roles of the allocated nurse and shift leader in the intensive care unit: findings of an...

Original article

Roles of the allocated nurse and shift leader in the intensive care unit: findings of an ethnographic study Ruth Endacott

In the UK, recent policy guidelines emphasize the role of nurses in managing the minute-by- minute care of critically ill patients (Department of Health 1996). This article reports on a study that explored the extent to which the nurse at the bedside (the allocated nurse) and the nurse in charge of the shift (the shift leader) make decisions about the needs of children who are critically ill. The study also identified areas of need using a modified Delphi study and explored how nurses perceive and act on the needs of critically ill children. These aspects are presented elsewhere (Endacott 1998a, 1998b, 1998c).

Ruth Endacott PhD, MA, RGN, DipN(Lond), Critical Care Researcher, Larch Court, Spreyton, Crediton, Devon EX17 5EA, UK Tel/fax: +44 (0) 1837 840024; E-mail: endacott@ eclipse.co.uk

(Requests for offprints to RE)

Manuscript accepted December 1998

This article is based on a paper presented at the 11th Annual Congress of the European Society of Intensive Care Medicine, Stockholm, Sweden, September 1998

Introduction

The intensive care unit (ICU) presents a strange environment to the uninitiated; apparently dominated by technology, with the patient in the midst. Not surprisingly, intensive care nursing is a complex mixture of roles, responsibilities and paradoxes. These complexities are also set within a range of issues facing the wider nursing profession, for example:

1. the nature of specialist practice, evidenced in the plethora of terms to be found in both the literature and on the duty rosters;

2. changes in the interface between medicine and nursing.

The aim of this study was to examine the work undertaken by the nurse allocated to care for a critically ill child, with particular reference to the way in which the needs of the child are identified, articulated and acted upon. The different roles of the allocated nurse and the shift leader, in respect of the needs of the child and the medicine-nursing interface, were apparent early on in the study and were explored in greater detail.

Background to the study

Nursing roles in intensive care

The importance of exploring and developing the nursing contribution to intensive care is evidenced in the funding provided by the King's Fund for two Intensive Care Nursing Development Units. Studies published by researchers from these two centres focus, in particular, on the critical care environment and therapeutic relationships (e.g. Scholes 1996; Scholes & Smith 1997; Scholes & Moore 1997) and the impact of primary nursing (e.g. Manley 1989, 1994; Manley et al 1996a; Manley et al 1996b) although work in both units is on-going.

Nursing roles in intensive care have undergone substantial change over the past few years, partly in response to technological advances and policy changes (RCN 1997), specifically the Scope of Professional Practice (UKCC 1992) and the reduction in junior doctors' hours (NHS Management Executive 1991). These policy changes are often viewed as a double- edged sword, giving nurses more autonomy to develop practice according to patient need, whilst

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Roles o f the allocated nurse and shift leader in the ICU

also forcing changes in the interface between nursing and medicine through altered medical staffing patterns. The net effect of these changes is an increased emphasis on the autonomy and accountability of the individual nurse (Endacott 1996; Endacott & Dawson 1997). A further factor influencing the role of nurses in intensive care is the increase, in recent years, in patient throughput in ICU (Audit Commission 1997, p.13).

Decision-making undertaken by nurses One area in which autonomy is evidenced is the clinical (as opposed to ethical) decision-making undertaken by nurses. Distinction is made between the two dimensions of decision-making, as the processes involved tend to differ. Ethical decision-making commonly involves discussion, often with the patient and /o r relatives as well as with intensive care staff, regarding treatment options (Watson 1993; Viney 1996). With the exception of resuscitation-type situations, such discussions can usually be conducted over a period of time, with the goal of consensus. Clinical decision-making in ICUs typically requires immediate action to enable treatment to continue, e.g. evaluation of the effects of changes in the patient's blood gas results and alteration of ventilation accordingly - 'minute-by-minute decision-making' (Doll 1996). This was evidenced in a recent telephone survey of intensive care nurses (RCN 1997). Detailed presentation of the survey findings is given by Endacott and Dawson (1997).

Such autonomy on the part of nurses does not appear to be found in all intensive care settings. In their study of the changing role of neonatal intensive care nurses, Harris and Redshaw (1994) found that areas of skill requiring nurses to make decisions were not yet accepted as part of the nursing role. Similarly, a European study exploring differences in the organization and management of intensive care in different countries (referred to as the EURICUS I study) found that nurses had very little participation in decision-making (Miranda et al 1998, p.18). The importance of decision-making also causes concerns amongst nurse teachers (Harbison 1991) who recognize the need to develop critical thinking abilities in students of nursing in order to prepare them for their future role.

Two perspectives on decision-making are evident in the literature: the rationalist analytical approach (reflecting the philosophy of Cartesian dualism) and the phenomenological, intuitive approach. In his exploration of clinical reasoning by medical students, Hammond (1980, cited in Hamm 1988, p.81) contrasted these two approaches, suggesting a cognitive continuum with analytical and intuitive cognition at opposing poles (the Cognitive Continuum Theory). He described the thinking that lies between the two as quasi-rational thinking. The theory proposes that tasks also lie on a continuum with analysis-inducing and intuition- inducing as the opposing poles. Features of the task - the complexity of the task structure, the ambiguity of the task content and the form of the task presentation - will influence the model of cognition adopted by the clinician. The theory of expertise proposed by Dreyfus and Dreyfus (and underpinning the work of Benner 1984) also focuses on analysis and intuition as key concepts but suggests that, as the individual develops expertise, he or she moves towards less analytical and more intuitive reasoning.

Whilst UK authors highlight the importance of intuition in informing the practice of intensive care nurses (e.g. Parsons 1994), developments in intensive care frequently take a rationalist approach, with the development of treatment protocols (e.g. Paediatric Advanced Life Support and Advanced Cardiac Life Support training) and the use of decision trees (Dowie 1997). Two possible explanations for this apparent paradox present themselves:

1. In the ICU, nurses and doctors often work in an interchangeable manner with respect to some aspects of clinical decision-making (RCN 1997). It is therefore not surprising that nurses tend to use the protocol (bio-medical) approach to decision-making. It is also suggested that nursing work is carried out 'in the context of medical care' (Cash 1995) and that nurses and doctors in ICU have a more equal role than in other settings - that of cus- todian (Briggs 1991).

2. As Dowie states, decision trees are not commonly employed at the bedside when the actual decision is made but tend, rather, to be available as backup, giving the nurse the confidence that the decision has a consensus

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Intensive and Critical Care Nursing

backing (Dowie R, 1997, personal communication). This may also reflect the current preoccupations with the legal context of care provision in intensive care units (Pace & McLean 1996).

Study methodology A case study approach, informed by ethnographic principles, was used to structure observations and interviews in one paediatric ICU and two general ICUs. Ethnography is associated with the importance of understanding the perspectives of the people under study and observing their activities in everyday life (Hammersley & Atkinson 1983). The research role commonly used in ethnography is participant observation, a role not appropriate for this study for a variety of practical, professional and ethical reasons, hence the pure ethnographic approach was not used. Data were collected through observation of care in the natural setting (paediatric and general ICUs) and interviews with the key informants who had been observed. Following initial data analysis, a focus group interview was conducted to explore the patterns of activity observed. The focus for data collection was strategies used to identify, legitimize and act on the needs of the critically ill child.

Study findings Role of the allocated nurse

The allocated nurse played a pivotal role in deciding whether a change in the child's condition (e.g. altered blood gases) represented a need. This decision often included reference to contextual information regarding the individual child's reaction to procedures like suction or change of position, or his response to altered physiology, as seen in the following excerpts from the observation transcripts:

ignore the high PA (pulmonary artery) pressures; they're just him

he gets bronchospasm really quickly

An indicator of the nursing role in the clinical management of the patient is identified as the need for nurses to titrate fluid and drugs (Doll 1996, p.18). In all three units, some drugs and infusion fluids were prescribed within parameters, rather than at set doses. This

indicates that nurses were expected to use their clinical judgement in deciding how much of a drug or fluid to administer. Whilst such prescriptions were commonly written to titrate dosage against one physiological parameter (e.g. urine output or blood pressure), in practice nurses exercised clinical judgement in deciding whether a change in that parameter warranted an alteration in the drug/f luid infusion rate or was merely a transient change resulting from nursing or medical activity (e.g. change of position or endotracheal suction).

The allocated nurse used three types of strategy when managing the needs of the child (Endacott 1998c):

j u g g l i n g - concentrating on getting the job done or 'keeping all the balls in the air'; p r i o r i t i z i n g - deciding which aspects of care could be safely left until later; g a t e - k e e p i n g - co-ordinating the overall pattern of activities and (often) ensuring the child had as much sleep and rest as possible, usually by preventing doctors from putting in new lines, etc.

Further examples of prioritizing were collected in a quantitative manner when one activity was delayed because of another (e.g. the recording of observations delayed because the nurse was discussing the child's care with parents) - see Table 1.

An earlier stage of the study used a modified Delphi technique to explore the needs of the critically ill child using scenarios. The panel (Paediatric ICU Sisters) were asked initially to identify the needs of the child and, in subsequent rounds of the study, to indicate the importance of each need and the frequency with which each need should be met (Endacott 1998b; Endacott 1998a). The prioritizing data in Table i were analysed in the light of the modified Delphi data in two respects:

1. whether the priority given to one need over another (in the observation) reflected the decisions of the modified Delphi panel;

2. whether the length of delay was appropriate in the light of the modified Delphi results.

For each of the priorities, the decision was the same as that of the modified Delphi panel. However, with four of the delayed activities, the delay observed was longer than the median 'Maximum Acceptable Delay' score provided by the modified Delphi panel. On three of the four


Roles o f the allocated nurse and shift leader in the ICU

Table 1 Prioritizing data: activities delayed and the reasons for the delay

REASON FOR DELAY

Time MPT Family Family Awaiting N-N Assist with Case Delayed activity (mins) Bagging Suction disc. d isc . support family CXR disc. procedure Other

G1 Charting observations 5 G2 Temperature 5 G3 Ventilator observations 3 G3 Fluid balance 7 G3 Ventilator/monitor obs 10 G3 Temperature 21 P1 Wash P1 Fluid balance calculations 12 P1 Charting observations 4 P1 Charting observations 45 P2 Charting observations 22 P2 NG feed 30 P2 Charting observations 5 P2 Drug administration 30 P3 Charting observations 7 P3 Fluid balance charting 35

P4 Charting observations 17 P4 Chest physio 10 P5 Charting observations 5 P6 Charting observations 30 P6 Eye care/mouth care P6 Change drug infusions P6 Nursing care P6 Suction P7 Observations/fluid balance 7 P8 Charting observations 20 P8 Eye/mouth care P9 Charting observations 5

(.,9

,/ ,/

J ,/ 4

4

¢,

(J) (¢) J J / 4 J

(4)

4 4

09 09

4 4

4 (4) (4)

4 Prevent extubation

,I Arterial line v" Arterial line. Giving

colloid 4 Liver USS 4 Grandparent visit

4 Awaiting mum 4 New chest drain 4 New chest drain 4 New chest drain

4 Checking IV lines

v" Awaiting mum / Checking drugs "for

colleague

Key: 4 Prioritizing accorded with the modified Delphi data; (V') Prioritizing in accordance with the modified Delphi data but longer time delay than advocated by the Delphi panel median. Where no time is provided, the delay extended beyond the period of observation. MPT disc. Discussion between members of the Multi-Professional Team. N-N disc. Discussion between nurses.

occasions, the activity being delayed was the recording of observations. As patient assessment is an on-going visual activity, frequently carried out concurrently with other activities, it would be inappropriate to state that, on these three occasions, the child was not being safely monitored. With the fourth activity, the contextual field notes are of value as this situation involved the titration of colloid infusion fluid in a baby who was critically sick. Assessment of her cardiovascular status was on-going and reflected in the constant monitoring of haemodynamic pressures, rather than the recording of fluid balance. These differences between the expert opinion (provided by the modified Delphi data) and observed practice highlight the contextual nature of intensive care activity. It may or may not be of relevance that the extended delays were all observed in the paediatric ICU. In each case the nurse was not concerned that the activity had been delayed. This could be interpreted as confidence on the

part of the nurse that other activities could take priority without causing harm to the child.

The most common reason for delay was talking with parents. This matches /suppor ts the Delphi results. Although the nurses did engage in 'social' conversation with parents, in each situation where care activity was delayed because the nurse was talking with parents, the conversation related to the child and was of an explanatory/suppor t ive nature. One aspect not documented in the modified Delphi study but causing considerable delay was discussion with medical staff, either individually or as part of the ward round.

The allocated nurse treated the child as an individual, addressing need according to that specific situation (for example, the age of the child, whether the child was ventilated, whether parents were present). Examples of these individual needs are provided in Table 2. Assessment was carried out according to the child's condit ion/perceived risk of deterioration,

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Table 2 Examples of individual needs

Factor Individual need I X .......... ! I " I I . ± ! i I I J J ~

Age Ensuring privacy and maintaining dignity with the older child Parental needs Awareness of Mum's need for a cuddle with her child before going home to rest Child's level of awareness Sedation scoring, providing appropriate stimulation Family role Leaving aspects of care for parents to do when they arrive;

Involving Dad in the bedside handover; Enabling the involvement of grandparents according to the wishes of parents

using, for example, visual assessment or moni tor ing of b lood gases.

Confl ict ing percept ions of need

It was apparent that, at times, doctors ' and nurses ' perceptions of need differed, in particular relating to which needs should take priority, as seen in the fol lowing interview extract:

we have different priorities because nurses are there all the time and concerned with just one child and family; medics have to consider others.

These differences in priorities became more evident w h e n the child was in a more stable condition:

our priority now is the family, ensuring that they know enough to understand and that they are doing all that they want to; the medics' priority is getting the investigations done.

sometimes they want to put in new drips and drains but other things need doing. You need to say 'go away for half an hour'.

they'd like him to wake up faster. They probably think we should be disturbing him to get his tube out but he's not ready yet .... he goes back to sleep again after suction so I know he's not ready.

This was explored further in the Focus Group Interview, where the experience of the doctors also emerged as a factor in the nu r s ing /doc to r conflict (numbers refer to focus g roup members):

(1) before we had intensivists, you did have to do a lot more gate-keeping in a crisis situation because there were so many medics involved (4) yes... (3) and as the nurse responsible for the child you'd say 'hang on, he's just done that; you don't need to do it again' or, you know, 'if he's going to intubate then you're not doing the LP (lumbar puncture)'.

(1) it's more co-ordinating isn't it? (3) yes and you were prioritizing for the medics, weren't you?

This conversat ion suggests that the roles adopted by the nurse differ considerably w h e n the doctor is an intensivist, requir ing less gate- keeping and co-ordinat ing and more of an assisting, assessing and anticipating role. Whilst it is impor tant to acknowledge that this difference in priorities was not observed by the researcher, it was also highl ighted in an interview on the paediatric ICU with a nurse who had previously worked in a general ICU. He stressed that one thing he wou ld do differently, having gained paediatric ICU experience, was to be more assertive with doctors and take a more active role in co-ordinat ing crisis situations.

Conf idence

The prioritizing under taken by the allocated nurse appeared to be related to confidence. The not ion of confidence was, however , heavily dependent not only on the amoun t of experience that a nurse had bu t also on eve ryday situations that could enhance or decimate that confidence. Dur ing the focus group, members felt that confidence was not a fixed asset bu t could drop, even with highly experienced specialist nurses. The whole issue of confidence was closely tied up with bo th medical and nurs ing skill-mix. The nurses needed to have confidence in the doctors as well as in themselves in order to be able to function effectively. However , one nurse stated very firmly that the less confidence she had in the doctors, the more confidence she needed in herself, to ensure that the child received the mos t appropr ia te care - a form of inverse relationship.

The personal knowing of self is also evidenced in the w a y in which the individual nurse approached the child 's care and was reflected in one of the Focus Groups:

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Roles of the allocated nurse and shift leader in the/CU

It depends on how you interpret what a need is. I think all of us would probably interpret a patient's needs slightly differently. And I think that causes a lot of conflict on the Unit, a lot of unnecessary problems because when you come in on a late shift you see things completely differently from the person on the early shift. You see things with a fresh mind, you've had a lay-in, had breakfast, and that person has been there since seven o'clock in the morning and some people will just come in and say 'what... have you been doing all morning?' Some people are that blatant or they wait until they've walked off the Unit to lunch and they're only actually two paces behind when they go 'God have you seen this chart?' you know, things like that.

Shift leader role

Shift leader activities related to the case study child fell into four categories:

1. presence: the shift leader would appear at the bedside, invariably look at the child and the monitor, stay for a brief while and then move on to the next patient.

2. information gathering: the shift leader would appear, ask questions about the child or parents and then move on. The distinction between this code and the previous one was the overt seeking of information. It is acknowledged that this was almost definitely also part of the 'presencing' activity but was not directly observable.

3. supportive involvement: activity coded in this manner usually involved the shift leader acting as a 'runner' , fetching equipment, checking drugs, sorting out equipment problems and generally assisting the allocated nurse. The onus of patient management lay with the allocated nurse, rather than with the shift leader. Different aspects of this activity involved the giving of reassurance or practical advice to the allocated nurse, e.g. ' try this, it might work ' or 'have you thought about . . .?

4. directive involvement: this code was used when the shift leader took over the management of the child's care. It was seen only when the allocated nurse had left the bedside and another nurse was temporarily caring for the child.

When a less experienced nurse was observed and the shift leader maintained a 'supportive involvement' rather than 'directive involvement'

role, the appropriateness of the shift leader role was probed during interview with the nurse. The response was that the role was entirely appropriate and that the shift leader was available should the nurse require more focused assistance.

The shift leader role was similar in the three Units, with the majority of contact involving presence, information gathering or supportive involvement. Directive involvement only came into play when the allocated nurse was absent from the bedside. The information gathering role was similar to that identified by Strange (1996) who, in his review of the handover ritual, described the shift leader's actions immediately prior to the handover, which involved going to each bedspace to ask the allocated nurse the current condition of the patient.

The shift leader role was explored in the focus groups; members highlighted difficulty for the shift leader if the allocated nurse could not prioritize, resulting in a different role for the shift leader. However, this difficulty was not directly observed by the researcher. One of the general ICU shift leaders revealed in interview that, if a major event was taking place (for example, re- intubating the child) then he would become more directly involved in the situation. Again, this situation was not directly observed during the data collection.

Discuss ion

The role of the shift leader

The patterns identified indicated that the shift leader did not control the bedside work of the nurse but provided advice and support as necessary, only intervening when his /her expertise was required. When gathering information about the child, the shift leader frequently relied on the judgement of the allocated nurse asking questions like:

Were the gases OK? What is there to report at handover?

Similarly, when the shift leader adopted the 'supportive involvement' role, the allocated nurse was given the lead as seen in the following question asked of the nurse by the shift leader:

How many times do you want me to suction?

The experience of the allocated nurse had an impact on both his /her own role and that of the

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Prioritizing and gate-keeping activity

Allocated nurse v

Shift leader Increasing experience of the allocated nurse

Fig, 1 impact of the experience of the allocated nurse on the roles of allocated nurse and shift leader.

shift leader, as seen in Figure 1: the less experienced nurse concentrated on juggling, getting all the tasks done and had limited prioritizing or gate-keeping skills. This resulted in the shift leader undertaking these aspects of management for the individual child, with obvious workload implications.

Several issues arise from the analysis of the shift leader role:

1. The workload of the shift leader would increase dramatically if there were several inexperienced nurses on the same shift. Given the importance of contextual knowledge, it would be difficult for one person (the shift leader) to achieve a depth of contextual knowledge about each patient in the intensive care unit.

2. In order for both roles to function (or interact) effectively, the allocated nurse and shift leader need to acknowledge the complementary nature of their roles.

3. Whilst support for junior staff is seen by the profession as part of the intensive care nursing workload (RCN 1995; Dol l 1996; RCN 1997), this is not necessarily reflected in staffing levels. These findings suggest that inexperienced ICU nurses need supervision, rather than support, with the shift leader (or an experienced colleague) assisting in activities such as the prioritizing of care and explaining the rationale for priority decisions.

Conf idence of the al located nurse

From the allocated nurse and focus group interview data, confidence would appear to be dependent on the feedback received from others and should be viewed in the light of the doctor-nurse interface (see Fig. 2). Whilst other professionals are also involved, it is the nature of this relationship that appears to have the greatest impact on the confidence of the nurse.

The following patterns suggest themselves:

1. Doctors' confidence in nurses is reflected on two levels: generally in the manner in which drugs and fluids are prescribed and specifically in conversations between doctors and nurses, with the doctor seeking the opinion of the nurse on clinical management issues.

2. The confidence of the nurse in dealing with situations and, more specifically with people involved in the child's care (parents and other professionals), depends on her own self- confidence.

3. The nurses' confidence in the doctors is reflected in strategies used to meet the needs of the child.

A fourth pattern, that of the doctor's self- confidence, would be interesting to pursue in future work. This was not specifically explored or observed during this study.


Roles of the allocated nurse and shift leader in the ICU

Fig. 2

Confidence in

Nurse I ,

Confidencein

Feedback mechanisms associated wi th nurse confidence.

-'K .... I Doctor

Conclusions and recommendat ions

The nurse at the bedside (the allocated nurse) played a key role in identifying, legitimizing and acting on the needs of the critically ill child in intensive care, using strategies such as gate- keeping, prioritizing and making clinical decisions. The extent to which these strategies were used reflected the confidence and experience of the individual nurse. The findings highlight the importance of retaining experienced nurses at the bedside in ICU; this was identified as a central component in the nurse's ability to both identify and act on the needs of the critically ill child (Endacott 1998c). The issues of retention of experienced nurses in general and paediatric ICU and the provision of a clinical career ladder need to be addressed as a matter of some urgency if we are to retain an appropriate level of nursing expertise.

Within nursing, personal development has been given recognition through the emphasis on the use of reflective practice (Johns 1995a, 1995b) and clinical supervision (Doll 1993; Dol l 1994; UKCC 1996), both of which aim to increase the self-awareness of the nurse. However, these developments will only have an impact on

patient care when they are acknowledged as part of the workloa&

The shift leader acted in a supporting role, co- ordinating the activity of the Unit as a whole, rather than attempting to maintain an in-depth knowledge of the minute-by-minute situa~on with each patient. In order for both roles to interact effectively, the allocated nurse and shift leader need to acknowledge and understand the complementary nature of their roles.

Whilst support for junior staff is seen by the nursing profession in the UK as part of the intensive care workload, this is not necessarily reflected in staffing levels. The findings of this study suggest that inexperienced nurses need close supervision, with an experienced colleague assisting in activities such as the prioritizing of care and explaining the rationale for prioritizing decisions.

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