Article Review: Conflict in the surgical critical care unit Caroline Williams, RN

Page 12 Article Review: Conflict in the surgical critical care unit

Caroline Williams, RN, Nurse Resident - CRMH 6S ICU

Editor’s Note: Ms. Williams wrote this paper as part of her Carilion Nurse Residency experience. Article Reviewed: Pecanac, K. & Schwarze, M. (2018). Conflict in the intensive care unit: Nursing advocacy and surgical agency. Nurs Ethics, 25 (1), 69-79. Doi:10.1177/0969733016638144 Intra-professional stress and frustration between nurses and surgeons is an unfortunate but stark reality for most in either profession. Heightened by the already present anxiety brought on by caring for critically ill patients, there is often conflict between surgeons and nurses regarding lifesaving interventions in surgical critical care units. The purpose of Pecanac & Schwarze’s (2018) study was to gain further understanding of the different perspectives between nurses and surgeons regarding care of surgical patients in the intensive care unit. Moreover, the researchers examined how those perspectives are formed, how differing perspectives contribute to intra-professional conflict, and what can be done to help improve an understanding of each profession’s responsibilities with the goal of reducing intra-professional distress.

This qualitative study researched articles, books and professional documents to gain descriptions of nurses and surgeons’ responsibilities to patients. The study used discourse analysis (the study of language in the everyday sense of which most people use words) to gain an understanding of what “responsibility for patients” means to each profession broken down into “advocates” for nurses and “agents” for surgeons which were used to search the text. Eighteen sources were searched with the terms “patient advocacy” and “surgeon responsibility/agency” to gain an understanding of overall clinical responsibility for patients from both nursing and surgical views.

After the analysis, the results were broken down into themes organized around professional perspectives. Themes from the nurse as advocate perspective included: responsibility to support autonomy regarding treatment decisions, responsibility to protect the patient from the physician, responsibility to act as intermediary between the physician and the patient, and responsibility to support the well-being of the patient. Themes from the surgeon as agent perspective included: personal responsibility for the patient’s outcome, commitment to patient survival, and responsibility to prevent harm to the patient from surgery. These results show that while each profession meets the same goal of providing quality, safe care for the patient, nurses and surgeons have very different routes to lead them to the same goal.

Moreover, the results demonstrate the potential for conflict between nurses and physicians in two primary areas: goals of treatment and relationship with the patient. Nurses’ primary goals for treatment encompass patient autonomy and well-being, whereas surgeon’s view focuses on personal responsibility for patient survival. These differences surface when a patient faces the need for a life sustaining treatment that the physician feels personally responsible for performing where the nurse may feel it simply prolongs death and thus ultimately prohibits the patient’s wishes or well-being. Additionally, surgeons may feel push back from nurses who advocate for the patient against burdensome treatments. The relationship with the patient is another source of conflict as each professional builds a very different relationship with the patient. Nurses feel as if they know their patients, their family and their desires usually starting with their postoperative experience. The nurse spends hours at the bedside engaging in conversation with the patient about their concerns, goals and needs. However, the patient relationship with the surgeon begins in the preoperative phase where the potential benefit to the patient’s life is discussed. Conflict arises between the physician and the nurse when it is felt that the goals have changed; however, the surgeon is respecting the patient’s wishes to proceed with prior plan of care.

The results of this study bring forth a broader understanding of the root of surgeons’ practice and demonstrate the very significant difference in responsibility felt between surgeon duty and nursing advocacy. The results also bring to light the importance of having care management discussions where the goals of care are discussed from a multi-disciplinary standpoint. The moral distress experienced due to prolonging patient death is not an uncommon feeling or theme for a critical care nurse. It is important for nurses to feel like they are advocating for patients in the same way that it is important for surgeons to discuss their duty to the patient and how those goals may change throughout a patient’s hospital stay. I would recommend this article to colleagues as understanding the depth to which surgeons feel duty to a patient brings a greater respect for lifesaving measures in dire patient situations.