Intensive Care and Nursing Development Unit Report 2004-2006

Chelsea and Westminster Healthcare NHS Trust

Intensive Care and Nursing Development Unit

Report 2004-2006

Contents

Philosophy of Care ......................................................................................................................page 2

Foreword ............................................................................................................................................3

Introduction ........................................................................................................................................4

Unit projects ........................................................................................................................................5

Charter Mark - going the extra mile ..........................................................................................5Developing a weaning flow-sheet for ventilated patients ..........................................................7Patient focus groups ..................................................................................................................8Clinical incident reporting ........................................................................................................10Pharmacy developments ..........................................................................................................12Analysis of feedback from relatives ..........................................................................................13In-house preceptorship course ................................................................................................14Burns Intensive Care ................................................................................................................16

Research activity ................................................................................................................................17

Inter-team projects ............................................................................................................................19

Teaching ..................................................................................................................................19Quality Assurance ....................................................................................................................20Off-duty planning team ..........................................................................................................21Supplies and finance................................................................................................................22Marketing................................................................................................................................23Research group........................................................................................................................24Nursing diagnosis and Electronic Patient Record (EPR)..............................................................25

Developmental opportunities ............................................................................................................26

British Association of Critical Care Nurses Conference - September 2004 ................................26Presenting at an international conference ................................................................................27A staff member’s experience of climbing Kilimanjaro ..............................................................28Flexible working ......................................................................................................................29Acting Clinical Nurse Lead ......................................................................................................29Staff development role ............................................................................................................31Anaesthetic conference - Belle-Plagne ....................................................................................32

Staff development and education ......................................................................................................33

Summary of activity ................................................................................................................33

Publications and research ..................................................................................................................34

Unit staff - April 2006........................................................................................................................36

Contributions to working parties ......................................................................................................37

Acknowledgements ..........................................................................................................................38

1 Intensive Care and Nursing Development Unit Report

Philosophy of Care

Many different members ofstaff care for patients withinthis department. Together weare dedicated to providingcompassionate, exceptionalcare and service. We recognisethe uniqueness of eachindividual and his or her rightto dignity, and as such arededicated to providing the bestpossible, individualised care.

We respect the rights of ourpatients, and that our caremust be non-judgmental,based on sound ethical andmoral principles. We recognisethat the severity of illnessexperienced by our patientsmay render them incapable ofparticipation in the decisionmaking processes that affecttheir care. As direct care givers,we must serve as the patient’sadvocate, in consultation withfamily and significant others.We will provide care in such away as to respect the dignity,privacy and confidentiality ofpatients and families.

We aim to assist our patientstowards recovery andindependence. When it is notpossible, we try to preparethem for a peaceful anddignified death. We feel it isimportant not only to share inthe joy of a patient’s recovery,but also in the sorrow and painof a patient’s death, and toease others’ grief.

We believe that the caringenvironment we provide forour patients should bereflected in our attitudestowards each other and thateach member of the team is avaluable asset. Staff have theright to be treated with respectand to go about their workwithout risk to themselves.Every member of staff shouldhave the opportunity todevelop their skills through theprovision of professionaldevelopment tailored to theirown needs.

The intensive care team believethat our work makes adifference, benefiting patientsand their loved ones. We feelthat we are in a privilegedposition of trust and that thisprivilege should be repaid bythe provision of the higheststandards of care, delivered byquestioning and motivatedstaff.

Chelsea and Westminster Intensive Careand High Dependency Unit

2004-2006 2


Foreword

As a relatively newconsultant in the IntensiveCare Unit, I have found therole offers variouschallenges but these havebeen made all the moresurmountable due to thestrength of the unit ofwhich I am a part.

The term ‘unit’ describesperfectly the ethos behind theICU at Chelsea andWestminster. As a juniordoctor here I never feltwithout support from nursingand medical colleagues andthis certainly has not changedsince commencing my positionas a consultant. The unit hasan excellent reputation bothnationally and internationally.This is reflected in the receiptof the ‘Charter Mark’ awards

and the presence of our staffin the faculties of meetingsand conferences around theglobe.

Such cohesiveness is extremelyattractive to prospectiveemployees but is alsonecessary given the rapidlychanging environment ofacute hospital medicine.Reduced junior doctors’ hours,the European Working TimeDirective, increasing public

expectations and increasedprofessional accountability arejust a few of the majorchanges taking place atpresent. However, they neverseem to detract from ourobjective to achieve the verybest for our patients and theirrelatives.

What does the future hold?Education is an area ofpersonal interest andestablishing a comprehensiveteaching programme for thejunior doctors rotatingthrough ICU is proving to be achallenging area. Research andaudit has always been part ofthe ethos of the unit and Ihope to continue along thatpath. In addition there are anumber of exciting newventures on the horizonincluding the patient ‘follow-up’ clinic and the developmentof the Burns ICU. Suchexcursions into uncharteredterritory are typical of a unitwhich is prepared to leadrather than follow and willhopefully continue to do soover the decades to come.

Dr Jonathan HandyConsultant Intensivist

Last year due to a variety ofreasons the ICU annual reportwas not published and so wehave produced a bumperedition this year reflecting onactivities on the unit in 2005and 2006.

The report consists of theregular elements such asrecounting our progress in theinter-team projects andfeedback from the users ofour service. In addition, in thelast year the unit has gonethrough a major change inthat it is now responsible forthe care of the critically illburns intensive care patient.

Effective change depends onindividuals working as part ofan informed and committedteam who have a clear andexplicit vision of what is tryingto be achieved. Both the ICUand the Burns team havemade significant progress inthe last year, and thisundoubtedly is due toprofessionalism and flexibilityof staff. This annual reportcelebrates and recognises allthis hard work.

Jane-Marie HamillClinical Nurse Leader

2004-2006 4

Introduction

Unit projects

Charter Mark – going the extra mile

The staff on the Intensive CareUnit at Chelsea andWestminster often ‘go theextra mile’ to ensure thatpatients and their families getthe best. This could be byoffering overnight stay roomsto relatives, sorting out placesin the hospital school forpatients’ children or getting amuch loved video for patientsto watch.

It’s for these reasons that wehave been successfullyawarded the Charter Mark forthe third time. We have beenpreviously awarded the statusin 1998 and 2001.

The Charter Mark is astandard of excellent customerservice awarded by theGovernment to public sectoror voluntary organisations.This means that governmentagencies, police forces,prisons, museums, schools andhealthcare settings can beawarded the Charter Mark.

Out of the 2,481 organisationsthat currently hold the CharterMark, there are only six otherIntensive Care Units.

Charter Mark holders havedemonstrated that they haveset high standards, offeredchoice to their customers,looked to continuouslyimprove their service andempowered staff to makechanges for the better. Inshort Charter Mark holderslisten, act and deliver.

The first stage was to hold anumber of focus groups,where staff members‘brainstormed’ ideas of howwe demonstrated the evidencethe criteria were looking for.

The next stage was to meetfor half a day with theassessor to go through theevidence that we hadcollected together and identifyany areas that we wereweaker in. We were then ableto develop our full applicationand submit it for assessment.

The final stage was a full dayvisit to the ICU by ourassessor, Trevor James, onNovember 5 2004. On this dayTrevor met ICU staff, patients,relatives and other hospitalstaff to discuss the daily workof the ICU team.


He was very impressed withthe enthusiasm andcommitment of staff inproviding patient-focused careand he found that relativesand former patients wereequally impressed with thecare and services offered. Hewas also impressed with theway that the ICU staff workwith other departments andteams in the hospital toprovide a co-ordinated andstreamlined service forpatients.

Other areas that we werecommended for included:

• Our customer carestandards and the serviceswe offer to patients andvisitors

• The way that we monitorperformance

• The visitor and staffsatisfaction surveys and ourpatient focus groups,which we use to gaininformation on how wecan improve our services.

• Our annual report

• The way in which staff canbe identified by namebadges and photo boards

• The way in which weencourage and respond tofeedback from all our users

• The use of volunteers tohelp on the unit.

One of the advantages ofundertaking the Charter Markassessment is that we gainfeedback regarding ourpresent performance, but isalso gives us suggestions onhow to improve our service.These suggestions included:

• Developing a website toshare information on theunit

• Holding the patient focusgroups more frequently

• Developing a newsletter tocirculate to patients andvisitors

• Analysing the complimentsand complaints that wereceive in more depth toidentify themes that myhelp with serviceimprovement

• Consider ways to monitorour financial indicators todemonstrate that serviceimprovement is costeffective

• Consider ways that we canbecome more involved inour local community.

The whole process from startto finish took roughly ninemonths and requiredapproximately three workingweeks to co-ordinate theapplication and gather theevidence together. Althoughthis seems to be a largeinvestment of our staff timeand of unit resources, webelieve that the process hasbeen invaluable in helping usto plan for the future.

Elaine Manderson Clinical Nurse Specialist

2004-2006 6

The Charter Mark scheme is avoluntary process whichinvolved the staff on the ICUpreparing an applicationoutlining our performanceagainst six criteria. These are:

1 Set standards and performwell

2 Actively engage with yourcustomer, partners andstaff

3 Be fair and accessible toeveryone and promotechoice

4 Continuously develop andimprove

5 Use resources effectivelyand imaginatively

6 Contribute to improvingopportunities and qualityof life in communities.

Unit projects

An ongoing piece of work forthe nursing and physiotherapystaff on the ICU has been thedevelopment of a weaningflow-sheet.

Being on a ventilator has beenfound to increase the risk ofpatients developingcomplications. This projectaims to reduce the time apatient spends weaning fromthe ventilator by using a clearmethod of assessing a patient’sprogress and highlighting howreductions in ventilator supportcan be made.

The flow sheet has beenintroduced through aprogramme of education: • Weaning charts were

redeveloped

• Each staff member receiveda pack outlining the flowsheet and some researcharticles that were used inthe development of thesheet

• A week of teaching sessionsfollowed

• Each day patients identifiedas being suitable forweaning are commencedon the flow-sheet

• Support for staff is offeredby the Clinical NurseSpecialist and ClinicalPhysiotherapist Specialist.

It is hoped to follow on fromthis, by comparing time spenton the ventilator before theintroduction of the flow-sheet,with time spent after itsintroduction and by developinga flow-sheet for other modesof ventilation.

Elaine Manderson Clinical Nurse Specialist


Developing a weaning flow-sheet for ventilated patients

Patient focus groups

We started to hold patientfocus groups in September2003 in association with theDay Surgery Unit. Followingrecommendations from ourCharter Mark assessment wedecided to make thearrangements for these groupsmore focused.

We decided that it would bebeneficial to hold two or threeper year. These groups wouldbe for ex-patients or relativeswho had been on the IntensiveCare Unit. The purpose of thefocus groups would be to elicitthe experiences of the patientor carer while they were on theunit and since discharge. Anycomments, thoughts orsuggestions would be fed backto the quality group. In this waywe could action anysuggestions.

Each group lasts for an hourand is focused around thequestions outlined in Table 1.

The first group consisted of fiveex-patients and a carer. Theywere all eager to talk abouttheir experience. They also hadlots of unanswered questions.

All of the ex-patients had beenon the unit for longer than twoweeks. They were all ventilatedand had been given some formof sedation. Theyacknowledged that theirmemories were verydisorientated and confusing.

At times it was hard for themto distinguish between realityand fiction.

We did however try to capturesome of their memories andexperiences:

Dreams All of the ex-patientsexperienced some form ofdreams. They were unsure if thedreams happened before orafter consciousness. Some ofthe dreams were pleasant;others had dark dreams. Someof the ICU staff featured in thedreams.

In trying to explain this they feltthat perhaps they surfaced intoreality and registered a staffmember’s face so when theyslipped into a dream-like statethe staff member’s imagefeatured in the dream.

A patient whose bed wasopposite the staff noticeboardfelt that the faces werewatching him and appeared tocome alive. They mentionedthat seeing photos of theirfamily was very comforting.

InformationSome of the patients wereunsure if they were told whathappened to them. Othersfound that it was very helpfulfor staff to explain what theywere doing. The carer feltespecially comforted by thestaff talking to their relative.

Most of the ex-patients hadquestions:

‘How did I become so ill?’

‘How did I catch the bug?’

‘What happened to mewhile I was in the ICU?’

‘How can I be sure I won’tget this sick again?’

Some felt a summary of eventswhile they were on the unitmight be helpful, others feltthey needed to be strongerbefore they were given a fullaccount of what happened.

Table 1

Questions used for thefocus group

• How were you or yourcarer prepared for youradmission to theward/unit?

• What specific memoriesstick in your mind aboutyour experience on theIntensive Care Unit?

• How were you preparedby staff for leavingunit/hospital?

• How have you copedwith being at homefollowing your time inhospital?

• If you had anopportunity to changeanything about yourexperience what wouldit be?

2004-2006 8

Unit projects

EnvironmentOne patient felt theenvironment was very clinicaland bright. They could allremember noises, especiallybleeping sounds. They wereconscious of people speakingbut felt comforted as if it was aconfirmation of life. When onepatient was waking up, she feltvery claustrophobic. They allstated the unit was calm andthey felt loved and cared forwhile they were there.

Discharge from the unitWhen they spoke of the wardsthey commented that therewere less people around andtherefore they had lessattention. Some remarked thatthey had a great recovery, butexperienced up and down days.At times they were veryemotional. They felt theirconcentration was disrupted,making it difficult to read. Theyspoke about physiotherapy andhow they had to learn to walkagain. One patient commentedon being shocked andfrightened at the amount ofmuscle loss they hadexperienced, and another ofphysical symptoms theyexperienced that impaired theirrecovery and rehabilitation.Another felt the wardrehabilitation was rushed andthey were discharged home tooearly.

Discharge homeThey described feelings ofdistress and being unsure ifthey will ever get over thetrauma. They felt scared, with aloss of personal confidence, butalso afraid it will happen again.They were slow at doing things.The support from GPs wasvaried. However one patientstated it was hard to ask forhelp unless you admitted youneeded it.

What changes would youlike see?One suggestion was to have asupport group concentrating onemotional and psychologicalsupport following critical illness.In addition it might be useful tohave a diary, which woulddocument factual events ofwhat happened during theirstay.

There are a number of thingswe can learn from holdingthese focus groups. Firstly,discharge from ICU/HDU is onlythe beginning of the recoveryjourney from critical illness.Secondly, we should neverunderestimate the power oftouch and caring in ensuringthat a patient is treated as ahuman being especially in such

a technical environment. As onepatient commented, sheremembered being in a bigblack hole but because shecould hear the nurses speakingto her and holding her handshe was not frightened.The focus group is also a wayof letting patients know theyare not alone, it is boththerapeutic and enlightening.

As critical care professionals wehave a lot to gain from listeningto ex-patients and carersexperience of their criticalillness. We can learn about howthe drugs, treatment,interventions and environmentcan affect outcomes. As a unitwe can use this information todevelop a business plan for afollow up clinic. The purpose ofthe follow up clinic would be toaddress the psychological,physical and supportiverequirements that thesepatients need. This is the nextstep in helping patients cometo terms with what hashappened to them.


Amanda JoyceSenior Staff Nurse - Team B


Patient focus groups (continued)

Clinical incident reporting

Clinical incident reporting isnecessary and beneficial in helpingus to address risk issues on theIntensive Care Unit. A quarterlymeeting ensures that all staff takeresponsibility for incidents thathave occurred. In addition theirsuggestions on preventing theincident from occurring againmeans that any changes willhopefully be sustainable.

In 2004 there were 148 clinicalincidents reported on the unit, in2005 there were 181. See figuresand table below for specificcategories.

CATEGORY NUMBER

Blood transfusion 7Drug incidents 39Equipment 17Invasive line removed 1Needle stick 3Poor observation 1Procedural 39Sample collection 7Sample reporting 13Sharps disposal 2Staff accidents 11Staff assaults 10Staffing/grade mix 8Utility supplies 1Delay in discharge 3Lost property 1Security 1Theft 1Training 5Hypoglycaemia 1Patient accidents 4No identification 1Splash Injuries 5

Staff Accident

Procedure

Drug Incident

Transfusion

Splash

Equipment

Sharps

Staff Assault

Blood Reporting

Property Loss

No Identification (staff)

Blood Collection

Patient Accident

Invasive tube/line removal

7%

23%

20%

9%

4%

11%

1%

6%

10%

2%1%

2%1%3%

Clinical incidents on the Intensive Care Unit 2004

2004-2006 10

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Fig 1:1 Drug incidents ICU 2005

Unit projects

The following have beeninstigated during the incidentreviews and the followingactions devised:

Drugs In this period the main causesof drug incidents were due todrugs being given via thewrong route or the wrongdose. A number of strategieshave been put in place toreduce this:

• Quiz - held every threemonths by the unitpharmacist to update theknowledge base of staffregarding medications

• Audit - done to identify thenumber of drugs incidentslinked to ‘missed doses’ - asa result, there have beensome changes made to thepresent pre-printed drugchart

• Incidents discussed withPharmacist, Clinical NurseLead, raised individually andat unit meeting

• All staff involved in drugincidents are spoken withindividually andlearning/training needsidentified.

Procedural • The unit has devised a draft

procedure looking at dealingwith aggressive and violentpatients, with new restraintguidelines developed as part

of the North West LondonCritical Care Network

• Linen which was storedoutside Lift Bank A has nowbeen removed

• Patients who are dischargedfrom the unit with atracheostomy in place, havespecific paperwork on thecare of the tube that needsto be filled in.

Transfusion• Regular updates and

teaching from the BloodTransfusion Nurse

• Information on bloodtransfusion in times of majorhaemorrhage

• Informing Haematology andusing their guidelines and

storage system when we aretransferring patients toanother hospital with ablood transfusion inprogress.

Splash injuries • More disposable goggles

purchased and increasedawareness among staffabout how to use them

Everyone on the unit recognisesthe need to fill in clinicalincidents forms as part of ourrisk management strategy onthe unit. They also recognisethat practice can and doeschange as a result.



Clinical incident reporting (continued)

The recent work undertaken byPharmacy focused on reducingthe incidence of drug relatederrors on the ICU:

Risk Management Drug QuizAn interactive risk managementquiz based on common drugincidents that occurred over thelast three years is now run on aquarterly basis. Less commonincidents likely to cause seriousharm to the patient are alsoaddressed. A register ofparticipants is kept to ensure allnurses, regardless of shift work,annual leave etc, have attendedthe sessions. All participants todate have rated the session veryuseful and given positivefeedback on how it wouldchange their practice.

It was necessary to focus ondrug incidents involvingnursing staff as they wereassociated with the highestproportion of errors andtrends. However, therewas a small proportionfor which medical andpharmacy staff wereresponsible. Thishighlights theneed for amultidisciplinaryapproach toriskmanagementand regularreview of thesystems inplace.

Missed Dose AuditA high proportion of drugincidents were due to misseddoses, therefore, the misseddose audit last carried out inApril 2002 was carried outagain in July 2004 to identifyproblem areas.

Pharmacy Intervention Week‘Pharmacy Intervention Week’ isheld on a quarterly basis.Pharmacists are requested torecord all their interventionsand classify them according tominor, moderate or severe risk.The majority of interventionstend to fall within the moderateband. Details and actions takento prevent recurrence are fedback at the ICU Clinical

Governancemeetings.

Pharmacy Initiated CostSavingsPharmacy initiated cost savingsfor the financial year beginningApril 2004 have been in excessof £37,000. Strategies usedhave involved contract pricenegotiation, review ofmedicines and route, regularreview of intravenous feedingregimens and duration, andfree trial stock.

Chris ChungLead Pharmacist

Anaesthetics and Imaging

Pharmacy developments

2004-2006 12

Unit projects


On the Intensive Care Unit wecollect and collate thank youcards and letters from visitorsand patients. Thank you cardscan give a valuable insight intothe care that is being deliveredand can be used todemonstrate what givesrelatives and friends comfortwhen their loved one is criticallyill. They can make staff feelappreciated and be used tosupport them when difficultdecisions are made.

On the Intensive Care Unit wehave a visible philosophy ofcare. The sentiments expressedin the thank you cards show weare practising what webelieve...

‘We are dedicated toprovide the best possible,individualised care’

“It was comforting to bedealing with one person whoknew all the facts about mysister rather than speakingto someone who hadn’tmet her or didn’t know ofher condition”

JT (Nov 2005)

“......I was unaware of theastonishing care that I wasgiven, though I havereceived much feedbackfrom friends and relativeswho visited during that time asto the attention and totaldedication of staff”

JS (May 2006)

‘The intensive care teambelieve that our workmakes a difference,benefiting patients andtheir loved ones’

“.....deep thanks for the love,care and attention......to myselfand also to other relatives - allof whom commented on thecourtesy with which they weretreated whenever visiting orcalling the unit”

‘Respect the dignity, privacyand confidentiality ofpatients and families’

“All that you did forher and the way youpreserved her dignitywhich was importantto her”

MG (August 2005)

“You allowed us timeto wait for a miracleand then gave ustime to come toterms with reality”

DH (Feb 2006)

When reviewing a service, wehave a tendency to focus onwhat has gone wrong and seekmethods to improve andprevent complaints or issuesfrom reccurring. While it isextremely important to do thisequally we should focus onwhat has gone right andprovide feedback to our staffon this. Thank you cards dothis. In addition the themes of‘information, attention to detail,respect, care, compassion andkindness’ expressed in thank

you cards make usrealise what is importantand what makes thedifference to ourpatients and their lovedones during their stay inhospital.


Analysis of feedback from relatives

“Usually gratitude is expressed when

the patient leaves a unit alive and

well, but the family - grievous at

their loss - could not have been

more complimentary about the care

and kindness given by all of your

doctors and all of your nurses” TP (Dec 2005)

“......astonishing tendernesscombined with technicalefficiency.......all the kindness shownto my aunt, my daughters andmyself during that difficult time”

SM (Jan 2005)

Over the recent past, the ICUhas seen an increase in thenumber of learners coming tothe unit to develop critical careskills. At this time we have notseen the same increase innumbers of preceptors tosupport them; the result is ashortage of registered nursesbeing able to support students.

The ICU decided to take aproactive approach to thisproblem by designing aprogramme to develop skills innurses to be able to preceptorpre-registration student nurses.The programme was developedjointly between the ICU andthe local education provider,Thames Valley University (TVU).

A number of different formatswere considered before the

final programme format wasdecided. This involved buildingon existing work based aroundone hour workshops andassociated workbooks for staffmentoring studentsundertaking TVU critical caremodules. The resultantprogramme is a 12-weekprogramme consisting of threeworkshops, two workbooksand a period of supervised

mentorship (see Box 1 for abreakdown of the programme).

The programme focuses on theprinciples of adult learning andpromotes work-based, self-directed study with a strongemphasis upon reflectionmirroring the philosophy ofboth the pre-registrationnursing curriculum and theICU.

In-house preceptorship course

Box 1 Course format

Week 1 Start work on Workbook one - coaching and facilitation Start supervised preceptorship

Week 4 Workshop one - coaching and facilitationContinue supervised mentorship

Week 8 Workshop two - assessing competence Workbook two handed out Continue supervised mentorship

Week 12 Workshop three - reflective review

Table 1 Topics covered and learning outcomes covered in workshop one andworkbook one

What makes a preceptor? To consider the skills and attitudes required to bea preceptor

Domains of learning To consider the four areas that effect learning

When people learn best To reflect on own learning experience

Learning opportunities in the ICU To reflect own unit culture

Creating a learning culture What elements are needed to create a culture

Key elements of a learning culture What elements are needed to create a culture

Tools that help create a learning culture To identify the process they can put in place tofacilitate the development of a learning culture

Evaluating learning To identify methods of evaluating learning bothin students, by students and by self

Giving and receiving feedback To identify the skills required to do this effectively

2004-2006 14

Unit projects

The first aspect of theprogramme includes aworkshop and workbook thatare designed to introduce staffto the main roles andresponsibilities of coaching andfacilitation within theworkplace, activities and groupwork are used to help elicit thestaff members understanding ofthese.

A breakdown of the topics andlearning outcomes covered isseen in table 1. These are put inplace to enable the staffmember to gain the knowledgeand analytical skills to enablethem to reflect and evaluatetheir own experiences ofcoaching and facilitating staff inthe ICU.

The second part of theprogramme consists of aworkshop and workbookintroducing the principles andpractice of assessing clinicalcompetence. This is then putinto practice with the staffmember and their studentnurse through a number ofassessment tasks in the practicearea. Topics covered in thisaspect of the programmeinclude:

• Competence - what it means

• Assessing competence

• Feedback

• Making assessment decisions

Throughout the 12-weekprogramme the staff undertakea period of supervisedmentorship. A pre-registrationstudent nurse is allocated tothem for a duration of eightweeks during their critical caremodule placement. The staffmember is responsible foroverseeing the student’slearning experience and alsoassessing the student nurse’scompetence in relation to theirlearning outcomes for theirmodule.

Staff are encouraged to makeuse of reflective diaries torecord their progress inmentorship. During this periodthe staff member is supportedby their own clinical mentor,the Clinical Nurse Specialist andalso the university link lecturer.

In the final aspect of themodule in week 12 the staffmembers present a reflectivereview of their experiences toeach other. This has beenfound to be an excellent way offinishing the programme andacknowledging that this is justa starting point for continueddevelopment as mentors. Box 2presents the reflective questionsasked.

The course has resulted in anincrease in the number of staffwho can facilitate thedevelopment of student nurses,ensuring an even spread ofwork in this demanding role.

Elaine MandersonClinical Nurse Specialist

Audrey Blenkharn Senior lecturer, TVU


In-house preceptorship course (continued)

Box 2 Reflective review questions

What were my hopes for undertaking this course?

What factors have influenced your participation in this course?

What are the consequences of being involved in coaching andassessing, for yourself, your team, your patients and the service?

What have I learnt from being involved in coaching and assessingabout yourself, your role, your role in the ICU service?

Enjoyable aspects?

Less enjoyable?

What are the areas I want to focus on in coaching and assessing inthe future?

Development One of the biggest changes tooccur in 2005 was when theGeneral Intensive Care Unit(GICU) became responsible forthe operational management ofa Burns Intensive Care Unit(BICU) with two beds. Thismeant that the critical careneeds of these patients wouldbe provided by the GICU staff,while the burns unit staff wouldprovide expert care in the

management of the burnswounds. The unit has admittedand looked after 30 patientsthis year.

While the staff viewed themerger on the whole as verypositive with excellent learningopportunities a number ofissues were raised. These were:

• Education and training• Patient allocation

• Culture• Junior nurses working on the

unit• Isolation• Equipment• Information• Infection Control

In order to deal with theseissues constructively a smallworking group was establishedwith core members from GICUand BICU.

In the last year a number ofsmall but significant changeshave taken place. These areoutlined in Table 1.

The plan over the next year isto continue to build on thegood work which has beenstarted.

Finally, it is extremely importantto mention and thank all thestaff on the burns and theIntensive Care Unit for theirmaturity, co-operation and hardwork. It has been challenging attimes but in the end, if thepatient receives excellent care,then it has been worth it.


2004-2006 16

Burns Intensive Care

Table 1 An outline of the changes which have occurred as a result ofthe BICU and GICU merger

Education • Burns workshops run by CNS (attended by 60% ofstaff)

• Development of Work Books with a number of BICUcompetencies

• Burns Study Day (joint day done with Burns and ICUstaff)

• Plans to include care of the Burns Intensive Carepatient on the Intensive Care Course

• Staff have attended the Care of the Severely BurnsPatient course

Equipment • Standardisation of the ventilators and the monitors

Patient allocation • The same philosophy and care delivery as the GeneralIntensive Care Unit

• Development of an additional role of the BICU Co-ordinator

• Primary nursing team allocation, decided by staffthrough a process of consultant where staff had tovote for a number of options.

Drug • Development of a CD protocol

Infection control • Development of core standards for the Burns Unit andthe General Intensive Care Unit

Staff relationships • Improved working relationship between the two areas.

Research activity

The Intensive Care Unit hasbeen involved in a number ofareas of research over the pastyear. The following gives a shortaccount of some of the projectswe are currently involved in. Allof these studies aim to improvethe outcomes of critically illpatients.

1 Does Frusemide improverenal function in

patients with renalimpairment?A randomised controlled triallooking at the effect of aFrusemide infusion oncreatinine clearance in ICUpatients with renal impairment.This consists of randomallocation to Frusemide or noinfusion, with dailymeasurements of serum andurinary creatinine, urinaryvolume and thus calculation ofcreatinine clearance

2 Does Frusemideimprove renal function

in patients stopping renalreplacement therapy?A randomised controlled triallooking at the effect of aFrusemide infusion oncreatinine clearance in thoseICU patients who are finishingrenal replacement therapy. Thisconsists of random allocation toFrusemide infusion or noinfusion, with dailymeasurement of serum and

urinary creatinine, urinaryvolume and thus calculation ofcreatinine clearance. Both thisand the above trial are enteringtheir second year ofrecruitment.

3 Caspafungin vsMicafungin in the

treatment of systemiccandidiasis or candida sepsisThe Intensive Care Unit is oneof the hospitals involved in this

European multi-centre trialcomparing two antifungalagents in the treatment ofsystemic or invasive candidiasis.We hope to recruit two patientsduring the study period of twoyears.

4 Relationship betweenserum lactate, base

excess, ScvO2 and pH duringactive resuscitationNew admissions to the Intensive


Care Unit who are acidotic andrequire resuscitation will havethe above variables measured atintervals. The results gainedshould help to establish therelationships between thevariables and their individualbenefit in assessing the progressof the treatments beingadministered.

5 Auditing the use of anew generation of

central venous catheterA new design of central venouscatheter requires a differentmethod of insertion which webelieve is the future of centralvenous access in intensive carepatients. We are auditing itsintroduction to gatherinformation about its use andfurther modifications to itsdesign. Data is also beinggathered about anycomplications and infectionproblems that, whilstunexpected, might arise.

6 Audit of microbiologicaldata detected from the

Intensive Care patientsAll microbiological resultsobtained from the ICU patientsare being recorded, payingparticular attention to theappearance of multi-resistantstrains. The clinical effects ofthis data are also being studiedand an assessment of thelikelihood of infection vs.colonisation is being made.

Outcomes of the patients arealso being recorded to establishthe relative virulence of thedifferent flora seen on the ICU.

7 Audit of antibiotic useof the Intensive Care

UnitIn tandem with the abovestudy, the use of antibiotics inthe Intensive Care Unit is beingobserved. Are these drugsbeing used empirically or basedon appropriate microbiologicaldata? The indications for theirintroduction and the length oftheir use are also beingrecorded.

8 Outreach studies

Several studies looking into theclinical effectiveness of outreach

interventions, education andsupport are ongoing outsidethe ICU.

Future PlansThe use of new catheters andmonitors coupled with aninterest in early goal directedtherapy may lead tocollaboration with the OutreachTeam, A&E and the Burns Unit.This should permit the study ofthe effects and outcomes ofaggressive treatment for criticalillness, trauma and burns;leading to the development ofbetter guidelines, protocols andpractice for these groups ofpatients.

Dr Adrian WagstaffClinical Research Fellow

2004-2006 18

Inter-team projects

The teaching group isresponsible for facilitating anddeveloping both formal andinformal teaching and staffdevelopment programmes, aswell as organisingmultidisciplinary orientation.The attendance of the group isvery good and all groupmembers are activeparticipants and are keen totake projects forward.

One of our main focuses hasbeen to update the resourcefiles on the unit which cover alltopics related to intensive carenursing ranging fromventilation to disseminatedintravascular coagulation tocare of relatives. There are 15files in all and each member ofthe team was responsible forcertain files. We had a prize forthe best file which ensuredthere was healthy competitionbetween members. Ourresource files are now full of upto date, relevant informationwithin easy access to all staff.Other things we have been upto this year include:

• Acquired new books tomaintain our unitlibrary onmicrobiology andsurgical nursing

• Introduction of a newband 6 grade studyday on clinical andprofessional issues -this will hopefully

provide the opportunity forparticipants to reflect onclinical practice and currentissues outside of theimmediate clinicalenvironment. It is also anopportunity for members ofthe teaching group to gainexperience of facilitatingstudy days and all that thisentails. Guidelines have beenput together to offerguidance for study day co-ordinators.

• Multi-disciplinary teaching.

Our teaching rota has remainedfull to capacity throughout theyear as we endeavour to meetthe needs of all staff.

We now have a greater numberof student

nurseson

more frequent placements. Inresponse to this the group hasput together a number ofsessions that can be presentedto the group. This helps themwith their learning whilst on theunit and the sessions have beenthus far well evaluated. We aresure this work will continue toevolve.

Teaching group members areencouraged to produceteaching sessions that they canpresent if a teachingopportunity arises. This is aneffective way to shareknowledge, skills and to gainteaching experience. Membershave also found that it is auseful way of providingevidence for their educationalportfolios.

The teaching group continuesto monitor teaching activitieson the unit through six monthlyaudits. This, along with ideasand comments from the groupand unit, will guide develop-mental work in the future.

Helen BassTeam Leader - Team A

Hazel BoyleTeam Leader - Team C

Teaching


2004-2006 20

The Quality group focuses onthe quality of the service theIntensive Care Unit provides torelatives, patients and staff.

Our biggest achievement wasto be awarded the CharterMark for the third time. Thisaward was given in recognitionof the excellent service we offer,and that we are constantlystriving to improve for all ourusers. The work involved thecollection of a lot of evidence,which was needed by outsideassessors as proof of ouractivities. This was a huge joband many members of the Unitwhere involved, so a big thankyou to everyone.

We carry out both relative andstaff satisfaction surveys andaction any changes that havebeen flagged up from theresults. The relative satisfactionsurveys are given out on theadmission of a patient. Wemonitor responses and deviseaction plans to address themesthat have been raised. Over all,we receive very positive feedback, but try to respond toideas and comments made bythe relatives of our patients.Improvements as a direct resultof our surveys include:

• New entrance doors withnew intercom

• Information board betweenrelatives’ overnight rooms

• Improved information foldersin waiting room andovernight rooms

• The provision of informationleaflets on a variety ofsubjects that will be helpfulto relatives.

This coming year we plan torefurbish the relatives’ waitingarea, and provide a new hotdrinks dispenser in the room.For the patients, we are torefurbish the shower room tomake it easier and safer for thepatient to use.

We also hold bi-annual patientfocus groups to help usimprove the experiences thatour patients have while in ourcare.

Providing information torelatives and patients is animportant part of ourphilosophy of care, and thisyear we are updating ouradmission information booklet,and our relatives’ informationfolders. A new project we aredeveloping is an informationpack for relatives on someconditions that may contributeto the admission to theIntensive Care Unit. We areasking them what they mayfind helpful, and topics so farput forward include diabetes,renal failure, pneumonia andsepticaemia. We will gaugehow helpful they find this infuture surveys.

We are also producing adischarge booklet, designed forpatients and their families. Thishas been done as a directresponse to patient focusgroups, where a commontheme was the anxiety patientsfelt going from the ICU to award. It includes information onboth physical and emotionalresponses that people whohave spent time in intensivecare experience, andinformation on useful resourcesthat can be accessed to help.We received helpful advice fromthe outreach team,physiotherapists and medicalteams when writing thisbooklet, so thank you all forthat.

We will continue developingideas and improvementprojects for all who come incontact with the service, andthank everyone who hashelped us do so.

Rebecca Hill Team Leader - Team D

Quality Assurance

Inter-team projects

The aim is to facilitate thenursing staff in self-rostering.Each primary nursing team hasa representative on the group,and each rep will at some pointcomplete three consecutiverotas. This is time-consumingand can be a little frustratingon occasions, so the rest of thegroup provide support as andwhen required. In the monthlymeetings, issues that have beenraised by staff are discussed andclarified or resolved. This mayinvolve taking an issue to themonthly unit meeting to befurther discussed or it could, forexample, involve an audit.

Staff are able to work acombination of long days andshort days, to suit theirindividual requirements, andflexible working is consideredon an individual basis.

The group also keep a monthlyrecord of people’s workinghours, and will remind them ifthey should make up hours.

The Off-Duty Planning Teamprovide guidance and supportto staff, primarily to ensure thatthe unit skill mix is of therequired level, and also that theprimary nursing teams havereasonable cover through themonth.

Finally, and most importantly,the team recognise that therehas to be a balance between

home/social life and work life,hence advanced rota planningand a flexible approach to mostshort notice socialarrangements.

There have been many changeswithin the group over the lastyear.

More recently computerisedstaff rostering has beenintroduced. This is a totally newcomputerised off dutyManpower software systemwhich has three levels of access.

Level 1 - Access to all staff toenable them to input their datarequestsLevel 2 - Access to the group toauthorise shift changesLevel 3 - Access to managerialpersonnel to access personalinformation ie sickness, annualleave.

The team has been meetingwith the computerised rosteringrepresentative regardingcustomising the programme tothe unit’s requirements. Theprogramme will benefit thegroup in many ways.

Currently the ODPT hasdifficulty in obtaining an evenskill mix on the unit. Theprogramme will be set to onlyaccept a maximum of forexample 10 staff per shift, twoco-ordinators, four band sixand four band five nurses. Once

these shifts are filled, it will notallow staff to add to the shifts,therefore staff have to add toshifts which are vacant. This willassist the unit to maximise theskill mix.

At present all staff hand writeoff duty requests on themonthly rosta. The new systemrequires staff to enter their offduty into the computerthemselves, significantlyreducing the work for the ODPTby not having to individuallyenter all staff members off dutyrequests.

The programme recognises fulland part-time staff and theircontracted shift requirements,ie full-time staff are required towork five nights, 28 weekendhours and a Friday late everymonth. If these individualrequirements are not met it will


Off-duty planning team

highlight the discrepancies. The computerised system willenable the unit to use staffeffectively and decrease thework for the ODPT by having torearrange the off dutynumerous times before it isfinalised. The programme willkeep a ‘tally’ of cumulativehours worked. This willsignificantly reduce the work ofthe ‘hour keeper’. Theprogramme can be used as anaudit tool, the data can beaccessed to monitor sickness,team cover, skill mix, annualleave and study days.

The computerised staffrostering will enable the unit tokeep using self rostering as itmakes people feel valued andallows staff to have freedom towork shifts which wherepossible suit them.

This programme was on trial ona ward and ICU. It is now beingrolled out across the hospital. Inthe future it may be adapted toenable bank staff to use it too.

Ann HindsTeam Leader - Team F

Feriel Mahouit Deputy Team Leader

- Team F

The Supplies and FinanceGroup meets every two monthsto discuss ways to increase costeffectiveness and awarenessand to decrease wastagethrough action planning.

Members of the supplies andfinance group are available toraise suggestions andcomments on the way trustfund money could be used tobenefit the unit and its users.This includes the trialling andevaluating of new products, toeducation on reducing wastagethrough our annual quiz, whichhighlights the cost of bothdisposable and non-disposableitems. These members includeone representative from each ofthe Primary Nursing Teams, theunit’s Healthcare Assistant,Technician, Clinical Nurse Leadand Administrator.

The group’s recentaccomplishments this yearinclude:

• The introduction of new inline nebuliser pots andpatient hygiene wipes,evaluated by the nursingstaff and consequentlysaving the unit money onboth these items per annum

• A transport table thatattaches to each bed,designed to the unit’sspecifications, reducing therisk of equipment breakage

• Allocation of funds topurchase ICU textbooks,patient sundries such as ahair-dryer and a new sofabed for one of the relatives’overnight stay rooms

• Reorganisation and costlabelling of our mainstockroom

• Data projector which enablesPowerpoint presentations forall educational sessionsoccurring on the unit

• Ongoing monitoring of itemsborrowed by otherdepartments which highlightthe need of those items forother departments.

The work done by this group isongoing and will continue tofocus on troubleshootingsupplies and finance issues aswell as maintaining andpromoting positive relationswith our supplies departmentand other departments withinthe hospital.

Jason Tatlock Administrator/

Information Officer

Supplies and finance

2004-2006 22

Inter-team projects

This group continues to fundnurses to help them attendconferences. Two nurses wentto the British Association ofCritical Care Nurses WorldCongress; with another twopresenting their research twoothers attended the RCNconference in June. We alsoencourage nurses to submitarticles for publication.

We provide application formsfor the BACCN and keep a listof those members. The unitwas represented at two jobsfairs, one at Earls Court and theRoyal College of Nursing torecruit nurses, four nursesapplied for jobs following this.

The group was involved in theHospital Open Day in June2004, where we had a standwith a mocked up ICU bed, aswell as pictures of the unitexplaining the day to dayrunning of the ICU. Membersof the public were able to askquestions, some of whom hadbeen in ICU themselves andwere shocked to realise howmuch technology is used. Therewas also a quiz with prizesbeing gratefully donated bylocal businesses. We won amerit award for our stand.

Some of the group formed aworking group to gatherinformation for the CharterMark which was reapplied for

and successfully gained inNovember 2004.

We raised money for the charityShelter from our Christmashamper raffle, and are lookingat how we can contribute moreto Charity as a unit this year.The marketing group organisesstaff to attend conferences -this year two nurses went tothe RCN conference. One staffmember went to the BACCNconference which focused on‘Back to Basics’, whichhighlighted the issue of holisticnursing care. This is very muchin line with the way weorganise the nursing care in ourunit, using the Primary Nursingmodel. From this we are raisingthe profile of Primary Nursingon our unit, by revisiting ourUnit Philosophy (which we doevery 3-4 years).

The Intensive Care Unitparticipated in many fundraising events throughout2005/06. On July 7 2005, 33staff members had entered theJP Morgan Chase CorporateChallenge, a 5.6 kilometre runthrough Battersea Park. This isan event conducted throughoutmany countries throughout theworld aiming to bring togetherbusiness groups to promoteexercise; with a littlecompetition thrown in. 20,000people were to participate, butbecause of the horrific

bombings earlier that day theevent was cancelled. Yet later inthe year half of the originalgroup participated in the runthemselves, raising £250 for thecharities Asthma UK, and AgeConcern.

Over the winter period weasked staff that were clearingout their cupboards to bringany unwanted clothing into theunit to be gathered for a charityto sell, with the proceeds goingto Great Ormond StreetHospital.

Throughout 2006 themarketing group aims topromote the Intensive Care Unitagain through participation inas many fundraising events aspossible.

Danielle PinnockTeam Leader - Team H

John Gough Senior Staff Nurse - Team C


Marketing

2004-2006 24

The research group has had avery productive year. Newevidence-based guidelines ontopics, such as ventilation,discharge planning andintubation have been writtenand ratified. ‘Guidelines at aglance’ have evolved fromthese guidelines and arelaminated by the bedside

summarising the pertinentpoints of each guideline foreveryone to read.

The group has embracedactivities such as thetracheostomy care bundle andventilation care bundlessupported by the North WestCritical Care Network. These

bundles have not onlyreinforced present patient caredelivered to critically illpatients but also introducednew practices. Infectioncontrol has been highlightedas an area to focus on activelywith the intention ofencouraging best practice toreduce and contain infectionrates.

The research group continuesto provide teaching sessionssurrounding the need forresearch, the theoretical baseof research and to explore andexamine the methodologies bycritiquing research studies.Some of these are medical andnursing studies currentlyongoing or about to begin onthe unit. This process willallow us to continue tochallenge our own practicesand beliefs on the ICU.

Ann Sorrie Team Leader - Team H

Gordon Turpie Staff Development Charge

Nurse

Research group

Inter-team projects

The purpose of this group is tosupport staff using nursingdiagnosis in their care planning,and to further develop theirknowledge of this approach toclassifying patient problems,defining them and providing arange of potential interventionsto achieve specific patientoutcomes.

Nursing diagnosis has beenwidely adopted by nurses withinthe UK to provide a commonlanguage which enables aconsistent method of writtencommunication and actions that

is understood and accepted bynurses. The ICU team here atChelsea and Westminster wasthe first in the UK to adopt thisinto ICU practice.

The second aspect of this groupconcerns the involvement ofthe nursing team in thedevelopment of the hospitalsEPR system.

The main achievements of thepast two years include:

• Consulting staff to identifyissues, concerns and

suggestions in relation tousing nursing diagnosis andthe EPR system

• Assisting with the ongoingtraining of staff as the EPR ismodified

• Providing feedback to staffregarding the nationalstrategy for the developmentof an EPR system

• Attending trust meetingsconcerning nursing diagnosisand EPR to ensure the unit’sperspective

• Getting all bank staff trainingto use the EPR

• Access to the EPR system viathe Patientline system at thepatient’s bedsides

• Completing adocumentation audit - thegroup has now focused onthe following areas:

n Completion of nursingassessments

n Updating these as patientneeds change

n Consistently includingnursing diagnoses relatingto family needs

n Ensuring that care plansare used during handover.

Future plans include getting theEPR system installed on ournew monitoring system, thedevelopment of the ICU webpage and further audits ofdocumentation.

Caroline Younger Team Leader - Team B

Nursing diagnosis and Electronic Patient Record (EPR)


Cambridge in the autumn wasa beautiful and tranquil settingfor the conference, inconjunction with the WorldFederation of Critical CareNurses.

We were able to choose froman expansive repertoire ofspeakers and subjects over thefirst two days, and tookadvantage of the opportunityto hear about the experiencesand research, pleasurable andpainful, from nurses from allover the world.

Notable talks included a talkabout trauma from Americannurse specialists provided aninteresting if somewhat grislyinsight into treating burnsvictims in Philadelphia. Thiscontrasted with the awardwinning talk from a nursefrom New Zealand, who ispart of an ICU team thatarrange to take patients hometo die, and also arrange daytrips for patients who knowthey are going to die on theunit. It gives them theopportunity to experience onelast personal comfort.

One of the important parts ofthe conference was seeing anumber of colleagues givingtalks to the assembled crowds.It was an eye-opener to seethe range of topics coveredand to watch peopledemonstrate how theirresearch, however small,contributed in some way totheir esteem and to theprofession.

In addition to the talks therewere workshops and posterpresentations, which providedfurther information andevidence of the varied aspectsof work carried out by theIntensive Care Units. Eachcountry has its own way ofrunning the Health Service andICU, and what each foundimportant was different butstill interesting. It was a variedconference covering manyaspects of ITU from manyperspectives.

This was an interesting andinformative conference toattend. It provided a lot offood for thought, and its aimwas to encourage andappreciate the involvement of

nurses within their profession.This was evident from speakerswho were well known inspheres of nursing, such asRoyal College of NursingSecretary, Beverly Malone. Hertalk focused around nursesbecoming more politicallyactive, on a local and nationallevel. She argued well that ifnurses wish to shape healthpolicy they have to be moreinvolved. Her theme was‘knowledge is power’, and sheacknowledged that not everynurse would want to beinvolved in politics, but thatthe profession needsmotivated, enthusiasticmembers to become theinfluential body that it couldbe.

There were a large number ofdelegates and their commoninterest was the recognition ofthe ‘professionalisation’ ofnursing and the contributionthat nurses can make, fromclinical practice and researchto being an active andrespected political figure.

Ann Hinds Team Leader - Team F

British Association of Critical Care Nurses Conference -September 2004

Developmental opportunities

2004-2006 26


As part of my degree studies Iundertook a research project onnurses’ feelings and perceptionsof the ‘difficult to manage’patient on critical care.

Leading on from this I had theopportunity to present an oralpresentation of the findings ofmy research at the 2ndInternational British Associationof Critical Care NursesConference and 1st Congressof the World Federation ofCritical Care Nurses. Thisenabled me to share myfindings, not only with mycolleagues, which had beendone locally, but on a muchlarger scale. .

The findings fell into five broadcategories: Stress andworkload, control, ‘doing theright thing’, safety and‘knowing the patient’. Whatsurprised me was the impactthat this group of patients hadon staff and what copingstrategies the nurses had fordealing with the emotional andphysical stress involved. Theconclusions highlightedconcerns about planning andassessment of care, not only incritical care, but throughout thehospital.

The actual presentation was inthe afternoon and after anervously long wait, my turnfinally came. Despite mynervousness, this was notobvious to colleagues in theaudience who reported aconfident speaker who spokewith clarity and expression. Thiswas a reflection of months ofhard work which developed myresearch skills and knowledgewithin this subject.

At the end of it I felt a hugesense of relief, but also a greatsense of achievement, as it hadbeen a personal goal which Ihad finally achieved.

The research process enabledme to explore a difficultsituation of nursing whichfeatures in the intensive caresetting. This method of learningbroadened my perspectives andafforded me a clearer view ofthe current issues and opinions.Through this I gained a newmeasure of understanding andam now able to offer higherlevels of support making amore effective contribution toan area that requires greaterunderstanding and guidance.

Louise Saunders Team Leader - Team I


Presenting at an international conference

2004-2006 28

Kilimanjaro is the highest freestanding mountain and thehighest point in Africa. When Idecided to climb it on mysummer holidays, little did Iknow that it would be one ofthe most psychologicallychallenging walks I have evertaken.

Our climb took five days toclimb from the MaranguNational Park gate to thesummit. During this time manypeople felt the effects ofaltitude, suffering severeheadaches, shortness of breathand vomiting that werealleviated by rest and lots ofwater.

The final climb started atmidnight, we set off afterbreakfast. We proceeded slowlyin the darkness on a switchbacktrail over loose volcanic rock.

After an hour the snow fellthick and fast as we continuedour climb. My breathingbecame more difficult as mychest became tighter but withmy companion we continued toquietly walk and encourage oneanother.

Finally, as dawn was starting tobreak six hours later, I reachedGillmans point. What wassupposed to be a spectacularsunrise was actually a view ofmore snow and clouds. A hotcup of tea was welcomed, asour water had frozen a fewhours earlier, before deciding tounder take the three hourround trip to the summit.

The ascent to Uhuru peak wasslow and exhausting. On seeingthe summit sign, a burst ofenergy arose and reaching it asense of relief. It was at thispoint we were only allowed afew minutes for photos, due toair quality (or lack there of) withcloud cover.

On my descent, it was apparentjust how little oxygen had beentaken up by my lungs, as Ideveloped Sulphur dioxidepoisoning as Kilimanjaro is adormant volcano and still emitssulphur. I became drowsy, butyet within myself aware. Ondescending quickly to Kibo, Iwas amazed and overwhelmedat just how altitude affects you.

The next two days were spentdescending down the Maranguroute and a time to reflect onmy last four days and wonder ifI’m mad enough to walk theslopes again for a view that isbreathtaking.

Emma Long Deputy Team Leader

- Team A

A staff member’s experience of climbing Kilimanjaro


I have been employed on theICU/NDU since June 2000.Initially this was as an E gradestaff nurse, and currently I am aband 6 Deputy Team Leader.The unit has always offered theoption of flexible working, andin this way I have managed toachieve some personal goals.

In September of 2004, anopportunity arose for asecondment with theResuscitation Service. This wasto be for a period of fourmonths, to cover maternityleave. The plan was then toreturn to the Intensive CareUnit.

I enjoyed the new and variedaspects of my role. This involvedtraining all levels of staff in Basicand Advanced Life support,helping to run nationalResuscitation Council courses,attending Cardiac Arrest callsand assisting with auditing ofin-house cardiac arrests.

At the end of the secondment,a two day position becameavailable. I discussed this withthe ICU/NDU unit Clinical NurseLeader and my Team Leader,and am now in the enviableposition of having a dual role.This means I retain my ICU skills(working part-time) and am aResuscitation Officer two days aweek. I enjoy the variety, andhave expanded and enhancedmy teaching skills, (whichbenefits both departments); andboth sets of colleagues get theinside track on any newdevelopments!

Diana NilandDeputy Team Leader - Team J /

Resuscitation Officer


Flexible working

Due to the maternity leave ofour clinical nurse lead, theopportunity arose for one ofthe G grades (band 7 nurses)on the Intensive Care Unit to‘act up’. The post was foreight months, with handoversat each end. This wouldenable the smooth running ofthe unit, and also minimaldisruption. It also provided anopportunity to work adifferent pattern.

The post was advertisedinternally and there was muchdiscussion amongst the currentband 7 nurses about thepossibility of taking on therole. With some trepidation Iapplied and was successfuland in February 2005 becamethe Acting Clinical Nurse Lead’for ICU.

I received several weekshandover, which was aninsight itself, learning manynew things including how toensure that the payroll was upto date, attending Trustwidemeetings and attempting toorganise my own meetingsand time. I soon learned that Ineeded to work at a differentlevel in order to achieveobjectives. Prioritising becamesecond nature. Flexibility andadaptability were other skills Ihad to develop.

Acting Clinical Nurse Lead

2004-2006 30

During the eight months ofthis post the learning curvewas not just steep, at times itwas vertical. I was luckyenough to have some superbsupport networks in place andaccessed some new ones too. Isoon learned that therelationship with mycolleagues needed to bedifferent, that at times I wouldhave to be the leader,sometimes a manager andalso a friend. I believe myability to people manage wasenhanced a great deal, attimes stretched, but overall itgrew.

I have thought about what tosay about the job, but writinga list of what it entailed,appears somewhat boringwhich the post was certainlynot. During the eight monthsin the role, I began tounderstand about how theNHS works, projectmanagement, outsourcing,computer circuits, electronicdevices, amongst other things,none of which was expected!

I became more aware of theneed to respond to initiativesand directives from both theTrust and the Government.One of the changes thathappened was the merger ofthe Burns Intensive Care Unitand the ICU. This was amassive change for allconcerned and proved not

only difficult for all andchallenging but there was alsoa need for new ways ofworking, in order to resolvethe day-to-day issues andmaintain the service.

During this time myknowledge of people grew,not only my colleagues onICU, but about people ingeneral and how different weall are. I wanted to be able tomake time for colleagues whoneeded me in this role.

In hindsight I enjoyedelements of the role; it hasgiven me great deal ofconfidence, insight anddeveloped my own self-awareness even more. I havenew found respect for theperson in this role. I alsoappreciate the fact that it hasreinforced for me that I enjoyboth my clinical role and theflexibility of the hours I work.

I would like to formally takethis opportunity to thank all ofmy colleagues on IntensiveCare for the support that theygave me during this post, itwas most appreciated.

Louise SaundersEx-Acting Clinical NurseLead and Team Leader -

Team I


Since starting this post andrunning the Foundations ofCritical Care Course in July2005 I have been faced withmany new challenges. The firstsix months saw me settle intoand adjust to this new role.However I felt that after sixmonths it would be beneficialfor me to reinforce what I hadlearned by teaching a newcohort. This would also see meinvolved in the re-accreditationof the programme.

At present I am in the processof running my second coursewith another five students inthe cohort. Feedback from thefirst cohort concluded that thecourse was well received. Theyenjoyed the study days.

The study days also gaveexperienced nurses on the unita chance to develop their ownteaching skills by participatingin the teaching sessions.Students considered thestandard of teaching to begood with a sound variety ofspeakers and hand outs. Thepre-study day workbooks wereconsidered to be beneficial forrevision of anatomy andphysiology and introducedthem to the topics that wouldbe discussed in greater depthon the study days.

Students managed to meet upwith their preceptors on amonthly basis to review their

learning contracts andcompetencies. They believedthat the competencies weregood because they helped fillthe knowledge practice gap.

Overall the students found thecourse interesting. It helpedthem gain competence andconfidence when caring forcritically ill patients and theirfamilies. As one studentcommented “it helped makethings click”.

The course has now beenrunning for three years and isdue for re-accreditation. Thework is completed and was dueto be put forward to theThames Valley UniversityAccreditation of PriorExperiential Learningcommittee at the end of June2006. The major changes willinclude the course now beingoffered at level 6 (degree level).The competencies have beenstreamlined to 15 and theworkbooks are now offered asmultiple choice questionnaires.The element for accreditationwill be the summativeassessment which is a 3,000word reflective essay basedupon a patient assessment. Thiscompares to a 1,500 word

essay on the present course. Itis thought that the increasedword count will enable studentsto develop their analysis andideas further.

I will be leaving the post inAugust and wish to thankeveryone that has supportedme in this role in the last year.Finally I wish the newprogramme co-ordinators well.

Gordon TurpieStaff Development

Charge Nurse


Staff development role

2004-2006 32

In January I attended thisannual conference in France,with three other nurses andseven doctors from Chelseaand Westminster Hospital.

There were many topical issuesbeing presented including birdflu, how it will affect patientsand how it will affect all of usin our daily lives. Issues suchas the schools and transportsystems being closed down,meaning that many peoplewill have childcare problems ornot be able to get to workeasily. The message seemed tobe not if the HV1 virus willmutate, but when.

The bombings of July 7 2005and the kind of injuries thatpresented to A&E departmentswas another very good talkgiven by a registrar. Therewere a lot of blast injuries thatwere very horrific, with loss oflimbs and burns. Thecommunication system wasdiscussed as this was poorwith mobile phone lines beingblocked and the ambulanceservice not being able tocommunicate to one another,due to loss of radio contact,so it was not known howmany patients certain hospitalswere admitting. The use of e-mail as a very good method ofcommunication in these timeswas discussed.

Research was presented, forexample ‘The use of FacialCPAP & how it affects thepatient’s arterial blood gases’.Workshops were also beingrun concurrently - I attendedthe X-ray workshop which wasvery informative.

Alongside all of this was theskiing, which we managed to

fit in between the lectures.The snow was great and theresort not too busy, so not toomuch waiting on the lifts. Allin all, we all had a great timeand updated ourselves alongthe way - I would highlyrecommend it.

Dany Pinnock Team leader - Team H

Anaesthetic conference - Belle Plagne

Staff development and education

The continued development ofour staff working on the unit isof high importance. Over thepast two years our staffmembers have continued toundertake a number ofdifferent educational courses:

• Foundations of critical care

• Certificate of professionaldevelopment in critical care

• Supported Learning in theClinical Environment

During this time, in conjunctionwith our link lecturer fromThames Valley University, wehave developed an in-housePreceptorship course to assiststaff in developing their role inthe development of pre-registration student nurses. It ishoped that this course willmatch to the requirements forrole of associate preceptor asdiscussed by the Nursing andMidwifery Council.

The unit also recognises thatstaff may have differingdevelopmental needs and hasdevised a number ofdevelopmental pathways toguide staff through theirprofessional development. Notonly do these outline theacademic opportunitiesavailable, but also otherpotentially valuable ways ofenhancing the way in whichnurses practice. Examples ofelements in these pathwaysinclude:

• Clinical supervision andaction learning

• Shadowing staff

• Inter-team project work

• Study days run by the unitand the trusts LearningResource Centre

• Attending conferences

• Preceptorship

• Teaching on the Foundationsin Critical Care Course

• Writing for publication

We have also supported two ofour team leaders to attend aweek long course exploring theuse of practice development intheir roles. This course, run bythe Royal College of Nursing,helps to develop the facilitationskills required to promotepatient-centred care.

Pre-registration studentscontinue to be welcomed tothe unit for placements.Students spend eight weeksworking with a primary nursingteam in the delivery of patientcare in order to gain an insightand practical training inintensive care nursing. Duringthis year their orientation packand placement objectives havebeen revised and updated bythe teaching coordinatorsgroup.

Elaine MandersonClinical Nurse Specialist


Summary of activity

2003-2004 2004-2005 2005-2006

Discharged Level 3 192 Level 3 221 Level 3 196

patients (FCE’s) Level 2 187 Level 2 195 Level 2 200

Total 379 Total 416 Total 396

Occupied bed days Level 3 2567 Level 3 2292 Level 3 2448

Level 2 783 Level 2 1125 Level 2 791

Total 3350 Total 3417 Total 3239

Refused admissions Total 16 Total 20 Total 9

Publications and research

Manley, K (1990) the birth of anursing development unitNursing Standard 4 (26) 36-38

Warfield, C. & Manley, K.(1990). Developing a newphilosophy in the NDU NursingStandard 4 (41) 27-30

Manley, K. (1990) IntensiveCaring Nursing Times 86 (19)67-69

Manley, K. (1991) IntensiveDisagreement Nursing Times87 (4) 66-67

Jenkins, D. (1991) Developingan NDU: the manager’s role.Nursing Standard 6 (8) 36-9

Clayton, J. & McCabe, S. (1991)Continuing education in anNDU Nursing Standard 6 (9)28-31

Manley, K. (1992) Flow controlin intravenous therapy.Surgical Nurse 5 (3) 11-16

Manley, K. (1992) Qualityassurance; the pathway toexcellence. In Bryksyneka, G. &Jolley, M. Nursing: thechallenge to change

Manley, K. (1992) SponsorshipSurgical Nurse 5 (3) 4-8

Pritchard, T. (1993) IntensiveChanges Nursing Times 89 (1)55-57

Manley, K. (1993) Patientfocused hospitals Editorial:Surgical Nurse 6 (2) 7

Manley, K. (1993) Continuingand Higher Education Editorial:Surgical Nurse 6 (6) 7

Mills, C. (1993) The namednurse in an adult intensive care.Chapter 21 in The namednurse, Midwife and HealthVisitor HMSO, Department ofHealth 71 -73

Younger, C. (1993) The ICU as anursing development unit Careof the Critically Ill 9 (3) 110-112

Manley, K. (1993) The clinicalnurse specialist Surgical Nurse6 (3) 21-25

Welch, J. (1993) Chest drains -chest drains and Pleuraldrainage Surgical Nurse 6 (5)7-12

Welch, J., Parr, S. & Manley, K.(1994) Hopelessness: a nursingconcept Surgical Nurse 7 (3)26-31

Manley, K. (1994) Primarynursing in critical care In: Millar,B & Burnard, P. Critical CareNursing: Care of theCritically Ill Bailliere Tindall,London

Manley, K. (1994) ClinicalSupervision: Why surgicalnurses need it Editorial SurgicalNurse February

Cruse, S. (1994) Profile of theChelsea and WestminsterIntensive Care / NursingDevelopment Unit RCN CriticalCare Nursing ForumNewsletter RCN London

Mills, C. (1995) Transfer to theward from ICU: familiesexperiences, Nursing inCritical Care September 20-25

Mills, C. (1995) Evaluation ofPrimary Nursing in a NursingDevelopment Unit NursingTimes 91 (39) 35-7

Soni, N., Welch, J. & Sibbald,W. (1996) Haemodynamicmonitoring: a handbook fordoctors and nurses BOCOhmeda, Helsingborg, Sweden

Newham, C. and Howie, A.(1996) Reflection on a patientreceiving high frequencyoscillatory therapy Nursing inCritical Care 1 (1) 42-44

Manley, K., Cruse, S. andKeogh, S. (1996) Jobsatisfaction of intensive carenurses practising primarynursing Nursing in CriticalCare 1 (1) 31-41

Creasey, J. (1996) Sedationscoring; assessment tools inpractice Nursing in CriticalCare 1 (4) 171-177

Mills, C. (1996) The consultantnurse: a model for advancedpractice Nursing Times 92 (33)36-37

Pritchard, T. (1997) Supervisionin Practice Nursing in CriticalCare 2 (1) 34-37

2004-2006 34

Publications and research

Manley, K. (1997) A conceptualframework for advancedpractice: an action researchproject operationalising anadvanced practitioner /consultant nurse role Journal ofClinical Nursing 6 (3) 179-190

Manley, K., Hamill, J.M. andHanlon, M (1997) Nursing staffsperceptions and experiences ofprimary nursing practice fouryears on on Journal of ClinicalNursing 66 (4) 227-228

Mills, C. (1997) PulmonaryEmbolus Nursing Times 93 (5)50-53

Mills, C., Howie, A. & Mone, F.(1997) Nursing Diagnosis: useand potential in critical careNursing in Critical Care 2 (1)11-16

Pinnock, D. (1998) Experience ofbeing a shift Nursing in CriticalCare 3 (5) 227-236

Theaker, C, Ormond-Walshe, S,Azadian, B,.& Soni, N (2001)MRSA in the Critically ill. Journalof Hospital Infection 48; 89-102Theaker, C et al. (2002)Comparison of bacterialcolonization rates of antisepticimpregnated and pure polymercentral venous cathethers in thecritically ill . Journal of HospitalInfection 52: 310-312

Theaker, C. (2002) Pressure soreprevention in the critically ill:What you don’t know, what youshould know and why it isimportant. Current Anaesthesia& Critical Care

Completed research

Mills, C. (1993) The Livedexperience of families whosefamily member is transferredfrom an Intensive Care Unitpractising primary nursing to award that is not

Welch, J. (1993) Nurses’perceptions of different alarmsounds.

Manley, K. (1993) The role ofthe clinical nurse specialist inthe facilitation of nurses andnursing in order to provide aquality service: Action researchPhD Thesis: Universtiy ofManchester / Institute ofAdvanced Nursing EducationRCN

Manley, K., Welch, J. & Hanlon,M. (1994) Perception of primarynursing by members of themulti-disciplinary team and staff

Manley, K., Hamill, JM. &Hanlon, M. (1994) Intensivecare nurses’ perceptions ofprimary nursing: four years on

Manley, K., Cruse, S. & Keogh,S. (1994) Job Satisfaction inintensive care nurses

Creasey, J. (1996) Aphenomenological study, of thelived experience of familymembers of patients who arenursed in a general IntensiveCare Unit

Cruse, S. (1996) The livedexperience of primary nursescaring for long-term patients inan Intensive Care Unit

Howie, A. (1998) Canventilatory weaning bepredicted?

Welch, J. An insight intointensive care nurses”thinkingin practice” a naturalisticperspective. MSc DissertationCity University.

Pinnock, D. (2000) The skillscritical care nurses can use toappropriately include significantothers in the care of patients.An action research Study. MScDissertation: RCNI / ManchesterUniversity

Manderson, E (2003) The livedexperience of nurses caring forpatients weaning frommechanical ventilation. Aphenomenological study. MScdissertation. University ofManchester/ RCNI

Saunders, L (2004) Nursesfeelings and perceptions aboutdifficult to manage patients inICU. BSc dissertation. KingstonUniversity.


Unit staff – April 2006

Team A Team B Team C Helen Bass Caroline Younger Hazel BoyleEmma Long Gerry Fitzgerald-O’Connor Angelo BatoonHwee Leng Lim Amanda Joyce Rachel Cowey Alberto Albortra Imelda San Miguel John GoughMartina Sauer Basino Reyes Laura EdmondsMichelle Bulfin Ramon Flojemon Marion Blennerhasset Gina Paluga Julianne Poulin Francis Douds

Enrico Esguerra

Team D Team E Team FRebecca Hill Jane-Marie Hamil / Ann HindsAmanda Dixon Nerrisa Verdejo Feriel MahioutRodney Fernandez Josephine Bien Rose Le CordeurSaowanit Kampinij Jane Mbaluku Alexis PelinaChristopher Bray Elaini Loannou Amy Wood

Emily Chetty Ciara McKenna

Team H Team I Team J Ann Sorrie / Dany Pinnock Louise Saunders Maria Stockmayr Denise Box Sarah Hector Diana NilandCorazon Basbas Sharon Wyatt Rebecca Foeken Aldrin Litang Laura Giron Rubina Vard Marietes Velasco Nadia MarinkovichNoku Kashiri Shona Keogh

Hilary Taylor

Elaine Manderson Jane-Marie Hamill Jason Tatlock Clinical Nurse Specialist Clinical Nurse Leader Admin/Information Officer

Mark Costello Magdalena Johnstone Mavis KyeremetengTechnician Housekeeper Housekeeper

Caroline Heslop Claudia Thompson Blanche TakwiVolunteer Volunteer Healthcare Assistant

Emer Delany Lorna Soares-Smith Gordon TurpieDietician Physiotherapist Staff Development C/N

Chris ChungPharmacist

2004-2006 36

Contributions to working parties

Supplies/ Finance GroupJane Marie Hamill CNL

PEAT groupJane-Marie Hamill, CNL

Recruitment and RetentionGroup Jane-Marie Hamil, CNL

Staff Site GroupLouise Saunders, Sister

Tissue Viability GroupCaroline Younger, Sister

Trust Documentation Group Elaine Manderson, CNS

Internal

Pan London Critical CarePractice Development Forum Elaine Manderson, CNS(secretary)

North West London CriticalCare Network – Nursesgroup Elaine Manderson, CNS

London Standing Conference– Critical Care GroupJane-Marie Hamill, CNL

External


Nurses’ perceptions ofdifficult to manage patients(free paper) – LouiseSaunders, BACCN/WFCCNconference. Cambridge, UK.

Nurses’ experiences ofweaning from mechanicalventilation (free paper) –Elaine Manderson.BACCN/WFCCN conference.Cambridge, UK.

Critical Care Needs Must!(poster presentation) – HazelBoyle/ Audrey Blenkharn.BACCN/WFCCN conference.Cambridge, UK.

Beyond the 998: aninnovative approach tofilling the mentorshipblackhole (free paper) –Elaine Manderson/ AudreyBlenkharn. BACCN conference.Weston-super-Mare, UK

Conference presentations

Acknowledgements

The staff of the ICU/NDU would like to acknowledge and thank thefollowing for their continued support

Dr Neil SoniDirector ICU

All the members of the ICU Multi-disciplinary and the CriticalCare Outreach teams

The Trust’s Nursing and Quality directorate

Kate Hall, Amanda Pritchard and Alison HeeralallGeneral Managers and Acting General Manager - Anaesthetics,Imaging and Surgery

Lyn GarbarinoSenior Fellow, Practice Development, RCN Institute

2004-2006 38

© 2006 Intensive Care & Nursing Development Unit

Chelsea and Westminster Healthcare NHS Trust369 Fulham Road, London, SW10 9NH

Documents

Intensive Care and Nursing Development Unit Report 2004-2006