried out "behind closed doors ' , conveying the impression of secrecy and elitism. It is also important to recognize that nurses working in acute medical or surgical wards do not have the luxury of the relationship with one or two patients that (perhaps) makes it easier to identify those subtle changes in the patient 's condition.

Given the findings of McQuillan et al (1998), it is also important to acknowledge the increasing trend towards managing critically ill patients, or undertaking procedures once deemed 'critical care', in the wards. This is reflected in recent developments in nursing practice; early data from the aforementioned Audit Commission s tudy demonstrate some interesting findings. Ninety-four per cent of the 243 Units responding stated that critical care nurses visit wards to

advise on specialist areas of care, whilst on 70% of the Units, critical care nurses visit wards to liaise regarding the admission and /o r discharge of patients (Waite 1998). Coad (1998) provides insight into an innovative role for ICU nursing staff supporting nurses caring for ICU patients in wards. In order to promote inter-professional debate regarding the future configuration of, and support for, critical care, it is important for developments such as this to enter the public domain, through both conference presentation and publication.

It is crucial to share experiences and expertise across specialist and professional boundaries. The changing pattern of critical care provides both opportunity and motivation for critical care nurses to take the lead.

Ruth Endacott Chair,

RCN Critical Care Forum

References

Coad S 1988 Supporting staff caring for critically- iil patients outside the ICU environment: the development of a new educational role. Unpublished paper presented at BACCN National Conference, Manchester Conference Centre, October 1998

Department of Health (Dot) 1994 The challenges for nursing, midwifery and health visiting in the 21 ~ century (The Heathrow debate). HMSO, London

Department of Health 1996 Guidelines on admission to and discharge from intensive care and high dependency units. NHSE, London

Department of Health 1997 Intensive and High Dependency Care Data Collection: User's Manual for the Augmented Care Period (ACP) Dataset. NHSE, London

McQuillan P, Pilkington S, Allan A et al. 1998 Confidential inquiry- into quality of care before admission to intensive care. British Medical Journal 1853-1858

Royal College of Nursing (RCN) 1997 The nature of nursing work in intensive care: findings of a telephone survey. RCN, London

Waite D 1998 The Audit Commission: impact on critical care services in England and Wales. Unpublished paper presented at BACCN National Conference, Manchester Conference Centre, October 1998

© 1999 Harcour t Brace & Company Ltd Intensive and Critical Care Nursing (1999) 15, 4-5 5