Critical care nursing and older people - is there an issue?

Abstract

In 2012, I was approached by the editors of Nursing in Critical Care (NICC) asking if I would ‘guest edit’ a special issue of NICC focusing on the care needs of older people. I was delighted to accept such an invitation because older people now occupy a significant proportion of critical care service delivery. In 2013, the call for papers was developed and distributed widely through a variety of international networks. I eagerly anticipated the range of papers that would be submitted and felt excited at the prospect of raising the profile of nurse research with older people in critical care. At the end of the agreed submission period, three papers had been submitted, but found unsuitable for publication in NICC. A further targeted call for papers to known researchers in the field resulted in no submissions. Needless to say, the editors and I were surprised and perplexed at this poor response and it raised many questions, not least of which is – where is the research into the nursing needs of older people in critical care actually happening? A simple Google search using the terms ‘elderly’, ‘critical care’, and ‘nursing’ (combined) reveals few studies that are about the holistic care needs of older people in critical care settings. Many studies can be found that focus on particular technical aspects of care, specific symptomology and some that focus on ethical aspects of care (such as care futility), but I question if this is really nursing research or merely research done by nurses? As a gerontological nurse, it seems sad and indeed disturbing to me, that the nursing research community seems to be so disinterested in older people as a focus of research in critical care. These days it is so clichéd to say that the population is ageing as it is indeed stating the obvious. These days it is so clichéd to say that the population is ageing as it is indeed stating the obvious. Twenty percent of the UK population is over the age of 60 and those over the age of 90 will double by 2025. Jones (2010) drawing on data from the ‘Intensive Care National Audit and Research Centre Case Mix Programme Database (ICNARC:CMPD)’ www.neics.org.uk/sites/.../Critical%20Care%20for%20the%20Elderly.ppt showed that in the period 2006–2007, 49.3% of all those admitted to an intensive care unit (ICU) were over the age of 65 years (www.icnarg.org). With this high percentage of older people occupying critical care services, it is imperative that nursing researchers take on the challenge of advancing nursing knowledge in this field and ensuring that the highest possible quality of care is delivered. Older people in critical care are a complex population, with multiple morbidities compounding complex acute illnesses, chronic diseases that require long-term care packages and social needs that are rarely straightforward. With almost 50% of the ICU population over the age of 65, is it time for critical care nurses to recognize their role as gerontological nurses also? Gerontology has never been a specialty of choice for most graduating nurses and nurses' attitudes towards working with older people remain ‘mixed’ at best (Liu et al., 2013). Therefore, the challenges associated with raising the profile of gerontology in critical care are immense – for example, the clash of cultures, the complexity of care and treatment needs and the additional knowledge required to overlay the specialist critical care knowledge of nurses. However, it is obvious that if critical care nursing of the future is to embrace an ageing population, then these challenges need to be profiled in the education of critical care nurses, in the development of person-centred practice cultures and in the shaping of nursing expertise in critical care nursing. Expert nurses working with older people do not focus on the resolution of disconnected problems. Instead, they focus on patients' overall coping resources through processes of negotiation and working flexibly with them. Focusing on patients' agendas facilitates patient decision-making, but for older people this needs to be offered at a pace appropriate to their coping resources. Holding the individual patient's beliefs, values and biography central in decision-making is essential to a person-centred approach to practice (McCormack and McCance, 2010). Maintaining the older person's identity is central to care decisions and helping them to maintain that in the sense of who they are in the context of their lives, i.e. their biography. Rather than removing older people from their biographies, an approach that holds values as central to care decisions would determine actions based on what older people want for their future life plan. The alternative scenario is that of the older person being seen as a ‘care thing’, i.e. an object. Holding values as central allows a variety of possible ‘futures’ to emerge. The challenge in accepting person-centred risk assessment is that of balancing professional knowledge and personal knowledge or the blending of the professional with the personal. Critical care nurses need to be able to balance their technical competence and expertise and their professional caring roles with the patient's understanding of their own well-being and their potential futures. The interactions of expert critical care nurses underpinned with foundational gerontological knowledge enable a person-centred approach to practice in critical care settings. This person-centred gerontological nursing agenda opens up many avenues for research in critical care nursing. Whilst ongoing research into specific treatment and care practices will always be needed, there is also significant scope for a broader research perspective that is person-centred in focus and that challenges established norms in critical care nursing. Critical questions about the role, knowledge, skills and expertise of critical care nurses from a gerontological perspective need to be asked and further research is needed to explore the integration of these specialist areas of nursing knowledge that on the face of it, seem to ‘clash’. However, their integration is essential for older people in critical care and it may be too far a leap to hope for a gerontology sub-specialty in critical care nursing – but I am forever hopeful!