The role of the intensive care nurse in the medical emergency team : a constructivist grounded theory study

Intensive care nurses are essential members of rapid response systems (RRS), but few qualitative data are available to capture what Intensive Care nurses do as they navigate the complexity of a medical emergency call. The introduction of rapid response systems has reduced the incidence of in-hospital adverse events such as deterioration in the cardiorespiratory system and unplanned admissions to the Intensive Care Unit. Medical emergency teams (MET) are part of the RRS, and play an important role in the provision of timely care to the deteriorating patient. The composition of METs varies internationally, but in the Australian setting, the majority of are comprised of clinicians with critical care knowledge and skills. Using constructivist grounded theory, this study developed a substantive theory to describe and explain the role of the Intensive Care nurse within the MET of a tertiary hospital. A qualitative research approach used a two-phase constructivist grounded theory design to collect data from Intensive Care nurses who had experience attending medical emergency team calls. Data were collected through participant observation, followed by semi-structured interviews, to develop an in-depth understanding of the Intensive Care nurse's role, the way it is enacted, and their responsibilities within the team. In phase one, eight hours of observation of experienced Intensive Care nurses attending medical emergency team calls captured the context of the research setting, providing a framework for data collection in the next phase. In phase two, 12 interviews were conducted with Intensive Care nurses, 10 of whom had been observed during the first phase. These in-depth interviews facilitated a deeper exploration of participant experiences during a MET call. This study found that the substantive theory of 'keeping patients safe' is a fundamental role of the Intensive Care nurse within the MET. Intensive care nurses maintain a close physical presence with the patient, and seek to understand their needs, providing explanations and reassurance, advocating for them, and protecting them from harm. Intensive care nurses utilised a routine framework for decision-making that is underpinned by highly developed assessment skills, deep knowledge of emergency algorithms and protocols for treating cardiorespiratory changes, and a theoretical understanding of the physiology of the deteriorating patient. This informed their clinical practice and enabled them to work in an organised and systematic way with a reliance on technical skills to assess and monitor the patient. In addition to this, the Intensive Care nurse utilised critical thinking skills to 'figure out' what is happening during a MET call and to make sense of the situation. Intensive care nurses were found to draw on a range of critical decision-making skills to inform their practice, which included being able to anticipate care, problem solve and question care. This enabled the Intensive Care nurse to work in an organised, systematic manner, often under pressure in a busy, dynamic environment to deliver care in a timely way. Intensive care nurses assumed a nursing leadership role within the MET, which was identifiable in, and characterised by, assertiveness, competence and confidence. They would direct care by delegating tasks, co-coordinating and prioritising care, and keeping everyone on track. Intensive care nurses had a clear understanding of their role, which was not always reflected in other team members. Intensive care nurses maintained a close working relationship with ward nurses during a MET call. There was a mutual reliance on each other's skill set as they worked collaboratively to promote and deliver a high standard of care. The Intensive Care nurse acted as a resource for ward nurses, providing support, education, and reassurance. This thesis describes the roles and responsibilities of Intensive Care nurses functioning effectively as part of the medical emergency team. It provides new insights and an in depth understanding of the ways Intensive Care nurses work within the team, and makes a significant contribution to our existing understanding of the role. These findings have relevance for health care organisations, providers of health professional education, and for individuals working in the role.