Key Issues in Critical Care Nursing

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224 Key Issues in Critical Care Nursing

Franco A. Carnevale, Annie S. Chevrier

Prevailing issues in critical care nursing are reviewed in this chapter. The topics examined have particular importance for nurses but have broad multidisciplinary implications as well. Special focus is placed on contributions from nursing research. The reader is invited to delve further into the nursing literature by examining the numerous excellent critical care nursing journals and textbooks that are currently available, as well as CINAHL (Cumulative Index to Nursing and Allied Health Literature), the nursing literature database (a “nursing Medline”).

image Critical Care Nursing Knowledge and Skill Development

Patricia Benner is said to have revolutionized our understanding of clinical expertise in nursing. In her landmark book, From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Benner related the Dreyfus Model of Skill Acquisition to her study of nursing expertise.1 This model was originally developed through a study of skill development among nonclinicians (e.g., chess players and airline pilots). Benner and her colleagues have recently directed their analysis specifically to critical care nursing.2

Benner has challenged the prevailing “top-down” view of clinical expertise that believes clinicians acquire theoretical and empirical knowledge from books, journals, and classrooms and then apply this to practice. Rather, she demonstrated that such a form of practice is characteristic of novices. Lacking an experiential base to draw on, novices refer to their formal learning as well as various “rules of thumb” to help them sort through clinical problems.

An expert, however, will have acquired a rich store of clinical cases. This serves as a “bottom-up” foundation that enables expert nurses to rapidly discern what is meaningful in a clinical scenario without having to go through a step wise, linear, algorithm-like process. Therefore, expert critical care nurses (as well as other clinicians) are able to “think in action.” Expert know-how enables experienced nurses to readily identify patterns in a presenting case by immediately referring to numerous comparable cases—directly inferring hypotheses about the likely problem, the gravity of the situation, and how it should be managed. As the expert proceeds to manage the situation, the patient’s response presents further cues that can either confirm the nurse’s initial interpretation or generate new probable hypotheses.

Some have argued that Benner’s conception of skill acquisition is also relevant to medicine.3 A recent study demonstrated that critical care physicians employ a similar mode of thinking in their practice of diagnostic reasoning.4

Concurrent with this management of a specific case, Benner and her associates further described how an expert nurse also monitors and limits potential hazards in the highly technological critical care environment, fosters teamwork, and initiates preventive and corrective management of systems breakdown.2 These functions are commonly performed without the nurse necessarily being consciously aware of the reasoning that underlies them.

This experience-based view of nursing expertise raises important implications for nursing education and management. First, it suggests that the extent to which clinical expertise can be acquired from books or in a classroom is highly limited. The development of complex clinical judgment requires naturalistic exposure to numerous real-life cases. Although some useful learning can be acquired through formal educational methods such as formal lectures and readings, Benner’s framework favors an apprenticeship model of nursing education. A tailored program of clinical experiences, with access to expert guidance, will most effectively foster the development of expert knowledge and skill among critical care nurses. This framework provides a rich guide for the orientation of newly hired nurses and preceptors in critical care.

Second, this calls for management approaches that recognize the complexity of clinical expertise and the significant investment required to develop it. Expert nurses do not simply perform tasks prescribed by physicians or protocols. Expert nurses bring sophisticated knowledge and judgment that is essential to early and effective management of both patient and unit problems. This implies that skilled critical care nurses should be regarded as essential resources.

Administrators need to exercise extreme caution when making decisions that aim to reduce costs by relying on strategies such as “de-skilling” (i.e., relying on less qualified health professionals to perform nursing work), “casualization” (i.e., reducing the number of full-time staff to rely on casual, typically less experienced staff that can be called in ad hoc), or “downsizing” (i.e., dismissing skilled staff to reduce staffing levels).

Any strategy that diminishes or fragments the depth of critical care nursing expertise will fundamentally diminish the strength of a critical care service.5 Cho and associates have demonstrated that efforts to reduce nursing staffing levels can significantly increase levels of patient morbidity. A 1-hour decrease of worked nursing hours per patient was associated with a 8.9% increased probability of patients acquiring pneumonia.6

image Clinical Topics

Critical care nurses are concerned about the same issues as physicians and other allied professionals. Some nurses have emerged across disciplines as respected leaders because of their impressive research work on selected critical care problems.

The remainder of this chapter is devoted to topics nurses are particularly concerned about. They address key problems that have especially perplexed nursing practice and captured the research attention of nurses. Although the following primarily highlights nursing contributions, and space constraints limit the number of topics that can be reviewed, the reader is encouraged to learn more from the rich body of related research in other disciplines.

Pain and Discomfort

It is likely most nurses would list patient pain and discomfort as their most challenging clinical problems. The constancy and proximity of a nurse’s bedside relationship with a patient heightens awareness and attentiveness to unresolved pain and discomfort and can take a deep toll. This is partly due to nursing’s traditional commitment to the promotion of comfort and caring.7,8 Although significant advances have been made over the years in developing effective pharmacologic agents for managing these problems, pain and discomfort commonly persist.9,10

One factor that has limited successful management of these problems is the challenge involved in their evaluation.11 Outside the critical care setting, pain management has benefited from systematic measurement and documentation. Widely accepted pain measures such as the Visual Analogue Scale or numeric rating scales rely on patient self-report, but self-report is typically not accessible in critical care, given patients’ diminished level of consciousness. Thus, observational methods are most appropriate for this population. The Critical-Care Pain Observation Tool (CPOT) has demonstrated reliability and validity for critically ill adults regardless of their level of consciousness.12,13 The CPOT measures four behavioral categories: facial expression, body movements, muscle tension, and compliance with the ventilator for intubated patients or vocalization for extubated patients. Significant experience exists in pediatrics with the utilization of observational pain measures such as the FACES Pain Scale14 and the Children’s Hospital of Eastern Ontario Pain Scale, CHEOPS.15 However, most research has been conducted outside of critical care settings.

In critical care settings, overall “comfort” is increasingly measured with sedation scales.16,17 The Ramsay Scale, likely the most widely used sedation scale in the intensive care unit (ICU), has established some reliability and validity for critically ill adults.18 This is a six-level sedation scale, three levels for when the patient is awake and three levels for when the patient is asleep: 1—anxious, agitated, or restless; 2— cooperative, oriented, or tranquil; 3—responds to commands only; 4—asleep, brisk response to light touch on cheek or loud auditory stimulus; 5—sluggish response; and 6—no response. The American Association of Critical-Care Nurses has published a sedation assessment scale for critically ill patients that may be more sensitive to the end goals of sedation.19 It comprises five domains of assessment (consciousness, agitation, anxiety, sleep, patient-ventilator synchrony) as compared to many existing scales that focus only on one or two domains such as consciousness and agitation. In pediatric critical care, the COMFORT Scale has demonstrated impressive merits.20 This consists of eight behavioral and physiologic parameters including alertness, calmness/agitation, respiratory response, physical movement, blood pressure, heart rate, muscle tone, and facial tension. Each parameter is measured along a 5-point rating scale and summed to provide a total score that ranges from 8 to 40. Some work with this tool has indicated that physiologic parameters such as blood pressure and heart rate have weak validity as indicators of discomfort.21 Although these signs are commonly and intuitively associated with patient discomfort, they are also affected by numerous other phenomena within the critical care setting, such as cardiovascular dysfunction.

Delirium is the most common psychiatric diagnosis in critical care; its evaluation and management is therefore a key comfort concern for this population. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a valid and reliable tool developed for bedside assessment of delirium in aduts.22

Sedation in critical care is closely tied to the management of mechanical ventilation discomfort. A problem arising from this sedation-ventilation relation is the complex process of weaning patients from both therapies.23,24 Some research has examined the merits of daily interruption of sedation to permit spontaneous breathing.25,26 The use of a daily “sedation vacation” can help prevent some significant iatrogenic effects of critical care and shorten ICU and hospital stay.

Overall improvements in pharmacologic management of pain and discomfort have contributed to a more recent concern: withdrawal reactions.27 Overly rapid weaning of sedation and analgesia can precipitate a constellation of phenomena such as acute pain, excessive agitation, “ICU psychosis,” as well as withdrawal reactions. Reliable and valid measures for evaluating withdrawal reactions are therefore important in successfully managing this problem. Some strong measurement tools have been documented for the pediatric population.28,29

Although guidelines have been published for recommended rates of weaning, very little empirical research has established the optimal rate for reducing opioid and benzodiazepine infusions, balancing the need to rapidly extubate patients (and therefore minimize ventilation-related morbidities) with the prevention of withdrawal reactions. Some evidence suggests that one optimal weaning rate does not exist.30 It must be tailored to the length of time the patient has been receiving such infusions, whereby 20% daily weaning is optimal for patients receiving continuous infusions for 1 to 3 days, 13% to 20% for 4 to 7 days of infusions, 8% to 13% for 1 to 2 weeks, 8% for 2 to 3 weeks, and 2% to 4% for more than 4 weeks of infusions.30

Cumbersome decisional processes further complicate the management of pain and discomfort in critical care. A common occurrence in a university setting is for the intensivist to direct house staff and nurses to wean a patient’s sedation and analgesia overnight so the patient will be ready for extubation in the morning. However, such weaning can trigger significant discomfort, whereby the house staff and nurses can enter into disputes over how to balance the need to wean with the need to maintain patient comfort through a series of repeated adjustments in infusion rates and ad hoc bolus doses.

In their study of critical care nursing judgment in the management of pain, Stannard et al. reported that nurses demonstrated a sophisticated balancing of patients’ analgesic needs against other competing needs.31 A less cumbersome pain and discomfort management process can be established through the use of a sedation protocol or standing orders that “transfer” some decisional autonomy to nurses. A protocol can authorize nurses to modify sedation and analgesia infusion rates and bolus administration according to a prescribed target level of patient comfort.

For example, Alexander and associates reported on a sedation protocol used in pediatric critical care where the COMFORT Scale was used to measure patients’ level of comfort.32 The physician’s prescription specifies a target COMFORT Scale range for the patient, which the nurse can then use as a guideline for modifying the administration of sedation and analgesia. This study reported that patient comfort was managed effectively while facilitating the decision-making process.

Finally, the nursing literature has devoted some attention to the use of nonpharmacologic means for managing pain and discomfort: massage, relaxation exercises, transcutaneous electrical nerve stimulation (TENS), acupuncture, guided imagery, and hypnosis, among others.33 However, these techniques have undergone very little clinical research investigation within critical care. In light of major adverse effects associated with pharmacologic agents, as well as their limitations in fully ensuring patient comfort, these adjunctive measures should be further developed for the critically ill.

Pressure Ulcers

Given the significant responsibility nurses have conventionally held in the care of basic needs such as skin care, the nursing literature has devoted particular attention to the prevention and care of pressure ulcers.

In their study of iatrogenic problems, Cho and associates reported that pressure ulcers had the greatest impact on length of stay (i.e., a 1.84-fold increase).6 Documented prevalence rates vary from 7.1% to 11.1%.34 Jiricka et al. have reported that prevalence rates are even higher among the critically ill.35 This is attributable to the greater likelihood of immobility and reduced skin perfusion.

The principal extrinsic causes of pressure ulcers are pressure, friction, and shear. Therefore, preventive strategies are directed toward minimizing these extrinsic forces. Although over 200 pressure-relieving devices are commercially available, a paucity of controlled clinical trials have examined their efficacy.36

An emerging body of literature is effectively identifying the sites of pressure ulcers and the relative significance of various risk factors. This will help build a base of evidence from which clinical trials can be designed. This literature has led to the development of scoring systems for predicting the risk of pressure ulcers. A highly regarded system is the Braden Scale,37

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