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ACCCNS CRITICA
L
CARE NURSING
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(021) 66485438 66485457 www.ketabpezeshki.com

ACCCNS CRITICA
L
CARE NURSIN
G
SECOND EDITION
Doug Elliott Leanne Aitken Wendy Chaboyer

RN, PhD BAppSc(Nurs), RN, PhD, BHSc(Nurs)Hons, RN, PhD, MN, BSc(Nurs)Hons,
MAppSc(Nurs), ICCert GradCertMgt, CritCareCert
Professor of Nursing GradDipScMed(ClinEpi), ICCert, Professor & Director, NHMRC Centre
Faculty of Nursing, Midwifery FRCNA of Research Excellence in Nursing
and Health Professor of Critical Care Nursing Interventions for Hospitalised Patients
University of Technology Griffith University & Princess Griffith Health Institute
Sydney, New South Wales Alexandra Hospital Griffith University
Brisbane, Queensland Gold Coast, Queensland
Sydney Edinburgh London NewYork Philadelphia StLouis Toronto

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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would welcome any information to redress the situation.
This publication has been carefully reviewed and checked to ensure that the content is as
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
in this book. Neither the author, the contributors, nor the publisher assume any liability
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.

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 Cardiac Rhythm Assessment and
(ACCCN) ix Management
About the Editors x
Contributors xi 251
Reviewers xiii Malcolm Dennis, David Glanville
Acknowledgements xiv
Detailed Contents xv
Abbreviations xviii
Section 1
Scope of Critical Care 1
1 Scope of Critical Care Practice 3
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 103
6 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
Margherita Murgo, Gavin Leslie
21 Multiple Organ Dysfunction Syndrome 562
Melanie Greenwood, Alison Juers
12 Cardiac Surgery and Transplantation 291 Section 3 Specialty Practice in

Judy Currey, Michael Graan Critical Care 579
13 Respiratory Assessment and Monitoring 325 22 Emergency Presentations 581
Amanda Corley, Mona Ringdal David Johnson, Mark Wilson
14 Respiratory Alterations and Management 352 23 Trauma Management 623
Maria Murphy, Sharon Wetzig, Judy Currey Louise Niggemeyer, Paul Thurman
15 Ventilation and Oxygenation Management 381 24 Resuscitation 654
Louise Rose, Gabrielle Hanlon Trudy Dwyer, Jennifer Dennett
16 Neurological Assessment and Monitoring 414 25 Paediatric Considerations in Critical Care 679
Di Chamberlain, Leila Kuzmiuk Tina Kendrick, Anne-Sylvie Ramelet
17 Neurological Alterations and Management 445 26 Pregnancy and Postpartum Considerations 710
Di Chamberlain, Wendy Corkill Wendy Pollock, Clare Fitzpatrick
18 Support of Renal Function 479 27 Organ Donation and Transplantation 746
Ian Baldwin, Gavin Leslie Debbie Austen, Elizabeth Skewes
19 Gastrointestinal, Liver and Nutritional Appendices 763
Alterations 506 Glossary 783
Andrea Marshall, Teresa Williams, Picture Credits 790
Christopher Gordon Index 793
20 Management of Shock 539 v

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 evidence-
based
practices and the chapters incorporate a variety of e
duca-
tional 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 Ruth Kleinpell PhD, RN, FAAN, FCCM
ill patients and their families. Director, Center for Clinical Research and Scholarship
Internationally, there are more than 500,000 critical care Rush University Medical Center;
nurses, representing one of the largest specialty areas of Professor, Rush University College of Nursing;
nursing practice. The importance of maintaining knowl- 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

Preface
environment, while still allowing the universal
core ele-
ments 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
e 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 beyond the
posed by critical care nurses as they practise in the l learning needs of these students. The aim
ocal 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 com-
rsing. 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, psycho-
logical, 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 multi-
organ 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

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.
cquisi- Doug Elliott
tion. Extensive use of tables, figures and practice tips Leanne Aitken
are Wendy Chaboyer
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.
About the Australian College of
Critical Care Nurses (ACCCN)
and provides local and at times nation o
al representation. C
The ACCCN Editorial Committee and
The Australian College of Critical Care Nurses, with o Editorial Board, f
ver under the leadership of the editor of th
2400 members, is the peak professional organi e Australian Critical a
sation Care (ACC) journal, are responsible for i
representing critical care nurses in Australia. Me the College pub- b
mber- lications including the journal Australia c
ship types include standard membership, internati n Critical Care and u
onal newspaper Critical Times. t
members, life members, honorary members and There are a number of national ad t
corpo- visory panels and e
rate members. All individual members are eligible special interest groups dedicated to pr Z
and oviding the organi- A
are encouraged to participate in the activities sation with expert opinion on issues C
of the relating to critical
College; to receive the College journal and Critical Ti care nursing. These include: n
mes Resuscitation Advisory l
publication, in addition to discounts for ACCCN confer Panel: consists n
- of eight M
ence registration and for ACCCN publications. Life members representing each branch i
and of ACCCN, plus a n
honorary memberships are awarded to individuals paediatric nurse representative. e
in It has developed a e
recognition of their outstanding contribution to ACCC complete suite of contemporary ad e
N vanced life support
and/or to critical care nursing excellence in Australia. and resuscitation educational mat d
ACCCN is a company limited by guarantee a erial and offers its t
nd has ACCCN National ALS Courses throug
branches in each state of Australia, with two me hout Australia; i
mbers Research Advisory Panel: in ad
from each state branch management committee for dition to providing e
ming expert advice to ACCCN, the panel i d
the ACCCN National Board of Directors. Each committ s responsible for s
ee evaluating and making recommend C
facilitates the activities of the college at a local/state ations on research o
level strategy and grant submissions t l
matters relating to education specific to critica In addi
l care tion to
nursing. This panel has developed a position pape branc
r on committees. The panel has also developed p h educ
critical care nursing education and written sub osition ational
mis- statements on nurse staffing for intensive carevents
sions on behalf of ACCCN to national reviews e and and sy
of high-dependency units in Australia, and an mpo-
nursing education; nually siums,
Workforce Advisory Panel: has represented A reviews the dataset design for national workforc ACCCN
CCCN e data conduc
on a number of national health workforce and nurs collection in conjunction with ANZICS; ts thre
ing 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; olleagu
Paediatric Advisory Panel: provides expert es fro
knowl- m
edge, advice and information to ACCCN on The A
matters ustralia
relevant to paediatric critical care nursing in addi n and
tion New Z
to recommending content and speakers for the a ealand
nnual Intensi
ACCCN conferences; 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 al Scie
nursing focus. ntific M
eeting
on Intensive Care and the Australian and New Zealand
Paediatric & Neonatal Intensive Care Conference.
ACCCN has a representative on the Australian Resuscita-
tion Council (ARC), and has representation at a federal
government advisory level through the Nursing and Mid-
wifery 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

About the Editors
uni-
versity funding sources. He has published over 8
0 peer-
reviewed 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 Critical Care Nurses in 2006 in recognition of ov
h- er 20
nology, Sydney. During his 25 years as a nurse acade years of service to critical care. He has previously be
mic, en an
Doug has been a faculty Director of Research, Cl Associate Editor and on the Editorial Board for Austra
inical lian
Professor, Head of Department and a conjoint ho Critical Care, was the inaugural Chair of the Res
spital earch
appointment as Assistant Director of Nursing Resea Advisory Panel, a member of the Education Advis
rch. ory
Prior to this, he worked as a clinician in acute and crit Panel, and also served on the NSW committee. He is
ical cur-
care areas in tertiary hospitals in Sydney and Perth. rently on the Editorial Board for the American Journal
Dougs clinical and health services research focus of
es on Critical Care, and peer-reviews for several critical
the health-related quality of life (HRQOL) and illn care
ess medicine and nursing journals, and a range of compe
experiences of individuals with critical and ac ti-
ute ill- tive funding bodies. Doug has been an invited speake
nesses, and the use of technologies to improve r to
patient international and national multi-disciplinary critical c
outcomes. Doug has received research funding from are
the meetings on numerous occasions.
NHMRC and the Australian Commission on Safety Leanne Aitken
and Leanne Aitken is Professor of Critical Care Nursin
Quality in Health Care, as well as competitive fu g at
nding Griffith University and Princess Alexandra Hosp
from other national organisations, health service and 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, coor-
long 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 Federa-
tion of Critical Care Nurses representative on a number
of sepsis related working groups including an interna-
tional 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 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 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 (Higher Educ), 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 School of Nursing and Midwifery 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
New South Wales Clinical Nurse Specialist
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
School of Nursing and Midwifery 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
Clinical Nurse Specialist 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

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
School of Nursing and Midwifery 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

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
eci-
sion to publish this second edition was supported ent
hu-
siastically 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
abora-
tors 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

Detailed Contents
5 Ethical Issues in Critical Care
78
Principles, rights and the link with law
78
Section 1 Scope of Critical Care 1 End-of-life decision making
1 Scope of Critical Care Practice 3
Development of critical care nursing 3 83
Roles of critical care nurses 6 Brain death
Clinical decision making 6
Leadership in critical care nursing 7 88
Developing a body of knowledge 11 Organ donation
Summary 12
2 Resourcing Critical Care 17 89
Ethical allocation and utilisation of Ethics in research
resources 17
Historical influences 18 91
Economic considerations and principles 19 Summary
Budget 20
Critical care environment 22 96
Equipment 22
Staff 23
Risk management 28
Measures of nursing workload or activity 30
Management of pandemics 33
Summary 34
3 Quality and Safety 38
Quality and safety monitoring 42
Patient safety 49
Summary 52
4 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
Sedation 138
Pain 141
Sleep 145
Summary 149
8 Family and Cultural Care of the Critically Ill
Section 2 Principles and Practice of Patient 156
Critical Care 103 Overview of models of care 157
6 Essential Nursing Care of the Critically Ill Cultural care 161
Patient 105 Religious considerations 170
Personal hygiene 105 End-of-life issues and bereavement 172
Eye care 107 Summary 173
Oral hygiene 109 9 Cardiovascular Assessment and Monitoring 180
Patient positioning and mobilisation 110 Related anatomy and physiology 180
Bowel management 115 Assessment 190
Urinary catheter care 116 Haemodynamic monitoring 195
Bariatric considerations 117 Diagnostics 206
Infection control in the critical care unit: Summary 210
general principles 118 10 Cardiovascular Alterations and Management 215
Transport of critically Ill patients: general Coronary heart disease 215
principles 123 Heart failure 227
Summary 125 Selected cases:
7 Psychological Care 133 Cardiomyopathy 241
Anxiety 133 Hypertensive emergencies 242 xv
Delirium 136

xvi D E TA I L E D C O N T E N T S
tracheostomy 387
Infective endocarditis 243 Tracheal suction 387
Aortic aneurysm 244 Extubation 387
Ventricular aneurysm 245 Mechanical ventilation 388
Summary 245 Non-invasive ventilation 389
11 Cardiac Rhythm Assessment and Invasive mechanical ventilation 392
Management 251 Summary 404
The cardiac conduction system 251 16 Neurological Assessment and Monitoring
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
12 Cardiac Surgery and Transplantation 291
Cardiac surgery 291
Intra-aortic balloon pumping 302
Heart transplantation 308
Summary 319
13 Respiratory Assessment and
Monitoring 325
Related anatomy and physiology 325
Pathophysiology 333
Assessment 335
Respiratory monitoring 338
Bedside and laboratory investigations 341
Diagnostic procedures 344
Summary 347
14 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 364
Pneumothorax 366
Pulmonary embolism 367
Lung transplantation 369
Summary 374
15 Ventilation and Oxygenation Management
381
Oxygen therapy 381
Airway support 383
Intubation 384
Tracheostomy 386
Complications of endotracheal intubation and
Pathophysiology 539
17 Neurological Alterations and Management 445 Patient assessment 541
Concepts of neurological dysfunction 445 Hypovolaemic shock 542
Neurological therapeutic management 449 Cardiogenic shock 545
Central nervous system disorders 455 Distributive shock states 551
Selected neurological cases 470 Anaphylaxis 554
Summary 472 Neurogenic/spinal shock 556
18 Support of Renal Function 479 Summary 557
Related anatomy and physiology 480 21 Multiple Organ Dysfunction Syndrome 562
Pathophysiology and classification of renal Pathophysiology 563
failure 483 Systemic response 564
Acute renal failure: clinical and diagnostic Organ dysfunction 567
criteria for classification and management 486 Multiorgan dysfunction 569
Renal dialysis 488 Summary 572
Approaches to renal replacement therapy 491
Summary 501 Section 3 Specialty Practice in
19 Gastrointestinal, Liver and Nutritional Critical Care 579
Alterations 506 22 Emergency Presentations 581
Gastrointestinal physiology 506 Triage 582
Nutrition 508 Extended roles 586
Nutrition support 509 Retrievals and transport of critically ill patients 587
Stress-related mucosal disease 513 Multiple patient triage/disaster 588
Liver dysfunction 516 Respiratory presentations 589
Liver transplantation 522 Chest pain presentations 591
Glycaemic control in critical illness 525 Abdominal symptom presentations 593
Incidence of diabetes in Australasia 526 Acute stroke 594
Summary 528 Overdose and poisoning 596
20 Management of Shock 539 Near-drowning 612

D E TA I L E D C O N T E N T S xvi
i
Hypothermia 614 Special considerations 729

Hyperthermia and heat illness 615 Caring for pregnant women in ICU 731
Summary 615 Caring for postpartum women in ICU 735
23 Trauma Management 623 Summary 738
Trauma systems and processes 623 27 Organ Donation and Transplantation 746
Common clinical presentations 626 Opt-in system of donation in Australia and
Summary 649 New Zealand 746
24 Resuscitation 654 Types of donor and donation 747
Pathophysiology 655 Organ donation and transplant networks in
Resuscitation systems and processes 655 Australasia 747
Management 655 Identification of organ and tissue donors 749
Roles during cardiac arrest 670 Organ donor care 755
Family presence during an arrest 670 Donation after cardiac death 757
Ceasing CPR 671 Tissue-only donor 758
Postresuscitation phase 671 Summary 758
Near-death experiences 671
Legal and ethical considerations 672
Summary 672 APPENDIX A1 Declaration of Madrid: Education 763
25 Paediatric Considerations in Critical Care APPENDIX A2 Declaration of Buenos Aires:
679 Workforce 765
Anatomical and physiological considerations APPENDIX A3 Declaration of Vienna: Patient
in children 680 Rights 76
Developmental considerations 684 7
Comfort measures 685 APPENDIX A4 Declaration of Vienna: Patient
Family issues and consent 686 Safety in Intensive Care Medicine 768
The child experiencing upper airway APPENDIX B1 ACCCN Position Statement (2006)
obstruction 686 on the Provision of Critical Care Nursing
The child experiencing lower airway disease 691 Education 77
Nursing the ventilated child 693 3
The child experiencing shock 695 APPENDIX B2 ACCCN ICU Staffing Position
The child experiencing acute neurological Statement (2003) on Intensive Care Nursing
dysfunction 696 Staffing 77
Gastrointestinal and renal considerations in 5
children 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 777
26 Pregnancy and Postpartum Considerations APPENDIX B4 ACCCN Resuscitation Position
710 Statement (2006) Adult & Paediatric
Epidemiology of critical illness in pregnancy 710 Resuscitation by Nurses 77
Adapted physiology of pregnancy 711 9
Diseases and conditions unique to pregnancy 716 APPENDIX C Normal Values 78
Exacerbation of medical disease associated 0
with pregnancy 726 GLOSSARY 78
3
PICTURE CREDITS 79
0
INDEX 793

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 Society
A/C MV assist-controlled mechanical ventilation ANZOD Australia and New Zealand Organ Donation
AACN American Association of Critical-care Nurses Registry
AATT aseptic non-touch technique xviii AoCLF acute-on-chronic liver failure
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
AV atrioventricular
AVDO 2 arteriovenous difference in oxygen
AVM arteriovenous malformation
AVPU Alert/response to Voice/only responds to
AODR Australian Organ Donor Register Pain/Unconscious
AORTIC Australasian Outcomes Research Tool for BBB bloodbrain barrier
Intensive Care BDI Beck Depression Inventory
APACHE acute physiology and chronic health BiPAP bilevel positive airway pressure
evaluation 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
ASL arterial spin labelling BTF Brain Trauma Foundation
AST aspartate aminotransferase BURP Backwards, upwards, rightward pressure
ATC automatic tube compensation BVM bagvalvemask
ATCA Australasian Transplant Coordinators CaO 2 content of arterial oxygen in the blood
Association CABG coronary artery bypass graft
ATN acute tubular necrosis CAM-ICU Confusion Assessment Method Intensive
ATP adenosine triphosphate Care Unit
ATS Australasian Triage Scale CAP community-acquired pneumonia
AV arteriovenous

A B B R E V I AT I O N S xix
CPOT Critical Care Pain Observation Tool
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 t
CCF chronic cardiac failure head injury
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 2 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
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 System
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
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
(Vasopressin) ERC European Resuscitation Council
DKA diabetic ketoacidosis ESBL-E extended-spectrum beta-lactamase-
DO 2 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 (o)esophagealtracheal Combitube
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

xx A B B R E V I AT I O N S
HRQOL health-related quality of life

FAST 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
FEV 1 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
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
HCO 3 sodium bicarbonate
H CO2 3 carbonic acid
H 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
technologies LN liaison nurse
ICU intensive care unit LOC level of consciousness
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
Resuscitation MARS molecular adsorbent(s) recirculating system
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 bypass
IVC inferior vena cava MIDCM minimally invasive direct cardiac massage
IVIg intravenous immunoglobulin mmHg millimetres of mercury
JE Japanese B encephalitis MODS multiple organ dysfunction syndrome
LAD left anterior descending coronary artery MRI magnetic resonance imaging
LAP left atrial pressure MRO multi-resistant organisms

A B B R E V I AT I O N S xxi
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 2 partial pressure of oxygen in arterial blood
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 venous pressure
PDU practice development unit PvO 2 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
PROWESS (recombinant human-activated) protein C ROSC return of spontaneous circulation
worldwide evaluation in severe sepsis RRS rapid response system
PRVC pressure-regulated volume control RR respiratory rate

xxii A B B R E V I AT I O N S
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 2 saturation of oxygen in arterial blood
SpO 2 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 2 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
SWS slow wave sleep URTI upper respiratory tract infection
TAFI thrombin-activatable fibrinolysis inhibitor V ventilation
TB tuberculosis V/Q ventilation/perfusion
TBI traumatic brain injury VT tidal volume
TCD transcranial Doppler VALI ventilator-associated lung injury
TEG thromboelastograph VAP ventilator-acquired pneumonia
TIPS transjugular intrahepatic portosystemic VAS Visual analogue scale
shunt/stent VAS-A Visual analogue scale Anxiety
TISS therapeutic intervention scoring system VC vital capacity
TLC total lung capacity VC volume-controlled (ventilation)
TNF tumour necrosis factor alpha 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
TSANZ Transplant Society of Australia and New VTE venous thromboembolism
Zealand VV veno-venous
TSC trauma symptom checklist WBC white blood cell
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

SECTION
1
Scope of Critical Care

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Scope of Critical Care Practice
1
Leanne Aitken
Wendy Chaboyer
expenditure.2
Doug Elliott
Learning objectives consumables and the rest to clinical support and capital
After reading this chapter, you should be able to: 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
of 0 patient re-
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 high-
expense component of hospital care; one
conservative
INTRODUCTION 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 spe-
cialty 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 mani-
fest 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
gh-
dependency, cardiothoracic, paediatric and general inten-
sive 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

4 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 to observe patients and appropriate nursing intensity
the development of a new, comprehensive partne
velop-
rship are
the collective
ments experience
in renal, metabolic andofneurological
a steep learning curv
managem now considered essential elements of critical care.12
ente for As the practice of critical care nursing evolved, s
the courage to work in an unfamiliar setting,
ledcaring
to the principles and context of critical care that e o did
xist the associated areas of critical care nursing educ
today.
a high demand for education specific to critic ation
al care
Development of critical care nursing was characteris and specialty professional organisations such a
ed by s the
the development of technology such as mech
a number
anical of features,4 including: Australian College of Critical Care Nurses (ACCCN). T
he
between nursing and medical clinicians 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 complete needs of patients and their families is esse
that ntial
required development of higher levels of compete to optimise the outcomes of critical care. As critical c
nce are
and practice continues to evolve, the challenge remains to co
mbine
practice, which was initially difficult to meet owing excellence in nursing care with judicious use of t
to echno-
the absence of experienced nurses in the specialt logy to optimise patient and family outcomes.
y
CRITICAL CARE NURSING EDUCATION
ventilators, cardiac monitors, pacemakers defib Appropriate preparation of specialist critical care
rilla- nurses
tors, dialysers, intra-aortic balloon pumps and car is a vital component in providing quality care to patie
diac nts
assist devices, which prompted development of ad and their families.5 A central tenet within this framew
di- ork
tional knowledge and skills. of preparation is the formalised education of
There was also recognition that improving patient nurses
out- 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 learn-
e have ing together. For example, medical staff brought expertise
been articulated in competency statements in in physiology, pathophysiology and interpretation of
many electrocardiographic rhythm strips, while nurses brought
countries. 14-16 expertise in patient care and how patients behaved and
responded to treatment.12,17 Training was, however, frag-
mented and fitted in around ward staffing needs. Post-
registration 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 spe-
cific 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 knowl-
edge 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 identi-
fied 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 institu-
tions 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 edu-
cation 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 imple-
mented.23 In relation to critical care nursing, this has led
to the expansion of programs, primarily at the postgradu-
ate level, for specialist nursing education. Critical care
nursing education in the USA maintains a slightly differ-
ent 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. 24 Employment in critical required to underpin specialty practice remain controver-
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

Scope of Critical Care Practice 5
beginner competent specialist expert
Induction/ continuing experience/experiential learning Practice

orientation
to critical short courses/skills updates/in-service education Training
care
nursing initial competencies increasing complexity of competencies Education
education Graduate
Diploma Masters
Postgraduate 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 SPECIALIST CRITICAL CARE COMPET
e and 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
itua-
tion33 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 profes-
sional 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 under-
gone considerable development in the past three decades.
Within Australia, the ACCCN (formerly the Confedera-
tion 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 pro-
fessional leadership for critical care nurses since the early
1970s. In New Zealand, the professional interests of criti-
cal 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 pro-
fessional 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 devel-
oped 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

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
4) includes in Chapter 3. care, management of
the
critical illness, and follow-up care in hospital, clinic an
d
home settings.42 This continuum also includes the pr
ac-
tice 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 the implementation, development and evaluation of the
PRACTITIONER 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- domain (see Chapter 22).
consultant 45-47
advanced practice48/nurse practitioner roles in ICU,4

CLINICAL DECISION MAKING
6 Clinical decision making is integral to critical care nursing
trauma, 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
der-
ship and the development and dissemination of know
l-
edge45,46 within a multidisciplinary team are integr
al to
effective practice.47 Practice includes role-
modelling 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 deci-
sions to assist in problem resolution and to achieve positive THEORETICAL PERSPECTIVES ON
patient outcomes.58 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

and context in clinical decision making.40,62,
The analytical approaches arise from a positivist or ra 63 That is,
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 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 RESEARCH ON DECISION MAKING IN
memory. Additionally, IPT claims that there are limits 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
e as observation, interviewing and thinking
aloud. Two
studies reported the types and frequency of deci Other studies indicated that experienced and inexperi-
sions 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 assist-
al ing to develop decision making skills.72
care nurses decisions were related to interventio
ns and RECOMMENDATIONS FOR DEVELOPING
communication, 61,68 evaluation, 61 assessment, orga CLINICAL DECISION MAKING SKILLS
nisa- Several strategies can be used to help critical care nurses
tion and education. 68 A further study demonstrated t to develop their clinical decision-making abilities (Table
hat 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 analys-
actice. 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 analys-
ing 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 sur-
rounding 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 conference presentations, representation o
essential to ensure excellence in practice, as well as ade- n
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. 76

TABLE 1.1 Australian and international critical care nurses decision-making research
Author [Country] Sample Data collection Findings
Bucknall, 200061
[Australia] 18 CC nurses (range of Observation (2-hour periods) Three types of decision:
levels and experiences; evaluation (51%)
all had completed a CC communication (30%)
course) intervention (19%)
200168 [Australia] 12 CC nurses with 2 years
Average: 238 decisions/2 hours (i.e. 2.0/min)
Currey & Worrall-Carter, 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
Thinking interview
aloud (2-hour periods) Hypotheses
assessmentdeveloped
(19%) as a framework for decision
organisation (13%)
[Australia] CC nurses from 2 semi-structured interview 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 67
Vignettes with decision Time pressure significantly reduced the nurses
and Australian whether or not to contact a decision tendency to intervene.
registered nurses senior nurse/doctor. The There were no statistically significant differences in
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 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.
interviews The presence of a role model or mentor to help
[various countries] 245 Dutch, UK, Canadian

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
Expert nurses in reasoning
were more strategies:
proactive in collecting
relevant cues to anticipate problems and make
decisions.
Ramezani-Badr, 2009 104 In-depth, semi-structured
hospitals, currently intuition
working in the CCU, recognising similar situations
with 3 years CC hypothesis testing.
[Various countries] 245experience andCanadian

Dutch, UK, holding 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 66
Judgement classification Critical care experience was associated with
and Australian systems, Continuous (0100) estimates of risk, but not with the decision to
testing74 registered
Description of anurses
clinical situation forratings
whichorthe
dichotomous
clinician has to generateintervene.
questions and develop hypotheses; with
working in surgical, ratings on 3 nursing Nurses varied considerably in their risk assessments,
medical, ICU or HDU. judgements were used 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 r-
com- ship are described in many different ways, sometimes
mitment of many critical care leaders throughout using theoretical underpinnings such as transactional
the
world.

elements vary according to leadership style.

satisfied staff, with a high level of retenti
and transformational and sometimes by using le Different of staff through an effective coa
development
on
ader- ching styles for example, transactional, transformat
ship characteristics. Regardless of the terminology in ional,
articulate a personal vision and expectatio
use, authoritative or laissez faire incorporate different c
act as a catalyst for chang
ns
some common
establish principles organisational
and implement can be expressed.
standa D har-
model
rds
esired effective leadership behaviours through acteristics and activities. Having leaders with diff
both
leadership
monitor characteristics include
practice in relation the ability and
to standards to: take erent
cor- styles ensures that there is leadership for all stages o
recognise the characteristics and strengths of
f an
indivi-
organisations operation or a professions develop
empower staff to act independently and ment.
change
80-85 processes and stable contexts A combination of leadership styles also helps to
over-
rective action when necessary come team member preferences and problems e
xperi-
critical care personnel are aware of, and willi
duals, and stimulate individual development ng toenced when a particularly visionary leader leaves
personnel in other areas of the hospital or outside
and the . The
commitment challenges often associated with the departure of a l
eader
interdependently patients
fromreceive optimal quality
a healthcare of car are generally redu
organisation
e. ced in
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.
rust-
ing 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 the
di- general characteristics listed above, but has the
viduals within the organisation. 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 nical
effective and safe patient car
eving leaders work within an effective interdisciplinary mod
evidence-based healthcar
a higher
e standard of practice. el,
Although all leaders share common characteristics, s so that all aspects of patient care and family support,
ome as
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 stimula-
tion 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 contem-
porary 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 leader-
ship ensures that:

fulfil, their changing roles

hospital recognise the benefits and limitations of

developments, are not threatened by the develop-
ments 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 begin-
ning to be available internationally that are designed to
develop clinical leaders.79,87 Factors that influence leader-
ship ability include the external and internal environ-
ment, 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

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 , quantitative
research involves the measurement (in numer
DEVELOPING A BODY OF ic form) of
variables and the use of statistics to
KNOWLEDGE 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 T), is used
QUAL QUANT: both approaches are given e
(ICN) 96 is that it is based on a core body of nur to test the effect of a new nursing interventio
qual
sing n on patient
QUAL quant: qualitative methods are the domin
knowledge that is being continually expanded and re ant outcomes. In essence, clinical trials involve:
QUAL quant: the qualitative study is given priori
fined ty
by research. Importantly, the ICN acknowledge
s that
mechanisms are needed to support, review and disse
mi-
nate research.
RESEARCH
As noted above, research is fundamental in the devel
op-
ment of nursing knowledge and practice. Researc
h is a
systematic inquiry using structured methods to u
nder-
stand an issue, solve a problem or refine existing kno
wl-
edge. 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
tial data collection. For example:
1. randomly allocating patients to receive either a
new intervention (the experimental or interven- status and data collection occurs concurrently.
tion group) or an alternative or standard interven-
tion (the control group) approach and data collection occurs concurrently.
2. delivering the 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 e
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
or approvals. Approval of the proposed researchaudits
by a human
are tworesearch ethics committee
issues (HREC) is required before the study can
problem issue. Clinical experience and practice ways that clinical 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
obtained.
question. A concise question includes both the phenomenon of interest and the patient population.
Disseminate the
proposal. Clear
and description
are vital to of the proposed
ensure that both research design and
nursing practice sample and
and nursing a plan continue
knowledge for data collection and analysis. Ethical
to be developed.
research findings. Conference presentations and journal publications are two common ways that research findings are disseminated
Research program
issues Technology & training Policy
Practice Patient Education
outcomes assessment issues
development systems
Clinical information Competencies Commonwealth &
Practice Health status/

based practice evaluation
Product Credentialling Impact of
HRQOL state policies
Evidence- Patient/family evaluation Ethical &

experiences international factors
Resource Economic Impact of Program

utilisation evaluation technology on legal issues
patient care
FIGURE 1.2 Example of critical care nursing research program.
oher-
ent 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
prac- on patients in ICU only has given way to a broader
tice. 101 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 individu-
ally, 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

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- A
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 t
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 occa-
sions for two hours of care. Follow-up interviews were conducted
to collect data from five expert critical care nurses pre- and post-
implementation 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 neuro-
logical status. On average each participant raised 48 attributes
related to sedation assessment and management in the preinter-
vention 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.

9. Prien T, Meyer J, Lawin P. Development of intensive care medicine in
Learning activities 1. Drennan K, Hicks P, Hart GK. Intensive care resources and activity: Aus
1. Consider the leaders to whom you are exposed in your tralia &
work environment and identify the characteristics they New Zealand 2007/2008. Melbourne: Australian and New Zealand Inte
display that influence patient care. Reflect on whether nsive
these are characteristics that you possess or how you might Care Society; 2010.
develop them. 2. Rechner I, Lipman J. The costs of caring for patients in a tertiary referr
2. Mentors are generally individuals who have excelled in al
their chosen profession and who are willing to share their Australian intensive care unit. Anaesth Intensive Care 2005; 33(4): 477
experiences and expertise with others. Think about your 82.
aspirations in your career as a critical care nurse. With the 3. Hilberman M. The evolution of intensive care units. Crit Care Med 197
help of others, try to identify a potential mentor. Consider 5;
asking this person to meet you on a regular basis to discuss 3(4): 15965.
your professional goals and your strategies to meet these 4. Wiles V, Daffurn K. Theres a bird in my hand and a bear by the bed I
goals and to provide you with advice. must be
3. Review the strategies outlined in Table 1.2 and develop in ICU. The pivotal years of Australian critical care nursing. Melbourne:
a plan of how you might improve your clinical decision- Austra-
making skills. Approach a mentor in your clinical environ- lian College of Critical Care Nurses; 2002.
ment and ask him/her to provide feedback over a period of 5. World Federation of Critical Care Nurses. Constitution of the World Fed
months on any changes observed in your clinical decision- era-
making skills. tion of Critical Care Nurses. 2007:1. Available from: http://www.wfccn.o
4. Consider the role that you have within critical care and rg/
examine the influence that research has on that role. How pub_constitution.php.
might you use research to inform your practice more effec- 6. American Association of Critical-Care Nurses. Critical care nursing fact
tively? Are there strategies that you could implement to sheet.
influence the research that is undertaken so that it meets Aliso Viejo CA: American Association of Critical Care Nurses; 2008. [Cit
your needs? ed
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domains14 of professional practice; reflective practice; 7. Australian College of Critical Care Nurses website. [Cited October 201
enabling; clinical problem solving; teamwork; and leader- 0].
ship. To what extent does your current practice address Available from: www.acccn.com.au.
these domains? What strategies can you implement to 8. Gordon IJ, Jones ES. The evolution and nursing history of a general int
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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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Resourcing Critical Care
2
Denise Harris
Learning objectives INTRODUCTION Ged Williams
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
ry 1966
not Dr B Galbally,
necessarily
does a hospital
continue until resuscitation
the patient officer
dies, aat
After reading this chapter, you should be able to: should
nd it not continue after the patient is consider
longer
ed no recoverable.1
describe historical influences on the development of critical
The need for prudent and rational allocation of
care and the way this resource is currently viewed and used
financial and human resources was as import
limited
explain the organisational arrangements and interfaces that Australias
ant for first ICU (St Vincents, Melbourne, 1961)
is
as for
it the 200 or more now scattered across Australi
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
n the of critical care and the way this resour
governance and management of a critical care unit currently
ce is viewed and used; describes various org
tional, staffing and training arrangements that need
anisa-
describe considerations in planning for the physical designin
to place;
be considers the planning, design and equipm
and equipment requirements of a critical care unit needs
ent of a critical care unit; covers other
resource
aspects management
of including the budget; and fini
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
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
competence
ETHICAL ALLOCATION AND
credentialling
governance
UTILISATION OF RESOURCES
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 compro-
mise 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, 1
7

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 1970s
well with pragmatic managers and policy makers. saw the development of the first critical care uni
2 An 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 itals
economies
disease of scale
prevention by cohorting
campaign lends acritically
greater ill patie
benefit was, at its fundamental conclusion, the existence
nts
to adevelopment of expertise in doctors and nurs of a
es who
greater number in the population than does one critical care unit.4 Over time, practical reasons for est
trans- ab-
an ever-growing body of research demonstrating t
plant
hatprocedure. lishing critical care units have led to their spread to
The appropriate provision and allocation of critical ca most
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
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 funding provided for a patient admitted for chronic
patients 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 jurisdic-
ical tion.5 For instance, Queensland tends to fund ICU
care unit.4 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 high-
dependency patients in ICU are funded through the hos-
pital 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 occu-
pied bed days in the ICU. However, within states and
specific health services and hospitals the actual alloca-
tion 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 under-
funding were voiced in all systems reviewed. Arrange-
ments 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. 13 This is one crude yet common way that hospitals of the service available. The capping of beds and qualified
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

Resourcing Critical Care 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 all teams to of treatment and the inherent
The benefit
were using their resources only for those patient manage. The professional isolation and limite
s who d access to
were most likely to achieve positive outcomes in ter approach Evaluate the
education, benefit and cost
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 the cost and
more common, whereas in the public hospitals of mo tyranny of distance.
st
Western countries an educated guess/risk is often ap
ECONOMIC CONSIDERATIONS
plied
to the decision as to whether a patient should enter t
AND PRINCIPLES
he One early comprehensive study of costs f
critical care unit or not. ound that 8%
It is vital to note the very important role played by ru 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 Description
An Australian study showed that in 2002, ICU pa Benefitrisk
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 The medical practitioner provides the
and capital expenditure.17 Nevertheless, some 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 Others cost and implicit approaches.
have 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
deci-
sion 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 appro-
priate decision in critical care. The following equation
expresses the concept value simply:
Quality Benefit Sustainability
Cost 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

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. 2 these budget types, there are two basic cost typ
es: fixed
BUDGET 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 esta-
nd 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 equip-
ment, maintenance contracts, utility costs (e.g. electric-
ity), 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 criti-
cal 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, pressure-
reduction mattresses, traditionally purchased as a fixed
asset with variable (and unpredictable) repair and main-
tenance 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 coop-
erating 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 equip-
ment purchases. Capital budget items tend to be con-
sidered 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.

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
r 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 budget is
year-to-date expenditures for personnel actively to engage staff in the process
(productive and 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 A BUSINESS CASE
ntial 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 organi-
sation. 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 ques-
tions 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 organisa-
tions will have standardised headings and formats for the
presentation of these documents. If the document
is
lengthy, the inclusion of an executive summary is recom-
mended, 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. How? How much money, people and equipment, for
When? What are the timelines for the implementation and example, will be required to achieve the benefits?
achievement of the project/solution? A clear costbenefit analysis should be included in
Where? What is the context within which the project will be response to this question.

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 gov-
In 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 staff station, clean utility, dirty utility, store room
the (s),
solution. education and teaching space, staff amenities, pa
tients
CRITICAL CARE ENVIRONMENT 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 Therapeutic
and Monitors (including central station) Ventilators (invasive and
End-tidal CO2 monitoring non-invasive)
Arterial blood gas analyser Infusion pumps
(electrolytes) Syringe drivers
Invasive monitoring CVVHDF
arterial EDD-f
central venous pressure Resuscitators
intracranial pressure Temporary pacemaker
PiCCO Defibrillator
pulmonary artery 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 techno-
logy to deliver that care. Equipment can be categorised
into several funding groups: capital expenditure (gener-
ally in excess of $10,000), equipment expenditure (all
equipment less than $10,000), and the disposable prod-
ucts and devices required to support the use of equip-
ment. 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 neu-
rosurgery 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

The decision to purchase or lease equipment
will, to some
BOX 2.2 Example criteria for product extent, be governed by the purchasing strate
evaluation
Safety
28,29 gy approved
Performance by the hospital or state government. The
Quality
advantages of
Use
leasing equipment include the capital expendi
ture being
Costbenefit analysis
purpose defrayed over the life of the lease (usuall
Cleaning
ease of 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
Adaptability to future supply unit (CSSU)
technological advancements final presen-
Service
agreements
infection control tation from the product evaluation commit
Training requirements
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 initia-
provided 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- s
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

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- a
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 care, coronary care and high-dependency
The development of the nursing establishment is dep patients, 34 different nurse-to-patient ratios are required
en- for these often diverse groups of patients. It is important
dent on many variables. Historical data from pre to note that nurse-to-patient ratios are provided
vious 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 devel-
oped 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 clini-
cally 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 high-
dependency 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 state-
ment identified 10 key principles to meet the expected
standards of critical care nursing (Table 2.5).
These recommendations serve merely to guide nurse-to-
patient ratios, as extraneous factors such as the clinical
practice setting, patient acuity and the knowledge and
expertise of available staff will influence final staffing pat-
terns. In particular, patient dependency scoring tools are
designed to guide these staffing decisions and are dis-
cussed 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. 38 For nurse-to-patient ratios of 1 : 1 for ICU patients and 1 : 2
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.

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 30 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
Division 1 Registered Nurses in 1:2 should have a registered nurse (division 1) allocated exclusively to their care.
Intensive Care 35 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 36
nurse for two patients at all times.
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).
The majority of nursing staff should have a post-registration qualification in intensive care or in the
CICM: Recommendations on 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) Require ahigh-dependency nursing. ratio of at least 1 :1.

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.

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 are not
the 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
e 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 substi-
of 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 compre-
hensive review of hospital nurse staffing and patient out-
comes 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 profession-
als 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 inten-
sive 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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Doug Elliott Leanne Aitken Wendy Chaboyer

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Elsevier Australia. ACN 001 002 357

2012 Elsevier Australia

National Library of Australia Cataloguing-in-Publication Data

Edition: 2nd ed.

ISBN: 9780729540681 (pbk.)

Notes: Includes index.

Subjects: Intensive care nursingAustralia.

Other Authors/Contributors: Elliott, Doug. Aitken, Leanne. Chaboyer, Wendy.

Dewey Number: 616.028

Publisher: Libby Houston

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Section 2 Principles and Practice of

12 Cardiac Surgery and Transplantation 291 Section 3 Specialty Practice in

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Hypothermia 614 Special considerations 729

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HRQOL health-related quality of life

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STEMI ST-elevation myocardial infarction

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beginner competent specialist expert

Induction/ continuing experience/experiential learning Practice

important in promoting quality critical c

CRITICAL CARE NURSING PROFESSIONAL

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This section focuses on the scope of critical care

ROLES OF CRITICAL CARE NURSES

chapters in Section 2, and the specialty chapt

advanced practice48/nurse practitioner roles in ICU,4

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interviews The presence of a role model or mentor to help

[various countries] 245 Dutch, UK, Canadian

TABLE 1.1, Continued

[Various countries] 245experience andCanadian

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elements vary according to leadership style.

leadership of critical care is essential in achieving:

and mentoring process.81,86

fulfil, their changing roles

hospital recognise the benefits and limitations of