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ACCCNS CRITICA
L
CARE NURSING
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(021) 66485438 66485457
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ACCCNS CRITICA
L
CARE NURSIN
G
SECOND EDITION
Doug Elliott
Leanne Aitken
Wendy Chaboyer
RN, PhD BAppSc(Nurs),

MAppSc(Nurs), ICCert
Professor of Nursing
Faculty of Nursing, Midwifery
and Health
University of Technology
Sydney, New South Wales
RN, PhD, BHSc(Nurs)Hons,

GradCertMgt,
GradDipScMed(ClinEpi), ICCert,
FRCNA
Professor of Critical Care Nursing
Griffith University & Princess
Alexandra Hospital
Brisbane, Queensland
RN, PhD, MN, BSc(Nurs)Hons,

CritCareCert
Professor & Director, NHMRC Centre
of Research Excellence in Nursing
Interventions for Hospitalised Patients
Griffith Health Institute
Griffith University
Gold Coast, Queensland
Sydney Edinburgh London NewYork Philadelphia StLouis Toronto
(021) 66485438 66485457
Mosby
is an imprint of Elsevier
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
2012 Elsevier Australia

This publication is copyright. Except as expressly provided in the Copyright Act 1968 and
the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be
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accurate and current as possible at time of publication. We would recommend, however,
that the reader verify any procedures, treatments, drug dosages or legal content described
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for injury and/or damage to persons or property arising from any error in or omission
from this publication.
National Library of Australia Cataloguing-in-Publication Data
Title: ACCCNs critical care nursing / [editors] Doug Elliott, Leanne Aitken and Wendy
Chaboyer.
Edition: 2nd ed.
ISBN: 9780729540681 (pbk.)
Notes: Includes index.
Subjects: Intensive care nursingAustralia.
Other Authors/Contributors: Elliott, Doug. Aitken, Leanne. Chaboyer, Wendy.
Australian College of Critical Care Nurses.
Dewey Number: 616.028
Publisher: Libby Houston
Developmental Editor: Elizabeth Coady
Publishing Services Manager: Helena Klijn
Editorial Coordinator: Geraldine Minto
Edited by Melissa Read
Proofread by Tim Learner
Indexed by Cynthia Swanson
Cover design by Lamond Art & Design
Typeset by Toppan Best-set Premedia Limited
Printed by China Translating & Printing Services Ltd.
(021) 66485438 66485457
Contents
9
Cardiovascular Assessment and Monitoring

180
Thomas Buckley, Frances Lin
10
Cardiovascular Alterations and Management
Foreword
vi
215
Preface
vii
Robyn Gallagher, Andrea Driscoll
About the Australian College of Critical Care Nurses
11
(ACCCN)
ix
About the Editors
Contributors
xi
Reviewers
xiii
Acknowledgements
xiv
Detailed Contents
xv
Abbreviations
xviii
Section 1
Scope of Critical Care
1
Scope of Critical Care Practice
Leanne Aitken, Wendy Chaboyer, Doug Elliott

2
Resourcing Critical Care
17
Denise Harris, Ged Williams

3
Quality and Safety
38
Wendy Chaboyer, Karena Hewson-Conroy

4
Recovery and Rehabilitation
57
Doug Elliott, Janice Rattray

5
Ethical Issues in Critical Care
78
Amanda Rischbieth, Julie Benbenishty
Section 2 Principles and Practice of

Critical Care
6
103
Essential Nursing Care of the Critically

Ill Patient
105
Bernadette Grealy, Wendy Chaboyer

7
Psychological Care
133
Leanne Aitken, Rosalind Elliott

8
Family and Cultural Care of the Critically

Ill Patient
156
Marion Mitchell, Denise Wilson, Vicki Wade
Cardiac Rhythm Assessment and

Management
251
Malcolm Dennis, David Glanville
Margherita Murgo, Gavin Leslie

21
Multiple Organ Dysfunction Syndrome
562
Melanie Greenwood, Alison Juers

12
Cardiac Surgery and Transplantation
Section 3 Specialty Practice in

Critical Care
291
Judy Currey, Michael Graan

13
Respiratory Assessment and Monitoring
325
22
Amanda Corley, Mona Ringdal

14
Respiratory Alterations and Management
352
23
Ventilation and Oxygenation Management
381
24
414
25
Neurological Alterations and Management
445
26
Support of Renal Function
479
27
Gastrointestinal, Liver and Nutritional
Paediatric Considerations in Critical Care

Pregnancy and Postpartum Considerations
Organ Donation and Transplantation
Appendices
506
Andrea Marshall, Teresa Williams,
Glossary
Picture Credits
Christopher Gordon
Management of Shock
654
679
710
746
Debbie Austen, Elizabeth Skewes
Alterations
20
Resuscitation
Wendy Pollock, Clare Fitzpatrick
Ian Baldwin, Gavin Leslie

19
623
Tina Kendrick, Anne-Sylvie Ramelet
Di Chamberlain, Wendy Corkill

18
Trauma Management
Trudy Dwyer, Jennifer Dennett
Neurological Assessment and Monitoring

Di Chamberlain, Leila Kuzmiuk
17
581
Louise Niggemeyer, Paul Thurman
Louise Rose, Gabrielle Hanlon

16
Emergency Presentations
David Johnson, Mark Wilson
Maria Murphy, Sharon Wetzig, Judy Currey

15
579
Index
539
(021) 66485438 66485457
763
783
790
793
Foreword
practice tips.
ACCCNs Critical Care Nursing is a beneficial resource
for
As a specialty area of nursing practice, critical care n
critical care nurses, regardless of practice set
ursing
ting. In
is focused on the care of patients who are expe
seeking to provide complex high intensity care, thera
riencing
pies
life-threatening illness. Globally, critical care n
and interventions, critical care nurses will find th
urses
at the
provide care to ensure that critically ill patients and t
book reviews essential content related to critical
heir
care
families receive optimal care. This second edition of t

he
Australian College of Critical Care Nurses (ACCCN
s)
Critical Care Nursing is a valuable resource for critical
care
nursing practice. The editors, who are acknow
ledged
expert practitioners, educators, and researchers in cr
itical
care, have organised the book into topics coverin
g the
scope of critical care, principles and practice of
critical
care, and specialty practice in critical care. The
content
covered in this book, written by established experts i
n the
field of critical care, provides a comprehensive o
verview
of critical care nursing concepts and practices
. The
book provides up-to-date information on evidencebased
practices and the chapters incorporate a variety of e
ducational resources including website links, case studies
and
nurses seeking to further develop their knowledge and

enhance their clinical practice expertise.
nursing knowledge and skills to provide care to acutely
ill patients and their families.
Ruth Kleinpell PhD, RN, FAAN, FCCM

Director, Center for Clinical Research and Scholarship
Internationally, there are more than 500,000 critical care

nurses, representing one of the largest specialty areas of
nursing practice. The importance of maintaining knowl-
Rush University Medical Center;

Professor, Rush University College of Nursing;
Nurse Practitioner, Mercy Hospital & Medical Center
edge of best practices, utilising evidence-based approaches,
Chicago, Illinois, USA
and applying research to clinical practice for critical

care patients remain essential components of critical
President of the World Federation of
care nursing. This second edition of ACCCNs Critical Care
Critical Care Nurses
Nursing is a comprehensive resource for critical care
http://www.wfccn.org
vi
(021) 66485438 66485457
Preface
environment, while still allowing the universal
core elements that represent critical care practice int
ernationally.
This second edition of ACCCNs Critical Care N
ursing has
Critical care as a clinical specialty is over half a
27 chapters that reflect the collective talent a
century
nd expertise
old. With every successive decade, advances in the e
of 50 contributors a strong mix of academic
duca-
s and clini-
tion and practices of critical care nurses have been m
cians with a passion for critical care nursing
ade.
in showcas-
Today, critical care nurses are some of the most
ing the practice of critical care nursing in Aust
knowl-
ralia, New
edgeable and highly skilled nurses in the world,
Zealand, Asia and the Pacific. We also engage
and
d contribu-
ongoing professional development and educatio
tors beyond Australasia to reflect global practi
n are
ces and to
fundamental elements in ensuring we deliver the hig
extend the applicability of our text to a wider
hest
geographic
quality care to our patients and their families.
audience. All contributors were carefully chos
This book is intended to encourage and challenge nur
en for their
ses
current knowledge, clinical expertise and s
to further develop their critical care nursing practice.
trong profes-
Our
sional reputations.
vision for the first edition was for an original tex
The book has been developed primarily for us
t from
e by prac-
Australasian authors, not an adaptation of texts prod
tising critical care clinicians, managers, res
uced
earchers and
in other parts of the world. This writing approach mor
graduate students undertaking a specialty
critical care
accurately captures the uniquely local elements that
qualification. In addition, senior undergraduat
form
e students
contemporary critical care nursing in Australia and N
studying high acuity nursing subjects will find
ew
this book
Zealand and help to answer the myriad of quest
a valuable reference tool, although it goes
ions
posed by critical care nurses as they practise in the l
ocal
beyond the
learning needs of these students. The aim
of the book
is to be a comprehensive resource, as well as a

portal
to an array of other important resources, for
critical
care nurses. The nature and timeline of book publishi
ng
dictates that the information contained in this have been included in each chapter to facilitate t
book
his
reflects a snapshot in time of our knowledge and und process.

er-
This second edition is again organised in three broad
standing of the complex world of critical care nu sections: the scope of critical care nursing, core comrsing.
ponents of critical care nursing, and specialty aspects
We therefore encourage our readers to continue of critical care nursing. Inclusion of new chapters and
to also
significant revisions to existing chapters were based o
search for the most contemporary sources of knowle n

dge
our reflections and suggestions from colleagues and
to guide their clinical practice. A range of websit reviewers as well as on evolving and emerging practic
e links
es
in critical care.
Section 1 introduces a broad range of professional issues
related to practice that are relevant across critical car
e.
Initial chapters provide contemporary information on
the scope of practice, systems and resources, quality and
safety, recovery and rehabilitation, and ethical issues.
Content presented in the second section is relevant to the
majority of critical care nurses, with a focus on concepts
that underpin practice such as essential physical, psychological, social and cultural care. Remaining chapters in
this section present a systems approach in supporting
physiological function for a critically ill individual. This
edition now has multiple linked chapters for some of the
major physiological systems 4 chapters for cardiovas
cular, 3 for respiratory, and 2 for neurological. Chapters
on support of renal function, gastrointestinal, liver and
nutritional alterations, management of shock, and multiorgan dysfunction complete this section.
The third section presents specific clinical condition
s
such as emergency presentations, trauma, resuscitation
,
paediatric considerations, pregnancy and post-partum
considerations, and organ donation, by building on the
principles outlined in Section 2. This section enables
readers to explore some of the more complex or unique
aspects of specialty critical care nursing practice.
Chapters have been organised in a consistent format t
o
ease identification of relevant material. Where appropri-
ate, each chapter commences with an overview of relevant
healthcare team, is then presented. Pedagogical featur
anatomy and physiology, and the epidemiology of the
es
clinical states in the Australian and New Zealand setting.
include a case study that elaborates relevant care issu
Nursing care of the patient, both delivered independently
es,
vii
or provided collaboratively with other members of the
(021) 66485438 66485457
viii
P R E FA C E
a critique of a research publication that explores a rel The delivery of effective, high-quality critical care nursing
ated
practice is a challenge in contemporary health care.
topic, and learning activities to assist both the reader We trust that this book will be a valuable resource in
and
supporting your care of critically ill patients and their
those in educational roles to assess knowledge a loved ones.

cquisition. Extensive use of tables, figures and practice tips
are
located throughout each chapter to identify areas of
care
that are particularly pertinent for readers. It is n
ot our
intention that readers progress sequentially throu
gh the
book, but rather explore chapters or sections tha
t are
relevant for different episodes of learning or practice.
Doug Elliott
Leanne Aitken
Wendy Chaboyer
(021) 66485438 66485457
About the Australian College of

Critical Care Nurses (ACCCN)
and provides local and at times nation
al representation.
The ACCCN Editorial Committee and

The Australian College of Critical Care Nurses, with o
Editorial Board,
ver
under the leadership of the editor of th
2400 members, is the peak professional organi
e Australian Critical
sation
Care (ACC) journal, are responsible for
representing critical care nurses in Australia. Me
the College pub-
mber-
lications including the journal Australia
ship types include standard membership, internati
n Critical Care and
onal
newspaper Critical Times.
members, life members, honorary members and
There are a number of national ad
corpo-
visory panels and
rate members. All individual members are eligible
special interest groups dedicated to pr
oviding the organi-
sation with expert opinion on issues
and
are encouraged to participate in the activities
of the
College; to receive the College journal and Critical Ti
mes
relating to critical
care nursing. These include:
Resuscitation
publication, in addition to discounts for ACCCN confer

ence registration and for ACCCN publications. Life
and
honorary memberships are awarded to individuals
in
recognition of their outstanding contribution to ACCC
N
and/or to critical care nursing excellence in Australia.
ACCCN is a company limited by guarantee a
nd has
branches in each state of Australia, with two me
mbers
from each state branch management committee for
ming
the ACCCN National Board of Directors. Each committ
ee
facilitates the activities of the college at a local/state
level
Advisory
Panel:
consists
of
eight
members representing each branch

of ACCCN, plus a
paediatric nurse representative.
It has developed a
complete suite of contemporary ad
vanced life support

and resuscitation educational mat
erial and offers its
ACCCN National ALS Courses throug

hout Australia;
Research Advisory Panel: in ad

dition to providing
expert advice to ACCCN, the panel i
s responsible for
evaluating and making recommend
ations on research
strategy and grant submissions t
matters relating to education specific to critica
In addi
l care
tion to
nursing. This panel has developed a position pape

r on
branc
committees. The panel has also developed p h educ
critical care nursing education and written sub osition

mis-
ational
statements on nurse staffing for intensive carevents
sions on behalf of ACCCN to national reviews e and

of
and sy
high-dependency units in Australia, and an mponursing education;

Workforce Advisory Panel: has represented A
CCCN
on a number of national health workforce and nurs
ing
nually
siums,
reviews the dataset design for national workforc ACCCN

e data
conduc
collection in conjunction with ANZICS;
ts thre
Organ & Tissue Donation & Transplantatio e natio

n Advi-
nal con
sory Panel: advises the board and develope ference

d a posi-
s each
tion statement on organ donation and transplant year:

ation
ACCCN
as it relates to intensive care. It disseminate Institu

s related
te of
information to critical care nurses regarding the Contin

pro-
uing E
motion and national reform objectives of org ducatio

an and
n (ICE)
tissue donation in Australia;
Quality Advisory Panel: provides expert kno and, in

wledge,
conjun
advice and information to ACCCN on matters ction

rele-
with o
vant to critical care nursing practice relating ur me

specifi-
dical c
cally to patient management;

Paediatric
Advisory
Panel: provides expert es fro
knowledge, advice and information to ACCCN on

matters
olleagu
m
The A
ustralia
relevant to paediatric critical care nursing in addi n and

tion
New Z
to recommending content and speakers for the a ealand

nnual
ACCCN conferences;
Intensi
ve Car
The ICU Liaison Special Interest Group: is ae Soci

collec-
ety
tive group of ACCCN members who have an inter (ANZIC

est
S), the
in ICU liaison/outreach and work together to disc ANZICS

uss
/ACCC
matters relevant to this increasing area of critical N Annu

care
nursing focus.
al Scie
ntific M
eeting
on Intensive Care and the Australian and New Zealand
Paediatric & Neonatal Intensive Care Conference.
ACCCN has a representative on the Australian Resuscitation Council (ARC), and has representation at a federal
government advisory level through the Nursing and Midwifery Stakeholder Reference Group (NMSRG) chaired by
the Chief Nurse of Australia, and is also a member of the
Coalition of National Nursing Organisations (CoNNO).
The founding Chairperson of the World Federation of
Critical Care Nurses (WFCCN) continues to represent
ACCCN on the WFCCN Council, and the College also
has representatives on the World Federation of Paediatric
Intensive and Critical Care Societies, and is a member of
the Intensive Care Foundation.
More information can be found on the ACCCN website:
www.acccn.com.au
ix
(021) 66485438 66485457
About the Editors

university funding sources. He has published over 8
0 peerreviewed articles and book chapters, and is co-editor
for
two additional books, on nursing and midwifery resea
rch,
Doug Elliott
and pathophysiology and nursing practice.
Doug Elliott is Professor of Nursing in the Faculty
Doug became a Life Member of the Australian Colleg
of
e of
Nursing, Midwifery and Health at the University of Tec

h-
Critical Care Nurses in 2006 in recognition of ov

er 20
nology, Sydney. During his 25 years as a nurse acade

mic,
years of service to critical care. He has previously be

en an
Doug has been a faculty Director of Research, Cl

inical
Associate Editor and on the Editorial Board for Austra

lian
Professor, Head of Department and a conjoint ho

spital
Critical Care, was the inaugural Chair of the Res

earch
appointment as Assistant Director of Nursing Resea

rch.
Advisory Panel, a member of the Education Advis

ory
Prior to this, he worked as a clinician in acute and crit

ical
Panel, and also served on the NSW committee. He is

cur-
care areas in tertiary hospitals in Sydney and Perth.

Dougs clinical and health services research focus
rently on the Editorial Board for the American Journal

of
es on
the health-related quality of life (HRQOL) and illn
Critical Care, and peer-reviews for several critical

care
ess
experiences of individuals with critical and ac
ute illnesses, and the use of technologies to improve
patient
outcomes. Doug has received research funding from
the
NHMRC and the Australian Commission on Safety
and
Quality in Health Care, as well as competitive fu
nding
from other national organisations, health service and
medicine and nursing journals, and a range of compe

ti-
tive funding bodies. Doug has been an invited speake

r to
international and national multi-disciplinary critical c
are
meetings on numerous occasions.
Leanne Aitken
Leanne Aitken is Professor of Critical Care Nursin
g at
Griffith University and Princess Alexandra Hosp
ital,
Queensland. She has a long career in critical care nur

sing,
including practice, education and research roles. I
n all
her roles in nursing, Leanne has been inspired by a s
ense
of enquiry, pride in the value of expert nursing
and a
decision-making practices of critical care nurses and a
belief that improvement in practice and resultant pat range of clinical practice issues within critical care and
ient
trauma.
outcomes is always possible. Research interests i Leanne has been active in ACCCN for more than 20 years
nclude
and was made a Life Member of the College in 2006 after
developing and refining interventions to improve having held positions on state and national boards, coorlong
dinated the Advanced Life Support course in Western
x term recovery of critically ill and injured pat Australia in its early years, chaired the Education Advisory
ients,
Panel and been an Associate Editor with Australian Critical

Care. In addition, she is a peer reviewer for a number of
national and international journals and reviews grant
applications for a range of organisations including the
National Health and Medical Research Council (NHMRC)
and Intensive Care Foundation. She is the World Federation of Critical Care Nurses representative on a number
of sepsis related working groups including an international group who authored a companion paper to the
Surviving Sepsis Campaign guidelines to summarise the
evidence underpinning nursing care of the septic patient,
the revision of the Surviving Sepsis Campaign Guidelines
and the Global Sepsis Alliance.
Wendy Chaboyer
Wendy Chaboyer is a Professor of Nursing at Griffith
University and the Director of the Centre of Research
Excellence in Nursing Interventions for Hospitalised
Patients, funded by the National Health and Medical
Research Council (NHMRC) (20102015). Wendy has 30
years experience in the critical care area, as a clinician,
educator and researcher and she is passionate about the
contribution nurses can make to a patients, and their
familys, hospital experience. Her research has focused on
ICU patients transitions and on continuity of care for
ICU patients. More recently, she has focused on patient
safety, undertaking research into adverse events after ICU,
clinical handover and transforming care at the bedside.
Wendy has been active in ACCCN since her arrival in
Australia in the early 1990s. She has been a National
Board member and member of the Queensland Branch
Management Committee. Wendy is a past Chair of the
Research Advisory Panel and past Chair of the Quality
Advisory Panel of the ACCCN. Wendy played a role in
the formation of the World Federation of Critical Care
Nurses and continues to support their activities. Wendy
reviews for a number of journals and funding bodies such
(021) 66485438 66485457
as the NHMRC and the Australian Research Council.
Contributors
Leanne Aitken RN, PhD, BHSc(Nurs)Hons,
Amanda Corley BN, ICU Cert, GradCert
Clare Fitzpatrick
GradCertMgt, GradDipScMed(ClinEpi),
HealthSci, M AdvPrac (candidate)
Registered Nurse, Registered Midwife
ICCert, FRCNA
Nurse Researcher
BA (Hons)
Professor of Critical Care Nursing
Critical Care Research Group, The Prince
Lead for Critical Care
Griffith University & Princess
Charles Hospital
Liverpool Womens NHS Foundation Trust
Alexandra Hospital
Queensland
Liverpool, United Kingdom
Brisbane, Queensland
Judy Currey RN, BN, BN(Hons) Crit Care
Robyn Gallagher RN, BA (Psych), MN, PhD
Debbie Austen RN, BaHSc, Grad Cert
Cert, Grad Cert Higher Ed, Grad Cert Sc
Associate Professor Chronic and
Critical Care, Grad Cert Management,
(App Stats), PhD
Complex Care
JP (Qual)
Associate Professor in Nursing
Faculty of Nursing, Midwifery and Health
Registered Nurse, Capricorn Coast Hospital
Deakin University
University of Technology, Sydney
and Health Service
Victoria
New South Wales
Queensland
Jennifer Dennett RN, MN, BAppSc
David Glanville RN, BN, Grad Dip Crit Care
Ian Baldwin RN, PhD
(Nursing), CritCareCert, Dip Management,
Nursing, MN
Post Graduate Educator
MRCNA
Nurse Educator
Intensive Care Unit, Austin Health
Nurse Unit Manager
Intensive Care Unit
Victoria
Critical Care, Oncology, Cardiology, Renal
Epworth Freemasons Hospital
Julie Benbenishty MNS
Dialysis, Central Gippsland Health Service
East Melbourne, Victoria
Academic Consultant Surgical Division
Victoria
Christopher Gordon RN, MExSc, PhD
Hadassah Hebrew University Medical Center
Malcolm Dennis RN, BEd, CritCareCert(ICU)
Senior Lecturer
Jerusalem, Israel
Bed Field Technical Specialist
Director of Postgraduate Advanced Studies
Tom Buckley RN(UK), PhD MNRes, BScHlth
Cardiac Rhythm Management Division,
Sydney Nursing School, The University
CertICU, CertTeaching&Assessing
St Jude Medical
of Sydney
Senior Lecturer and Co-ordinator Master
New South Wales
New South Wales
of Nursing (Clinical Nursing & Nurse
Andrea Driscoll RN, CCC, BN, MN, MEd, PhD
Michael Graan RN, GradDip CritCare
Practitioner)
Senior Research Fellow
Clinical Nurse Educator (ICU)
Sydney Nursing School, The University
Monash University, Melbourne
Epworth HealthCare
of Sydney
Victoria
Richmond, Victoria
New South Wales

Wendy Chaboyer RN, BSc (Nu) Hon,
(RCCCPI)
Flinders University
Trudy D
MN, PhD
Griffith Health Institute
South Australia
wyer RN,
Director
Queensland
Wendy Corkill RN
ICU Cert,
NHMRC Centre of Research Excellence in
Diane Chamberlain RN, BN,
Clinical Nurse Specialist
BHlth, GC
Nursing Interventions for Hospitalised
BSc MNSc
Alice Springs Hospital
ert
Patients (NCREN), Research Centre for
(Critical Care), MPH, PhD
Northern Territory
FlexLrn,
Clinical and Community Practice Innovation
Senior Lecturer
MClinEd,
PhD
Bernadette Grealy RN, RM, CritCareCert,
Associate Professor
BN, MN
School of Nursing and Midwifery, Faculty of
Clinical Services Coordinator Intensive
Sciences, Engineering & Health
Care Unit
Central Queensland University
Queen Elizabeth Hospital
Queensland
South Australia
Doug Elliott RN, PhD, BAppSc(Nurs),
Melanie Greenwood MN, Grad Cert.
MAppSc(Nurs), ICCert
UniTeach&Learn, ICCert, NeurosciCert
Professor of Nursing
Senior Lecturer,
Faculty of Nursing, Midwifery and Health
School of Nursing and Midwifery
University of Technology
University of Tasmania
Sydney, New South Wales
Tasmania
Rosalind Elliott RN, BSc (Hons), PG Dip
Gabrielle Hanlon RN, Crit Care Cert, BN,
(Crit Care), MN
GDBL, MRCNA
PhD candidate
Project Manager
University of Technology Sydney
Australian Commission on Safety & Quality
New South Wales
in Health Care
New South Wales
(021) 66485438 66485457
xi
xii
CONTRIBUTORS
Western Australia
Denise Harris RN, BHSc(Nurs),
Frances Lin RN, BMN, MN (Hons), Marion Mitchell RN, BN (Hon), Grad Cert
GradDipHlthAdmin& InfoSys,
PhD
MN(Res), ICCert
Lecturer & Program Convenor (Master Senior Research Fellow Critical Care
Assistant Director of NursingMedicine &
of
Griffith University and Princess
Critical Care
Nursing Critical Care)
Alexandra Hospital
The Tweed Hospital
Queensland
Tweed Heads, New South Wales
Griffith University
Margherita Murgo BN, MN (Crit Care)
Karena Hewson-Conroy BSocSci(Hons),
Queensland
Project Officer
PhD candidate
Andrea Marshall RN PhD
Clinical Excellence Commission
Research & Quality Manager, Intensive Care
Sesqui Senior Lecturer Critical Care Nu New South Wales
Co-ordination & Monitoring Unit
rsing
Maria Murphy RN PhD, Grad Dip Crit Care,
Honorary Associate, Faculty of Nursing,
Sydney Nursing School
Grad Cert Tert Ed, BN, Dip App Sci (Nursing)
Midwifery & Health, University of
University of Sydney
Lecturer
Technology, Sydney
New South Wales
LaTrobe University
(Higher Educ), PhD.
New South Wales
David Johnson RN, Grad Dip (Acute Care
Austin Health
Nurs), MHealth Sci Ed, A&E Cert, MCN
Victoria
Director of Nursing
Louise E Niggemeyer RN, MEd, BEdSt,
Caloundra Health Service
IC Cert, MRCNA
Sunshine Coast Wide Bay Health
Trauma Program Manager
Service District
The Alfred Hospital
Queensland
Senior Researcher
Alison Juers RN, BN (Dist), MN (Crit Care)
Trauma Systems & Education Consultant
Nurse Educator
National Trauma Research Institute
Brisbane Private Hospital
Alfred Health
Queensland
Victoria
Tina Kendrick RN, PIC Cert, BNurs(Hons),
Wendy Pollock RN, RM, Grad Dip Crit
MNurs, FCN, FRCNA
Care Nsg, Grad Dip Ed, Grad Cert Adv
Clinical Nurse Consultant Paediatrics
Learn & Leadership,
NSW Newborn and Paediatric Emergency
PhD Research Fellow
Transport Service
La Trobe University/Mercy Hospital
New South Wales
for Women
Leila Kuzmuik RN, BN, DipAdvClinNurs, MN,
Victoria
Grad Cert HlthServMgt
Anne-Sylvie Ramelet RN, ICU Cert, PhD
Nurse Educator
Senior Lecturer
Intensive Care Services
Institute of Higher Education and
John Hunter Hospital, Hunter New
Nursing Research
England Health
Lausanne University-Centre Hospitalier
New South Wales
Universitaire Vaudois, Switzerland
Gavin D Leslie RN, IC Cert, PhD, BAppSc,
Professor, HECVSant
Post Grad Dip (Clin Nurs), FRCNA
University of Applied Sciences
Professor Critical Care Nursing
Western Switzerland
Royal Perth Hospital
Switzerland
Director Research & Development
Janice Rattray PhD, MN, DipN (CT),
School of Nursing & Midwifery,
RGN, SCM
Curtin University
Reader
Princess Alexandra Hospital
University of Dundee
Louise Rose BN, MN, PhD, ICU Cert
Queensland
United Kingdom
Assistant Professor
Ged Williams RN, RM, CritCareCert, MHA,
Mona Ringdal RN, PhD, MSc
Lawrence S. Bloomberg Faculty of Nursing,
LLM, FACHSM, FRCNA, FAAN
Senior Lecturer
University of Toronto
Executive Director of Nursing and Midwifery
Institute of Health and Care Sciences
Research Director and Advanced Practice
Gold Coast Health Service District
The Sahlgrenska Academy, University
Nurse, Prolonged-ventilation Weaning
Professor of Nursing, Griffith University
of Gothenburg
Centre, Toronto East General Hospital,
Founding President, World Federation of
Sweden
Toronto
Critical Care Nurses
Amanda Rischbieth RN, Grad Dip (Intens
Ontario, Canada
Queensland
Care), MNSc, PhD
Elizabeth Skewes DAppSc(Nursing), CCRN
Teresa Williams RN, ICUCert, BN, MHlthSci
School of Nursing University of Adelaide
Senior Nurse of Organ and Tissue Donation
(Res), GradDipClinEpi, PhD
South Australia
St Vincents Hospital
Research Assistant Professor and NH MRC
Victoria
Clinical Research Postdoctoral Fellow
Paul Thurman RN, MS, ACNPC, CCNS,
Discipline of Emergency Medicine (SPARHC)
CCRN, CNRN
The University of Western Australia
Western Australia
R Adams Cowley Shock Trauma Center
Denise Wilson PhD, RN, FCNA(NZ)
University of Maryland Medical Center
Associate Professor Mori Health
Baltimore, Maryland, USA
Auckland University of Technology
Vicki Wade Dip Nsg, BHSc, MN
Auckland, New Zealand
Leader
Mark Wilson DipAppSc (Nursing),
National Aboriginal Health Unit
GDipClPrac (Emergency Nursing), MHScEd
Heart Foundation Australia
Emergency Department Nurse Educator
Sharon Wetzig RN, BN, Grad Cert
Illawarra Shoalhaven Local Health District
(Critical Care), MEd
New South Wales
Clinical Nurse Consultant
(021) 66485438 66485457
Reviewers
Steven Frost RN, MPH
Holly Northam RN, RM, MCritCareNsg M Critical Care Nursing
Lecturer, School of Nursing and Midwifery
Assistant Professor of Critical Care Nursing
University of Western Sydney
University of Canberra
New South Wales
Australian Capital Territory
Melanie Greenwood MN, Grad Cert UniTeach&Learn,
Jon Mould PhD candidate, MSc, RGN, RSCN, RMN, Adult Cert Ed
ICCert, NeurosciCert
Senior Lecturer
Senior Lecturer
Edith Cowan University
Western Australia
University of Tasmania
Helena Sanderson RN, BHSc, ICU Cert, MN(Advanced
Tasmania
Clinical Education)
Nichole Harvey RN, EM, CritCareCert, BN (Post Reg), MNSt,
Lecturer in Nursing
GradCertEd (TT), PhD Candidate
School of Health
Senior Lecturer
University of New England
School of Medicine and Dentistry
Armidale, New South Wales
James Cook University
Natashia Scully RN, BA, BN, PGDipNSc(Critical Care),
Queensland
MPH(Candidate)
Ann Kuypers RN, Med Grad Dip(Clin Ed), Grad Cert (Periop)
Lecturer in Nursing
Lecturer Nursing
School of Health
Academic Language and Learning Unit
University of New England
LaTrobe University, Albury Wodonga Campus
Armidale, New South Wales
Victoria
Kerry Southerland RN, ICCert, BSc, MCN, GCTT, MRCNA
Renee McGill MN, Grad Cert Crit Care, BS(Nurs)
Lecturer
Lecturer in Nursing, Academic Advisor
School of Nursing & Midwifery
School of Nursing, Midwifery and Indigenous Health
Curtin University
Charles Sturt University
Western Australia
New South Wales
Peter Thomas RN, BSc, GradDipEd, PhD
Stephen McNally RN, BApp Sc (Nursing), PhD
Lecturer
Lecturer, Head of Program
School of Nursing, Midwifery & Indigenous Health
University of Western Sydney
University of Wollongong
New South Wales
New South Wales
xiii
(021) 66485438 66485457
Acknowledgements
and members of ACCCN, for having the belief in
us as
editors and authors to uphold the values of the Colle
A project of this nature and scope requires many tale
ge,
nted
is much appreciated. We also acknowledge support fr
and committed people to see it to completion. The d
om
ecision to publish this second edition was supported ent

husiastically by the Board of the Australian Coll
ege of
Critical Care Nurses (ACCCN) and Elsevier Australia. T
o
our chapter contributors for this edition, both
those
returning from the first edition and our new coll
aborators thank you for accepting our offer to write,
for
having the courage and confidence in yourselves and
us
to be involved in the text, and for being commit
ted in
meeting writing deadlines while developing the d
epth
and quality of content that we had planned. We
also
acknowledge the work of chapter contributors
from
our first edition Harriet Adamson, Susan Ba
iley,
Martin Boyle, Sidney Cuthbertson, Suzana Dim
ovski,
Bruce Dowd,
Ruth
Endacott, Paul
Fulbrook,
Michelle Kelly, Bridie Kent, Anne Morrison, We

ndy
Swope and Jane Treloggen.
Continued encouragement and support from the
Board
text such as this would never come to fruition, thank you.

We acknowledge our external reviewers who devoted
their time to provide insightful suggestions in improving
the staff at Elsevier Australia, our publishing partner.
the text and contributed to the quality of the finished
Thanks to our Publisher, Libby Houston, for guiding this
product.
major project; our Developmental Editors initially
Finally, and most importantly, to our respective loved
Larissa Norrie, and then Elizabeth Coady for the majority
ones Maureen, Kate, Nick and Josh; Steve; and Michael
of the project; and to Melissa Read our editor. In Publish-
thanks for your belief in us, and your understanding
ing Services, Geraldine Minto, thanks for your work with
and commitment in supporting our careers.
typesetting issues. To others who produced the high
Doug Elliott
quality figures, developed and executed the marketing
Leanne Aitken
plan, and the myriad other activities, without which a
Wendy Chaboyer
xiv
(021) 66485438 66485457
Detailed Contents
5
Ethical Issues in Critical Care

78
Principles, rights and the link with law
78
Section 1 Scope of Critical Care

1
Development of critical care nursing
Roles of critical care nurses
Clinical decision making
Leadership in critical care nursing
Developing a body of knowledge
11
Summary
12
17
End-of-life decision making

83
Brain death
88
Organ donation
89
Ethical allocation and utilisation of

resources
Ethics in research
17
Historical influences
18
Economic considerations and principles
19
Budget
20
Critical care environment
22
Equipment
22
Staff
23
Risk management
28
Measures of nursing workload or activity
30
Management of pandemics
33
Summary
34
Quality and Safety
38
Quality and safety monitoring
42
Patient safety
49
Summary
52
Recovery and Rehabilitation
57
ICU-acquired weakness
58
Patient outcomes following a critical illness
59
Psychological recovery
61
Rehabilitation and mobility in ICU
66
Ward-based post-ICU recovery
68
Recovery after hospital discharge
68
Summary
72
91
Summary
96
Sedation
138
Pain
141
Sleep
145
Summary
8
Section 2 Principles and Practice of

Critical Care
6
Family and Cultural Care of the Critically Ill

Patient
103
Overview of models of care
Essential Nursing Care of the Critically Ill

105
Personal hygiene
Eye care
End-of-life issues and bereavement
107
109
Patient positioning and mobilisation
157
161
Religious considerations
105
Oral hygiene
156
Cultural care
Patient
170
172
Summary
9
110
173
Cardiovascular Assessment and Monitoring

Related anatomy and physiology
180
180
Bowel management
115
Assessment
Urinary catheter care
116
Haemodynamic monitoring
Bariatric considerations
117
Diagnostics
206
Summary
210
Infection control in the critical care unit:

general principles
10
118
Transport of critically Ill patients: general

principles
Summary
7
149
195
Cardiovascular Alterations and Management

Coronary heart disease
123
Heart failure
125
Selected cases:
Psychological Care
133
Cardiomyopathy
Anxiety
133
Hypertensive emergencies
Delirium
136
(021) 66485438 66485457
190
215
215
227
241
242
xv
xvi
D E TA I L E D C O N T E N T S
243
Tracheal suction
387
Aortic aneurysm
244
Extubation
387
Ventricular aneurysm
245
Mechanical ventilation
388
245
Non-invasive ventilation
389
Invasive mechanical ventilation
392
Summary
404
Cardiac Rhythm Assessment and

Management
12
13
251
Neurological Assessment and Monitoring
251
Arrhythmias and arrhythmia management
252
414
Cardiac pacing
265
Neurological anatomy and physiology
414
Cardioversion
280
Neurological assessment and monitoring
431
Ablation
285
Summary
440
Summary
285
Cardiac Surgery and Transplantation
291
Cardiac surgery
291
Intra-aortic balloon pumping
302
Heart transplantation
308
Summary
319
Respiratory Assessment and

325
325
Pathophysiology
333
Assessment
335
Respiratory monitoring
338
Bedside and laboratory investigations
341
Diagnostic procedures
344
Summary
347
Respiratory Alterations and Management

352
Incidence of respiratory alterations
352
Respiratory failure
353
Pneumonia
357
Respiratory pandemics
360
Acute lung injury
362
Asthma and chronic obstructive pulmonary

disease
15
16
The cardiac conduction system
Monitoring
14
387
Infective endocarditis
Summary
11
tracheostomy
364
Pneumothorax
366
Pulmonary embolism
367
Lung transplantation
369
Summary
374
Ventilation and Oxygenation Management

381
Oxygen therapy
381
Airway support
383
Intubation
384
Tracheostomy
386
Complications of endotracheal intubation and
Pathophysiology
17
Neurological Alterations and Management

Concepts of neurological dysfunction
445
445
Neurological therapeutic management
449
Central nervous system disorders
455
Selected neurological cases
470
Support of Renal Function
21
480
failure
483
Acute renal failure: clinical and diagnostic

486
Renal dialysis
488
501
Gastrointestinal, Liver and Nutritional

Alterations
Gastrointestinal physiology
506
506
Nutrition
509
Summary
20
Management of Shock
556
557
562
Pathophysiology
563
Systemic response
564
Organ dysfunction
567
Multiorgan dysfunction
569
Summary
572
Section 3 Specialty Practice in

Critical Care
22
579
Emergency Presentations
581
522
525
586
587
588
Respiratory presentations
589
Chest pain presentations
591
Abdominal symptom presentations
526
582
Extended roles
Multiple patient triage/disaster
516
Liver transplantation
Incidence of diabetes in Australasia
554
Multiple Organ Dysfunction Syndrome
Retrievals and transport of critically ill patients
513
Liver dysfunction
Glycaemic control in critical illness
551
Triage
508
Nutrition support
Stress-related mucosal disease
545
491
Summary
19
Cardiogenic shock
Summary
Pathophysiology and classification of renal
Approaches to renal replacement therapy
542
Neurogenic/spinal shock
479
criteria for classification and management
541
Hypovolaemic shock
Anaphylaxis
472
Patient assessment
Distributive shock states
Summary
18
539
593
Acute stroke
528
539
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Overdose and poisoning

Near-drowning
594
596
612
xvi
D E TA I L E D C O N T E N T S
23
24
25
Hypothermia
614
Special considerations
Hyperthermia and heat illness
615
Caring for pregnant women in ICU
731
Summary
615
Caring for postpartum women in ICU
735
Trauma Management
623
Summary
Trauma systems and processes
623
Common clinical presentations
626
Summary
649
Resuscitation
654
Types of donor and donation
Pathophysiology
655
Organ donation and transplant networks in
Resuscitation systems and processes
655
Management
655
Identification of organ and tissue donors
Roles during cardiac arrest
670
Organ donor care
Family presence during an arrest
670
Donation after cardiac death
Ceasing CPR
671
Tissue-only donor
Postresuscitation phase
671
Summary
Near-death experiences
671
Legal and ethical considerations
672
Summary
672
Paediatric Considerations in Critical Care
27
Organ Donation and Transplantation
746
New Zealand
746
747
Australasia
747
749
Rights
680
Comfort measures
685
APPENDIX A4 Declaration of Vienna: Patient
Family issues and consent
686
763
765
Safety in Intensive Care Medicine
76
768
APPENDIX B1 ACCCN Position Statement (2006)
The child experiencing upper airway
on the Provision of Critical Care Nursing
686
Education
The child experiencing lower airway disease
691
Nursing the ventilated child
693
The child experiencing shock
695
APPENDIX B2 ACCCN ICU Staffing Position
77
Statement (2003) on Intensive Care Nursing
The child experiencing acute neurological
Staffing
696
77
Gastrointestinal and renal considerations in

698
APPENDIX B3 Position Statement (2006) on the
Paediatric trauma
700
Use of Healthcare Workers other than Division
Summary
702
1* Registered Nurses in Intensive Care
Pregnancy and Postpartum Considerations
777
APPENDIX B4 ACCCN Resuscitation Position
710
Statement (2006) Adult & Paediatric

Resuscitation by Nurses
77
711
716
APPENDIX C Normal Values
78
Epidemiology of critical illness in pregnancy
710
Adapted physiology of pregnancy

Diseases and conditions unique to pregnancy
Exacerbation of medical disease associated

with pregnancy
758
APPENDIX A3 Declaration of Vienna: Patient

7
children
758
APPENDIX A2 Declaration of Buenos Aires:
684
dysfunction
757
APPENDIX A1 Declaration of Madrid: Education
Developmental considerations
obstruction
755
Workforce
Anatomical and physiological considerations
26
738
Opt-in system of donation in Australia and
679
in children
729
726
GLOSSARY
78
3
PICTURE CREDITS
79
0
INDEX
793
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Abbreviations
ALT
alanine aminotransferase
AMI
acute myocardial infarction
AND
autonomic nerve dysfunction
ANP
atrial natriuretic peptide
2-PAM
pralidoxime
ANZBA
Australian and New Zealand Burn Association
6MWT
six-minute walk test
ANZICS
Australian and New Zealand Intensive Care
A/C
assist control
A/C MV
assist-controlled mechanical ventilation
AACN
American Association of Critical-care Nurses
AATT
aseptic non-touch technique
ABG
arterial blood gas
ACCCN
Australian College of Critical Care Nurses
ACD
active compressiondecompression
ACE
angiotensin-converting enzyme
ACEM
Australasian College of Emergency Medicine
ACh
acetylcholine
AChE
acetylcholinesterase
ACN
advanced clinical nurse
ACNP
acute care nurse practitioner
ACS
acute coronary syndrome
ACS
abdominal compartment syndrome
ACT
activated clotting time
ACTH
adrenocorticotrophic hormone
ADAPT
Australasian Donor Awareness Program

Training
ADE
adverse drug event
ADH
antidiuretic hormone
ADL
activities of daily living
ADP
adenosine diphosphate
AE
adverse event
AED
automatic external defibrillator
AHA
American Heart Association
AHEC
Australian Health Ethics Committee
AIS
abbreviated injury score
AKI
acute kidney infection
ALF
acute liver failure
ALI
acute lung injury
ALP
alkaline phosphatase
ALS
advanced life support
Society
ANZOD
Australia and New Zealand Organ Donation

Registry
xviii AoCLF
acute-on-chronic liver failure
AV
atrioventricular
AVDO
arteriovenous difference in oxygen
AVM
arteriovenous malformation
AVPU
Alert/response to Voice/only responds to
AODR
AORTIC
Australian Organ Donor Register

Australasian Outcomes Research Tool for
Intensive Care
APACHE
acute physiology and chronic health

evaluation
Pain/Unconscious
BBB
bloodbrain barrier
BDI
Beck Depression Inventory
BiPAP
bilevel positive airway pressure
BiVAD
biventricular assist device
APC
activated protein C
BIS
bispectral index
APRV
airway pressure release ventilation
BLS
basic life support
aPTT
activated partial thromboplastin time
BMV
Bag/mask ventilation
ARAS
ascending reticular activating system
BP
blood pressure
ARC
Australian Resuscitation Council
BPS
Behavioural Pain Scale
ARDS
acute respiratory distress syndrome
BSA
body surface area
ARF
acute renal failure
BSLTx
bilateral sequential lung transplantation
BTF
Brain Trauma Foundation
ASL
AST
ATC
ATCA
arterial spin labelling

aspartate aminotransferase
automatic tube compensation
Australasian Transplant Coordinators
Association
ATN
acute tubular necrosis
ATP
adenosine triphosphate
ATS
Australasian Triage Scale
AV
arteriovenous
BURP
Backwards, upwards, rightward pressure
BVM
bagvalvemask
CaO
content of arterial oxygen in the blood
CABG
coronary artery bypass graft
CAM-ICU
Confusion Assessment Method Intensive

Care Unit
CAP
(021) 66485438 66485457
community-acquired pneumonia
A B B R E V I AT I O N S
CPOT
Critical Care Pain Observation Tool
xix
CAUTI
catheter associated urinary tract infection
CPP
cerebral perfusion pressure
CAV
cardiac allograft vasculopathy
CPP
coronary perfusion pressure
CAVH
continuous arteriovenous haemofiltration
CPR
cardiopulmonary resuscitation
CBF
cerebral blood flow
CRASH
corticosteroid randomisation after significan
CBG
corticosteroid-binding globulin
CCF
chronic cardiac failure
CCU
critical care unitmay be intensive care,
CRF
chronic renal failure
coronary care, high dependency or a
CRH
corticotrophin-releasing hormone
combination of these
CRP
C-reactive protein
CCU
coronary care unit
CRRT
continuous renal replacement therapy
CDSS
clinical decision support system
CSF
cerebrospinal fluid
CEO2
cerebral oxygen extraction
CESD
Center for Epidemiologic StudiesDepression
CFI
cardiac function index
CFM
cerebral function monitoring
CHD
coronary heart disease
CHF
chronic heart failure
CI
cardiac index
CI
critical illness
CIM
critical illness myopathy
CINM
critical illness neuromyopathy
CIP
critical illness polyneuropathy
CIPNP
critical illness polyneuropathy
CIS
clinical information system
CK
creatine kinase
CLAB
central line associated bacteraemia
CLD
chronic liver disease
CLF
chronic liver failure
cLMA
classic laryngeal mask airway
CLRT
continuous lateral rotation therapy
CMV
controlled mechanical ventilation
CMV
cytomegalovirus
CNE
clinical nurse educator
CNPI
checklist of nonverbal pain indicators
CNS
central nervous system
CO
carbon monoxide
CO
cardiac output
CO
carbon dioxide
COAD
chronic obstructive airways disease
COPD
chronic obstructive pulmonary disease
CPAP
continuous positive airway pressure
CPB
cardiopulmonary bypass
CPDU
clinical practice development unit
CPG
clinical practice guideline
CPM
cuff pressure monitoring
CPOE
computerised physician (provider) order entry
head injury
EC
extracorporeal circuit
CSSU
central sterile supply unit
ECC
external cardiac compression
CSWS
cerebral salt-wasting syndrome
ECG
electrocardiograph/y
CT
computerised tomography
ECMO
extracorporeal membrane oxygenation
CTG
clinical trials group (of ANZICS)
ED
emergency department
CVC
central venous catheter
EDD
extended daily diafiltration
CVD
cardiovascular disease
EDD-f
extended daily dialysis filtration
CvO2
central venous oxygenation
EDIS
Emergency Department Information
CVP
central venous pressure
CVVH
continuous veno-venous haemofiltration
EEG
electroencephalogram
CVVHDf
continuous veno-venous haemodiafiltration
EGDT
early goal-directed therapy
CXR
chest X-ray
EMD
electromechanical dissociation
DAI
diffuse axonal injury
EMS
emergency medical system
System
DASS
Depression Anxiety and Stress Scale
EN
enteral nutrition
DAT
decision analysis theory
ENID
emerging novel infectious disease
DCD
donor after cardiac death
EPAP
expiratory positive airway pressure
DCM
dilated cardiomyopathy
ePD
emancipatory practice development
DDAVP
1-deamino-8-D-arginine vasopressin
EQ-5D
Euroquol 5D
ERC
European Resuscitation Council
ESBL-E
extended-spectrum beta-lactamase-
(Vasopressin)
DKA
DO
diabetic ketoacidosis
oxygen delivery
producing Enterobacteriaceae
DPL
diagnostic peritoneal lavage
ESLD
end stage liver disease
DRG
diagnosis-related group
ESLF
end-stage liver failure
DSC
(MRI) dynamic susceptibility contrast
ETC
DVT
deep venous thrombosis
ETCO2
end-tidal carbon dioxide
EBI
electrical burn injury
ETIC-7
experience after treatment in intensive care
EBN
evidence based nursing
ETT
endotracheal tube
EBP
evidence based practice
EVLW
extravascular lung water
EC
ethics committee
FAED
fully automatic external defibrillator
(021) 66485438 66485457
(o)esophagealtracheal Combitube
xx
HRQOL
health-related quality of life
focused assessment with sonography for
HRS
hepatorenal syndrome
trauma
HSV
herpes simplex virus
FBC
full blood count
HTLV
human T-lymphotropic virus
FDA
(US) Food and Drug Administration
IABP
intra-aortic balloon pump
FES
fat embolism syndrome
IAC
interposed abdominal compression
forced expiratory volume in 1 second
IAP
intra-abdominal pressure
FFA
free fatty acid
ICC
intercostal catheter
FFP
fresh frozen plasma
ICD
implantable cardioverter defibrillator
FI
fear index
ICDSC
Intensive Care Delirium Screening Checklist
FiO2
fraction of inspired oxygen
ICG
indocyanine green
fMRI
functional magnetic resonance imaging
FRC
functional residual capacity
FTE
full-time equivalent (equivalent to 76-hour
FAST
FEV
fortnight)
FVC
forced vital capacity
FWR
family witness resuscitation
GABA
gamma-aminobutyric acid
GAS
general adaptation syndrome
GCS
Glasgow Coma Scale
GEDV
global end-diastolic volume
GGT
gamma-glutamyl transpeptidase
GI
gastrointestinal
GIT
gastrointestinal tract
GM1
monosialoganglioside
GTN
glyceryl trinitrate
3
HCO
H CO
2
sodium bicarbonate
carbonic acid
hydrogen
HADS
hospital anxiety and depression scale
HAI
healthcare acquired infection
Hb
haemoglobin
HbF
fetal haemoglobin
HCM
hypertrophic cardiomyopathy
HDU
high-dependency unit
HE
hepatic encephalopathy
HFA
Heart Foundation Australia
HFNC
high flow nasal cannula(e)
HFOV
high-frequency oscillatory ventilation
HH
heated humidification
HHNS
hyperglycaemic hyperosmolar non-ketotic

state
Hib
Haemophilus influenzae type b
HIT
Heparin-induced thrombocytopenia
HME
heatmoisture exchanger
HPA
hypothalamicpituitaryadrenal
HRC
Health Research Council (New Zealand)
LDL
low-density lipoprotein
ICH
intracranial haemorrhage
LDLT
living donor liver transplantation
ICP
intracranial pressure
LFTs
liver function tests
ICT
information and communications
LMA
laryngeal mask airway
LN
liaison nurse
LOC
level of consciousness
technologies
ICU
intensive care unit
ICU-AW
intensive care unit acquired weakness
LOC
loss of consciousness
ICU LN
intensive care unit liaison nurse
LP
lumbar puncture
IDC
indwelling catheter
LVAD
left ventricular assist device
I:E
inspiratory:expiratory (ratio)
LVEDV
left ventricular end-diastolic volume
IES
impact of events scale
LVEF
left ventricular ejection fraction
IgE
immunoglobulin E
LVF
left ventricular failure
IHD
intermittent haemodialysis
LVP
left ventricular pressure
IL
interleukin
LVSWI
left ventricular stroke work index
ILCOR
International Liaison Committee on
MAP
mean arterial pressure
MARS
molecular adsorbent(s) recirculating system
Resuscitation
IMA
internal mammary artery
MASS
Motor Activity Assessment Scale
INR
International Normalized Ratio
MCA
middle cerebral artery
IO
intraosseous
MED
manual external defibrillator
IPP
information privacy principles
MET
medical emergency team
IPPV
intermittent positive pressure ventilation
MET(s)
metabolic equivalent(s)
IPT
information-processing theory
MEWS
medical early-warning system
ISS
injury severity score
MIDCAB
minimally invasive direct coronary artery
ITBV
intrathoracic total blood volume
IVC
inferior vena cava
MIDCM
IVIg
intravenous immunoglobulin
mmHg
JE
Japanese B encephalitis
MODS
LAD
left anterior descending coronary artery
MRI
LAP
left atrial pressure
MRO
(021) 66485438 66485457
bypass
minimally invasive direct cardiac massage
millimetres of mercury
multiple organ dysfunction syndrome
magnetic resonance imaging
multi-resistant organisms
Paw
peak airway pressure
MRS
magnetic resonance spectroscopy
Pv
venous pressure
MRSA
methicillin-resistant Staphylococcus aureus
PAC
pulmonary artery catheter
MVC
motor vehicle collision
PAF
platelet-activating factor
MVE
Murray Valley encephalitis
PALS
paediatric advanced life support
NAC
N-acetylcysteine
PaO2
partial pressure of arterial oxygen
NAS
nursing activities scale
PAOP
pulmonary artery occlusion pressure
NASCIS
National Acute Spinal Cord Injury Study
PAP
pulmonary artery pressure
NAT
nucleic acid testing
PART
patient-at-risk team
NDE
near-death experience
PAWP
pulmonary artery wedge pressure
NDU
nursing development unit
PbtO2
brain tissue oxygen
NE
norepinephrine
NF B
nuclear factor kappa B
NGT
nasogastric tube
NHBD
non-heart-beating donation
NHMRC
National Health and Medical Research Council
NHP
Nottingham Health Profile
NIBP
non-invasive blood pressure
NIRS
near-infrared spectroscopy
NIV
non-invasive ventilation
NMB
neuromuscular blocking
NMDA
N-methyl-d-aspartate
NMJ
neuromuscular junction
NO
nitrous oxide
NO2
nitric oxide
NOC
nurse observation checklist
NOK
next of kin
NP
nurse practitioner
NPA
nasopharyngeal aspirate
NPP
national privacy principles
NPY
neuropeptide Y
NSAIDs
non-steroidal anti-inflammatory drugs
NTS
national triage scale
NTT
nasotracheal tube
NYHA
New York Heart Association
O2
oxygen
ODIN
organ dysfunction and/or infection
OEF
oxygen extraction fraction
OHCA
out-of-hospital cardiac arrest
OLTx
orthotopic liver transplantation
OSA
obstructive sleep apnoea
OTDA
Organ and Tissue Donation Agency
PA
alveolar pressure
Pa
arterial pressure
PaCO2
partial pressure of carbon dioxide in arterial

blood
PaO
partial pressure of oxygen in arterial blood
xxi
PSG
polysomnography
PCI
percutaneous coronary intervention
PT
prothrombin time
PCT
dynamic perfusion computed tomography
PTA
posttraumatic amnesia
PCV
pressure-controlled ventilation
PTCA
percutaneous transluminal coronary
PCWP
pulmonary capillary wedge pressure
angioplasty
PD
peritoneal dialysis
PTSD
posttraumatic stress disorder
PDH
pulmonary dynamic hyperinflation
PTSS
posttraumatic stress symptoms
PDR
plasma disappearance rate
PTT
partial thromboplastin time
PDSA
plan, do, study, act
Pv
PDU
practice development unit
PvO
mixed venous oxygen pressure
PE
pulmonary embolism
PVR
peripheral vascular resistance
PEA
pulseless electrical activity
QI
quality improvement
PEEP
positive end-expiratory pressure
QOL
quality of life
PEFR
peak expired flow rate
QOLIT
quality of lifeItalian version
PET
positron emission tomography
QOLSP
quality of lifeSpanish version
PETCO2
positive end-tidal carbon dioxide
QUM
quality use of medicines
pH
acidalkaline logarithmic scale
QWB
quality of wellbeing
PI
pulsatility index
RAAS
reninangiotensinaldosterone system
PICC
peripherally inserted central catheter
RASS
Richmond AgitationSedation Scale
PiCCO
pulse-induced contour cardiac output
RAS
reticular activating system
PICU
paediatric intensive care unit
RBC
red blood cell
PN
parenteral nutrition
RCA
root cause analysis
PND
paroxysmal nocturnal dyspnoea
RCA
right coronary artery
PNS
peripheral nervous system
RCSQ
Richards-Campbell Sleep Questionnaire
Pplat
plateau pressure
REM
rapid eye movement
PPE
personal protective equipment
RICA
right internal carotid artery
(recombinant human-activated) protein C
ROSC
return of spontaneous circulation
worldwide evaluation in severe sepsis
RRS
rapid response system
RR
respiratory rate
PROWESS
PRVC
venous pressure
2
pressure-regulated volume control
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xxii
STEMI
ST-elevation myocardial infarction
RRT
rapid response teams
SVDK
snake venom detection kit
RRT
renal replacement therapy
SVG
saphenous vein graft
RTS
revised trauma score
SVR
systemic vascular resistance
RVF
right ventricular failure
SVT
supraventricular tachycardia
RVP
right ventricular pressure
SVV
stroke volume variation
RVSWI
right ventricular stroke work index
SaO
saturation of oxygen in arterial blood
SpO
saturation of oxygen in peripheral tissues
SvO2
venous oxygen saturation
SA
sinoatrial
SAC
safety assessment coding
SAED
semiautomatic external defibrillator
SAFE
Saline versus Albumin Fluid Evaluation (trial)
SAH
subarachnoid haemorrhage
SAI
State Anxiety Inventory
SAPS
simplified acute physiology score
SARS
severe acute respiratory syndrome
SARS-CoV
severe acute respiratory syndrome

coronavirus
SAS
Sedation Agitation Scale
SBE
serum base excess
SBP
systolic blood pressure
SCA
sudden cardiac arrest
SCI
spinal cord injury
SCUF
slow continuous ultrafiltration
SE
status epilepticus
SEI
sleep efficiency index
SF-36
Short Form 36
SGRQ
St Georges Respiratory Questionnaire
SIADH
syndrome of inappropriate antidiuretic

hormone secretion
SICQ
Sleep in Intensive Care Questionnaire
SIG
strong ion gap
SIMV
synchronised intermittent mandatory

ventilation
SIP
sickness impact profile
SIRS
systemic inflammatory response syndrome
SjvO
jugular venous oxygen saturation
SLTx
single lung transplantation
SOFA
sepsis-related/sequential organ failure
assessment
SPECT
single photon emission computed

tomography
SR
systematic review
SSG
surviving sepsis guidelines
STAI
State Trait Anxiety Inventory
UO
urine output
upper respiratory tract infection
SWS
slow wave sleep
URTI
TAFI
thrombin-activatable fibrinolysis inhibitor
ventilation
TB
tuberculosis
V/Q
ventilation/perfusion
TBI
traumatic brain injury
VT
tidal volume
ventilator-associated lung injury
TCD
transcranial Doppler
VALI
TEG
thromboelastograph
VAP
ventilator-acquired pneumonia
TIPS
transjugular intrahepatic portosystemic
VAS
Visual analogue scale
VAS-A
Visual analogue scale Anxiety
shunt/stent
TISS
therapeutic intervention scoring system
VC
vital capacity
TLC
total lung capacity
VC
volume-controlled (ventilation)
TNF
VCv
volume controlled ventilation
TNS
tumour necrosis factor
VE
minute ventilation
TOE
transoesophageal echocardiograph/y
VF
ventricular fibrillation
tPA
tissue plasminogen activator
VICS
Vancouver Interaction and Calmness Scale
tPD
technical practice development
VO2
oxygen consumption
TPN
total parenteral nutrition
VRE
vancomycin-resistant Enterococcus
TPR
temperature, pulse, respirations
VT
ventricular tachycardia
VTE
venous thromboembolism
VV
veno-venous
TSANZ
tumour necrosis factor alpha
Transplant Society of Australia and New

Zealand
TSC
trauma symptom checklist
WBC
TSH
thyroid-stimulating hormone
WCC
white cell count
TST
total sleep time
WFCCN
World Federation of Critical Care Nurses
TT
thrombin time
WHO
World Health Organization
TV
tidal volume
WOB
work of breathing
TVI
time velocity interval
XeCT
xenon-enhanced computed tomography
UEC
urea, electrolytes, creatinine
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white blood cell
SECTION
Scope of Critical Care
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This page intentionally left blank
(021) 66485438 66485457
Leanne Aitken
expenditure.2
Wendy Chaboyer
Doug Elliott
Learning objectives
After reading this chapter, you should be able to:
consumables and the rest to clinical support and capital

globally. In our region, there are approximatel
describe the history and development of critical care
y 119,000
nursing practice, education and professional activities
admissions to 141 general intensive care
discuss the influences on the development of critical care
units (ICUs)
nursing as a discipline and the professional development
in Australia per year; this includes 550

0 patient re-
of
individual nurses
admissions during the same hospital episo
outline the various roles available to nurses within critical
de. In New
care areas or in outreach services
Zealand, there are 18,000 admissions per yea
discuss the potential impact of clinical decision-making
r to 26 ICUs,
processes on patient outcomes
including 500 re-admissions.1 Patients admitt
consider processes in the work and professional
ed to coro-
environment that are influenced by local leadership styles.
nary care, paediatric or other specialty units n

ot classified
as a general ICU are not included in these figu
res, so the
Key words
overall clinical activity for critical care is
critical care nursing
much higher
roles of critical care nurses
(e.g. there were also 5500 paediatric a
clinical decision making
dmissions to
clinical leadership
PICUs).1 Importantly, critical care treatment

is a highexpense component of hospital care; one
INTRODUCTION
conservative
estimate of cost exceeded $A2600 per da
There is unprecedented demand for critical care servi
y, with more
ces
than two-thirds going to staff costs, one
fifth to clinical
Critical care as a specialty in nursing has developed over

the last 30 years.3,4 Importantly, development of our specialty in Australia and New Zealand has been in concert
with development of intensive care medicine as a defined
clinical specialty. Critical care nursing is defined by the
World Federation of Critical Care Nurses as:
Specialised nursing care of critically ill patients who have manifest or potential disturbances of vital organ functions. Critical
care nursing means assisting, supporting and restoring the
patient towards health, or to ease the patients pain and to
prepare them for a dignified death. The aim of critical care
nursing is to establish a therapeutic relationship with patients
and their relatives and to empower the individuals physical
,
psychological, sociological, cultural and spiritual capabilities by
preventive, curative and rehabilitative interventions.5
Critically ill patients are those at high risk of actual o

r
potential life-threatening health problems.6 Care of the
critically ill can occur in a number of different locations
in hospitals. In Australia and New Zealand, critical car
e
is generally considered a broad term, incorporating
subspecialty areas of emergency, coronary care, hi
ghdependency, cardiothoracic, paediatric and general intensive care units.7
This chapter provides a context for subsequent chapters,
outlining some key principles and concepts for studying
and practising nursing in a range of critical care areas. The
scope of critical care nursing is described in the Australian
and New Zealand contexts, which in turn have some
influence on clinical practice in Southeast Asia and the
Pacific. Development of the specialty is discussed, along
with the professional development and evolving roles of
critical care nurses in contemporary health care, including
clinical decision making and leadership.
DEVELOPMENT OF CRITICAL
CARE NURSING
Critical care as a specialty emerged in the 1950s and
1960s in Australasia, North America, Europe and South
Africa.4,8-11 During these early stages, critical care consisted
3
(021) 66485438 66485457
SCOPE OF CRITICAL CARE
e units
primarily of coronary care units for the care of cardiol
was recognised as essential from an early stage,8 an
ogy
d led
patients, cardiothoracic units for the care of postoper
to the development of the nursing specialty of critical
ative
care.
patients, and general intensive care units for the
Although not initially accepted, nursing expertise, abi
care of
lity
patients with respiratory compromise. Later de

the development of a new, comprehensive partne
veloprship
the collective
experience
a steep learning
curv
ments
in renal, metabolic
andofneurological
managem
e
for
ent
the courage to work in an unfamiliar setting,
ledcaring
to the principles and context of critical care that e
xist
to observe patients and appropriate nursing intensity
today.
a high demand for education specific to critic
al care
Development
of critical care nursing was characteris
ation
ed by
the development of technology such as mech
a number
anical of features,4 including:
s the
he
between nursing and medical clinicians
are
now considered essential elements of critical care.12
As the practice of critical care nursing evolved, s
o did
the associated areas of critical care nursing educ
and specialty professional organisations such a
Australian College of Critical Care Nurses (ACCCN). T
combination of adequate nurse staffing, observati
on of
nursing and medical staff
the patient and the expertise of nurses to consi

der the
for patients who were extremely sick a role

that
complete needs of patients and their families is esse

ntial
required development of higher levels of compete

nce
to optimise the outcomes of critical care. As critical c

are
and practice
continues to evolve, the challenge remains to co

mbine
practice, which was initially difficult to meet owing

to
excellence in nursing care with judicious use of t

echno-
the absence of experienced nurses in the specialt
logy to optimise patient and family outcomes.
CRITICAL CARE NURSING EDUCATION
ventilators, cardiac monitors, pacemakers defib

rilla-
Appropriate preparation of specialist critical care

nurses
tors, dialysers, intra-aortic balloon pumps and car

diac
is a vital component in providing quality care to patie

nts
assist devices, which prompted development of ad

di-
and their families.5 A central tenet within this framew

ork
tional knowledge and skills.
of preparation is the formalised education of
There was also recognition that improving patient

out-
nurses
to practise in critical care areas.13 Formal educati
comes through optimal use of this technology was lin
on
ked
in conjunction with experiential learning, conti
to nurses skills and staffing levels.
12
The role of
nuing
ade-
professional development and training, and re
quately educated and experienced nurses in thes
flective
clinical practice is required to develop compete

nce in
Critical care nursing education developed in unison with
critical care nursing. The knowledge, skills and atthe advent of specialist critical care units. Initially, this
titude
consisted of ad-hoc training developed and delivered in
necessary for quality critical care nursing practic the work setting, with nurses and medical officers learne have
ing together. For example, medical staff brought expertise
been articulated in competency statements in in physiology, pathophysiology and interpretation of

many
countries.
electrocardiographic rhythm strips, while nurses brought

14-16
expertise in patient care and how patients behaved and

responded to treatment.12,17 Training was, however, fragmented and fitted in around ward staffing needs. Postregistration critical care nursing courses were subsequently
developed from the early 1960s in both Australasia and
the UK.4,8 Courses ranged in length from 6 to 12 months
and generally incorporated employment as well as specific days for lectures and class work. Given the local
nature of these courses developed for the local needs of
individual hospitals and regions, differences in content
and practice therefore developed between hospitals,
regions and countries.18-20
During the 1990s the majority of these hospital-based
courses in Australasia were discontinued as universities
developed postgraduate curricula to extend the knowledge and skills gained in pre-registration undergraduate
courses. A significant proportion of critical care nurses
now undertake specialty education in the tertiary sector,
often in a collaborative relationship with one or more
hospitals.4 One early study of students enrolled in
university-based critical care courses in Australia21 identified a number of burdens (workload, financial, study
work conflicts), but also a number of benefits (e.g. better
job prospects, job security).
Within Australia and New Zealand, most tertiary institutions currently offer postgraduate critical care nursing
education at a Graduate Certificate or Graduate Diploma
level as preparation for specialty practice, although this
is often provided as a Masters degree.22 In the UK, similar
provisions for postgraduate critical care nursing education at multiple levels are available, although some
universities also offer critical care specialisation at the
undergraduate
level
(for
example,
Kings
College,
London). Education throughout Europe has undergone

significant change in the past 10 years as the framework
articulated under the Bologna Process has been implemented.23 In relation to critical care nursing, this has led
to the expansion of programs, primarily at the postgraduate level, for specialist nursing education. Critical care
nursing education in the USA maintains a slightly different focus, with most postgraduate studies being generic
in nature, including a focus on advanced practice roles
such as clinical nurse specialists and nurse practitioners,
Both the impact of post-registration education on prac-
while specialty education for critical care nurses is under-
tice and the most appropriate level of education that is
taken as continuing education.
required to underpin specialty practice remain controver-
24
Employment in critical
care, with associated assessment of clinical competence,
sial, with no universal acceptance internationally.26-29
remains an essential component of many university-
Globally, the Declaration of Madrid, which was endorsed
based critical care nursing courses.
22,25
(021) 66485438 66485457
beginner
competent
specialist
expert
continuing experience/experiential learning
Induction/
Practice
orientation
to critical
short courses/skills updates/in-service education
Training
care
nursing
education
Postgraduate
initial competencies
increasing complexity of competencies

Graduate
Diploma
Masters
Education
Graduate
Certificate
FIGURE 1.1 Critical care nursing practice: training and education continuum.
important in promoting quality critical c

are nursing
by the World Federation of Critical Care Nurses, provi
practice. Practice- or skills-based continuin
des
g education
a baseline for critical care nursing education (see Ap
sessions support clinical practice at the
pen-
unit level.30
dix A for the position statement).5
(Orientation and continuing education issue
A range of factors continue to influence criti
s are dis-
cal care
cussed further in the context of staffing le
nursing education provision, including government p
vels and skills
oli-
mix in Chapter 2.)
cies at national and state levels, funding mechanism
Many countries now incorporate requireme
s and
nts for con-
resource implications for organisations and individ
tinuing professional development into th
ual
eir annual
students, education provider and healthcare secto
licensing processes. Specific requirements
r part-
include ele-
nership arrangements, and tensions between wor
ments such as minimum hours of required pro
kforce
fessional
and professional development needs.13 Recruitment,
development and/or ongoing demonstration
ori-
of compe-
entation, training and education of critical care n
tence against predefined competency standar
urses
ds.31,32
can be viewed as a continuum of learning, experienc

e and
SPECIALIST CRITICAL CARE COMPET

ENCIES
professional development.5 The relationships be
Critical care nursing involves a range of s
tween
kills, classified
the various components related to practice, training
as psychomotor (or technical), cognitive or int
and
erpersonal.
education are illustrated in Figure 1.1, on a conti
Performance of specific skills requires special
nuum
training and
from beginner to expert and incorporating incr
practice to enable proficiency. Clinical c
easing
ompetence is
complexities of competency. All elements are
a combination of skills, behaviours and
equally
knowledge,
demonstrated by performance within a practice s

ituation33 and specific to the context in which it is
Appendix B). The validity of this structure of six domains
demon-
has been questioned, however, as a number of compe
strated.34 A nurse who learns a skill and is asse ssed as
tency statements are linked to several domains.35 Further
performing that skill within the clinical environme research is therefore required to refine the structure of a
nt is
competency model with improved construct validity.35
deemed competent. As noted above, a set of compet Other competency domains and assessment tools have
ency
also been developed.25 Although articulated slightly dif-
statements for specialist critical care practice co ferently, the American Association of Critical-Care Nurses
mprises
(AACN) provides Standards of Practice and Performance
20 competency standards grouped into six do for the Acute and Critical Care Clinical Nurse Specialist,36
mains:
which outlines six standards of practice (assessmen
professional practice, reflective practice, enabling, cli t,

nical
diagnosis, outcome identification, planning, implemen-
problem solving, teamwork and leadership (see

14
tation and evaluation) and eight standards of professional performance (quality of care, individual practice
evaluation, education, collegiality, ethics, collaboration,
research and resource utilisation) (see Online resources).
CRITICAL CARE NURSING PROFESSIONAL

ORGANISATIONS
Professional leadership of critical care nursing has undergone considerable development in the past three decades.
Within Australia, the ACCCN (formerly the Confederation of Australian Critical Care Nurses) was formed from
a number of preceding state-based specialty nursin
g
bodies (e.g. Australian Society of Critical Care Nurses,
Clinical Nurse Specialists Association) that provided professional leadership for critical care nurses since the early
1970s. In New Zealand, the professional interests of critical care nurses are represented by the New Zealand Nurse
s
Organisation, Critical Care Nurses Section, as well as
affiliation with the ACCCN. The ACCCN has strong professional relationships with other national peak nursing
bodies, the Australian and New Zealand Intensive Care
Society (ANZICS), government agencies and individuals,
and healthcare companies.
Professional
organisations
representing
critical
care
nurses were formed as early as the 1960s in the USA with

the formation of the American Association of Critical
Care Nurses (AACN).37 Other organisations have developed around the world, with critical care nursing bodies
now operating in countries from Australasia, Asia, North
America, South America, Africa and Europe. In 2001 the
inaugural meeting of the World Federation of Critical
Care Nurses (WFCCN) was formed to provide profes-
sional leadership at an international level.38,39 The ACCCN
(021) 66485438 66485457
This section focuses on the scope of critical care

was a foundation member of the WFCCN and a mem
nurses
ber
roles inside and external to the critical care area
association of the World Federation of Societies of Int
, and
en-
provides links to other specific chapters.44 These
sive Care and Critical Care Medicine, and maintai
roles
ns a
include:
representative on the councils of both these internati

onal
bodies. (See the ACCCN website, listed in Online reso
urces,
for further details about professional activities.)
ROLES OF CRITICAL CARE NURSES

As the discipline of critical care has developed, so too
has
the range of roles performed by specialty critical
carer, in Chapters 6, 7 and 8, all practic
care
e-related
nurses.40,41 The continuum of critical illness (see Chap
terocate, in Chapters 5 and 8
educator,pre-crisis/proactive
in Chapter 3.
4) includes
care, management of
the
critical illness, and follow-up care in hospital, clinic an
d
home settings.42 This continuum also includes the pr
actice of palliative care in the ICU environment.43 Clinic
al
(bedside) roles and nurse-to-patient ratios for var
ious
levels of critical care unit, as well as the roles o
f unit
manager and clinical nurse educator, are discuss
ed in
Chapter 2. Practice issues for critical care clinicia
ns are
detailed in the remaining chapters of this book.
Roles
that apply to all nursing professionals are specifi
cally
highlighted; for example:
chapters in Section 2, and the specialty chapt

ers in
Section 3
stration agencies in Australia and New Zealand, with

of critical care outreach or ICU liaison nurse roles (see
similar roles present in the UK and USA prior to this.48
Chapter 2 for further discussion of these services).
Nurse practitioner roles in critical care (or high depen-
In practice, the role of clinical consultant and that of an
dency) range from emergency department practitioners
advanced practice nurse or nurse practitioner can become
through to community-based cardiac failure specialists,
blurred, with hospital administrators believing that one
and, as noted above for the nurse consultants role, often
role can replace the other. Clearly, however, the con-
lack clarity regarding their scope of practice.56,57 Factors
sultants role has a broader portfolio, with a focus on
influencing the establishment of these roles include the
supporting clinical colleagues in providing safe, quality
accrediting process, defining the scope of practice through
patient care, while the role of advanced practice nurse or
specific clinical practice guideline development, prescrib-
nurse practitioner has a direct patient care focus (see
ing rights and the prevailing medical views, and the level
below).
of support provided by health service administrators for
ADVANCED PRACTICE NURSE/NURSE

PRACTITIONER
the implementation, development and evaluation of the

role.48,56 Advanced practice roles in the emergency depart-
Processes for authorisation to practise as a nurse practi- ment are the most well-established in the critical care
tioner (NP) have been introduced by professional regi
consultant
advanced practice48/nurse practitioner roles in ICU,4
45-47
CLINICAL DECISION MAKING

Clinical decision making is integral to critical care nursing
trauma,
domain (see Chapter 22).
49
emergency
50
(Chapter 22), critical care ou practice and forms part of the clinical reasoning process.
t-
Clinical reasoning is
reach /ICU liaison

51
52-54
(Chapter 2)
research/quality coordinator (Chapter 3).

Developing a body of knowledge and the integral role
vel-
of
opment to support clinical care, and facilitating p
research and nurse researchers in that process is des
rofes-
cribed
sional development of colleagues in collaboration
in a later section of this chapter.
with
CONSULTANT
the nurse educator role. The benefits that this role br
Expert clinicians in one of the subspecialties of c
ought
ritical
to the critical care area led to the introduction of a si
care emergency, general ICU, cardiology, cardiotho
milar
racic,
service for non-critical care areas, particularly
neurosciences play important roles in facilit
in the
ating
context of clinical deterioration of patients or for pati
improvements in clinical practice for both critical car
ents
e and
recently discharged from the ICU, with the developm
non-critical care patients. The consultants role
ent
involves
clinical practice, education, quality improvemen
t and
research activities.55 Within these work portfolios, lea
dership and the development and dissemination of know
ledge45,46 within a multidisciplinary team are integr
al to
effective practice.47 Practice includes rolemodelling of
expected behaviours, policy and clinical guideline de
the cognitive processes and strategies that nurses use to under-
are reviewed. Finally, strategies for developing clinical
stand the significance of patient data, to identify and diagnose
decision-making skills are provided.
actual or potential patient problems, and to make clinical decisions to assist in problem resolution and to achieve positive
patient outcomes.58
THEORETICAL PERSPECTIVES ON
DECISION MAKING
Clinical information and prior knowledge are therefore
There are numerous theoretical perspectives on decision
used to inform a decision. This section focuses on the
making, but they can be grouped into two main
decision-making component of clinical reasoning. A brief
categories:
overview of the theoretical perspectives that have been
1. analytical or rationalist
used to understand clinical decision making is provided
2. intuitive or humanistic.
and then studies that focus on critical care nursing
(021) 66485438 66485457
and context in clinical decision making.40,62,

The analytical approaches arise from a positivist or ra
63
tio-
expert intuition develops with experience
nalist perspective and focus on analysing beh
and can be
aviours
used to make complex decisions. Both int
and the steps involved in problem solving. Some of t
uitive knowl-
he
edge and analytical reasoning contribute to cli
specific theories that fall into this category include inf
nical deci-
or-
sions.63 Intuitive approaches to decision maki
mation-processing theory (IPT)59 and decision anal
ng therefore
ysis
focus on understanding the development of in
theory (DAT).60
tuition, the
Fundamental to IPT is the premise that reasoning con
role of experience and articulating how nurse
sists
s use intu-
of a relationship between the problem solver and
ition to make a decision. In addition, Australia
the
That is,
n authors64
context within which the problem occurs. This th
have described a naturalistic framework to ex
eory
amine criti-
asserts that relevant information is stored in ones m
cal care nurses decision making, describin
emory
g it as a way
and that problem solving occurs when the problem s
of considering how people use their experi
olver
ence when
retrieves information from both short- and long-
making real-life decisions.
term
memory. Additionally, IPT claims that there are limits
RESEARCH ON DECISION MAKING IN

CRITICAL CARE NURSING
to
Critical care nursing practice has been the foc
the amount of information that can be processed at a
us of many
ny
studies on decision making. As multiple, c
given time. Thus, IPT focuses on understandin
omplex deci-
g how
sions are made in rapid succession in critical c
information is gathered, stored and retrieved. DAT fo
are, it is an
cuses
ideal setting for studying clinical decision mak
on the use of decision trees, mathematical formulas
ing.61 The
and
seminal work by Benner and colleagues40,63,65 f
other techniques to determine the likelihood of mean
ocused on
ing-
critical care nurses. Table 1.1 summarises
ful clinical data. These rationalist approaches foc
10 studies (11
us on
publications) conducted on critical care nurse
diagnosing a problem, intervening and evaluating
s decision
the
making over the past decade.
outcome.61
Of note, 7 of the 10 studies were conducted in
Contrary to the analytical approaches, intuitive appro
Australia,
aches
with two multinational studies also includin
(also termed humanistic, hermeneutic or phenom
g Australia.
eno-
All but two studies66,67 used qualitative approa
logical) focus on the importance of intuitive knowledg
ches such
as observation, interviewing and thinking
aloud. Two
studies reported the types and frequency of deci Other studies indicated that experienced and inexperisions
enced nurses differ in their decision making skills,67,70,71
made during the time period and identified that critic and that role models or mentors are important in assistal
ing to develop decision making skills.72
care nurses decisions were related to interventio

ns and
communication,
61,68
evaluation,
nisation and education.

hat
61
RECOMMENDATIONS FOR DEVELOPING

assessment, orga CLINICAL DECISION MAKING SKILLS
Several strategies can be used to help critical care nurses
68
A further study demonstrated t to develop their clinical decision-making abilities (Table

1.2).73-75 These strategies can be used by nurses at an
critical care nurses generate one or more hy y

potheses
level to develop their own decision-making skills, or
about a situation prior to decision making.69 All t by

hree
educators in planning educational sessions.
studies highlighted the importance of enabling ex In summary, clinical decision making is a component of
pert
the clinical reasoning process that is part of everyday criti-
nurses to provide a narrative account of their pr cal care nursing practice. It involves gathering and analysactice.
ing information in order to arrive at a decision about

a
particular course of action. The analytical or rationalist
perspective of clinical decision making focuses on analysing behaviours and the steps in solving a problem, while
the intuitive or humanistic approach centres on intuitive
knowledge and the context of the decision. In this spe
cialty area nurses are making clinical decisions at a r
ate
of two to three per minute.61,68 Given this, it is important
that clinical decision-making skills be developed through
experience, training and education. Previous research has
demonstrated that a number of strategies, such as ca
se
studies and reflection on action, can be used to assist
nurses in developing these important skills.
LEADERSHIP IN CRITICAL
CARE NURSING
Effective leadership within critical care nursing is essen
tial at several organisational levels, including the unit and
hospital levels, as well as within the specialty on a broader
professional scale. The leadership required at any give
n
time and in any specific setting is a reflection of the surrounding environment. Regardless of the setting, effective
leadership involves having and communicating a clear
vision, motivating a team to achieve a common goal,
communicating effectively with others, role modelling,
Leadership is essential to achieve the growth and develop-
creating and sustaining the critical elements of a healthy
ment in our specialty and is demonstrated through such
work environment and implementing change and inno-
activities as conducting research, producing publications,
vation.76-79 Leadership at the unit and hospital levels is
making
essential to ensure excellence in practice, as well as ade-
quate clinical governance. In addition to the generic strat-
relevant government and healthcare councils and com-
egies described above, it is essential for leaders in critical
mittees, and participation in organisations such as the
care units and hospitals to demonstrate a patient focus,
ACCCN and the WFCCN. As outlined earlier in this
establish and maintain standards of practice and collabo-
chapter, we have seen the field of critical care grow from
rate with other members of the multi-disciplinary health-
early ideas and makeshift units to a well-developed and
care team.
conference
76
(021) 66485438 66485457
presentations,
representation
TABLE 1.1 Australian and international critical care nurses decision-making research
Author [Country]
Bucknall, 200061
[Australia]
200168 [Australia]
Sample
18 CC nurses (range of
Data collection
Observation (2-hour periods)
Findings
Three types of decision:
levels and experiences;
evaluation (51%)
all had completed a CC
communication (30%)
intervention (19%)
course)
12 CC nurses with 2 years
Currey & Worrall-Carter,
Average: 238 decisions/2 hours (i.e. 2.0/min)

Clinical decision record (of
Five types of decision:
CC experience from 3
2-hour periods) and focus
intervention (40%)
units
groups
communication (26%)
years CC experience
and follow-up
interview
Thinking
aloud (2-hour
periods)
Hypotheses
as a framework for decision
assessmentdeveloped
(19%)
[Australia]
CC nurses from 2
semi-structured interview
organisation (13%)
Clinical
processes
education
(2%)
that affected decision making
Average: 395 decisions/2 hours (i.e. 3.3/min)

Aitken, 2003 [Australia]
69
8 expert CC nurses with 5

making
A combination of strategies used to gather data
Currey & Botti, 200670
Observation followed by
metropolitan hospitals;
following the settling in phase post cardiac
18 inexperienced
surgery were:
(3 years) and 20
handover from anaesthetists
experienced CC nurses
settling in procedures
(3 years).
collegial assistance.
15 nurses (13 inexperienced) felt daunted by

decision making while 7 nurses (1 inexperienced)
felt challenged with a sense of being stimulated,
excited and positive.
Currey, Browne & Botti
Same as above
Observation in 2 phases:
Quality of haemodynamic decision making in the 2
(2006)70 [Same study
1st phase comprised
hours post cardiac surgery was influenced by
as above] [Australia]
unstructured, narrative
decision complexity, nurses level of experience,
observational data; 2nd
and forms of decision support provided by
phase comprised a 2-page
nursing colleagues.
structured observation
Experience was a dominant influence in recognising
checklist. Followed up by
patterns of haemodynamic cues that were
interview.
suggestive of complications.
Adherence to evidence-based practice also
influenced quality of decision making.
Aitken, 2008102 [Australia]
7 CC nurses with a CC
Observation and/or thinking
A range of concepts related to the assessment and
qualification, 5 years
aloud, along with follow-up
management of sedation needs. Assessment
CC experience, and
interviews
included:
working 2 days/week
patients condition
response to therapy
multiple sources of information during

assessment
consideration of relevant history
consideration of the impact on physiology and
implications of treatment
pathophysiology
options in treatment.
Hough, 2008103 [USA]
15 CC nurses from 4 units,
In-depth, semi-structured
with varied experience
guide the ethical decision-making process,
and education levels
through reflection-in-action, was critical for

focused ethical discourse and the decision
making.
Enhanced ethical decision making occurred
through experiential learning.
Thompson, 2008
Vignettes with decision
67
Time pressure significantly reduced the nurses
and Australian
whether or not to contact a
registered nurses
senior nurse/doctor. The
working in surgical,
proportion of true positives
decision-making ability between years of generic
medical, ICU or HDU
(the patient is at risk of a
clinical experience.
critical event and the nurse
decision tendency to intervene.

There were no statistically significant differences in
There were statistically significant differences in
takes action) and false
decision-making ability between years of critical
positives (the nurse takes
care experience when participants were not
action when it was not
under time pressure: those with greater critical
warranted) was calculated.
care experience performed better.

Under time pressure, there were no differences in
decision-making ability between years of critical
care experience.
(021) 66485438 66485457
interviews
[various countries]
245 Dutch, UK, Canadian
The presence of a role model or mentor to help
TABLE 1.1, Continued

Author [Country]
Sample
Data collection
Findings
Hoffman, 200971
[Australia]
8 CC
4 expert
nurses: 4 novice and
Thinking
period of
aloud
care);
(during
interview
2-hour
Cue usage and clustering during decision making:
Expert nurses collected 89 different cues, while

novices collected 49 different cues.
Expert nurses clustered a greater number of cues

when making decisions regarding the patients
haemodynamic status.
[Iran]
14 CC nurses from 4
interviews
3 themes
were involved
in reasoning
strategies:
Expert nurses
were more
proactive in
collecting
relevant cues to anticipate problems and make
decisions.
Ramezani-Badr, 2009
In-depth, semi-structured
104
[Various countries]
hospitals, currently
intuition
working in the CCU,
recognising similar situations
with 3 years CC
hypothesis testing.
andCanadian
holding
245experience
Dutch, UK,
3 other themes regarding participants criteria to
at least a bachelor of
make decisions:
nursing.
patients risk-benefits
organisational necessities (i.e. complying with

organisational policy even if it meant they were
capable of doing more)
complementary sources of information (e.g.

research papers and pharmacology texts).
Thompson, 2009
Judgement classification
66
and Australian
systems, Continuous (0100)
Critical care experience was associated with

estimates of risk, but not with the decision to
registered
dichotomous
Description
of anurses
clinical situation forratings
whichorthe
clinician has to generateintervene.
questions and develop hypotheses; with
testing74
working in surgical,
ratings on 3 nursing
medical, ICU or HDU.
judgements were used
Nurses varied considerably in their risk assessments,

this being partly explained by variability in
weightings given to information.
Information was synthesised in non-linear ways that
contributed little to decisional accuracy.
action74
Clinicians are asked to reflect on their actions after a particular event. Reflection focuses on clinical judgments made,
TABLE 1.2 Strategies to develop clinical decision-making skills

Strategy
Description
Iterative hypothesis
additional questioning the clinician will develop further hypotheses. Three phases:
1. asking questions to gather data about a patient
2. justifying the data sought
3. interpreting the data to describe the influence of new information on decisions.
Interactive model
74
Schema (mental structures) used to teach new knowledge by building on previous learning. Three components:
1. advanced organisers blueprint that previews the material to be learned and connects it to previous materials
2. progressive differentiation a general concept presented first is broken down into smaller ideas
3. integrative reconciliation similarities and differences and relationships between concepts explored.
Case study75
Description of a clinical situation with a number of cues, followed by a series of questions. Three types:
1. stable presents information, then asks clinicians about it
2. dynamic presents information, asks the clinicians about it, presents more information, asks more questions
3. dynamic with expert feedback combines the dynamic method with immediate expert feedback.
Reflection on
feelings surrounding the actions and the actions themselves. Reflection on action can be undertaken as an individual
or group activity and is often facilitated by an expert.
Thinking aloud
74
A clinical situation is provided and the clinician is asked to think aloud, or verbalise his/her decisions. Thinking aloud is
generally facilitated by an expert and can be undertaken individually or in groups.
highly organised international specialty in the course Leadership styles vary and are influenced by the mission
of
and values of the organisation as well as the val
half a generation. Such development would not
ues
have
and beliefs of individual leaders. These styles of leade
been possible without the vision, enthusiasm and rcom-
ship are described in many different ways, sometimes
mitment of many critical care leaders throughout using theoretical underpinnings such as transactional
the
world.
(021) 66485438 66485457
10
and transformational and sometimes by using le

adership characteristics. Regardless of the terminology in
articulate a personal vision and expectatio
use,
act as a catalyst for chang
ns
some
common
principles organisational
can be expressed.
and implement
standa D
establish
model
effective
leadership
behaviours
through
rds
esired
both
leadership
include
the ability and
to: take
monitor characteristics
practice in relation
to standards
correcognise the characteristics and strengths of
indivi
empower staff
to
act
independently and
change
processes and stable contexts
80-85
elements vary according to leadership style.

satisfied staff, with a high level of retenti
Different of staff through an effective coa
development
on
ching styles for example, transactional, transformat
ional,
authoritative or laissez faire incorporate different c
haracteristics and activities. Having leaders with diff
erent
styles ensures that there is leadership for all stages o
f an
organisations operation or a professions develop
ment.
A combination of leadership styles also helps to
over-
rective action when necessary
come team member preferences and problems e
duals, and stimulate individual development

and
commitment
xpericritical
care personnel are aware of, and willi
ng toenced when a particularly visionary leader leaves
personnel in other areas of the hospital or outside
the . The
challenges often associated with the departure of a l
eader
patients
receive
optimal quality
of car are generally redu
from
a healthcare
organisation
e.
ced in
interdependently
Personal characteristics of an effective leader, re
the clinical critical care environment, where a nu
gardless
rsing
of the style, include honesty, integrity, commitment
leader is usually part of a multidisciplinary team,
and
with
credibility, as well as the ability to develop an open, t
resultant shared values and objectives.
rusting environment.85 Effective leaders inspire their t
CLINICAL LEADERSHIP
eam
Effective critical care nurses demonstrate leadership
members to take the extra step towards achievin
char-
g the
acteristics regardless of their role or level of practice.
goals articulated by the leader and to feel that
Lead-
they are
ership in the clinical environment incorporates
valued, independent, responsible and autonomous in

dividuals within the organisation.
the
general characteristics listed above, but has the
85
Members of teams
added
with
challenges of working within the boundaries creat
effective leaders are not satisfied with maintainin
ed by
g the
the requirements of providing safe patient care 24 ho
status quo, but believe in the vision and goals articul
urs
ated
a day, 7 days a week. It is therefore essential that cli
by the leader and are prepared to work towards achi

effective and safe patient car
eving
evidence-based healthcar
a higher
standard of practice.
e
Although all leaders share common characteristics, s
nical
ome
as
leaders work within an effective interdisciplinary mod

el,
so that all aspects of patient care and family support,
well as the needs of all staff, are met. Effective

clinical
leadership of critical care is essential in achieving:
and mentoring process.81,86
Effective clinical leaders build cohesive and adaptive

work teams.84 They also promote the intellectual stimulation of individual staff members, which encourages the
analysis and exploration of practice that is essential for
evidence-based nursing.85
Clinical leadership is particularly important in contemporary critical care environments in times of dynamic
change and development. We are currently witnessing
significant changes in the organisation and delivery of
care, with the development of new roles such as nurse
practitioner (see this chapter) and liaison nurse (see
Chapter 3), the introduction of services such as rapid
response systems, including medical emergency teams
(see Chapter 3), and the extension of activities across the
care continuum (see Chapter 4). Effective clinical leadership ensures that:
fulfil, their changing roles
hospital recognise the benefits and limitations of

developments, are not threatened by the developments and are enthusiastic to use the new or refined
services
The need to provide educational opportunities to develop

effective clinical leadership skills is recognised.80 Although
not numerous in number or variety, programs are beginning to be available internationally that are designed to
develop clinical leaders.79,87 Factors that influence leadership ability include the external and internal environment, demographic characteristics such as age, experience,
understanding, stage of personal development including
self-awareness capability, and communication skills.80,82,87
In relation to clinical leadership, these factors can be
developed only in a clinical setting, so development of
clinical leaders must be based in that environment.
Development programs based on mentorship are superbly
suited to developing those that demonstrate potential for
such capabilities.80
Mentorship has received significant attention in the
healthcare literature and has been specifically identified
as a strategy for clinical leadership development.88-90
Although many different definitions of mentoring exist,
common principles include a relationship between two
people with the primary purpose of one person in the
relationship
developing
new
skills
related
to
their
career. 91,92 Mentoring programs can be either formal or
decisions, providing emotional and psychological support
informal and either internal or external to the work
and assisting the mentee in the socialisation process both
setting. Mentorship involves a variety of activities directed
within and outside the work organisation to build profes-
towards facilitating new learning experiences for the
sional networks.89,91 Role modelling of occupational and
mentee, guiding professional development and career
professional skills and characteristics is an important
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11
reported as narrative (where words rather tha

component of mentoring that helps develop future cli
n numbers
ni-
describe the research findings). In contrast
cal leaders.
89,92
DEVELOPING A BODY OF
KNOWLEDGE
, quantitative
research involves the measurement (in numer
ic form) of
variables and the use of statistics to
test hypotheses.
Development of a body of knowledge is a key charact
Results of quantitative research are oft
er-
en reported in
istic of both professions93-95 and the specialties w
tables and figures, identifying statistically sig
ithin
nificant find-
professions. One criterion for a specialty identifie
ings. One particular type of quantitative r
d over
esearch, the
two decades ago by the International Council of Nurs
clinical trial (randomised controlled trial, or RC
es
(ICN)
96
is that it is based on a core body of nur
sing
knowledge that is being continually expanded and re
fined
by research. Importantly, the ICN acknowledge
s that
mechanisms are needed to support, review and disse
minate research.
RESEARCH
As noted above, research is fundamental in the devel
opment of nursing knowledge and practice. Researc
h is a
systematic inquiry using structured methods to u
nderstand an issue, solve a problem or refine existing kno
wledge. Qualitative research involves in-depth examina
tion
of a phenomenon of interest, typically using intervie
ws,
observation or document analysis to build knowle
dge
and enable depth of understanding. Qualitativ
e data
analysis is in narrative (text) form and involves some
form
of content or thematic analysis, with findings ge
nerally
T), is used
QUAL QUANT: both approaches are given e
to test the effect of a new nursing interventio
qual
n on patient
QUAL quant:
qualitative methods are the domin
ant
outcomes. In essence, clinical trials involve:
QUAL quant: the qualitative study is given priori
ty
tial data collection. For example:

1. randomly allocating patients to receive either a
new intervention (the experimental or intervention group) or an alternative or standard interven-
status and data collection occurs concurrently.
tion (the control group)

2. delivering
the
approach and data collection occurs concurrently.
intervention
or
alternative
treatment
and qualitative data collection will occur before quan-
3. measuring an a priori identified patient outcome.
titative data collection.
Statistical analyses are used to determine if the new
Irrespective of which type of research design is used, there
intervention is better for patients than the alternative
are a number of common steps in the research proce
treatment.
ss
Mixed methods research have now emerged as an
(Table 1.3), consisting of three phases: planning for the
approach that integrates data from qualitative and quan-
research, undertaking the research and analysing a
titative research at some stage in the research process.97
nd
In mixed methods approaches, researchers decide on
reporting on the research findings.
both priority and sequence of qualitative and quantitative
Clinical research and the related activities of unit-
methods. In terms of priority, equal status may be given
based
to both approaches. Priority is indicated by using capital
quality improvement are integral components in th
letters for the dominant approach, followed by the
symbols and to indicate either concurrent or sequen-
practice, education and research triad.98 Partnerships
TABLE 1.3 Steps in the research process

Step
Description
Identify a clinical
Review the literature.
A comprehensive literature review is vital to ensure that the issue or problem has not yet been solved and that the
proposed research will fill a gap in knowledge.
State a clear research
Write a research
considerations and the required resources (i.e. budget) for the research are identified.
Secure resources.
Resources such as funding for supplies and research staff, institutional support and access to experienced
researchers are needed to ensure a study can be completed.
Obtain
ethics
problem
or approvals.
issue.
Approval
of the proposed
researchaudits
by a human
ethics
committee
is required
before the study can
Clinical experience
and practice
are tworesearch
ways that
clinical
issues (HREC)
or problems
are identified.
commence.
Conduct the research.
Adequate time for recruitment of participants and data collection are crucial to ensure that accurate data are
question.
Disseminate the
proposal.
obtained.
A concise question includes both the phenomenon of interest and the patient population.
Clear
the proposed
design and
sample and
a plan continue
for data collection
and analysis. Ethical
and description
are vital to of
ensure
that both research
nursing practice
and nursing
knowledge
to be developed.
(021) 66485438 66485457
research findings.
Conference presentations and journal publications are two common ways that research findings are disseminated
12
Research program
issues
& training
Technology
Practice
Patient
development
outcomes
Practice
based practice
Health status/
Evidence-
Patient/family
HRQOL
Policy
Education
assessment
systems
Clinical
information
Competencies
issues
Commonwealth &
evaluation
Product
Credentialling
Impact of
state policies
evaluation
experiences
Ethical &
international factors
Resource
Economic
Impact of
utilisation
evaluation
technology on
Program
legal issues
patient care
FIGURE 1.2 Example of critical care nursing research program.
oherent research program that highlights the major i

ssues
between clinicians and academics, and the implemen
affecting critical care nursing practice is illustrate
ta-
d in
tion of clinical academic positions, including at the pr
Figure 1.2, with identified themes and topic exemplar
o-
s.
fessorial level,
99
provide the necessary infrastructure
A number of resources are available to critical care n
and
urses
organisation for sustainable clinical nursing and
interested in undertaking research. For exampl
multi-
e, the
disciplinary research. A strong research culture in crit
ACCCN provides funding for research on a comp
ical
etitive
care nursing is evident in Australasia, transcendi
basis, with its Research Advisory Panel assessing
ng geo-
grant
graphical, epistemological and disciplinary boundarie
applications and providing feedback to applicants.
s to
The
focus on the core business of improving care for critic
Intensive Care Foundation, whose members are d
ally
rawn
ill patients. Our collective aim is to develop a sustain
from the Australia and New Zealand Intensive
able
Care
research culture that incorporates strategies that faci
Society (ANZICS), the College of Intensive Care Medic
litate
ine
communication, cooperation, collaboration and coord
(CICM) and ACCCN, also has a research funding sche
i-
me.
nation both between researchers with common intere
Additionally, the ANZICS Clinical Trials Group (CTG
sts
and with clinicians who seek to use research findings
holds regular meetings where potential research
in
can be
their practice. A sample of a guiding structure for a c
discussed and research proposals refined. There i
s great
value in receiving a critical review of proposed r
esearch
before the study is undertaken, as assessors co research utilisation approaches, with a description of
mments
evidence-based practice and the use of evidence-based
help to refine the research plan.
clinical practice guidelines. In addition, each chapter in
Over the years, various groups have identified pr this text contains a research critique to assist nurses in
iorities
developing critical appraisal skills, which will help to
for critical care research. A review of this literature id determine whether research evidence should change
enti-
practice.
fied the following research priorities: nutrition sup

port,
infection control, other patient care issues, nursing ro
SUMMARY
les,
This chapter has provided a context for subsequent chap-
staffing and end-of-life decision making.100
ters, outlining some key issues, principles and concepts
While not all nurses are expected to conduct researc for studying and practising nursing in a range of critical
h, it
care areas. Critical care nursing now encompasses a wide
is a professional responsibility to use research in and ever-expanding scope of practice. The previous focus
practice.
101
on patients in ICU only has given way to a broader

Chapter 3 provides a detailed descripti concept of caring for an individual located in a variety of
on of
clinical locations across a continuum of critical illness.

The discipline of critical care nursing, in collaboration
with multidisciplinary colleagues, continues to develop
to meet the expanding challenges of clinical practice in
todays healthcare environment. Critical care clinicians
also continue their professional development individually, focusing on clinical practice development, education
and training, and on quality improvement and research
activities, to facilitate quality patient and family care
during a time of acute physiological derangement and
emotional turmoil. The principles of decision making
and clinical leadership at all levels of practice serve to
enhance patient safety in the critical care environment.
ONLINE RESOURCES
American Association of Critical-Care Nurses, www.aacn.org
Annual Scientific Meeting on Intensive Care, www.intensivecareasm.com.au
Australian College of Critical Care Nurses, www.acccn.com.au
Australia and New Zealand Intensive Care Society, www.anzics.com.au
British Association of Critical Care Nurses, www.baccn.org.uk
College of Intensive Care Medicine, www.cicm.org.au
Intensive Care Foundation (Australia and New Zealand),
www.intensivecareappeal.com
Kings College, London, www.kcl.ac.uk/schools/nursing
World Federation of Critical Care Nurses, http://en.wfccn.org
(021) 66485438 66485457
13
Research vignette
Aitken L, Marshall AP, Elliott R, McKinley S. Critical care nurses deci-
Critique
sion making: sedation assessment and management in intensive
The study aim was to identify the concepts and attributes used
care. Journal of Clinical Nursing 2008; 18: 3645.
by
Abstract
Australian critical care nurses in their decision making before and
Aims
after the implementation of a nurse-initiated sedation protocol.
This study was designed to examine the decision-making pro-
cesses that nurses use when assessing and managing sedation for
number of educational strategies were used to support impleme
a critically ill patient, specifically the attributes and concepts used
n-
to determine sedation needs and the influence of a sedation
tation of the sedation protocol including: individual and group
guideline on the decision-making processes.
education; protocol and its supporting evidence placed on the
Background
intranet; laminated copies of the protocol available in the patien
Sedation management forms an integral component of the care of
critical care patients. Despite this, there is little understanding of
care areas; poster reminders; and audit and feedback. The aims
how nurses make decisions regarding assessment and manage-
of the study were easy to identify and clearly stated, but the incl
ment of intensive care patients sedation requirements. Appropri-
u-
ate nursing assessment and management of sedation therapy is
sion of definitions of attributes and concepts would have been
essential to quality patient care.
helpful, because some phrases (such as level of sedation, comfo
Design
rt
Observational study.
Methods
Nurses providing sedation management for a critically ill patient
were observed and asked to think aloud during two separate occasions for two hours of care. Follow-up interviews were conducted
to collect data from five expert critical care nurses pre- and postimplementation of a sedation guideline. Data from all sources were
integrated, with data analysis identifying the type and number of
attributes and concepts used to form decisions.
Results
Attributes and concepts most frequently used related to sedation
and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes
related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes
related to assessment (pre, 58%; post, 65%), physiology (pre, 10%;
post, 9%) and treatment (pre, 31%; post, 26%) aspects of care.
Conclusions
Decision making in this setting is highly complex, incorporating a
wide range of attributes that concentrate primarily on assessment
aspects of care.
Relevance to clinical practice
Clinical guidelines should provide support for strategies known to
positively influence practice. Further, the education of nurses to
use such guidelines optimally must take into account the highly
complex iterative process and wide range of data sources used to
make decisions.
and level of consciousness) were labelled as both attribute and
always possible that some would not have been judged to be
concept.
expertby their peers and superiors. It was not clear, however, how
Three methods of data collection were used: think aloud, observa-
the data of the two pilot nurses was actually incorporated into the
tion and interviews. Specifically, during the think-aloud approach,
findings. That is, as their data was only pre-protocol, the reported
nurses wore a collar-mounted microphone attached to an audio-
number of attributes after protocol was implemented could be
recorder and were asked to verbalise their thought processes
expected to be influenced by two fewer participants. This issue was
during the data collection period. At the same time, an observer
not addressed in the report.
recorded the activities that the nurses were undertaking while
The fact that a number of strategies were used to educate the
thinking aloud. A follow-up interview was then undertaken to help
nurses about the sedation protocol should be applauded, as it is
clarify the activities that were observed. Two observers were used
generally recognised that didactic education is not effective in
to collect the data. The qualitative nature of the study and the data
getting clinicians to use guidelines with multi-mode strategies, as
collection methods are accepted methods to examine decision-
in this study. The method used for analysing data that is, having
making processes. The researchers are to be commended for train-
the observers analyse the data they collected, and the investigator
ing the participants in the think-aloud method and for piloting
also assessing the analysis is a strength of the study. The research-
various forms of observational data collection.
ers note that they integrated the think-aloud, observation and
The data from the think-aloud method and the observations
interview data but do not elaborate how this was done, possibly
were analysed independently by the data collector who had
because of the word limit imposed by the journal. Anyone inter-
collected the data for that particular nurse. As part of this analysis,
ested in how this actually occurred would have to contact the
the think-aloud, observation and interview data were integrated
researchers. In their discussion, the researchers note that they were
for each nurse. The actual analysis involved identifying concepts
not able to determine the path between attributes and concepts
and attributes related to three predefined categories: assessment,
(i.e. which came first) or the actual decision-making methods used.
physiology and treatment. All analyses were assessed by the chief
They note, however, that that they were able to identify relation-
investigator and any differences were resolved by consensus.
ships between attributes and concepts. They suggest that their
The sample size five nurses observed twice each (i.e. before and
findings can be used by educators when designing educational
after implementation of the sedation protocol) and two nurses
activities such as concept mapping to help to develop decision-
observed once in the pilot study is appropriate. It is obvious that
making skills in nurses. The findings were clearly reported, the
a very large amount of data was generated. While selection criteria
table was easy to understand and the discussion considered the
were described to identify expert nurses, and included the need
implications of the main findings. Overall, this study provides addi-
to have critical care qualifications and more than five years experi-
tional evidence about the concepts and attributes that critical care
ence, the fact that they self-nominated as expert means that it is
nurses draw on when they are making decisions about sedation.
(021) 66485438 66485457
14
9. Prien T, Meyer J, Lawin P. Development of intensive care medicine in
Learning activities
1. Consider the leaders to whom you are exposed in your
1. Drennan K, Hicks P, Hart GK. Intensive care resources and activity: Aus
tralia &
work environment and identify the characteristics they

display that influence patient care. Reflect on whether
New Zealand 2007/2008. Melbourne: Australian and New Zealand Inte

nsive
these are characteristics that you possess or how you might
Care Society; 2010.
develop them.
2. Mentors are generally individuals who have excelled in
2. Rechner I, Lipman J. The costs of caring for patients in a tertiary referr

al
their chosen profession and who are willing to share their

experiences and expertise with others. Think about your
Australian intensive care unit. Anaesth Intensive Care 2005; 33(4): 477
82.
aspirations in your career as a critical care nurse. With the

help of others, try to identify a potential mentor. Consider
3. Hilberman M. The evolution of intensive care units. Crit Care Med 197
5;
asking this person to meet you on a regular basis to discuss

your professional goals and your strategies to meet these
goals and to provide you with advice.
3(4): 15965.
4. Wiles V, Daffurn K. Theres a bird in my hand and a bear by the bed I
must be
3. Review the strategies outlined in Table 1.2 and develop

a plan of how you might improve your clinical decision-
in ICU. The pivotal years of Australian critical care nursing. Melbourne:

Austra-
making skills. Approach a mentor in your clinical environment and ask him/her to provide feedback over a period of
months on any changes observed in your clinical decision-
lian College of Critical Care Nurses; 2002.

5. World Federation of Critical Care Nurses. Constitution of the World Fed
era-
making skills.
4. Consider the role that you have within critical care and
tion of Critical Care Nurses. 2007:1. Available from: http://www.wfccn.o

rg/
examine the influence that research has on that role. How

might you use research to inform your practice more effectively? Are there strategies that you could implement to
pub_constitution.php.
6. American Association of Critical-Care Nurses. Critical care nursing fact
sheet.
influence the research that is undertaken so that it meets

your needs?
Aliso Viejo CA: American Association of Critical Care Nurses; 2008. [Cit
ed
5. Reflect on your practice in terms of the ACCCN competency

domains14 of professional practice; reflective practice;
enabling; clinical problem solving; teamwork; and leadership. To what extent does your current practice address
these domains? What strategies can you implement to
enhance your practice in these domains?
October 2010]. Available from: www.aacn.org.

7. Australian College of Critical Care Nurses website. [Cited October 201
0].
Available from: www.acccn.com.au.
8. Gordon IJ, Jones ES. The evolution and nursing history of a general int
ensive
care unit (196283). Intensive Crit Care Nurs 1998; 14(5): 2527.
FURTHER READING
Andrew S, Halcomb EJ. Mixed methods research for nursing and the health scie
nces.
Oxford: Wiley-Blackwell; 2009.
Thompson C, Dowding D. Essential decision making and clinical judgment for
nurses.
Edinburgh: Churchill Livingstone; 2010.
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(021) 66485438 66485457
Denise Harris
INTRODUCTION Ged Williams
Learning objectives
St Vincents Hospital, Melbourne, published th

article
e firston the planning and organisation of an intensi
care unit (ICU) in Australia.1 He identified that critica
ve
ill patients who have a reasonable chance of re
lly
require life-saving treatments and constant nursi
covery
medical
ng and care, but this intensity of service delive
In
Dr B Galbally,
a hospital
not
necessarily
continue
until resuscitation
the patient officer
dies, aat
ry 1966
does
should
nd it not continue after the patient is consider
longer
ed no recoverable.1
After reading this chapter, you should be able to:
describe historical influences on the development of critical
The need for prudent and rational allocation of

and human resources was as import
limited
Australias
first ICU (St Vincents, Melbourne, 1961)
explain the organisational arrangements and interfaces that
ant for
is
for
the
200
or more now scattered across Australi
as
it
may be established to govern a critical care unit
New
a andZealand. This chapter explores the influences o
identify external resources and supports that assist in the development
of critical care and the way this resour
n the
currently
viewed
and used; describes various org
ce
is
governance and management of a critical care unit
tional, staffing and training arrangements that need
anisadescribe considerations in planning for the physical designin
considers the planning, design and equipm
to place;
be
needs
of
a critical care unit; covers other
ent
and equipment requirements of a critical care unit
resource
including the budget; and fini
aspects management
of
describe the human resource requirements, supports and
with a description of how critical care staff may resp
shes
training necessary to ensure a safe and appropriate
ond
care and the way this resource is currently viewed and used
financial
workforce
explain common risks and the appropriate strategies,

policies and contingencies necessary to support staff and
patient safety
discuss leadership and management principles that

influence the quality, efficacy and appropriateness of the
critical care unit
discuss common considerations from a critical care

perspective in responding to the threat of a pandemic.
to a pandemic. First, however, important ethical decisions

in managing the resources of a critical care unit, whi
ch
are just as important as the ethical resources that govern
the care decisions for an individual patient (see Chapter
6), are discussed below.
Key words
resource management
critical care
business case
staf
ETHICAL ALLOCATION AND
competence
credentialling
UTILISATION OF RESOURCES
governance
skill mix
In management, as in clinical practice, careful consider-
budget
ation of the pros and cons of various decisions must be
risk management
made on a daily basis. The interests of the individual
pandemic
patient, extended family, treating team, bureaucracy and
patient dependency
the broader community are rarely congruent, nor are they

usually consistent. Decisions surrounding the provision
of critical care services are often governed by a compromise between conflicting interests and ethical theories.
Two main perspectives on ethical decision making,
deontological and utilitarian, are explored briefly.
The deontological principle suggests that a person has
a
fundamental duty to act in a certain way for example,
7
(021) 66485438 66485457
18
these two extreme positions. This dilemma is true of

to provide full, active treatment to all persons. T
all
he rule
health services, but critical care, because of
of rescue, or the innate desire to do something anyt
its high-
hing
technology, high-cost, low-volume outputs, is under
to help those in dire need, may be a corollary
par-
to the
ticular scrutiny to justify its resource usage
deontological principle. These two concepts, the duty
within a
to
healthcare system. Therefore, not only do critical
act and the rule of rescue, tend to sit well with
care
many
managers need to be prudent, responsible and e
trained and skilled clinicians and the Hippocratic Oat
fficient
h.
guardians of this precious resource they need to be
In critical care there are some families and some
seen
clini-
as such if they are to retain the confidence of, and le
cians who, for personal and/or religious reasons,
giti-
take a
macy with, the broader community values of the day.
strong stand and demand treatments and actions

based
on a deontological view (i.e. the fundamental belief t
HISTORICAL INFLUENCES
hat
An often-held view is that managers in government h
a certain action is the only one that should be consid
ealth
ered
services have no incentive to spend or expand s
in a given situation).
ervices.3
At the other extreme is the utilitarian view, which sug
However, the opposite is probably true. Developing l
gests
arger
an action is right only if it achieves the greatest good
and more sophisticated services such as ICUs can att
for
ract
the greatest number of people. This concept tends to
media and public attention. The 1960s and early
sit
well with pragmatic managers and policy makers.
2
An
1970s
saw the development of the first critical care uni
ts in
example of a utilitarian view might be to ration fundi
Australia and New Zealand. If a hospital was to be rel
ng
e-
allocated to heart transplantation and to utilise any s
vant, it had to have one. In fact, what distinguis
aved
hed a
money for prevention and awareness campaigns. A h
tertiary referral teaching hospital from other hosp
eart
economies
of scale
by cohorting
patie
disease
prevention
campaign
lends acritically
greater ill
benefit
nts
to adevelopment of expertise in doctors and nurs
es who
greater
number in the population than does one
itals
transan ever-growing body of research demonstrating t

plant
hatprocedure.
The appropriate provision and allocation of critical ca
ab-
re
acute hospitals with more than 100 beds. Reasons for
services and resources tend to sit somewhere be
the
tween
proliferation of critical care services include, but are
was, at its fundamental conclusion, the existence

of a
critical care unit.4 Over time, practical reasons for est
lishing critical care units have led to their spread to
most
not
limited to:
Funding for critical care services has evolved over time
to be somewhat separate from mainstream patient

to one area
funding, owing to the unique requirements of critical

care units. Critical care is unique because patients are at
specialise in the care and treatment of critical the severe end of the disease spectrum. For instance, the
ly ill
patients
funding provided for a patient admitted for chronic

obstructive airway disease in an ICU on a ventilator is
very different from that provided for a patient with the
critically ill patient outcomes are better if patients same diagnosis, but treated only in a medical ward. Each
are
jurisdictional health department tends to create its own
cared for in a specifically equipped and staffed crit unique approach to funding ICU services in its jurisdicical
care unit.4
tion.5 For instance, Queensland tends to fund ICU

patients who are specifically identified and defined in
the Clinical Services Capability Framework for Intensive
Care6 with a prescribed price per diem, depending on
the level of intensive care given to the patient or a price
per weighted activity unit, as defined in the business
rules and updated on an annual basis.7 In Victoria, the
diagnosis-related group (DRG) payment for individual
patient types admitted to the hospital also pays for
ICU episodes, with some co-payment elements added
for mechanical ventilation.8 In New South Wales a per
diem rate is established for ICU patients, while highdependency patients in ICU are funded through the hospital DRG payment; in South Australia a flat per diem
rate exists.9,10 Most other states have a global ICU budget
payment system based on funded beds or expected occupied bed days in the ICU. However, within states and
specific health services and hospitals the actual allocation of funding to the ICU may vary, depending on the
nature of the specific ICU and demands and priorities
of the health service.11
The RAND study12 examined funding methods in many
countries and concluded that there was no obvious
example of best practice or a dominant approach used
by a majority of systems. Each approach had advantages
and disadvantages, particularly in relation to the financial
risk involved in providing intensive care. While the risk
of underfunding intensive care may be highest in systems
that apply DRGs to the entire episode of hospital care,
including intensive care, concerns about potential underfunding were voiced in all systems reviewed. Arrangements for additional funding in the form of co-payments
or surcharges may reduce the risk of underfunding.
However, these approaches also face the difficulty of
determining the appropriate level.12
At the hospital level, most critical care units have capped
and finite budgets that are linked to open beds that is,
beds that are equipped, staffed and ready to be occupied
by a patient, regardless of whether they are actually occu-
in a shortage of critical care beds, resulting in a rationing
pied.
of the service available. The capping of beds and qualified
13
This is one crude yet common way that hospitals
can control costs emanating from the critical care unit.
critical care nurse positions can be convenient mecha-
The other method is to limit the number of trained and
nisms to limit access and utilisation of this expensive
experienced nurses available to the specialty; conse-
service critical care.
quently, a shortage of qualified critical care nurses results
(021) 66485438 66485457
19
make
Funding based on achieving positive patient outc
workforce planning and the management of c
omes
all-in/over-
would be ideal, as it would ensure that critical care u
time and fatigue problems difficult for sm
nits
approach
were using their resources only for those patient
manage. The professional isolation and limite
s who
were most likely to achieve positive outcomes in ter
all teams
to of treatment and the inherent
The benefit
d access to
approach
Evaluate the
benefit and cost
education,
training
andof the
peer support ca
ms of
n also create
morbidity and mortality, but such an ideal has not de
morale problems for some members of the te
vel-
am. Further-
oped sufficiently to date. Funding based on healt
more, the diseconomies and isolation require
h out-
empathetic
comes only does, however, raise the risk of encourag
funding processes to recognise the difficulties
ing
unique to
clinicians to cherry-pick only the most profitabl
regional and isolated critical care services.
e or
If such units
successful patient groups at the expense of oth
are to remain viable and capable of deliv
ers. In
ering levels of
private (for-profit) hospitals or countries with very po
safe and effective care equivalent to thos
or
e expected in
health systems, cherry-picking only those patien
larger metropolitan hospitals, then addition
ts for
al funding
whom a successful outcome is guaranteed is likely to
and support is required to compensate for
be
more common, whereas in the public hospitals of mo
st
Western countries an educated guess/risk is often ap
plied
to the decision as to whether a patient should enter t
he
critical care unit or not.
It is vital to note the very important role played by ru
the cost and

tyranny of distance.
ECONOMIC CONSIDERATIONS
AND PRINCIPLES
One early comprehensive study of costs f
ound that 8%
Valueof patients
admitted to the ICU consu
ral
med 50% of
and isolated health services and, in particular, critical
resources but had a mortality rate of 70%, wh
care
ile 41% of
units and outreach services in these regions. Many of
patients received no acute interventions a
the
nd consumed
contemporary activity-based funding formulas are
only 10% of resources.14 More recent Aust
diffi-
ralian studies
cult to apply to these settings. There are diseconomi
show that, although critical care service is
es of
increasingly
scale in such settings as a result of small bed n
being provided to patients with a higher sever
umbers,
ity of acute
limited but highly skilled nurses and doctors, and unp
and chronic illnesses, long-term survival o
re-
utcome has
dictable peaks and troughs in demand, which
improved with time, suggesting that critica
l care service
may still be cost-effective
despite
the
changes in
TABLE 2.1 Approaches to assessing treatment options12
case-mix.15,16
Approach
An Australian study showed that in 2002, ICU pa
Benefitrisk
Description
tients
risks to the patient are assessed to inform
cost around $2670 per day or $9852 per ICU admissi
a decision; this approach excludes
on,
monetary costs.
with more than two-thirds going to staff costs, one-
Benefitcost
fifth
decision to proceed; this approach
to clinical consumables and the rest to clinical s
incorporates cost to patient and society.
upport
Implicit approach
and capital expenditure.17 Nevertheless, some
The medical practitioner provides the

service and judges its appropriateness.
authors
provide scenarios as examples of poor economic deci suggested that if all healthcare provided were appropriate,
sion
rationing would not be required.3 Defining what is
making in critical care and argue for less extrem appropriate can be subjective, although not always. The
e vari-
RAND12,20 group suggests that there are at least three
ances in the types of patient ICUs choose to treat in o approaches that can be used to assess appropriateness of
rder
care (Table 2.1). These include the benefitrisk, benefit
to reduce the burden of the health dollar.
18,19
have
Others cost and implicit approaches.

The first two approaches are considered to be explicit
approaches, while the third tends to be subjective.
However, all approaches have a subjective element. While
the implicit approach is considered to be subjective in
nature,
the
medical
practitioner
must
contemplat
e
benefitrisk and benefitcost considerations but should
also involve the patient/family in the contemplation and
ultimate decision. What is best for the patient is not just
the opinion of the treating doctor and needs to
be
considered in much broader terms, such as the patients
previous expressed wishes and the familys opinion as
de-facto patient representatives. The quality of the
decision and the quality of the expected outcome require
many competing considerations.
The quality agenda in healthcare has argued for bes
t
practice and best outcomes in the provision of healt
h
services, although it may be more pragmatic to consider
value when discussing what is and what is not an appropriate decision in critical care. The following equation
expresses the concept value simply:
Quality
Cost
Benefit Sustainability
Price Suffering
The quality of the outcome is a function of the benefit to

be achieved and the sustainability of the benefit. The
benefit of critical care is associated with such factors as
include such considerations as morbidity, mortality, pain
survival, longevity and improved quality of life (e.g.
and anxiety in the individual, or broader societal costs
greater functioning capacity and less pain and anxiety).
and suffering (e.g. opportunity costs to others who might
The benefit is enhanced by sustainability: the longer the
have used the resources but for the current occupants, and
benefit is maintained, the better it is.21
what other health services might have been provided but
Cost is separated into two components, monetary (price)
for the cost of this service).21
and
non-monetary
(suffering).
Non-monetary
costs
(021) 66485438 66485457
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uisite
Ethico-economic analyses of services like critical care
knowledge to empower clinicians to manage the
and
key
expensive treatments like organ transplantation a
components of budget development and budget setti
re the
ng,
new consideration of this century and are as im
and to know what questions to ask when confronted
portant
by
to good governance as are discussions of medico
this most daunting responsibility of managing a units
-legal
or
considerations. Sound ethical principles to inform
services budget.
and
TYPES OF BUDGET
guide human and material resource management
There are essentially three types of budget that a ma
and
nager
budgets ought to prevail in the management of
must consider: personnel, operational and capital. Wi
critical
thin
care resources.
BUDGET
these budget types, there are two basic cost typ

es: fixed
and variable. Fixed costs are those essential to the se
This section provides information on types of budget,
rvice
the
and are relatively constant, regardless of the fluctuati
budgeting process, and how to analyse costs and exp
ons
en-
in workload or throughput (e.g. nurse unit m
diture to ensure that resources are utilised appropriat
anager
ely.
salary, security, ventilators). Variable costs chang
As noted by one author, Nothing is so terrifying for cl
e with
ini-
changing throughput (e.g. nurse agency usage or
cians accustomed to daily issues of life and deat
staff
h as to
overtime), especially if used in response to in
be given responsibility for the financial affairs of
flux of
their
demand and resulting consumables such as linen, dr
hospital division!.3 Yet, in essence, developing and m
ess-
an-
ings and drugs.
aging a budget for a critical care unit follows many of
Personnel Budget
the
Healthcare is a labour-intensive service, and critical c
same principles as managing a family budget. Consid
are
er-
epitomises this fact with personnel costs, the most e
ation of value for money, prioritising needs and
xpen-
wants,
sive component of the units budget. The staffing req
and living within a relatively fixed income is common
uire-
to
ment for critical care generally follows a formula
all. This section in no way undermines the skill and pr
of x
eci-
nurses per open (funded) bed. This figure is exp
sion provided by the accounting profession, nor
ressed
will it
in full time equivalents (FTEs): in Australia, the e
enable clinicians to usurp the role of hospital bu
quiva-
siness
lent of a person working a 38-hour week. This e
managers. Rather, the aim is to provide the req
quates
to 5 8-hour shifts per week with an 8-hour acc

rued
the hourly rate of pay and any penalties that are to be
day off every 4 weeks, or 19 12-hour shif attributed to work done during the after-business-hours
ts in a
period. Non-productive hours include sick leave, holiday
6-week period.
leave, paid education hours, paid maternity leave and any
Personnel costs include productive and non-
other paid time away from the actual job that staff are
productive
employed to do.
hours. Productive hours are those utilised to prov Personnel budgets tend to be fixed costs, in that the
ide
majority of staff are employed permanently, based on an
direct work. A manager will determine the minimum expected or forecast demand. Prudent managers tend to
or
employ 510% less than the actual forecast demand and
optimum number of nurses to be rostered per shift a use casual staff to flex-up the available FTE staff estand
blishment in periods of increasing demand, hence con-
then calculate the nursing hours per day, multipl tributing a small but variable component to the personnel
ied by
budget.22
Operational Budget
All other non-personnel costs (except major capital
equipment) tend to be allocated to the operational
budget. This includes fixed costs such as minor equipment, maintenance contracts, utility costs (e.g. electricity), and variable costs that fluctuate with patient type
and number (e.g. pharmaceuticals, meals, consumable
supplies such as gloves and dressings, laundry).
Compared with personnel costs, operational costs in critical care tend to be relatively small, but they can be
managed and rationed with the help of good information
and cooperation. For example, there is a range of dressing
materials available on the market, and a simple dressing
that requires less expensive materials should always be
used unless a more expensive product is indicated and a
protocol exists to inform staff of this clinical need.
Fixed costs can also be turned into variable costs and
hence encourage efficient usage. For example, pressurereduction mattresses, traditionally purchased as a fixed
asset with variable (and unpredictable) repair and maintenance costs, can now be leased on a per-day or per-week
basis, with no need for storage, cleaning or maintenance
costs. Further, critical care managers can work with other
hospital managers to create purchasing power by cooperating to standardise the range of products used to obtain
a better price for a product that will benefit all users.
Capital Budget
Capital budget items are generally expensive and/or large
fixed assets that are considered long-term investments,
such as building extensions, renovations and large equipment purchases. Capital budget items tend to be considered as assets that are depreciated over time. Most
hospitals consider these items as a global asset that is,
as a group of investment items and activities for the hos-
whether it replaces an existing items service or function,
pital rather than attributing these costs to an individual
the cost, possible revenue and cost-mitigating benefits.
unit or department.
This analysis does not always have to demonstrate a
To request a capital budget item, a written proposal is
profit, although the value and benefit of the service would
required
describing
the
item,
its
expected
benefits, need to be established.
(021) 66485438 66485457
21
non-productive), and operational (fixed and
BUDGET PROCESS
variable)
The budget includes three fundamental steps: bu
costs, should be matched against other kn
dget
own measur-
preparation and approval, budget analysis and report
able indicators of activity or productivity (
ing,
e.g. patient
and budget control or action.
bed-days, patient types/DRGs and staffing ho
Budget Preparation and Approval
urs, includ-
A budget plan essentially runs in parallel with a unit o
ing overtime and other special payments).3
One common management maxim is: if it
service management plan, forecasting likely activi
cannot be
ty and
measured, then it cannot be controlled. Clinic
resulting financial costs. In most circumstances t
al manag-
he pre-
ers therefore need to work closely with financ
ceding years activity and costs are a good benchmar
e managers
k on
to develop consistent data measurements an
which to base the next years budget. However,
d reports to
hospital
inform themselves and staff about where t
expectations in terms of new services, greater p
hey should
atient
focus their efforts to achieve the approved bu
throughput or changes to staff entitlements will need
dget target.
to
Budget Control and Action
be factored into the new budget.
When signs of poor performance or financial o
The budget period is generally a financial year, but d
verrun are
evel-
evident, managers cannot merely analyse
oping monthly budgets (cash flowing) to coincide
the financial
with
reports, hoping that things will sort themselve
predictable variations allows for a more realistic repr
s out. Every
esen-
variance of a sizeable amount requires an
tation of how costs are incurred and paid throughout
explanation.
the
Some will be obvious: an outbreak of commun
financial year period. If the budget plan is well constr
ity influ-
ucted,
enza among staff will increase sick leave and
one always hopes and expects the final budget alloca
casual staff
tion
costs for a period of time. Other overruns can
(i.e. the approved budget) to be close to achievable.
be insidious
Budget Analysis and Reporting
but no less important: overtime payme
Most critical care managers analyse their exp
nts, although
enditure
sometimes unavoidable, can also reflect poor
against budget projections on a monthly basis, to ide
time man-
ntify
agement or a culture of some staff wanting to
variances from planned expenditure. Information sho
boost their
uld
income surreptitiously.22
not merely be financial: a breakdown of the monthly
An effectivemethod of controlling the
and
year-to-date expenditures for personnel
(productive and
budget is
actively to engage staff in the process
of managing
costs. Managers can explain to staff how the budget

has
responsibility for the budget performance can encourage
been developed and how their performance a an esprit de corps and improvements from the whole
gainst
team that a single manager cannot achieve alone.
budget is progressing, and identify areas for poteDEVELOPING

ntial
A BUSINESS CASE
The most common reason for writing a business case is
improvement. Seeking ideas from staff on how to im to justify the resources and capital expenditure to gain
prove
the support and/or approval for a change in service provi-
efficiency and productivity and giving them some
sion and/or purchase of a significant new piece of

equipment/technology. This section provides an overview
of a business case and a format for its presentation. The
business case can be an invaluable tool in the strateg
ic
decision-making process, particularly in an environment
of constrained resources.23
A business case is a management tool that is used in the
process of meeting the overall strategic plan of an organisation. Within a setting such as healthcare, the business
case is required to outline clearly the clinical need an
d
implications to be understood by leaders. Financial
imperatives, such as return on investment, must also be
defined and identified.2325 A business case is a document
in which all the facts relevant to the case are documented
and linked cohesively. Various templates are available
(see Online Resources) to assist with the layout. Key questions are generally the starting point for the response to
a business case: why, what, when, where and how, with
each questions response adding additional information
to the process (Table 2.2). Business cases can vary in
length from many pages to just a couple. Most organisations will have standardised headings and formats for the
presentation of these documents. If the document
is
lengthy, the inclusion of an executive summary is recommended, to summarise the salient points of the business
case (Box 2.1).
TABLE 2.2 Key questions in writing a business case

Question
Example
Why?
What is the background to the project, and why is it

needed: PEST (political, economic, sociological,
technological) and SWOT (strengths, weaknesses,
opportunities and threats) analysis?
What?
Clearly identify and define the project and the

purpose of the business case and outline the
solution. Clearly defined, measurable benefits
should be documented; goals and outcomes.
What if?
A risk assessment of the current situation, including
any controls currently in place to address/mitigate
undertaken, if not already included in the
the issue, and a risk assessment following the
background material?
implementation of the proposed solution.

When?
Where?
What are the timelines for the implementation and
How?
How much money, people and equipment, for

example, will be required to achieve the benefits?
achievement of the project/solution?
A clear costbenefit analysis should be included in
What is the context within which the project will be
response to this question.
(021) 66485438 66485457
22
onal
policies of each individual facility. In smaller facili
BOX 2.1
Business case: sample headings
ties,
Title
the broad spectrum of critical care may be provi
Purpose
ded in
Background
combined units (intensive care, high-dependency,
Key issues
coro-
Costbenefit analysis
nary care) to improve flexibility and aid the efficient
Recommendations
use
Risk assessment
of available resources.26
ORGANISATIONAL DESIGN
The functional organisational and unit designs ar
e govIn summary, the business case is an important tool t
erned by available finances, an operational brief and
hat
the
is increasingly required at all levels of an organisatio
building and design standards of the state or country
n to
in
clearly define a proposed change or purchase. This d
which the hospital is located. A critical care unit shou
ocu-
ld
ment should include clear goals and outcomes, a
have access to minimum support facilities, which incl
cost-
ude
benefit analysis and timelines for achievement of

the
staff station, clean utility, dirty utility, store room

(s),
solution.
education and teaching space, staff amenities, pa
CRITICAL CARE ENVIRONMENT
tients
ensuites, patients bathroom, linen storage, dis
A critical care unit is a distinct unit within a hospital t
posal
hat
room, sub-pathology area and offices. Most notably, t
has easy access to the emergency department, o
he
perating
actual bed space/care area for patients needs to
theatre and medical imaging. It provides care to pati
be well
ents
designed.26
with a life-threatening illness or injury and concentrat
The design of the patients bed-space has received c
es
onsid-
the clinical expertise and technological and thera
erable attention in the past few years. In Australia, m
peutic
ost
resources required.
26
The College of Intensive Care M
state governments have developed minimum guid
edi-
elines
cine (CICM) defines three levels of intensive
to assist in the design process. Each bed space shoul
care to
d be
support the role delineation of a particular h
a minimum of 20 square metres and provide for
ospital,
visual
dependent upon staffing expertise, facilities and supp
privacy from casual observation. At least one handba
ort
sin
services.
27
Critical care facilities vary in nature and ex
per single room or per two beds should be provi
tent
ded
between hospitals and are dependent on the operati
to meet minimum infection control guidelines.26 E
ach
bed space should have piped medical gases (oxygen
and
TABLE 2.3 Basic equipment requirements
air), suction, adequate electrical outlets (essential
Monitoring
and
Monitors (including central station)
Therapeutic
Ventilators (invasive and
End-tidal CO2 monitoring

Arterial blood gas analyser
(electrolytes)
Invasive monitoring
arterial
central venous pressure
intracranial pressure
PiCCO
pulmonary artery
non-invasive)
Infusion pumps
Syringe drivers
CVVHDF
EDD-f
Resuscitators
Temporary pacemaker
Defibrillator
Suctioning apparatus
Access to image intensifier

Ultrasound
Access to CT/MRI
CT computerised tomography; CVVHDF continuous veno-venous
haemodiafiltration; EDD-f extended daily dialysis filtration; MRI
magnetic resonance imaging; PiCCO pulse-induced contour cardiac
output.
non-essential), data points and task lighting sufficient for

use during the performance of bedside procedures.
Further detailed descriptions are available in various
health department documents.26
EQUIPMENT
Since the advent of critical care units, healthcare delivery
has become increasingly dependent on medical technology to deliver that care. Equipment can be categorised
into several funding groups: capital expenditure (generally in excess of $10,000), equipment expenditure (all
equipment less than $10,000), and the disposable products and devices required to support the use of equipment. This section examines how to evaluate, procure and
maintain that equipment.
INITIAL SET-UP REQUIREMENTS

Critical care units require baseline equipment that allows
the unit to deliver safe and effective patient care. The list
of specific equipment required by each individual unit
will be governed by the scope of that units function. For
example, a unit that provides care to patients after neurosurgery will require the ability to monitor intracranial
pressure. Table 2.3 lists the basic equipment requirements
for a critical care unit.
PURCHASING
The procurement of any equipment or medical device
requires a rigorous process of selection and evaluation.
most healthcare facilities, a product evaluation commit-
This process should be designed to select functional, reli-
tee exists to support this process, but if this is not the case
able products that are safe, cost-effective and environ-
it is strongly recommended that a multidisciplinary com-
mentally conscious and that promote quality of care
mittee be set up, particularly when considering the pur-
while avoiding duplication or rapid obsolescence.28 In
chase of equipment requiring capital expenditure.29
(021) 66485438 66485457
23
The decision to purchase or lease equipment

will, to some
BOX 2.2 Example criteria for product

28,29
evaluation
Safety
Performance
Quality
Use
Costbenefit analysis
purpose
Cleaning
ease of
gy approved
by the hospital or state government. The
advantages of
leasing equipment include the capital expendi
ture being
defrayed over the life of the lease (usuall
y 36 months),
with ongoing servicing and product upgrad
include disposables
Regulatory
control
es built into
the lease agreement and price structure. Any
central sterilising
unit (CSSU)
Adaptability
to future supply
technological
advancements
Service
agreements
infection
control
Training requirements
extent, be governed by the purchasing strate
final presentation from the product evaluation commit

tee should
Therapeutic Goods Administration
therefore include a recommendation to purch
Australian Standards
ase or lease,
based on a costbenefit analysis of the ongoin
g expendi-
ture required to maintain the equipment.
REPLACEMENT AND MAINTENANCE

The process for replacement of equipm
The product evaluation committee should include
ent is closely
members who have an interest in the equipment
aligned with the process for the purchase of n
being
ew equip-
considered and should comprise, for example, biome
ment. The stimulus for the process to begin, h
di-
owever, can
cal engineers and representatives from the central st
be either the condemning of equipment b
erile
y biomedical
supply unit (CSSU), administration, infection contr
engineers or the planned replacement
ol,
of equipment
end users and other departments that may have
nearing the end of its life cycle. In general, ca
similar
pital equip-
needs. Once a product evaluation committee has
ment is deemed to have a life cycle of five ye
been
ars. This time
established, clear, objective criteria for the evaluatio
frame takes into account both the longevity of
n of
the physi-
the product should be determined (Box 2.2). Ideally, t
cal equipment and its technology.
he
Ongoing maintenance of equipment is an imp
committee will screen products and medical d
ortant part
evices
of facilitating safety within the unit. Maintena
before a clinical evaluation is conducted to estab
nce may be
lish its
viability, thus avoiding any unnecessary expendit
ure in
time and money.28
ence patient outcomes both directly, through the initiaprovided in-house by individual facility biomedical
tion of appropriate nursing care strategies, and indirectly,
departments or as part of a service contract arrangement
by mediating and implementing the care strategies of
with the vendor company. The provision of a maintenance/
other members of the multidisciplinary healthcare team.
service plan should be clearly identified during the pro-
Therefore, ensuring an appropriate skill mix is an impor-
curement phase of the equipments purchase process.
tant aspect of unit management. This section consider
While equipment maintenance is not the direct respon-
sibility of the nurses in charge of the unit, they should be
how appropriate staffing levels are determined and the
aware of the maintenance plan for all equipment and
factors, such as nursepatient ratios and skill mix, that
ensure that timely maintenance is undertaken.
influence them.
Routine ongoing care of equipment is outlined in the

product information and user manuals that accompany
STAFFING ROLES
devices. This documentation clearly outlines routine care
There are a number of different nursing roles in the ICU
required for cleaning, storage and maintenance. All staff
nursing team, and various guidelines determine the
involved in the maintenance of clinical equipment should
requirements of these roles. Both the Australian College
be trained and competent to carry it out. As specialist
of Critical Care Nurses (ACCCN) (see Appendix B2) and
equipment is a fundamental element of critical care,
the World Federation of Critical Care Nurses (WFCCN)
effective resourcing includes consideration of the pur-
(see Appendix A2) have position statements surrounding
chase, set-up, maintenance and replacement of equip-
the critical care workforce and staffing. A designat
ment. Equipment is therefore an important aspect of the
ed
budget process.
nursing manager (nursing unit manager/clinical nurse

consultant/nurse
practice
coordinator/clinical
nurse
manager, or equivalent title) is required for each unit to
STAFF
direct and guide clinical practice. The nurse manager
Staffing critical care units is an important human resource
must possess a post-registration qualification in critical
consideration. The focus of this section is on nursing
care or in the clinical specialty of the unit.27,30 A clinical
staff, although the important role that medical staff and
nurse educator (CNE) should be available in each unit.
other ancillary health personnel provide is acknowledged.
The ACCCN recommends a minimum ratio of one full-
Nurses salaries consume a considerable portion of any
time equivalent (FTE) CNE for every 50 nurses on the
unit budget and, owing to the constant presence of nurses
roster, to provide unit-based education and staff develop-
at the bedside, appropriate staffing plays a significant role
ment.27,30 The clinical nurse consultant (CNC) role is
in the quality of care delivered. Nurse staffing levels influ-
utilised at the unit, hospital and area health service level
(021) 66485438 66485457
24
such
to provide resources, education and leadership.30
as the population served, the services provided
Regis-
by the
tered nurses within the unit are generally nurses
hospital and by its neighbouring hospitals, and the su
with
b-
formal critical care postgraduate
specialties of medical staff working at each hospital a
qualifications
and
lso
varying levels of critical care experience.
influence staffing. Specific issues to be considered
Prior to the mid-1990s, when specialist critical care n
include nurse-to-patient ratios, nursing compete
urse
ncies
education moved into the tertiary education sector, c
and skill mix.
riti-
The starting point for most units in the establishment
cal care education took the form of hospital-based ce
of
rtifi-
minimum, or base, staffing levels is the patient
cates.
31
Since this move, postgraduate, university-
census
based
approach. This approach uses the number and classi
programs at the graduate certificate or postgr
fica-
aduate
tion (ICU or HDU) of patients within the unit to deter-
diploma level are now available, although some hosp
mine the number of nurses required to be roster
ital-
ed on
based courses that articulate to formal university
duty on any given shift. In Australia and New Zealand
pro-
grams continue to be accessible. The ACCCN
registered nurse-to-patient ratio of 1 : 1 for ICU
(see
patients
Appendix B1) and the WFCCN (see Appendix A1)
and 1 : 2 for high-dependency unit (HDU) patient
have
s has
developed position statements on the provision of cri
been accepted for many years. Recently in Australia t
tical
here
care nursing education. Various support staff are
have been several projects examining the use of end
also
orsed
required to ensure the efficient functioning of the de
enrolled nurses (EEN) in the critical care setting. The
part-
New
ment, including, but not limited to, administra
South Wales project identified difficulties with
tive/
EENs
clerical staff, domestic/ward assistant staff and biom
undertaking direct patient care, but determined that
edi-
there
cal engineering staff.
may be a role for them in providing support and

assis-
STAFFING LEVELS
tance to the RN.27,30,32 Other countries, such as the US
A staff establishment refers to the number o
A,
f nurses
have lower nurse staffing levels, but in those co
required to provide safe, efficient, quality care to
untries
patients. Staffing levels are influenced by many f
nursing staff is augmented by other types of clin
actors,
ical or
including the economic, political and individual ch
support staff, such as respiratory technicians.33 The li
ar-
mi-
acteristics of the unit in question. Other factors,
tations of this staffing approach are discussed later in
this
chapter. Once the base staffing numbers per shif helpful for new units to contact a unit of similar size and
t have
service profile to ascertain their experiences.
been established, the unit manager is required to cal

cu-
NURSE-TO-PATIENT RATIOS
late the number of full-time equivalents that are requ Nurse-to-patient ratios refer to the number of nursing
ired
hours required to care for a patient with a particular set
to implement the roster. In Australia, one FTE is equal of needs. With approximately 30% of Australian and New
to
Zealand units identified as combined units incorporating
a 38-hour working week.
intensive
The development of the nursing establishment is dep patients,

en-
coronary
care
and
high-dependency
different nurse-to-patient ratios are required
for these often diverse groups of patients. It is important
dent on many variables. Historical data from pre to

vious
care,
34
note
that
nurse-to-patient
ratios
are
provided
merely as a guide to staffing levels, and implementation
years of patient throughput and patient acuity asshould depend on patient acuity, local knowledge and
sist in
expertise.
the determination of future requirements. It is Within the intensive care environment in Australia and
often
New Zealand, there are several documents that guide

nurse-to-patient ratios (Table 2.4). The ACCCN has developed and endorsed two position statements that identify
the need for a minimum nurse-to-patient ratio of 1 : 1 for
intensive care patients and 1 : 2 for high-dependency
patients.30,35 In New Zealand, the Critical Care Nurses
Section
of
the
New
Zealand
Nursing
Organisation
(NZNO)32 also determines that critically ill or ventilated

patients require a minimum 1 : 1 nurse-to-patient ratio.
Both of these nursing bodies state that this ratio is clinically determined. The WFCCN states that critically ill
patients require one registered nurse to be allocated at all
times.36 The College of Intensive Care Medicine (CICM)
also identifies the need for a minimum nurse-to-patient
ratio of 1 : 1 for intensive care patients and 1 : 2 for highdependency patients.27,37
The ACCCN30 and the NZNO Critical Care Nurses
Section32 have outlined the appropriate nurse staffing
standards in Australia and New Zealand for ICUs within
the context of accepted minimum national standards and
evidence that supports best practice. The ACCCN statement identified 10 key principles to meet the expected
standards of critical care nursing (Table 2.5).
These recommendations serve merely to guide nurse-topatient ratios, as extraneous factors such as the clinical
practice setting, patient acuity and the knowledge and
expertise of available staff will influence final staffing patterns. In particular, patient dependency scoring tools are
designed to guide these staffing decisions and are discussed below.
PATIENT DEPENDENCY
Patient dependency refers to an approach to quantify the
care needs of individual patients, so as to match these
nurses required to care for them, based on the accepted
needs to the nursing staff workload and skill mix.
nurse-to-patient ratios of 1 : 1 for ICU patients and 1 : 2
38
For
many years, patient census was the commonest method
for HDU patients. This reflects the unit-based workload,
for determining the nursing workload within an ICU.
and is also the common funding approach for ICU
That is, the number of patients dictated the number of
bed-day costs.
(021) 66485438 66485457
TABLE 2.4 Documents that guide the nurse-to-patient ratios in critical care
Document
Recommendations
ACCCN: Position statement on
ICU patients (clinically determined) should have a 1 :1 nurse-to-patient ratio.
intensive care nurse staffing
HDU patients (clinically determined) should have a 1 :2 nurse-to-patient ratio.
ACCCN: Position statement on the
All intensive care patients must have a registered nurse (division 1) allocated exclusively to their care.
healthcare workers other than
High-dependency or step-down patients (in intensive care) who require a nurse-to-patient ratio of
30
Division 1 Registered Nurses in

Intensive Care
35
1:2 should have a registered nurse (division 1) allocated exclusively to their care.
Enrolled nurses (division 2) and unlicensed assistive personnel may be allocated roles to assist the
registered nurse, but any activities that involve direct contact with the patient must always be
NZNO, Critical Care Section:
performed in the immediate presence of the registered nurse (division 1).
Philosophy and Standards for
The critically ill and/or ventilated patient will require a minimum 1 :1 nurse-to-patient ratio.
Nursing Practice in Critical Care32
At times, patients in the critical care unit may have higher or lower nursing acuity; the critical care
nurse in charge of the shift determines any variation from the 1 :1 ratio, taking into account context,
WFCCN: Declaration of Buenos
skill mix and complexity.
Aires, Position Statement on the
Critically ill patients (clinically determined) require one registered nurse at all times.
Provision of Critical Care Nursing
High-dependency patients (clinically determined) in a critical care unit require no less than one
Workforce
nurse for two patients at all times.
36
CICM: Minimum Standards for

Intensive Care Units27
A minimum of 1 :1 nursing is required for ventilated and other similarly critically ill patients, and
nursing staff must be available to greater than 1 :1 ratio for patients requiring complex management
(e.g. ventricular assist device).
CICM: Recommendations on
The majority of nursing staff should have a post-registration qualification in intensive care or in the
specialty of the unit.
Standards for High-Dependency
All nursing staff in the unit responsible for direct patient care should be registered nurses.
Units Seeking Accreditation for
The ratio of nursing staff to patients should be 1 :2.
Training in Intensive Care
All nursing staff in the HDU responsible for direct patient care should be registered nurses, and the
Medicine
37
majority of all senior nurses should have a post-registration qualification in intensive care or
determined)
nursing. ratio of at least 1 :1.

Require ahigh-dependency
standard nurse-to-patient
A minimum of two registered nurses should be present in the unit at all times when a patient is
(clinically determined)
Require apresent.
standard nurse-to-patient ratio of at least 1 :2
ACCCN Australian College of Critical Care Nurses; NZNO New Zealand Nurses Organisation; WFCCN World Federation of Critical Care Nurses; CICM College of
leader)
There must be a designated critical-care-qualified senior nurse per shift who is supernumerary and whose
Intensive Care Medicine.
TABLE 2.5 Ten key points of intensive care nursing staffing30

Point
Description
1. ICU patients (clinically
2. High dependency patients
3. Clinical coordinator (team

primary role is responsibility for the logistical management of patients, staff, service provision and resource
utilisation during a shift.
4. ACCESS nurses
These are nurses in addition to the bedside nurses, clinical coordinator, unit manager, educators and
non-nursing support staff. They provide Assistance, Coordination, Contingency, Education, Supervision
and Support.
5. Nursing manager
At least one designated nursing manager (NUM/CNC/NPC/CNM or equivalent) who is formally recognised as
the unit nurse leader is required per ICU.
6. Clinical nurse educator
At least one designated CNE should be available in each unit. The recommended ratio is one FTE CNE for
every 50 nurses on the ICU roster.
7. Clinical nurse consultants
Provide global critical care resources, education and leadership to specific units, to hospital and area-wide
services, and to the tertiary education sector.
8. Critical care nurses
The ACCCN recommends an optimum specialty qualified critical care nurse proportion of 75%.
9. Resources
These are allocated to support nursing time and costs associated with quality assurance activities, nursing
and multidisciplinary research, and conference attendance.
10. Support staff
ICUs are provided with adequate administrative staff, ward assistants, manual handling assistance/
equipment, cleaning and other support staff to ensure that such tasks are not the responsibility of nursing
personnel.
ACCCN Australian College of Critical Care Nurses; CNC clinical nurse consultant; CNE clinical nurse educator; CNM clinical nurse manager; FTE full-time
equivalent; NPC nurse practice coordinator; NUM nursing unit manager.
(021) 66485438 66485457
26
as the acute physiological and chronic health evaluat

The nursing workload at the individual patient le
ion
vel,
(APACHE) and simplified acute physiology score (SAP
however, is also reflective of patient acuity, the com
S)
plexity
systems.Althoughthesescoringsystemshavevalueinde
of care required and both the physical and the
ter-
psycho-
mining the probability of in-hospital mortality, they
logical status of the patient.
38
Strict adherence to
the
are not
good predictors of nursing dependency or workload.38
patient census model leads to the inflexibility of matc
The therapeutic intervention scoring system (TISS
h-
) was
ing nursing resources to demand. For example, some
developed to determine severity of illness, to est
ICU
ablish
patients receive care that is so complex that mo
nurse-to-patient ratios and to assess current bed
re than
utilisa-
one nurse is required, and an HDU patient may requir
tion.38 This system attributes a score to each pro
cedure/
less medical care than an ICU patient, but conversely
intervention performed on a patient, with the pre
may
mise
require more than 1 : 2 nursing care level secon
that the greater the number of procedures performed
dary to
, the
such factors as physical care requirements, patient c
higher the score, the higher the severity of illne
onfu-
ss, the
sion, anxiety, pain or hallucinations.
38
A patient c
higher the intensity of nursing care required.38 Si
ensus
nce its
approach therefore does not allow for the varying nur
development in the mid-1970s, TISS has undergone
sing
mul-
hours required for individual patients over a shift
tiple revisions, but this scoring system, like APACHE a
, nor
nd
does it allow for unpredicted peaks and troughs in ac
SAPS, still captures the therapeutic requirements
tiv-
of the
ity, such as multiple admissions or multiple discharge
patient. It does not, however, capture the entirety of
s.
the
There are many varied patient dependency/classifica
nursing role. Therefore, while these scoring systems
tion
may
tools available, with their prime purpose being to clas
provide valuable information on the acuity of the pati
sify
ents
patients into groups requiring similar nursing care an
within the ICU, it must be remembered that they are
d to
not
attribute a numerical score that indicates the amount
accurate indicators of total nursing workload. Other s
of
pe-
nursing care required. Patients may also be class
cific nursing measures have been developed, but hav
ified
e not
according to the severity of their illness. These s
gained widespread clinical acceptance in Australia or
coring
New
systems are generally based on physiological variabl
Zealand. (For further discussion of nursing wo
es, such
rkload
measures, see Measures of Nursing Workload or Ac

tivity in
registered nurses possessing a formal specialist critical
this chapter.)
care qualification. The ACCCN recommends an optimum
While not strictly workload tools, various early w qualified critical care nurse to unqualified critical care
arning
nurse ratio of 75%30 (see Appendix B2). In Australia and
scoring systems are increasingly being used to f New Zealand, approximately 50% of the nurses employed
acilitate
in critical care units currently have some form of critical
the early detection of the deteriorating patient. Tcare qualification.34

hese
Debate
continues
in
an
attempt
to
determine
the
early warning systems generally take the format of a optimum skill mix required to provide safe, effective
stan-
nursing care to patients.4248 Much of the research fuelling
dardised observation chart with an in-built track this debate has been undertaken in the general ward
and
setting, and still predominantly in the USA. However, it
trigger process.3941
has provided the starting point for specialty fields of

nursing to begin to examine this issue. The use of nurses
SKILL MIX
other than registered nurses in the critical care setting has
Skill mix refers to the ratio of caregivers with va been discussed as one potential solution to the current
rying
critical care nursing shortage. Projects in Australia trial-
levels of skill, training and experience in a clinic ling the use of EENs in the critical care environment have
al unit.
largely proved inconclusive.49
In critical care, skill mix also refers to the proportion Published research on skill mix has examined the substiof
tution of one grade of staff with a lesser skilled, trained

or experienced grade of staff and has utilised adverse
events as the outcome measure. A significant proportion
of research suggests that a rich registered nurse skill mix
reduces the occurrence of adverse events.4248 A comprehensive review of hospital nurse staffing and patient outcomes noted that existing research findings with regard
to staffing levels and patient outcomes should be used to
better understand the effects of skill mix dilution, and
justify the need for greater numbers of skilled professionals at the bedside.50
While there has not been a formal examination of skill
mix in the critical care setting in Australia and New
Zealand, two publications51,52 informing this debate
emerged from the Australian Incident Monitoring Study
ICU (AIMSICU). Of note, 81% of the reported adverse
events resulted from inappropriate numbers of nursing
staff or inappropriate skill mix.51 Furthermore, nursing
care without expertise could be considered a potentially
harmful intrusion for the patient, as the rate of errors by
experienced critical care nurses was likely to rise during
periods of staffing shortages, when inexperienced nurses
required supervision and assistance.51 These important
findings provide some insight into the issues surrounding
skill mix.
In Australia and New Zealand, an annual review of intensive care resources53 reported that there were 6633.7 FTE
registered nurses currently employed in the critical care
nursing workforce (5587.2 in the public sector and
1046.5 in the private sector). More recently, in 2005,
Enrolled nurse training has not occurred in New Zealand
categories of nurses in the workforce other than registered
since 1993, and those who are currently employed in the
nurses were captured and reported for the first time,
healthcare system are restricted to a scope of practice that
showing that there were 53.9 FTE enrolled nurses cur-
does not call for complex nursing judgements. Thus, no
rently employed in the critical care setting in Australia
enrolled nurses were reported to be working in critical
(44.6 in the public sector and 9.3 in the private sector).
34
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ACCCNS CRITICA

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(021) 66485438 66485457

RN, PhD BAppSc(Nurs),

RN, PhD, BHSc(Nurs)Hons,

RN, PhD, MN, BSc(Nurs)Hons,

Sydney Edinburgh London NewYork Philadelphia StLouis Toronto

(021) 66485438 66485457

2012 Elsevier Australia

(021) 66485438 66485457

Cardiovascular Assessment and Monitoring

Cardiovascular Alterations and Management

Robyn Gallagher, Andrea Driscoll

About the Australian College of Critical Care Nurses

About the Editors

Scope of Critical Care Practice

Leanne Aitken, Wendy Chaboyer, Doug Elliott

Resourcing Critical Care

Denise Harris, Ged Williams

Quality and Safety

Wendy Chaboyer, Karena Hewson-Conroy

Recovery and Rehabilitation

Doug Elliott, Janice Rattray

Ethical Issues in Critical Care

Amanda Rischbieth, Julie Benbenishty

Section 2 Principles and Practice of

Essential Nursing Care of the Critically

Bernadette Grealy, Wendy Chaboyer

Leanne Aitken, Rosalind Elliott

Family and Cultural Care of the Critically

Marion Mitchell, Denise Wilson, Vicki Wade

Cardiac Rhythm Assessment and

Margherita Murgo, Gavin Leslie

Multiple Organ Dysfunction Syndrome

Melanie Greenwood, Alison Juers

Cardiac Surgery and Transplantation

Section 3 Specialty Practice in

Judy Currey, Michael Graan

Respiratory Assessment and Monitoring

Amanda Corley, Mona Ringdal

Respiratory Alterations and Management

Ventilation and Oxygenation Management

Neurological Alterations and Management

Support of Renal Function

Gastrointestinal, Liver and Nutritional

Paediatric Considerations in Critical Care

Andrea Marshall, Teresa Williams,

Debbie Austen, Elizabeth Skewes

Wendy Pollock, Clare Fitzpatrick

Ian Baldwin, Gavin Leslie

Tina Kendrick, Anne-Sylvie Ramelet

Di Chamberlain, Wendy Corkill

Trudy Dwyer, Jennifer Dennett

Neurological Assessment and Monitoring

Louise Niggemeyer, Paul Thurman

Louise Rose, Gabrielle Hanlon

Maria Murphy, Sharon Wetzig, Judy Currey

(021) 66485438 66485457

critical care nurses, regardless of practice set

is focused on the care of patients who are expe

seeking to provide complex high intensity care, thera

life-threatening illness. Globally, critical care n

and interventions, critical care nurses will find th