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ntensive and Critical Care Nursing (2006) 22, 313—314

DITORIAL

he art of nursing: A hidden science?

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s a consultant nurse, I am frequently asked toiscuss the role of nurses and nursing in intensiveare. Often this is to justify the number of nursesequired or the large amount of study time pro-ided to ensure safe delivery of care to criticallyll patients. However, recently I was invited by aedical colleague to present a lecture on nursing

esponsibility in the intensive care unit. This pro-ided me with an opportunity to think about theesponsibility placed on nurses and nursing in crit-cal care and what expectations the critical careopulation of patients and professionals might havef us.

In identifying the role of the critical care nurse,he World Federation of Critical Care Nurses (2005)tate:

The role of the critical care nurse is essentialo the multidisciplinary team needed to providepecialist knowledge and skill when caring for crit-cally ill patients. The critical care nurse, whichnhances delivery of a holistic, patient centredpproach in a high tech environment, brings to thiseam a unique combination of knowledge and car-ng. In order to fulfil their role, nurses requireppropriate specialised knowledge and skills notypically included in the basic nursing programs ofost countries.’

This suggests that in order to provide effec-ive care at the bedside, the critical care nurses required to be technologically competent whilstroviding compassionate nursing care. Implicitithin this statement is the need for the nurse toe educated and subsequently an educator.

Nurses choose to work in critical care to pro-ide high quality care to patients and their fam-lies, to maintain direct patient contact (Heskins,997) and to gain knowledge and skills (Farnell

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964-3397/$ — see front matter © 2006 Elsevier Ltd. All rights reservoi:10.1016/j.iccn.2006.09.001

nd Dawson, 2006). It is suggested that as knowl-dge improves and experience increases, risk to theatient reduces due to timely patient progressionBall and McElligott, 2003). Interestingly, it is sug-ested that mastering the technology also enableshe caring aspects of nursing (Wilkin and Slevin,004). Therefore developing skills and retainingxperienced staff is not a luxury but a necessityn order to ensure appropriate decision-making andare for the critically ill patient.

As the role of the critical care nurse haseveloped, the differences between nursing andedicine have become blurred; many factors have

nfluenced this development. Critical care nursesork in an ever more autonomous manner, with

he nursing role expanding to include the manage-ent of highly technical equipment and the resul-

ant decision-making based on the data producedy these advances. Nurses have embraced changingatterns of work among their nursing and medicalolleagues, often being required to extend theirursing practice into areas that were previouslydentified as medical roles. Indeed, the contem-orary role of the nurse within critical care maynclude making differential diagnosis and prescrib-ng, once the sole remit of medicine.

The patient population is changing with a dra-atic worldwide increase in the number of peopleho live to old age. This has resulted in an increasedritical care population of elderly patients whoften have complex co-morbidity. Increased tech-ical and patient complexity requires greater edu-ation in order to maintain and develop skill, withn increasing awareness that basic nurse education

oes not develop the requisite level of specialisedkills and knowledge to practice safely within crit-cal care. This skills deficiency is exacerbated by ahortage of nurses, resulting in many critical care

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314

units employing nursing staff who have need of edu-cation to develop the skills to practice effectively.To provide effective education, the educator mustinterrogate the evidence, however the research tosteer nursing care is often lacking. Consequently,there is a need for nurses to be researchers toestablish an appropriate evidence base.

These changing practices have had a profoundimpact on the workload of the critical care nurse.The bedside nurse, faced with a variety of demandson their time is left to solve the dilemma of man-aging and co-ordinating the very visible science ofcritical care technology versus the often invisibleart of nursing care.

As a professional, the nurse has the legitimatefreedom to choose one course of action or interven-tion over another, combined with the responsibilityfor making correct choices in each clinical situation(Holden, 1991). The responsibility for the decisionsa nurse might make, is demonstrated through thenurses’ legal liability in four areas. Criminal: Thenurse is accountable to the public. Civil: The nurseis accountable to the patient (or relatives). Profes-sional: The nurse is accountable through their codeof conduct. Contractual: The nurse is accountableto their employer and so long as they meet theircriminal, civil, professional and contractual obli-gations, then the employer provides for vicariousliability.

Despite these competing demands and responsi-bilities, nurses are in a unique position to influencethe way in which care is delivered and thus thepatients’ and relatives’ experiences of critical care.It is often the art of nursing, the invisible care thatis remembered by the patient or their family. Thetime taken to explain procedures to a patient withlittle ability to communicate; the organisation ofcare so that the patient is in control; providing indi-vidualised care, knowing when and how to ‘breakthe rules’.

‘those who look at only the surface level, at whatis very obvious, see some equipment and activi-ties which are different from elsewhere. But theycompletely miss the essence of what is really hap-

Editorial

pening, the skills and knowledge in use, the joysand achievements and the actual or potential dan-gers’ (Ashworth, 1992).

The art of nursing can easily be hidden by the sci-ence of technical healthcare and because of that,perhaps the wide-ranging responsibilities nurseshave are often forgotten. Nursing responsibility iscomplex, it requires the nurse to be conscientious,listening to the patient while responding to theneeds of other professionals, being innovative intheir care and often working across boundaries,whilst developing and constantly updating theirskills and knowledge. Nurses are the invisibleco-ordinators of care. In the hands of experts, theuntrained eye may even think the art of nursing issimple.

References

Ashworth P. Nursing is not just the tasks nurses do. Intens CritCare Nurs 1992;8(3):129.

Ball C, McElligott M. Realising the potential of critical carenursing. An exploration of the factors that affect and com-prise the nursing contribution to the recovery of criti-cally ill patients. Intens Crit Care Nurs 2003;19(4):226—38.

Farnell S, Dawson D. ’It’s not like the wards’. Experiences ofnurses new to critical care: a qualitative study. Int J NursStud 2006, March;43(3):319—31.

Heskins F. Exploring dichotomies of caring, gender and technol-ogy in intensive care nursing: a qualitative approach. IntensCrit Care Nurs 1997;13(2):65—71, Apr.

Holden J. Responsibility and autonomous nursing practice. J AdvNurs 1991;16(4):398—403.

The World Federation of Critical Care Nurses (WFCCN).(2005).Position statement on the provision of critical care nurs-ing education http://www.wfccn.org/webdocs/EducationMay 05.doc last accessed 29th August, 2006.

Wilkin K, Slevin E. The meaning of caring to nurses: an investiga-tion into the nature of caring work in an intensive care unit.J Clin Nurs 2004;13(1):50—9.

Associate Editor

Deborah Dawson

St George’s Hospital, NHS Trust, London,United Kingdom

E-mail address: deborah.dawson@stgeorges.nhs.uk