To the Editor:

I would like to share with all the readers some reflection points about the nursing clinical practice in intensive care unit (ICU) settings. I was employed in an emergency department (ED) of a large teaching hospital for about 10 years. Since 2008, I have been working as staff nurse in the ICU near the ED. This new experience is really interesting, but also challenging. One of the most difficult things I have faced, together with the high-tech impact of this setting, is the different concept of clinical priorities. In the ED, the approach to patients was very standardized, in the fashion of airways, breathing, circulation, disability, and exposure (ABCDE). This kind of methodology respects the vital priority in the rigid order of ABCDE, came from the Advanced Trauma Life Support, and is widely shared and accepted from the international community of health care workers. The ABCDE method is actually applied to all kinds of emergencies and to the nursing assessment-interventions performed in the ED. Although there is a close link between EDs and ICUs, these ones are actually "other worlds." In fact, in the ICU, the concept of priority not only is connected to lifesaving actions, but also includes all the tasks accomplished by the interprofessional team. It means that the agenda of nursing activities can undergo frequent changes in order to meet the continuous variation of diagnostic and therapeutic needs of the patients. For example, the prescription of a computed tomography scan can superimpose the scheduled bed-bath of the patients. As a result, the referral nurse for that patient will rearrange the plan of care. As far as here, no one can question this point.

But if we move further in deep in the "convulsive" clinical setting of the ICU, we can see how much the nursing frame of work becomes faint in front of new admission of patients, emergency codes, bureaucratic paperworks, nursing or medical/surgical procedures requiring more than a nurse at the bedside, and so on.

The feature of this kind of work is often called "multitasking." But in the ED, multitasking is quite different than that in the ICU, because nurses in the emergency setting have to think about few and well-defined interventions and the clinical steps that are the same for all patients. This is the opposite case in the ICU, where nurses are in charge of fewer patients with a lot of things to be assessed and done, but in extremely variable sequences. So, where is the problem? The nursing interventions that have evidence of effectiveness for patients' outcomes may frequently end at the bottom in the list of the things to do. Let's think, for example, about the consequences in terms of complications, length of stay, and mortality that ventilator-associated pneumonia, intravascular catheter-related bloodstream infections, or pressure ulcers have on our patients.1-3 They are topics of quality indicators in critical care4 and for the most part depend on the compliance to bundles of care,5 containing simple nursing measures to be carried out with continuity.

Therefore, we can imagine the impact on patients' outcomes of leaving or excessively delaying nursing care acts such as oral hygiene, head-of-the-bed elevation, controlling the cuff pressure of endotracheal tubes, regular position changes, scrubbing the hub of a central venous catheter before drug administration, and, worst, hand hygiene. Patient outcomes can and will suffer.

There is certainly a matter related to task-time imperatives that characterized the nursing frame of work during a single shift.6 And it is likewise difficult to indicate a solution to avoid that the "little" nursing interventions (but "greatly" lifesaving) remain undone.

I always felt a sensation about "something is going wrong" when some colleagues told me, "today, it's a mess, and we have to work on priority basis[horizontal ellipsis]." This could mean diagnostic or therapeutic priorities. I do not know if nursing care plans or bundle-of-care checklists can represent a solution to this important issue. And I do not think that this is only a matter of nursing staff shortage. Perhaps we have lost sight of basic nursing intervention in front of the ever more present complex lifesaving technologies? I believe there is the risk to routinely forgetting the basic needs care acts because we settled into the mood that "today it's a mess again[horizontal ellipsis]."

I am a lecturer in critical care and emergency nursing courses at Florence University, and I always say to my students that priorities are not an excuse to leave "our things undone," but only the right order to follow "all the things we have to do." What do you think about it?

Submitted by:

Stefano Bambi, DNS, MSN, RN

Emergency Intensive Care Unit

Azienda Ospedaliero Universitaria Careggi

50139 Florence, Italy

References