What's in this issue?

Welcome to the New Year and Volume 18 of Nursing in Critical Care. At this time of year, we make New Year resolutions to address past weaknesses and invest hope in the future. This puts us in a reflexive mood: reflecting on what has gone before and how that might affect what we do in the coming months. This natural analytical cycle is made more deliberate when we consider research, service evaluation or audit to inform practice development. The papers in this issue provoke us to consider what we might otherwise have taken for granted or may have neglected previously. The papers vary from the usual to the exceptional, but each illuminates the complexity of practice. Too often, we conclude to adopt a range of solutions. However, when viewed through a different theoretical lens, some of those solutions may raise more questions than they answer. The first commentary by Juliet Anderson (2013) offers a motivating message on how experienced and expert colleagues can inspire the next generation of nurses. Her reflective review of the Olympic games interwoven with her own career experience and viewed through the theoretical lens of positive psychology are used as a tool to consider how we can make a difference to those we encounter. Role modelling as well as encouraging a junior colleague to achieve all that they can be and considering how we can make things better for those around us relies on persistent positivity and celebration to ultimately change a culture. Such a stance is very uplifting but measures to ensure it is sustainable and enduring need to be considered. Leonard and Timmins' (2013) editorial offers a timely reminder of the importance of managing strict adherence to infection control measures to prevent blood-borne infections. They critically explore a range of issues that address not only the practical but also the emotional factors and financial circumstances that surround such initiatives. They illuminate the range of issues that need to be considered when undertaking practice developments of this type and that any one strategy would not suffice to address all of the elements. Moving on, Shaughnessy's (2013) paper outlines the challenges faced when implementing a delirium screening scoring tool. The tool, CAM-ICU endorsed by NICE (2010), can assess a patient's disorganized thinking. Other tools assess altered levels of consciousness. It is the altered level of consciousness that determines the type of delirium. The paper outlines the type of educational and promotional activities that were undertaken to safely embed CAM-ICU to support the delivery of care. The importance of these activities was in raising awareness and keeping people focused on the issues of delirium and the interventions to prevent onset wherever possible. Many of the interventions were simple and inexpensive but required thought and deliberation on an issue that might otherwise not have been considered. Allen et al. (2013) outline a service evaluation on the introduction of assistant practitioners on the critical care unit. Generic competencies for critical care and operating department were generated bound by a workforce planning philosophy. The service evaluation was designed to include a questionnaire and interviews to capture a range of stakeholder's opinion on the role. These data illuminate a tension inherent when any new substitution role is introduced: in finding the balance between limiting what the practitioner can do (established from the outset before training begins) with the desire for the practitioner to do more when individuals are assessed, become known to the team and found they can be trusted. Then the cycle of extending competencies starts as ambitions for the role increase. A new set of debates are opened then about what level of education is a pre-requisite to prepare the practitioners for this evolving role and how identity formation can be shaped as a consequence (conferred by self, the organization and their colleagues). Consistency needs to run through any service evaluation to ensure that the philosophy that shapes an initiative (e.g. workforce planning models) is specifically captured by the evaluation data (in this case, identity formation). What is made visible, what invisible? How does this change when we shift the evaluative lens and provide an alternative theoretical explanation to explain the findings? Stewart and Rae's (2013) paper reports on an interpretive phenomenological analysis of how registered nurses related the knowledge and skills framework (KSF) to their professional role. The authors provide an excellent summary of the analytical framework they deployed to make sense of the data and illuminate the implications of their findings for practice. The intention of any national initiative will inevitably shift during implementation as the organization, local unit or individual practitioner interprets it. Time will further colour that interpretation. The authors suggest that the theory-practice gap, or as has been suggested here, the intention – interpretation gap, can be closed by marrying the organizational and personal values about the KSF. In this way, the KSF can serve as a reflective tool to enable practitioners to consider new ways of thinking about their career development. This is one particular interpretation. An alternative theoretical, philosophical or political assumption might cast a very different interpretation. This might be that the KSF could be viewed as a managerially, bureaucratic tool employed to prescribe standards and behaviours without challenging whether they are desirable or reasonable. Of note, the authors declare the KSF to be: ‘omnipresent but not yet embedded in practice’. This suggests that passive resistance was exercised by distancing the framework from the everyday lives of the practitioners. Understanding the different discourses that shape these views help us to make sense of the complexity that is inherent in any system. That understanding helps us towards meaningful conclusions even if they are challenging and critical of the status quo. Cotton's (2013) paper is another example of a system-based approach to introducing a guideline. The ‘how to guide’ published by NICE provided a simple procedure that unearthed complexity during the guideline's implementation. Cotton describes the circumstances created when trying to implement a post intensive care unit rehabilitation pathway that involved crossing organizational and disciplinary boundaries. It fundamentally forced the ‘system’ (or people who make that system) to confront and enact patient-centred services and joint care. Placing ‘patients at the centre of services’ and ‘joint care’ are rhetorical labels that can get people to unite – but when put into practice (implementation), surface opposition. Who funds the service opens further debate especially when considering this at a budget holder level rather than funding from the public purse. The uncontested position of managerialism within the NHS, suggested by language, procedure and performance is given priority but obscures the importance of design when thinking about providing new services. Here concepts from the world of engineering and architecture may better serve us alongside models adopted, uncritically and solely, from the world of business. The final paper by Birchley and Cejer (2013) addresses the withdrawal of life sustaining treatment in a paediatric intensive care unit (PICU). The authors used a 12-item survey in one regional PICU and followed this with a 3-item electronic survey distributed to 22 PICU managers across the UK. The response rate was disappointing with 15/100 local nurses responding and 8/22 national nurse mangers returning the survey. Some practical factors were cited as influencing the low response rate that could be summarized as casting doubt over the reliability and validity of the tools that were in use. Is a questionnaire the best method to capture data that raises ethical and legal issues about the reality of practice relating to the withdrawal of life sustaining treatment? A questionnaire offers anonymity (theoretically) so people may well feel able to write about a difficult topic. However, the subject of the core question raises so much complexity inherent to, and contingent upon, the individual circumstances that surround the case, it would raise doubt over a nurse's confidence to respond in a simple format questionnaire. Reflective and thoughtful writing might do much to illuminate the circumstances that surround practice but careful probes and facilitative guiding questions would be required to capture all of that complexity. The invaluable legal review provided by the authors alongside the survey data (however limited) had caused them to conclude that clear and unambiguous legal and professional guidance is necessary to legitimate the nurses' actions in the context of withdrawing life-sustaining treatment on PICU. However, could that guidance be created? The concepts to guide practice in this area would have to be so broad to cover all the potential circumstances they may become too abstract to be useful. The converse of this would be to provide guidance so specific it was over complicated and very limiting. It is circumstances like these where advice from an expert and careful deliberation with the family and all the professionals involved are the only solution to answering such complicated, context specific and difficult situations. There are many critical care nurses in all spheres of practice, management, education and research who continue to question long-established assumptions and care approaches by reframing our understanding through different theoretical and philosophical lenses. This is healthy. It signals that as a discipline we are willing and receptive to explore and consider radically different and alternative perspectives to inform our thinking and approaches to inform the quality of our care. From an editorial perspective, 2012 was successful and rewarding in achieving peer and international recognition in the form of an impact factor for Nursing in Critical Care. Our ambitions and New Year resolution will build on this aiming to ensure excellence, rigour and relevance in the papers published.

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