Overview

Health care is undergoing dramatic change at a speed that makes it almost impossible to remain current and be proactive. The chaos and many challenges facing health care providers and consumers are evident in critical care, in which new treatment modalities and technology interface with the continuing effort to strive for quality care and positive outcomes. Efficiency and cost-effectiveness in relation to health care services are frequently discussed and are emphasized to all health care providers. To some, it appears that quality patient care has taken a back seat to the emphasis on cost containment and that quality and cost-effectiveness are not congruent. It is incumbent on all critical care health care providers to face these challenges from their individual discipline’s scope of practice and collectively from collaborative and interdisciplinary approaches.

The ever-changing health care environment creates many challenges for providers and consumers of care. Sensitivity to the appropriate time to eliminate or modify practices and adopt innovations is key to maintaining quality, cost-effective care delivery. Willingness to step outside of traditional structures and roles is the first step in making necessary changes. Change is constant. Flexibility and adaptation to change are essential to maintaining personal and organizational balance and to surviving in today’s health care environment.

This chapter provides an overview of the evolution of critical care and describes the trends and current issues affecting critical care nurses and interdisciplinary team. The information in this chapter serves as the framework for the remainder of the book in the areas of professional nurse decision making, holistic care, interdisciplinary collaboration, evidence-based practice (EBP), quality, and safety.

History of Critical Care

Critical care evolved from the recognition that the needs of patients with acute, life-threatening illness or injury could be better met if the patients were organized in distinct areas of the hospital. In the 1800s, Florence Nightingale described the advantages of placing patients recovering from surgery in a separate area of the hospital. A three-bed postoperative neurosurgical intensive care unit was opened in the early 1900s at Johns Hopkins Hospital in Baltimore. This was soon followed by a premature infant unit in Chicago.¹

Major societal issues have affected the development of intensive care as a specialty. During World War II, shock wards were established to care for critically injured patients. The nursing shortage after the war forced the grouping of postoperative patients into designated recovery areas so that appropriate monitoring and care could be provided. The technologies and combat experiences of health care providers during the wars of the 20th century also provided an impetus for specialized medical and nursing care in the civilian setting. The 1950s brought the new technology of mechanical ventilation and the need to group patients receiving this new therapy in one location.

Critical Care Nursing

Critical care nursing was organized as a specialty less than 60 years ago; before that time, critical care nursing was practiced wherever there were critically ill patients. The development of new medical interventions and technology prompted recognition that nursing was important in the monitoring and observation of critically ill patients. Physicians depended on nurses to watch for critical changes in the condition of patients in the physicians’ absence, and they sometimes depended on the nurses to initiate emergency medical treatment.

As sophisticated technology began to support more elaborate medical interventions, hospitals began to organize separate units to make more efficient use of equipment and specially trained staff. Postoperative care, once provided by private duty nurses on general nursing wards throughout the hospital, was moved into recovery rooms, where nurses with specialized knowledge regarding anesthesia recovery provided the patient care. Medical and surgical intensive care units segregated the most critically ill patients in locations where they could be cared for by nurses with specialized knowledge in those areas of care. By the 1960s, nurses had begun to consolidate their knowledge and practice into focused areas such as coronary care, nephrology, and intensive care. In the hospital units established for patients needing such specialized care, nurses assumed many functions and responsibilities formerly reserved for physicians, and they assumed a new authority by virtue of their knowledge and expertise.

Contemporary Critical Care

Modern critical care is provided to patients by a multidisciplinary team of health care professionals who have in-depth education in the specialty field of critical care. The team consists of physician intensivists, specialty physicians, nurses, advanced practice nurses and other specialty nurse clinicians, pharmacists, respiratory therapy practitioners, other specialized therapists and clinicians, social workers, and clergy. Critical care is provided in specialized units or departments, and importance is placed on the continuum of care, with an efficient transition of care from one setting to another.

Critical care patients are at high risk for actual or potential life-threatening health problems. Those who are more critically ill require more intensive and vigilant nursing care. There are more than 500,000 nurses in the United States who care for critically ill patients.

These nurses practice in a variety of settings: adult, pediatric, and neonatal critical care units; step-down, telemetry, progressive, or transitional care units; cardiac catheterization laboratories; and postoperative recovery units.² Nurses are now considered to be knowledge workers because they are highly vigilant and use their intelligence and cognition to go past tasks in order to quickly pull together multiple data to make decisions regarding subtle and/or deteriorating conditions. Nurses work technically with theoretical knowledge.³

A growing trend in acute care settings is the designation of progressive care units, considered to be part of the continuum of critical care. In past years, patients who are placed on these units would have been exclusively in critical care units. However, with the use of additional technology and monitoring capabilities, newer care delivery models, and additional nurse education, these units are considered the best environment. The patients are less complex, more stable, have a decreased need for physiologic monitoring, and more self-care capabilities. They can serve as a bridge between critical care units and medical-surgical units, while providing high quality and cost effective care at the same time.⁴ Additionally, these progressive units can be found throughout the acute care setting, thus leaving critical care unit beds for those who need the highest level of care and monitoring.⁵

Critical Care Nursing Roles

Nurses provide and contribute to the care of critically ill patients in a variety of roles. The most prevalent role for the professional registered nurse is that of direct care provider. The American Association of Critical-Care Nurses (AACN) has delineated role responsibilities important for the critical care nurse⁵ (Box 1-1).

Critical Care Professional Accountability

Professional organizations support critical care practitioners by providing numerous resources and networks. The Society of Critical Care Medicine (SCCM) is a multidisciplinary, multispecialty, international organization. Its mission is to secure the highest quality, cost-efficient care for all critically ill patients.¹ Numerous publications and educational opportunities provide cutting-edge critical care information to critical care practitioners.

The organization most closely associated with critical care nurses is the AACN. It is the world’s largest specialty nursing organization and was created in 1969. AACN is focused on “creating a healthcare system driven by the needs of patients and their families, where acute and critical care nurses make their optimal contribution.”⁷ The top priority of the organization is education of critical care nurses. AACN publishes numerous materials, evidence-based practice summaries, and practice alerts related to the specialty and is at the forefront of setting professional standards of care.

AACN serves its members through a national organization and many local chapters. The AACN Certification Corporation, a separate company, develops and administers many critical care specialty certification examinations for registered nurses. The examinations are provided in specialties such as neonatal, pediatric, and for those who practice in diverse settings, such as critical care, progressive care, “virtual” ICU, or remote monitoring (e-ICU). Certification is considered one method to maintain high quality of care and to protect consumers of care and services. Research has demonstrated more positive outcomes when care is delivered by health care providers who are certified in their specialty.⁸ AACN also recognizes critical care and acute care units who achieve a high level of excellence through its Beacon Award for Excellence. The unit that receives this award has demonstrated exceptional care through improved outcomes and greater overall satisfaction. It reflects on a supportive overall environment, teamwork and collaboration, and distinguishes itself with lower turnover and higher morale.⁹

Critical Care Nursing Standards

AACN has established nursing standards that provide a framework for critical care nurses. Nursing practice varies depending on the setting in which the nurse is employed and the patients cared for in that setting. The standards set forth by AACN describe the practice of the nurse who cares for an acutely or critically ill patient in the health care environment. The standards are authoritative statements that describe the level of care and performance by which the quality of nursing care can be judged. They serve as descriptions of the expected roles and responsibilities, describing the standards of care and the standards of professional practice.

Evidence-Based Nursing Practice

Much of early medical and nursing practice was based on non-scientific traditions, intuition, and traditions. 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 practitioner to another. Examples of non–scientific-based critical care nursing practice include Trendelenburg positioning for hypotension, use of rectal tubes to manage fecal incontinence, gastric residual volume and aspiration risk, accuracy of assessment of body temperature, and suctioning artificial airways every 2 hours—to name a few. In order to deliver the highest quality of care, EBP is essential and must be embraced by all nurses.¹⁰

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. Emphasis is on greater efficiency, cost-effectiveness, quality of life, and patient satisfaction ratings. It has become essential for nurses to use the best data available to make patient care decisions and carry out the appropriate nursing interventions.10–11 By using an approach employing 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 research-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 many challenges to creating an EBP. Appropriate research studies must be designed to answer clinical questions, and research findings must be used to make necessary changes for implementation in practice. Multiple EBP 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 evidence and research as the bases for practice.¹² Cullen and Adams describe a framework with four key phases to implement EBP: 1) create awareness and interest; 2) build knowledge and commitment; 3) promote action and adoption; and 4) pursue integration and sustained use. Each step has multiple strategies that will facilitate successful progression to the next phase. The authors indicate that this model is particularly suited to complex static organizations.¹¹

Just as there has been such an exponential growth of EBP literature, reports, publications and acceptance, others are posing the question, “But at what cost?” Newhouse describes this as a complex issue to address and states that economists would go beyond the costs of human labor and materials in their analysis. Another way to evaluate this is to examine “whose” cost is being considered.¹³ More recently, a published article reported estimates of costs per event for several health-acquired conditions (HACs). The estimated cost of care for one catheter-associated urinary tract infection (CAUTI) was $758. A patient fall was estimated to be $4,233 per fall; and a surgical “never event” cost $62,000 per event. These are most likely underestimated; but it is easy to realize the tremendous impact of situations that should not occur because there is sufficient evidence to prevent such outcomes.¹⁴ Thus, inquisitive practitioners who strive for best practices using valid and reliable data will demonstrate quality outcomes-driven care and practices.

Evidence-based nursing practice considers the best research evidence on the care topic, along with clinical expertise of the nurse, and patient preferences. 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),¹⁵ 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.¹⁶

The AACN has promulgated several EBP 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.¹⁷ An example of one of the alerts is found on in Box 1-2.

The high technology–driven critical care environment is fast paced and directed toward monitoring and treating life-threatening changes in patients’ conditions. For this reason, attention is often focused on the technology and treatments necessary for maintaining stability in the physiologic functioning of the patient. Great emphasis is placed on technical skills and professional competence and responsiveness to critical emergencies. Concern has been voiced about the diminished emphasis on the caring component of nursing in this fast-paced, highly technologic health care environment.18,19 Nowhere is this more evident than in areas in which critical care nursing is practiced. It has been said that keeping the care in nursing care is one of our biggest challenges.¹⁹ The critical care nurse must be able to deliver high-quality care skillfully, using all appropriate technologies, while incorporating psychosocial and other holistic approaches as appropriate to the time and condition of the patient.

The caring aspect between nurses and patients is most fundamental to the relationship and to the health care experience. The literature demonstrates that nurse clinicians focus on psychosocial aspects of caring, whereas patients place more emphasis on the technical skills and professional competence.²⁰ Physical and emotional absence, inhumane and belittling interactions, and lack of recognition of the patient’s uniqueness indicate noncaring. Holistic care focuses on human integrity and stresses that the body, the mind, and the spirit are interdependent and inseparable. All aspects need to be considered in planning and delivering care.²¹

Complementary and Alternative Therapies

Consumer activism has increased, and consumers are advocating for quality health care that is cost-effective and humane. They are asking whether options other than traditional Western medical care exist for treating various diseases and disorders. The possibilities of using centuries-old practices that are considered alternative or complementary to current Western medicine have been in demand.28–29 These types of therapies can be seen in all health care settings, including the critical care unit. Complementary therapies offer patients, families, and health care providers additional options to assist with healing and recovery.³⁰

Two terms, alternative and complementary, have been in the mainstream for several years. Alternative denotes that a specific therapy is an option or alternative to what is considered conventional treatment of a condition or state. The term complementary was proposed to describe therapies that can be used to complement or support conventional treatments.³⁰ The remainder of this section includes a brief discussion about nontraditional complementary therapies that have been used in critical care areas.

Nursing’s Unique Role in Health Care

Today’s health care environment necessitates a nursing framework that is flexible and responsive to the needs of the public that is served. The American Nurses Association (ANA) has defined nursing as the “protection, promotion, and optimization of health, and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.”³⁷ Although nursing has independent and dependent nursing actions, it is essential that an interdependence with all health care professionals is actualized.

Critical Care Nursing Practice

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.³⁸ These major categories are delineated in Box 1-3.

Technology in Critical Care

The growth in technologies has been seen throughout health care, especially in critical care settings. All providers are challenged to learn new equipment, monitoring devices, and related therapies that contribute to care and services. Take, for example, the evolving electronic health record (EHR) that was originally designed to capture data for clinical decision making and to increase the efficiency of health care providers. There are complexities inherent in providing a “user-friendly” EHR. Thus, one that meets the needs and reflects the thought processes and actual work flow of diverse clinicians has been greatly lacking. Add to that the fact that staff-created “work-arounds” to some of the software/procedures have not significantly reduced errors or increased productivity. There is a tremendous amount of data, but those data are not turned into meaningful information on which to make decisions.⁴¹ For this reason, it is important that critical care nurses are involved in the selection, trial, education, and evaluation of any health care informatics technologies that are being considered for their practice areas. Nurse informaticians, clinical nurse specialists, educators, and managers are also essential in the selection processes so that all aspects are considered.⁴² Another area for critical care nurse involvement is in assessing new products that come into the system. Often, there are numerous “avenues” that products enter, such as product fairs, individual physicians, vendors, and supply departments, to name a few. It is important that all proposed new products are overseen by a central committee or group who establishes criteria by which to select, pilot, evaluate, adopt, and communicate about the new product. Some criteria that can be used in the initial assessment are: 1) clinical relevance; 2) clinical void; 3) cost; 4) extra costs; and 5) safety.⁴³ This type of process ensures consistency and the same standards regarding product selection across the organization.

A more recent opportunity for critical care nurses is working in a role that encompasses the Tele-ICU. Telemedicine was initially employed in outpatient areas, remote, rural geographic locations, and areas where there was a dearth of medical providers. Currently, there are Tele-ICUs in areas where there are limited resources on site. However, there are experts (critical care nurses, intensivists) located in a central distant site. Technologies relay continuous surveillance with monitoring information and communication among care providers. Each Tele-ICU varies in size and location; the key component is the availability of back-up experts. Goran describes competencies for critical care nurses who practice in a Tele-ICU.⁴⁴

Interprofessional Collaborative Practice

The growing managed care environment has placed emphasis on examining methods of care delivery and processes of care by all health care professionals. Collaboration and partnerships have been shown to increase quality of care and services while containing or decreasing costs.45–50 It is more important than ever to create and enhance partnerships, because the resulting interdependence and collaboration among disciplines is essential to achieving positive patient outcomes. A recent article reported a study in which physician-nurse relationships improved collaboration after meeting together to create a method to change the unit culture. They met together to examine collaboratively on what the issues were and create strategies to resolve them. There were higher scores on openness of communication within groups, between groups, accuracy between groups, and overall collaboration.⁵¹

The Interprofessional Education Collaborative (IEC) published their Core Competencies for Interprofessional Collaborative Practice in 2011. The IEC sponsors include the American associations of nursing, dentistry, medicine, osteopathy, public health, and pharmacy. Their goal was to establish a set of competencies to serve as a framework for professional socialization of health care professionals. They also intended to assess the relevance of the competencies and develop an action plan for implementation.⁵² These competencies are especially important at this time as we move forward with health care reform and explore innovative care delivery models using the skill sets of all health care providers in the most effective and efficient manner. Box 1-5 delineates the four core competencies.

Interdisciplinary Care Management Models and Tools

Several models of care delivery and care management are used in health care. An overview of the various terms and models are presented in this chapter, but it is a good idea to seek additional resources and consultation for a more in-depth explanation of the models.

Patient safety has become a major focus of attention by health care consumers, providers of care, and administrators of health care institutions. The Institute of Medicine (IOM) publication Crossing the Quality Chasm: A New Health System for the 21st Century was the impetus for debate and actions to improve the safety of health care environments. In this seminal report, information and details were given indicating that health care harms patients too frequently and routinely fails to deliver its potential benefits.⁵⁴ Often, the definitions of medical errors and approaches to resolving patient safety issues differ among nurses, physicians, administrators, and other health care providers.⁵⁵ Subsequently through its use of expert panels, the IOM has published numerous other important reports related to quality, safety, and the nursing environment.

Patient safety has been described as an ethical imperative, and one that is inherent in health care professionals’ actions and interpersonal processes.⁵⁶ In critical care units errors may occur because of the hectic, complex environment, where there is little room for error and safety is essential.^56–57 In this environment, patients are particularly vulnerable because of their compromised physiologic status, multiple technologic and pharmacologic interventions, and multiple care providers who frequently work at a fast pace. It is essential that care delivery processes that minimize the opportunity for errors are designed and that a “safety culture” rather than a “blame culture” is created.⁵⁸ One author discussed results of a research study in which nurses were hesitant to report medication errors or unsafe practices so that they would not be ridiculed or “talked about” by their peer nurses. This uncivil behavior was thought to continue to contribute to an unsafe environment and one in which true error or unsafe practices and systems were greatly unreported.⁵⁹

Medication administration continues to be one of the most error-prone nursing interventions for the critical care nurse.⁶⁰ Many medication errors are related to system failures, with distraction as a major factor. Various interventions have been created in an attempt to decrease medication errors. One article reported establishing a “no interruption zone” for medication safety in a critical care unit. In this pilot study, there was a 40% decrease in interruptions from the baseline measurement. Although researchers questioned the feasibility of sustaining this decrease in interruptions in the future,⁶¹ this is an example of an approach that could be used to increase medication safety in the critical care unit.

When an injury or inappropriate care occurs, it is crucial that health care professionals promptly give an explanation of how the injury or mistake occurred and the short- or long-term effects on the patient and family. They should be informed that the factors involved in the injury will be investigated so that steps can be taken to reduce or prevent the likelihood of similar injury to other patients.

It has been shown that intimidating and disruptive clinician behaviors can lead to errors and preventable adverse patient outcomes. Verbal outbursts, physical threats, and more passive behaviors such as refusing to carry out a task or procedure are all under this category. Unfortunately, these types of behavior are not rare in health care organizations. If these behaviors go unaddressed, it can lead to extreme dissatisfaction, depression, and turnover. There also may be systems issues that lead to or perpetuate these situations, such as push for increased productivity, financial constraints, fear of litigation, and embedded hierarchies in the organization.⁵⁸

Technologies are both a solution to error-prone procedures and functions, and another potential cause for error. Consider bar-code medication administration procedures, multiple bedside testing devices, computerized medical records, bedside monitoring, computerized physician order entry (CPOE), and many other technologies now in development. Each in itself can be a great assistance to the clinician, but must be monitored for effectiveness and accuracy to ensure the best in outcomes as intended for specific use.⁶⁰

Privacy and Confidentiality

A landmark law was passed to provide consumers with greater access to health care insurance, promote more standardization and efficiency in the health care industry, and protect the privacy of health care data.⁷⁰ The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has created additional challenges for health care organizations and providers because of the stringent requirements and additional resources needed to meet the requirements of the law. Most specific to critical care clinicians is the privacy and confidentiality related to protection of health care data. This has implications when interacting with family members and others, and the oftentimes very close work environment, tight working spaces, and emergency situations. Clinicians are referred to their organizational policies and procedures for specific procedures for their organizations.

Healthy Work Environment

The health care environment is stressful, and increasing challenges in the areas of financial constraints, regulatory requirements, consumer scrutiny, quickly changing technologies and treatment regimens, and workforce diversity contribute to conflicts and difficulties on a daily basis. In this environment, it is essential to offer support for health care providers that can mitigate these challenges and ensure a healthy place to work.

There is an increasing amount of evidence that unhealthy work environments lead to medical errors, suboptimal safety monitoring, ineffective communication among health care providers, and increased conflict and stress among care providers. Synthesis of research in the area of work environment has demonstrated that a combination of leadership styles and characteristics contributes to the development and sustainability of healthy work environments.⁷¹

The AACN has formulated standards for establishing and sustaining healthy work environments (HWE).⁷² The intent of the standards is to promote creation of environments that will have a positive impact on nursing and patient outcomes. Evidence-based and relationship-centered principles were used to create the standards of professional performance. A summary of the six standards is provided in Box 1-9. Figure 1-1 illustrates the interdependence of each standard, and the ultimate impact on optimal patient outcomes and clinical excellence.

Everyone has a role in creating and sustaining a healthy work environment. Although the manager has a major role in establishing the culture, it is the staff who greatly impact the culture by mentoring new staff, role modeling behaviors, and leading interdisciplinary teams. It is this peer pressure that has the most impact on all other staff.73–74 Bylone discussed her experience of talking with many staff members about how they think that they can influence the work unit culture. She recommends asking them how they influence each of the HWE standards, thus making it a personal experience and journey in achieving the HWE.⁷⁵ Kupperschmidt and colleagues posed a five-factor model for becoming a skilled communicator: 1) becoming aware of self-deception; 2) becoming authentic; 3) becoming candid; 4) becoming mindful; and 5) becoming reflective; all of which lead to being a skilled communicator, thus creating a healthy work environment.⁷⁶ An additional approach for implementing the HWE model was offered by Blake, who suggested five steps: 1) rallying the team; 2) surveying the team; 3) establishing work groups; 4) setting goals and developing action steps; and 5) celebrating successes along the way.⁷⁷ Whatever approach taken will depend on the passion and commitment of the team.

Summary