What we “DO” needs to be heard! ~ Find Your Voice

As this blog goes live I am making my way to London, Ontario to participate in my final meeting as President of the Canadian Association of Critical Care Nurses Board of Directors (BOD). As such the “current” BOD will finish up business in an all day meeting on the first day while we handover and orientate the new board members taking over the various portfolios and then I and Joanne Baird will leave the next day as we conclude our terms. The Board will continue to meet with new President Teddie Tanguay as she leads a further two days of planning meetings. The three days of meetings at this time of year allow the planning work of the BOD to be efficient and supplements our other teleconference meetings throughout the year.

It has been a great five years for me on the Board of Directors and in the last two years as President I have come to appreciate how much energy there is in critical care nurses across the country. What I want to see is that same energy beginning to transform into nurses speaking up and speaking about what you do. As I write my last blog for CACCN, I would like to reflect on the President’s theme that I chose for my term of “Find Your Voice!” I chose this theme because I truly believe that the work that we “do” in critical care needs to be made visible by speaking about what we “do” every chance we can get.

Personally I am tired of the “guardian angel” theme that you hear so often when people describe nurses. Caring is a very positive virtue for nursing (and angels too!) but it is not all we “do.” In many of my blogs I have spoken about the caring aspect of nursing as an essential component of the therapeutic relationship we have with patients and their families, but equally important is the knowledge we acquire that enables us to diagnose what is happening with our patient and the technical abilities we must master to keep them alive. There will always be people who require acute care and intensive care and it concerns me that the focus of acute care hospitals continues to shift the emphasis (and resources) away from what is required to look after really sick people in the name of promoting primary health initiatives. It almost stigmatizes those that become acutely or critically ill, implying that they could have prevented an illness or injury and sadly it can minimize the contribution of Registered Nurses (RN’s) in making really sick people well again.

In the ICU we know what we have to “do” to make this a reality and it is those kinds of things that I think we need to speak about more often to ensure the full image of nursing is appreciated by the public and by those who determine resource allocation for services. I very much believe in primary health and injury prevention strategies, but it must also be recognized that people get sick…really sick and they should not bear any blame in that regard and it takes expert and knowledgeable nurses to look after them when they end up in an intensive care unit to make them well again or to allow them to die a peaceful death.

Across the country the role of the Registered Nurse is being challenged to describe it in terms of a cost/benefit analysis at these times of fiscal restraint. Can we afford the care that RN’s provide in the same numbers we have in the past? This question remains in spite of the abundance of research evidence that demonstrates repeatedly that patient outcomes are better and overall costs are less through reduced lengths of stays and decreased complication rates in those units and hospitals with a higher ratio of RN’s to other care providers (some unregulated). Increasingly there is a movement (often led by nurses themselves) to divide the patient into “tasks” that need to be completed and assign the tasks to various care providers, while the role of the RN is seen as best used as the coordinator and planner of care. In the Intensive Care Unit we need to be very cautious how this model of care “movement” impacts things like appropriate and safe RN:Patient ratios (CACCN is working on developing a position statement on this issue later this year) and the ability to have time to form therapeutic relationships with patients and families when there are no “tasks” that need to be done.

As an administrator myself for over 25 years in critical care, I have seen and been part of the development of nursing workload measurement systems from their infancy in the early 90′s that attempt to measure how long it takes on “average” for a nurse to perform certain tasks and functions for the patient. This data then gets analyzed and through mathematical formulas computes how many hours of care a patient requires per day. I have seen how these tools can do harm if not used by administrators with the appreciation of their limitations of what they actually measure in describing the time that nurses need to do their work. These workload tools never capture what the nurse was unable to “do” for her/his patient because there was not enough time to “do” everything that the patient and their family needed. The danger lies within these workload tools when administrators expect nurses to work to these “numbers” as if it was all the evidence they need to measure how well a unit is functioning or how hard the staff is working. I know as I have been challenged by senior hospital administrators to reduce hours per patient day based on this “numbers” game when I knew that the numbers were only a partial view of the PICU I managed.

Like the expert bedside clinician the expert administrator “knows” the unit she/he manages and what it takes to keep the staff motivated and the unit staffed appropriately to allow the RN’s to perform their job expertly and with job satisfaction to get good patient outcomes and satisfaction with the care they received. So working to achieve targeted hours per day to measure productivity might be ok if we were producing donuts but it is not ok when critical care is needed in a timely manner by knowledgeable and skilled RN’s at the bedside. The danger lies within when we come to believe that all patient care is “average” and the experience of the nurse and context of care in which she/he practices is the same every day, so the formula can be applied uniformly. These workload measurement systems seldom take into account the time that is needed for nurses to continually acquire new knowledge and update and practice new skills to keep patients safe. The real danger lies when administrators fail to listen to the voice of RN’s that they need more time, not less time to be with their patients. If we fragment RN care by delegation of tasks to other (let’s admit it)…cheaper staff, then the safety net around patient care is being weakened and may be developing some holes. There is a tipping point that will be reached if the drive to decrease costs overtakes the quality of care for the “whole” patient that the RN currently provides in many areas of acute care but probably the greatest impact being in the ICU.

But before you think I am against any different way of looking at collaborative models of care, I want you to know that I am totally supportive of any role that assists the work of the RN in critical care to enable the nurse to focus on the assessment and ongoing care of her/his patient. The continuity of hands-on-care in the ICU is what keeps patients safe. If tasks like baths are delegated to another type of care provider, then the bedside RN will fail to see the beginnings of skin redness, so that she/he can reassess nutritional requirements and have the discussion with the Dietician and Clinical Pharmacist about feeding and/or TPN before skin breakdown results or fail to see the subtle skin mottling that tells a story of decreased tissue perfusion that requires adjustment of vasoactive intravenous medications. When doing the bath, if the blood pressure and heart rate or intracranial pressure changes, these are all things the RN “puts together” to make adjustments to the care plan. It is often at these most intimate times that the RN forms the deepest therapeutic relationship with the patient as the conversation that takes place, although may appear superficial to others overhearing it, is really about finding out so much more about your patient as you perform the bed bath. It is a continuous assessment. This view cannot be fragmented without an impact on the coordination of care that is expected of the RN.

What I AM for, is support for nurses through appropriate and safe staffing levels that enables another person to assist the RN with the bed bath and turning the patient, and the bed change so she/he does not struggle to do this independently. What I AM for is the investment in safe “lift” systems by hospitals so that the nurse uses technology to preserve her/his back. Within the ICU there needs to be secretarial and ward aide support staff scheduled around the clock to take phone calls and perform cleaning tasks, restock supplies and do paperwork and not just on the day shift. We all know in critical care how many “tasks” we pick up from other professions (particularly physiotherapy or a clinical pharmacist) because they are not scheduled 24 hours. Those are the kinds of models of care we need to support the work of the ICU RN.

If we fail to “find our voice” and fail to describe what we “do” and leave the image of nursing focused only on the caring virtues of nurses then we have failed ourselves. If we can’t describe the work we “do” in more concrete terms to the public (who already trust us highly second only to firefighters) then RN:patient ratios will be determined by imperfect workload measurement systems and processes that are designed to find a cheaper way to deliver the “tasks” of care.

So as I leave the Board of Directors, I encourage a Call for Action where ever you may work…watch how the image of nursing and nurses is portrayed in your ICU, your hospital and in your province and have your voice heard in a meaningful way. We cannot be quiet about such things. You can tell your stories of extraordinary patient care that you deliver every day without violating patient confidentiality by focusing on the expert knowledge that you have in meeting the patient’s needs and by describing what you “do” every day as the ICU nurse to keep the patient alive. These are the images I want people to remember of critical care nurses…not the angel!

Stay tuned and watch this blog in a couple of weeks as your new President, Teddie Tanguay and the 2012-2013 Board of Directors announce an exciting new and action oriented President’s theme building on the theme of Find Your Voice!

It has been a privilege to serve critical care nurses in Canada in my time on the National Board and I am proud and honoured to have been your President for the past two years. I hope to cross paths with many of you in the months ahead.

Until then and as always…take care of yourself and each other,

Kate Mahon

Yes we care… but we also know a lot!

There is no doubt that to be able to work as a nurse you have to care a lot about the people you care for. That was certainly well portrayed in my last blog in the story of Jim Mulcahy as he described the nurses who cared for him. In this week’s blog I want to focus on what it takes beyond caring to be really good at what you do as a critical care nurse. When you get down to it, the patient wants us to be very knowledgeable and skilled at what we do while we care for them. Nursing as a profession, with many of its roots originating from religious orders and portrayed as a self sacrificing “calling” often is not given the proper recognition it deserves for the expert knowledge, superb technical skills and outstanding organizational capability that it takes to competently care for a patient, making a diagnosis (that word and skill does not just belong to physicians!) when necessary to keep patients safe and on the road to recovery. As critical care nurses we know only too well the vast body of knowledge we draw upon as we assess our patients minute by minute that enables us to recognize (i.e. diagnose) and anticipate problems and then determine a plan of action to expertly provide the “care” a patient needs. It is not just physicians who work for a cure…nurses do too.

The critical care environment is not one for those who are risk averse or for those who are more comfortable waiting for the physician to make a diagnosis before you act. Many of the policies that are within ICU’s across the country which enable the critical care nurse to “act” based on a nurse’s clinical judgement are unique to this environment because failure to act in a timely manner can often have more serious consequences. Therefore I was surprised and dismayed to hear that some senior nursing leaders in one large teaching institution identified a couple of ICU nursing practices as ones where “ICU nurses are working beyond their scope of practice.” The practice you ask? ICU nurses were ordering their own blood work and x-rays without first getting a Doctors order! Of course there are processes within each province/territory and organization that regulate practice and one must ensure this function is properly sanctioned, but can you imagine in the ICU if you did not have the freedom to act and instead you had to stop and get an order for every time you needed to do blood work or get an x-ray when your assessment indicated they were warranted? If there is a failure to appreciate these kinds of “scopes of practice” within a critical care unit by the nursing leaders who oversee practice within our organizations, it is difficult for the ICU bedside nurse to function autonomously without fear of reprisal by the very leaders who need to support and endorse their practice.

Nursing in critical care is not about just being good at a series of tasks and skills and working within protocols. The nurse who works in ICU must acquire an enormous amount of clinical knowledge, understanding and drawing upon the same kind of science-based information that physicians (and other disciplines) utilize and then be able to use this understanding to assess what she/he is seeing in a critically ill patient, while simultaneously (and often) directing and teaching less experienced medical learners. The journey of learning in the ICU is not an easy one for the nurse when you first enter critical care. It takes a commitment to learning often going back to review your university science courses to draw upon general chemistry, biology, nutrition, microbiology, anatomy and physiology to truly appreciate what is happening to the patient you are caring for today who is in multi-system failure.

As organizational cutbacks have been steadily eroding the time that is provided for staff to attend in-services, teaching sessions, conferences and other learning opportunities, the ICU nurse has had to become more self-directed. Roles like the clinical nurse specialist were introduced in the 80′s and 90′s to advance the nursing practice of all nurses by particularly supporting the bedside nurse and by building capacity within nursing to care for the complex patient and family. It is therefore unfortunate that these positions are being considered a “luxury” in the critical care unit, rather than a necessity during times of fiscal restraint.

As a critical care nurse, not only must your knowledge be extensive, but your ability to perform many technical skills and cope with an enormous amount of technology “attached” to your patient must be mastered to enable you to competently work in the ICU. Organizational skills, multi-tasking ability and capacity to prioritize based on a multitude of competing demands are hallmarks of any nurse but probably demonstrated at a high intensity level in the intensive care unit. I am still amazed when I walk into the PICU and see the nurse quietly and efficiently caring for a small patient who may be recovering one day post-op from a major cardiovascular surgery. On the left side of her bed there is a “tree” of 15 or more infusion pumps infusing life-sustaining medication; above the bed is the patient monitor reading out 6 or more vital sign parameters; to the right of the bed is the ventilator breathing for the patient… and sitting in rocking chairs are family who have become comfortable with all of this because of the constant, expert and confident presence of the nurse caring for their child. The nurse is always “busy” ( even when he/she may not appear to be) assessing, watching, looking for the subtle patterns of changes in the vital signs he/she is monitoring to alert him/her to take action to avert any deterioration in his/her patient, all the while providing emotional support to the ever present family. That is pretty awesome when you think about it, yet those are the routine days in the PICU (or ICU) where you work. Add ECMO or an LVAD or a Berlin Heart or dialysis and well…you just keep coping with it when you work in critical care.

So yes…we do like to be known for the “caring” aspect of being a nurse, but it is time to balance that with a recognition of the knowledgeable and expertly skilled practitioners we are and we need not hide that or apologize for it or be demure about it. We need to make it visible. We need to speak about it and describe it as much as we depict the caring aspects of what we do. We need to partner with media to get our message out when we should speak on issues as we “find our voice” and articulate what we “know” as expert critical care nurses. It is time to get out of any shadow that blocks that light. In the ICU the knowledge and skills of nurses in the constant minute-to-minute care are what keeps patients alive and on the path to recovery.

Yes we care…but we know a lot too!

As always…take care of yourself and each other,

Kate Mahon
CACCN President