Preparedness of Intensive Care Unit Nurses - Case Study Example

TABLE OF CONTENTS Introduction 2 Review of Literature 3 Discussion and Conclusion 11 Bibliography 18 List of Tables and Figures Table 1: Principles of Breaking Bad News 5 Table 2: Common Physical Symptoms During the Last Days of Life 7 Figure 1: Roles in the Continuum of Dying 8 A Literature Survey Exploring the Preparedness of Intensive Care Unit Nurses for the Challenges of End-of-Life Care in the UK Abstract Background: As more and more stress is put on patient-centered approach, end-of-life care is starting to be of prime importance not only in hospices but also in intensive care units. This being the case, it would be interesting to make an initial survey as to the level of preparedness of ICU nurses for such a task. This paper makes an initial review of literature regarding this matter; such will be followed by a discussion of what palliative care nursing is, compared to the present case of ICU nurses. Such a comparison will make it possible for us to judge the prepareness of ICU nurses for the task. Method: This paper makes a survey of literature, specifically academic journals, dating 1998 to present. Search words used are the following: end of life care UK,” “ICU nurses UK,” “end of life care nurses UK,” “end of life care palliative care nurses,” “nurse training UK.” Findings and Conclusion: This study concludes that ICU nurses are ill-equipped for end-of-life care in the ICU. Introduction There has been a lot of talk on the preparedness of health care practitioners when it comes to end-of-life care. These talks are multi-spanning: from hospices, to palliative care units, geriatric care unit, to coronary care units, oncology departments, emergency unit, and of course, in intensive care units (ICUs). Relatively a good number of literatures are available as regards the correlation between the nursing practice, palliative care, and end-of-life care, and this is for obvious reasons. It might not be too presumptuous to say that end-of-life care has been a more emphasized in palliative care units and hospices, leaving other units to concentrate on other stuff. Nevertheless, as more researches and conferences express concern as regards end-of-life care in ICUs, it seems necessary to address the issue whether ICU nurses are ready for such a challenge. This is in fact no new challenge. It must have existed since Florence Nightingale. But its emphasis now, especially amidst calls for the ethic of care and the prominence of principles like autonomy and beneficence, makes this challenge for ICU nurses something that we need to immediately attend to. This dissertation will specifically look at the preparedness of ICU nurses for the demands of end-of-life care in the UK. To be able to do this, a comparison of the demands of palliative care nurses and the existing situation of ICU nurses shall be done. Review of the Literature There are some preliminary literatures that would aid us to look at this issue within a certain perspective. For one, White et al. (2001: 147), in the essay, Are Nurses Adequately Prepared for End-of-Life Care?, made a descriptive survey on nurses who are members of the Oncology Nursing Society in Georgia, Virginia, Washington, and Wisconsin in 1999 and came up with the conclusion that there is a need to revise the American Nursing Curricula as well as setting up guidelines as to the characteristics that are necessary for nurses for such a care. Such a conclusion was drawn after responses from nurses reflected a certain ambivalence: a number of them said that their collegiate education prepared them for the task; at the same time, most of them admitted that they only have at most two hours of continuing education program in end-of-life care (White et al. 2001: 149-150). Also, a number of them found dealing with certain concrete end-of-life issue difficult to deal with. For the purposes of specification, the following are the top four core competencies that the respondents wished they learned in nursing school, but apparently didn’t (or at the very least insufficient): how to talk to families about dying; pain control techniques; comfort care nursing interventions; and palliative treatments (White et al. 2001: 149). That nurses put on top of their list the need to know how to deal with family members as regards the impending death of their loved one highlights something that may have been overlooked in American (and probably in nursing schools in other countries as well) nursing schools: that nurses face the patient and consequently the family more often than the doctors. It is expected of geriatricians, psychiatrists, and family physicians (Abrahm 2003: 56) to get the proper training as regards this matter, but for some reason, training for nurses in this regard has not been taken seriously. This is plainly alarming as nurses are frontliners in end-of-life care, whether in hospices or in other settings. Nurses also expressed the need to train in pain control specifically in other pharmacologic or non-pharmacologic interventions. Comfort care interventions were specifically recommended by White et al. (2001: 150): massage, hydrotherapy, and other modalities that might be useful in decreasing pain. This again points out to the need for a revised nursing curriculum that incorporates not only pharmacologic interventions for palliative care but such other measures such as comfort care as well. This specific study by White et al. does have its limitations. For one, it is limited to a certain organization, and hence, it may not reflect the wishes of other nurses from other units (White et al, 2001: 151). Nevertheless, I would say that the feedback of the nurses from such an organization is very important since they are the ones who are directly involved in palliative care. This study comes up with two recommendations: a revision of the American curriculum; and the need for additional training. Later on, we will see if such needs are also present in the UK. Janet Abrahm (2003) in the essay, Update in Palliative Medicine and End-of-Life Care, gives us an update regarding some of the concerns mentioned above, though, it would be necessary to state that this paper gives a general update (i.e., update that applies to health care workers in general, not only to nurses). Hence, the concerns stated above may or may not be sufficiently addressed by this update. In this short paper, Abrahm (2003) makes a special mention of what palliative care in end-of-life care really means. She specifically points out that palliative care encompasses and goes beyond disease-oriented treatment (2003: 54). It encompasses both disease oriented treatment and patient-focused treatment, and may well extend up to the bereavement of the loved ones (Abrahm 2003: 54). After such a clarification of the definition of palliative care, she outlined the updates on the following factors in palliative care: communication, relief of suffering, and grief and the bereaved survivors. As regards communication, Abrahm (2003) gave suggestions on how health care workers should break bad news. Table 1 outlines her suggestions as regards breaking bad news: TABLE 1: Principles of Breaking Bad News (Abrahm 2003: 56) 1. Make yourself, the patient, and the family comfortable. 2. Find out what they know. 3. Indicate that you are planning to tell them something that is unpleasant and may be disturbing. 4. Find out whether they want to be told, or whether they want someone else to be told. 5. Find out how much they want to know (the big picture versus the all the details). 6. Tell them in words they can understand, allowing time for questions along the way. 7. Respond to their feelings. 8. Let them know that this is only the first of many discussions with you. 9. Ask them to summarize what they heard you say; ask if they have further questions. 10. Arrange your next meeting with them. Still within the realm of communication, Abrahm mentioned the importance of discussing prognosis to the family and to the patient (if such is possible). She mentions here the lack of training of medical workers in this aspect, probably with the exception of gerontologists, psychiatrists, and family physicians (Abrahm 2003: 56). As regards relief of suffering, she discussed pain, common physical symptoms during the last days of life, and psychological concerns. As regards pain, she made mention of the pharmacologic, nonpharmacologic, and radiopharmaceutical techniques to be able to handle pain without excessive sedation (Abrahm 2003: 58). As for the common physical symptoms during the last days of life, again she outlines some of the indicators. It is worth mentioning at this point that in the earlier article reviewed, i.e., the article by White et al., nurses made mention of the need for the competency to recognize impending death as the fifth core competency they wished they had. Here, Abrahm gives a check list of common symptoms during the last days of life: TABLE 2: Common Physical Symptoms During the Last Days of Life % of Incidence Pain Noisy or moist breathing Restlessness, agitation, delirium Urinary incontinence Dyspnea Nausea and vomiting Fatigue Arms and legs cool Mottled skin (due to decrease in blood pressure) Fecal incontinence 70% 60% 50% 20% 10% As regards psychological concerns, Abrahm made mention of the need to determine between the somatic signs of the illnesss and depression (2003: 62). Aside from depression, she also made mention of the signs of delirium and the need of the health worker to attend to both, seek the help of a psychiatrist if necessary. As regards grief and the bereaved survivors, Abrahm mentions the importance for health workers to identify both “somatic and psychological manifestations” of it (2003: 66) and then giving “emotional, psychological, and spiritual support as well as physical comfort, helping families resolve outstanding issues, and making the final days and the death as peaceful as possible” (2003: 66-67) after prognosis of grief were important tasks that Abrahm again assigns to the health worker. In the North American and in the UK setting, where does the nurse fit in this entire palliative care picture? Though Abrahm does not make mention of the specific task of nurses in this broad and challenging picture of palliative and hospice care, Johnston does: the role of the nurse gets bigger as the role of the doctor diminishes as the patient heads towards death (1999: 16). She illustrates the figure as such: This is something that we will discuss in more detail in the succeeding chapter. For the meantime, it is imperative to look at another literature. We have looked at the literatures as regards palliative and end-of-life care are and role as well as the readiness of nurses for such. Let us now turn our attention to end-of-life care in the ICU. In April 2003, an International Consensus Conference in Critical Care happened in Belgium. In this conference, a number of problems were identified and a number of recommendations and resolutions were given. This is an important document and hence it seems imperative that an elucidation of the main points as to the problems identified and the recommendations given is called for. We shall limit our discussion on the problems and recommendations that have direct impact on the topic to be developed in this paper. The conference identified at least nine problems as regards end-of-life care in the ICU. These nine problems are as follows: the need for sensitivity, precision, and less emotionally laden terminologies; wide variability as to end-of-life practices from one country to another, and from one ICU to another; prognostic uncertainty which makes decisions for or against withholding or withdrawing life-sustaining devices difficult; patient preferences are difficult to know since only 5% of patients are capable of decision; discrepancies between scientific societies’ recommendations and actual practice; who the ultimate decision maker is (whether it is the patient, the family, the physician, other health workers, or a collaboration of most if not all); lack of sufficient communication between ICU staff and patient and family; “inadequate” training of ICU staff; lack of routine evaluation and regular documentation (Carlet et al. 2004: 771-772). In spite of these problems, there seems to be some encouraging news from the UK, i.e., there is beginning to be some sort of convergence happening as to what good practice means when we talk of end-of-life care in the ICU. Though, the conference jurors expressed some concern regarding the final decider. The conference mentions a statement of the General Medical Council in the UK stating that the final decision rests solely on the clinician: It is important to take time to try and reach a consensus about treatment and it may be appropriate to seek a second opinion or other independent review. However, if a patient wished to have a treatment that—in the doctor’s view—is not clinically indicated, there is no ethical or legal obligation on the doctor to provide it. (Carlet et al. 2004: 776). Such is a concern since the conference endorses a cooperative decision for end-of-life care decisions. This is what the jurors call the “shared-decision paradigm” (Carlet et al. 2004: 780). At this point, it will be best to mention that although the UK puts the final decision on the clinician, the UK is also a country where nurses have some say in the decision. True, they do not give the final decision, nevertheless, their opinions are taken into account (Yaguchi 2005: 1972). This is in contrast to many other countries where the nurses’ voices are not taken into account when an end-of-life decision is made (Carlet et al. 2004: 779). Finally, we can mention the conferences’ recommendations. There are six recommendations as regards palliative care in the ICU (Carlet et al. 2004: 781): 1. provides relief from pain and other distressing symptoms 2. intends neither to hasten nor to postpone death 3. affirms life and regards dying as a normal process 4. integrates the psychological and spiritual aspects of patient care 5. offers a support system to help patients live as actively as possible until death 6. offers a support system to help the family cope during the patient’s illness and in their bereavement. When we look at these recommendations of the conference, we notice that the bulk if not all these recommendations are the very tasks of nurses in palliative care. Given such, let us now go to the main purpose of this paper, i.e., to make an initial investigation on the preparedness of UK ICU nurses as to end-of-life care. Discussion and Conclusion We have seen above that ultimately, the ideal ICU end-of-life care is almost synonymous to palliative care provided by nurses in hospices and similar units. Let us go through the ideal end-of-life care that nurses are expected to practices in hospices and similar units. At least as regards the ideal, there seems to be a clear divergence. We have seen this ideal as made explicit by the conference we have just mentioned. Bowman et al. (2000: 53) mentions five qualifiers as to what quality end-of-life care means: 1. Relieving adequate pain and symptoms management; 2. Avoiding inappropriate prolongation of dying; 3. Achieving a sense of control; 4. Relieving the burden on loved ones; 5. Strengthening relationships with loved ones. It must be noticed that there is something like a one-to-one correspondence between these qualifiers and the recommendations of the conference mentioned above. More than a correspondence, actually, the paradigm of Bowman et al. and the conference is almost the same: Bowman et al. works on a patient-centered paradigm (2000: 52) while the conference, as mentioned, works on a shared-decision paradigm, which, we may speculate, tries to give a bigger role to the patient and/or family when it comes to end-of-life decisions. Bridget Johnston(1999) concurs with both the conference and Bowman et al. as regards quality end-of-life care. In the essay, “Overview of nursing developments in palliative care,”, Johnston (1999: 15), citing Degner et al., mentions the behavior of nurses that are needed and critical in palliative care: 1. Responding during the death scene; 2. Providing comfort; 3. Responding to anger; 4. Enhancing personal growth; 5. Responding to colleagues; 6. Enhancing the quality of life during dying; 7. Responding to the family. Further, Johnston (1999: 20), this time citing Dobratz, enumerates the roles of the nurse in the hospice. These are as follows: 1. Intensive caring, managing the physical, psychological, social, and spiritual problems of dying persons and their families 2. Collaborative sharing, the co-ordinated and collaborated efforts of the extended and expanded components of hospice care services 3. Continuous knowing, the acquisition of the counseling, managing, instructing, caring and communicating skills/ knowledge required for the specialty of hospice nursing 4. Continuous giving, the balance of the hospice nurses’ own self-care needs with the complexities and intensities of death and dying. Just by the looks of it, not only are researchers in agreement as to what good palliative care is; there is also a tall task that is assigned to nurses in palliative care. Amidst constant cry for better training and preparation, palliative care nurses are expected to perform these tasks that entail not only academic inputs, but psychological and emotional preparedness as well. As we have seen above, even oncology nurses find themselves still wanting when it comes to providing quality end-of-life care, though, no one can deny that palliative nurses are supposed to be the model for end-of-life care. Given these demands of palliative care, and given the fact that even the conference cites palliative care as the guide for quality end-of-life care in the ICU, let us now turn to examine the present situation of UK ICU nurses. After which, we shall see whether they are prepared for end-of-life care, as discussed above, or if they are still wanting. Let us first look at some facts about UK ICU Nurses. We will do the assessment as to their preparedness or unpreparedness after. ICU nurses may receive training for advanced life support skills. That nurses may undergo training to be able to provide the following: manual defibrillation, shock advisory defibrillation, intravenous cannulation, intravenous adrenaline administration, laryngeal mask airway insertion, and tracheal intubation (O’Higgins et al. 2001: 46-47). This is an improvement in line with an earlier survey which states that only “12 percent of British nurses regularly performed arterial puncture” compared to 75 percent of Swedish nurses that regularly do such a procedure (Depasse et al. 1998: 939). Within the same report, it was also stated that British nurses are less involved in invasive procedures, in spite of higher levels of staffing (1998: 944). ICU nurses are overworked. In the magazine, Nursing (2000: 32 cc6), it was reported that aside from ICU nurses being overworked which may result in increased mortality rate, other factors exist that may contribute to higher mortality rates during peak hours: “insufficient time for nurses to perform clinical procedures, inadequate supervision, errors, overcrowding, limited availability of equipment, and premature discharge from ICU.” ICU nurses may not necessarily receive special training before starting in ICU, but, they receive special training after starting in ICU. The UK scored the highest as regards ICU training of nurses after starting in ICU, compared to other European countries (Depasse et al. 1998: 941-942). Given such available data on the status of ICU nurses, we may then see whether they are prepared for end-of-life care. Before doing so, it is important to state another fact, something that affects UK nurses in general, not only ICU nurses: that the National Health Service, in the desire to address immediate need, focus on short term programs, not the long term ones (Thompson & Watson 2005: 1039). As such, there seems to be an urgent need to give attention to school curricula and other long term training modules. Another fact is that there exists a gap between nursing researchers and practitioners (Mulhall 2001). Such a gap is brought about by two different cultures, i.e., the research culture and the practitioners’ culture. To be able to narrow this gap, Mulhall recommends collaborative reporting and exposition of the research process (2001: 125-126). Are ICU nurses prepared then for the challenges of end-of-life care? Though there are good signs that ICU nurses are beginning to be prepared for the challenges of ICU per se, there are bleak signs that ICU nurses are prepared for end-of-life care in the ICU. The increasing involvement of ICU nurses in procedures as well as the participation of nurses in end-of-life decisions is a good sign; such makes possible a more collaborative approach towards end-of-life caring. Nevertheless, there seems to be an emphasis more on collaboration as regards procedure than collaboration as regards end-of-life decisions. As training in invasive procedures are happening only lately, there seems little to expect as regards long term training such as counseling, psychological preparedness, etcetera. Given the demands that we have mentioned above, it seems that nurses would need more units in psychology to be able to meet the demands put to them as regards end-of-life care. True, some nurses may be naturally disposed to deal with such grave matters as some may be naturally more endowed than others, but we cannot count on natural endowment when it comes to preparing them with such tasks. An additional note would have to be given as regards even technical training. True, nurses are presently gaining training in invasive procedures, but there was no mention at all that ICU nurses are being trained for pharmacological and non-pharmacological procedures for palliative care. These skills are very much needed specially at the imminent death of the patient where the goal is not anymore curative but the comfort of the dying. As such, not only are ICU nurses inadequate when it comes to the psychological/emotional/spiritual demands of palliative care; they are also ill equipped (just like the oncology nurses mentioned above) when it comes to pain relief. This is something that cannot be overlooked when we talk of end-of-life care. Corollary to the lack of skills mentioned so far, such also implies that nurses are inadequately prepared for the demand to make the life of the patient active, and hence, incapable of enhancing the life of the patient while still alive. With such limited scope of influence, and wanting in needed training for the daunting task, coupled with lack of time, the ICU nurse is just not capable of even establishing some sort of “relationship” with the family and patient to be able to influence their lives, albeit in a small way, positively. As for the demand that nurses support the bereaved and empowering them to achieve a certain degree of control as regards end-of-life decision, apart from being prepared for counseling, this also means having the time to deal with such matters. Given that UK nurses are presently overworked, there seems to be no way that they can handle such. Dealing with the bereaved and relieving them of the stresses and pain that come with the death of a loved one entail experience, long hours of training, as well as availability. These things the ICU nurses simply do not have. Apart from the requirements to be able to deal with the patient and the family, the nurses also has to deal with herself in the process. Such limitations of the ICU nurse mentioned above gives us bleak hope that something is done to make the nurse prepared emotionally, psychologically, and spiritually to deal with the demands of end-of-life care in the ICU. As such, we cannot talk of enhancing personal growth. The need for a revised nursing curriculum, the narrowing of the gap between research and nursing practice, the lack of proper supervision, being overworked, the lack of specific end-of-life care in ICU training, the limited counseling exposure of nurses, all speak of the difficulty of the ICU nurse in coping with demands such as responding to anger, responding to family needs, enhancing the life of the patient, integration of psychological and spiritual aspects of patient care, etcetera. Indeed, if palliative nurses themselves feel inadequate to deal with the tall task of palliative care, ICU nurses seem to have a long way to go to be able to be adequately prepared for end-of-life care. As of now, the more basic need to be less burdened with work seems to be an issue that still is yet to be addressed. Since ICU nursing has yet to address basic issues such as this, more effort has to be done to address more sophisticated issues as those dealt with by palliative care nurses. Given thus, it is recommended that the case of the ICU nurse be looked into more systematically. It is alarming that there is little effort put to be able to prepare her to such a heavy task. It is as if expecting a miracle from the ICU nurse that she deals with the demands of end-of-life care, something that she is always faced with, without giving her the ample support to be able to do what is expected from her. Given that end-of-life care is a task that needs urgency, there is also an equivalent urgency to prepare the health care worker that deals with such every single moment. This is the ICU nurse. BIBLIOGRAPHY 1. Abrahm, J. (2003) Update in palliative medicine and end-of-life care. Annual Review of Medicine. 54: 53-72. 2. Bowman, K., Martin, D. and Singer, P. (2000) Quality end-of-life care. Journal of Evolution in Clinical Practice. 8(1): 51-61. 3. Carlet, J., Thijs. L., Antonelli, M., Cox, P., Hill, N., Hinds, C., Pimentel, M., Reinhart, K. and Thompson, B.T. (2004). 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