From American Association of Critical-Care Nurses. Fact sheet: about critical care nursing (press room). http://www.aacn.org. Accessed December 2008.

Expanded-Role Nursing Positions

Expanded-role nursing positions interact with critical care patients, families, and the health care team. Nurse case managers work closely with the care providers to ensure appropriate, timely care and services and to promote continuity of care from one setting to another. Other nurse clinicians, such as patient educators, cardiac rehabilitation specialists, physician office nurses, and infection control specialists, also contribute to the care. The specific types of expanded-role nursing positions are determined by patient needs and individual organizational resources.

Advanced Practice Nurses

Advanced practice nurses (APNs) have met educational and clinical requirements beyond the basic nursing educational requirements for all nurses. The most commonly seen APNs in the critical care areas are the clinical nurse specialist (CNS) and the nurse practitioner (NP) or acute care nurse practitioner (ACNP). APNs have a broad depth of knowledge and expertise in their specialty area and manage complex clinical and systems issues. The organizational system and existing resources of an institution determine what roles may be needed and how the roles function.

CNSs serve in specialty roles that use their clinical, teaching, research, leadership, and consultative abilities. They work in direct clinical roles and systems or administrative roles and in various other settings in the health care system. CNSs work closely with all members of the health care team, mentor staff, lead quality teams, and consult on complex patients. They are instrumental in ensuring that care is evidence-based and that safety programs are in place. They may be organized by specialty, such as cardiovascular care, or by function, such as cardiac rehabilitation. CNSs also may be designated as case managers for specific patient populations.

NPs and ACNPs manage direct 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 health care team.⁶

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.

Box 1-2 Aacn Practice Alert

Family Presence During Resuscitation and Invasive Procedures

Expected Practice:

• Family members* of all patients undergoing resuscitation and invasive procedures should be given the option of presence at the bedside. [Level B]

• All patient care units should have an approved written practice document (i.e., policy, procedure, or standard of care) for presenting the option of family presence during resuscitation and bedside invasive procedures. [Level D]

*Family members are those individuals who are relatives or significant others with whom the patient shares an established relationship.

Scope and Impact of the Problem:

Evidence is mounting that family presence during resuscitation and invasive procedures is beneficial to patients, families, and staff. Meeting psychosocial needs in a time of crisis exemplifies care driven by the needs of patients and families.

Supporting Evidence:

• Research 1–11 and public opinion polls^12–14 have found that 50% to 96% of consumers believe family members should be offered the opportunity to be present during emergency procedures and at the time of their loved one’s death.

• Despite support by professional organizations and critical care experts,15–24 only 5% of critical care units in the U.S. have written policies allowing family presence.²⁵ Surveys of nurses’ practice find that most critical care nurses have been requested by family members to be present during resuscitation and invasive procedures and have brought families to the bedside, despite the lack of formal hospital policies.^25–27

• Studies find the following benefits of family presence:

• For patients: Almost all children want their parents present during medical procedures 28–30; and adult patients report that having family members at the bedside comforted and helped them.^3,31–32

• For family members: Their presence at the bedside helped in removing doubt about the patient’s condition by witnessing that everything possible was being done.8,9,32–35 It decreased their anxiety and fear about what was happening to their loved one.^{7,10,29,32,36–37} It facilitated their need to be together^8,10 and the need to help and support their loved one.^{8–11,33–4,36} They experienced a sense of closure^3,8,11,34 and their presence facilitated the grief process should death occur.^{3,5,11,32–36}

• Studies show that 94% to 100% of families involved in family presence events would do so again.3,7,8,9,33,36

• Studies also find that there are no patient-care disruptions, no negative outcomes during family presence events,8,9,29,32–34,38–39 and no adverse psychologic effects among family members who participated at the bedside.^8,10,32,40

AACN Evidence Leveling System

Level A Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment.

Level B Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment.

Level C Qualitative studies, descriptive or correlational studies, integrative review, systematic reviews, or randomized controlled trials with inconsistent results.

Level D Peer-reviewed professional organizational standards with clinical studies to support recommendations.

Level E Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

Level M Manufacturer’s recommendations only.

Actions for Nursing Practice:

• Ensure that your health care facility has written policies and procedures that support family presence during resuscitation and invasive procedures.

• Policies and procedures, and educational programs for professional staff should include the following components:

• Benefits of family presence for the patient and family.²³

• Criteria for assessing the family to ensure uninterrupted patient care.9,20,23

• Role of the family facilitator in preparing families for being at the bedside and supporting them before, during, and after the event, including handling the development of untoward reactions by family members.21–22,34,41 Family facilitators may include nurses, physicians, social workers, chaplains, child life specialists, respiratory care practitioners, family therapists, and nursing students.^20,23,41

• Support for patient’s or family members’ decision not to have family members present.²³

• Contraindications to family presence (for example, family members who demonstrate combative or violent behaviors; uncontrolled emotional outbursts; behaviors consistent with an altered mental state from drugs or alcohol; or those suspected of abuse).9,20,22–23

• Develop proficiency standards for all staff involved in family presence to ensure patient, family, and staff safety.

• Determine your unit’s rate of compliance in offering families the option of family presence during resuscitation and invasive procedures. If compliance is ≤90%, develop a plan to improve compliance:

• Consider forming a multidisciplinary task force (e.g., nurses, physicians, chaplains, social workers, child life specialists) or a unit core group of staff to discuss approaches to improve compliance.

• Re-educate staff about family presence; discuss the intervention as a component of family-centered care and evidence-based practice.

• Incorporate content into orientation programs as well as initial and annual competency verifications.

• Develop a variety of communications strategies to alert and remind staff about the family presence option.

• Develop documentation standards for family presence and include rationale for when family presence would not be offered as an option to family members.

Need More Information or Help?

• Go to www.aacn.org and select Practice Resource Network.

• The guidelines for “Presenting the Option for Family Presence,”²³ developed by the Emergency Nurses Association and endorsed by AACN, are suitable for adaptation to critical care units and include educational slides and handouts, a family presence department assessment tool, a staff assessment tool, an educational needs assessment tool, a sample family presence guideline, and other supporting documents. This resource (Product #120632) is available online at www.aacn.org or by calling (800) 899-2226.

• AACN endorses the American College of Chest Physician’s Critical Care Family Assistance Program. This toolkit empowers you and your team to create a family-friendly critical care environment at your hospital. This resource (Product #120631) is available online at www.aacn.org or by calling (800) 899-2226.