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,