Nurse Practitioners (NPs) and ACNPs manage clinical care of a group of patients and have various levels of prescriptive authority, depending on the state and practice area in which they work. They also provide care consistency, interact with families, plan for patient discharge, and provide teaching to patients, families, and other members of the heath care team.1

The American Association of Critical-Care Nurses (AACN) has established nursing standards to provide a framework for critical care nurses. The standards are authoritative statements that describe the level of care and performance by which the quality of nursing care can be judged. Standards serve as descriptions of expected nursing roles and responsibilities.2 The six AACN Standards of Care for Acute and Critical Care Nursing Practice are prescriptive of a competent level of nursing practice: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.

Much of early medical and nursing practice was based on nonscientific traditions that resulted in variable and haphazard patient outcomes.3 These traditions and rituals, which were based on folklore, gut instinct, trial and error, and personal preference, were often passed down from one generation of practitioners to another.^3–5 Examples of nonscientific-based critical care nursing practice include suctioning artificial airways every two hours, using iced saline injectable when measuring cardiac output, always using lead II for cardiac monitoring, stripping chest tubes every two hours, and limiting visiting hours for all patients.⁴

The dramatic and multiple changes in health care and the ever-increasing presence of managed care in all geographic regions have placed greater emphasis on demonstrating the effectiveness of treatments and practices on outcomes.^6,7 In addition, emphasis is greater on efficiency, cost-effectiveness, quality of life, and patient satisfaction ratings.⁸ It has become essential for nurses to use the best data available to make patient care decisions and carry out the appropriate nursing interventions.⁸ By means of a scientific basis, with its ability to explain and predict, nurses are able to provide research-based interventions with consistent, positive outcomes. The content of this book is evidence based, with the most current, cutting-edge research abstracted and placed throughout the chapters as appropriate to topical discussions.

The increasingly complex and changing health care system presents multiple challenges for creating an evidence-based practice. Not only must appropriate research studies be designed to answer clinical questions, but also research findings must be used to make necessary changes for implementation in practice.⁹ Multiple evidence-based practice and research utilization models exist to guide practitioners in the use of existing research findings. One such model is the Iowa Model of Evidence-Based Practice to Promote Quality Care, which incorporates both evidence and research as the basis for practice.¹⁰ Inquisitive practitioners who strive for best practices using valid and reliable data will demonstrate quality outcomes-driven care and practices.¹¹

Evidence-based nursing practice considers the best research evidence on the care topic, along with clinical expertise of the nurse, and patient preferences.¹² For instance, when determining the frequency of vital sign measurement, the nurse would use available research, nursing judgment (stability, complexity, predictability, vulnerability, and resilience of the patient),¹³ along with the patient’s preference for decreased interruptions and the ability to sleep for longer periods of time. At other times the nurse will implement an evidence-based protocol or procedure that is based on evidence, including research. An example of an evidence-based protocol is one in which the prevalence of indwelling catheterization and incidence of hospital-acquired catheter-associated urinary tract infections in the critical care unit can be decreased.¹⁴

The AACN has promulgated several practice summaries in the form of a “Practice Alert.” These alerts are short directives that can be used as a quick reference for practice areas (e.g., oral care, noninvasive blood pressure monitoring, ST segment monitoring). They are succinct, supported by evidence, and address both nursing and multidisciplinary activities. Each alert includes the clinical information, followed by references that support the practice.¹⁵

The high-technology–driven critical care environment is fast paced and directed toward monitoring and treating life-threatening changes in patient conditions. For this reason, attention is often focused on the technology and treatments necessary for maintaining stability in the physiological functioning of the patient. Great emphasis is placed on technical skills, professional competence, and responsiveness to critical emergencies. Concern has been voiced about the lesser emphasis on the caring component of nursing in this fast-paced, highly technological health care environment.16,17 Nowhere is this more evident than in areas where critical care nursing is practiced. Keeping the care in nursing care is one of the greatest challenges.¹⁷ The critical care nurse must be able to deliver high-quality care skillfully, using all applicable technologies, while incorporating psychosocial and other holistic approaches as appropriate to the time and the patient’s condition.

The caring aspect is fundamental to the nurse-patient relationship and to the health care experience. Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable. Thus all aspects need to be considered in planning and delivering care.^18,19

Health care providers clearly understand that a patient’s physical condition progresses in fairly predictable stages, depending on the presence or absence of comorbid conditions. Less clearly understood is the effect of psychosocial issues on the healing process. For this reason, special consideration must be given to determining the unique interventions that will positively impact each individual patient and help the patient progress toward desired outcomes.

An important aspect in the care delivery to—and recovery of—critically ill patients is the personal support of family members and significant others. The value of both patient-centered and family-centered care should not be underestimated.²⁰ It is important for families to be included in care decisions and to be encouraged to participate in the care of the patient as appropriate for the patient’s level of needs and the family’s level of ability.

Cultural diversity in health care is not a new topic but is gaining emphasis and importance as the world becomes more accessible to all as the result of increasing technologies and interfaces with places and peoples. Diversity includes not only ethnicity but also differences in lifestyles, opinions, values, and beliefs.

Unless cultural differences are taken into account, optimal health care cannot be provided. More attention has been directed recently at determining the physiological and disease development and progression differences among various ethnic groups. Mortality rates from cardiovascular disease are significantly higher for both black men and black women than for white men and white women. The prevalence of coronary heart disease is highest in black women, followed by Mexican American men.²¹ Care providers must develop an increased sensitivity to the health care needs and vulnerabilities of all groups.

Cultural competence is one way to ensure that individual differences related to culture are incorporated into the plan of care.^22,23 Nurses must possess knowledge about biocultural, psychosocial, and linguistic differences in diverse populations to make accurate assessments.

Interventions must then be tailored to address the uniqueness of each patient and family.

Spirituality can become more important as people search for meaning and guidance in critical, emergent, and unexpected tragic circumstances.²⁴ Likewise, many health care practitioners turn to their own spirituality to manage stress and find answers to the health care issues that they face on a daily basis. Spiritual practices consist of meditation, prayer, and spiritual materials and are based on personal values and beliefs. Holt-Ashley²⁴ describes how to incorporate prayer into the critical care unit, concentrating on patients and families and the nurse. The author also offers strategies for creating an environment that is conducive to spiritual well-being for both patients and staff.

Researchers have studied critical care nurses to better understand their clinical judgment and interventions and the link between the two. They identified two major categories of thought and action and nine categories of practice that illustrate clinical judgment and the clinical knowledge development of critical care nurses. These major categories25 are delineated in Box 1-1.