From the past to the future

This seems to be the season for reminiscing. In the last issue Belinda Atkinson pondered on Greek temples. Since then many people in many parts o f the world have been celebrating Victory in Europe Day all over again, and reviving old memories. VE Day in 1945 seems a long time ago - a time when clinical use o f penicillin and streptomycin was still relatively new, when haemodialysis had hardly started, and blood transfusions were given through rubber tubes which had to be washed carefully after use and returned for re-sterilisation. It was still 7 years before the poliomyelitis epidemic in Denmark which stimulated the development o f mechanical intermittent positive pressure ven- tilation, a technique which is an essential fea- ture o f most intensive care units (ICUs) now (though in more sophisticated forms, o f course).

But even for those of us too young to have played an active part in the war (or too young to have been alive then!) that part of history is still relevant. For many nurses it led to a time of political freedom and a society which, while not perfect, has allowed nurses and nursing to develop in meeting people's needs in a changing world. Yes, it has sometimes been a struggle; but one o f the many changes in nursing in the United Kingdom (UK) has been the more gen- eral development of nurses' skills and ability to make decisions, to produce planned change, and to be accountable for it. There have always been a few innovators who have done this, but through education and professional develop- ment far more nurses are now prepared for it. In the upheaval of constant reorganisations in the National Health Service a number o f nurses have managed to use the currents o f change to produce improvements in patient care, some- times 'swimming against the tide', and even producing new roles. Just as beneficial develop- ments in medical treatment and care have often occurred during the horrors of war, so in the trauma of NHS changes one o f nurses' responses has been to begin to make more explicit what it is that nurses contribute to health care, which is more than just implement-

ing medical orders. The development of know- ledge, through research, about the outcomes and cost-effectiveness o f nursing is vital to the welfare o f patients/clients, nurses and nursing. But we have had to be 'pushed' to do it.

A look at Central and Eastern Europe, where nurses have comparatively recently gained freedom to communicate with nurses in other countries and try out some of the innova- tions from the West, should remind us o f the benefits o f a long-established democracy which nurses in the UK take for granted. We may not always like the institutions and authorities we have, but we can vote and use the systems to

• change them. Some nurses in Eastern Europe are making considerable progress in trying to achieve quickly what it has taken many years to achieve in the West. But they face even greater problems than we had in developing intensive care and nursing generally.

Another reason why World War II is still relevant in intensive care is that there are still many people who carry horrific memories from those times. These memories may 'come alive' in the traumatic situation o f being a patient in an ICU. The physical constraints, frequent disturbance and discomforts, and strange people and machines can evoke delu- sions of imprisonment and torture for any patient, but particularly those who really have been in such situations. It can help in nursing such patients if one knows a bit about the past; and age, national origin and other such cues may prompt enquiries to the family as to whether the patient has had any traumatic experiences in the past.

One of the greatest &fences against psycho- logical disturbances in ICU patients seems to be maintaining the normality o f life for them as much as possible. It is interesting that this issue contains both a paper about such disturbances and their causes (Dyer p. 130), which remain a problem for patients and nurses, and one about 'awake ventilation' (Monger p. 140). This prompts more reminiscence - about an ICU where in the 1960s the principle followed was that patients would feel better and progress bet- ter if enabled and encouraged to do and have as much as possible o f what was normal for them. The patients had varied problems from open- heart surgery or crushed chest and multiple injuries to myasthenia gravis and thymectomy. Paralysing agents were used only when there were specific reasons related to the individual patient; analgesics and sedatives/tranqnillisers were given as necessary to help patients settle to the then fairly primitive ventilators, to relieve pain, or distress for example during deliberate paralysis. But most patients were 'awake' unless their illness caused unconsciousness, or their condition was grossly unstable; and many

In~ensive and Critical Care Nursing (199B) I f , J21-122 © J 99S Pem~on Professional Ltd

122 Intensive and Critical Care Nursing

enjoyed sitting in a chair, despite numerous attachments, as a change from bed rest. The portable television, provided by the senior sur- geon, was popular with long-term patients. Those who could eat were encouraged to do so, and those who needed tube-feeding received liquidised food, instead of the milk and Com pl a n mixes used elsewhere, which gave many people diarrhoea. One of the advantages o f all this, particularly for patients with chronic respiratory disease, was that patients who had already been active to some extent were much more ready to begin to become more active as they were weaned from the ventilator, which appeared to help them. It is true that the unit had been designed to look pleasant as well as being functional, with noise reduction features to allow patients rest and sleep when possible.

All this was before Orern's model was pub- lished in 1971 (Orem 1985), defining as one o f the eight universal human self-care requisites normalcy 'The promotion o f human function- ing and development within social groups in accord with human potential, and the human desire to be normal.' (Orem 1985, p. 91). Probably nurses in other places and perhaps other ICUs had similar ideas. Sometimes nurses do the right things through intuition, experi- enced observation and reflection. But it is even better if ideas and methods can be tested and evaluated systematically through research, to add to knowledge for the future; and that is the difference between the 1960s and now.

I am delighted that Monger a n d her col- leagues are considering critically the advantages and disadvantages o f 'awake ventilation', and the different challenges it offers to nurses, If one encourages normality for patients as far as possible it seems likely that, at least sometimes, their bodies will be more likely to function normally; the 'skilled habitual body' described by Benner (1989, p. 71) will take over as the patient's condition improves. As Benner says 'We have adequately exploited the potential of the habitual, skilled body neither in rehabilita- tion nor in acute care settings, where the envi- ronment may strip the patient o f the possibility o f responding in habitual, skilled ways' (Benner 1989, p. 74).

There is much scope for trying to restore more o f their normality and normal function- ing to patients in ICUs, even though there has been progress; and for evaluating the effects of this by research.

Looking at the past can be useful - as long as it leads to consideration o f the present and progress in the future.

REFERENCES

Benner P, WrubelJ 1989 The primacy of caring. Addison- Wesley, New York

Orem D 1985 Nursing: concepts of practice. McGraw- Hill, New York

Pat Ashworth Editor