Technological equipment in critical care: the cost of progress

It was May 2000 when I was first employed as a nurse in the Anesthesiology Department and I clearly remember how strongly the equipment used in clinical practice had attracted my interest. Monitors, ventilators, infusion pumps and similar devices rendered my workplace a hi-tech environment and made me enthusiastic about their clinical application. Until one day 3 months later, when I administered intravenously an opioid drug at an infusion rate of 50 mL/h, instead of the desirable one of 5 mL/h. Fortunately, my serious error did not critically harm the patient; however, my enthusiasm was spontaneously turned into fear and anxiety when I realized the high risk for adverse events associated with equipment use. When a few years later I decided to investigate nurses' perceptions about technological equipment, I found that nurses with <5 years of experience were more positive than more experienced ones about the advantages of equipment use, but at the same time they were more concerned about increased risk from errors and felt increased stress when using technological equipment and devices (Kiekkas et al., 2006). Previous authors have highlighted the Janus-face of technology, that is, the potential for both benefits and risks according to its use, as well as for patient-care outcomes that range across all possibilities (Barnard, 2000; Almerud et al., 2008). Because the employing of technological equipment use has become an integral part of daily nursing practice in the intensive care unit (ICU), identifying how nurses perceive technology is of primary importance. In most studies, participants' responses generally reflect a tendency towards positive benefits for patient care (Noh et al., 2002; Kiekkas et al., 2006; Wikstrom et al., 2007). By embodying scientific progress into nursing practice, devices ensure higher care effectiveness and patient safety, easier and faster completion of nursing tasks and decreased workload. They are also considered to expedite the role of nurses, offering the potential for improving their knowledge, clinical skills and professional prestige (Wichowski, 1994; Kiekkas et al., 2006; Laila et al., 2011). Although nurses tend to overestimate the positive advantages of technological equipment (Almerud et al., 2008), existing studies reveal that they are also well aware of disadvantages and risks associated with its inappropriate use. Increasing complexity of devices renders them difficult to handle and raises high risks for human errors and mechanical faults, which may seriously compromise patient safety (Kiekkas et al., 2006; Wikstrom et al., 2007). In a recent study, a leading source of critical incidents occurring in seriously ill patients was owing to handling of equipment, accounting for 30% of incidents (Welters et al., 2011). In particular, faulty equipment, unfamiliarity with or incorrect use of equipment, disconnections and leaks were reported as major causes of these incidents. With regard to devices, infusion pumps have been reported as the most commonly involved in critical incidents occurring in intensive care or high dependency units, followed by ventilators, haemofilters and monitors (Thomas and Galvin, 2008). It is also worth noticing that 3% of these equipment-associated critical incidents resulted in increased length of ICU stay, permanent harm, life-threatening conditions, or even contributed to patient death. Besides patient harm, repeated induction and high complexity of new devices, along with limited time and training for mastering their use, could be a serious cause of stress for nurses, or even of technophobia, which refers to unreasonable fear about technology (Bucknall and Thomas, 1997; Kiekkas et al., 2006). In addition, the fact that equipment is usually purchased and controlled by physicians could possibly favour medical dominance, restrict autonomy of nursing profession and reduce nurses to technicians (Barnard, 2000). Concerns have also been expressed that technology may attract attention of personnel away from patients and minimize nurses' role as empathetic touchers (Barnard, 2000; Alasad, 2002). It can further constrain holistic care and lead to dehumanization, as devices render patients measurable objects whose psychosocial needs are ignored (Barnard and Sandelowski, 2001; Almerud et al., 2008). It is thus obvious that technology misuse can compromise both objective aspects and subjective qualities of care. How can critical incidents attributed to equipment be prevented? Technology can never substitute human judgement or skills and is neither good nor bad per se; it is only as good as the user is knowledgeable about its use (McConnell, 1998). For example, pulse oximetry has allowed more reliable and earlier oxygen desaturation detection, resulting in decreased incidence of hypoxemia. However, its appropriate use entails much more than simply reading oxygen saturation values. Nurses must know how pulse oximetry works and what it measures, be capable of correctly interpreting its readings, be aware of conditions being implicated for erroneous readings, and identify clinical limitations, possible artefacts or malfunctions of this monitoring, and factors affecting accuracy of its readings (Howell, 2002; Valdez-Lowe et al., 2009). Otherwise, false sense of safety may lead to decreased patient surveillance and increased risk for mishaps. What about the issues of personnel's dehumanization and decreased empathy? According to Almerud et al. (2008), the flaw is not turning our attention to the device, but rather turning it away from patients. Our ability for using tools is among those that discriminate us from animals. However, we should always think of technological equipment as nothing more but a sophisticated tool; in other words, as a means for achieving our purpose, which should definitely be the provision of holistic patient care. Technology is therefore not opposed to humanized care but should be specifically enrolled in the service of this care (Barnard and Sandelowski, 2001). In this context, life-supporting technology has been reported to bring experienced nurses very close to ICU patients and their families (McGrath, 2008). Negative effects of technology, such as personnel's errors, stress and limited autonomy, are closely related to the lack of appropriate education and training (Kiekkas et al., 2006). Because undergraduate education cannot cover training about rapidly changing equipment, ICU nurses need to acquire knowledge and clinical skills through a lifelong learning process to maintain competence (Huggins, 2004). Continuous education and training programmes are needed, which should follow technological advances and provide valid information about capabilities, potential uses, and user requirements for safe and effective use of new, more complicated devices, especially about their advantages over previously used ones. Newly employed, inexperienced nurses also need to be trained through well-organized programmes, so that they soon become familiar with equipment use, learn to operate within safety culture and develop positive attitude towards technological innovations. Training can be based on either clinical display by experts or simulation of user–device interfaces; the latter has the advantages of accurately detecting user errors or device faults, ensuring patient safety and decreasing costs (Elias et al., 2013). Besides training, the audit, documentation and cause analysis of mishaps associated with devices, along with feedback of findings to personnel and development of clinical guidelines for prevention of mishaps according to the ‘Matching Michigan’ framework are expected to further enhance personnel performance and promote patient safety (Montgomery-Taylor et al., 2013). Technology is undoubtedly a key concept for progress; however, progress often has its cost. To minimize this cost, we should always remember that devices are made to serve us in improving care quality, so that we keep our focus on patients. We are also called to develop high expertise on the optimal use of devices, in order to maximize their potential benefits and properly address safety issues.