This time of year heralds longer days, warmer weather, vivid colours and generally a mood of well-being. For many, this season is embraced for all it offers and brings. The collection of papers in this issue also brings some fresh and bright insights that examine important aspects of care and prompt us to consider the different ways by which patient safety can be enhanced and maintained. In many areas of critical care practice, there are many aspects of ongoing debate that often concern the safety of techniques and associated complications. For example, comparisons between open and closed suctioning manoeuvres in relation to lung dynamics and functioning have been studied; however, research on the effect on haemodynamic parameters is disputed. To address this, Özden and Görgülü (2015) using a quasi-experimental design, studied the effects of both approaches on a sample of 120 patients who underwent open heart surgery and evaluated changes in heart rate (HR), mean arterial blood pressure (MAP), Pa02, PaC02 and Sa02 at four time intervals (prior to and after suctioning). One group (n = 60) had suctioning using the open system, the other (n = 60) had the closed endotracheal suctioning system. Analysis of results indicates that HR, MAP and arterial blood gases were adversely affected more significantly during open endotracheal suctioning as compared with the closed suctioning technique. Additionally, disturbances in haemodynamic values compared with pre-suction levels were lower with the closed suction system than with the open approach. This study adds to the body of evidence regarding closed endotracheal suctioning for mechanically ventilated patients and serves to emphasize that critical care nurses must regularly question the evidence that underpins their practice and ensure that clinical interventions enhance patient safety and recovery. Many countries have developed national policies to promote organ donation among their citizens because of problems with shortfall relative to patient need. The role of intensive care nurses can be viewed as pivotal in brokering discussions with families of patients who have been identified as potential donors because of their underlying clinical condition being irrecoverable. Indeed, Collins (2012) has identified that the attitudes and beliefs of nurses may have an impact on whether a dialogue is initiated that will lead to possible organ donation. Caring for potential organ donors is demanding and it is essential that their humanity and dignity is maintained. To explore this further, Forsberg et al. (2015) have studied the attitudes of Swedish critical care nurses (n = 502) using a 32-item data collection questionnaire that embraced five dimensions framed within the Attitudes Towards Organ Donor Advocacy Scale (ATODAS). Respondents were more comfortable when advocating in relation to safeguarding the will and wishes of potential organ donors by professional actions and displayed a similar attitude to protecting the will and wishes of this patient group by active and personal behaviours. As in studies involving other attitudes of critical care nurses, seniority, length of experience and involvement in situations that related to the phenomenon of inquiry, were variables associated with a more positive outlook. However, respondents based in larger or university hospitals had a lower disposition towards organ donation advocacy. This seems counterintuitive and explanation for this observation would have been valuable. A key point from this study is that role models and mentoring of junior staff are vital in developing more positive attitudes in nurses. Including inexperienced colleagues in observing seasoned colleagues manage the care of families and how they are approached with a view to organ donation can be a powerful learning situation. This is also important as critical care staff may feel uncomfortable when approaching relatives for consent to retrieve the organs of potential donor because of insufficient training in this area (Collins, 2012; NHS Blood and Transplant, 2015). It is well known that healthy work environments can increase the commitment, productivity, job satisfaction and loyalty of the workforce as well as ensure staff retention. This may be measured through evidence of professional autonomy, having shared values, effective co-worker relationships and investment in staff development. The Essentials of Magnetism II tool is one approach developed for the purpose of assessing and analysing the performance of clinical environments in the Western countries, Bai et al. (2015) however sought to validate this within 28 Chinese intensive care settings. The validation of the tool underwent rigorous processes and translation and over 700 nurses completed the documentation. The analysis of psychometric properties indicated that the Essentials of Magnetism II tool did travel across cultures, with the scale offering a promising approach to measuring healthy work environments in China. Although the research team recognized that some aspects needed refinement to ensure congruence and resonance with Chinese clinical values and nursing practice. The learning to take away from this validation study is that regardless of culture or geographical location, strong nursing, valuing and respecting our colleagues and supporting their development remain core to promoting excellence in critical care nursing. The sophistication of medicotechnological devices for use in the clinical or home setting seems, in many areas, to be growing at a very rapid pace. How well we keep up to date with these advances and integrate the application of technology into care delivery and in supporting patients becoming self-managing are important professional questions. Within this context, Norekvål et al. (2015) studied the knowledge levels of critical care nurses in relation to implantable cardiac defibrillators (ICDs) particularly as their use is increasing worldwide and there are specific aspects of care that should be covered with patients prior to, following insertion and discharge home. Using a validated instrument, data collection covered a period of 8 years and included 463 nurses who attended a week's cardiac course offered once a year. The data identified that participant's knowledge around practical and technical matters was insufficient, although in areas of resuming physical and sexual activity, nurses' awareness was better. With respect to variables such as previous education, type of hospital and clinical area of practice, differences were not evident. What this study highlights, is that critical care nurses need to regularly update their knowledge and expertise ensuring that care delivery and practice is informed by novel scientific devices in particular. However, aside from individual nurses taking responsibility for maintaining their professionalism, this should be complemented by the commitment from health organizations in investing in the workforce through resourcing continuous professional development opportunities. Patient diaries (PD) have received much attention in the critical care literature as they have been reported to support both patients and families appreciation of the intensive care unit (ICU) experience. PD have been used in Germany for about 7 years, however to assess the extent of implementation within ICUs, Nydahl et al. (2015) undertook a mix-methods study across the country. In total, 221 units were initially surveyed and of these 43 reported implementing PDs of which 14 agreed to participate in semistructured telephone interviews. Data analysis indicates that often the introduction of PDs was a bottom-up approach and often championed by individuals. Application of PD's seemed to be variable in respect to the formatting, patient selection and degree of staff engagement. There were areas of contention that may have impacted on staff commitment and uneasiness to adopting PDs wholesale. Nevertheless, there appears to be a genuine enthusiasm in Germany to establishing PDs and there is a body of evidence that supports their value for patients and families. The development of European guidelines may be an important step forward as a way for ensuring consistency in standards of practice and for enabling comparisons in outcomes for patients and families. As can be noted, this collection of papers highlights the genuine curiosity and desire of critical care nurses to advance their practice for the benefit of patients, families and the standing of the discipline. Having a credible body of research is vital to inform and enrich nursing practice and to reassure patients and the public that care delivery is based on science, rather than on tradition, ritual or the whim of individuals. The studies included in this issue convincingly demonstrate the importance of a questioning and inquisitive mind, whether this is about the conduciveness of the environment in facilitating patient safety and family inclusivity, the interventions used to support patient care or the application of skills and knowledge by staff in the delivery of excellent nursing practice. The passion of critical care nurses in driving and innovating fresh approaches to quality and patient safety is what this summer issue seems to capture.

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