Intensive and Critical Care Nursing (2006) 22, 283—293

ORIGINAL ARTICLE

The experiences of trained nurses caring for

critically ill patients within a general ward setting
Helen Cox a,∗, Jayne James a,1, Julian Hunt b,2

a University of the West of England, Faculty of Health and Social Care, Glenside Campus, Blackberry Hill,
Bristol, BS16 1DD, UK
b Royal United Hospital, Combe Park, Bath, BA1 3NG, UK

Accepted 10 February 2006

KEYWORDS Summary
Critically ill patients; Background: The concept that critical care is a service rather than a location
Clinical environment; has been increasingly highlighted. However, there is limited information regarding
Patient assessment; nurses’ perceptions of caring for critically ill patients outside of high dependency
Emotional support areas.
Aim: The aim of this study was to explore the factors that influence the experiences
of trained nurses caring for critically ill patients within a general ward setting.
Method: This was an exploratory, descriptive study combining an interview and ques-
tionnaire methodology. A purposive sample of seven trained nurses reflecting a range
of grades and experience, from one medical ward were selected. A semi-structured
interview combined with an attitudinal scale was utilised.
Results: Following analysis five key themes emerged: clinical environment, profes-
sional relationships, patient assessment, nurse’s feelings and educational needs.
Conclusion: Whilst the findings of this study cannot be generalised, analysis of the
data has provided an insight into the complex factors that effect care delivery. In
order to respond to this study’s findings, there are resource implications. Educational
requirements and communication skills will need to be developed.
© 2006 Published by Elsevier Ltd.

Introduction
Many factors either singly or as part of a complex
∗
Corresponding author. Tel.: +44 117 3288856; interaction, influence the outcome of a critically ill
fax: +44 117 3288811. patient. These include patient age, speciality, need
E-mail addresses: helen3.cox@uwe.ac.uk (H. Cox),
for emergency admission, physiological reserve,
jayne.james@uwe.ac.uk (J. James),
julian.hunt@ruh-bath.swest.nhs.uk (J. Hunt). severity of illness and quality of care (Knaus et
1 Tel.: +44 117 3288428. al., 1985). McQuillan et al. (1998) found critically
2 Tel.: +44 1225 825010. ill patients on general wards sometimes received

0964-3397/$ — see front matter © 2006 Published by Elsevier Ltd.

doi:10.1016/j.iccn.2006.02.003
284
sub-optimal care, which adversely affected out-
come. The concept of critical care being a ser-
vice rather than a location is not a new one (Kings
Fund Panel, 1989). However, the implications of ser-
vice provision outside traditional high-dependency
areas, with regard to the provision of high quality
care, does not appear to have been fully investi-
gated. There is evidence to support the outcome
benefit of early recognition and treatment of dete-
riorating ward patients especially in those who go
on to cardiac arrest (Schein et al., 1990; Hourihan
et al., 1995).
A plethora of reports relating to the provision
of critical care have subsequently been produced
(Audit Commission, 1999; Department of Health,
2000, 2001). These documents were formative in
developing not only local organisational objectives,
but also regional and national responses, these
included influencing nursing and medical educa-
tion. One recommendation was the development
of critical care outreach teams to support patients
and nurses on general wards (Ball, 2002; Ball et al.,
2003; NHS Modernisation Agency, 2003; Priestley
et al., 2004). A further recommendation was the
implementation of physiological track and trigger
or early warning scoring (Morgan et al., 1997; NHS
Modernisation Agency, 2003). Many hospitals have
developed patient at risk teams (Goldhill et al.,
1999) or medical emergency teams (MET) as an
alternative to a cardiac arrest team (Buist et al.,
2002; Bellomo et al., 2004; Braithwaite et al.,
2004). Provision of these systems appears to be
widespread but not universal, with developments
based on local needs.
There is a proliferation of literature and research
surrounding these new initiatives with regard to
their development and perceived success (Bellomo
et al., 2004; Considine and Botti, 2004; Priestley et
al., 2004). These have suggested that further edu-
cation of ward staff to develop assessment skills
is crucial (Abner, 2000; McAuley and Perkins, 2002;
Massey and Ricketts, 2002). It therefore seems
timely to explore how these policies have affected
the experience of nurses in clinical practice.
Literature review
McQuillan et al. (1998) highlighted that patients
may receive sub-optimal care prior to their inten-
sive care admission. Inabilities in detecting clin-
ical deterioration, along with delays in seeking
advice, were common reasons cited. Specific fail-
ures in care were identified including poor organi-
sation and lack of supervision of medical and nurs-
ing staff. A retrospective analysis of unexpected
deaths and referrals to intensive care of patients
H. Cox et al.
on general wards in a teaching hospital was under-
taken by McGloin et al. (1999). It similarly revealed
poor assessment of critically ill patients, delays in
response and inappropriate treatment.
There is limited available data of nurses’ expe-
riences and perceptions of managing critically ill
patients in the general ward environment. How-
ever, there are two key studies regarding nurses’
experiences of decision making within this context.
Cioffi’s (2000) Australian study offers a valuable
insight regarding nurses’ experiences of decision
making in relation to calling a MET. Through an
explorative approach nurses described their experi-
ences. The sample consisted of 32 female qualified
nurses with at least five years experience and a
mean of 14 years experience. The grades of nurses
within this study were not specified. The nurses
sampled were from four wards in a teaching hospital
and three wards in a peripheral hospital. The sam-
ple provided a range of clinical specialties. Inclu-
sion criteria were based on the use of MET. Unstruc-
tured interviews allowed nurses to express their
feelings regarding calling of the team. Participants
reported worrying about calling the team unnec-
essarily and feeling the need to corroborate their
assessment with peers prior to calling for assis-
tance. Participants reported a sense of knowing
that something was wrong but were unable to quan-
tify those feelings. Interestingly, even when support
systems such as a MET were available, this did not
appear to reduce anxiety or increase the confidence
levels of participants. Whilst Cioffi’s study offers a
valuable insight its application to the United King-
dom (UK) may be limited due to organisational dif-
ferences in healthcare in the UK and Australia.
Cutler’s (2002) ethnographic case study within
the United Kingdom examined the real life expe-
riences of nurses caring for acutely ill patients
on one ward. Seven qualified nurses of varying
grades and experience were interviewed. The set-
ting was a surgical ward that received a large pro-
portion of patients transferred from intensive care.
It was unclear whether support mechanisms such
as critical care outreach existed. This may have
affected the responses. Data were collected by
semi-structured interviews. Participants described
the high dependency nature of patients within this
setting and inadequacy of staffing levels to sup-
port their needs. This was described as impact-
ing on time available to care for the other ward
patients. Participants reported feeling stressed and
frightened with lack of time being a major con-
cern. Effective assessment skills were seen to be
important and participants acknowledged their own
deficits in this field. A need for scenario-based edu-
cation and time to put theory into practice was
Experiences of trained nurses
highlighted. The necessity for effective communi-
cation and collaboration between nursing and med-
ical teams was also emphasised. Additional clinical
support was also requested, as existing mechanisms
were felt to be limited.
While these two papers provide valuable insight,
there was a need for further exploration to eluci-
date the factors that influence the nursing care of
the critically ill patient within the general ward
setting.
Aims of the study:
1. To uncover the experiences of trained nurses
caring for critically ill patients within a general
ward setting.
2. To explore the support mechanisms which
enable trained nurses to effectively care for this
client group.
3. To consider shortcomings in current care strate-
gies in the management of critically ill patients
within a general ward setting.
4. To consider the suitability of the semantic differ-
ential as a way of validating interview content.
5. To contribute to the knowledge base for practice
and education.
Methodology
Due to the paucity of research in this area,
an exploratory descriptive study was undertaken
using a semi-structured interview schedule (Clarke,
1999).
The study used a purposive sample of seven
trained nurses from one medical ward in a district
general hospital. The aim of sampling was to select
participants who reflected a range of gender, grade,
age and experience. All of the staff on the ward rota
were initially invited to participate. The ward oper-
ated a system of internal rotation, so variations in
night-day experience were automatically included.
Data collection
Participants were invited to participate in the
study by letter. Following written consent, a mutu-
ally agreeable time was arranged for interview
(LoBiondo-Wood and Haber, 2002). Interview ques-
tions were derived from key areas of the literature
review and from the experience of the research
team. In order to facilitate a confidential inter-
view this was conducted in a private place away
from the work setting (Clarke, 1999). Although
not a novice, the interviewer underwent interview
technique training prior to undertaking data col-
lection to minimise her affect on the interview
285
process (Parahoo, 1997). For purposes of continu-
ity one member of the research team conducted
all interviews. As note taking can affect the inter-
viewer’s ability to be attentive (Clarke, 1999) inter-
views were tape-recorded and transcribed verba-
tim. In addition, field notes were taken after each
interview in order to record relevant non-verbal
communication (LoBiondo-Wood and Haber, 2002).
During the interview, participants were asked to
recount an incident in which a patient in their care
had become increasingly unwell; their experiences
were elicited through open-ended prompts. At the
end of the interview participants were additionally
asked to complete a semantic differential mea-
surement (Miron and Osgood, 1966; Osgood et al.,
1957). This enabled validation of attitudes towards
the experiences explored in the interview.
Data analysis
Information obtained during the interviews
remained confidential (Parahoo, 1997). Data
analysis was completed by the research team
utilising a systematic approach (Burnard, 1991).
Content analysis was utilised. Transcripts were
read several times to get an overall impression
and main themes were then identified (Emden et
al., 2001; Woods et al., 2002). Each member of
the research team conducted this process inde-
pendently, disparities were resolved and consensus
reached. Subsequently, sub-codes within these
main themes were identified (Woods et al., 2002).
Validation of themes was undertaken both through
verification to one interviewee (Parahoo, 1997;
Burnard, 1991), and to one independent researcher
who did not have knowledge of this study (Parahoo,
1997; Burnard, 1991).
Data were also derived from a semantic differen-
tial questionnaire. A semantic differential scale was
filled in for each of the main interview questions.
The semantic differential scale was developed by
Osgood et al. (1957). It comprises a series of bipolar
word couplets that are rated in response to a partic-
ular word or concept. As a measure of attitude it has
been used frequently and is well validated (Heise,
1970). The semantic differential has been used par-
ticularly in validating other attitude measures, as
illustrated by Bailey and Pearson (1983) and Garcia-
Pena et al. (1996). The original authors used a large
number of word couplets applied to a large number
of subjects and isolated three aspects of attitude,
which they described as evaluation, potency and
activity (EPA). It is possible to examine data to a
refined level, using a large number of word cou-
plets and using a variety of methods and detailed
measurement of attitudinal dimension (EPA).
286
Table 1 The semantic differential used in the study
Table 2 Key to semantic differential showing which
items relate to each dimension
Dimension Couplet
Evaluation 1 4
Potency 2 6
Activity 3 8
For the purpose of this study the scoring con-
sisted of the combined EPA scores representing a
summary measure of attitude (Heise, 1970). This is
essentially an index of whether an attitude towards
a particular theme was positive or negative, and
some measure of strength. The bipolar adjective
pairs were selected from 50 commonly used cou-
plets (Drexel University, 1999) (Tables 1 and 2).
Ethical considerations
Potential participants were sent an explanatory
letter together with a consent form and asked
to return this to the researchers. Their right
to withdraw at any time was indicated at this
time (LoBiondo-Wood and Haber, 2002). Those who
returned their consent were contacted by tele-
phone and a mutually agreed time for interview was
arranged.
Efforts were made to minimise the effects of
possible relationship inequalities within the inter-
view by using a member of the research team
who was least involved with ward nurses. How-
ever, the interviewer may have had an educa-
tional role with some of the interviewees, this may
have affected the responses gained (Coghlan and
Brannick, 2005). Personal details were changed to
protect participants’ identity during the transcrib-
ing process (LoBiondo-Wood and Haber, 2002) and
H. Cox et al.
data remained confidential to the research team
(Parahoo, 1997).
Whilst it was anticipated the risk of psychological
harm as a result of the interview process would be
5 minimal; nevertheless steps were taken to ensure
7 participants were provided adequate support fol-
— lowing the interview process. Exploration of areas
of practice may give rise to feelings of anxiety,
embarrassment (Gelling, 1999) and reduced self-
esteem (Robinson, 1996). Furthermore the inter-
view process itself could potentially be harmful, as
participants may find themselves revealing issues,
which they may later find they regretted (Parahoo,
1997). In order to address these potential adverse
effects and to support those participating (Cerinus,
2000), each interviewee was provided with infor-
mation regarding post interview support accessed
via the local trust confidential counselling service.
Ethical approval was obtained from the Local
Research Ethics Committee, the University Ethics
committee and the Trust Research Governance
group.
Results
Seven trained nurses (age range 24—54 years) were
recruited. Participants ranged from newly qualified
to 20 years experience. Clinical grades ranged from
staff nurse to senior sister. No male subjects were
recruited.
Following data analysis five major themes
emerged which fragmented to 11 sub themes.
These suggested many influences which may affect
the quality and speed with which acutely ill patients
in a general ward setting are managed. Table 3
outlines the relationship between themes and sub-
themes.
Experiences of trained nurses 287

Table 3 Key themes and sub themes ‘‘We use BiPAP1 on the ward and we have not been
trained to use it and that makes you more anx-
Themes Sub-themes ious because we’re expected to use it quite often’’
1. Clinical environment • Being machine focused (Interview 6 nurse with many years experience).
• Distracted with other
patients ‘‘we’ve increasingly been getting CPAP in the
2. Professional • Nurses articulating
area at the moment and we’ve been given the
relationships concerns and gaining machine but no training’’ (Interview 5 experienced
action nurse).
• Clinical support good
• Emotional support not Distracted by other patients
evident The narratives illustrated the dilemmas ward
3. Patient assessment • Holistic assessment nurses may face when trying to look after a
• Observations verified number of patients one of whom may have
intuition become unwell. Whilst participants appreciated
the need to place the critically ill patient as
4. Feelings • Feeling panicky and
nervous their priority they additionally described con-
• Confidence was cerns regarding neglecting the care of their other
important patients.
5. Education needs • Education needs to be ‘‘You think oh God, because you realise you’ve got
ongoing six other patients to look after and yet this patient
• Lack of awareness of you know needs to be with you all the time, you
own training needs need to be with them when they’re unwell; it’s just
a balance of trying to look after other patients but
not being too far away’’ (Interview 6 nurse with
many years experience).
Theme 1—–Clinical environment ‘‘you have to be aware of the patients around you
as well, you can’t be focused on that one poorly
Participants highlighted the influence of the clin- patient’’ (interview1 very experienced nurse).
ical environment on their ability to assess the
patient’s deterioration and to take appropriate
Theme 2—–Professional relationships
action.
In this theme there are two sub-themes which indi-
cate the effect professional relationships had both
Being machine focused
on the nurses ability to gain action for the critically
There was a sense that for some participants the
ill patient and the levels of support they felt they
equipment was relied upon, to the detriment of a
had in achieving this outcome.
holistic approach to patient assessment
Nurses articulating concerns and gaining actions
‘‘We’ve become very machine orientated, any fool Participants described the process of getting action
can put somebody on a DinamapTM or put them on for their patient. It seemed that the more experi-
a pulse oximeter, it doesn’t tell you anything at enced nurses recognised the need to provide evi-
all and actually the relevance of doing the obs is dence and be assertive when attempting to gain
not only about the body systems but it is about action. Whilst in contrast the more inexperienced
getting close to the patient, about communicat- participants indicated they tended to wait for assis-
ing with the patient, touching them, feeling them, tance.
getting a feel for how they are-there’s no close
contact anymore’’ (Interview 3 very experienced ‘‘Good communication skills, a bit of assertiveness
nurse). having the courage to say this needs to be done and
I think you need to do it, so it’s not good enough to
For others, concerns arose regarding the use walk away from me until I’ve got a plan of what is
of equipment which was unfamiliar to them and
which hindered their assessment process. Access 1 BiPAP refers to a ventilatory mode Bi-level Positive Airway
to appropriate equipment was also raised as an Pressure, commonly used for non-invasive ventilation for respi-
issue. ratory failure.
288
going to happen to this patient’’ (interview 3 very
experienced nurse).
‘‘a little bit of panic at the beginning but when the
doctor got involved quickly it did calm me down’’
(interview 2 recently qualified nurse).
Clinical support was important
This sub-theme highlighted the necessity for par-
ticipants to gain clinical support. This came from
a variety of sources including intensive care and
peers. Outreach services were valued and missed
when not available. Both positive and negative
experiences were described which indicated the
variable clinical support available. Interestingly,
there was no mention of emotional support follow-
ing critical incidents despite a variety of heightened
emotions described below.
‘‘I didn’t feel supported enough then because I felt
totally out of my depth then but usually I do get
a lot of support’’ (interview 7 nurse with limited
experience).
‘‘We need more support too because that nurse
should have been given that support, somebody
should have been there’’ (interview 4 nurse with
many years experience but only very recent hospi-
tal experience).
Theme 3—–Patient assessment
Participants’ narratives indicated how intricate
the assessment process was. Participants reported
using a variety of methods some of which they could
quantify whilst others seemed intangible.
Holistic assessment
Participants described their assessment process,
which involved knowing their patient and the
importance of not only gaining baseline observa-
tions but also having the foresight to individualise
the assessment process. The importance of touch
was noted.
‘‘Being able to recognise that you just don’t auto-
matically do everything for everyone who comes in
so having a bit more in depth insight’’ (interview
5, experienced nurse).
Observations verified intuition
Participants reported that whilst they had taken
the necessary vital signs recordings, often these
verified what they had intuitively suspected. Respi-
rations were highlighted as a common first indicator
of patient deterioration.
H. Cox et al.
‘‘His breathing was just becoming more laboured
it wasn’t especially um rapid respirations but
there was a change in his breathing. You can
just hear it, sense it almost, you just know that
that’s not right’’ (Interview 1 very experienced
nurse).
Theme 4—–Feelings
Participants described heightened emotions asso-
ciated with managing patients, in their care, who
had become critically unwell. Perceived confidence
seemed to be a key issue as to how participants
coped and viewed this experience.
Feeling panicky and nervous
Negative feelings were described including feel-
ing anxious, panicky and on some occasions feeling
they had lost some control. These feelings were
described throughout the range of grades and expe-
rience.
‘‘When I received the patient (I’m a very panicky
person you know) I start sweating and thought oh
my god where do I start’’ (interview 4 nurse with
many years experience but only recent hospital
experience).
Having confidence was important
Participants described the importance they
afforded to confidence in dealing with these situa-
tions. The narratives highlighted various degrees of
confidence and how this influenced their reaction
to events. Whilst the less experienced nurses
described developing levels of confidence those
with more experience highlighted their confidence
to be able to recognise their own limitations and
thereby seek help promptly.
‘‘I think I am getting more confident with certain
things like contacting the Doctor, talking to the
Doctor about what’s happening with the patient.
I’m quite confident’’ (interview 2 recently quali-
fied nurse).
‘‘Confident enough to ask when I need help. . .. to
know when your expertise has reached its point and
when you need someone else’’ (interview 5 experi-
enced nurse).
Theme 5—–Education
The need for ongoing education
Participants described the importance of ongoing
education. Understanding body systems and their
relevance to clinical observations were identified.
In addition specific clinical skills training needs
Experiences of trained nurses
Table 4 Semantic differential scores showing direction and strength of attitude
were identified, for example central venous pres-
sure monitoring. Participants indicated the need
for local specific training rather than long post-
registration accredited modules.
‘‘I think I need regular updates because you forget
and you need to be reminded’’ (interview 6, nurse
with many years experience).
‘‘We have loads of central lines but not often
enough that you’re au fait with it all the time.
So I think we could really do with updates . . .. I
needed to be able to understand all the systems
why I needed to do the obs and what relevance
those obs were’’ (interview 1, very experienced
nurse).
Lack of awareness of own training needs
Whilst participants had highlighted their need for
further education they had difficulty in identifying
their own learning needs. Feedback regarding clin-
ical competence in acute care was not described.
‘‘I’m not sure whether what I am doing is right or
not . . .. There are quite a few skills that I think I
really need but it’s sort of like improving them. But
it’s quite difficult for me to identify which ones’’
(interview 2 recently qualified nurse).
‘‘You don’t really know what you don’t know!’’
(interview 1 very experienced nurse).
289
Semantic differential results
This was used as an index of attitude (positive or
negative) towards the themes identified when the
interview schedule was devised. The combined
data from all subjects was processed graphically
as raw scores. A positive number indicates a
positive attitude, a negative number a nega-
tive attitude. A score of zero would indicate
ambivalence of attitude. The data were presented
in terms of evaluation, potency and activity
(EPA), but the overall score was used in this
study.
The data demonstrates positive attitude related
to interview themes (Tables 3 and 4). The least pos-
itive attitude relates to subjects own confidence.
This data is broadly consistent with the interview
transcript data and therefore verified the themes
expressed.
Discussion
Despite the recognition that patients in a variety of
settings may have critical care needs (Department
of Health, 2000) this study has demonstrated there
are various issues which may determine the quality
of care patients receive. Environmental issues may
affect the delivery of appropriate care (Chellel,
2002). The increased use of technical equipment
predicates adequate resources are available and
training is given to ensure competence (Department
290
of Health, 2000). Bucknall (2003) has highlighted
the influence of resource availability on the qual-
ity of care, and the degree of autonomy partici-
pants felt they had. Over-reliance on equipment
needs to be recognised as a potential hazard.
Recording vital signs in isolation without regard for
more detailed assessment may have a detrimen-
tal effect. If critically ill patients are to be nursed
alongside those who are not so clinically compro-
mised then prioritising care and decision-making
skills need to be addressed (Coombs and Moores,
2002).
Patient staff ratios also seem to be crucial
in ensuring adequate standards of care (Ball and
McElligot, 2003). Increased ratios of patients to
nurses possibly contributing to poor assessment
(Chellel, 2002). Given that critical care areas have
established formulae for calculating patient/staff
ratio (Intensive Care Society, 1997; Royal College of
Nursing, 2003) it would seem timely that this should
have similar emphasis on acute wards. There-
fore, ward staff establishments should accurately
reflect patient acuity. Whilst development of a flex-
ible workforce has been suggested (Department of
Health, 2000) how this may best be accomplished
requires clarification. Further development of rota-
tional posts through higher dependency areas are
likely to be beneficial in developing skill and main-
taining quality.
Communication between doctors and nurses
is paramount in ensuring prompt patient assess-
ment and intervention. Whilst experienced nurses
seemed able to gain assistance, junior members had
difficulty in communicating urgency to the medi-
cal team. Nurses may feel afraid to get medical
help without first seeking peer support thereby
delaying the decision-making process (Bucknall,
2003). Whilst the use of EWS may enable inex-
perienced nurses to feel empowered to obtain
medical assistance (Robson, 2002), Cioffi’s (2000)
study demonstrated that even with a score in
place the need for peer support was paramount.
This study has highlighted that assertiveness on
behalf of nurses contributed to medical staff taking
action.
The value of outreach services has been widely
acknowledged in providing clinical support and edu-
cation (Groom et al., 2001). Limited availability
of an outreach service within this study setting
illustrates the differing models available through-
out individual trusts (Coombs and Dillon, 2002).
Further investigation of the clinical significance of
this service using a variety of models is needed.
Other supportive mechanisms need to be devel-
oped, as peer support is additionally important.
Use of handover time to reflect on situations and
H. Cox et al.
gain support may assist in this (Groom et al.,
2001).
Patient assessment cannot be purely task
orientated, and sensory skills (look, listen and
feel) should be emphasised. Use of equipment
such as the DinamapTM may lead to less patient
contact and poorer assessment. Therefore, while
basic observations are important, these need to
be considered within a more detailed approach.
Respiration as a key indicator to patients’ deteri-
oration has been previously acknowledged (Ahern
and Philpott, 2002; Goldhill et al., 1999). Despite
this Chellel’s (2002) survey has highlighted that
55% of patients who should have had respiratory
rate recorded did not. In contrast this study
demonstrated nurses’ use of this vital observation.
This may have been due to the high profile cam-
paign by the outreach team over the preceding
months.
Whilst objective measurements are essential
core skills, intuition can play a significant role and
should not be overlooked, particularly as intuition
within this study was an early indicator of patient
deterioration. Therefore, recognition that feeling
something is wrong should arguably be included in
early warning scores or emergency calling criteria
to enable the value of this to be recognised (Cioffi,
2000; Parr et al., 2001).
With recognition that patients with critical care
needs may be anywhere in a hospital, acknowl-
edgement is needed of the stress nurses may
have in managing acutely ill patients alongside
normal patient workload (Cutler, 2002a,b). Whilst
clinical support in this study was apparent there
was no indication of emotional support. Given the
negative feelings experienced by the participants,
strategies need to be developed and tested in sup-
porting nurses in this role. In addition to traditional
team meetings, opportunities for confidential
debriefing may be beneficial. Preceptorship for
less experienced staff may additionally provide
both emotional and clinical needs within this
context.
The participants highlighted the importance of
confidence; lack of this may arguably affect perfor-
mance (Cioffi, 2000). However, gaining confidence
may enable a swifter decision-making process (Dove
et al., 2001; Bucknall, 2003).
Comparisons with previous experiences or by
reflecting with peers may further facilitate con-
fidence in the decision-making process (Bucknall,
2003).
In an ever-changing healthcare environment the
provision of education needs to be responsive to
practice needs. Whilst critical care skills training is
essential (Department of Health, 2000), this needs
Experiences of trained nurses
to be multidisciplinary. Interprofessional problem
solving exercises may enable improved communi-
cation within the team and promote confidence
through shared understanding (Dove et al., 2001).
Scenario-based programmes are becoming increas-
ingly regarded as more effective than just the deliv-
ery of theory. The Acute Life Threatening Events
Recognition and Treatment (ALERTTM ) is an exam-
ple of a scenario-based, multidisciplinary course
(Smith, 2003). Assertiveness and communication
skills are valuable components of these courses. It
is essential that any educational programme is eval-
uated.
Some participants experienced difficulty in
articulating their own clinical educational needs
and limitations. Therefore, assistance identifying
developmental needs should be provided with the
aim to improve quality of care (Cutler, 2002a,b).
Staff appraisal may provide an opportunity to facil-
itate identification of both individual and local
needs.
Semantic differential data suggests that this is
a useful source of information to support interview
transcript data. This study used the semantic dif-
ferential in a simple way with an overall index of
positive or negative attitude in order to relate to
statements made by subjects in interview. It pro-
vided a check against a possible response set where
a subject’s responses may be influenced by factors
intrinsic to the individual rather than being valid
statements.
There is considerable detail in how the semantic
differential may be used to refine its use in future
research. The findings of this study are consistent
with the application of the semantic differential
in a variety of settings, as illustrated by Crocker
(1989), Asblund and Norberg (1993) and Slocumb
(1993).
Limitations
New vital signs assessment charts incorporating
early warning scoring, had been recently intro-
duced to the ward. In addition the provision of
outreach services within this setting was limited.
The use of a non-probability sample resulted in
no male representation therefore possible gender
issues have not been considered.
Whilst the use of a semi-structured interview
enabled participants to explore issues important
to them, this method of data collection may have
deterred some participants being completely hon-
est as they may have inadvertently answered in a
way, which pleased the researcher (Parahoo, 1997;
LoBiondo-Wood and Haber, 2002).
291
Further research
Further research is needed in order to explore
and challenge these findings in a wider study pop-
ulation. Utilising a survey design it is envisaged
that negative feelings identified such as stress
related issues and strategies to overcome these
could be investigated together with the themes
identified within this study. Gender differences
should be explored within this context. Compar-
isons between these data and managers’ perspec-
tives would enable a comprehensive study of this
topic area.
Conclusion
This study has highlighted the complexity of fac-
tors that surround the management of critically ill
patients within a general ward environment. Key
developmental issues will include resource manage-
ment, interprofessional communication, ongoing
emotional support, education, clinical assessment
and decision-making skills. If patient outcomes are
to be improved for this client group then contribut-
ing factors leading to poor patient outcome need to
be recognised and strategies developed to support
this nurses caring for the acutely unwell patient.
With increasing technological advances in caring for
critically ill patients it is imperative that nurses do
not lose sight of the importance of core assessment
skills.
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