Practical knowledge of experienced nurses in critical care: a qualitative study of their narratives

BMC Medical Education

Carme Ferré-Grau²  José Luis Medina-Noya¹  María Sagrario Acebedo-Urdiales² 

[1] University of Barcelona, Barcelona, Spain;Rovira i Virgili University, Av. Catalunya, 35 CP43002 Tarragona, Spain

关键词: Clinical experience;    Critical care;    Nursing;    Practical wisdom;    Practical knowledge;   

Others  :  1091843
DOI  :  10.1186/1472-6920-14-173

 received in 2014-01-07, accepted in 2014-08-05,  发布年份 2014

【 摘 要 】

Background

Scholars of nursing practices have claimed practical knowledge is source of knowledge in its own right, nevertheless we know little about this knowledge associated with day-to-day practice. The purpose of this study is to describe knowledge that the more experienced nurses the in ICU make use of and discover the components of care it includes. Understanding this knowledge can contribute to improving the working practices of nurses with less experience.

Methods

We used a phenomenologic and hermeneutic approach to conduct a qualitative study. Open in-depth dialogue interviews were conducted with 13 experienced ICU nurses selected by intentional sampling. Data was compiled on significant stories of their practice. The data analysis enabled units of meaning to be categorised and grouped into topics regarding everyday practical knowledge.

Results

Knowledge related to everyday practice was evaluated and grouped into seven topics corresponding to how the ICU nurses understand their patient care: 1) Connecting with, calming and situating patients who cannot communicate; 2) Situatingand providing relief to patients in transitions of mechanical respiration and non-invasiveventilation; 3) Providing reassurance and guaranteeing the safety of immobilised patients;4) The “connection” with patients in comas; 5) Taking care of the body; 6) The transitionfrom saving life to palliative care; and 7) How to protect and defend the patientfrom errors. The components of caretaking that guarantee success include: the calm, care and affection with which they do things; the time devoted to understanding, situating and comforting patients and families; and the commitment they take on with new staff and doctors for the benefit of the patient.

Conclusions

These results show that stories of experiences describe a contextual practical knowledge that the more experienced nurses develop as a natural and spontaneous response. In critical patients the application of everyday practical knowledge greatly influences their well-being. In those cases in which the nurses describe how they have protected the patients from error, this practical knowledge can mean the difference between life and death. The study highlights the need to manage practical knowledge and undertake further research. The study is useful in keeping clinical practice up-to-date.

【 授权许可】

   
2014 Acebedo-Urdiales et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Benner P, Hooper-Kyriakidis P, Stannard D: Clinical Wisdom and Interventions in Critical Care, A Thinking-in-Action Approach. Philadelphia: Saunders; 1999.
• [2]Thompson C: Clinical experience as evidence in evidence-based practice. J Adv Nurs 2003, 43:230-237.
• [3]Fulbrook P: Developing best practice in critical care nursing: Knowledge, evidence and practice. Nurs Crit Care 2003, 8:96-102.
• [4]Inger J, Andershed B, Gustavsson B, Ternestedt BM: Knowledge constructions in nursing practice: understanding and integrating different forms of knowledge. Qual Health Res 2010, 1:1500-1518.
• [5]Carper BA: Fundamental patterns of knowing in nursing. ANS Adv Nurs Sci 1978, 1:13-23.
• [6]Benner P: From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing; 1984.
• [7]Benner P, Tanner CA, Chesla C: Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. New York: Springer; 1996.
• [8]Estabrooks CA, Rutakumwa W, O’Leary KA, Profetto-McGrath J, Milner M, Levers MJ, Scott-Findlay S: Sources of practice knowledge among. Nurses Qual Health 2005, 15:460-476.
• [9]Benner P: Extending the dialogue about classification systems and the work of professional nurses. Am J Crit Care 2005, 14:242-272.
• [10]Spichiger E, Wallhagen MI, Benner P: Nursing as a caring practice from a phenomenological perspective. Scand J Caring Sci 2005, 19:303-309.
• [11]Medina JL, Sandin MP: La complejidad del cuidado y el cuidado de la complejidad: un tránsito pedagógico de los reduccionismos fragmentantes a las lógicas no linéales de la complejidad. Texto Contexto Enferm 2006, 15:312-319.
• [12]Huercanos I: Cuidado Invisible: donde los medicamentos no llegan. Index Enferm 2013, 22(edición digital):1-2.
• [13]McLaren SMG, Ross F: Implementation of evidence in practice settings: some methodological issues arising from the South Thames Evidence Based Practice Project. Clin Effect Nurs 2000, 4:99-108.
• [14]Gail JM: Implications of Holding Ideas of Evidence-Based Practice in Nursing. Nurs Sci Q 2013, 26:143-151.
• [15]Closs SJ, Cheater FM: Evidence for nursing practice: a clarification of the issues. J Adv Nurs 1999, 30:10-17.
• [16]Wilkin K, Slevin E: The meaning of caring to nurses: an investigation into the nature of caring work in an intensive care unit. J Clin Nurs 2004, 13:50-59.
• [17]Medina JL, Sandin MP: Epistemología y Enfermería II: Paradigmas de la investigación enfermera. Enferm Clin 1995, 5:32-44.
• [18]Benner P: The roles of embodiment, emotion and life world for rationality and agency in nursing practice. Nurs Philos 2000, 1:5-19.
• [19]Bourdieu P: Razones prácticas. Sobre la teoría de la acción. Barcelona: Anagrama; 1997.
• [20]Schön DA: The Reflective Practitioner: How Professionals Think In Action. London: Temple Smith; 1983.
• [21]Claxton G: Anatomía de la intuición. In El Profesor Intuitivo. 1ª ed edition. Barcelona: Octaedro; 2002:50-75.
• [22]Harada M: An investigation into the importance of practical knowledge for expert outpatient nurses' ‘job satisfaction’ [Japanese]. Nihon Kango Kagakkaishi 2011, 31:69-78.
• [23]Acebedo-Urdiales MS: Narrativa y conocimiento práctico. Experiencias y prácticas de las enfermeras expertas en UCI. Once relatos y veintitantas historias. PhD thesis. Universitat Rovira i Virgili, Departament Infermeria; 2012. http://www.tdx.cat/handle/10803/96268 webcite
• [24]Benner P: The role of narrative, experience, and community in expert ethical comportment. Adv Nurs Sci 1991, 14:1-21.
• [25]Pitre NY, Kushner KE, Raine KD, Hegadoren KM: Critical feminist narrative inquiry: advancing knowledge through double-hermeneutic narrative analysis. Adv Nurs Sci 2013, 36:118-132.
• [26]Gadamer HG: Verdad y método. 3ª edition. Salamanca: Ediciones Sígueme; 1988.
• [27]Lyneham J, Parkinson C, Denholm C: Explicating Benner's concept of expert practice: intuition in emergency nursing. J Adv Nurs 2008, 64:380-387.
• [28]Connelly FM, Clandinin DJ: Relatos de experiencia e investigación narrativa. In Déjame que te cuente. Ensayos sobre narrativa y educación. Barcelona: Laertes; 1995.
• [29]Giorgi A, Giorgi B: Interpretative phenomenological analysis. In Qualitative Psychology: A Practical Guide to Research Methods. 2nd edition. London: Sage Publications Ltd; 2008:26-59.
• [30]Van Manen M: Investigación educativa y experiencia vivida. Barcelona: Idea Books; 2003.
• [31]Ley orgánica 15/1999, de 13 de diciembre, de Protección de Datos de Carácter Personal BOE núm. 298, de 14-12-1999, pp. 43088–43099) http://www.boe.es/boe/dias/1999/12/14/pdfs/A43088-43099.pdf webcite
• [32]Ley 14/2007, de 3 de julio, de Investigación biomédica (BOE núm. 159, de 04-07-2007, pp. 28826–28848). http://www.boe.es/boe/dias/2007/07/04/pdfs/A28826-28848.pdf webcite
• [33]Lyneham J, Parkinson C, Denholm C: The experience of knowing: a phenomenological study of intuition. Int J Nurs Pract 2008, 14:101-108.
• [34]King L, Clark JM: Intuition and the development of expertise in surgical ward and intensive care nurses. J Adv Nurs 2002, 37:322-329.
• [35]Benner T, Wrubel J: Caring comes first. Am J Nurs 1989, 88:1072-1075.
• [36]Henneman EA, Dracup K, Ganz T, Molayeme O, Cooper C: The effect of a collaborative weaning plan on patient outcome in the critical care setting. Crit Care Med 2001, 1:297-303.
• [37]Rose L, Blackwood B, Egerod I, Haugdahl HS, Hofhuis J, Isfort M, Kydonaki K, Schubert M, Sperlinga R, Spronk P, Storli S, McAuley DF, Schultz MJ: Decisional responsibility for mechanical ventilation and weaning: an international study. Crit Care 2011, 15:R295.
• [38]Rose L, Nelson S, Johnston L: Decisions made by critical care nurses during mechanical ventilation and weaning in an Australian intensive care unit. Am J Crit Care 2007, 16:434-443.
• [39]Blackwood B: The art and science of predicting patient readiness for weaning from mechanical ventilation. Int J Nurs Stud 2000, 37:145-151.
• [40]Hess DR: Patient-ventilator interaction during noninvasive ventilation. Respir Care 2011, 56:153-165.
• [41]Sinuff T, Kahnamoui K, Cook DJ, Giacomini M: Practice guidelines as multipurpose tools: A qualitative study of noninvasive ventilation. Crit Care Med 2007, 35:776-782.
• [42]Sørensen D, Frederiksen K, Grøfte T, Lomborg K: Practical wisdom: A qualitative study of the care and management of non-invasive ventilation patients by experienced intensive care nurses. Intensive Crit Care Nurs 2013, 29:174-181.
• [43]Chuang YH, Huang HT: Nurses' feelings and thoughts about using physical restraints on hospitalized older patients. J Clin Nurs 2007, 16:486-494.
• [44]Choi E, Song M: Physical restraint use in a Korean ICU. J Clin Nurs 2003, 12:651-659.
• [45]Velasco JM: Position statement on the use of restraint. British Association of Critical Care Nurses. Nurs Crit Care 2004, 9:199-212.
• [46]Hine K: The use of physical restraint in critical care. Nurs Crit Care 2007, 12:6-11.
• [47]Mion L: Establishing alternatives to physical restraint in the acute care setting: a conceptual framework to assist nurses’ decision making. AACN Clin Issues 1996, 7:592-602.
• [48]Reigle J: The ethics of physical restraints in critical care. AACN Clin Issues 1996, 7:585-591.
• [49]Martin B: Restraint use in acute and critical care settings: changing practice. AACN Clin Issues 2002, 13:294-306.
• [50]Yeh S, Hsiao C, Ho T, Chiang M, Lin L, Hsu C, Lin S: The effects of continuing education in restraint reduction on novice nurses in intensive care units. J Nurs Res 2004, 12:246-255.
• [51]Baker C, Meley V: An investigation into the attitudes and practices of intensive care nurses towards verbal communication with unconscious patients. J Clin Nurs 1996, 5:185-192.
• [52]Tosch P: Patients' recollections of their post traumatic coma. J Neroscience Nurs 1988, 20:223-228.
• [53]Munger A, Rios Y, Ignowski C, Nelson M, Gass S, Festa C: Communicating with the unresponsive patient. Dimens Crit Care Nurs 2012, 31:275-282.
• [54]Owen AM, Coleman MR: Functional neuroimaging of the vegetative state. Nat Rev Neurosci 2008, 9:235-243.
• [55]Fernández-Espejo D, Owen AM: Detecting awareness after severe brain injury. Nat Rev Neurosci 2013, 14:801-809.
• [56]Siffleet J, Young J, Nikoletti S, Shaw T: Patients’ self-report of procedural pain in the intensive care unit. J Clin Nurs 2007, 16:2142-2148.
• [57]Rankin MA, Donahue MP, Davis K, Katseres JK, Wedig JA, Johnson M, Maas M: Dignified dying as a nursing outcome. Outcomes Manage Nurs Pract 1998, 2:105-110.
• [58]Kirchhoff KT, Beckstrand RL: Critical care nurses' perceptions of obstacles and helpful behaviors in providing end-of-life care to dying patients. Am J Crit Care 2000, 9:96-105.
• [59]Robichaux CM, Clark AP: Practice of expert critical care nurses in situations of prognostic conflict at the end of life. Am J Crit Care 2006, 15:480-489.
• [60]Beckstrand RL, Callister LC, Kirchhoff KT: Providing a “good death”: critical care nurses' suggestions for improving end-of-life care. Am J Crit Care 2006, 15:38-45.
• [61]Del Barrio M, Jimeno L, López P, Ezenarro A, Margall MA, Asiain MC: Cuidados del paciente al final de la vida: ayudas y obstáculos que perciben las enfermeras de cuidados intensivos. Enferm Intensiva 2007, 18:3-14.
• [62]Gálvez M, Munumel G: Cerrando la brecha entre los cuidados paliativos y los cuidados intensivos. Index Enferm 2010, 19:191-195.
• [63]Badger JM: Factors That Enable or Complicate End-of-Life Transitions in Critical Care. Am J Crit Care 2005, 14:513-521.