1. Hanneman, Sandra K. PhD, RN, FAAN

Article Content

Individuals who require critical care become both physiologically and psychologically vulnerable from the circumstances of illness and injury. Critical care nurses provide vital services that include vigilant monitoring to prevent complications, interventions to promote purposeful recovery, and humanistic care to assuage the multiple assaults on the critically ill patient's personhood. 1 Providing these vital services mandates the appropriate blend of the science and art of caring. The art of caring alone cannot prevent complications and promote purposeful recovery. It must be provided with a strong foundation of biomedical and behavioral knowledge. It is the science of caring to which this issue of Critical Care Nursing Quarterly (24:4) is devoted.


The issue was designed to highlight the range of research being conducted by nurse scientists and clinicians. The variability in questions asked and in approaches used reflects the exciting diversity in critical care nursing research. Moreover, this issue tells the story of the "coming of age" of nursing research. Some of the brightest minds, most expert clinicians, and accomplished researchers have been assembled to tell the story.


Less than two decades have passed since a report by the Institute of Medicine recommended that nursing research be included in the mainstream of biomedical and behavioral science. The recommendation set the stage for what today is the National Institute of Nursing Research, an institute of the National Institutes of Health supporting clinical and basic research to establish a scientific basis for the care of individuals across the lifespan. The story portrayed in this issue reflects funded research, grounded in clinical practice expertise and rigorous research methods. The story highlights the maturation of critical care nursing research from isolated studies with predominantly local import to programs of research building substantive knowledge that can be widely applied to practice.


The article by Hanneman, Cozart, and Swank makes two major contributions to the nursing literature. These authors evaluated the reliability of the common nursing assessment of patient cough effort with an uncommon approach. We often take such everyday assessments for granted, yet make clinical decisions based on the findings. As the results indicate, clinicians are advised to rethink the dependability of simple assessments. Hanneman et al employed a measurement model that nurse researchers use infrequently. Given the multiple sources of error in most clinical measurements made in critical care settings, generalizability theory holds promise for efficiently capturing in one study the major sources of error. Being able to identify the major sources of error in measurement permits appropriate and targeted error reduction, thereby giving us greater confidence in the reliability of our assessments.


Dr Shiao reports the results of her pilot study on the reliability and accuracy of oxygen saturation monitoring in neonates. She compared oxygen saturation measured with pulse oximetry with saturation measured with a fiberoptic umbilical artery catheter in mechanically ventilated neonates. This article contains abundant and precise quantification of the differences in saturation and the neonate's response to care events. While the detail is sure to warm the cockles of the researcher's heart, the significance of this research should not be lost on the clinician who cares for critically ill neonates. It is clear from these results that the technology used to monitor the well-being of the sickest neonates is not up to the task. Oxygen saturation measurement that stops measuring when hypoxemia is most likely to be present is hardly useful. Oxygen saturation measurement that overestimates saturation places the neonate at risk by falsely assuring the clinician that all is well.


Holtzclaw and Hanneman are clinical researchers who turned to an animal model to better understand perplexing phenomena observed in critically ill patients. Holtzclaw used a rabbit model to study physiologic mechanisms underlying the interaction of thirst, fluid intake, and fever. Hanneman developed a porcine model of prolonged acute stress to test the relevance of a chronobiology framework for weaning patients from mechanical ventilation. Their experiences with both clinical and basic research posture them well for discussing the use of non-human biobehavioral models for critical care nursing research.


Clinicians who focus on time domain indicators of well-being, such as heart rate and respiratory rate, may have a particular interest in the article by Verklan. While Dr Verklan uses transition from fetal to neonatal life as the context, her message is that frequency domain patterns in physiologic variability may be more reliable and valid measures of physiologic status than the traditional time domain measures of beats or breaths per minute. Her cutting-edge research is in the preliminary phases and, therefore, is not now directly applicable to bedside assessment. In addition to testing the physiologic interactions of the sympathetic and parasympathetic nervous systems, this program of research has the burden of developing the data acquisition, processing, and analysis techniques that are essential for real-time monitoring in the frequency domain. Comparable to previous findings in adults, 2 Verklan's preliminary data suggest that compromised neonates exhibit less physiologic variability than do healthy ones, despite similar heart rates.


Last but not least, Wojner and colleagues are testing the common intervention of patient position on intracranial arterial blood flow. They report here their pilot study findings, which suggest a large effect from head of bed position. Imagine the possibility of improving morbidity and mortality after ischemic stroke with patient positioning. While longer-term outcomes need to be studied, the simplicity of the intervention validates the power of nursing practice to effect improved patient outcomes. Whereas the techniques being used by Verklan are not ready for use at the bedside, the sonographic system used by Wojner et al can be used at the bedside, albeit not practically for continuous monitoring.


Lest the reader conjure images of critically ill patients "wired for sound," it is useful to remember that, with the exception of transcranial Doppler, the technologies used in the studies reported here are now routinely used in the care of the critically ill. Ambulatory blood pressure monitoring technology is used in the critical care unit, although we call it noninvasive blood pressure monitoring and often have access to more continuous and direct blood pressure monitoring. Critically ill neonates are likely to have an umbilical arterial line even if it is not a fiberoptic one as used by Dr Shiao. Much of the technology discussed in this issue is routine with intensive care unit patients, and every critically ill patient has continuous electrocardiogram monitoring. What I find exciting in this issue is the blend of clinical expertise and scientific methods that have the collective potential to inform two of the three vital services provided by critical care nurses: vigilant monitoring to prevent complications and interventions to promote purposeful recovery. Furthermore, many of the research studies are oriented toward reliable and valid measurement of patient response to the stress of critical care. Reliable and valid monitoring is a prerequisite to effective intervention and assessment. Contributions to this end will benefit all medical disciplines in prognostic, diagnostic, and therapeutic endeavors.


Bright minds, clinical expertise, and strong research skills unite the lead authors in this issue of Critical Care Nursing Quarterly as heroes in the story of critical care nursing research. They are doing important research that is important to clinical practice. They validate the Institute of Medicine's conclusion that nursing research belongs in the mainstream biomedical research enterprise. I am proud to have them as colleagues in the quest for the best possible science and art of caring for the vulnerable patients we serve.




1. Hanneman SK. Advancing nursing practice with a unit-based expert nurse. Image J Nurs Schol. 1996;28(4):331-337. [Context Link]


2. Goldberger AL, Rigney DR, West BJ. Chaos and fractals in human physiology. Sci Am. 1990;262(2):42-49. [Context Link]