<scp>WiJ</scp> 2016 (March/April)

This issue introduces a journal milestone: to publish on line and bound papers. This creates an opportunity to publish more clinically focused subjects at the cutting edge of critical care research and practice development. Members and organizations with a subscription will continue to have full access to journal content. In a digital age, it is important to remain agile, current and dynamic, this entails being ambitious, distinctive and reflect the modern aspirations and priorities of our readership and authors. We see this landmark for the journal as a very positive way as ensuring that we disseminate important high-quality work in a timely manner and in providing added value to critical care nurses. The editorial by Corbally and Timmins (2016) proposes a tool to enable less experienced critical care nurses build a more holistic assessment of their patients. Simple in its conception, yet powerful in its application, a modified acronym of ASSESS helps uncover elements of understanding about the patient that may have otherwise gone unreported or undiscovered. Thus a deceptively simple tool packaged as 4 Ss, has the potential to improve the nurses' capacity for clinical reasoning and decision making. In addition, this issue brings therefore brings together eight papers tackling diverse and contemporary topics that help us to consider all that needs attention when caring for a critically ill patient. Responding to the patient who is suddenly deteriorating and ensure their safety, wellbeing and, minimize further risk remains a universal challenge, but a pivotal role of nurses. Recognition that care of patients who are deteriorating can be suboptimal has led to a number of measures to improve standards and outcomes. Lavoie et al.'s (2016) Canadian study sought to address, through a dimensional thematic analysis of 34 papers covering a 10-year period, how patient deterioration is defined and identified between nurses in acute care wards and intensive care units (ICU). While the analysis identified a lack of a shared definition, differences between ICU and acute wards nurses were evident in terms of how deterioration was conceptualized and on the validity of core indicators of declining health status. The important contribution of this paper, is an explanatory matrix of patient deterioration as viewed by nurses from acute care wards and ICUs which helps to incorporate not only clinical properties but also contextual features (e.g. organizational and technological), process activities (e.g. surveillance, responding) and consequence dimensions (e.g. adverse events, and engaging other specialists). This paper provides a distinctive and a more encompassing lens through which we might begin to develop sensitive and specific indicators and approaches tailored for staff working in acute care wards. Physical restraints to manage patients, who become delirious, confused and agitated resulting in their health and safety becoming compromised remains controversial. While professional guidelines urge nurses to act in the patient's best interests, there remain variations in the use of chemical and physical restraint across the UK. To this end Freeman et al. (2016) undertook a postal survey to investigate nurses' experiences, attitudes and perspectives on the application of physical restraint in two large ICUs in England. A response rate of 39% (n = 75) and sampling framework limit data generalizability, but the findings confirm a belief among survey respondents that restraints should be applied to promote patient safety. Around two-thirds had received training in assessing need and in the application of physical restraint, and most respondents were happy to discuss the intervention with the patient's family members. While some respondents expressed unease in applying physical restraints, it was generally acknowledged that more guidance and evidence was required by ICU staff to facilitate decisions. However, it is perhaps more relevant to assess for risk factors and apply interventions to prevent delirium and associated behaviours to ameliorate the potential of using physical restraints. The use of patient diaries is a subject that has drawn much attention in the pages of the journal, yet the angle of how relatives perceive reading and writing entries and how this affects them was the basis of systematic review led by Nielsen and Angel (2016b). The search strategy yielded 10 papers that focused on family members inscribing content in ICU diaries. The analysis identified that relatives were often instructed on making diary entries, but the nature of what was written encompassed sentiments of love, affection, hope and concern for the vulnerability of their relative. This articulation of emotions and feelings combined with the entries made by health care staff is believed not only to be of benefit for recovering patients but also for relatives themselves in understanding how their loved one is responding to clinical interventions. Clearly, the extent to which diary entries minimize stress and aid emotional wellbeing of relatives needs further investigation, although arguably disclosing their emotions and feelings in the diary could be therapeutic and cathartic. Health care professionals rather than users of health care services, including critical care provision, are more likely to understand the concept of patient centred care (PCC). Esmaeili et al. (2016) undertook an exploratory qualitative study with 18 patients in Tehran with different cardiac conditions, including myocardial infarction, heart failure and acute coronary syndrome to determine their perception of PCC. The participants seemed to relate PCC to managing their uncertainty, the provision of flexible approaches to care delivery and maintaining therapeutic communication. Further they saw the role of the nurse in PCC to provide individualized care and to play a role as negotiator and facilitator in enabling patients to regain their independence. Core to this outcome was empowering the patient to engage in decisions affecting their health and wellbeing. This study is a reminder that as nurses we need to work with patients and families to ensure their unique needs are identified and met at time when they feel vulnerable and distressed. In this way we can positively influence the patient's experience of hospitalization and the nursing care they receive. The paper by Rfii et al. (2016) explores the experiences of Kurdish critical care nurses delivering end of life (EOL) care. Deploying Van Maanen's hermeneutic phenomenological procedures, they align their findings to the concept of ‘emotional labour’. The authors do not provide a critical discourse on the sociological aspects of emotional labour and how this translates to the Kurdish context rather, they concentrate on describing the emotion work that is involved in EOL care. Therefore, the translation of Arlie Hochchilds (1983) Western concept of commercialized human feelings (emotional labour) into the Middle Eastern context does require further elaboration. Notwithstanding, Rfii et al. (2016) do illuminate an international shared experience among critical care nurses to ensure the highest standard of care whatever the circumstance. How that is managed through surface or deep acting to maintain a professional face to the public or how the suppression of emotion impacts in the longer term on the Kurdish nurses' well being would be of interest. Rfii et al. (2016) assert religious beliefs enable the nurses to sustain high standards of care but also suggest more secular remedies such as access to appropriate equipment, good management and seamless interdisciplinary working practices to ensure the best EOL care. The next three papers are all accessible on line. They include the work of Dillworth et al. (2016) that provide the perspectives of US Critical Care nurses on EOL care for older patients. This paper illuminates an international shared experience of critical care nurses to alleviate suffering, and when this creates dissonance for the nurses notably when aggressive interventions aimed at prolonging life are considered futile. Another point of tension was revealed when family's expectations differed to the patient's wishes or where a family could not accept EOL care was appropriate. Advocating on behalf of a patient without capacity to communicate treatment preferences and interacting with family members whose opinion differed were also key points of tension. The solutions they proffer include the provision of robust palliative care specialists and specific directed communication skills enhancement for all those involved In EOL care planning. The second paper on line by Troccaceli et al. (2016) examines the Shock Index to determine a care pathway for patients with multiple injuries or major trauma. The SI tool can be used at the scene of injury and repeated in the Emergency Room (ER). The assessment made by the Si tool in the ER was found to be more effective in determining where the patient with multiple injuries is best admitted following the ER resuscitation. The authors conclude the SI tool is triage indicator that can be used to determine clinical pathways. The final paper in our on line sample is by Rawajfah and examines infection control (IC) practices of critical care nurses. A cross sectional descriptive design was implemented to capture the self reported practices of nurses working in 21 hospitals across Jordan. The study revealed that 25% of the sample declared they had not been trained in IC practices, but those who had received the training were more likely to comply with IC guidelines. The lack of resources were identified as a factor that affected poor hand washing habits, sharing of equipment between patients without appropriate sterilization, as well as a lack of protective equipment for nurses to wear to serve as an additional barrier from infectious material or body fluid. The solution offered to this problem was to increase IC education to inspire the nurses to invent new solutions to address this resource hardship. In reading all these papers we are able to see what unites the international community of critical care nurses is a quest to strive for excellence in care delivery, while also identifying specific challenges that face other practitioners in different countries. We learn to both appreciate our own good fortune but to also consider how we might potentially practice in a more sustainable and efficient manner by reading how others have to adapt their practice around reduced resources.

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