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 which has six subscales: mobility, activity, friction and shear, sensory perception, skin moisture, and nutrition; it provides a total score that ranges from 6 to 23 points (high scores indicate less risk). A Braden score of 16 has demonstrated a high degree of sensitivity and specificity in predicting pressure ulcer formation in critically ill adults. This tool has recently been adapted and validated for the pediatric critical care population.38

Whereas pressure ulcers in adults predominantly appear on the lower body (sacrum, ischium, and heels), they are more common on the upper body of children (occiput and ears). This is a result of proportional differences in body weight distribution between these age -groups. A 27% rate of pressure ulcer incidence has been reported in critically ill children, 57% of which were identified on their second day in the ICU.39 Particularly disturbing was that an additional 27 ulcers were identified as caused by medical devices such as oximetry probes, BiPAP masks, and endotracheal tubes.

It is remarkable that wide disparities of preventive measures are currently practiced, including some high-cost pressure-relieving mattresses.36,40 These include some aids that are largely regarded as ineffective, such as synthetic sheepskins.39 Although a substantial amount of evidence has examined this problem outside of critical care, systematic evaluations of management strategies are required to understand their efficacy among the critically ill.

Psychosocial Issues in Critically Ill Patients and Their Families

Nursing has consistently demonstrated a strong interest in psychosocial aspects of illness. In critical care, nurses have directed some of the most respected psychosocial research. A number of studies have examined the psychological impact of critical illness on patients, whereas others have concentrated on their families. Although most nursing research employs quantitative methods, nurses have also conducted a significant number of qualitative studies within the health sciences.

Patients

Many critically ill patients endure profound psychological trauma, and many others develop delirium or “ICU psychosis.”41,42 One group of patients examined up to 8 weeks after their discharge from an ICU reported “experiences of chaos,” feelings of extreme instability, vulnerability, and fear, as well as prolonged inner tension.43 It was found that even trivial events could trigger changes in their feelings of fear or inner tension. The caring behaviors of nurses provided an important degree of security and comfort. Hupcey reported that the overarching need of critically ill patients is the need to feel safe.44

In an investigation of the experiences of patients through their transfer out of ICU, patients exhibited feelings of significant despondency and apprehension.45 These findings highlight the mandate for greater attentiveness to the needs of these highly vulnerable adults. A number of studies suggest that some of these patients exhibit manifestations of posttraumatic stress disorder (PTSD).46–48 More research is needed, as the prevalence of PTSD and the optimum timing and method for assessing PTSD among the critically ill has not yet been determined.49

McKinley and colleagues50 have developed a tool for assessing anxiety in critically ill patients: the Faces Anxiety Scale. This single-item tool requires patients to select one of five drawings of faces. The scale exhibits minimal subject burden, while eliciting self-reports more often than other self-report scales.

Among psychological studies of critically ill children, Rennick et al. have reported that children who were younger, more severely ill, and underwent more invasive procedures demonstrated more medical fears, a lower sense of control over their health, and ongoing posttraumatic stress responses up to 6 months after discharge.47 In a long-term follow-up study of critically ill children, significant dispositional and mental function changes were reported.51 Parental accounts and clinical evaluations suggested that these children were profoundly transformed by their critical illness for variable lengths of time. Papathanassoglou and Patiraki reported similar observations among critically ill adults.52

Families

Many studies of families of the critically ill can be traced to Molter’s examination of family needs.53 Following Molter’s introduction of the Critical Care Family Needs Inventory, several studies systematically investigated the needs of these families. This body of research has demonstrated that families need honest, clear, and timely information, liberal visiting policies, and competent and compassionate care for their family member.54 “Hope” has been described as the most frequently used method of coping,55 which has complex implications for how clinicians portray the patient’s outlook. The latter report also indicated that families identified the provision of information, emotional support, and the competence and manner of the nurse as helpful nursing interventions. A systematic review has examined the impact of pediatric critical illness and injury on families.56 Although it is clear pediatric critical illness is stressful for the family, the reported effects on parents, siblings, and marital relations are variable. It is evident that many of these families’ needs go unmet.

Carnevale51,57 has described a family systems model for understanding the experiences of families of critically ill patients. Drawing on family therapy theory, this model recognizes families as constellations of interrelationships among members, including the critically ill patient. Variable levels of attachments or conflicts that continually change over time characterize these ties (Figures 224-1 and 224-2). Space constraints preclude additional discussion of death and dying in critical care, but some relevant issues will be discussed in the ethics review in the next section.

image

Figure 224-1 Diagrams showing relational shifts experienced by the family of an 8-year-old boy with multiple trauma. Number of straight lines between persons indicate strength of attachment in the relationship, whereas number of wavy lines represent intensity of conflict.

image

Figure 224-2 Diagrams demonstrating the profound relational transitions that followed the death of a family member.

Any significant event that affects one member of a family system will necessarily affect the entire family constellation. A common feature that appears to characterize the response of families of critically ill children is a deeply motivated attempt to recapture life as it was before the need for critical care.51 Although it is plausible that families of critically ill adults have similar responses, this requires further study. This work suggests that the quality of the patient’s experience through his/her critical illness is intimately intertwined with the quality of the family’s experience. For example, efforts to preserve family integration—through the rigorous promotion of family presence and participation in the care of the patient—help satisfy numerous family needs while also profoundly comforting the patient’s deepest stresses. Generally, what is good for the family tends to be good for the patient, and vice versa.

These findings highlight a central problem in the conventional ICU view of families as “visitors.” Units commonly have visiting policies and visitors’ rooms. Families are not visitors. Rather, they are spouses, partners, parents, children, siblings, and grandparents, among others, and can help foster a sense of continuity for the patient. Meanwhile, family members are personally adapting to the new reality confronting them. Whatever enables the patient and family to carry on as congruently as possible—fostering family cohesion within the available resources—is important. These views can also be extended to the significant friends of the patient.

Therefore, ICUs should promote the implementation of family support and follow-up programs to help alleviate patient and family distress. Some data have demonstrated that such programs can be highly effective.58

Ethical Dilemmas in Critical Care Nursing

In an anonymous survey of 852 critical care nurses in the United States, Asch reported that 16% stated they had either performed euthanasia or assisted in suicide, following the requests of patients or family members.59 Several informant quotes were provided that suggested these nurses were quite frustrated with the physicians they were working with, whom they described as detached and insensitive to patients’ suffering. The paper implies that these frustrated nurses unilaterally took matters into their own hands to do what they thought was right for the patient. Following the release of this paper and the understandable media attention that followed, many hospital centers turned to their critical care nurses to examine whether such practices were performed within their own institution. Although the practice of euthanasia or assisted suicide was clearly illegal and therefore unacceptable within the study’s jurisdictions, many of the controversies that ensued missed the central phenomenon highlighted by the study: these nurses attempted to report serious problems in their units that placed them in significant ethical binds.

Nurses are autonomous professionals who bear responsibility for patient well-being (albeit within a multidisciplinary team context). Nurses practice according to a professional code of ethics (which may vary somewhat across regions) that requires them to do everything they can to ensure that patient needs are adequately met. Bioethicist Tristram Engelhardt60 observed that:

Nurses are caught between physicians, on the one hand, who are authorities regarding scientific and technological knowledge and are in authority, and patients, on the other hand, who give authority for health care endeavors. Nurses are often placed, as a result, in ambiguous circumstances regarding which side is authorizing them to do what.

Critical care nurses frequently find themselves in a moral bind in which they judge that the current medical plan conflicts with their appraisal of the wishes or needs of the patient. This can create moral distress among nurses if they find themselves in a situation where they do not have the power to do what they believe should be done.61

The Manitoba, Canada, government commissioned an inquest into a series of pediatric cardiac deaths in which there was suspicion regarding a surgeon’s competence. The inquest report recognized that the nurses held important insights into the unfolding situation and were inadequately “heard” by their organization.62 The report highlighted that nurses bear a responsibility to ensure patients are protected from harms and risks, and that the organization is responsible for creating mechanisms that can facilitate the inclusion of nurses in clinical and administrative decisions. One such mechanism can include the creation of a nursing ethics committee where nurses can feel free to examine nursing-specific concerns.63

This “in-between” viewpoint of nurses (between the patient and the physician) can help shed new light on a number of ethical dilemmas in critical care and foster new strategies for resolving them. For example, one study examined the controversy over the practice of judging some critical care interventions as “futile” under certain conditions (e.g., cardiopulmonary resuscitation in a patient with a very grave prognosis) and can therefore be unilaterally withheld or withdrawn by the critical care team.64 This study highlighted that such conflicts are rarely related to an intervention’s actual physiologic futility (i.e., whether or not it will achieve its intended purpose) but about fundamental disparities in the beliefs and values of the various persons involved in the conflict. Therefore, ethically sensitive strategies should aim to address these differences through reciprocal discussions and negotiations that seek to reconcile the disparities rather than assert declarations of futility.

Chambers-Evans has illuminated the particular difficulties involved in being a surrogate decision maker (i.e., a family member making decisions for a critically ill patient).65,66 She has proposed a model that promotes shared decision making. This ensures that the surrogate’s intimate understanding of the patient’s wishes and interests are adequately considered while diminishing the surrogate’s moral burden associated with feeling solely responsible for the life and death of their loved one.

Finally, some nurses have examined the impact of family presence during resuscitation.67–68 This work suggests that there is increasing recognition of the merits of family presence, although priorities for further research are outlined. In sum, nursing perspectives on ethical issues in critical care both foster an awareness of the particular moral binds of nurses and illuminate new insights into the multidisciplinary management of prevalent ethical problems.

image Conclusion

Over 20 years ago, Knaus and associates demonstrated that the mortality outcomes of a critical care unit are not a function of the level of technology the unit possesses, its university-teaching status, or a closed (versus open) unit.69 Rather, outcomes are strongly associated with the strength of the interdisciplinary collaboration practiced within the unit.

The aim of this chapter was not to assert that nurses possess privileged knowledge or views about critical care but rather to highlight that critical care nurses offer (along with other practitioners) a rich body of clinical and research knowledge as well as shared professional responsibility for patient and family outcomes. The quality of critical care services can be strengthened when the potential and actual contributions of critical care nursing are recognized.

Key Points

1 Studies have demonstrated that critical care nurses’ expertise is highly sophisticated and consists predominantly of experientially acquired knowledge rather than learning from books and classrooms.
2 Observational pain-rating methods are important in the critical care setting, because this population is often incapable of self-report.
3 Improvements in the pharmacologic management of pain and discomfort have contributed to the increased incidence of withdrawal reactions.
4 The American Association of Critical-Care Nurses’ Sedation Assessment Scale provides a comprehensive evaluation of sedation for critically ill patients.
5 Given the significant responsibility nurses have conventionally held in providing basic patient needs such as skin care, the nursing literature has devoted particular attention to prevention and care of pressure ulcers.
6 The Braden Scale is a highly regarded scoring system for predicting the risk of pressure ulcers.
7 Nursing research has consistently demonstrated a strong interest in the psychosocial aspects of critical illness.
8 A significant number of critically ill patients endure profound psychological trauma.
9 Families of critically ill patients are not “visitors.”
10 Critical care nurses can experience moral distress because they frequently find themselves in situations in which they do not have the power to do what they believe should be done.

Annotated References

Benner P, Hooper-Kyriakidis P, Stannard D. Clinical wisdom and interventions in critical care: a thinking-in-action approach. Philadelphia: Saunders; 1999.

This is an extensive study of expertise among critical care nurses and demonstrates that in addition to employing complex experience-based patient management judgment, an expert nurse also monitors and limits potential hazards, fosters teamwork, and initiates preventive and corrective management of systems breakdown.

Cho SH, Ketefian S, Barkauskas VH, et al. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res. 2003;52:71-79.

This study reported 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 an 8.9% increased probability of patients acquiring pneumonia.

Gélinas C, Fillion L, Puntillo KA, et al. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care. 2006;15:420-427.

The Critical-Care Pain Observation Tool (CPOT) has demonstrated reliability and validity for critically ill adults regardless of their level of consciousness. 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.

Bergstrom N, Braden BJ, Laguzza A, et al. The Braden Scale for predicting pressure sore risk. Nurs Res. 1987;36:205-210.

The Braden Scale is a highly regarded scoring system for predicting the risk of pressure ulcers. The scale has six subscales (mobility, activity, friction and shear, sensory perception, skin moisture, and nutrition), providing a total score that ranges from 6 to 23 points (high scores indicate less risk); a score of 16 has demonstrated a high degree of sensitivity and specificity in predicting pressure ulcer formation in critically ill adults.

Austin W, Kelecevic J, Goble E, Mekechuk J. An overview of moral distress and the paediatric intensive care team. Nurs Ethics. 2009;16:57-68.

This paper examines the existing literature related to moral distress and the pediatric intensive care unit. Moral distress relates to a person’s reaction when she/he believes to know the right thing to do but does not do it, either because of internal (personal) constraints or external (contextual) barriers.

References

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3 Gordon DR. Clinical science and clinical expertise: Changing boundaries between art and science in medicine. In: Lock M, Gordon DR, editors. Biomedicine examined. Dordrecht: Kluwer Academic Publishers; 1988:257-295.

4 Rashotte J, Carnevale FA. Medical and nursing clinical decision making: a comparative epistemological analysis. Nurs Philos. 2004;5:160-174.

5 Morrison AL, Beckmann U, Durie M, et al. The effects of nursing staff inexperience (NSI) on the occurrence of adverse patient experiences in ICUs. Aust Crit Care. 2001;14:116-121.

6 Cho SH, Ketefian S, Barkauskas VH, et al. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res. 2003;52:71-79.

7 Benner P, Wrubel J. The primacy of caring: stress and coping in health and illness. Menlo Park, CA: Addison-Wesley; 1989.

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9 Carroll KC, Atkins PJ, Herold GR, et al. Pain assessment and management in critically ill postoperative and trauma patients: A multisite study. Am J Crit Care. 1999;8:105-117.

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35 Jiricka MK, Ryan P, Carvalho MA, et al. Pressure ulcer risk factors in an ICU population. Am J Crit Care. 1995;4:361-367.

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37 Bergstrom N, Braden BJ, Laguzza A, et al. The Braden Scale for Predicting Pressure Sore Risk. Nurs Res. 1987;36:205-210.

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