So hard to care …
Critical care nursing in Hellas

… How will more knowledge help? I have my patients, I have my orders, I know my way … When the shift is over I go home and that’s the end of it. […] We need to face it, the decisions are not ours to make [means clinical decision making], they [physicians] make the decisions, they do not listen to what we have to say, and we might have something to suggest. I used to read a lot, I attend seminars and conferences, there are things we can do … NURSING [interviewee’s emphasis] things that will help them [means the patients]. BUT… even nurses do not care, we are exhausted … not able to endure any more … you know we work for weeks without a day off? … yet we are invisible, they do not respect us. It is US, WE are the problem. It is like nursing is not a profession … we are scared to argue. Do not get me wrong, I do believe our contribution, what we have to offer to patients, is TREMENDOUS. BUT only because we CARE, WE CARE for them [means the patients]. It is so hard to care … This quote from a bachelor degree Hellenic critical care nurse’s interview, as extreme as it might seem, does reflect, I believe, the stance of many critical care nurses in Hellas, who suffer from excessive workloads and limited opportunities to implement change in their practice (Vouzavali and Papathanassoglou, 2005). What is more alarming is that, as in the case of the nurse above, it may be the majority of experienced and expert nurses who subscribe to such views, probably due to chronic exhaustion and disappointment precipitated by the severe staff shortage, lack of support and the medical dominance in health care delivery. Additionally, from an educator’s perspective, the main obstacle one encounters while trying to engage experienced and inexperienced Hellenic critical care nurses alike in issues of advancing care is the collective perception that change is unlikely, since nurses have very limited control over their work environment and practice. While it is probable that the antecedents of this phenomenon are linked to the rules of social psychology, its consequences are quite severe, undermining both the profession, as well the effectiveness of critical care nursing, and patient survival and well-being. In the midst of accumulating advancements in the field of intensive care, critical care in Hellas needs to address some pressing yet lingering nursing issues, which are so imperative that they may eventually neutralize the favourable effects of advancements in therapy and technology. If the aim of critical care is indeed the survival, rehabilitation and well-being of individuals, rather than the prolongation of a near-death limbo, then the role of nurses is vast, and critical care nurses as professionals need to enjoy the recognition, respect and freedom required in order to fully develop their practice towards maximizing the well-being of patients. Research evidence on critical care nursing workforce issues in Hellas is limited, nonetheless, low decisional autonomy (Papathanassoglou et al., 2005) and associations with job satisfaction, burn-out and self-esteem (Karanikola et al., 2006), along with very low nurse/patient ratios, absence of orientation and continuous education programs (Merkouris et al., 2003), and an almost complete lack of implementation of the nursing process, or of some other systematic way for meaningful patient-centered nursing decision-making (Papathanassoglou et al., 2005). Additionally, due to the nursing shortage, one third, approximately, of staff who function as nurses in Hellenic critical care are, in fact, nurse assistants (Papathanassoglou et al., 2005). This type of staffing, obviously, undermines both the organization and quality of care (Merkouris et al., 2001), as well as nurses’ efforts to advance their practice and autonomy. On top of these confines, one should consider that the big majority (over 90%) of critical care nurses in Hellas have not attended a specialized course on critical care nursing during either their pre- or postregistration education (Papathanassoglou et al., 2005), which, in association with the scarcity of orientation training, may have a negative impact on their professional role and development. Low clinical autonomy and authority are so persistent in Hellenic nursing that they may have been incorporated into the conceptualization of the profession and image of nursing; thus, they may not be perceived as problems anymore, since nurses form very low expectations for their desired input in clinical decision-making (Karanikola et al., 2006). Nonetheless, one cannot overemphasize the implications of low autonomy in clinical practice. Increased nursing autonomy in intensive care is associated with better patient outcomes (i.e. Curley, 2002), as well as with health outcomes in nursing personnel (Erlen and Sereika, 1997; Budge et al., 2003), while it is a factor in supporting evidence-based practice (Parahoo, 2000), as well as in nursing satisfaction and staff retention (Scott et al., 1999). Nursing professional autonomy should not be confused with independence. Obviously, independence is unattainable for any member of the health care team. Conversely, autonomy is the ability of nurses to make clinical decisions and to regulate their practice and type of care according to the principles of the nursing science and individual patient needs. Wade (1999) defines professional nurse autonomy as ‘the belief in the centrality of the client when making responsible discretionary decisions, both independently and interdependently, that reflect advocacy for the client’. Autonomy and control over education, practice and decision-making are fundamental prerequisites any discipline must meet in order to comprise a profession (Varjus et al., 2003). Hall (1996) posits that ‘people in occupations that want to be professionals seek to increase the thinking part of their jobs and […] to decrease the time they spend on doing physical things’. The restriction of Hellenic nursing to such ‘physical things’, the persistent belief that nurses’ role may be upgraded when more ‘physical tasks’ are passed from doctors to them and the pervasive devaluation of nurses’ clinical reasoning deprive Hellenic nurses of opportunities for increased professionalization and autonomy. More importantly, I will argue that they rob the critically ill of chances for increased survival and well-being. Recent advancements in intensive care, that were shown to improve patient outcomes, rely heavily on nursing. Progressive patient positioning for acute respiratory distress, intensive glycaemic control, continuous haemofiltration techniques, nutritional management, management of agitation/sedation and analgesia, patient communication techniques, early weaning protocols, monitoring of tissue oxygenation, haemodynamic status and respiratory pressures, less traumatic ventilatory modes, and early recognition and management of sepsis and shock, along with protocols for minimizing ventilator-associated pneumonia and intravascular-catheter-related infections are a few of a long list of new and/or revisited approaches for improving patient survival. Such approaches depend greatly or even completely on the professional judgment and skills of nurses (i.e. Kollef et al., 1997; Brook et al., 1999; Luyt et al., 2002), as well as on their ability to implement change and to control and evaluate their performance. Professional nurse autonomy encompasses yet another important dimension. Patient advocacy and ethical decision-making are primary nursing responsibilities, and public’s trust is invested in nurses as advocates and as patient-family-physician communication mediators. However, in order to fulfill this role, moral reasoning alone is not enough. Nurses need to be free to act on their moral decisions. In Hellenic critical care, the restraints imposed on nursing’s ethical decision-making and action leave nurses vulnerable to moral conflict, job dissatisfaction and burn-out. Additionally, as recently documented in a nation-wide survey (Papathanassoglou et al., 2005), the persistent devaluation of nurses’ knowledge and judgment may often deprive nurses of yet another primary area of nursing responsibility, that is the communication with, and the delivery of information to, patients and families. Furthermore, nurses’ role within the critical care team is unique in that they address issues beyond recovery per se. Due to the interpersonal, intimate nature of nursing and by virtue of their constant presence and observation of patient status, they are uniquely situated to offer psychological support, to instill hope, to communicate and empathize with patients and families and to provide care when cure is not possible (Ball, 2001). Undeniably, these functions are recognized as distinctive of nursing, nonetheless, in the often mechanistic task-oriented culture of critical care in Hellas, such activities fail to receive adequate priority. Although critical care nurses’ own inclination to technical tasks may be a factor in this, another significant cause may be the conceptualization of nursing as an activity aimed to support and to assist rather than to complement medicine. Psychosocial nursing tasks do not help physicians a lot and therefore they may be regarded as a well-meant but time-consuming nursing ‘oddity’. Nonetheless, based on research evidence, one could easily argue that psychosocial care for the critically ill does affect their overall morbidity and mortality (Lusk and Lash, 2005; Papathanassoglou, 2005) In Hellas, the social stereotype of the nurse/physician assistant is solid (Patiraki-Kourbani, 2003), presumably due to historical and gender issues that are beyond the scope of this discussion. However, such pervasive stereotypes may become hazardous, rather than picturesque, when they form the basis for national policy-making and legislative acts. Such is the case of a recent law that subordinates hospital nursing personnel and services to the medical hierarchy, defying former long-standing legislation, which safeguarded the autonomy of nursing, along with that of the medical and administrative hospital services. Such acts deny nurses the accountability for the outcomes of care and the right to control their practice. Moreover, the continual resistance of several ministry administrations to nurses’ pleas to advance nursing education to 4-year university programmes offered by academic institutions, rather than the current technical/vocational institutions, may reflect such stereotypes along with a lack of understanding of nursing’s role and extend of input to patient well-being. Given such restrictions in education, practice and legislation, critical care nurses in Hellas are far from being empowered. This phenomenon is not unique to Hellenic critical care, e.g. Coombs (2003) describes similar authority issues in clinical decision-making in the UK. However, in Hellas, by virtue of its intensity and extent, low autonomy may be particularly important in shaping the experience, as well as the development of critical care nursing. To address this multifaceted phenomenon, coordinated action is required to improve education and legislation as well as nurse staffing and retention. Due to its implications for the quality of care, the demand for nursing autonomy needs to be regarded not only as a mere professional aspiration of nurses but also as one of the fundamental patients’ rights. I thank Professor Chryssoula Lemonidou for useful discussions.