Critical Care Nursing: A Balancing Act
Noel Baldwin, BSN, RN - Clinical Care Coordinator, Critical Care Medicine Unit, University of Michigan Hospital
Critical care nurses are on the front lines of patient care. Critical decisions, highly stressful situations, and ethical dilemmas are all part of this unique environment. These nurses must consistently walk the line of maintaining focus and keeping their own emotions in check while witnessing every reality between admission and the long-awaited, but unfortunately sometimes never seen, discharge.
Though the importance of their role is often overlooked, critical care nurses hold it all together with every patient that comes through the ICU doors. Fortunately, unit collaboration paired with patient and family validation help to boost morale and keep the capacity for care high.
Noel Baldwin, BSN, RN, a nurse in the Critical Care Medicine Unit has been at the University of Michigan Hospital for 21 years. He is the Clinical Care Coordinator, dividing his time between bedside care and administrative duties. As a Unit veteran, he has seen a lot, but eloquently maintains his composure with consideration for every patient and loved one that comes into his care.
“There’s a great opportunity to help patients who are very very ill,” said Baldwin. “But it’s also a great opportunity to help families who are having a very difficult time.”
In addition to providing support and empathy, Baldwin notes how the experience and wealth of knowledge among critical care nurses can have an incredible impact on patients. “Nurses in the ICUs have an exceptional skill set which allows us to anticipate problems and alert physicians before they occur, and work together with the team to promote best outcomes,” said Noel.
Interdisciplinary Collaboration & Feeling Valued
Noel’s indication of a significant increase in unit teamwork is echoed in “A Historical Review of Nurse-Physicians Bedside Rounding,” an analysis by Genevieve Beaird, MS, RN, clinical assistant professor and a PhD student at Virginia Commonwealth University School of Nursing, Richmond. The article outlines how decades ago, there was a more hierarchical health structure viewing nurses as a labor force, but is now rooted in interdisciplinary collaboration.
Noel believes that the nurses in the CCMU are “absolutely” valued by the physicians, who are often telling the house officers to “listen to your nurses, they have years of experience.” However when Noel first started, he explained that nurses weren’t included in rounds and would later find out what the next course of action would be. Since then, in his experience, physicians now request the nurses at the bedside and many times they won’t even round on a patient until the nurse is there.
In the CCMU, every morning starts with multidisciplinary rounds that are held at the bedside to discuss patient care, goals, and the plan for the day. The whole core of the team - physicians, nurses, dietary, and respiratory therapy - can determine the best path forward. Nurses are actively involved and provide feedback into the patient’s mental status, ventilator settings, if they’re active and moving, and anything else that happened over night.
“I think what is nice about the ICU is that we really do collaborate to make sure we all understand what the plan of care is and that there are always projects going on to make sure we have more collaboration,” said Noel.
Noel recalls a situation validating his knowledge but also his value to the patient and their loved ones. “I had a patient many years ago who had a very tense abdomen requiring a lot of blood pressure support,” said Noel. “My intuition was that this was all secondary to the taut abdomen, but the numbers we had didn’t demonstrate that. I was insistent that my clinical exam suggested the patient was dying from the cause. Ultimately I was correct. Surgical became involved, fixed the problem, the patient improved dramatically within 12 hours. The patient came back to me, wrote me a card, and thanked me for saving their life.”
The CCMU has the highest mortality rate in all of the hospital due to the type of patients they care for (often those at the end stage of a chronic illness), but Noel wishes more well patients would come back to visit. Noel explains that from a nursing perspective, it’s valuable to see patients come back when they’re up on their feet. However, Noel says, “it is difficult for patients to come back to the ICU because it’s hard to relive it, and often have delirium in the ICU – nightmares and fears, the inability to recognize the reality for what it is.”
While there will always be room for improvement, previous nursing hurdles have been cleared for the benefit of the unit and ultimately the patients, whose outward appreciation is the best reward critical care nurses could receive.
The Personal Challenges
While regularly facing death, a hurdle that will never go away is the balancing act of remaining centered professionally.
“Sometimes you have to let it in, you have to be human,” said Noel. “After dealing with it so much it isn’t as impactful but you always have those patients where it’s very upsetting because you made a bond with their family and had a connection. It’s challenging.”
Noel says there are two challenges in the ICU associated with personal feelings.
First, meeting the expectations of families and loved ones. Oftentimes the patient is heavily sedated so loved ones are the decision makers. They want everything possible done for their loved one, but “…in this day and age of technology, they often don’t realize the degree that the technology is keeping their loved one alive and it may not be in line with what the patient would’ve wanted in terms of quality of life. Those conversations are difficult,” said Noel.
To address that challenge, Noel emphasizes the importance of respecting family and patients by not making value-based assumptions. “Your values can impact how you think but not your care. If we think, as medical providers, that we can get the patient to their ideal point of quality of life, not ours, then we should do so.”
Noel says it’s important to share your own values with your loved ones. “It’s surprising how many people live with chronic illnesses for many years but yet they’d never really had a discussion with their loved ones about what they would want. Yet, we want their loved one to make a decision and that’s a very difficult decision that’s going to impact the patient and them for the rest of their lives. We don’t want them walking away from the situation thinking they made the wrong decision. They have to have peace of mind.”
The second challenge? “Obviously, Google,” said Noel. “Loved ones read and think they have an understanding, but there’s just a lot of nuances that maybe aren’t included in what they read, resulting in conversations to help them understand that there’s more to it.”
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While every shift comes with its own challenges and threatens to throw off the balance critical care nurses strive to maintain every day, Noel is continually encouraged by the amazing team within the CCMU. At the end of the day, as the old saying goes, “we’d all be worse without a nurse.”