ACCCN’S CRITICAL
CARE NURSING
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ACCCN’S CRITICAL
CARE NURSING
SECOND EDITION
Doug Elliott Leanne Aitken Wendy Chaboyer
RN, PhD BAppSc(Nurs), RN, PhD, BHSc(Nurs)Hons, RN, PhD, MN, BSc(Nurs)Hons,
MAppSc(Nurs), ICCert GradCertMgt, CritCareCert
Professor of Nursing GradDipScMed(ClinEpi), ICCert, Professor & Director, NHMRC Centre
Faculty of Nursing, Midwifery FRCNA of Research Excellence in Nursing
and Health Professor of Critical Care Nursing Interventions for Hospitalised Patients
University of Technology Griffith University & Princess Griffith Health Institute
Sydney, New South Wales Alexandra Hospital Griffith University
Brisbane, Queensland Gold Coast, Queensland
Sydney Edinburgh London New York Philadelphia St Louis Toronto
Mosby
is an imprint of Elsevier
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
© 2012 Elsevier Australia
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National Library of Australia Cataloguing-in-Publication Data
Title: ACCCN’s critical care nursing / [editors] Doug Elliott, Leanne Aitken and Wendy
Chaboyer.
Edition: 2nd ed.
ISBN: 9780729540681 (pbk.)
Notes: Includes index.
Subjects: Intensive care nursing–Australia.
Other Authors/Contributors: Elliott, Doug. Aitken, Leanne. Chaboyer, Wendy.
Australian College of Critical Care Nurses.
Dewey Number: 616.028
Publisher: Libby Houston
Developmental Editor: Elizabeth Coady
Publishing Services Manager: Helena Klijn
Editorial Coordinator: Geraldine Minto
Edited by Melissa Read
Proofread by Tim Learner
Indexed by Cynthia Swanson
Cover design by Lamond Art & Design
Typeset by Toppan Best-set Premedia Limited
Printed by China Translating & Printing Services Ltd.
Contents
Foreword vi 12 Cardiac Surgery and Transplantation 291
Preface vii Judy Currey, Michael Graan
About the Australian College of Critical Care Nurses 13 Respiratory Assessment and Monitoring 325
(ACCCN) ix Amanda Corley, Mona Ringdal
About the Editors x
Contributors xi 14 Respiratory Alterations and Management 352
Reviewers xiii Maria Murphy, Sharon Wetzig, Judy Currey
Acknowledgements xiv 15 Ventilation and Oxygenation Management 381
Detailed Contents xv Louise Rose, Gabrielle Hanlon
Abbreviations xviii 16 Neurological Assessment and Monitoring 414
Di Chamberlain, Leila Kuzmiuk
17 Neurological Alterations and Management 445
Section 1 Scope of Critical Care 1
Di Chamberlain, Wendy Corkill
1 Scope of Critical Care Practice 3 18 Support of Renal Function 479
Leanne Aitken, Wendy Chaboyer, Doug Elliott Ian Baldwin, Gavin Leslie
2 Resourcing Critical Care 17 19 Gastrointestinal, Liver and Nutritional
Denise Harris, Ged Williams Alterations 506
3 Quality and Safety 38 Andrea Marshall, Teresa Williams,
Wendy Chaboyer, Karena Hewson-Conroy Christopher Gordon
4 Recovery and Rehabilitation 57 20 Management of Shock 539
Doug Elliott, Janice Rattray Margherita Murgo, Gavin Leslie
5 Ethical Issues in Critical Care 78 21 Multiple Organ Dysfunction Syndrome 562
Amanda Rischbieth, Julie Benbenishty Melanie Greenwood, Alison Juers
Section 3 Specialty Practice in
Section 2 Principles and Practice of Critical Care 579
Critical Care 103 22 Emergency Presentations 581
6 Essential Nursing Care of the Critically David Johnson, Mark Wilson
Ill Patient 105 23 Trauma Management 623
Bernadette Grealy, Wendy Chaboyer Louise Niggemeyer, Paul Thurman
7 Psychological Care 133 24 Resuscitation 654
Leanne Aitken, Rosalind Elliott Trudy Dwyer, Jennifer Dennett
8 Family and Cultural Care of the Critically 25 Paediatric Considerations in Critical Care 679
Ill Patient 156 Tina Kendrick, Anne-Sylvie Ramelet
Marion Mitchell, Denise Wilson, Vicki Wade 26 Pregnancy and Postpartum Considerations 710
9 Cardiovascular Assessment and Monitoring 180 Wendy Pollock, Clare Fitzpatrick
Thomas Buckley, Frances Lin 27 Organ Donation and Transplantation 746
10 Cardiovascular Alterations and Management 215 Debbie Austen, Elizabeth Skewes
Robyn Gallagher, Andrea Driscoll Appendices 763
11 Cardiac Rhythm Assessment and Glossary 783
Management 251 Picture Credits 790
Malcolm Dennis, David Glanville Index 793 v
Foreword
As a specialty area of nursing practice, critical care nursing nursing knowledge and skills to provide care to acutely
is focused on the care of patients who are experiencing ill patients and their families.
life-threatening illness. Globally, critical care nurses Internationally, there are more than 500,000 critical care
provide care to ensure that critically ill patients and their nurses, representing one of the largest specialty areas of
families receive optimal care. This second edition of the nursing practice. The importance of maintaining knowl-
Australian College of Critical Care Nurses (ACCCN’s) edge of best practices, utilising evidence-based approaches,
Critical Care Nursing is a valuable resource for critical care and applying research to clinical practice for critical
nursing practice. The editors, who are acknowledged care patients remain essential components of critical
expert practitioners, educators, and researchers in critical care nursing. This second edition of ACCCN’s Critical Care
care, have organised the book into topics covering the Nursing is a comprehensive resource for critical care
scope of critical care, principles and practice of critical nurses seeking to further develop their knowledge and
care, and specialty practice in critical care. The content enhance their clinical practice expertise.
covered in this book, written by established experts in the
field of critical care, provides a comprehensive overview
of critical care nursing concepts and practices. The Ruth Kleinpell PhD, RN, FAAN, FCCM
book provides up-to-date information on evidence-based Director, Center for Clinical Research and Scholarship
practices and the chapters incorporate a variety of educa- Rush University Medical Center;
tional resources including website links, case studies and Professor, Rush University College of Nursing;
practice tips. Nurse Practitioner, Mercy Hospital & Medical Center
Chicago, Illinois, USA
ACCCN’s Critical Care Nursing is a beneficial resource for
critical care nurses, regardless of practice setting. In
seeking to provide complex high intensity care, therapies President of the World Federation of
and interventions, critical care nurses will find that the Critical Care Nurses
book reviews essential content related to critical care http://www.wfccn.org
vi
Preface
Critical care as a clinical specialty is over half a century have been included in each chapter to facilitate this
old. With every successive decade, advances in the educa- process.
tion and practices of critical care nurses have been made.
Today, critical care nurses are some of the most knowl- This second edition is again organised in three broad
edgeable and highly skilled nurses in the world, and sections: the scope of critical care nursing, core com-
ongoing professional development and education are ponents of critical care nursing, and specialty aspects
fundamental elements in ensuring we deliver the highest of critical care nursing. Inclusion of new chapters and
quality care to our patients and their families. significant revisions to existing chapters were based on
our reflections and suggestions from colleagues and
This book is intended to encourage and challenge nurses reviewers as well as on evolving and emerging practices
to further develop their critical care nursing practice. Our in critical care.
vision for the first edition was for an original text from
Australasian authors, not an adaptation of texts produced Section 1 introduces a broad range of professional issues
in other parts of the world. This writing approach more related to practice that are relevant across critical care.
accurately captures the uniquely local elements that form Initial chapters provide contemporary information on
contemporary critical care nursing in Australia and New the scope of practice, systems and resources, quality and
Zealand and help to answer the myriad of questions safety, recovery and rehabilitation, and ethical issues.
posed by critical care nurses as they practise in the local
environment, while still allowing the universal core ele- Content presented in the second section is relevant to the
ments that represent critical care practice internationally. majority of critical care nurses, with a focus on concepts
This second edition of ACCCN’s Critical Care Nursing has that underpin practice such as essential physical, psycho-
27 chapters that reflect the collective talent and expertise logical, social and cultural care. Remaining chapters in
of 50 contributors – a strong mix of academics and clini- this section present a systems approach in supporting
cians with a passion for critical care nursing – in showcas- physiological function for a critically ill individual. This
ing the practice of critical care nursing in Australia, New edition now has multiple linked chapters for some of the
Zealand, Asia and the Pacific. We also engaged contribu- major physiological systems – 4 chapters for cardiovas-
tors beyond Australasia to reflect global practices and to cular, 3 for respiratory, and 2 for neurological. Chapters
extend the applicability of our text to a wider geographic on support of renal function, gastrointestinal, liver and
audience. All contributors were carefully chosen for their nutritional alterations, management of shock, and multi-
current knowledge, clinical expertise and strong profes- organ dysfunction complete this section.
sional reputations.
The third section presents specific clinical conditions
The book has been developed primarily for use by prac- such as emergency presentations, trauma, resuscitation,
tising critical care clinicians, managers, researchers and paediatric considerations, pregnancy and post-partum
graduate students undertaking a specialty critical care considerations, and organ donation, by building on the
qualification. In addition, senior undergraduate students principles outlined in Section 2. This section enables
studying high acuity nursing subjects will find this book readers to explore some of the more complex or unique
a valuable reference tool, although it goes beyond the aspects of specialty critical care nursing practice.
learning needs of these students. The aim of the book
is to be a comprehensive resource, as well as a portal Chapters have been organised in a consistent format to
to an array of other important resources, for critical ease identification of relevant material. Where appropri-
care nurses. The nature and timeline of book publishing ate, each chapter commences with an overview of relevant
dictates that the information contained in this book anatomy and physiology, and the epidemiology of the
reflects a snapshot in time of our knowledge and under- clinical states in the Australian and New Zealand setting.
standing of the complex world of critical care nursing. Nursing care of the patient, both delivered independently
We therefore encourage our readers to continue to also or provided collaboratively with other members of the
search for the most contemporary sources of knowledge healthcare team, is then presented. Pedagogical features
to guide their clinical practice. A range of website links include a case study that elaborates relevant care issues, vii
viii P R E FA C E
a critique of a research publication that explores a related The delivery of effective, high-quality critical care nursing
topic, and learning activities to assist both the reader and practice is a challenge in contemporary health care.
those in educational roles to assess knowledge acquisi- We trust that this book will be a valuable resource in
tion. Extensive use of tables, figures and practice tips are supporting your care of critically ill patients and their
located throughout each chapter to identify areas of care loved ones.
that are particularly pertinent for readers. It is not our
intention that readers progress sequentially through the Doug Elliott
book, but rather explore chapters or sections that are Leanne Aitken
relevant for different episodes of learning or practice. Wendy Chaboyer
About the Australian College of
Critical Care Nurses (ACCCN)
The Australian College of Critical Care Nurses, with over committees. The panel has also developed position
2400 members, is the peak professional organisation statements on nurse staffing for intensive care and
representing critical care nurses in Australia. Member- high-dependency units in Australia, and annually
ship types include standard membership, international reviews the dataset design for national workforce data
members, life members, honorary members and corpo- collection in conjunction with ANZICS;
rate members. All individual members are eligible and Organ & Tissue Donation & Transplantation Advi-
are encouraged to participate in the activities of the sory Panel: advises the board and developed a posi-
College; to receive the College journal and Critical Times tion statement on organ donation and transplantation
publication, in addition to discounts for ACCCN confer- as it relates to intensive care. It disseminates related
ence registration and for ACCCN publications. Life and information to critical care nurses regarding the pro-
honorary memberships are awarded to individuals in motion and national reform objectives of organ and
recognition of their outstanding contribution to ACCCN tissue donation in Australia;
and/or to critical care nursing excellence in Australia. Quality Advisory Panel: provides expert knowledge,
advice and information to ACCCN on matters rele-
ACCCN is a company limited by guarantee and has
branches in each state of Australia, with two members vant to critical care nursing practice relating specifi-
from each state branch management committee forming cally to patient management;
the ACCCN National Board of Directors. Each committee Paediatric Advisory Panel: provides expert knowl-
facilitates the activities of the college at a local/state level edge, advice and information to ACCCN on matters
and provides local and at times national representation. relevant to paediatric critical care nursing in addition
The ACCCN Editorial Committee and Editorial Board, to recommending content and speakers for the annual
under the leadership of the editor of the Australian Critical ACCCN conferences;
Care (ACC) journal, are responsible for the College pub- The ICU Liaison Special Interest Group: is a collec-
lications including the journal Australian Critical Care and tive group of ACCCN members who have an interest
newspaper Critical Times. in ICU liaison/outreach and work together to discuss
matters relevant to this increasing area of critical care
There are a number of national advisory panels and nursing focus.
special interest groups dedicated to providing the organi- In addition to branch educational events and sympo-
sation with expert opinion on issues relating to critical siums, ACCCN conducts three national conferences each
care nursing. These include:
year: ACCCN Institute of Continuing Education (ICE);
Resuscitation Advisory Panel: consists of eight and, in conjunction with our medical colleagues from
members representing each branch of ACCCN, plus a The Australian and New Zealand Intensive Care Society
paediatric nurse representative. It has developed a (ANZICS), the ANZICS/ACCCN Annual Scientific Meeting
complete suite of contemporary advanced life support on Intensive Care and the Australian and New Zealand
and resuscitation educational material and offers its Paediatric & Neonatal Intensive Care Conference.
ACCCN National ALS Courses throughout Australia;
Research Advisory Panel: in addition to providing ACCCN has a representative on the Australian Resuscita-
expert advice to ACCCN, the panel is responsible for tion Council (ARC), and has representation at a federal
evaluating and making recommendations on research government advisory level through the Nursing and Mid-
strategy and grant submissions to ACCCN, and for wifery Stakeholder Reference Group (NMSRG) chaired by
evaluating abstracts submitted to the ANZICS/ACCCN the Chief Nurse of Australia, and is also a member of the
Annual Scientific Meeting on Intensive Care; Coalition of National Nursing Organisations (CoNNO).
Education Advisory Panel: advises ACCCN on all The founding Chairperson of the World Federation of
matters relating to education specific to critical care Critical Care Nurses (WFCCN) continues to represent
nursing. This panel has developed a position paper on ACCCN on the WFCCN Council, and the College also
critical care nursing education and written submis- has representatives on the World Federation of Paediatric
sions on behalf of ACCCN to national reviews of Intensive and Critical Care Societies, and is a member of
nursing education; the Intensive Care Foundation.
Workforce Advisory Panel: has represented ACCCN More information can be found on the ACCCN website:
on a number of national health workforce and nursing www.acccn.com.au
ix
About the Editors
Doug Elliott decision-making practices of critical care nurses and a
Doug Elliott is Professor of Nursing in the Faculty of range of clinical practice issues within critical care and
Nursing, Midwifery and Health at the University of Tech- trauma.
nology, Sydney. During his 25 years as a nurse academic,
Doug has been a faculty Director of Research, Clinical Leanne has been active in ACCCN for more than 20 years
Professor, Head of Department and a conjoint hospital and was made a Life Member of the College in 2006 after
appointment as Assistant Director of Nursing – Research. having held positions on state and national boards, coor-
Prior to this, he worked as a clinician in acute and critical dinated the Advanced Life Support course in Western
care areas in tertiary hospitals in Sydney and Perth. Australia in its early years, chaired the Education Advisory
Panel and been an Associate Editor with Australian Critical
Doug’s clinical and health services research focuses on Care. In addition, she is a peer reviewer for a number of
the health-related quality of life (HRQOL) and illness national and international journals and reviews grant
experiences of individuals with critical and acute ill- applications for a range of organisations including the
nesses, and the use of technologies to improve patient National Health and Medical Research Council (NHMRC)
outcomes. Doug has received research funding from the and Intensive Care Foundation. She is the World Federa-
NHMRC and the Australian Commission on Safety and tion of Critical Care Nurses’ representative on a number
Quality in Health Care, as well as competitive funding of sepsis related working groups including an interna-
from other national organisations, health service and uni- tional group who authored a companion paper to the
versity funding sources. He has published over 80 peer- Surviving Sepsis Campaign guidelines to summarise the
reviewed articles and book chapters, and is co-editor for evidence underpinning nursing care of the septic patient,
two additional books, on nursing and midwifery research, the revision of the Surviving Sepsis Campaign Guidelines
and pathophysiology and nursing practice. and the Global Sepsis Alliance.
Doug became a Life Member of the Australian College of Wendy Chaboyer
Critical Care Nurses in 2006 in recognition of over 20 Wendy Chaboyer is a Professor of Nursing at Griffith
years of service to critical care. He has previously been an University and the Director of the Centre of Research
Associate Editor and on the Editorial Board for Australian Excellence in Nursing Interventions for Hospitalised
Critical Care, was the inaugural Chair of the Research Patients, funded by the National Health and Medical
Advisory Panel, a member of the Education Advisory Research Council (NHMRC) (2010–2015). Wendy has 30
Panel, and also served on the NSW committee. He is cur- years experience in the critical care area, as a clinician,
rently on the Editorial Board for the American Journal of educator and researcher and she is passionate about the
Critical Care, and peer-reviews for several critical care contribution nurses can make to a patient’s, and their
medicine and nursing journals, and a range of competi- family’s, hospital experience. Her research has focused on
tive funding bodies. Doug has been an invited speaker to ICU patients’ transitions and on continuity of care for
international and national multi-disciplinary critical care ICU patients. More recently, she has focused on patient
meetings on numerous occasions. safety, undertaking research into adverse events after ICU,
clinical handover and ‘transforming care at the bedside’.
Leanne Aitken
Leanne Aitken is Professor of Critical Care Nursing at Wendy has been active in ACCCN since her arrival in
Griffith University and Princess Alexandra Hospital, Australia in the early 1990s. She has been a National
Queensland. She has a long career in critical care nursing, Board member and member of the Queensland Branch
including practice, education and research roles. In all Management Committee. Wendy is a past Chair of the
her roles in nursing, Leanne has been inspired by a sense Research Advisory Panel and past Chair of the Quality
of enquiry, pride in the value of expert nursing and a Advisory Panel of the ACCCN. Wendy played a role in
belief that improvement in practice and resultant patient the formation of the World Federation of Critical Care
outcomes is always possible. Research interests include Nurses and continues to support their activities. Wendy
developing and refining interventions to improve long reviews for a number of journals and funding bodies such
x term recovery of critically ill and injured patients, as the NHMRC and the Australian Research Council.
Contributors
Leanne Aitken RN, PhD, BHSc(Nurs)Hons, Amanda Corley BN, ICU Cert, GradCert Clare Fitzpatrick
GradCertMgt, GradDipScMed(ClinEpi), HealthSci, M AdvPrac (candidate) Registered Nurse, Registered Midwife
ICCert, FRCNA Nurse Researcher BA (Hons)
Professor of Critical Care Nursing Critical Care Research Group, The Prince Lead for Critical Care
Griffith University & Princess Charles Hospital Liverpool Women’s NHS Foundation Trust
Alexandra Hospital Queensland Liverpool, United Kingdom
Brisbane, Queensland
Judy Currey RN, BN, BN(Hons) Crit Care Robyn Gallagher RN, BA (Psych), MN, PhD
Debbie Austen RN, BaHSc, Grad Cert Cert, Grad Cert Higher Ed, Grad Cert Sc Associate Professor Chronic and
Critical Care, Grad Cert Management, (App Stats), PhD Complex Care
JP (Qual) Associate Professor in Nursing Faculty of Nursing, Midwifery and Health
Registered Nurse, Capricorn Coast Hospital Deakin University University of Technology, Sydney
and Health Service Victoria New South Wales
Queensland
Jennifer Dennett RN, MN, BAppSc David Glanville RN, BN, Grad Dip Crit Care
Ian Baldwin RN, PhD (Nursing), CritCareCert, Dip Management, Nursing, MN
Post Graduate Educator MRCNA Nurse Educator
Intensive Care Unit, Austin Health Nurse Unit Manager Intensive Care Unit
Victoria Critical Care, Oncology, Cardiology, Renal Epworth Freemasons Hospital
Dialysis, Central Gippsland Health Service East Melbourne, Victoria
Julie Benbenishty MNS Victoria
Academic Consultant Surgical Division Christopher Gordon RN, MExSc, PhD
Hadassah Hebrew University Medical Center Malcolm Dennis RN, BEd, CritCareCert(ICU) Senior Lecturer
Jerusalem, Israel Bed Field Technical Specialist Director of Postgraduate Advanced Studies
Cardiac Rhythm Management Division, Sydney Nursing School, The University
Tom Buckley RN(UK), PhD MNRes, BScHlth St Jude Medical of Sydney
CertICU, CertTeaching&Assessing New South Wales New South Wales
Senior Lecturer and Co-ordinator Master
of Nursing (Clinical Nursing & Nurse Andrea Driscoll RN, CCC, BN, MN, MEd, PhD Michael Graan RN, GradDip CritCare
Practitioner) Senior Research Fellow Clinical Nurse Educator (ICU)
Sydney Nursing School, The University Monash University, Melbourne Epworth HealthCare
of Sydney Victoria Richmond, Victoria
New South Wales
Trudy Dwyer RN, ICU Cert, BHlth, GCert Bernadette Grealy RN, RM, CritCareCert,
Wendy Chaboyer RN, BSc (Nu) Hon, FlexLrn, MClinEd, PhD BN, MN
MN, PhD Associate Professor Clinical Services Coordinator Intensive
Director School of Nursing and Midwifery, Faculty of Care Unit
NHMRC Centre of Research Excellence in Sciences, Engineering & Health Queen Elizabeth Hospital
Nursing Interventions for Hospitalised Central Queensland University South Australia
Patients (NCREN), Research Centre for Queensland
Clinical and Community Practice Innovation Melanie Greenwood MN, Grad Cert.
(RCCCPI) Doug Elliott RN, PhD, BAppSc(Nurs), UniTeach&Learn, ICCert, NeurosciCert
Griffith Health Institute MAppSc(Nurs), ICCert Senior Lecturer,
Queensland Professor of Nursing School of Nursing and Midwifery
Faculty of Nursing, Midwifery and Health University of Tasmania
Diane Chamberlain RN, BN, BSc MNSc University of Technology Tasmania
(Critical Care), MPH, PhD Sydney, New South Wales
Senior Lecturer Gabrielle Hanlon RN, Crit Care Cert, BN,
Flinders University Rosalind Elliott RN, BSc (Hons), PG Dip GDBL, MRCNA
South Australia (Crit Care), MN Project Manager
PhD candidate Australian Commission on Safety & Quality
Wendy Corkill RN University of Technology Sydney in Health Care
Clinical Nurse Specialist New South Wales New South Wales
Alice Springs Hospital xi
Northern Territory
xii C O N T R I B U T O R S
Denise Harris RN, BHSc(Nurs), Marion Mitchell RN, BN (Hon), Grad Cert Louise Rose BN, MN, PhD, ICU Cert
GradDipHlthAdmin& InfoSys, (Higher Educ), PhD. Assistant Professor
MN(Res), ICCert Senior Research Fellow Critical Care Lawrence S. Bloomberg Faculty of Nursing,
Assistant Director of Nursing—Medicine & Griffith University and Princess University of Toronto
Critical Care Alexandra Hospital Research Director and Advanced Practice
The Tweed Hospital Queensland Nurse, Prolonged-ventilation Weaning
Tweed Heads, New South Wales Centre, Toronto East General Hospital,
Margherita Murgo BN, MN (Crit Care) Toronto
Karena Hewson-Conroy BSocSci(Hons), Project Officer Ontario, Canada
PhD candidate Clinical Excellence Commission
Research & Quality Manager, Intensive Care New South Wales Elizabeth Skewes DAppSc(Nursing), CCRN
Co-ordination & Monitoring Unit Senior Nurse of Organ and Tissue Donation
Honorary Associate, Faculty of Nursing, Maria Murphy RN PhD, Grad Dip Crit Care, St Vincent’s Hospital
Midwifery & Health, University of Grad Cert Tert Ed, BN, Dip App Sci (Nursing) Victoria
Technology, Sydney Lecturer
New South Wales LaTrobe University Paul Thurman RN, MS, ACNPC, CCNS,
Clinical Nurse Specialist CCRN, CNRN
David Johnson RN, Grad Dip (Acute Care Austin Health Clinical Nurse Specialist
Nurs), MHealth Sci Ed, A&E Cert, MCN Victoria R Adams Cowley Shock Trauma Center
Director of Nursing University of Maryland Medical Center
Caloundra Health Service Louise E Niggemeyer RN, MEd, BEdSt, Baltimore, Maryland, USA
Sunshine Coast Wide Bay Health IC Cert, MRCNA
Service District Trauma Program Manager Vicki Wade Dip Nsg, BHSc, MN
Queensland The Alfred Hospital Leader
Senior Researcher National Aboriginal Health Unit
Alison Juers RN, BN (Dist), MN (Crit Care) Trauma Systems & Education Consultant Heart Foundation Australia
Nurse Educator National Trauma Research Institute
Brisbane Private Hospital Alfred Health Sharon Wetzig RN, BN, Grad Cert
Queensland Victoria (Critical Care), MEd
Clinical Nurse Consultant
Tina Kendrick RN, PIC Cert, BNurs(Hons), Wendy Pollock RN, RM, Grad Dip Crit Princess Alexandra Hospital
MNurs, FCN, FRCNA Care Nsg, Grad Dip Ed, Grad Cert Adv Queensland
Clinical Nurse Consultant – Paediatrics Learn & Leadership,
NSW Newborn and Paediatric Emergency PhD Research Fellow Ged Williams RN, RM, CritCareCert, MHA,
Transport Service La Trobe University/Mercy Hospital LLM, FACHSM, FRCNA, FAAN
New South Wales for Women Executive Director of Nursing and Midwifery
Victoria Gold Coast Health Service District
Leila Kuzmuik RN, BN, DipAdvClinNurs, MN, Professor of Nursing, Griffith University
Grad Cert HlthServMgt Anne-Sylvie Ramelet RN, ICU Cert, PhD Founding President, World Federation of
Nurse Educator Senior Lecturer Critical Care Nurses
Intensive Care Services Institute of Higher Education and Queensland
John Hunter Hospital, Hunter New Nursing Research
England Health Lausanne University-Centre Hospitalier Teresa Williams RN, ICUCert, BN, MHlthSci
New South Wales Universitaire Vaudois, Switzerland (Res), GradDipClinEpi, PhD
Professor, HECVSanté Research Assistant Professor and NH MRC
Gavin D Leslie RN, IC Cert, PhD, BAppSc, University of Applied Sciences Clinical Research Postdoctoral Fellow
Post Grad Dip (Clin Nurs), FRCNA Western Switzerland Discipline of Emergency Medicine (SPARHC)
Professor Critical Care Nursing Switzerland The University of Western Australia
Royal Perth Hospital Western Australia
Director Research & Development Janice Rattray PhD, MN, DipN (CT),
School of Nursing & Midwifery, RGN, SCM Denise Wilson PhD, RN, FCNA(NZ)
Curtin University Reader Associate Professor Māori Health
Western Australia School of Nursing and Midwifery Auckland University of Technology
University of Dundee Auckland, New Zealand
Frances Lin RN, BMN, MN (Hons), PhD United Kingdom
Lecturer & Program Convenor (Master of Mark Wilson DipAppSc (Nursing),
Nursing – Critical Care) Mona Ringdal RN, PhD, MSc GDipClPrac (Emergency Nursing), MHScEd
School of Nursing and Midwifery Senior Lecturer Emergency Department Nurse Educator
Griffith University Institute of Health and Care Sciences Illawarra Shoalhaven Local Health District
Queensland The Sahlgrenska Academy, University New South Wales
of Gothenburg
Andrea Marshall RN PhD Sweden
Sesqui Senior Lecturer Critical Care Nursing
Sydney Nursing School Amanda Rischbieth RN, Grad Dip (Intens
University of Sydney Care), MNSc, PhD
New South Wales School of Nursing University of Adelaide
South Australia
Reviewers
Steven Frost RN, MPH Holly Northam RN, RM, MCritCareNsg M Critical Care Nursing
Lecturer, School of Nursing and Midwifery Assistant Professor of Critical Care Nursing
University of Western Sydney University of Canberra
New South Wales Australian Capital Territory
Melanie Greenwood MN, Grad Cert UniTeach&Learn, Jon Mould PhD candidate, MSc, RGN, RSCN, RMN, Adult Cert Ed
ICCert, NeurosciCert Senior Lecturer
Senior Lecturer Edith Cowan University
School of Nursing and Midwifery Western Australia
University of Tasmania
Tasmania Helena Sanderson RN, BHSc, ICU Cert, MN(Advanced
Clinical Education)
Nichole Harvey RN, EM, CritCareCert, BN (Post Reg), MNSt, Lecturer in Nursing
GradCertEd (TT), PhD Candidate School of Health
Senior Lecturer University of New England
School of Medicine and Dentistry Armidale, New South Wales
James Cook University
Queensland Natashia Scully RN, BA, BN, PGDipNSc(Critical Care),
MPH(Candidate)
Ann Kuypers RN, Med Grad Dip(Clin Ed), Grad Cert (Periop) Lecturer in Nursing
Lecturer Nursing School of Health
Academic Language and Learning Unit University of New England
LaTrobe University, Albury Wodonga Campus Armidale, New South Wales
Victoria
Kerry Southerland RN, ICCert, BSc, MCN, GCTT, MRCNA
Renee McGill MN, Grad Cert Crit Care, BS(Nurs) Lecturer
Lecturer in Nursing, Academic Advisor School of Nursing & Midwifery
School of Nursing, Midwifery and Indigenous Health Curtin University
Charles Sturt University Western Australia
New South Wales
Peter Thomas RN, BSc, GradDipEd, PhD
Stephen McNally RN, BApp Sc (Nursing), PhD Lecturer
Lecturer, Head of Program School of Nursing, Midwifery & Indigenous Health
University of Western Sydney University of Wollongong
New South Wales New South Wales
xiii
Acknowledgements
A project of this nature and scope requires many talented the staff at Elsevier Australia, our publishing partner.
and committed people to see it to completion. The deci- Thanks to our Publisher, Libby Houston, for guiding this
sion to publish this second edition was supported enthu- major project; our Developmental Editors – initially
siastically by the Board of the Australian College of Larissa Norrie, and then Elizabeth Coady for the majority
Critical Care Nurses (ACCCN) and Elsevier Australia. To of the project; and to Melissa Read our editor. In Publish-
our chapter contributors for this edition, both those ing Services, Geraldine Minto, thanks for your work with
returning from the first edition and our new collabora- typesetting issues. To others who produced the high
tors – thank you for accepting our offer to write, for quality figures, developed and executed the marketing
having the courage and confidence in yourselves and us plan, and the myriad other activities, without which a
to be involved in the text, and for being committed in text such as this would never come to fruition, thank you.
meeting writing deadlines while developing the depth We acknowledge our external reviewers who devoted
and quality of content that we had planned. We also their time to provide insightful suggestions in improving
acknowledge the work of chapter contributors from the text and contributed to the quality of the finished
our first edition – Harriet Adamson, Susan Bailey, product.
Martin Boyle, Sidney Cuthbertson, Suzana Dimovski, Finally, and most importantly, to our respective loved
Bruce Dowd, Ruth Endacott, Paul Fulbrook, ones – Maureen, Kate, Nick and Josh; Steve; and Michael
Michelle Kelly, Bridie Kent, Anne Morrison, Wendy – thanks for your belief in us, and your understanding
Swope and Jane Treloggen.
and commitment in supporting our careers.
Continued encouragement and support from the Board
and members of ACCCN, for having the belief in us as Doug Elliott
editors and authors to uphold the values of the College, Leanne Aitken
is much appreciated. We also acknowledge support from Wendy Chaboyer
xiv
Detailed Contents
Section 1 Scope of Critical Care 1 Section 2 Principles and Practice of
Critical Care 103
1 Scope of Critical Care Practice 3
Development of critical care nursing 3 6 Essential Nursing Care of the Critically Ill
Roles of critical care nurses 6 Patient 105
Clinical decision making 6 Personal hygiene 105
Leadership in critical care nursing 7 Eye care 107
Developing a body of knowledge 11 Oral hygiene 109
Summary 12 Patient positioning and mobilisation 110
Bowel management 115
2 Resourcing Critical Care 17 Urinary catheter care 116
Ethical allocation and utilisation of Bariatric considerations 117
resources 17
Historical influences 18 Infection control in the critical care unit: 118
general principles
Economic considerations and principles 19 Transport of critically Ill patients: general
Budget 20 principles 123
Critical care environment 22 Summary 125
Equipment 22
Staff 23 7 Psychological Care 133
Risk management 28 Anxiety 133
Measures of nursing workload or activity 30 Delirium 136
Management of pandemics 33 Sedation 138
Summary 34 Pain 141
Sleep 145
3 Quality and Safety 38 Summary 149
Quality and safety monitoring 42 8 Family and Cultural Care of the Critically Ill
Patient safety 49 Patient 156
Summary 52 Overview of models of care 157
Cultural care 161
4 Recovery and Rehabilitation 57 Religious considerations 170
ICU-acquired weakness 58 End-of-life issues and bereavement 172
Patient outcomes following a critical illness 59 Summary 173
Psychological recovery 61
Rehabilitation and mobility in ICU 66 9 Cardiovascular Assessment and Monitoring 180
Ward-based post-ICU recovery 68 Related anatomy and physiology 180
Recovery after hospital discharge 68 Assessment 190
Summary 72 Haemodynamic monitoring 195
Diagnostics 206
5 Ethical Issues in Critical Care 78 Summary 210
Principles, rights and the link with law 78 10 Cardiovascular Alterations and Management 215
End-of-life decision making 83 Coronary heart disease 215
Brain death 88 Heart failure 227
Organ donation 89 Selected cases:
Ethics in research 91 Cardiomyopathy 241
Summary 96 Hypertensive emergencies 242 xv
xvi D E TA I L E D C O N T E N T S
Infective endocarditis 243 17 Neurological Alterations and Management 445
Aortic aneurysm 244 Concepts of neurological dysfunction 445
Ventricular aneurysm 245 Neurological therapeutic management 449
Summary 245 Central nervous system disorders 455
11 Cardiac Rhythm Assessment and Selected neurological cases 470
Management 251 Summary 472
The cardiac conduction system 251 18 Support of Renal Function 479
Arrhythmias and arrhythmia management 252 Related anatomy and physiology 480
Cardiac pacing 265 Pathophysiology and classification of renal
Cardioversion 280 failure 483
Ablation 285 Acute renal failure: clinical and diagnostic
Summary 285 criteria for classification and management 486
12 Cardiac Surgery and Transplantation 291 Renal dialysis 488
Cardiac surgery 291 Approaches to renal replacement therapy 491
Intra-aortic balloon pumping 302 Summary 501
Heart transplantation 308 19 Gastrointestinal, Liver and Nutritional
Summary 319 Alterations 506
13 Respiratory Assessment and Gastrointestinal physiology 506
Monitoring 325 Nutrition 508
Related anatomy and physiology 325 Nutrition support 509
Pathophysiology 333 Stress-related mucosal disease 513
Assessment 335 Liver dysfunction 516
Respiratory monitoring 338 Liver transplantation 522
Bedside and laboratory investigations 341 Glycaemic control in critical illness 525
Diagnostic procedures 344 Incidence of diabetes in Australasia 526
Summary 347 Summary 528
20 Management of Shock 539
14 Respiratory Alterations and Management 352 Pathophysiology 539
Incidence of respiratory alterations 352 Patient assessment 541
Respiratory failure 353 Hypovolaemic shock 542
Pneumonia 357 Cardiogenic shock 545
Respiratory pandemics 360 Distributive shock states 551
Acute lung injury 362 Anaphylaxis 554
Asthma and chronic obstructive pulmonary Neurogenic/spinal shock 556
disease 364
Pneumothorax 366 Summary 557
Pulmonary embolism 367 21 Multiple Organ Dysfunction Syndrome 562
Lung transplantation 369 Pathophysiology 563
Summary 374 Systemic response 564
15 Ventilation and Oxygenation Management 381 Organ dysfunction 567
Multiorgan dysfunction
569
Oxygen therapy 381 Summary 572
Airway support 383
Intubation 384
Tracheostomy 386 Section 3 Specialty Practice in
Complications of endotracheal intubation and Critical Care 579
tracheostomy 387 22 Emergency Presentations 581
Tracheal suction 387 Triage 582
Extubation 387 Extended roles 586
Mechanical ventilation 388 Retrievals and transport of critically ill patients 587
Non-invasive ventilation 389 Multiple patient triage/disaster 588
Invasive mechanical ventilation 392 Respiratory presentations 589
Summary 404 Chest pain presentations 591
16 Neurological Assessment and Monitoring 414 Abdominal symptom presentations 593
Neurological anatomy and physiology 414 Acute stroke 594
Neurological assessment and monitoring 431 Overdose and poisoning 596
Summary 440 Near-drowning 612
D E TA I L E D C O N T E N T S xvii
Hypothermia 614 Special considerations 729
Hyperthermia and heat illness 615 Caring for pregnant women in ICU 731
Summary 615 Caring for postpartum women in ICU 735
Summary 738
23 Trauma Management 623
Trauma systems and processes 623 27 Organ Donation and Transplantation 746
Common clinical presentations 626 ‘Opt-in’ system of donation in Australia and
Summary 649 New Zealand 746
Types of donor and donation 747
24 Resuscitation 654 Organ donation and transplant networks in
Pathophysiology 655 Australasia 747
Resuscitation systems and processes 655 Identification of organ and tissue donors 749
Management 655 Organ donor care 755
Roles during cardiac arrest 670 Donation after cardiac death 757
Family presence during an arrest 670 Tissue-only donor 758
Ceasing CPR 671 Summary 758
Postresuscitation phase 671
Near-death experiences 671
Legal and ethical considerations 672 APPENDIX A1 Declaration of Madrid: Education 763
Summary 672
APPENDIX A2 Declaration of Buenos Aires:
25 Paediatric Considerations in Critical Care 679 Workforce 765
Anatomical and physiological considerations APPENDIX A3 Declaration of Vienna: Patient
in children 680 Rights 767
Developmental considerations 684 APPENDIX A4 Declaration of Vienna: Patient
Comfort measures 685 Safety in Intensive Care Medicine 768
Family issues and consent 686
The child experiencing upper airway APPENDIX B1 ACCCN Position Statement (2006)
obstruction 686 on the Provision of Critical Care Nursing
The child experiencing lower airway disease 691 Education 773
Nursing the ventilated child 693 APPENDIX B2 ACCCN ICU Staffing Position
The child experiencing shock 695 Statement (2003) on Intensive Care Nursing
The child experiencing acute neurological Staffing 775
dysfunction 696 APPENDIX B3 Position Statement (2006) on the
Gastrointestinal and renal considerations in Use of Healthcare Workers other than Division
children 698 1* Registered Nurses in Intensive Care 777
Paediatric trauma 700 APPENDIX B4 ACCCN Resuscitation Position
Summary 702
Statement (2006) – Adult & Paediatric
26 Pregnancy and Postpartum Considerations 710 Resuscitation by Nurses 779
Epidemiology of critical illness in pregnancy 710 APPENDIX C Normal Values 780
Adapted physiology of pregnancy 711 GLOSSARY 783
Diseases and conditions unique to pregnancy 716
Exacerbation of medical disease associated PICTURE CREDITS 790
with pregnancy 726 INDEX 793
Abbreviations
2-PAM pralidoxime AODR Australian Organ Donor Register
6MWT six-minute walk test AORTIC Australasian Outcomes Research Tool for
A/C assist control Intensive Care
A/C MV assist-controlled mechanical ventilation APACHE acute physiology and chronic health
AACN American Association of Critical-care Nurses evaluation
AATT aseptic non-touch technique APC activated protein C
ABG arterial blood gas APRV airway pressure release ventilation
ACCCN Australian College of Critical Care Nurses aPTT activated partial thromboplastin time
ACD active compression–decompression ARAS ascending reticular activating system
ACE angiotensin-converting enzyme ARC Australian Resuscitation Council
ACEM Australasian College of Emergency Medicine ARDS acute respiratory distress syndrome
ACh acetylcholine ARF acute renal failure
AChE acetylcholinesterase ASL arterial spin labelling
ACN advanced clinical nurse AST aspartate aminotransferase
ACNP acute care nurse practitioner ATC automatic tube compensation
ACS acute coronary syndrome ATCA Australasian Transplant Coordinators
ACS abdominal compartment syndrome Association
ACT activated clotting time ATN acute tubular necrosis
ACTH adrenocorticotrophic hormone ATP adenosine triphosphate
ADAPT Australasian Donor Awareness Program ATS Australasian Triage Scale
Training AV arteriovenous
ADE adverse drug event AV atrioventricular
ADH antidiuretic hormone AVDO 2 arteriovenous difference in oxygen
ADL activities of daily living AVM arteriovenous malformation
ADP adenosine diphosphate AVPU Alert/response to Voice/only responds to
AE adverse event Pain/Unconscious
AED automatic external defibrillator BBB blood–brain barrier
AHA American Heart Association BDI Beck Depression Inventory
AHEC Australian Health Ethics Committee BiPAP bilevel positive airway pressure
AIS abbreviated injury score BiVAD biventricular assist device
AKI acute kidney infection BIS bispectral index
ALF acute liver failure BLS basic life support
ALI acute lung injury BMV Bag/mask ventilation
ALP alkaline phosphatase BP blood pressure
ALS advanced life support BPS Behavioural Pain Scale
ALT alanine aminotransferase BSA body surface area
AMI acute myocardial infarction BSLTx bilateral sequential lung transplantation
AND autonomic nerve dysfunction BTF Brain Trauma Foundation
ANP atrial natriuretic peptide BURP Backwards, upwards, rightward pressure
ANZBA Australian and New Zealand Burn Association BVM bag–valve–mask
ANZICS Australian and New Zealand Intensive Care CaO 2 content of arterial oxygen in the blood
Society CABG coronary artery bypass graft
ANZOD Australia and New Zealand Organ Donation CAM-ICU Confusion Assessment Method – Intensive
Registry Care Unit
xviii AoCLF acute-on-chronic liver failure CAP community-acquired pneumonia
A B B R E V I AT I O N S xix
CAUTI catheter associated urinary tract infection CSSU central sterile supply unit
CAV cardiac allograft vasculopathy CSWS cerebral salt-wasting syndrome
CAVH continuous arteriovenous haemofiltration CT computerised tomography
CBF cerebral blood flow CTG clinical trials group (of ANZICS)
CBG corticosteroid-binding globulin CVC central venous catheter
CCF chronic cardiac failure CVD cardiovascular disease
CCU critical care unit—may be intensive care, CvO 2 central venous oxygenation
coronary care, high dependency or a CVP central venous pressure
combination of these CVVH continuous veno-venous haemofiltration
CCU coronary care unit CVVHDf continuous veno-venous haemodiafiltration
CDSS clinical decision support system CXR chest X-ray
CEO 2 cerebral oxygen extraction DAI diffuse axonal injury
CES–D Center for Epidemiologic Studies–Depression DASS Depression Anxiety and Stress Scale
CFI cardiac function index DAT decision analysis theory
CFM cerebral function monitoring DCD donor after cardiac death
CHD coronary heart disease DCM dilated cardiomyopathy
CHF chronic heart failure DDAVP 1-deamino-8-D-arginine vasopressin
CI cardiac index (Vasopressin)
CI critical illness DKA diabetic ketoacidosis
CIM critical illness myopathy DO 2 oxygen delivery
CINM critical illness neuromyopathy DPL diagnostic peritoneal lavage
CIP critical illness polyneuropathy DRG diagnosis-related group
CIPNP critical illness polyneuropathy DSC (MRI) dynamic susceptibility contrast
CIS clinical information system DVT deep venous thrombosis
CK creatine kinase EBI electrical burn injury
CLAB central line associated bacteraemia EBN evidence based nursing
CLD chronic liver disease EBP evidence based practice
CLF chronic liver failure EC ethics committee
cLMA classic laryngeal mask airway EC extracorporeal circuit
CLRT continuous lateral rotation therapy ECC external cardiac compression
CMV controlled mechanical ventilation ECG electrocardiograph/y
CMV cytomegalovirus ECMO extracorporeal membrane oxygenation
CNE clinical nurse educator ED emergency department
CNPI checklist of nonverbal pain indicators EDD extended daily diafiltration
CNS central nervous system EDD-f extended daily dialysis filtration
CO carbon monoxide EDIS Emergency Department Information
CO cardiac output System
CO 2 carbon dioxide EEG electroencephalogram
COAD chronic obstructive airways disease EGDT early goal-directed therapy
COPD chronic obstructive pulmonary disease EMD electromechanical dissociation
CPAP continuous positive airway pressure EMS emergency medical system
CPB cardiopulmonary bypass EN enteral nutrition
CPDU clinical practice development unit ENID emerging novel infectious disease
CPG clinical practice guideline EPAP expiratory positive airway pressure
CPM cuff pressure monitoring ePD emancipatory practice development
CPOE computerised physician (provider) order entry EQ-5D Euroquol 5D
CPOT Critical Care Pain Observation Tool ERC European Resuscitation Council
CPP cerebral perfusion pressure ESBL-E extended-spectrum beta-lactamase-
CPP coronary perfusion pressure producing Enterobacteriaceae
CPR cardiopulmonary resuscitation ESLD end stage liver disease
CRASH corticosteroid randomisation after significant ESLF end-stage liver failure
head injury ETC (o)esophageal–tracheal Combitube
CRF chronic renal failure ETCO 2 end-tidal carbon dioxide
CRH corticotrophin-releasing hormone ETIC-7 experience after treatment in intensive care
CRP C-reactive protein ETT endotracheal tube
CRRT continuous renal replacement therapy EVLW extravascular lung water
CSF cerebrospinal fluid FAED fully automatic external defibrillator
xx A B B R E V I AT I O N S
FAST focused assessment with sonography for ICH intracranial haemorrhage
trauma ICP intracranial pressure
FBC full blood count ICT information and communications
FDA (US) Food and Drug Administration technologies
FES fat embolism syndrome ICU intensive care unit
FEV 1 forced expiratory volume in 1 second ICU-AW intensive care unit acquired weakness
FFA free fatty acid ICU LN intensive care unit liaison nurse
FFP fresh frozen plasma IDC indwelling catheter
FI fear index I:E inspiratory:expiratory (ratio)
FiO 2 fraction of inspired oxygen IES impact of events scale
fMRI functional magnetic resonance imaging IgE immunoglobulin E
FRC functional residual capacity IHD intermittent haemodialysis
FTE full-time equivalent (equivalent to 76-hour IL interleukin
fortnight) ILCOR International Liaison Committee on
FVC forced vital capacity Resuscitation
FWR family witness resuscitation IMA internal mammary artery
GABA gamma-aminobutyric acid INR International Normalized Ratio
GAS general adaptation syndrome IO intraosseous
GCS Glasgow Coma Scale IPP information privacy principles
GEDV global end-diastolic volume IPPV intermittent positive pressure ventilation
GGT gamma-glutamyl transpeptidase IPT information-processing theory
GI gastrointestinal ISS injury severity score
GIT gastrointestinal tract ITBV intrathoracic total blood volume
GM1 monosialoganglioside IVC inferior vena cava
GTN glyceryl trinitrate IVIg intravenous immunoglobulin
−
HCO 3 sodium bicarbonate JE Japanese B encephalitis
H 2 CO 3 carbonic acid LAD left anterior descending coronary artery
+
H hydrogen LAP left atrial pressure
HADS hospital anxiety and depression scale LDL low-density lipoprotein
HAI healthcare acquired infection LDLT living donor liver transplantation
Hb haemoglobin LFTs liver function tests
HbF fetal haemoglobin LMA laryngeal mask airway
HCM hypertrophic cardiomyopathy LN liaison nurse
HDU high-dependency unit LOC level of consciousness
HE hepatic encephalopathy LOC loss of consciousness
HFA Heart Foundation Australia LP lumbar puncture
HFNC high flow nasal cannula(e) LVAD left ventricular assist device
HFOV high-frequency oscillatory ventilation LVEDV left ventricular end-diastolic volume
HH heated humidification LVEF left ventricular ejection fraction
HHNS hyperglycaemic hyperosmolar non-ketotic LVF left ventricular failure
state LVP left ventricular pressure
Hib Haemophilus influenzae type b LVSWI left ventricular stroke work index
HIT Heparin-induced thrombocytopenia MAP mean arterial pressure
HME heat–moisture exchanger MARS molecular adsorbent(s) recirculating system
HPA hypothalamic–pituitary–adrenal MASS Motor Activity Assessment Scale
HRC Health Research Council (New Zealand) MCA middle cerebral artery
HRQOL health-related quality of life MED manual external defibrillator
HRS hepatorenal syndrome MET medical emergency team
HSV herpes simplex virus MET(s) metabolic equivalent(s)
HTLV human T-lymphotropic virus MEWS medical early-warning system
IABP intra-aortic balloon pump MIDCAB minimally invasive direct coronary artery
IAC interposed abdominal compression bypass
IAP intra-abdominal pressure MIDCM minimally invasive direct cardiac massage
ICC intercostal catheter mmHg millimetres of mercury
ICD implantable cardioverter defibrillator MODS multiple organ dysfunction syndrome
ICDSC Intensive Care Delirium Screening Checklist MRI magnetic resonance imaging
ICG indocyanine green MRO multi-resistant organisms
A B B R E V I AT I O N S xxi
MRS magnetic resonance spectroscopy PCI percutaneous coronary intervention
MRSA methicillin-resistant Staphylococcus aureus PCT dynamic perfusion computed tomography
MVC motor vehicle collision PCV pressure-controlled ventilation
MVE Murray Valley encephalitis PCWP pulmonary capillary wedge pressure
NAC N-acetylcysteine PD peritoneal dialysis
NAS nursing activities scale PDH pulmonary dynamic hyperinflation
NASCIS National Acute Spinal Cord Injury Study PDR plasma disappearance rate
NAT nucleic acid testing PDSA plan, do, study, act
NDE near-death experience PDU practice development unit
NDU nursing development unit PE pulmonary embolism
NE norepinephrine PEA pulseless electrical activity
NFκB nuclear factor kappa B PEEP positive end-expiratory pressure
NGT nasogastric tube PEFR peak expired flow rate
NHBD non-heart-beating donation PET positron emission tomography
NHMRC National Health and Medical Research Council PETCO 2 positive end-tidal carbon dioxide
NHP Nottingham Health Profile pH acid–alkaline logarithmic scale
NIBP non-invasive blood pressure PI pulsatility index
NIRS near-infrared spectroscopy PICC peripherally inserted central catheter
NIV non-invasive ventilation PiCCO pulse-induced contour cardiac output
NMB neuromuscular blocking PICU paediatric intensive care unit
NMDA N-methyl-d-aspartate PN parenteral nutrition
NMJ neuromuscular junction PND paroxysmal nocturnal dyspnoea
NO nitrous oxide PNS peripheral nervous system
NO 2 nitric oxide P plat plateau pressure
NOC nurse observation checklist PPE personal protective equipment
NOK next of kin PROWESS (recombinant human-activated) protein C
NP nurse practitioner worldwide evaluation in severe sepsis
NPA nasopharyngeal aspirate PRVC pressure-regulated volume control
NPP national privacy principles PSG polysomnography
NPY neuropeptide Y PT prothrombin time
NSAIDs non-steroidal anti-inflammatory drugs PTA posttraumatic amnesia
NTS national triage scale PTCA percutaneous transluminal coronary
NTT nasotracheal tube angioplasty
NYHA New York Heart Association PTSD posttraumatic stress disorder
O 2 oxygen PTSS posttraumatic stress symptoms
ODIN organ dysfunction and/or infection PTT partial thromboplastin time
OEF oxygen extraction fraction Pv venous pressure
OHCA out-of-hospital cardiac arrest PvO 2 mixed venous oxygen pressure
OLTx orthotopic liver transplantation PVR peripheral vascular resistance
OSA obstructive sleep apnoea QI quality improvement
OTDA Organ and Tissue Donation Agency QOL quality of life
P A alveolar pressure QOL–IT quality of life–Italian version
P a arterial pressure QOL–SP quality of life–Spanish version
PaCO 2 partial pressure of carbon dioxide in arterial QUM quality use of medicines
blood QWB quality of wellbeing
PaO 2 partial pressure of oxygen in arterial blood RAAS renin–angiotensin–aldosterone system
Pa w peak airway pressure RASS Richmond Agitation–Sedation Scale
P v venous pressure RAS reticular activating system
PAC pulmonary artery catheter RBC red blood cell
PAF platelet-activating factor RCA root cause analysis
PALS paediatric advanced life support RCA right coronary artery
PaO 2 partial pressure of arterial oxygen RCSQ Richards-Campbell Sleep Questionnaire
PAOP pulmonary artery occlusion pressure REM rapid eye movement
PAP pulmonary artery pressure RICA right internal carotid artery
PART patient-at-risk team ROSC return of spontaneous circulation
PAWP pulmonary artery wedge pressure RRS rapid response system
PbtO 2 brain tissue oxygen RR respiratory rate
xxii A B B R E V I AT I O N S
RRT rapid response teams SWS slow wave sleep
RRT renal replacement therapy TAFI thrombin-activatable fibrinolysis inhibitor
RTS revised trauma score TB tuberculosis
RVF right ventricular failure TBI traumatic brain injury
RVP right ventricular pressure TCD transcranial Doppler
RVSWI right ventricular stroke work index TEG thromboelastograph
SaO 2 saturation of oxygen in arterial blood TIPS transjugular intrahepatic portosystemic
SpO 2 saturation of oxygen in peripheral tissues shunt/stent
SvO 2 venous oxygen saturation TISS therapeutic intervention scoring system
SA sinoatrial TLC total lung capacity
SAC safety assessment coding TNFα tumour necrosis factor alpha
SAED semiautomatic external defibrillator TNS tumour necrosis factor
SAFE Saline versus Albumin Fluid Evaluation (trial) TOE transoesophageal echocardiograph/y
SAH subarachnoid haemorrhage tPA tissue plasminogen activator
SAI State Anxiety Inventory tPD technical practice development
SAPS simplified acute physiology score TPN total parenteral nutrition
SARS severe acute respiratory syndrome TPR temperature, pulse, respirations
SARS-CoV severe acute respiratory syndrome TSANZ Transplant Society of Australia and New
coronavirus Zealand
SAS Sedation Agitation Scale TSC trauma symptom checklist
SBE serum base excess TSH thyroid-stimulating hormone
SBP systolic blood pressure TST total sleep time
SCA sudden cardiac arrest TT thrombin time
SCI spinal cord injury TV tidal volume
SCUF slow continuous ultrafiltration TVI time velocity interval
SE status epilepticus UEC urea, electrolytes, creatinine
SEI sleep efficiency index UO urine output
SF-36 Short Form 36 URTI upper respiratory tract infection
SGRQ St George’s Respiratory Questionnaire V ventilation
SIADH syndrome of inappropriate antidiuretic V/Q ventilation/perfusion
hormone secretion V T tidal volume
SICQ Sleep in Intensive Care Questionnaire VALI ventilator-associated lung injury
SIG strong ion gap VAP ventilator-acquired pneumonia
SIMV synchronised intermittent mandatory VAS Visual analogue scale
ventilation VAS-A Visual analogue scale – Anxiety
SIP sickness impact profile VC vital capacity
SIRS systemic inflammatory response syndrome VC volume-controlled (ventilation)
SjvO 2 jugular venous oxygen saturation VCv volume controlled ventilation
SLTx single lung transplantation VE minute ventilation
SOFA sepsis-related/sequential organ failure VF ventricular fibrillation
assessment VICS Vancouver Interaction and Calmness Scale
SPECT single photon emission computed VO 2 oxygen consumption
tomography VRE vancomycin-resistant Enterococcus
SR systematic review VT ventricular tachycardia
SSG surviving sepsis guidelines VTE venous thromboembolism
STAI State Trait Anxiety Inventory VV veno-venous
STEMI ST-elevation myocardial infarction WBC white blood cell
SVDK snake venom detection kit WCC white cell count
SVG saphenous vein graft WFCCN World Federation of Critical Care Nurses
SVR systemic vascular resistance WHO World Health Organization
SVT supraventricular tachycardia WOB work of breathing
SVV stroke volume variation XeCT xenon-enhanced computed tomography
1
S E C T I O N
Scope of Critical Care
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Scope of Critical Care Practice 1
Leanne Aitken
Wendy Chaboyer
Doug Elliott
consumables and the rest to clinical support and capital
Learning objectives expenditure. 2
Critical care as a specialty in nursing has developed over
After reading this chapter, you should be able to: the last 30 years. Importantly, development of our spe-
3,4
● describe the history and development of critical care cialty in Australia and New Zealand has been in concert
nursing practice, education and professional activities with development of intensive care medicine as a defined
● discuss the influences on the development of critical care clinical specialty. Critical care nursing is defined by the
nursing as a discipline and the professional development of World Federation of Critical Care Nurses as:
individual nurses
● outline the various roles available to nurses within critical Specialised nursing care of critically ill patients who have mani-
care areas or in outreach services fest or potential disturbances of vital organ functions. Critical
● discuss the potential impact of clinical decision-making care nursing means assisting, supporting and restoring the
processes on patient outcomes patient towards health, or to ease the patient’s pain and to
● consider processes in the work and professional prepare them for a dignified death. The aim of critical care
nursing is to establish a therapeutic relationship with patients
environment that are influenced by local leadership styles.
and their relatives and to empower the individuals’ physical,
psychological, sociological, cultural and spiritual capabilities by
preventive, curative and rehabilitative interventions. 5
Critically ill patients are those at high risk of actual or
Key words potential life-threatening health problems. Care of the
6
critically ill can occur in a number of different locations
critical care nursing in hospitals. In Australia and New Zealand, critical care
roles of critical care nurses is generally considered a broad term, incorporating
clinical decision making subspecialty areas of emergency, coronary care, high-
clinical leadership dependency, cardiothoracic, paediatric and general inten-
sive care units. 7
This chapter provides a context for subsequent chapters,
INTRODUCTION outlining some key principles and concepts for studying
and practising nursing in a range of critical care areas. The
There is unprecedented demand for critical care services scope of critical care nursing is described in the Australian
globally. In our region, there are approximately 119,000 and New Zealand contexts, which in turn have some
admissions to 141 general intensive care units (ICUs) influence on clinical practice in Southeast Asia and the
in Australia per year; this includes 5500 patient re- Pacific. Development of the specialty is discussed, along
admissions during the same hospital episode. In New with the professional development and evolving roles of
Zealand, there are 18,000 admissions per year to 26 ICUs, critical care nurses in contemporary health care, including
1
including 500 re-admissions. Patients admitted to coro- clinical decision making and leadership.
nary care, paediatric or other specialty units not classified
as a general ICU are not included in these figures, so the
overall clinical activity for ‘critical care’ is much higher DEVELOPMENT OF CRITICAL
(e.g. there were also 5500 paediatric admissions to CARE NURSING
1
PICUs). Importantly, critical care treatment is a high-
expense component of hospital care; one conservative Critical care as a specialty emerged in the 1950s and
estimate of cost exceeded $A2600 per day, with more 1960s in Australasia, North America, Europe and South
than two-thirds going to staff costs, one fifth to clinical Africa. 4,8-11 During these early stages, critical care consisted 3
4 S C O P E O F C R I T I C A L C A R E
primarily of coronary care units for the care of cardiology Critical care nursing education developed in unison with
patients, cardiothoracic units for the care of postoperative the advent of specialist critical care units. Initially, this
patients, and general intensive care units for the care of consisted of ad-hoc training developed and delivered in
patients with respiratory compromise. Later develop- the work setting, with nurses and medical officers learn-
ments in renal, metabolic and neurological management ing together. For example, medical staff brought expertise
led to the principles and context of critical care that exist in physiology, pathophysiology and interpretation of
today. electrocardiographic rhythm strips, while nurses brought
expertise in patient care and how patients behaved and
Development of critical care nursing was characterised by 12,17
4
a number of features, including: responded to treatment. Training was, however, frag-
mented and ‘fitted in’ around ward staffing needs. Post-
● the development of a new, comprehensive partnership registration critical care nursing courses were subsequently
between nursing and medical clinicians developed from the early 1960s in both Australasia and
4,8
● the collective experience of a steep learning curve for the UK. Courses ranged in length from 6 to 12 months
nursing and medical staff and generally incorporated employment as well as spe-
● the courage to work in an unfamiliar setting, caring cific days for lectures and class work. Given the local
for patients who were extremely sick – a role that nature of these courses developed for the local needs of
required development of higher levels of competence individual hospitals and regions, differences in content
and practice and practice therefore developed between hospitals,
● a high demand for education specific to critical care regions and countries. 18-20
practice, which was initially difficult to meet owing to
the absence of experienced nurses in the specialty During the 1990s the majority of these hospital-based
● the development of technology such as mechanical courses in Australasia were discontinued as universities
ventilators, cardiac monitors, pacemakers defibrilla- developed postgraduate curricula to extend the knowl-
tors, dialysers, intra-aortic balloon pumps and cardiac edge and skills gained in pre-registration undergraduate
assist devices, which prompted development of addi- courses. A significant proportion of critical care nurses
tional knowledge and skills. now undertake specialty education in the tertiary sector,
often in a collaborative relationship with one or more
There was also recognition that improving patient out- hospitals. One early study of students enrolled in
4
comes through optimal use of this technology was linked university-based critical care courses in Australia identi-
21
to nurses’ skills and staffing levels. The role of ade- fied a number of burdens (workload, financial, study–
12
quately educated and experienced nurses in these units work conflicts), but also a number of benefits (e.g. better
was recognised as essential from an early stage, and led job prospects, job security).
8
to the development of the nursing specialty of critical care.
Although not initially accepted, nursing expertise, ability Within Australia and New Zealand, most tertiary institu-
to observe patients and appropriate nursing intensity are tions currently offer postgraduate critical care nursing
now considered essential elements of critical care. 12 education at a Graduate Certificate or Graduate Diploma
level as preparation for specialty practice, although this
As the practice of critical care nursing evolved, so did is often provided as a Master’s degree. In the UK, similar
22
the associated areas of critical care nursing education provisions for postgraduate critical care nursing edu-
and specialty professional organisations such as the cation at multiple levels are available, although some
Australian College of Critical Care Nurses (ACCCN). The universities also offer critical care specialisation at the
combination of adequate nurse staffing, observation of undergraduate level (for example, King’s College,
the patient and the expertise of nurses to consider the London). Education throughout Europe has undergone
complete needs of patients and their families is essential significant change in the past 10 years as the framework
to optimise the outcomes of critical care. As critical care articulated under the Bologna Process has been imple-
continues to evolve, the challenge remains to combine mented. In relation to critical care nursing, this has led
23
excellence in nursing care with judicious use of techno- to the expansion of programs, primarily at the postgradu-
logy to optimise patient and family outcomes. ate level, for specialist nursing education. Critical care
nursing education in the USA maintains a slightly differ-
CRITICAL CARE NURSING EDUCATION ent focus, with most postgraduate studies being generic
Appropriate preparation of specialist critical care nurses in nature, including a focus on advanced practice roles
such as clinical nurse specialists and nurse practitioners,
is a vital component in providing quality care to patients while specialty education for critical care nurses is under-
5
and their families. A central tenet within this framework taken as continuing education. Employment in critical
24
of preparation is the formalised education of nurses care, with associated assessment of clinical competence,
13
to practise in critical care areas. Formal education – remains an essential component of many university-
in conjunction with experiential learning, continuing based critical care nursing courses. 22,25
professional development and training, and reflective
clinical practice – is required to develop competence in Both the impact of post-registration education on prac-
critical care nursing. The knowledge, skills and attitude tice and the most appropriate level of education that is
necessary for quality critical care nursing practice have required to underpin specialty practice remain controver-
been articulated in competency statements in many sial, with no universal acceptance internationally. 26-29
countries. 14-16 Globally, the Declaration of Madrid, which was endorsed
Scope of Critical Care Practice 5
‘beginner’ ‘competent’ ‘specialist’ ‘expert’
continuing experience/experiential learning Practice
Induction/
orientation
to critical short courses/skills updates/in-service education Training
care
nursing
initial competencies increasing complexity of competencies Education
Postgraduate Graduate Graduate Masters
education Certificate Diploma
FIGURE 1.1 Critical care nursing practice: training and education continuum.
by the World Federation of Critical Care Nurses, provides Appendix B). The validity of this structure of six domains
a baseline for critical care nursing education (see Appen- has been questioned, however, as a number of compe-
35
dix A for the position statement). 5 tency statements are linked to several domains. Further
research is therefore required to refine the structure of a
A range of factors continue to influence critical care 35
nursing education provision, including government poli- competency model with improved construct validity.
cies at national and state levels, funding mechanisms and Other competency domains and assessment tools have
25
resource implications for organisations and individual also been developed. Although articulated slightly dif-
students, education provider and healthcare sector part- ferently, the American Association of Critical-Care Nurses
nership arrangements, and tensions between workforce (AACN) provides ‘Standards of Practice and Performance
36
and professional development needs. Recruitment, ori- for the Acute and Critical Care Clinical Nurse Specialist’,
13
entation, training and education of critical care nurses which outlines six standards of practice (assessment,
can be viewed as a continuum of learning, experience and diagnosis, outcome identification, planning, implemen-
professional development. The relationships between tation and evaluation) and eight standards of profes-
5
the various components related to practice, training and sional performance (quality of care, individual practice
education are illustrated in Figure 1.1, on a continuum evaluation, education, collegiality, ethics, collaboration,
from ‘beginner’ to ‘expert’ and incorporating increasing research and resource utilisation) (see Online resources).
complexities of competency. All elements are equally
important in promoting quality critical care nursing CRITICAL CARE NURSING PROFESSIONAL
practice. Practice- or skills-based continuing education ORGANISATIONS
sessions support clinical practice at the unit level. Professional leadership of critical care nursing has under-
30
(Orientation and continuing education issues are dis- gone considerable development in the past three decades.
cussed further in the context of staffing levels and skills Within Australia, the ACCCN (formerly the Confedera-
mix in Chapter 2.) tion of Australian Critical Care Nurses) was formed from
Many countries now incorporate requirements for con- a number of preceding state-based specialty nursing
tinuing professional development into their annual bodies (e.g. Australian Society of Critical Care Nurses,
licensing processes. Specific requirements include ele- Clinical Nurse Specialists Association) that provided pro-
ments such as minimum hours of required professional fessional leadership for critical care nurses since the early
development and/or ongoing demonstration of compe- 1970s. In New Zealand, the professional interests of criti-
tence against predefined competency standards. 31,32 cal care nurses are represented by the New Zealand Nurses
Organisation, Critical Care Nurses Section, as well as
SPECIALIST CRITICAL CARE COMPETENCIES affiliation with the ACCCN. The ACCCN has strong pro-
Critical care nursing involves a range of skills, classified fessional relationships with other national peak nursing
bodies, the Australian and New Zealand Intensive Care
as psychomotor (or technical), cognitive or interpersonal. Society (ANZICS), government agencies and individuals,
Performance of specific skills requires special training and and healthcare companies.
practice to enable proficiency. Clinical competence is
a combination of skills, behaviours and knowledge, Professional organisations representing critical care
demonstrated by performance within a practice situa- nurses were formed as early as the 1960s in the USA with
33
tion and specific to the context in which it is demon- the formation of the American Association of Critical
37
34
strated. A nurse who learns a skill and is assessed as Care Nurses (AACN). Other organisations have devel-
performing that skill within the clinical environment is oped around the world, with critical care nursing bodies
deemed competent. As noted above, a set of competency now operating in countries from Australasia, Asia, North
statements for specialist critical care practice comprises America, South America, Africa and Europe. In 2001 the
20 competency standards grouped into six domains: inaugural meeting of the World Federation of Critical
professional practice, reflective practice, enabling, clinical Care Nurses (WFCCN) was formed to provide profes-
14
problem solving, teamwork and leadership (see sional leadership at an international level. 38,39 The ACCCN
6 S C O P E O F C R I T I C A L C A R E
was a foundation member of the WFCCN and a member of critical care outreach or ICU liaison nurse roles (see
association of the World Federation of Societies of Inten- Chapter 2 for further discussion of these services).
sive Care and Critical Care Medicine, and maintains a In practice, the role of clinical consultant and that of an
representative on the councils of both these international advanced practice nurse or nurse practitioner can become
bodies. (See the ACCCN website, listed in Online resources, blurred, with hospital administrators believing that one
for further details about professional activities.)
role can replace the other. Clearly, however, the con-
ROLES OF CRITICAL CARE NURSES sultant’s role has a broader portfolio, with a focus on
supporting clinical colleagues in providing safe, quality
As the discipline of critical care has developed, so too has patient care, while the role of advanced practice nurse or
the range of roles performed by specialty critical care nurse practitioner has a direct patient care focus (see
nurses. 40,41 The continuum of critical illness (see Chapter below).
4) includes pre-crisis/proactive care, management of the
critical illness, and follow-up care in hospital, clinic and ADVANCED PRACTICE NURSE/NURSE
42
home settings. This continuum also includes the prac- PRACTITIONER
tice of palliative care in the ICU environment. Clinical Processes for authorisation to practise as a nurse practi-
43
(bedside) roles and nurse-to-patient ratios for various tioner (NP) have been introduced by professional regi-
levels of critical care unit, as well as the roles of unit stration agencies in Australia and New Zealand, with
manager and clinical nurse educator, are discussed in similar roles present in the UK and USA prior to this.
48
Chapter 2. Practice issues for critical care clinicians are Nurse practitioner roles in ‘critical care’ (or high depen-
detailed in the remaining chapters of this book. Roles dency) range from emergency department practitioners
that apply to all nursing professionals are specifically through to community-based cardiac failure specialists,
highlighted; for example: and, as noted above for the nurse consultant’s role, often
● carer, in Chapters 6, 7 and 8, all practice-related lack clarity regarding their scope of practice. 56,57 Factors
chapters in Section 2, and the specialty chapters in influencing the establishment of these roles include the
Section 3 accrediting process, defining the scope of practice through
● patient and family advocate, in Chapters 5 and 8 specific clinical practice guideline development, prescrib-
● educator, in Chapter 3. ing rights and the prevailing medical views, and the level
of support provided by health service administrators for
This section focuses on the scope of critical care nurses’ the implementation, development and evaluation of the
roles inside and external to the critical care area, and role. 48,56 Advanced practice roles in the emergency depart-
44
provides links to other specific chapters. These roles ment are the most well-established in the critical care
include: domain (see Chapter 22).
● consultant 45-47
46
48
● advanced practice /nurse practitioner roles in ICU, CLINICAL DECISION MAKING
50
49
trauma, emergency (Chapter 22), critical care out- Clinical decision making is integral to critical care nursing
51
reach /ICU liaison 52-54 (Chapter 2) practice and forms part of the clinical reasoning process.
● research/quality coordinator (Chapter 3).
Clinical reasoning is
Developing a body of knowledge and the integral role of
research and nurse researchers in that process is described the cognitive processes and strategies that nurses use to under-
in a later section of this chapter. stand the significance of patient data, to identify and diagnose
actual or potential patient problems, and to make clinical deci-
CONSULTANT sions to assist in problem resolution and to achieve positive
58
Expert clinicians in one of the subspecialties of critical patient outcomes.
care – emergency, general ICU, cardiology, cardiothoracic, Clinical information and prior knowledge are therefore
neurosciences – play important roles in facilitating used to inform a decision. This section focuses on the
improvements in clinical practice for both critical care and decision-making component of clinical reasoning. A brief
non-critical care patients. The consultant’s role involves overview of the theoretical perspectives that have been
clinical practice, education, quality improvement and used to understand clinical decision making is provided
55
research activities. Within these work port folios, leader- and then studies that focus on critical care nursing
ship and the development and dissemination of knowl- are reviewed. Finally, strategies for developing clinical
edge 45,46 within a multidisciplinary team are integral to decision-making skills are provided.
47
effective practice. Practice includes role-modelling of
expected behaviours, policy and clinical guideline devel- THEORETICAL PERSPECTIVES ON
opment to support clinical care, and facilitating profes- DECISION MAKING
sional development of colleagues in collaboration with There are numerous theoretical perspectives on decision
the nurse educator role. The benefits that this role brought making, but they can be grouped into two main
to the critical care area led to the introduction of a similar categories:
service for non-critical care areas, particularly in the
context of clinical deterioration of patients or for patients 1. analytical or rationalist
recently discharged from the ICU, with the development 2. intuitive or humanistic.
Scope of Critical Care Practice 7
The analytical approaches arise from a positivist or ratio- Other studies indicated that experienced and inexperi-
nalist perspective and focus on analysing behaviours enced nurses differ in their decision making skills, 67,70,71
and the steps involved in problem solving. Some of the and that role models or mentors are important in assist-
specific theories that fall into this category include infor- ing to develop decision making skills. 72
59
mation-processing theory (IPT) and decision analysis
theory (DAT). 60 RECOMMENDATIONS FOR DEVELOPING
Fundamental to IPT is the premise that reasoning consists CLINICAL DECISION MAKING SKILLS
of a relationship between the problem solver and the Several strategies can be used to help critical care nurses
context within which the problem occurs. This theory to develop their clinical decision-making abilities (Table
asserts that relevant information is stored in one’s memory 1.2). 73-75 These strategies can be used by nurses at any
and that problem solving occurs when the problem solver level to develop their own decision-making skills, or by
retrieves information from both short- and long-term educators in planning educational sessions.
memory. Additionally, IPT claims that there are limits to
the amount of information that can be processed at any In summary, clinical decision making is a component of
given time. Thus, IPT focuses on understanding how the clinical reasoning process that is part of everyday criti-
information is gathered, stored and retrieved. DAT focuses cal care nursing practice. It involves gathering and analys-
on the use of decision trees, mathematical formulas and ing information in order to arrive at a decision about a
other techniques to determine the likelihood of meaning- particular course of action. The analytical or rationalist
ful clinical data. These rationalist approaches focus on perspective of clinical decision making focuses on analys-
diagnosing a problem, intervening and evaluating the ing behaviours and the steps in solving a problem, while
outcome. 61 the intuitive or humanistic approach centres on intuitive
knowledge and the context of the decision. In this spe-
Contrary to the analytical approaches, intuitive approaches cialty area nurses are making clinical decisions at a rate
(also termed humanistic, hermeneutic or phenomeno- of two to three per minute. 61,68 Given this, it is important
logical) focus on the importance of intuitive knowledge that clinical decision-making skills be developed through
and context in clinical decision making. 40,62,63 That is, experience, training and education. Previous research has
expert intuition develops with experience and can be demonstrated that a number of strategies, such as case
used to make complex decisions. Both intuitive knowl- studies and reflection on action, can be used to assist
edge and analytical reasoning contribute to clinical deci- nurses in developing these important skills.
63
sions. Intuitive approaches to decision making therefore
focus on understanding the development of intuition, the LEADERSHIP IN CRITICAL
role of experience and articulating how nurses use intu-
64
ition to make a decision. In addition, Australian authors CARE NURSING
have described a naturalistic framework to examine criti- Effective leadership within critical care nursing is essen-
cal care nurses’ decision making, describing it as a way tial at several organisational levels, including the unit and
of considering how people use their experience when hospital levels, as well as within the specialty on a broader
making real-life decisions.
professional scale. The leadership required at any given
RESEARCH ON DECISION MAKING IN time and in any specific setting is a reflection of the sur-
rounding environment. Regardless of the setting, effective
CRITICAL CARE NURSING leadership involves having and communicating a clear
Critical care nursing practice has been the focus of many vision, motivating a team to achieve a common goal,
studies on decision making. As multiple, complex deci- communicating effectively with others, role modelling,
sions are made in rapid succession in critical care, it is an creating and sustaining the critical elements of a healthy
61
ideal setting for studying clinical decision making. The work environment and implementing change and inno-
seminal work by Benner and colleagues 40,63,65 focused on vation. 76-79 Leadership at the unit and hospital levels is
critical care nurses. Table 1.1 summarises 10 studies (11 essential to ensure excellence in practice, as well as ade-
publications) conducted on critical care nurses’ decision quate clinical governance. In addition to the generic strat-
making over the past decade. egies described above, it is essential for leaders in critical
care units and hospitals to demonstrate a patient focus,
Of note, 7 of the 10 studies were conducted in Australia, establish and maintain standards of practice and collabo-
with two multinational studies also including Australia. rate with other members of the multi-disciplinary health-
All but two studies 66,67 used qualitative approaches such care team. 76
as observation, interviewing and thinking aloud. Two
studies reported the types and frequency of decisions Leadership is essential to achieve the growth and develop-
made during the time period and identified that critical ment in our specialty and is demonstrated through such
care nurses’ decisions were related to interventions and activities as conducting research, producing publications,
61
communication, 61,68 evaluation, assessment, organisa- making conference presentations, representation on
68
tion and education. A further study demonstrated that relevant government and healthcare councils and com-
critical care nurses generate one or more hypotheses mittees, and participation in organisations such as the
69
about a situation prior to decision making. All three ACCCN and the WFCCN. As outlined earlier in this
studies highlighted the importance of enabling expert chapter, we have seen the field of critical care grow from
nurses to provide a narrative account of their practice. early ideas and makeshift units to a well-developed and
8 S C O P E O F C R I T I C A L C A R E
TABLE 1.1 Australian and international critical care nurses decision-making research
Author [Country] Sample Data collection Findings
61
Bucknall, 2000 18 CC nurses (range of Observation (2-hour periods) Three types of decision:
[Australia] levels and experiences; ● evaluation (51%)
all had completed a CC ● communication (30%)
course) ● intervention (19%)
Average: 238 decisions/2 hours (i.e. 2.0/min)
Currey & Worrall-Carter, 12 CC nurses with 2+ years’ Clinical decision record (of Five types of decision:
2001 [Australia] CC experience from 3 2-hour periods) and focus ● intervention (40%)
68
units groups ● communication (26%)
● assessment (19%)
● organisation (13%)
● education (2%)
Average: 395 decisions/2 hours (i.e. 3.3/min)
69
Aitken, 2003 [Australia] 8 expert CC nurses with 5+ Thinking aloud (2-hour periods) Hypotheses developed as a framework for decision
years’ CC experience and follow-up interview making
A combination of strategies used to gather data
70
Currey & Botti, 2006 CC nurses from 2 Observation followed by Clinical processes that affected decision making
[Australia] metropolitan hospitals; semi-structured interview following the settling in phase post cardiac
18 inexperienced surgery were:
(≤3 years) and 20 ● handover from anaesthetists
experienced CC nurses ● settling in procedures
(>3 years). ● collegial assistance.
15 nurses (13 inexperienced) felt daunted by
decision making while 7 nurses (1 inexperienced)
felt challenged with a sense of being stimulated,
excited and positive.
Currey, Browne & Botti Same as above Observation in 2 phases: Quality of haemodynamic decision making in the 2
(2006) [Same study 1st phase comprised hours post cardiac surgery was influenced by
70
as above] [Australia] unstructured, narrative decision complexity, nurses’ level of experience,
observational data; 2nd and forms of decision support provided by
phase comprised a 2-page nursing colleagues.
structured observation Experience was a dominant influence in recognising
checklist. Followed up by patterns of haemodynamic cues that were
interview. suggestive of complications.
Adherence to evidence-based practice also
influenced quality of decision making.
Aitken, 2008 [Australia] 7 CC nurses with a CC Observation and/or thinking A range of concepts related to the assessment and
102
qualification, >5 years aloud, along with follow-up management of sedation needs. Assessment
CC experience, and interviews included:
working ≥2 days/week ● patient’s condition
● response to therapy
● multiple sources of information during
assessment
● consideration of relevant history
● consideration of the impact on physiology and
pathophysiology
● implications of treatment
● options in treatment.
103
Hough, 2008 [USA] 15 CC nurses from 4 units, In-depth, semi-structured The presence of a role model or mentor to help
with varied experience interviews guide the ethical decision-making process,
and education levels through reflection-in-action, was critical for
focused ethical discourse and the decision
making.
Enhanced ethical decision making occurred
through experiential learning.
67
Thompson, 2008 245 Dutch, UK, Canadian Vignettes with decision Time pressure significantly reduced the nurses’
[various countries] and Australian whether or not to contact a decision tendency to intervene.
registered nurses senior nurse/doctor. The There were no statistically significant differences in
working in surgical, proportion of true positives decision-making ability between years of generic
medical, ICU or HDU (the patient is at risk of a clinical experience.
critical event and the nurse There were statistically significant differences in
takes action) and false decision-making ability between years of critical
positives (the nurse takes care experience when participants were not
action when it was not under time pressure: those with greater critical
warranted) was calculated. care experience performed better.
Under time pressure, there were no differences in
decision-making ability between years of critical
care experience.
Scope of Critical Care Practice 9
TABLE 1.1, Continued
Author [Country] Sample Data collection Findings
71
Hoffman, 2009 8 CC nurses: 4 novice and Thinking aloud (during 2-hour Cue usage and clustering during decision making:
[Australia] 4 expert period of care); interview ● Expert nurses collected 89 different cues, while
novices collected 49 different cues.
● Expert nurses clustered a greater number of cues
when making decisions regarding the patient’s
haemodynamic status.
● Expert nurses were more proactive in collecting
relevant cues to anticipate problems and make
decisions.
104
Ramezani-Badr, 2009 14 CC nurses from 4 In-depth, semi-structured 3 themes were involved in reasoning strategies:
[Iran] hospitals, currently interviews ● intuition
working in the CCU, ● recognising similar situations
with ≥3 years CC ● hypothesis testing.
experience and holding 3 other themes regarding participants’ criteria to
at least a bachelor of make decisions:
nursing. ● patient’s risk-benefits
● organisational necessities (i.e. complying with
organisational policy even if it meant they were
capable of doing more)
● complementary sources of information (e.g.
research papers and pharmacology texts).
66
Thompson, 2009 245 Dutch, UK, Canadian Judgement classification Critical care experience was associated with
[Various countries] and Australian systems, Continuous (0–100) estimates of risk, but not with the decision to
registered nurses ratings or dichotomous intervene.
working in surgical, ratings on 3 nursing Nurses varied considerably in their risk assessments,
medical, ICU or HDU. judgements were used this being partly explained by variability in
weightings given to information.
Information was synthesised in non-linear ways that
contributed little to decisional accuracy.
TABLE 1.2 Strategies to develop clinical decision-making skills
Strategy Description
Iterative hypothesis Description of a clinical situation for which the clinician has to generate questions and develop hypotheses; with
testing 74 additional questioning the clinician will develop further hypotheses. Three phases:
1. asking questions to gather data about a patient
2. justifying the data sought
3. interpreting the data to describe the influence of new information on decisions.
Interactive model 74 Schema (mental structures) used to teach new knowledge by building on previous learning. Three components:
1. advanced organisers – blueprint that previews the material to be learned and connects it to previous materials
2. progressive differentiation – a general concept presented first is broken down into smaller ideas
3. integrative reconciliation – similarities and differences and relationships between concepts explored.
Case study 75 Description of a clinical situation with a number of cues, followed by a series of questions. Three types:
1. stable – presents information, then asks clinicians about it
2. dynamic – presents information, asks the clinicians about it, presents more information, asks more questions
3. dynamic with expert feedback – combines the dynamic method with immediate expert feedback.
Reflection on Clinicians are asked to reflect on their actions after a particular event. Reflection focuses on clinical judgments made,
action 74 feelings surrounding the actions and the actions themselves. Reflection on action can be undertaken as an individual
or group activity and is often facilitated by an expert.
Thinking aloud 74 A clinical situation is provided and the clinician is asked to think aloud, or verbalise his/her decisions. Thinking aloud is
generally facilitated by an expert and can be undertaken individually or in groups.
highly organised international specialty in the course of Leadership styles vary and are influenced by the mission
half a generation. Such development would not have and values of the organisation as well as the values
been possible without the vision, enthusiasm and com- and beliefs of individual leaders. These styles of leader-
mitment of many critical care leaders throughout the ship are described in many different ways, sometimes
world. using theoretical underpinnings such as ‘transactional’
10 S C O P E O F C R I T I C A L C A R E
and ‘transformational’ and sometimes by using leader- ● satisfied staff, with a high level of retention
ship characteristics. Regardless of the terminology in use, ● development of staff through an effective coaching
some common principles can be expressed. Desired and mentoring process. 81,86
leadership characteristics include the ability to:
Effective clinical leaders build cohesive and adaptive
84
● articulate a personal vision and expectations work teams. They also promote the intellectual stimula-
● act as a catalyst for change tion of individual staff members, which encourages the
● establish and implement organisational standards analysis and exploration of practice that is essential for
● model effective leadership behaviours through both evidence-based nursing. 85
change processes and stable contexts
● monitor practice in relation to standards and take cor- Clinical leadership is particularly important in contem-
rective action when necessary porary critical care environments in times of dynamic
● recognise the characteristics and strengths of indivi- change and development. We are currently witnessing
duals, and stimulate individual development and significant changes in the organisation and delivery of
commitment care, with the development of new roles such as nurse
● empower staff to act independently and practitioner (see this chapter) and liaison nurse (see
interdependently Chapter 3), the introduction of services such as rapid
● inspire team members to achieve excellence. 80-85 response systems, including medical emergency teams
(see Chapter 3), and the extension of activities across the
Personal characteristics of an effective leader, regardless care continuum (see Chapter 4). Effective clinical leader-
of the style, include honesty, integrity, commitment and ship ensures that:
credibility, as well as the ability to develop an open, trust-
85
ing environment. Effective leaders inspire their team ● critical care personnel are aware of, and willing to
members to take the extra step towards achieving the fulfil, their changing roles
goals articulated by the leader and to feel that they are ● personnel in other areas of the hospital or outside the
valued, independent, responsible and autonomous indi- hospital recognise the benefits and limitations of
85
viduals within the organisation. Members of teams with developments, are not threatened by the develop-
effective leaders are not satisfied with maintaining the ments and are enthusiastic to use the new or refined
status quo, but believe in the vision and goals articulated services
by the leader and are prepared to work towards achieving ● patients receive optimal quality of care.
a higher standard of practice. The need to provide educational opportunities to develop
80
Although all leaders share common characteristics, some effective clinical leadership skills is recognised. Although
elements vary according to leadership style. Different not numerous in number or variety, programs are begin-
styles – for example, transactional, transformational, ning to be available internationally that are designed to
authoritative or laissez faire – incorporate different char- develop clinical leaders. 79,87 Factors that influence leader-
acteristics and activities. Having leaders with different ship ability include the external and internal environ-
styles ensures that there is leadership for all stages of an ment, demographic characteristics such as age, experience,
organisation’s operation or a profession’s development. understanding, stage of personal development including
A combination of leadership styles also helps to over- self-awareness capability, and communication skills. 80,82,87
come team member preferences and problems experi- In relation to clinical leadership, these factors can be
enced when a particularly visionary leader leaves. The developed only in a clinical setting, so development of
challenges often associated with the departure of a leader clinical leaders must be based in that environment.
from a healthcare organisation are generally reduced in Development programs based on mentorship are superbly
the clinical critical care environment, where a nursing suited to developing those that demonstrate potential for
leader is usually part of a multidisciplinary team, with such capabilities. 80
resultant shared values and objectives. Mentorship has received significant attention in the
healthcare literature and has been specifically identified
CLINICAL LEADERSHIP as a strategy for clinical leadership development. 88-90
Effective critical care nurses demonstrate leadership char- Although many different definitions of mentoring exist,
acteristics regardless of their role or level of practice. Lead- common principles include a relationship between two
ership in the clinical environment incorporates the people with the primary purpose of one person in the
general characteristics listed above, but has the added relationship developing new skills related to their
91,92
challenges of working within the boundaries created by career. Mentoring programs can be either formal or
the requirements of providing safe patient care 24 hours informal and either internal or external to the work
a day, 7 days a week. It is therefore essential that clinical setting. Mentorship involves a variety of activities directed
leaders work within an effective interdisciplinary model, towards facilitating new learning experiences for the
so that all aspects of patient care and family support, as mentee, guiding professional development and career
well as the needs of all staff, are met. Effective clinical decisions, providing emotional and psychological support
leadership of critical care is essential in achieving: and assisting the mentee in the socialisation process both
within and outside the work organisation to build profes-
● effective and safe patient care sional networks. 89,91 Role modelling of occupational and
● evidence-based healthcare professional skills and characteristics is an important
Scope of Critical Care Practice 11
component of mentoring that helps develop future clini- 1. randomly allocating patients to receive either a
cal leaders. 89,92 new intervention (the experimental or interven-
tion group) or an alternative or standard interven-
DEVELOPING A BODY OF tion (the control group)
KNOWLEDGE 2. delivering the intervention or alternative
treatment
Development of a body of knowledge is a key character- 3. measuring an a priori identified patient outcome.
istic of both professions 93-95 and the specialties within Statistical analyses are used to determine if the new
professions. One criterion for a specialty identified over intervention is better for patients than the alternative
two decades ago by the International Council of Nurses treatment.
(ICN) is that it is based on a core body of nursing
96
knowledge that is being continually expanded and refined Mixed methods research have now emerged as an
by research. Importantly, the ICN acknowledges that approach that integrates data from qualitative and quan-
97
mechanisms are needed to support, review and dissemi- titative research at some stage in the research process.
nate research. In mixed methods approaches, researchers decide on
both priority and sequence of qualitative and quantitative
RESEARCH methods. In terms of priority, equal status may be given
As noted above, research is fundamental in the develop- to both approaches. Priority is indicated by using capital
ment of nursing knowledge and practice. Research is a letters for the dominant approach, followed by the
systematic inquiry using structured methods to under- symbols + and → to indicate either concurrent or sequen-
stand an issue, solve a problem or refine existing knowl- tial data collection. For example:
edge. Qualitative research involves in-depth examination ● QUAL + QUANT: both approaches are given equal
of a phenomenon of interest, typically using interviews, status and data collection occurs concurrently.
observation or document analysis to build knowledge ● QUAL + quant: qualitative methods are the dominant
and enable depth of understanding. Qualitative data approach and data collection occurs concurrently.
analysis is in narrative (text) form and involves some form ● QUAL → quant: the qualitative study is given priority
of content or thematic analysis, with findings generally and qualitative data collection will occur before quan-
reported as narrative (where words rather than numbers titative data collection.
describe the research findings). In contrast, quantitative
research involves the measurement (in numeric form) of Irrespective of which type of research design is used, there
variables and the use of statistics to test hypotheses. are a number of common steps in the research process
Results of quantitative research are often reported in (Table 1.3), consisting of three phases: planning for the
tables and figures, identifying statistically significant find- research, undertaking the research and analysing and
ings. One particular type of quantitative research, the reporting on the research findings.
clinical trial (randomised controlled trial, or RCT), is used Clinical research and the related activities of unit-based
to test the effect of a new nursing intervention on patient quality improvement are integral components in the
98
outcomes. In essence, clinical trials involve: practice, education and research triad. Partnerships
TABLE 1.3 Steps in the research process
Step Description
Identify a clinical Clinical experience and practice audits are two ways that clinical issues or problems are identified.
problem or issue.
Review the literature. A comprehensive literature review is vital to ensure that the issue or problem has not yet been solved and that the
proposed research will fill a gap in knowledge.
State a clear research A concise question includes both the phenomenon of interest and the patient population.
question.
Write a research Clear description of the proposed research design and sample and a plan for data collection and analysis. Ethical
proposal. considerations and the required resources (i.e. budget) for the research are identified.
Secure resources. Resources such as funding for supplies and research staff, institutional support and access to experienced
researchers are needed to ensure a study can be completed.
Obtain ethics approvals. Approval of the proposed research by a human research ethics committee (HREC) is required before the study can
commence.
Conduct the research. Adequate time for recruitment of participants and data collection are crucial to ensure that accurate data are
obtained.
Disseminate the Conference presentations and journal publications are two common ways that research findings are disseminated
research findings. and are vital to ensure that both nursing practice and nursing knowledge continue to be developed.
12 S C O P E O F C R I T I C A L C A R E
Research program
Practice Patient Technology Education Policy
issues outcomes assessment & training issues
Practice Health status/ Clinical information Commonwealth &
development HRQOL systems Competencies state policies
Evidence- Patient/family Product Impact of
based practice experiences evaluation Credentialling international factors
Impact of
Resource Economic technology on Program Ethical &
utilisation evaluation evaluation legal issues
patient care
FIGURE 1.2 Example of critical care nursing research program.
between clinicians and academics, and the implementa- research utilisation approaches, with a description of
tion of clinical academic positions, including at the pro- evidence-based practice and the use of evidence-based
99
fessorial level, provide the necessary infrastructure and clinical practice guidelines. In addition, each chapter in
organisation for sustainable clinical nursing and multi- this text contains a research critique to assist nurses in
disciplinary research. A strong research culture in critical developing critical appraisal skills, which will help to
care nursing is evident in Australasia, transcending geo- determine whether research evidence should change
graphical, epistemological and disciplinary boundaries to practice.
focus on the core business of improving care for critically
ill patients. Our collective aim is to develop a sustainable SUMMARY
research culture that incorporates strategies that facilitate
communication, cooperation, collaboration and coordi- This chapter has provided a context for subsequent chap-
nation both between researchers with common interests ters, outlining some key issues, principles and concepts
and with clinicians who seek to use research findings in for studying and practising nursing in a range of critical
their practice. A sample of a guiding structure for a coher- care areas. Critical care nursing now encompasses a wide
ent research program that highlights the major issues and ever-expanding scope of practice. The previous focus
affecting critical care nursing practice is illustrated in on patients in ICU only has given way to a broader
Figure 1.2, with identified themes and topic exemplars. concept of caring for an individual located in a variety of
clinical locations across a continuum of critical illness.
A number of resources are available to critical care nurses
interested in undertaking research. For example, the The discipline of critical care nursing, in collaboration
ACCCN provides funding for research on a competitive with multidisciplinary colleagues, continues to develop
basis, with its Research Advisory Panel assessing grant to meet the expanding challenges of clinical practice in
applications and providing feedback to applicants. The today’s healthcare environment. Critical care clinicians
Intensive Care Foundation, whose members are drawn also continue their professional development individu-
from the Australia and New Zealand Intensive Care ally, focusing on clinical practice development, education
Society (ANZICS), the College of Intensive Care Medicine and training, and on quality improvement and research
(CICM) and ACCCN, also has a research funding scheme. activities, to facilitate quality patient and family care
Additionally, the ANZICS Clinical Trials Group (CTG) during a time of acute physiological derangement and
holds regular meetings where potential research can be emotional turmoil. The principles of decision making
discussed and research proposals refined. There is great and clinical leadership at all levels of practice serve to
value in receiving a critical review of proposed research enhance patient safety in the critical care environment.
before the study is undertaken, as assessors’ comments
help to refine the research plan. ONLINE RESOURCES
Over the years, various groups have identified priorities American Association of Critical-Care Nurses, www.aacn.org
for critical care research. A review of this literature identi- Annual Scientific Meeting on Intensive Care, www.intensivecareasm.com.au
fied the following research priorities: nutrition support, Australian College of Critical Care Nurses, www.acccn.com.au
infection control, other patient care issues, nursing roles, Australia and New Zealand Intensive Care Society, www.anzics.com.au
staffing and end-of-life decision making. 100 British Association of Critical Care Nurses, www.baccn.org.uk
College of Intensive Care Medicine, www.cicm.org.au
While not all nurses are expected to conduct research, it Intensive Care Foundation (Australia and New Zealand),
www.intensivecareappeal.com
is a professional responsibility to use research in prac- King’s College, London, www.kcl.ac.uk/schools/nursing
101
tice. Chapter 3 provides a detailed description of World Federation of Critical Care Nurses, http://en.wfccn.org
Scope of Critical Care Practice 13
Research vignette
Aitken L, Marshall AP, Elliott R, McKinley S. Critical care nurses’ deci- and level of consciousness) were labelled as both attribute and
sion making: sedation assessment and management in intensive concept.
care. Journal of Clinical Nursing 2008; 18: 36–45. Three methods of data collection were used: ‘think aloud’, observa-
Abstract tion and interviews. Specifically, during the think-aloud approach,
Aims nurses wore a collar-mounted microphone attached to an audio-
This study was designed to examine the decision-making pro- recorder and were asked to verbalise their thought processes
cesses that nurses use when assessing and managing sedation for during the data collection period. At the same time, an observer
a critically ill patient, specifically the attributes and concepts used recorded the activities that the nurses were undertaking while
to determine sedation needs and the influence of a sedation thinking aloud. A follow-up interview was then undertaken to help
guideline on the decision-making processes. clarify the activities that were observed. Two observers were used
to collect the data. The qualitative nature of the study and the data
Background collection methods are accepted methods to examine decision-
Sedation management forms an integral component of the care of making processes. The researchers are to be commended for train-
critical care patients. Despite this, there is little understanding of ing the participants in the think-aloud method and for piloting
how nurses make decisions regarding assessment and manage- various forms of observational data collection.
ment of intensive care patients’ sedation requirements. Appropri-
ate nursing assessment and management of sedation therapy is The data from the think-aloud method and the observations
essential to quality patient care. were analysed independently by the data collector who had
collected the data for that particular nurse. As part of this analysis,
Design the think-aloud, observation and interview data were integrated
Observational study. for each nurse. The actual analysis involved identifying concepts
Methods and attributes related to three predefined categories: assessment,
Nurses providing sedation management for a critically ill patient physiology and treatment. All analyses were assessed by the chief
were observed and asked to think aloud during two separate occa- investigator and any differences were resolved by consensus.
sions for two hours of care. Follow-up interviews were conducted The sample size – five nurses observed twice each (i.e. before and
to collect data from five expert critical care nurses pre- and post- after implementation of the sedation protocol) and two nurses
implementation of a sedation guideline. Data from all sources were observed once in the pilot study – is appropriate. It is obvious that
integrated, with data analysis identifying the type and number of a very large amount of data was generated. While selection criteria
attributes and concepts used to form decisions. were described to identify ‘expert’ nurses, and included the need
to have critical care qualifications and more than five years experi-
Results ence, the fact that they self-nominated as expert means that it is
Attributes and concepts most frequently used related to sedation always possible that some would not have been judged to be
and sedatives, anxiety and agitation, pain and comfort and neuro- ‘expert’ by their peers and superiors. It was not clear, however, how
logical status. On average each participant raised 48 attributes the data of the two pilot nurses was actually incorporated into the
related to sedation assessment and management in the preinter- findings. That is, as their data was only pre-protocol, the reported
vention phase and 57 attributes postintervention. These attributes number of attributes after protocol was implemented could be
related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; expected to be influenced by two fewer participants. This issue was
post, 9%) and treatment (pre, 31%; post, 26%) aspects of care.
not addressed in the report.
Conclusions The fact that a number of strategies were used to educate the
Decision making in this setting is highly complex, incorporating a nurses about the sedation protocol should be applauded, as it is
wide range of attributes that concentrate primarily on assessment generally recognised that didactic education is not effective in
aspects of care. getting clinicians to use guidelines with multi-mode strategies, as
Relevance to clinical practice in this study. The method used for analysing data – that is, having
Clinical guidelines should provide support for strategies known to the observers analyse the data they collected, and the investigator
positively influence practice. Further, the education of nurses to also assessing the analysis – is a strength of the study. The research-
use such guidelines optimally must take into account the highly ers note that they integrated the think-aloud, observation and
complex iterative process and wide range of data sources used to interview data but do not elaborate how this was done, possibly
make decisions. because of the word limit imposed by the journal. Anyone inter-
ested in how this actually occurred would have to contact the
Critique researchers. In their discussion, the researchers note that they were
The study aim was to identify the concepts and attributes used by not able to determine the path between attributes and concepts
Australian critical care nurses in their decision making before and (i.e. which came first) or the actual decision-making methods used.
after the implementation of a nurse-initiated sedation protocol. A They note, however, that that they were able to identify relation-
number of educational strategies were used to support implemen- ships between attributes and concepts. They suggest that their
tation of the sedation protocol including: individual and group findings can be used by educators when designing educational
education; protocol and its supporting evidence placed on the activities such as concept mapping to help to develop decision-
intranet; laminated copies of the protocol available in the patient making skills in nurses. The findings were clearly reported, the
care areas; poster reminders; and audit and feedback. The aims table was easy to understand and the discussion considered the
of the study were easy to identify and clearly stated, but the inclu- implications of the main findings. Overall, this study provides addi-
sion of definitions of attributes and concepts would have been tional evidence about the concepts and attributes that critical care
helpful, because some phrases (such as level of sedation, comfort nurses draw on when they are making decisions about sedation.
14 S C O P E O F C R I T I C A L C A R E
9. Prien T, Meyer J, Lawin P. Development of intensive care medicine in
Germany. J Clin Anesth 1991; 3(3): 253–8.
Learning activities 10. Scribante J, Schmollgruber S, Nel E. Perspectives on critical care nursing:
South Africa. Connect: The World of Critical Care Nursing 2005; 3(4):
1. Consider the leaders to whom you are exposed in your 111–15.
work environment and identify the characteristics they 11. Grenvik A, Pinsky MR. Evolution of the intensive care unit as a clinical center
display that influence patient care. Reflect on whether and critical care medicine as a discipline. Crit Care Clinics 2009; 25(1):
these are characteristics that you possess or how you might 239–50.
develop them. 12. Fairman J, Lynaugh JE. Critical care nursing: a history. Philadelphia: University
of Pennsylvania Press; 1998.
2. Mentors are generally individuals who have excelled in 13. Underwood M, Elliott D, Aitken L et al. Position statement on postgraduate
their chosen profession and who are willing to share their critical care nursing education: October 1999. Aust Crit Care 1999; 12(4):
experiences and expertise with others. Think about your 160–4.
aspirations in your career as a critical care nurse. With the 14. Australian College of Critical Care Nurses. Competency standards for specialist
critical care nurses, 2nd edn. Melbourne: Australian College of Critical Care
help of others, try to identify a potential mentor. Consider Nurses; 2002.
asking this person to meet you on a regular basis to discuss 15. Aari R-L, Tarja S, Leino-Kilpi H. Competence in intensive and critical care
your professional goals and your strategies to meet these nursing: a literature review. Intensive Crit Care Nurs 2008; 24: 78–89.
goals and to provide you with advice. 16. Bench S, Crowe D, Day T et al. Developing a competency framework for
3. Review the strategies outlined in Table 1.2 and develop critical care to match patient need. Intensive Crit Care Nurs 2003; 19:
136–42.
a plan of how you might improve your clinical decision- 17. Coghlan J. Critical care nursing in Australia. Intensive Care Nurs 1986; 2(1):
making skills. Approach a mentor in your clinical environ- 3–7.
ment and ask him/her to provide feedback over a period of 18. Armstrong DJ, Adam J. The impact of a postgraduate critical care course on
nursing practice. Nurse Education in Practice 2002; 2(3): 169–75.
months on any changes observed in your clinical decision- 19. Badir A. A review of international critical care education requirements and
making skills. comparisons with Turkey. Connect: The World of Critical Care Nursing 2004;
4. Consider the role that you have within critical care and 3(2): 48–51.
examine the influence that research has on that role. How 20. Baktoft B, Drigo E, Hohl ML et al. A survey of critical care nursing education
might you use research to inform your practice more effec- in Europe. Connect: The World of Critical Care Nursing 2003; 2(3): 85–7.
tively? Are there strategies that you could implement to 21. Chaboyer W, Dunn SV, Aitken L et al. Critical care education: an examination
of students’ perspectives. Nurse Educ Today 2001; 21: 526–33.
influence the research that is undertaken so that it meets 22. Aitken L, Currey J, Marshall A et al. The diversity of critical care nursing
your needs? education in Australian universities. Australian Crit Care 2006; 19(2):
5. Reflect on your practice in terms of the ACCCN competency 46–52.
domains of professional practice; reflective practice; 23. European Commission Education & Training. The Bologna Process:
14
towards the European higher education area. European Commission; 2011.
enabling; clinical problem solving; teamwork; and leader- [Cited January 2011]. Available from: http://ec.europa.eu/education/higher-
ship. To what extent does your current practice address education/doc1290_en.htm.
these domains? What strategies can you implement to 24. Skees J. Continuing education: a bridge to excellence in critical care nursing.
enhance your practice in these domains? Crit Care Nurs Q 2010; 33(2): 104–16.
25. Hanley E, Higgins A. Assessment of clinical practice in intensive care: a
review of the literature. Intensive Crit Care Nurs 2005; 21(5): 268–75.
26. Hardcastle JE. ‘Back to the bedside’: graduate level education in critical care.
Nurse Educ Pract 2008; 8(1): 46–53.
FURTHER READING 27. Rose L, Goldsworthy S, O’Brien-Pallas L et al. Critical care nursing education
and practice in Canada and Australia: a comparative review. Int J Nurs Studies
2008; 45(7): 1103–9.
Andrew S, Halcomb EJ. Mixed methods research for nursing and the health sciences. 28. Gijbels H, O’Connell R, Dalton-O’Connor C et al. A systematic review evalu-
Oxford: Wiley-Blackwell; 2009. ating the impact of post-registration nursing and midwifery education on
Thompson C, Dowding D. Essential decision making and clinical judgment for nurses. practice. Nurse Educ Pract 2010; 10(2): 64–9.
Edinburgh: Churchill Livingstone; 2010. 29. Pirret A. Master’s level critical care nursing education: a time for review and
debate. Intensive Crit Care Nurs 2007; 23(4): 183–6.
REFERENCES 30. Nalle MA, Brown ML, Herrin DM. The Nursing Continuing Education Con-
sortium: a collaborative model for education and practice. Nurs Admin Q
1. Drennan K, Hicks P, Hart GK. Intensive care resources and activity: Australia & 2001; 26(1): 60–66.
New Zealand 2007/2008. Melbourne: Australian and New Zealand Intensive 31. Nursing and Midwifery Board of Australia. Australian Health Practitioner
Care Society; 2010. Regulation Agency; 2011. [Cited January 2011] Available from: http://www.
2. Rechner I, Lipman J. The costs of caring for patients in a tertiary referral nursingmidwiferyboard.gov.au.
Australian intensive care unit. Anaesth Intensive Care 2005; 33(4): 477–82. 32. Nursing Council of New Zealand. Welcome to the Nursing Council of New
3. Hilberman M. The evolution of intensive care units. Crit Care Med 1975; Zealand. Nursing Council of New Zealand; 2008. [Cited January 2011]. Avail-
3(4): 159–65. able from: http://www.nursingcouncil.org.nz/index.cfm/1,25,html/Home.
4. Wiles V, Daffurn K. There’s a bird in my hand and a bear by the bed – I must be 33. Cowan DT, Norman I, Coopamah VP. Competence in nursing practice: a
in ICU. The pivotal years of Australian critical care nursing. Melbourne: Austra- controversial concept – a focused review of literature. Nurs Educ Today 2005;
lian College of Critical Care Nurses; 2002. 25: 355–62.
5. World Federation of Critical Care Nurses. Constitution of the World Federa- 34. Boyle M, Butcher R, Kenney C. Study to validate the outcome goal, compe-
tion of Critical Care Nurses. 2007:1. Available from: http://www.wfccn.org/ tencies and educational objectives for use in intensive care orientation pro-
pub_constitution.php. grams. Aust Crit Care 1998; 11: 20–4.
6. American Association of Critical-Care Nurses. Critical care nursing fact sheet. 35. Fisher MJ, Marshall AP, Kendrick TS. Competency standards for critical care
Aliso Viejo CA: American Association of Critical Care Nurses; 2008. [Cited nurses: do they measure up? Aust J Adv Nurs 2005; 22(4): 32–9.
October 2010]. Available from: www.aacn.org. 36. American Association of Critical-Care Nurses. Scope of practice and standards
7. Australian College of Critical Care Nurses website. [Cited October 2010]. of professional performance for the acute and critical care clinical nurse specialist.
Available from: www.acccn.com.au. Aliso Viejo, CA: AACN; 2002.
8. Gordon IJ, Jones ES. The evolution and nursing history of a general intensive 37. American Association of Critical Care Nurses. [Cited January 2011] Available
care unit (1962–83). Intensive Crit Care Nurs 1998; 14(5): 252–7. from: http://www.aacn.org
Scope of Critical Care Practice 15
38. Williams G, Chaboyer W, Thornsteindottir R et al. World wide overview of 67. Thompson C, Dalgleish L, Bucknall T et al. The effects of time pressure and
critical care nursing organisations and their activities. Int Nurs Rev 2001; 48: experience on nurses’ risk assessment decisions: a signal detection analysis.
208–17. Nurs Res 2008; 57(5): 302–11.
39. World Federation of Critical Care Nurses (WFCCN). [Cited January 2011]. 68. Currey J, Worral-Carter L. Making decisions: nursing practices in critical care.
Available from: http://en.wfccn.org. Aust Crit Care 2001; 14(3): 127–31.
40. Benner P. Designing formal classification systems to better articulate knowl- 69. Aitken LM. Critical care nurses’ use of decision making strategies. J Clin Nurs
edge, skills, and meanings in nursing practice. Am J Crit Care 2004; 13(5): 2003; 12(4): 476–83.
426–30. 70. Currey J, Botti M. The influence of patient complexity and nurses’ experience
41. Hravnak M, Tuies P, Baldisseri M. Expanding acute care nurse practitioner on haemodynamic decision-making following cardiac surgery. Intensive Crit
and clinical nurse specialist education: invasive procedure training and Care Nurs 2006; 22(4): 194–205.
human simulation in critical care. AACN Clinical Issues 2005; 16: 89–104. 71. Hoffman KA, Aitken LM, Duffield C. A comparison of novice and expert
42. Angus DC, Carlet J. Surviving intensive care: a report from the 2002 Brussels nurses’ cue collection during clinical decision-making: verbal protocol analy-
Roundtable. Intensive Care Med 2003; 29(3): 368–77. sis. Int J Nurs Stud 2009; 46(10): 1335–44.
43. Bailly N, Perrier M, Bougle M et al. The relationship between palliative and 72. Hough M. Learning, decisions and transformation in critical care nursing
intensive care. Eur J Palliat Care 2003; 10(5): 199–201. practice. Nurs Ethics 2008; 15(3): 322.
44. Ball C. Defining the nursing contribution in critical care. Intensive Crit Care 73. Corcoran S, Narayan S, Moreland H. ‘Thinking aloud’ as a strategy to
Nurs 2001; 17(2): 65–6. improve clinical decision making. Heart Lung 1988; 17(5): 463–8.
45. Ball C, Cox CL. Restoring patients to health: outcomes and indicators of 74. Narayan S, Corcoran-Perry S. Teaching clinical reasoning in nursing
advanced nursing practice in adult critical care, Part One. Int J Nurs Pract education. In: Higgs J, Jones MA, Loftus S et al, eds. Clinical reasoning in
2003; 9(6): 356–67. the health professions, 3rd edn. Philadelphia: Butterworth-Heinemann; 2008.
46. Ball C, Cox CL. The core components of legitimate influence and the condi- p. 405–30.
tions that constrain or facilitate advanced nursing practice in adult critical 75. Rivett DA, Jones MA. Using case reports to teach clinical reasoning. In: Higgs
care. Int J Nur Prac 2004; 10(1): 10–20. J, Jones M, Loftus S et al, eds. Clinical reasoning in the health professions, 3rd
47. Fairley D. Discovering the nature of advanced nursing practice in high depen- edn. Philadelphia: Butterworth-Heinemann; 2008. p. 477–84.
dency care: a critical care nurse consultant’s experience. Intensive Crit Care 76. Davidson PM, Elliott D, Daly J. Clinical leadership in contemporary clinical
Nurs 2005; 21(3): 140–8. practice: implications for nursing in Australia. J Nurs Manag 2006; 14:
48. Lloyd Jones M. Role development and effective practice in specialist and 180–87.
advanced practice roles in acute hospital settings: systematic review and 77. Shirey MR. Authentic leaders creating healthy work environments for nursing
meta-synthesis. J Adv Nurs 2005; 49: 191–209. practice. Am J Crit Care 2006; 15(3): 256–68.
49. Martin KD. Trauma advanced practice nurses: implementing the role. J 78. Shirey MR, Fisher ML. Leadership agenda for change toward healthy work
Trauma Nurs 2004; 11(2): 67–74. environments in acute and critical care. Crit Care Nurse 2008; 28(5): 66.
50. Fry M, Borg A, Jackson S et al. The advanced clinical nurse, a new model of 79. Crofts L. A leadership programme for critical care. Intensive Crit Care Nurs
practice: meeting the challenge of peak activity periods. Aust Emerg Nurs J 2006; 22(4): 220–7.
1999; 2(3): 26–8. 80. Cook MJ. The renaissance of clinical leadership. Int Nurs Rev 2001;
51. Priestley G, Watson W, Rashidan A et al. Introducing critical care outreach: 48(1):38–46.
a ward-randomised trial of phased introduction in a general hospital. Inten- 81. De Geest S, Claessens P, Longerich H et al. Transformational leadership:
sive Care Med 2004; 30: 1398–404. worthwhile the investment! Eur J Cardiovasc Nurs 2003; 2(1): 3–5.
52. Eliott SJ, Ernest D, Doric AG et al. The impact of an ICU liaison nurse service 82. Manojlovich M. The effect of nursing leadership on hospital nurses’ profes-
on patient outcomes. Crit Care Resusc 2008; 10(4): 296–300. sional practice behaviors. J Nurs Adm 2005; 35(7–8): 366–74.
53. Endacott R, Chaboyer W, Edington J et al. Impact of an ICU liaison nurse 83. Murphy L. Transformational leadership: a cascading chain reaction. J Nurs
service on major adverse events in patients recently discharged from ICU. Manag 2005; 13(2): 128–36.
Resuscitation 2010; 81(2): 198–201. 84. Ohman KA. Nurse manager leadership. J Nurs Adm 1999; 29(12): 16, 21.
54. Green A, Edmonds L. Bridging the gap between intensive care unit and 85. Ohman KA. The transformational leadership of critical care nurse-managers.
general wards: the ICU liaison nurse. Intensive Crit Care Nurs 2004; 20: Dimens Crit Care Nurs 2000; 19(1): 46–54.
133–43. 86. Tregunno D, Jeffs L, Hall LM et al. On the ball: leadership for patient safety
55. Elliott D, Giles B, deLeon T et al. Development and implementation of an and learning in critical care. J Nurs Admin 2009; 39(7–8): 334–9.
instrument measuring CNCs’ activities. Aust J Adv Nurs 1992; 10: 26–34. 87. Dierckx de Casterlé B, Willemse A, Verschueren M et al. Impact of clinical
56. Gardner G, Gardner A, Middleton S et al. The work of nurse practitioners. J leadership development on the clinical leader, nursing team and care-giving
Adv Nurs 2010; 66(10): 2160–9. process: a case study. J Nurs Manag 2008; 16(6): 753–63.
57. Middleton S, Gardner G, Gardner A et al. The first Australian nurse practi- 88. McCloughen A, O’Brien L, Jackson D. Esteemed connection: creating a
tioner census: a protocol to guide standardized collection of information mentoring relationship for nurse leadership. Nurs Inq 2009; 16(4):
about an emergent professional group. Int J Nurs Pract 2010; 16(5): 326–36.
517–24. 89. Taylor CA, Taylor JC, Stoller JK. The influence of mentorship and role model-
58. Fonteyn ME, Ritter BJ. Clinical reasoning in nursing. In: Higgs J, Jones MA, ing on developing physician-leaders: views of aspiring and established phy-
Loftus S, Christensen N, eds. Clinical reasoning in the health professions, 3rd sician-leaders. J Gen Intern Med 2009; 24(10): 1130–34.
edn. Philadelphia: Butterworth-Heinemann; 2008. p. 235–44. 90. Williams AK, Parker VT, Milson-Hawke S et al. Preparing clinical nurse
59. Newell A, Simon HA. Human problem solving. Englewood Cliffs: Prentice- leaders in a regional Australian teaching hospital. J Continuing Educ Nurs
Hall; 1972. 2009; 40(12): 571–7.
60. Kassirer JP, Moskowitz AJ, Lau J et al. Decision analysis: a progress report. 91. Redman RW. Leadership succession planning: an evidence-based approach
Ann Intern Med 1987; 106(2): 275–91. for managing the future. J Nurs Admin 2006; 36(6): 292–7.
61. Bucknall TK. Critical care nurses’ decision-making activities in the natural 92. Waters D, Clarke M, Ingall AH et al. Evaluation of a pilot mentoring pro-
clinical setting. J Clin Nurs 2000; 9(1): 25–36. gramme for nurse managers. J Adv Nurs 2003; 42(5): 516–26.
62. Benner P, Tanner C. Clinical judgment: how expert nurses use intuition. Am 93. Flexner A. Is social work a profession? Proceedings of the National Conference
J Nurs 1987; 87(1): 23–31. of Charities and Corrections. Chicago: Hildermann Printing; 1915. p. 578–
63. Benner P, Tanner C, Chesla C. Expert practice. Expertise in nursing practice: 81.
caring, clinical judgment, and ethics, 2nd edn. New York: Springer Publishing 94. Friedson E. Professionalism reborn: theory, prophesy and policy. Cambridge:
Company; 2009. p. 137–69. Polity Press; 1994.
64. Currey J, Botti M. Naturalistic decision making: a model to overcome metho- 95. Brewer L. Bureaucratic organisation of professional labour. Aust N Z J Sociol
dological challenges in the study of critical care nurses’ decision making 1996; 32(3): 21–38.
about patients’ hemodynamic status. Am J Crit Care 2003; 12(3): 206–11. 96. International Council of Nurses. Guidelines on Specialisation in Nursing.
65. Benner P, Tanner C, Chesla C. From beginner to expert: gaining a differenti- Geneva: International Council of Nurses; 1992.
ated clinical world in critical care nursing. Adv Nurs Sci 1992; 14(3): 97. Halcomb EJ, Andrew S, Brannen J. Introduction to mixed methods research
13–28. for nursing and the health sciences. In: Andrew S, Halcomb EJ, eds. Mixed
66. Thompson C, Bucknall T, Estabrookes CA et al. Nurses’ critical event risk methods research for nursing and the health sciences. Oxford: Wiley-Blackwell;
assessments: a judgement analysis. J Clin Nurs 2009; 18(4): 601–12. 2009. p. 3–12.
16 S C O P E O F C R I T I C A L C A R E
98. Elliott D. Making research connections to improve clinical practice [edito- 102. Aitken LM, Marshall AP, Elliott R et al. Critical care nurses’ decision making:
rial]. Australian Crit Care 2000; 13:2–3. sedation assessment and management in intensive care. J Clin Nurs 2008;
99. Dunn S, Yates P. The roles of Australian chairs in clinical nursing. J Adv Nurs 18(1): 36–45.
2000; 31(1): 165–171. 103. Hough MC. Learning, decisions and transformation in critical care nursing
100. Marshall AP. Research priorities for Australian critical care nurses: Do we practice. Nurs Ethics 2008; 15(3): 322–31.
need them? Australian Crit Care 2004; 17(4): 142–50. 104. Ramezani-Badr F, Nasrabadi AN, Yekta ZP et al. Strategies and criteria for
101. Swenson-Britt E, Reineck C. Research education for clinical nurses: a pilot clinical decision making in critical care nurses: a qualitative study. J Nurs
study to determine research self-efficacy in critical care nurses. J Continuing Scholarship 2009; 41(4): 351–8.
Educ Nurs 2009; 40(10): 454–61.
Resourcing Critical Care 2
Denise Harris
Ged Williams
INTRODUCTION
Learning objectives
In 1966 Dr B Galbally, a hospital resuscitation officer at
St Vincent’s Hospital, Melbourne, published the first
After reading this chapter, you should be able to: article on the planning and organisation of an intensive
● describe historical influences on the development of critical care unit (ICU) in Australia. He identified that critically
1
care and the way this resource is currently viewed and used ill patients who have a reasonable chance of recovery
● explain the organisational arrangements and interfaces that require life-saving treatments and constant nursing and
may be established to govern a critical care unit medical care, but this intensity of service delivery ‘does
● identify external resources and supports that assist in the not necessarily continue until the patient dies, and it
governance and management of a critical care unit should not continue after the patient is considered no
● describe considerations in planning for the physical design longer recoverable’. 1
and equipment requirements of a critical care unit
● describe the human resource requirements, supports and The need for prudent and rational allocation of limited
training necessary to ensure a safe and appropriate financial and human resources was as important for
workforce Australia’s first ICU (St Vincent’s, Melbourne, 1961) as it
● explain common risks and the appropriate strategies, is for the 200 or more now scattered across Australia and
policies and contingencies necessary to support staff and New Zealand. This chapter explores the influences on the
patient safety development of critical care and the way this resource is
● discuss leadership and management principles that currently viewed and used; describes various organisa-
tional, staffing and training arrangements that need to be
influence the quality, efficacy and appropriateness of the in place; considers the planning, design and equipment
critical care unit needs of a critical care unit; covers other aspects of
● discuss common considerations from a critical care resource management including the budget; and finishes
perspective in responding to the threat of a pandemic.
with a description of how critical care staff may respond
to a pandemic. First, however, important ethical decisions
in managing the resources of a critical care unit, which
are just as important as the ethical resources that govern
the care decisions for an individual patient (see Chapter
6), are discussed below.
Key words
ETHICAL ALLOCATION AND
critical care UTILISATION OF RESOURCES
resource management In management, as in clinical practice, careful consider-
business case ation of the pros and cons of various decisions must be
staff made on a daily basis. The interests of the individual
competence patient, extended family, treating team, bureaucracy and
credentialling the broader community are rarely congruent, nor are they
governance usually consistent. Decisions surrounding the provision
skill mix of critical care services are often governed by a compro-
budget mise between conflicting interests and ethical theories.
risk management Two main perspectives on ethical decision making,
pandemic deontological and utilitarian, are explored briefly.
patient dependency The deontological principle suggests that a person has a
fundamental duty to act in a certain way – for example, 17
18 S C O P E O F C R I T I C A L C A R E
to provide full, active treatment to all persons. The rule Funding for critical care services has evolved over time
of rescue, or the innate desire to do something – anything to be somewhat separate from mainstream patient
– to help those in dire need, may be a corollary to the funding, owing to the unique requirements of critical
deontological principle. These two concepts, the duty to care units. Critical care is unique because patients are at
act and the rule of rescue, tend to sit well with many the severe end of the disease spectrum. For instance, the
trained and skilled clinicians and the Hippocratic Oath. funding provided for a patient admitted for chronic
In critical care there are some families and some clini- obstructive airway disease in an ICU on a ventilator is
cians who, for personal and/or religious reasons, take a very different from that provided for a patient with the
strong stand and demand treatments and actions based same diagnosis, but treated only in a medical ward. Each
on a deontological view (i.e. the fundamental belief that jurisdictional health department tends to create its own
a certain action is the only one that should be considered unique approach to funding ICU services in its jurisdic-
5
in a given situation). tion. For instance, Queensland tends to fund ICU
patients who are specifically identified and defined in
At the other extreme is the utilitarian view, which suggests
an action is right only if it achieves the greatest good for the Clinical Services Capability Framework for Intensive
6
the greatest number of people. This concept tends to sit Care with a prescribed price per diem, depending on
well with pragmatic managers and policy makers. An the level of intensive care given to the patient or a price
2
example of a utilitarian view might be to ration funding per weighted activity unit, as defined in the business
7
allocated to heart transplantation and to utilise any saved rules and updated on an annual basis. In Victoria, the
money for prevention and awareness campaigns. A heart diagnosis-related group (DRG) payment for individual
disease prevention campaign lends a greater benefit to a patient types admitted to the hospital also pays for
greater number in the population than does one trans- ICU episodes, with some co-payment elements added
8
plant procedure. for mechanical ventilation. In New South Wales a per
diem rate is established for ICU patients, while high-
The appropriate provision and allocation of critical care dependency patients in ICU are funded through the hos-
services and resources tend to sit somewhere between pital DRG payment; in South Australia a flat per diem
these two extreme positions. This dilemma is true of all rate exists. 9,10 Most other states have a global ICU budget
health services, but critical care, because of its high- payment system based on funded beds or expected occu-
technology, high-cost, low-volume outputs, is under par- pied bed days in the ICU. However, within states and
ticular scrutiny to justify its resource usage within a specific health services and hospitals the actual alloca-
healthcare system. Therefore, not only do critical care tion of funding to the ICU may vary, depending on the
managers need to be prudent, responsible and efficient nature of the specific ICU and demands and priorities
guardians of this precious resource – they need to be seen of the health service. 11
as such if they are to retain the confidence of, and legiti-
12
macy with, the broader community values of the day. The RAND study examined funding methods in many
countries and concluded that there was no obvious
example of ‘best practice’ or a dominant approach used
HISTORICAL INFLUENCES by a majority of systems. Each approach had advantages
An often-held view is that managers in government health and disadvantages, particularly in relation to the financial
3
services have no incentive to spend or expand services. risk involved in providing intensive care. While the risk
However, the opposite is probably true. Developing larger of underfunding intensive care may be highest in systems
and more sophisticated services such as ICUs can attract that apply DRGs to the entire episode of hospital care,
media and public attention. The 1960s and early 1970s including intensive care, concerns about potential under-
saw the development of the first critical care units in funding were voiced in all systems reviewed. Arrange-
Australia and New Zealand. If a hospital was to be rele- ments for additional funding in the form of co-payments
vant, it had to have one. In fact, what distinguished a or surcharges may reduce the risk of underfunding.
tertiary referral teaching hospital from other hospitals However, these approaches also face the difficulty of
12
was, at its fundamental conclusion, the existence of a determining the appropriate level.
4
critical care unit. Over time, practical reasons for estab-
lishing critical care units have led to their spread to most At the hospital level, most critical care units have capped
acute hospitals with more than 100 beds. Reasons for the and finite budgets that are linked to ‘open beds’ – that is,
proliferation of critical care services include, but are not beds that are equipped, staffed and ready to be occupied
limited to: by a patient, regardless of whether they are actually occu-
13
pied. This is one crude yet common way that hospitals
● economies of scale by cohorting critically ill patients can control costs emanating from the critical care unit.
to one area The other method is to limit the number of trained and
● development of expertise in doctors and nurses who experienced nurses available to the specialty; conse-
specialise in the care and treatment of critically ill quently, a shortage of qualified critical care nurses results
patients in a shortage of critical care beds, resulting in a rationing
● an ever-growing body of research demonstrating that of the service available. The capping of beds and qualified
critically ill patient outcomes are better if patients are critical care nurse positions can be convenient mecha-
cared for in a specifically equipped and staffed critical nisms to limit access and utilisation of this expensive
care unit. 4 service – critical care.
Resourcing Critical Care 19
Funding based on achieving positive patient outcomes
would be ideal, as it would ensure that critical care units TABLE 2.1 Approaches to assessing treatment options 12
were using their resources only for those patients who
were most likely to achieve positive outcomes in terms of Approach Description
morbidity and mortality, but such an ideal has not devel-
oped sufficiently to date. Funding based on health out- Benefit–risk The benefit of treatment and the inherent
risks to the patient are assessed to inform
approach
comes only does, however, raise the risk of encouraging a decision; this approach excludes
clinicians to ‘cherry-pick’ only the most ‘profitable’ or monetary costs.
‘successful’ patient groups at the expense of others. In Benefit–cost Evaluate the benefit and cost of the
private (for-profit) hospitals or countries with very poor approach decision to proceed; this approach
health systems, ‘cherry-picking’ only those patients for incorporates cost to patient and society.
whom a successful outcome is guaranteed is likely to be Implicit approach The medical practitioner provides the
more common, whereas in the public hospitals of most service and judges its appropriateness.
Western countries an educated guess/risk is often applied
to the decision as to whether a patient should enter the
critical care unit or not. suggested that if all healthcare provided were appropriate,
3
It is vital to note the very important role played by rural rationing would not be required. Defining what is
and isolated health services and, in particular, critical care ‘appropriate’ can be subjective, although not always. The
12,20
units and outreach services in these regions. Many of the RAND group suggests that there are at least three
contemporary activity-based funding formulas are diffi- approaches that can be used to assess appropriateness of
cult to apply to these settings. There are diseconomies of care (Table 2.1). These include the benefit–risk, benefit–
scale in such settings as a result of small bed numbers, cost and implicit approaches.
limited but highly skilled nurses and doctors, and unpre- The first two approaches are considered to be explicit
dictable peaks and troughs in demand, which make approaches, while the third tends to be subjective.
workforce planning and the management of call-in/over- However, all approaches have a subjective element. While
time and fatigue problems difficult for small teams to the implicit approach is considered to be subjective in
manage. The professional isolation and limited access to nature, the medical practitioner must contemplate
education, training and peer support can also create ‘benefit–risk’ and ‘benefit–cost’ considerations but should
morale problems for some members of the team. Further- also involve the patient/family in the contemplation and
more, the diseconomies and isolation require empathetic ultimate decision. What is best for the patient is not just
funding processes to recognise the difficulties unique to the opinion of the treating doctor and needs to be
regional and isolated critical care services. If such units considered in much broader terms, such as the patient’s
are to remain viable and capable of delivering levels of previous expressed wishes and the family’s opinion as
safe and effective care equivalent to those expected in de-facto patient representatives. The quality of the deci-
larger metropolitan hospitals, then additional funding sion and the quality of the expected outcome require
and support is required to compensate for the cost and many competing considerations.
tyranny of distance.
The ‘quality’ agenda in healthcare has argued for ‘best
ECONOMIC CONSIDERATIONS practice’ and ‘best outcomes’ in the provision of health
services, although it may be more pragmatic to consider
AND PRINCIPLES ‘value’ when discussing what is and what is not an appro-
One early comprehensive study of costs found that 8% priate decision in critical care. The following equation
of patients admitted to the ICU consumed 50% of expresses the concept ‘value’ simply:
resources but had a mortality rate of 70%, while 41% of Quality Benefit × Sustainability
patients received no acute interventions and consumed Value = =
×
only 10% of resources. More recent Australian studies Cost Price Suffering
14
show that, although critical care service is increasingly The quality of the outcome is a function of the benefit to
being provided to patients with a higher severity of acute be achieved and the sustainability of the benefit. The
and chronic illnesses, long-term survival outcome has benefit of critical care is associated with such factors as
improved with time, suggesting that critical care service survival, longevity and improved quality of life (e.g.
may still be cost-effective despite the changes in greater functioning capacity and less pain and anxiety).
case-mix. 15,16 The benefit is enhanced by sustainability: the longer the
benefit is maintained, the better it is. 21
An Australian study showed that in 2002, ICU patients
cost around $2670 per day or $9852 per ICU admission, Cost is separated into two components, monetary (price)
with more than two-thirds going to staff costs, one-fifth and non-monetary (suffering). Non-monetary costs
to clinical consumables and the rest to clinical support include such considerations as morbidity, mortality, pain
and capital expenditure. Nevertheless, some authors and anxiety in the individual, or broader societal costs
17
provide scenarios as examples of poor economic decision and suffering (e.g. opportunity costs to others who might
making in critical care and argue for less extreme vari- have used the resources but for the current occupants, and
ances in the types of patient ICUs choose to treat in order what other health services might have been provided but
to reduce the burden of the health dollar. 18,19 Others have for the cost of this service). 21
20 S C O P E O F C R I T I C A L C A R E
Ethico-economic analyses of services like critical care and the hourly rate of pay and any penalties that are to be
expensive treatments like organ transplantation are the attributed to work done during the after-business-hours
new consideration of this century and are as important period. Non-productive hours include sick leave, holiday
to good governance as are discussions of medico-legal leave, paid education hours, paid maternity leave and any
considerations. Sound ethical principles to inform and other paid time away from the actual job that staff are
guide human and material resource management and employed to do.
budgets ought to prevail in the management of critical Personnel budgets tend to be fixed costs, in that the
care resources. 2
majority of staff are employed permanently, based on an
BUDGET expected or forecast demand. Prudent managers tend to
employ 5–10% less than the actual forecast demand and
This section provides information on types of budget, the use casual staff to ‘flex-up’ the available FTE staff esta-
budgeting process, and how to analyse costs and expen- blishment in periods of increasing demand, hence con-
diture to ensure that resources are utilised appropriately. tributing a small but variable component to the personnel
As noted by one author, ‘Nothing is so terrifying for clini- budget. 22
cians accustomed to daily issues of life and death as to
be given responsibility for the financial affairs of their Operational Budget
hospital division!’. Yet, in essence, developing and man- All other non-personnel costs (except major capital
3
aging a budget for a critical care unit follows many of the equipment) tend to be allocated to the operational
same principles as managing a family budget. Consider- budget. This includes fixed costs such as minor equip-
ation of value for money, prioritising needs and wants, ment, maintenance contracts, utility costs (e.g. electric-
and living within a relatively fixed income is common to ity), and variable costs that fluctuate with patient type
all. This section in no way undermines the skill and preci- and number (e.g. pharmaceuticals, meals, consumable
sion provided by the accounting profession, nor will it supplies such as gloves and dressings, laundry).
enable clinicians to usurp the role of hospital business
managers. Rather, the aim is to provide the requisite Compared with personnel costs, operational costs in criti-
knowledge to empower clinicians to manage the key cal care tend to be relatively small, but they can be
components of budget development and budget setting, managed and rationed with the help of good information
and to know what questions to ask when confronted by and cooperation. For example, there is a range of dressing
this most daunting responsibility of managing a unit’s or materials available on the market, and a simple dressing
service’s budget. that requires less expensive materials should always be
used unless a more expensive product is indicated and a
TYPES OF BUDGET protocol exists to inform staff of this clinical need.
There are essentially three types of budget that a manager Fixed costs can also be turned into variable costs and
must consider: personnel, operational and capital. Within hence encourage efficient usage. For example, pressure-
these budget types, there are two basic cost types: fixed reduction mattresses, traditionally purchased as a fixed
and variable. Fixed costs are those essential to the service asset with variable (and unpredictable) repair and main-
and are relatively constant, regardless of the fluctuations tenance costs, can now be leased on a per-day or per-week
in workload or throughput (e.g. nurse unit manager basis, with no need for storage, cleaning or maintenance
salary, security, ventilators). Variable costs change with costs. Further, critical care managers can work with other
changing throughput (e.g. nurse agency usage or staff hospital managers to create ‘purchasing power’ by coop-
overtime), especially if used in response to influx of erating to standardise the range of products used to obtain
demand and resulting consumables such as linen, dress- a better price for a product that will benefit all users.
ings and drugs.
Capital Budget
Personnel Budget Capital budget items are generally expensive and/or large
Healthcare is a labour-intensive service, and critical care fixed assets that are considered long-term investments,
epitomises this fact with personnel costs, the most expen- such as building extensions, renovations and large equip-
sive component of the unit’s budget. The staffing require- ment purchases. Capital budget items tend to be con-
ment for critical care generally follows a formula of x sidered as assets that are depreciated over time. Most
nurses per open (funded) bed. This figure is expressed hospitals consider these items as a global asset – that is,
in full time equivalents (FTEs): in Australia, the equiva- as a group of investment items and activities for the hos-
lent of a person working a 38-hour week. This equates pital – rather than attributing these costs to an individual
to 5 × 8-hour shifts per week with an 8-hour accrued unit or department.
day off every 4 weeks, or 19 × 12-hour shifts in a
6-week period. To request a capital budget item, a written proposal is
required describing the item, its expected benefits,
Personnel costs include productive and non-productive whether it replaces an existing item’s service or function,
hours. Productive hours are those utilised to provide the cost, possible revenue and cost-mitigating benefits.
direct work. A manager will determine the minimum or This analysis does not always have to demonstrate a
optimum number of nurses to be rostered per shift and profit, although the value and benefit of the service would
then calculate the nursing hours per day, multiplied by need to be established.
Resourcing Critical Care 21
BUDGET PROCESS responsibility for the budget performance can encourage
The budget includes three fundamental steps: budget an esprit de corps and improvements from the whole
preparation and approval, budget analysis and reporting, team that a single manager cannot achieve alone.
and budget control or action.
DEVELOPING A BUSINESS CASE
Budget Preparation and Approval The most common reason for writing a business case is
A budget plan essentially runs in parallel with a unit or to justify the resources and capital expenditure to gain
service management plan, forecasting likely activity and the support and/or approval for a change in service provi-
resulting financial costs. In most circumstances the pre- sion and/or purchase of a significant new piece of
ceding year’s activity and costs are a good benchmark on equipment/technology. This section provides an overview
which to base the next year’s budget. However, hospital of a business case and a format for its presentation. The
expectations in terms of new services, greater patient business case can be an invaluable tool in the strategic
throughput or changes to staff entitlements will need to decision-making process, particularly in an environment
23
be factored into the new budget. of constrained resources.
A business case is a management tool that is used in the
The budget period is generally a financial year, but devel-
oping monthly budgets (cash flowing) to coincide with process of meeting the overall strategic plan of an organi-
predictable variations allows for a more realistic represen- sation. Within a setting such as healthcare, the business
tation of how costs are incurred and paid throughout the case is required to outline clearly the clinical need and
financial year period. If the budget plan is well constructed, implications to be understood by leaders. Financial
one always hopes and expects the final budget allocation imperatives, such as return on investment, must also be
23–25
(i.e. the approved budget) to be close to achievable. defined and identified. A business case is a document
in which all the facts relevant to the case are documented
Budget Analysis and Reporting and linked cohesively. Various templates are available
(see Online Resources) to assist with the layout. Key ques-
Most critical care managers analyse their expenditure tions are generally the starting point for the response to
against budget projections on a monthly basis, to identify a business case: why, what, when, where and how, with
variances from planned expenditure. Information should each question’s response adding additional information
not merely be financial: a breakdown of the monthly and to the process (Table 2.2). Business cases can vary in
year-to-date expenditures for personnel (productive and length from many pages to just a couple. Most organisa-
non-productive), and operational (fixed and variable) tions will have standardised headings and formats for the
costs, should be matched against other known measur- presentation of these documents. If the document is
able indicators of activity or productivity (e.g. patient lengthy, the inclusion of an executive summary is recom-
bed-days, patient types/DRGs and staffing hours, includ- mended, to summarise the salient points of the business
ing overtime and other special payments). 3 case (Box 2.1).
One common management maxim is: if it cannot be
measured, then it cannot be controlled. Clinical manag-
ers therefore need to work closely with finance managers
to develop consistent data measurements and reports to TABLE 2.2 Key questions in writing a business case
inform themselves and staff about where they should
focus their efforts to achieve the approved budget target. Question Example
Why? What is the background to the project, and why is it
Budget Control and Action needed: PEST (political, economic, sociological,
technological) and SWOT (strengths, weaknesses,
When signs of poor performance or financial overrun are opportunities and threats) analysis?
evident, managers cannot merely analyse the financial
reports, hoping that things will sort themselves out. Every What? Clearly identify and define the project and the
variance of a sizeable amount requires an explanation. purpose of the business case and outline the
solution. Clearly defined, measurable benefits
Some will be obvious: an outbreak of community influ- should be documented; goals and outcomes.
enza among staff will increase sick leave and casual staff
costs for a period of time. Other overruns can be insidious What if? A risk assessment of the current situation, including
any controls currently in place to address/mitigate
but no less important: overtime payments, although the issue, and a risk assessment following the
sometimes unavoidable, can also reflect poor time man- implementation of the proposed solution.
agement or a culture of some staff wanting to boost their When? What are the timelines for the implementation and
income surreptitiously. 22 achievement of the project/solution?
An effective method of controlling the budget is Where? What is the context within which the project will be
actively to engage staff in the process of managing undertaken, if not already included in the
costs. Managers can explain to staff how the budget has background material?
been developed and how their performance against How? How much money, people and equipment, for
budget is progressing, and identify areas for potential example, will be required to achieve the benefits?
improvement. Seeking ideas from staff on how to improve A clear cost–benefit analysis should be included in
efficiency and productivity and giving them some response to this question.
22 S C O P E O F C R I T I C A L C A R E
BOX 2.1 Business case: sample headings TABLE 2.3 Basic equipment requirements
Title Monitoring Therapeutic
Purpose
Background Monitors (including central station) Ventilators (invasive and
non-invasive)
End-tidal CO 2 monitoring
Key issues Arterial blood gas analyser Infusion pumps
Cost–benefit analysis (±electrolytes) Syringe drivers
Recommendations Invasive monitoring CVVHDF
Risk assessment ● arterial EDD-f
● central venous pressure Resuscitators
● intracranial pressure Temporary pacemaker
● PiCCO Defibrillator
● pulmonary artery Suctioning apparatus
Access to image intensifier
In summary, the business case is an important tool that Ultrasound
is increasingly required at all levels of an organisation to Access to CT/MRI
clearly define a proposed change or purchase. This docu-
ment should include clear goals and outcomes, a cost- CT = computerised tomography; CVVHDF = continuous veno-venous
haemodiafiltration; EDD-f = extended daily dialysis filtration; MRI =
benefit analysis and timelines for achievement of the magnetic resonance imaging; PiCCO = pulse-induced contour cardiac
solution. output.
CRITICAL CARE ENVIRONMENT
A critical care unit is a distinct unit within a hospital that non-essential), data points and task lighting sufficient for
has easy access to the emergency department, operating use during the performance of bedside procedures.
theatre and medical imaging. It provides care to patients Further detailed descriptions are available in various
with a life-threatening illness or injury and concentrates health department documents. 26
the clinical expertise and technological and therapeutic
resources required. The College of Intensive Care Medi- EQUIPMENT
26
cine (CICM) defines three levels of intensive care to
support the role delineation of a particular hospital, Since the advent of critical care units, healthcare delivery
dependent upon staffing expertise, facilities and support has become increasingly dependent on medical techno-
services. Critical care facilities vary in nature and extent logy to deliver that care. Equipment can be categorised
27
between hospitals and are dependent on the operational into several funding groups: capital expenditure (gener-
policies of each individual facility. In smaller facilities, ally in excess of $10,000), equipment expenditure (all
the broad spectrum of critical care may be provided in equipment less than $10,000), and the disposable prod-
combined units (intensive care, high-dependency, coro- ucts and devices required to support the use of equip-
nary care) to improve flexibility and aid the efficient use ment. This section examines how to evaluate, procure and
of available resources. 26 maintain that equipment.
ORGANISATIONAL DESIGN INITIAL SET-UP REQUIREMENTS
The functional organisational and unit designs are gov- Critical care units require baseline equipment that allows
erned by available finances, an operational brief and the the unit to deliver safe and effective patient care. The list
building and design standards of the state or country in of specific equipment required by each individual unit
which the hospital is located. A critical care unit should will be governed by the scope of that unit’s function. For
have access to minimum support facilities, which include example, a unit that provides care to patients after neu-
staff station, clean utility, dirty utility, store room(s), rosurgery will require the ability to monitor intracranial
education and teaching space, staff amenities, patients’ pressure. Table 2.3 lists the basic equipment requirements
ensuites, patients’ bathroom, linen storage, disposal for a critical care unit.
room, sub-pathology area and offices. Most notably, the
actual bed space/care area for patients needs to be well PURCHASING
designed. 26
The procurement of any equipment or medical device
The design of the patient’s bed-space has received consid- requires a rigorous process of selection and evaluation.
erable attention in the past few years. In Australia, most This process should be designed to select functional, reli-
state governments have developed minimum guidelines able products that are safe, cost-effective and environ-
to assist in the design process. Each bed space should be mentally conscious and that promote quality of care
28
a minimum of 20 square metres and provide for visual while avoiding duplication or rapid obsolescence. In
privacy from casual observation. At least one handbasin most healthcare facilities, a product evaluation commit-
per single room or per two beds should be provided tee exists to support this process, but if this is not the case
26
to meet minimum infection control guidelines. Each it is strongly recommended that a multidisciplinary com-
bed space should have piped medical gases (oxygen and mittee be set up, particularly when considering the pur-
air), suction, adequate electrical outlets (essential and chase of equipment requiring capital expenditure. 29
Resourcing Critical Care 23
provided in-house by individual facility biomedical
BOX 2.2 Example criteria for product departments or as part of a service contract arrangement
evaluation 28,29 with the vendor company. The provision of a maintenance/
service plan should be clearly identified during the pro-
● Safety curement phase of the equipment’s purchase process.
● Performance While equipment maintenance is not the direct respon-
● Quality sibility of the nurses in charge of the unit, they should be
● Use aware of the maintenance plan for all equipment and
● purpose ensure that timely maintenance is undertaken.
● ease of Routine ongoing care of equipment is outlined in the
● Cost–benefit analysis product information and user manuals that accompany
● include disposables devices. This documentation clearly outlines routine care
● Cleaning required for cleaning, storage and maintenance. All staff
● central sterilising supply unit (CSSU) involved in the maintenance of clinical equipment should
● infection control be trained and competent to carry it out. As specialist
● Regulatory control equipment is a fundamental element of critical care,
● Therapeutic Goods Administration effective resourcing includes consideration of the pur-
● Australian Standards chase, set-up, maintenance and replacement of equip-
● Adaptability to future technological advancements ment. Equipment is therefore an important aspect of the
● Service agreements budget process.
● Training requirements
STAFF
The product evaluation committee should include Staffing critical care units is an important human resource
members who have an interest in the equipment being consideration. The focus of this section is on nursing
considered and should comprise, for example, biomedi- staff, although the important role that medical staff and
cal engineers and representatives from the central sterile other ancillary health personnel provide is acknowledged.
supply unit (CSSU), administration, infection control, Nurses’ salaries consume a considerable portion of any
end users and other departments that may have similar unit budget and, owing to the constant presence of nurses
needs. Once a product evaluation committee has been at the bedside, appropriate staffing plays a significant role
established, clear, objective criteria for the evaluation of in the quality of care delivered. Nurse staffing levels influ-
the product should be determined (Box 2.2). Ideally, the ence patient outcomes both directly, through the initia-
committee will screen products and medical devices tion of appropriate nursing care strategies, and indirectly,
before a clinical evaluation is conducted to establish its by mediating and implementing the care strategies of
viability, thus avoiding any unnecessary expenditure in other members of the multidisciplinary healthcare team.
time and money. 28 Therefore, ensuring an appropriate skill mix is an impor-
tant aspect of unit management. This section considers
The decision to purchase or lease equipment will, to some how appropriate staffing levels are determined and the
extent, be governed by the purchasing strategy approved factors, such as nurse–patient ratios and skill mix, that
by the hospital or state government. The advantages of influence them.
leasing equipment include the capital expenditure being
defrayed over the life of the lease (usually 36 months),
with ongoing servicing and product upgrades built into STAFFING ROLES
the lease agreement and price structure. Any final presen- There are a number of different nursing roles in the ICU
tation from the product evaluation committee should nursing team, and various guidelines determine the
therefore include a recommendation to purchase or lease, requirements of these roles. Both the Australian College
based on a cost–benefit analysis of the ongoing expendi- of Critical Care Nurses (ACCCN) (see Appendix B2) and
ture required to maintain the equipment. the World Federation of Critical Care Nurses (WFCCN)
(see Appendix A2) have position statements surrounding
REPLACEMENT AND MAINTENANCE the critical care workforce and staffing. A designated
The process for replacement of equipment is closely nursing manager (nursing unit manager/clinical nurse
aligned with the process for the purchase of new equip- consultant/nurse practice coordinator/clinical nurse
ment. The stimulus for the process to begin, however, can manager, or equivalent title) is required for each unit to
be either the condemning of equipment by biomedical direct and guide clinical practice. The nurse manager
engineers or the planned replacement of equipment must possess a post-registration qualification in critical
27,30
nearing the end of its life cycle. In general, capital equip- care or in the clinical specialty of the unit. A clinical
ment is deemed to have a life cycle of five years. This time nurse educator (CNE) should be available in each unit.
frame takes into account both the longevity of the physi- The ACCCN recommends a minimum ratio of one full-
cal equipment and its technology. time equivalent (FTE) CNE for every 50 nurses on the
roster, to provide unit-based education and staff develop-
Ongoing maintenance of equipment is an important part ment. 27,30 The clinical nurse consultant (CNC) role is
of facilitating safety within the unit. Maintenance may be utilised at the unit, hospital and area health service level
24 S C O P E O F C R I T I C A L C A R E
30
to provide resources, education and leadership. Regis- helpful for new units to contact a unit of similar size and
tered nurses within the unit are generally nurses with service profile to ascertain their experiences.
formal critical care postgraduate qualifications and
varying levels of critical care experience. NURSE-TO-PATIENT RATIOS
Prior to the mid-1990s, when specialist critical care nurse Nurse-to-patient ratios refer to the number of nursing
education moved into the tertiary education sector, criti- hours required to care for a patient with a particular set
cal care education took the form of hospital-based certifi- of needs. With approximately 30% of Australian and New
31
cates. Since this move, postgraduate, university-based Zealand units identified as combined units incorporating
programs at the graduate certificate or postgraduate intensive care, coronary care and high-dependency
diploma level are now available, although some hospital- patients, different nurse-to-patient ratios are required
34
based courses that articulate to formal university pro- for these often diverse groups of patients. It is important
grams continue to be accessible. The ACCCN (see to note that nurse-to-patient ratios are provided
Appendix B1) and the WFCCN (see Appendix A1) have merely as a guide to staffing levels, and implementation
developed position statements on the provision of critical should depend on patient acuity, local knowledge and
care nursing education. Various support staff are also expertise.
required to ensure the efficient functioning of the depart-
ment, including, but not limited to, administrative/ Within the intensive care environment in Australia and
clerical staff, domestic/ward assistant staff and biomedi- New Zealand, there are several documents that guide
cal engineering staff. nurse-to-patient ratios (Table 2.4). The ACCCN has devel-
oped and endorsed two position statements that identify
STAFFING LEVELS the need for a minimum nurse-to-patient ratio of 1 : 1 for
intensive care patients and 1 : 2 for high-dependency
A staff establishment refers to the number of nurses patients. 30,35 In New Zealand, the Critical Care Nurses
required to provide safe, efficient, quality care to Section of the New Zealand Nursing Organisation
patients. Staffing levels are influenced by many factors, (NZNO) also determines that critically ill or ventilated
32
including the economic, political and individual char- patients require a minimum 1 : 1 nurse-to-patient ratio.
acteristics of the unit in question. Other factors, such Both of these nursing bodies state that this ratio is clini-
as the population served, the services provided by the cally determined. The WFCCN states that critically ill
hospital and by its neighbouring hospitals, and the sub- patients require one registered nurse to be allocated at all
specialties of medical staff working at each hospital also times. The College of Intensive Care Medicine (CICM)
36
influence staffing. Specific issues to be considered also identifies the need for a minimum nurse-to-patient
include nurse-to-patient ratios, nursing competencies ratio of 1 : 1 for intensive care patients and 1 : 2 for high-
and skill mix. dependency patients. 27,37
The starting point for most units in the establishment of The ACCCN and the NZNO Critical Care Nurses
30
minimum, or base, staffing levels is the patient census Section have outlined the appropriate nurse staffing
32
approach. This approach uses the number and classifica- standards in Australia and New Zealand for ICUs within
tion (ICU or HDU) of patients within the unit to deter- the context of accepted minimum national standards and
mine the number of nurses required to be rostered on evidence that supports best practice. The ACCCN state-
duty on any given shift. In Australia and New Zealand a ment identified 10 key principles to meet the expected
registered nurse-to-patient ratio of 1 : 1 for ICU patients standards of critical care nursing (Table 2.5).
and 1 : 2 for high-dependency unit (HDU) patients has
been accepted for many years. Recently in Australia there These recommendations serve merely to guide nurse-to-
have been several projects examining the use of endorsed patient ratios, as extraneous factors such as the clinical
enrolled nurses (EEN) in the critical care setting. The New practice setting, patient acuity and the knowledge and
South Wales project identified difficulties with EENs expertise of available staff will influence final staffing pat-
undertaking direct patient care, but determined that there terns. In particular, patient dependency scoring tools are
may be a role for them in providing support and assis- designed to guide these staffing decisions and are dis-
tance to the RN. 27,30,32 Other countries, such as the USA, cussed below.
have lower nurse staffing levels, but in those countries
nursing staff is augmented by other types of clinical or PATIENT DEPENDENCY
33
support staff, such as respiratory technicians. The limi-
tations of this staffing approach are discussed later in this Patient dependency refers to an approach to quantify the
chapter. Once the base staffing numbers per shift have care needs of individual patients, so as to match these
38
been established, the unit manager is required to calcu- needs to the nursing staff workload and skill mix. For
late the number of full-time equivalents that are required many years, patient census was the commonest method
to implement the roster. In Australia, one FTE is equal to for determining the nursing workload within an ICU.
a 38-hour working week. That is, the number of patients dictated the number of
nurses required to care for them, based on the accepted
The development of the nursing establishment is depen- nurse-to-patient ratios of 1 : 1 for ICU patients and 1 : 2
dent on many variables. Historical data from previous for HDU patients. This reflects the unit-based workload,
years of patient throughput and patient acuity assist in and is also the common funding approach for ICU
the determination of future requirements. It is often bed-day costs.
TABLE 2.4 Documents that guide the nurse-to-patient ratios in critical care
Document Recommendations
ACCCN: Position statement on ● ICU patients (clinically determined) should have a 1 : 1 nurse-to-patient ratio.
intensive care nurse staffing 30 ● HDU patients (clinically determined) should have a 1 : 2 nurse-to-patient ratio.
ACCCN: Position statement on the ● All intensive care patients must have a registered nurse (division 1) allocated exclusively to their care.
healthcare workers other than ● High-dependency or step-down patients (in intensive care) who require a nurse-to-patient ratio of
Division 1 Registered Nurses in 1 : 2 should have a registered nurse (division 1) allocated exclusively to their care.
Intensive Care 35 ● Enrolled nurses (division 2) and unlicensed assistive personnel may be allocated roles to assist the
registered nurse, but any activities that involve direct contact with the patient must always be
performed in the immediate presence of the registered nurse (division 1).
NZNO, Critical Care Section: ● The critically ill and/or ventilated patient will require a minimum 1 : 1 nurse-to-patient ratio.
Philosophy and Standards for ● At times, patients in the critical care unit may have higher or lower nursing acuity; the critical care
Nursing Practice in Critical Care 32 nurse in charge of the shift determines any variation from the 1 : 1 ratio, taking into account context,
skill mix and complexity.
WFCCN: Declaration of Buenos ● Critically ill patients (clinically determined) require one registered nurse at all times.
Aires, Position Statement on the ● High-dependency patients (clinically determined) in a critical care unit require no less than one
Provision of Critical Care Nursing nurse for two patients at all times.
Workforce 36
CICM: Minimum Standards for ● A minimum of 1 : 1 nursing is required for ventilated and other similarly critically ill patients, and
Intensive Care Units 27 nursing staff must be available to greater than 1 : 1 ratio for patients requiring complex management
(e.g. ventricular assist device).
● The majority of nursing staff should have a post-registration qualification in intensive care or in the
specialty of the unit.
● All nursing staff in the unit responsible for direct patient care should be registered nurses.
CICM: Recommendations on ● The ratio of nursing staff to patients should be 1 : 2.
Standards for High-Dependency ● All nursing staff in the HDU responsible for direct patient care should be registered nurses, and the
Units Seeking Accreditation for majority of all senior nurses should have a post-registration qualification in intensive care or
Training in Intensive Care high-dependency nursing.
Medicine 37 ● A minimum of two registered nurses should be present in the unit at all times when a patient is
present.
ACCCN = Australian College of Critical Care Nurses; NZNO = New Zealand Nurses Organisation; WFCCN = World Federation of Critical Care Nurses; CICM = College of
Intensive Care Medicine.
TABLE 2.5 Ten key points of intensive care nursing staffing 30
Point Description
1. ICU patients (clinically Require a standard nurse-to-patient ratio of at least 1 : 1.
determined)
2. High dependency patients Require a standard nurse-to-patient ratio of at least 1 : 2
(clinically determined)
3. Clinical coordinator (team There must be a designated critical-care-qualified senior nurse per shift who is supernumerary and whose
leader) primary role is responsibility for the logistical management of patients, staff, service provision and resource
utilisation during a shift.
4. ACCESS nurses These are nurses in addition to the bedside nurses, clinical coordinator, unit manager, educators and
non-nursing support staff. They provide Assistance, Coordination, Contingency, Education, Supervision
and Support.
5. Nursing manager At least one designated nursing manager (NUM/CNC/NPC/CNM or equivalent) who is formally recognised as
the unit nurse leader is required per ICU.
6. Clinical nurse educator At least one designated CNE should be available in each unit. The recommended ratio is one FTE CNE for
every 50 nurses on the ICU roster.
7. Clinical nurse consultants Provide global critical care resources, education and leadership to specific units, to hospital and area-wide
services, and to the tertiary education sector.
8. Critical care nurses The ACCCN recommends an optimum specialty qualified critical care nurse proportion of 75%.
9. Resources These are allocated to support nursing time and costs associated with quality assurance activities, nursing
and multidisciplinary research, and conference attendance.
10. Support staff ICUs are provided with adequate administrative staff, ward assistants, manual handling assistance/
equipment, cleaning and other support staff to ensure that such tasks are not the responsibility of nursing
personnel.
ACCCN = Australian College of Critical Care Nurses; CNC = clinical nurse consultant; CNE = clinical nurse educator; CNM = clinical nurse manager; FTE = full-time
equivalent; NPC = nurse practice coordinator; NUM = nursing unit manager.
26 S C O P E O F C R I T I C A L C A R E
The nursing workload at the individual patient level, registered nurses possessing a formal specialist critical
however, is also reflective of patient acuity, the complexity care qualification. The ACCCN recommends an optimum
of care required and both the physical and the psycho- qualified critical care nurse to unqualified critical care
38
30
logical status of the patient. Strict adherence to the nurse ratio of 75% (see Appendix B2). In Australia and
patient census model leads to the inflexibility of match- New Zealand, approximately 50% of the nurses employed
ing nursing resources to demand. For example, some ICU in critical care units currently have some form of critical
patients receive care that is so complex that more than care qualification. 34
one nurse is required, and an HDU patient may require Debate continues in an attempt to determine the
less medical care than an ICU patient, but conversely may optimum skill mix required to provide safe, effective
require more than 1 : 2 nursing care level secondary to nursing care to patients. 42–48 Much of the research fuelling
such factors as physical care requirements, patient confu- this debate has been undertaken in the general ward
38
sion, anxiety, pain or hallucinations. A patient census setting, and still predominantly in the USA. However, it
approach therefore does not allow for the varying nursing has provided the starting point for specialty fields of
hours required for individual patients over a shift, nor nursing to begin to examine this issue. The use of nurses
does it allow for unpredicted peaks and troughs in activ- other than registered nurses in the critical care setting has
ity, such as multiple admissions or multiple discharges.
been discussed as one potential solution to the current
There are many varied patient dependency/classification critical care nursing shortage. Projects in Australia trial-
tools available, with their prime purpose being to classify ling the use of EENs in the critical care environment have
patients into groups requiring similar nursing care and to largely proved inconclusive. 49
attribute a numerical score that indicates the amount of Published research on skill mix has examined the substi-
nursing care required. Patients may also be classified tution of one grade of staff with a lesser skilled, trained
according to the severity of their illness. These scoring or experienced grade of staff and has utilised adverse
systems are generally based on physiological variables, such events as the outcome measure. A significant proportion
as the acute physiological and chronic health evaluation of research suggests that a rich registered nurse skill mix
(APACHE) and simplified acute physiology score (SAPS) reduces the occurrence of adverse events. 42–48 A compre-
systems. Although these scoring systems have value in deter- hensive review of hospital nurse staffing and patient out-
mining the probability of in-hospital mortality, they are not comes noted that existing research findings with regard
good predictors of nursing dependency or workload. 38
to staffing levels and patient outcomes should be used to
The therapeutic intervention scoring system (TISS) was better understand the effects of skill mix dilution, and
developed to determine severity of illness, to establish justify the need for greater numbers of skilled profession-
nurse-to-patient ratios and to assess current bed utilisa- als at the bedside. 50
38
tion. This system attributes a score to each procedure/ While there has not been a formal examination of skill
intervention performed on a patient, with the premise mix in the critical care setting in Australia and New
that the greater the number of procedures performed, the Zealand, two publications 51,52 informing this debate
higher the score, the higher the severity of illness, the emerged from the Australian Incident Monitoring Study–
38
higher the intensity of nursing care required. Since its ICU (AIMS–ICU). Of note, 81% of the reported adverse
development in the mid-1970s, TISS has undergone mul- events resulted from inappropriate numbers of nursing
tiple revisions, but this scoring system, like APACHE and staff or inappropriate skill mix. Furthermore, nursing
51
SAPS, still captures the therapeutic requirements of the care without expertise could be considered a potentially
patient. It does not, however, capture the entirety of the harmful intrusion for the patient, as the rate of errors by
nursing role. Therefore, while these scoring systems may experienced critical care nurses was likely to rise during
provide valuable information on the acuity of the patients periods of staffing shortages, when inexperienced nurses
within the ICU, it must be remembered that they are not required supervision and assistance. These important
51
accurate indicators of total nursing workload. Other spe- findings provide some insight into the issues surrounding
cific nursing measures have been developed, but have not skill mix.
gained widespread clinical acceptance in Australia or New
Zealand. (For further discussion of nursing workload In Australia and New Zealand, an annual review of inten-
53
measures, see Measures of Nursing Workload or Activity in sive care resources reported that there were 6633.7 FTE
this chapter.) registered nurses currently employed in the critical care
nursing workforce (5587.2 in the public sector and
While not strictly workload tools, various early warning 1046.5 in the private sector). More recently, in 2005,
scoring systems are increasingly being used to facilitate categories of nurses in the workforce other than registered
the early detection of the deteriorating patient. These nurses were captured and reported for the first time,
early warning systems generally take the format of a stan- showing that there were 53.9 FTE enrolled nurses cur-
dardised observation chart with an in-built ‘track and rently employed in the critical care setting in Australia
trigger’ process. 39–41
34
(44.6 in the public sector and 9.3 in the private sector).
Enrolled nurse training has not occurred in New Zealand
SKILL MIX since 1993, and those who are currently employed in the
Skill mix refers to the ratio of caregivers with varying healthcare system are restricted to a scope of practice that
levels of skill, training and experience in a clinical unit. does not call for complex nursing judgements. Thus, no
In critical care, skill mix also refers to the proportion of enrolled nurses were reported to be working in critical
Resourcing Critical Care 27
The following example is for a six-bed intensive care unit. A roster has been determined to employ six
nurses using a three-shift/day approach (morning, evening, night [10 h]). A 2-hour morning (a.m.) to
afternoon (p.m.) shift handover period, and a 30-minute afternoon to night (ND) shift handover period, is
included. Local shift times and practices can be substituted.
Step 1 Calculate the number of working hours needed:
a.m. shift 0700 to 1530 = 7.6 h × 6 nurses × 7 days 319.2 h
p.m. shift 1330 to 2200 = 7.6 h × 6 nurses × 7 days 319.2 h
Night shift 2130 to 0730 = 10 h × 6 nurses × 7 days 420 h
Total 1058.4 h
These initial figures do not include sick leave or annual leave. An additional adjustment is therefore required
to factor in paid, unpaid, sick and study leave. A 22% ‘leave allowance’ is included to accommodate these
aspects. A locally derived figure may be substituted here, usually available from the finance or personnel
department.
Step 2 Adding the leave allowance:
1058.4 h × 1.22 (leave allowance) = 1291.2 h/38 h (1 FTE) = 33.9 FTEs
With a staffing pattern of six staff per shift, this unit requires an establishment of 33.9 full-time equivalents
(FTEs) to meet the needs of this roster. This figure does not include positions such as the nurse unit
manager, team leader/shift coordinator and clinical nurse educator, as outlined in the ACCCN guidelines 30
and Table 2.5.
FIGURE 2.1 Calculating staff requirements.
care settings at the time of the most recent annual review morning and evening shifts, with the option of a 10-hour
of intensive care resources in New Zealand. 34 night shift (Figure 2.1). With the increased demand for
flexible rosters has come the introduction of additional
Other professional organisations have also developed shift lengths, most notably the 12-hour shift. The imple-
position statements on the use of staff other than regis- mentation of a 12-hour roster requires careful consider-
tered nurses in the critical care environment. 54,55 The ation of its risks and benefits, with full consultation of all
Canadian Association of Critical Care Nurses (CACCN) parties, unit staff, hospital management and the relevant
states that non-regulated personnel may provide non- nurses’ union. Perceived benefits of working a 12-hour
direct and direct patient care only under the supervision roster include improvement in personal/social life,
54
of registered nurses. The British Association of Critical enhanced work satisfaction and improved patient care
Care Nurses (BACCN) similarly determines that health- continuity. Perceived risks, such as an alteration in the
care assistants employed in a critical care setting must level of sick-leave hours, decreased reaction times and
undertake only direct patient care activities for which reduced alertness during the longer shift, have not been
they have received training and for which they have been found to be significant. A reported disadvantage of
56
assessed competent under the supervision of a registered 12-hour shifts is the loss of the shift overlap time, which
nurse. 55
has traditionally been used for providing in-unit educa-
Staffing levels and skill mix within Australian and New tional sessions. A consideration, therefore, for units
Zealand units should therefore be based on individual proposing the implementation of a 12-hour shift pattern
unit needs (e.g. unit size and location) and patient clini- is to build formal staff education sessions into the
cal presentations/acuity, and be guided by the best avail- proposal.
able evidence to ensure safe, quality care for their
patients. EDUCATION AND TRAINING
In the mid-1990s, specialist critical care nursing qualifica-
ROSTERING tions made the transition from hospital-based courses to
Once the nursing establishment for a unit is determined the tertiary education sector. While some hospitals main-
and skill mix considered, the rostering format is decided. tain in-house critical care courses, these are generally
In this time of nursing shortages, one of the factors identi- designed to meet the tertiary requirements of postgradu-
fied as affecting the retention of staff is the ability to ate education and to articulate with higher-level univer-
provide flexibility in rostering practices. To some extent, sity programs.
rostering practices are governed by individual state
nursing awards, and these should be considered when Some organisations, both private and public, continue to
deciding the roster format for individual units. offer a variety of short continuing education courses as
well, generally at a fairly basic level of knowledge and
The traditional shift pattern is contingent on a 38-hour skills, but which play a role in providing an introduction
31
per week roster for full-time staff and is based on 8-hour for a novice practitioner. Position statements on the
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