The impact of the COVID-19 pandemic has drawn attention worldwide to the management of mechanical ventilation. Analgesia and sedation are used to ensure patient comfort and safety and also to reduce sympathetic stress responses. However, over-sedation is associated with longer stays in the intensive care unit (ICU) and with Post ICU Syndrome (Colbenson et al. 2019).
Nurses are responsible and accountable for titrating the sedation of ventilated patient to hit a sweet spot of maximum benefit with minimum harm. Many countries use scales such as the Richmond Agitation and Sedation Scale (RASS), and this has been widely validated in English speaking countries. Assessment of agitation may have cultural cues and therefore this study of its use in Iran is a useful addition to the literature, although it is a small study and statistical generalisation should be drawn with caution.
The authors note that an Australian study (Bucknall et al. 2008) showed no significant difference in ICU and hospital stay duration between patients who were assessed using RASS and those who had followed a conventional protocol procedure. They suggest this may be due to greater capability and competency of Australian ICU nurses. This raises, yet again, the issue of professional judgement versus task-based checklists. A number of recent studies, including McGaughey et al. (2017) have raised concerns about early warning scoring systems that facilitate the delegation of observations to unregistered staff.
Whilst scoring systems such as RASS offer an aide-memoire and a common language for recording observations, professional judgement goes much further. As I set out with my colleague recently (Maxwell and Leary 2020), professional judgment is the combination of theory and experience. Using well-evidenced theory, an expert draws on their experience of both typical and atypical cases to subliminally match appropriate evidence to each given situation and whether that unique situation requires adaptations. The complexity of these patients physiologically and socially means that the confounding variables become too numerous for a simple scoring system or pathway.
COVID-19 has led to a dilution of nursing skill mix in critical care units in England and questions are being asked by some about whether this should become the new ‘normal’. It is therefore important that future studies into any assessment scales and tools examine what they do not cover, and what can be ascertained only by a practitioner who has developed expertise through praxis and theory. To do this, we need to step away from the model of researcher as academic and co-produce research as a partnership between theorists, methodologists and practitioners with, of course, our patients.
Biography
Elaine Maxwell is a knowledge broker with the National Institute of Health Research Centre for Engagement and Dissemination. She holds an Intensive Care Nursing qualification.
References
- Bucknall TK, Manias E, Presneill J. (2008) A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit. Critical Care Medicine 36(2): 1444–1450. [DOI] [PubMed] [Google Scholar]
- Colbenson GA, Johnson A, Wilson ME. (2019) Post-intensive care syndrome: Impact, prevention, and management. Breathe 15: 98–101. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Maxwell E and Leary A (2020) In praise of professional judgement. BMJ Opinion. Available at: https://blogs.bmj.com/bmj/2020/05/26/elaine-maxwell-alison-leary-praise-professional-judgment/ (accessed 17 July 2020).
- McGaughey J, O'Halloran P, Porter S, et al. (2017) Early warning systems and rapid response to the deteriorating patient in hospital: A realist evaluation. Journal of Advanced Nursing 73(12): 3119–3132. [DOI] [PubMed] [Google Scholar]