ACCCN’s
2nd edition
Critical Care
Nursing
Doug Elliott QLeanne Aitken QWendy Chaboyer
ACCCN’S CRITICAL
CARE NURSING
ACCCN’S CRITICAL
CARE NURSING
SECOND EDITION
Doug Elliott
Leanne Aitken
Wendy Chaboyer
RN, PhD BAppSc(Nurs),
MAppSc(Nurs), ICCert, Professor
of Nursing, Faculty of Nursing,
Midwifery and Health University
of Technology, Sydney, New South
Wales
RN, PhD, BHSc(Nurs)Hons,
GradCertMgt,
GradDipScMed(ClinEpi), ICCert,
FRCNA Professor of Critical Care
Nursing Griffith University & Princess
Alexandra Hospital Brisbane,
Queensland
RN, PhD, MN, BSc(Nurs)Hons,
CritCareCert Professor & Director,
NHMRC Centre of Research
Excellence in Nursing Interventions
for Hospitalised Patients, Griffith
Health Institute, Griffith University
Gold Coast, Queensland
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
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This publication has been carefully reviewed and checked to ensure that the content is as
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from this publication.
National Library of Australia Cataloguing-in-Publication Data
Title: ACCCN’s critical care nursing / [editors] Doug Elliott, Leanne Aitken and Wendy
Chaboyer.
Edition: 2nd ed.
ISBN: 9780729540681 (pbk.)
Notes: Includes index.
Subjects: Intensive care nursing–Australia.
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 ••
Contents
Foreword
Preface
About the Australian College of Critical Care Nurses
(ACCCN)
About the Editors
Contributors
Reviewers
Acknowledgements
Detailed Contents
Abbreviations
Section 1 Scope of Critical Care
1
2
3
4
5
Scope of Critical Care Practice
Leanne Aitken, Wendy Chaboyer, Doug Elliott
Resourcing Critical Care
Denise Harris, Ged Williams
Quality and Safety
Wendy Chaboyer, Karena Hewson-Conroy
Recovery and Rehabilitation
Doug Elliott, Janice Rattray
Ethical Issues in Critical Care
Amanda Rischbieth, Julie Benbenishty
Section 2 Principles and Practice of
Critical Care
6
7
8
9
10
11
Essential Nursing Care of the Critically
Ill Patient
Bernadette Grealy, Wendy Chaboyer
Psychological Care
Leanne Aitken, Rosalind Elliott
Family and Cultural Care of the Critically
Ill Patient
Marion Mitchell, Denise Wilson, Vicki Wade
Cardiovascular Assessment and Monitoring
Thomas Buckley, Frances Lin
Cardiovascular Alterations and Management
Robyn Gallagher, Andrea Driscoll
Cardiac Rhythm Assessment and
Management
Malcolm Dennis, David Glanville
vi
vii
ix
x
xi
xiii
xiv
xv
xviii
1
12
Cardiac Surgery and Transplantation
Judy Currey, Michael Graan
291
13
Respiratory Assessment and Monitoring
Amanda Corley, Mona Ringdal
Respiratory Alterations and Management
Maria Murphy, Sharon Wetzig, Judy Currey
Ventilation and Oxygenation Management
Louise Rose, Gabrielle Hanlon
Neurological Assessment and Monitoring
Di Chamberlain, Leila Kuzmiuk
Neurological Alterations and Management
Di Chamberlain, Wendy Corkill
Support of Renal Function
Ian Baldwin, Gavin Leslie
325
14
15
16
17
3
18
17
19
38
57
20
78
21
Gastrointestinal, Liver and Nutritional
Alterations
Andrea Marshall, Teresa Williams,
Christopher Gordon
Management of Shock
Margherita Murgo, Gavin Leslie
Multiple Organ Dysfunction Sydrome
Melanie Greenwood, Alison Juers
352
381
414
446
480
507
540
563
Section 3 Specialty Practice in
Critical Care
579
103
22
581
105
23
133
24
25
156
180
215
251
Emergency Presentations
David Johnson, Mark Wilson
Trauma Management
Louise Niggemeyer, Paul Thurman
Resuscitation
Trudy Dwyer, Jennifer Dennett
Paediatric Considerations in Critical Care
Tina Kendrick, Anne-Sylvie Ramelet
26 Pregnancy and Postpartum Considerations
Wendy Pollock, Clare Fitzpatrick
27 Organ Donation and Transplantation
Debbie Austen, Elizabeth Skewes
Appendices
Glossary
Picture Credits
Index
623
654
679
710
746
763
783
790
793 v
Foreword
As a specialty area of nursing practice, critical care nursing
is focused on the care of patients who are experiencing
life-threatening illness. Globally, critical care nurses
provide care to ensure that critically ill patients and their
families receive optimal care. This second edition of the
Australian College of Critical Care Nurses (ACCCN’s)
Critical Care Nursing is a valuable resource for critical care
nursing practice. The editors, who are acknowledged
expert practitioners, educators, and researchers in critical
care, have organised the book into topics covering 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 in the
ﬁeld of critical care, provide a comprehensive overview
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 educational resources including website links, case studies and
practice tips.
ACCCN’s Critical Care Nursing is a beneﬁcial resource for
critical care nurses, regardless of practice setting. In
seeking to provide complex high intensity care, therapies
and interventions, critical care nurses will ﬁnd that the
vi
book reviews essential content related to critical care
nursing knowledge and skills to provide care to acutely
ill patients and their families.
Internationally, there are more than 500,000 critical care
nurses, representing one of the largest specialty areas of
nursing practice. The importance of maintaining knowledge of best practices, utilising evidence-based approaches,
and applying research to clinical practice for critical
care patients remain essential components of critical
care nursing. This second edition of ACCCN’s Critical Care
Nursing is a comprehensive resource for critical care
nurses seeking to further develop their knowledge and
enhance their clinical practice expertise.
Ruth Kleinpell PhD RN FAAN FCCM
Director, Center for Clinical Research and Scholarship
Rush University Medical Center;
Professor, Rush University College of Nursing;
Nurse Practitioner, Mercy Hospital & Medical Center
Chicago Illinois, USA
President of World Federation of Critical Care Nurses
http://www.wfccn.org
Preface
Critical care as a clinical specialty is over half a century
old. With every successive decade, advances in the education and practices of critical care nurses have been made.
Today, critical care nurses are some of the most knowledgeable and highly skilled nurses in the world, and
ongoing professional development and education are
fundamental elements in ensuring we deliver the highest
quality care to our patients and their families.
This book is intended to encourage and challenge nurses
to further develop their critical care nursing practice. Our
vision for the ﬁrst edition was for an original text from
Australasian authors, not an adaptation of texts produced
in other parts of the world. This writing approach more
accurately captures the uniquely local elements that form
contemporary critical care nursing in Australia and New
Zealand and help to answer the myriad of questions
posed by critical care nurses as they practise in the local
environment, while still allowing the universal core elements that represent critical care practice internationally.
This second edition of ACCCN’s Critical Care Nursing has
27 chapters that reﬂect the collective talent and expertise
of 50 contributors – a strong mix of academics and clinicians with a passion for critical care nursing – in showcasing the practice of critical care nursing in Australia, New
Zealand, Asia and the Paciﬁc. We also engaged contributors beyond Australasia to reﬂect global practices and to
extend the applicability of out text to a wider geographic
audience. All contributors were carefully chosen for their
current knowledge, clinical expertise and strong professional reputations.
The book has been developed primarily for use by practising critical care clinicians, managers, researchers and
graduate students undertaking a specialty critical care
qualiﬁcation. In addition, senior undergraduate students
studying high acuity nursing subjects will ﬁnd this book
a valuable reference tool, although it goes beyond the
learning needs of these students. The aim of the book
is to be a comprehensive resource, as well as a portal
to an array of other important resources, for critical
care nurses. The nature and timeline of book publishing
dictates that the information contained in this book
reﬂects a snapshot in time of our knowledge and understanding of the complex world of critical care nursing.
We therefore encourage our readers to continue to also
search for the most contemporary sources of knowledge
to guide their clinical practice. A range of website links
have been included in each chapter to facilitate this
process.
This second edition is again organised in three broad
sections: the scope of critical care nursing, core components of critical care nursing, and specialty aspects
of critical care nursing. Inclusion of new chapters and
signiﬁcant revisions to existing chapters were based on
our reﬂections and suggestions from colleagues and
reviewers as well as on evolving and emerging practices
in critical care.
Section 1 introduces a broad range of professional issues
related to practice that are relevant across critical care.
Initial chapters provide contemporary information on
the scope of practice, systems and resources, quality and
safety, recovery and rehabilitation, and ethical issues.
Content presented in the second section is relevant to the
majority of critical care nurses, with a focus on concepts
that underpin practice such as essential physical, psychological, social and cultural care. Remaining chapters in
this section present a systems approach in supporting
physiological function for a critically ill individual. This
edition now has multiple linked chapters for some of the
major physiological systems – 4 chapters for cardiovascular, 3 for respiratory, and 2 for neurological. Chapters
on support of renal function, gastrointestinal, liver and
nutritional alterations, management of shock, and multiorgan dysfunction complete this section.
The third section presents speciﬁc clinical conditions
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 to
ease identiﬁcation of relevant material. Where appropriate, each chapter commences with an overview of relevant
anatomy and physiology, and the epidemiology of the
clinical states in the Australian and New Zealand setting.
Nursing care of the patient, both delivered independently
or provided collaboratively with other members of the
healthcare team, is then presented. Pedagogical features
include a case study that elaborates relevant care issues, vii
viii P R E F A C E
a critique of a research publication that explores a related
topic, and learning activities to assist both the reader and
those in educational roles to assess knowledge acquisition. Extensive use of tables, ﬁgures and practice tips are
located throughout each chapter to identify areas of care
that are particularly pertinent for readers. It is not our
intention that readers progress sequentially through the
book, but rather explore chapters or sections that are
relevant for different episodes of learning or practice.
The delivery of effective, high-quality critical care nursing
practice is a challenge in contemporary health care.
We trust that this book will be a valuable resource in
supporting your care of critically ill patients and their
loved ones.
Doug Elliott
Leanne Aitken
Wendy Chaboyer
About the Australian College of
Critical Care Nurses (ACCCN)
The Australian College of Critical Care Nurses, with over
2400 members, is the peak professional organisation
representing critical care nurses in Australia. Membership types include standard membership, international
members, life members, honorary members and corporate members. All individual members are eligible and
are encouraged to participate in the activities of the
College; to receive the College journal and Critical Times
publication, in addition to discounts for ACCCN conference registration and for ACCCN publications. Life and
honorary memberships are awarded to individuals in
recognition of their outstanding contribution to ACCCN
and/or to critical care nursing excellence in Australia.
ACCCN is a company limited by guarantee and has
branches in each state of Australia, with two members
from each state branch management committee forming
the ACCCN National Board of Directors. Each committee
facilitates the activities of the college at a local/state level
and provides local and at times national representation.
The ACCCN Editorial Committee and Editorial Board,
under the leadership of the editor of the Australian Critical
Care (ACC) journal, are responsible for the College publications including the journal Australian Critical Care and
newspaper Critical Times.
There are a number of national advisory panels and
special interest groups dedicated to providing the organisation with expert opinion on issues relating to critical
care nursing. These include:
Resuscitation Advisory Panel: consists of eight
members representing each branch of ACCCN, plus a
paediatric nurse representative. It has developed a
complete suite of contemporary advanced life support
and resuscitation educational material and offers its
ACCCN National ALS Courses throughout Australia;
Research Advisory Panel: in addition to providing
expert advice to ACCCN, the panel is responsible for
evaluating and making recommendations on research
strategy and grant submissions to ACCCN, and for
evaluating abstracts submitted to the ANZICS/ACCCN
Annual Scientiﬁc Meeting on Intensive Care;
Education Advisory Panel: advises ACCCN on all
matters relating to education speciﬁc to critical care
nursing. This panel has developed a position paper on
critical care nursing education and written submissions on behalf of ACCCN to national reviews of
nursing education;
Workforce Advisory Panel: has represented ACCCN
on a number of national health workforce and nursing
committees. The panel has also developed position
statements on nurse stafﬁng for intensive care and
high-dependency units in Australia, and annually
reviews the dataset design for national workforce data
collection in conjunction with ANZICS;
Organ & Tissue Donation & Transplantation Advisory Panel: advises the board and developed a position statement on organ donation and transplantation
as it relates to intensive care. It disseminates related
information to critical care nurses regarding the promotion and national reform objectives of organ and
tissue donation in Australia;
Quality Advisory Panel: provides expert knowledge,
advice and information to ACCCN on matters relevant to critical care nursing practice relating speciﬁcally to patient management.
Paediatric Advisory Panel: provides expert knowledge, advice and information to ACCCN on matters
relevant to paediatric critical care nursing in addition
to recommending content and speakers for the annual
ACCCN conferences.
The ICU Liaison Special Interest Group: is a collective group of ACCCN members who have an interest
in ICU liaison/outreach and work together to discuss
matters relevant to this increasing area of critical care
nursing focus.
In addition to branch educational events and symposiums, ACCCN conducts three national conferences each
year: ACCCN Institute of Continuing Education (ICE);
and, in conjunction with our medical colleagues from
The Australian and New Zealand Intensive Care Society
(ANZICS), the ANZICS/ACCCN Annual Scientiﬁc Meeting
on Intensive Care and the Australian and New Zealand
Paediatric & Neonatal Intensive Care Conference.
ACCCN has a representative on the Australian Resuscitation Council (ARC), and has representation at a federal
government advisory level through the Nursing and Midwifery Stakeholder Reference Group (NMSRG) chaired by
the Chief Nurse of Australia, and is also a member of the
Coalition of National Nursing Organisations (CoNNO).
The founding Chairperson of the World Federation of
Critical Care Nurses (WFCCN) continues to represent
ACCCN on the WFCCN Council, and the College also
has representatives on the World Federation of Paediatric
Intensive and Critical Care Societies, and is a member of
the Intensive Care Foundation.
More information can be found on the ACCCN website:
www.acccn.com.au
ix
About the Editors
Doug Elliott
Doug Elliott is Professor of Nursing in the Faculty of
Nursing, Midwifery and Health at the University of Technology, Sydney. During his 25 years as a nurse academic,
Doug has been a faculty Director of Research, Clinical
Professor, Head of Department and a conjoint hospital
appointment as Assistant Director of Nursing – Research.
Prior to this, he worked as a clinician in acute and critical
care areas in tertiary hospitals in Sydney and Perth.
Doug’s clinical and health services research focuses on
the health-related quality of life (HRQOL) and illness
experiences of individuals with critical and acute illnesses, and the use of technologies to improve patient
outcomes. Doug has received research funding from the
NHMRC and the Australian Commission on Safety and
Quality in Health Care, as well as competitive funding
from other national organisations, health service and university funding sources. He has published over 80 peerreviewed articles and book chapters, and is co-editor for
two additional books, on nursing and midwifery research,
and pathophysiology and nursing practice.
Doug became a Life Member of the Australian College of
Critical Care Nurses in 2006 in recognition of over 20
years of service to critical care. He has previously been an
Associate Editor and on the Editorial Board for Australian
Critical Care, was the inaugural Chair of the Research
Advisory Panel, a member of the Education Advisory
Panel, and also served on the NSW committee. He is currently on the Editorial Board for the American Journal of
Critical Care, and peer-reviews for several critical care
medicine and nursing journals, and a range of competitive funding bodies. Doug has been an invited speaker to
international and national multi-disciplinary critical care
meetings on numerous occasions.
Leanne Aitken
Leanne Aitken is Professor of Critical Care Nursing at
Grifﬁth University and Princess Alexandra Hospital,
Queensland. She has a long career in critical care nursing,
including practice, education and research roles. In all
her roles in nursing, Leanne has been inspired by a sense
of enquiry, pride in the value of expert nursing and a
belief that improvement in practice and resultant patient
outcomes is always possible. Research interests include
developing and reﬁning interventions to improve long
x term recovery of critically ill and injured patients,
decision-making practices of critical care nurses and a
range of clinical practice issues within critical care and
trauma.
Leanne has been active in ACCCN for more than 20 years
and was made a Life Member of the College in 2006 after
having held positions on state and national boards, coordinated the Advanced Life Support course in Western
Australia in its early years, chaired the Education Advisory
Panel and been an Associate Editor with Australian Critical
Care. In addition, she is a peer reviewer for a number of
national and international journals and reviews grant
applications for a range of organisations including the
National Health and Medical Research Council (NHMRC)
and Intensive Care Foundation. She is the World Federation of Critical Care Nurses’ representative on a number
of sepsis related working groups including an international group who authored a companion paper to the
Surviving Sepsis Campaign guidelines to summarise the
evidence underpinning nursing care of the septic patient,
the revision of the Surviving Sepsis Campaign Guidelines
and the Global Sepsis Alliance.
Wendy Chaboyer
Wendy Chaboyer is a Professor of Nursing at Grifﬁth
University and the Director of the Centre of Research
Excellence in Nursing Interventions for Hospitalised
Patients, funded by the National Health and Medical
Research Council (NHMRC) (2010–2015). 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 patient’s, and their
family’s, 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,
GradCertMgt, GradDipScMed(ClinEpi),
ICCert, FRCNA
Professor of Critical Care Nursing
Griffith University & Princess
Alexandra Hospital
Brisbane, Queensland
Debbie Austen RN, BaHSc, Grad Cert
Critical Care, Grad Cert Management,
JP (Qual)
Registered Nurse, Capricorn Coast Hospital
and Health Service
Queensland
Ian Baldwin RN, PhD
Post Graduate Educator
Intensive Care Unit, Austin Health
Victoria
Julie Benbenishty MNS
Academic Consultant Surgical Division
Hadassah Hebrew University Medical Center
Jerusalem, Israel
Tom Buckley RN(UK), PhD MNRes, BScHlth
CertICU, CertTeaching&Assessing
Senior Lecturer and Co-ordinator Master
of Nursing (Clinical Nursing & Nurse
Practitioner)
Sydney Nursing School, The University
of Sydney
New South Wales
Wendy Chaboyer RN, BSc (Nu) Hon,
MN, PhD
Director
NHMRC Centre of Research Excellence in
Nursing Interventions for Hospitalised
Patients (NCREN), Research Centre for
Clinical and Community Practice Innovation
(RCCCPI)
Griffith Health Institute
Queensland
Diane Chamberlain RN BN BSc MNSc
(Critical Care) MPH PhD
Senior Lecturer
Flinders University
South Australia
Wendy Corkill RN
Clinical Nurse Specialist
Alice Springs Hospital
Northern Territory
Amanda Corley BN, ICU Cert, GradCert
HealthSci, M AdvPrac (candidate)
Nurse Researcher
Critical Care Research Group, The Prince
Charles Hospital
Queensland
Clare Fitzpatrick
Registered Nurse, Registered Midwife
BA (Hons)
Lead for Critical Care
Liverpool Women’s NHS Foundation Trust
Liverpool, United Kingdom
Judy Currey RN BN BN(Hons) Crit Care
Cert Grad Cert Higher Ed Grad Cert Sc
(App Stats) PhD
Associate Professor in Nursing
Deakin University
Victoria
Robyn Gallagher RN, BA (Psych), MN, PhD
Associate Professor Chronic and
Complex Care
Faculty of Nursing, Midwifery and Health
University of Technology, Sydney
New South Wales
Jennifer Dennett RN, MN, BAppSc
(Nursing), CritCareCert, Dip Management,
MRCNA
Nurse Unit Manager
Critical Care, Oncology, Cardiology, Renal
Dialysis, Central Gippsland Health Service
Victoria
David Glanville RN, BN, Grad Dip Crit Care
Nursing, MN
Nurse Educator
Intensive Care Unit
Epworth Freemasons Hospital
East Melbourne, Victoria
Malcolm Dennis RN, Bed, CritCareCert(ICU)
Bed Field Technical Specialist
Cardiac Rhythm Management Division,
St Jude Medical
New South Wales
Christopher Gordon RN, MExSc, PhD
Senior Lecturer
Director of Postgraduate Advanced Studies
Sydney Nursing School, The University
of Sydney
New South Wales
Andrea Driscoll RN, CCC, BN, MN, MEd, PhD
Senior Research Fellow
Monash University, Melbourne
Victoria
Michael Graan RN, GradDip CritCare
Clinical Nurse Educator (ICU)
Epworth HealthCare
Richmond, Victoria
Trudy Dwyer RN, ICU Cert, BHlth, GCert
FlexLrn, MClinEd, PhD
Associate Professor
School of Nursing and Midwifery, Faculty of
Sciences, Engineering & Health
Central Queensland University
Queensland
Bernadette Grealy RN, RM, CritCareCert,
BN, MN
Clinical Services Coordinator Intensive
Care Unit
Queen Elizabeth Hospital
South Australia
Doug Elliott RN, PhD BAppSc(Nurs),
MAppSc(Nurs), ICCert
Professor of Nursing
Faculty of Nursing, Midwifery and Health
University of Technology
Sydney, New South Wales
Rosalind Elliott RN, BSc (Hons), PG Dip
(Crit Care), MN
PhD candidate
University of Technology Sydney
New South Wales
Melanie Greenwood MN, Grad Cert.
UniTeach&Learn, ICCert, NeurosciCert
Senior Lecturer,
School of Nursing and Midwifery
University of Tasmania
Tasmania
Gabrielle Hanlon RN, Crit Care Cert, BN,
GDBL, MRCNA
Project Manager
Australian Commission on Safety & Quality
in Health Care
New South Wales
xi
xii C O N T R I B U T O R S
Denise Harris RN, BHSc(Nurs),
GradDipHlthAdmin& InfoSys,
MN(Res), ICCert
Assistant Director of Nursing—Medicine &
Critical Care
The Tweed Hospital
Tweed Heads, New South Wales
Karena Hewson-Conroy BSocSci(Hons),
PhD candidate
Research & Quality Manager, Intensive Care
Co-ordination & Monitoring Unit
Honorary Associate, Faculty of Nursing,
Midwifery & Health, University of
Technology
New South Wales
David Johnson RN, Grad Dip (Acute Care
Nurs), MHealth Sci Ed, A&E Cert, MCN
Director of Nursing
Caloundra Health Service
Sunshine Coast Wide Bay Health
Service District
Queensland
Alison Juers RN, BN (Dist), MN (Crit Care)
Nurse Educator
Brisbane Private Hospital
Queensland
Tina Kendrick RN, PIC Cert, BNurs(Hons),
MNurs, FCN, FRCNA
Clinical Nurse Consultant – Paediatrics
NSW Newborn and Paediatric Emergency
Transport Service
New South Wales
Leila Kuzmuik RN, BN, DipAdvClinNurs, MN,
Grad Cert HlthServMgt
Nurse Educator
Intensive Care Services
John Hunter Hospital, Hunter New
England Health
New South Wales
Gavin D Leslie RN, IC Cert, PhD, BAppSc,
Post Grad Dip (Clin Nurs), FRCNA
Professor Critical Care Nursing
Royal Perth Hospital
Director Research & Development
School of Nursing & Midwifery,
Curtin University
Western Australia
Frances Lin RN, BMN, MN (Hons), PhD
Lecturer & Program Convenor (Master of
Nursing – Critical Care)
School of Nursing and Midwifery
Griffith University
Queensland
Andrea Marshall RN PhD
Sesqui Senior Lecturer Critical Care Nursing
Sydney Nursing School
University of Sydney
New South Wales
Marion Mitchell RN, BN (Hon), Grad Cert
(Higher Educ), Ph.D.
Senior Research Fellow Critical Care
Griffith University and Princess
Alexandra Hospital
Queensland
Margherita Murgo BN, MN (Crit Care)
Project Officer
Clinical Excellence Commission
New South Wales
Maria Murphy RN PhD, Grad Dip Crit Care,
Grad Cert Tert Ed, BN, Dip App Sci (Nursing)
Lecturer
LaTrobe University
Clinical Nurse Specialist
Austin Health
Victoria
Louise E Niggemeyer RN, MEd, BEdSt,
IC Cert, MRCNA
Trauma Program Manager
The Alfred Hospital
Senior Researcher
Trauma Systems & Education Consultant
National Trauma Research Institute
Alfred Health
Victoria
Wendy Pollock RN, RM, Grad Dip Crit
Care Nsg, Grad Dip Ed, Grad Cert Adv
Learn & Leadership,
PhD Research Fellow
La Trobe University/Mercy Hospital
for Women
Victoria
Anne-Sylvie Ramelet RN, ICU Cert, PhD
Senior Lecturer
Institute of Higher Education and
Nursing Research
Lausanne University-Centre Hospitalier
Universitaire Vaudois, Switzerland
Professor, HECVSanté
University of Applied Sciences
Western Switzerland
Switzerland
Janice Rattray PhD, MN, DipN (CT),
RGN, SCM
Reader
School of Nursing and Midwifery
University of Dundee
United Kingdom
Mona Ringdal RN, PhD, MSc
Senior Lecturer
Institute of Health and Care Sciences
The Sahlgrenska Academy, University
of Gothenburg
Sweden
Amanda Rischbieth RN, Grad Dip (Intens
Care), MNSc, PhD
School of Nursing University of Adelaide
South Australia
Louise Rose BN, MN, PhD, ICU Cert
Assistant Professor
Lawrence S. Bloomberg Faculty of Nursing,
University of Toronto
Research Director and Advanced Practice
Nurse, Prolonged-ventilation Weaning
Centre, Toronto East General Hospital,
Toronto
Ontario, Canada
Elizabeth Skewes DAppSc(Nursing), CCRN
Senior Nurse of Organ and Tissue Donation
St Vincent’s Hospital
Victoria
Paul Thurman RN, MS, ACNPC, CCNS,
CCRN, CNRN
Clinical Nurse Specialist
R Adams Cowley Shock Trauma Center
University of Maryland Medical Center
Baltimore, Maryland, USA
Vicki Wade Dip Nsg, BHSc, MN
Leader
National Aboriginal Health Unit
Heart Foundation Australia
Sharon Wetzig RN, BN, Grad Cert
(Critical Care), MEd
Clinical Nurse Consultant
Princess Alexandra Hospital
Queensland
Ged Williams RN, RM, CritCareCert, MHA,
LLM, FACHSM, FRCNA, FAAN
Executive Director of Nursing and Midwifery
Gold Coast Health Service District
Professor of Nursing, Griffith University
Founding President, World Federation of
Critical Care Nurses
Queensland
Teresa Williams RN, ICUCert, BN, MHlthSci
(Res), GradDipClinEpi, PhD
Research Assistant Professor and NH&MRC
Clinical Research Postdoctoral Fellow
Discipline of Emergency Medicine (SPARHC)
The University of Western Australia
Western Australia
Denise Wilson PhD, RN, FCNA(NZ)
Associate Professor Māori Health
Auckland University of Technology
Auckland, New Zealand
Mark Wilson DipAppSc (Nursing),
GDipClPrac (Emergency Nursing), MHScEd
Emergency Department Nurse Educator
Illawarra Shoalhaven Local Health District
New South Wales
Reviewers
Steven Frost RN, MPH
Lecturer, School of Nursing and Midwifery
University of Western Sydney
New South Wales
Holly Northam RN, RM, M Critical Care Nursing
Assistant Professor of Critical Care Nursing
University of Canberra
Australian Capital Territory
Melanie Greenwood MN, Grad Cert. UniTeach&Learn,
ICCert, NeurosciCert
Senior Lecturer
School of Nursing and Midwifery
University of Tasmania
Tasmania
Jon Mould PhD candidate, MSc, RGN, RSCN, RMN, Adult Cert Ed
Senior Lecturer
Edith Cowan University
Western Australia
Nichole Harvey RN, EM, CritCareCert, BN (Post Reg), MNSt,
GradCertEd (TT), PhD Candidate
Senior Lecturer
School of Medicine and Dentistry
James Cook University
Queensland
Ann Kuypers RN, Med Grad Dip(Clin Ed), Grad Cert (Periop)
Lecturer Nursing
Academic Language and Learning Unit
LaTrobe University, Albury Wodonga Campus
Victoria
Renee McGill MN, Grad Cert Crit Care, BS(Nurs)
Lecturer in Nursing, Academic Advisor
School of Nursing, Midwifery and Indigenous Health
Charles Sturt University
New South Wales
Stephen McNally RN, BApp Sc (Nursing), PhD
Lecturer, Head of Program
University of Western Sydney
New South Wales
Helena Sanderson RN, BHSc, ICU Cert, MN(Advanced
Clinical Education)
Lecturer in Nursing
School of Health
University of New England
Armidale, New South Wales
Natashia Scully RN, BA, BN, PGDipNSc(Critical Care),
MPH(Candidate)
Lecturer in Nursing
School of Health
University of New England
Armidale, New South Wales
Kerry Southerland RN, ICCert, BSc, MCN, GCTT, MRCNA
Lecturer
School of Nursing & Midwifery
Curtin University
Western Australia
Peter Thomas RN, BSc, GradDipEd, PhD
Lecturer
School of Nursing, Midwifery & Indigenous Health
University of Wollongong
New South Wales
xiii
Acknowledgements
A project of this nature and scope requires many talented
and committed people to see it to completion. The decision to publish this second edition was supported enthusiastically by the Board of the Australian College of
Critical Care Nurses (ACCCN) and Elsevier Australia. To
our chapter contributors for this edition, both those
returning from the ﬁrst edition and our new collaborators – 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 committed in
meeting writing deadlines while developing the depth
and quality of content that we had planned. We also
acknowledge the work of chapter contributors from
our ﬁrst edition – Harriet Adamson, Susan Bailey,
Martin Boyle, Sidney Cuthbertson, Suzana Dimovski,
Bruce Dowd, Ruth Endacott, Paul Fulbrook,
Michelle Kelly, Bridie Kent, Anne Morrison, Wendy
Swope and Jane Treloggen.
Continued encouragement and support from the Board
and members of ACCCN, for having the belief in us as
editors and authors to uphold the values of the College,
is much appreciated. We also acknowledge support from
xiv
the staff at Elsevier Australia, our publishing partner.
Thanks to our Publishing Editor Libby Houston, for
guiding this major project; our Developmental Editors
– initially Larissa Norrie, and then Elizabeth Coady for
the majority of the project; and to Melissa Read our
editor. In Publishing Services, Geraldine Minto, thanks
for your work with typesetting issues. To others who produced the high quality ﬁgures, developed and executed
the marketing plan, and the myriad of other activities,
without which a 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 text and contributed to the quality
of the ﬁnished product.
Finally, and most importantly, to our respective loved
ones – Maureen, Kate, Nick and Josh; Steve; and Michael
– thanks for your belief in us, and your understanding
and commitment in supporting our careers.
Doug Elliott
Leanne Aitken
Wendy Chaboyer
Detailed Contents
Section 1 Scope of Critical Care
1
2
3
4
5
1
Section 2 Principles and Practice of
Critical Care
Scope of Critical Care Practice
Development of critical care nursing
Roles of critical care nurses
Clinical decision making
Leadership in critical care nursing
Developing a body of knowledge
Summary
3
3
6
6
7
11
12
Resourcing Critical Care
Ethical allocation and utilisation of
resources
Historical influences
Economic considerations and principles
Budget
Critical care environment
Equipment
Staff
Risk management
Measures of nursing workload or activity
Management of pandemics
Summary
17
Quality and Safety
Quality and safety monitoring
Patient safety
Summary
38
42
49
52
8
Recovery and Rehabilitation
ICU-acquired weakness
Patient outcomes following a critical illness
Psychological recovery
Rehabilitation and mobility in ICU
Ward-based post-ICU recovery
Recovery after hospital discharge
Summary
57
58
59
61
66
68
68
72
9
Ethical Issues in Critical Care
Principles, rights and the link with law
End-of-life decision making
Brain death
Organ donation
Ethics in research
Summary
78
78
83
88
89
91
96
17
18
19
20
22
22
23
28
30
33
34
6
7
10
Essential Nursing Care of the Critically Ill
Patient
Personal hygiene
Eye care
Oral hygiene
Patient positioning and mobilisation
Bowel management
Urinary catheter care
Bariatric considerations
Infection control in the critical care unit:
general principles
Transport of critically Ill patients: general
principles
Summary
Psychological Care
Anxiety
Delirium
Sedation
Pain
Sleep
Summary
Family and Cultural Care of the Critically Ill
Patient
Overview of models of care
Cultural care
Religious considerations
End-of-life issues and bereavement
Summary
103
105
105
107
109
110
115
116
117
118
123
125
133
133
136
138
141
145
149
156
157
161
170
172
173
Cardiovascular Assessment and Monitoring 180
Related anatomy and physiology
180
Assessment
190
Haemodynamic monitoring
195
Diagnostics
206
Summary
210
Cardiovascular Alterations and Management 215
Coronary heart disease
215
Heart failure
227
Selected cases:
Cardiomyopathy
241
Hypertensive emergencies
242 xv
xvi D E T A I L E D C O N T E N T S
11
12
13
14
15
16
Infective endocarditis
Aortic aneurysm
Ventricular aneurysm
Summary
Cardiac Rhythm Assessment and
Management
The cardiac conduction system
Arrhythmias and arrhythmia management
Cardiac pacing
Cardioversion
Ablation
Summary
243
244
245
245
17
251
251
252
265
280
285
285
18
Cardiac Surgery and Transplantation
Cardiac surgery
Intra-aortic balloon pumping
Heart transplantation
Summary
291
291
302
308
319
Respiratory Assessment and
Measurement
Related anatomy and physiology
Pathophysiology
Assessment
Respiratory monitoring
Bedside and laboratory investigations
Diagnostic procedures
Summary
325
325
333
335
338
341
344
347
Respiratory Alterations and Management
Incidence of respiratory alterations
Respiratory failure
Pneumonia
Respiratory pandemics
Acute lung injury
Asthma and chronic obstructive pulmonary
disease
Pneumothorax
Pulmonary embolism
Lung transplantation
Summary
352
352
353
357
360
362
Ventilation and Oxygenation Management
Oxygen therapy
Airway support
Intubation
Tracheostomy
Complications of endotracheal intubation and
tracheostomy
Tracheal suction
Extubation
Mechanical ventilation
Non-invasive ventilation
Invasive mechanical ventilation
Summary
381
381
383
384
386
Neurological Assessment and Monitoring
Neurological anatomy and physiology
Neurological assessment and monitoring
Summary
414
414
431
440
364
366
367
369
374
387
387
387
388
389
392
404
19
20
21
Neurological Alterations and Management
Neurological therapeutic management
Central nervous system disorders
Selected neurological cases
Summary
Support of Renal Function
Related anatomy and physiology
Pathophysiology and classification of renal
failure
Acute renal failure: clinical and diagnostic
criteria for classification and management
Renal dialysis
Approaches to renal replacement therapy
Summary
Gastrointestinal, Liver and Nutritional
Alterations
Gastrointestinal physiology
Nutrition
Nutrition support
Stress-related mucosal disease
Liver dysfunction
Liver transplantation
Glycaemic control in critical illness
Incidence of diabetes in Australasia
Summary
Management of Shock
Pathophysiology
Patient assessment
Hypovolaemic shock
Cardiogenic shock
Distributive shock states
Anaphylaxis
Neurogenic/spinal shock
Summary
Multiple Organ Dysfunction Syndrome
Pathophysiology
Systemic response
Organ dysfunction
Multiorgan dysfunction
Summary
Section 3 Specialty Practice in
Critical Care
22
Emergency Presentations
Triage
Extended roles
Retrievals and transport of critically ill patients
Multiple patient triage/disaster
Respiratory presentations
Chest pain presentations
Abdominal symptom presentations
Acute stroke
Overdose and poisoning
Near-drowning
Hypothermia
446
450
456
471
473
480
481
484
487
489
492
502
507
507
509
510
514
517
523
526
527
529
540
540
542
543
546
552
555
557
558
563
564
565
568
570
573
579
581
582
586
587
588
589
591
593
594
596
612
614
D E TA I L E D C O N T E N T S
Hyperthermia and heat illness
Summary
615
615
23
Trauma Management
Trauma systems and processes
Common clinical presentations
Summary
623
623
626
649
24
Resuscitation
Pathophysiology
Resuscitation systems and processes
Management
Roles during cardiac arrest
Family presence during an arrest
Ceasing CPR
Postresuscitation phase
Near-death experiences
Legal and ethical considerations
Summary
654
655
655
655
670
670
671
671
671
672
672
Paediatric Considerations in Critical Care
Anatomical and physiological considerations
in children
Developmental considerations
Comfort measures
Family issues and consent
The child experiencing upper airway
obstruction
The child experiencing lower airway disease
Nursing the ventilated child
The child experiencing shock
The child experiencing acute neurological
dysfunction
Gastrointestinal and renal considerations in
children
Paediatric trauma
Summary
679
Pregnancy and Postpartum Considerations
Epidemiology of critical illness in pregnancy
Adapted physiology of pregnancy
Diseases and conditions unique to pregnancy
710
710
711
716
25
26
680
684
685
686
686
691
693
695
696
698
700
702
27
Exacerbation of medical disease associated
with pregnancy
Special considerations
Caring for pregnant women in ICU
Caring for postpartum women in ICU
Summary
Organ Donation and Transplantation
‘Opt-in’ system of donation in Australia and
New Zealand
Types of donor and donation
Organ donation and transplant networks in
Australasia 0
Identification of organ and tissue donors
Organ donor care
Donation after cardiac death
Tissue-only donor
Summary
APPENDIX A1 Declaration of Madrid: Education
APPENDIX A2 Declaration of Buenos Aires:
Workforce
726
729
731
735
738
746
746
747
747
749
755
757
758
758
763
765
APPENDIX A3 Declaration of Vienna
APPENDIX B1 ACCCN Position Statement (2006)
on the Provision of Critical Care Nursing
Education
APPENDIX B2 ACCCN ICU Staffing Position
Statement (2003) on Intensive Care Nursing
Staffing
APPENDIX B3 Position Statement (2006) on the
Use of Healthcare Workers other than Division
1* Registered Nurses in Intensive Care
APPENDIX B4 ACCCN Resuscitation Position
Statement (2006) – Adult & Paediatric
Resuscitation by Nurses
APPENDIX C Normal Values
767
779
780
GLOSSARY
LIST OF FIGURES
INDEX
783
790
799
773
775
777
xvii
Abbreviations
2-PAM pralidoxime
6MWT six-minute walk test
A/C assist control
A/C MV assist-controlled mechanical ventilation
AACN American Association of Critical-care Nurses
AATT aseptic non-touch technique
ABG arterial blood gas
ACCCN Australian College of Critical Care Nurses
ACD active compression–decompression
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
ALT alanine aminotransferase
AMI acute myocardial infarction
AND autonomic nerve dysfunction
ANP atrial natriuretic peptide
ANZBA Australian and New Zealand Burn Association
ANZICS Australian and New Zealand Intensive Care
Society
ANZOD Australia and New Zealand Organ Donation
Registry
AoCLF acute-on-chronic liver failure
xviii AODR Australian Organ Donor Register
AORTIC Australasian Outcomes Research Tool for
Intensive Care
APACHE acute physiology and chronic health evaluation
APC activated protein C
APRV airway pressure release ventilation
aPTT activated partial thromboplastin time
ARAS ascending reticular activating system
ARC Australian Resuscitation Council
ARDS acute respiratory distress syndrome
ARF acute renal failure
ASL arterial spin labelling
AST aspartate aminotransferase
ATC automatic tube compensation
ATCA Australasian Transplant Coordinators Association
ATN acute tubular necrosis
ATP adenosine triphosphate
ATS Australasian Triage Scale
AV arteriovenous
AV atrioventricular
AVDO 2 arteriovenous difference in oxygen
AVM arteriovenous malformation
AVPU Alert/response to Voice/only responds to Pain/
Unconscious
BBB blood–brain barrier
BDI Beck Depression Inventory
BiPAP bilevel positive airway pressure
BiVAD biventricular assist device
BIS bispectral index
BLS basic life support
BMV Bag/mask ventilation
BP blood pressure
BPS Behavioural Pain Scale
BSA body surface area
BSLTx bilateral sequential lung transplantation
BTF Brain Trauma Foundation
BURP Backwards, upwards, rightward pressure
BVM bag–valve–mask
CaO2 content of arterial oxygen in the blood
CABG Coronary artery bypass graft
CAM-ICU Confusion Assessment Method – Intensive Care
Unit
CAP community-acquired pneumonia
CAUTI Catheter associated urinary tract infection
CAV cardiac allograft vasculopathy
CAVH continuous arteriovenous haemofiltration
A B B R E V I AT I O N S
CBF cerebral blood flow
CBG corticosteroid-binding globulin
CCF chronic cardiac failure
CCU critical care unit—may be intensive care, coronary
care, high dependency or a combination of these
CCU coronary care unit
CDSS clinical decision support system
CEO2 cerebral oxygen extraction
CES–D Center for Epidemiologic Studies–Depression
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 bacteremia
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
CO2 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
CPOT Critical Care Pain Observation Tool
CPP cerebral perfusion pressure
CPP coronary perfusion pressure
CPR cardiopulmonary resuscitation
CRASH corticosteroid randomisation after significant head
injury
CRF chronic renal failure
CRH corticotrophin-releasing hormone
CRP c-reactive protein
CRRT continuous renal replacement therapy
CSF cerebrospinal fluid
CSSU central sterile supply unit
CSWS cerebral salt-wasting syndrome
CT computerised tomography
CTG clinical trials group (of ANZICS)
CVC central venous catheter
CVD cardiovascular disease
CvO2 central venous oxygenation
CVP central venous pressure
CVVH continuous veno-venous haemofiltration
CVVHDf continuous veno-venous haemodiafiltration
CXR chest X-ray
DAI diffuse axonal injury
DASS Depression Anxiety and Stress Scale
DAT decision analysis theory
DCD donor after cardiac death
DCM dilated cardiomyopathy
DDAVP 1-deamino-8-D-arginine vasopressin (Vasopressin)
DKA diabetic ketoacidosis
DO2 oxygen delivery
DPL diagnostic peritoneal lavage
DRG diagnosis-related group
DSC (MRI) dynamic susceptibility contrast
DVT deep venous thrombosis
EBI electrical burn injury
EBN evidence based nursing
EBP evidence based practice
EC ethics committee
EC extracorporeal circuit
ECC external cardiac compression
ECG electrocardiograph/y
ECMO extracorporeal membrane oxygenation
ED emergency department
EDD extended daily diafiltration
EDD-f extended daily dialysis filtration
EDIS Emergency Department Information System
EEG electroencephalogram
EGDT early goal-directed therapy
EMD electromechanical dissociation
EMS emergency medical system
EN enteral nutrition
ENID emerging novel infectious disease
EPAP expiratory positive airway pressure
ePD emancipatory practice development
EQ-5D Euroquol 5D
ERC European Resuscitation Council
ESBL-E extended-spectrum beta-lactamase-producing
Enterobacteriaceae
ESLD end stage liver disease
ESLF end-stage liver failure
ETC (o)esophageal–tracheal Combitube
ETCO2 end-tidal carbon dioxide
ETIC-7 experience after treatment in intensive care
ETT endotracheal tube
EVLW extravascular lung water
FAED fully automatic external defibrillator
FAST focused assessment with sonography for trauma
FBC full blood count
FDA (US) Food and Drug Administration
FES fat embolism syndrome
FEV1 forced expiratory volume in 1 second
FFA free fatty acid
xix
xx A B B R E V I A T I O N S
FFP fresh frozen plasma
FI fear index
FiO2 fraction of inspired oxygen
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
HCO3− sodium bicarbonate
H2CO3 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 cannuala(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 heat–moisture exchanger
HPA hypothalamic–pituitary–adrenal
HRC Health Research Council (New Zealand)
HRQOL health-related quality of life
HRS hepatorenal syndrome
HSV herpes simplex virus
HTLV human T-lymphotropic virus
I:E inspiratory:expiratory (ratio)
IABP intra-aortic balloon pump
IAC interposed abdominal compression
IAP intra-abdominal pressure
ICC intercostal catheter
ICD implantable cardioverter defibrillator
ICDSC Intensive Care Delirium Screening Checklist
ICG indocyanine green
ICH intracranial haemorrhage
ICP intracranial pressure
ICT information and communications technologies
ICU intensive care unit
ICU-AW intensive care unit acquired weakness
ICU LN intensive care unit liaison nurse
IDC indwelling catheter
I:E inspiratory:expiratory (ratio)
IES impact of events scale
IgE immunoglobulin E
IHD intermittent haemodialysis
IL interleukin
ILCOR International Liaison Committee on Resuscitation
IMA internal mammary artery
INR International Normalized Ratio
IO intraosseous
IPP information privacy principles
IPPV intermittent positive pressure ventilation
IPT information-processing theory
ISS injury severity score
ITBV intrathoracic total blood volume
IVC inferior vena cava
IVIg intravenous immunoglobulin
JE Japanese B encephalitis
LAD left anterior descending coronary artery
LAP left atrial pressure
LDL low-density lipoprotein
LDLT living donor liver transplantation
LFTs liver function tests
LMA laryngeal mask airway
LN liaison nurse
LOC level of consciousness
LOC loss of consciousness
LP lumbar puncture
LVAD left ventricular assist device
LVEDV left ventricular end-diastolic volume
LVEF left ventricular ejection fraction
LVF left ventricular failure
LVP left ventricular pressure
LVSWI left ventricular stroke work index
MAP mean arterial pressure
MARS molecular adsorbent(s) recirculating system
MASS Motor Activity Assessment Scale
MCA middle cerebral artery
MED manual external defibrillator
MET medical emergency team
MET(s) metabolic equivalent(s)
MEWS medical early-warning system
MIDCAB minimally invasive direct coronary artery bypass
MIDCM minimally invasive direct cardiac massage
mmHg millimetres of mercury
MODS multiple organ dysfunction syndrome
MRI magnetic resonance imaging
MRO Multi-resistant organisms
MRS magnetic resonance spectroscopy
MRSA methicillin-resistant Staphylococcus aureus
MVC motor vehicle collision
MVE Murray Valley encephalitis
NAC N-acetylcysteine
NAS nursing activities scale
NASCIS National Acute Spinal Cord Injury Study
NAT nucleic acid testing
NDE near-death experience
NDU nursing development unit
NE norepinephrine
A B B R E V I AT I O N S
NFκB 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
PaO2 partial pressure of oxygen in arterial blood
Paw peak airway pressure
Pv venous pressure
PAC pulmonary artery catheter
PAF platelet-activating factor
PALS paediatric advanced life support
PaO2 partial pressure of arterial oxygen
PAOP pulmonary artery occlusion pressure
PAP pulmonary artery pressure
PART patient-at-risk team
PAWP pulmonary artery wedge pressure
PbtO2 brain tissue oxygen
PCI percutaneous coronary intervention
PCT dynamic perfusion computed tomography
PCV pressure-controlled ventilation
PCWP pulmonary capillary wedge pressure
PD peritoneal dialysis
PDH pulmonary dynamic hyperinflation
PDR plasma disappearance rate
PDSA plan, do, study, act
PDU practice development unit
PE pulmonary embolism
PEA pulseless electrical activity
PEEP positive end-expiratory pressure
PEFR peak expired flow rate
PET positron emission tomography
PETCO2 positive end-tidal carbon dioxide
pH acid–alkaline logarithmic scale
PI pulsatility index
PICC peripherally inserted central catheter
PiCCO pulse-induced contour cardiac output
PICU paediatric intensive care unit
PN parenteral nutrition
PND paroxysmal nocturnal dyspnoea
PNS peripheral nervous system
Pplat plateau pressure
PPE personal protective equipment
PROWESS (recombinant human-activated) protein C
worldwide evaluation in severe sepsis
PRVC pressure-regulated volume control
PSG Polysomnography
PT prothrombin time
PTA posttraumatic amnesia
PTCA percutaneous transluminal coronary angioplasty
PTSD posttraumatic stress disorder
PTSS posttraumatic stress symptoms
PTT partial thromboplastin time
Pv venous pressure
PvO2 mixed venous oxygen pressure
PVR peripheral vascular resistance
QI quality improvement
QOL quality of life
QOL–IT quality of life–Italian version
QOL–SP quality of life–Spanish version
QUM quality use of medicines
QWB quality of wellbeing
RAAS renin–angiotensin–aldosterone system
RASS Richmond Agitation–Sedation Scale
RAS reticular activating system
RBC red blood cell
RCA root cause analysis
RCA right coronary artery
RCSQ Richards-Campbell Sleep Questionnaire
REM Rapid eye movement
RICA Right Internal Carotid Artery
ROSC return of spontaneous circulation
RRS rapid response system
RR respiratory rate
RRT rapid response teams
RRT renal replacement therapy
RTS revised trauma score
RVF right ventricular failure
RVP right ventricular pressure
RVSWI right ventricular stroke work index
SaO2 saturation of oxygen in arterial blood
SpO2 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)
xxi
xxii A B B R E V I A T I O N S
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 George’s 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
SjvO2 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
STEMI ST-elevation myocardial infarction
SVDK snake venom detection kit
SVG saphenous vein graft
SVR systemic vascular resistance
SVT supraventricular tachycardia
SVV stroke volume variation
SWS Slow wave sleep
TAFI thrombin-activatable fibrinolysis inhibitor
TB tuberculosis
TBI traumatic brain injury
TCD transcranial Doppler
TEG thromboelastograph
TIPS transjugular intrahepatic portosystemic shunt/stent
TISS therapeutic intervention scoring system
TLC total lung capacity
TNF[alpha] tumour necrosis factor alpha
TNS Tumour Necrosis Factor
TOE transoesophageal echocardiograph/y
tPA tissue plasminogen activator
tPD technical practice development
TPN total parenteral nutrition
TPR temperature, pulse, respirations
TSANZ Transplant Society of Australia and
New Zealand
TSC trauma symptom checklist
TSH thyroid-stimulating hormone
TST Total sleep time
TT thrombin time
TV tidal volume
TVI time velocity interval
UEC urea, electrolytes, creatinine
UO urine output
URTI upper respiratory tract infection
V ventilation
V/Q ventilation/perfusion
V T tidal volume
VALI ventilator-associated lung injury
VAP ventilator-acquired pneumonia
VAS Visual analogue scale
VAS-A Visual analogue scale – Anxiety
VC Vital capacity
VC volume-controlled (ventilation)
VCV volume controlled ventilation
VE minute ventilation
VF ventricular fibrillation
VICS Vancouver Interaction and Calmness Scale
VO2 oxygen consumption
VRE vancomycin-resistant Enterococcus
VT ventricular tachycardia
VTE venous thromboembolism
VV veno-venous
WBC white blood cell
WCC white cell count
WFCCN World Federation of Critical Care Nurses
WHO World Health Organization
WOB work of breathing
XeCT xenon-enhanced computed tomography
SECTION
1
Scope of Critical Care
Scope of Critical Care Practice
1
Leanne Aitken
Wendy Chaboyer
Doug Elliott
Learning objectives
After reading this chapter, you should be able to:
● describe the history and development of critical care
nursing practice, education and professional activities
● discuss the influences on the development of critical care
nursing as a discipline and the professional development of
individual nurses
● outline the various roles available to nurses within critical
care areas or in outreach services
● discuss the potential impact of clinical decision-making
processes on patient outcomes
● consider processes in the work and professional
environment that are influenced by local leadership styles.
Key words
critical care nursing
roles of critical care nurses
clinical decision making
clinical leadership
INTRODUCTION
There is unprecedented demand for critical care services
globally. In our region, there are approximately 119,000
admissions to 141 general intensive care units (ICUs)
in Australia per year; this includes 5500 patient readmissions during the same hospital episode. In New
Zealand, there are 18,000 admissions per year to 26 ICUs,
including 500 re-admissions.1 Patients admitted to coronary care, paediatric or other specialty units not classiﬁed
as a general ICU are not included in these ﬁgures, so the
overall clinical activity for ‘critical care’ is much higher
(e.g. there were also 5500 paediatric admissions to
PICUs).1 Importantly, critical care treatment is a highexpense component of hospital care; one conservative
estimate of cost exceeded $A2600 per day, with more
than two-thirds going to staff costs, one ﬁfth to clinical
consumables and the rest to clinical support and capital
expenditure.2
Critical care as a specialty in nursing has developed over
the last 30 years.3,4 Importantly, development of our specialty in Australia and New Zealand has been in concert
with development of intensive care medicine as a deﬁned
clinical specialty. Critical care nursing is deﬁned by the
World Federation of Critical Care Nurses as:
Specialised nursing care of critically ill patients who have manifest or potential disturbances of vital organ functions. Critical
care nursing means assisting, supporting and restoring the
patient towards health, or to ease the patient’s 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 or
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 care
is generally considered a broad term, incorporating
subspecialty areas of emergency, coronary care, highdependency, cardiothoracic, paediatric and general intensive care units.7
This chapter provides a context for subsequent chapters,
outlining some key principles and concepts for studying
and practising nursing in a range of critical care areas. The
scope of critical care nursing is described in the Australian
and New Zealand contexts, which in turn have some
inﬂuence on clinical practice in Southeast Asia and the
Paciﬁc. Development of the specialty is discussed, along
with the professional development and evolving roles of
critical care nurses in contemporary health care, including
clinical decision making and leadership.
DEVELOPMENT OF CRITICAL
CARE NURSING
Critical care as a specialty emerged in the 1950s and
1960s in Australasia, North America, Europe and South
Africa.4,8-11 During these early stages, critical care consisted 3
4 SCOPE OF CRITICAL CARE
primarily of coronary care units for the care of cardiology
patients, cardiothoracic units for the care of postoperative
patients, and general intensive care units for the care of
patients with respiratory compromise. Later developments in renal, metabolic and neurological management
led to the principles and context of critical care that exist
today.
Development of critical care nursing was characterised by
a number of features,4 including:
●
●
●
●
●
the development of a new, comprehensive partnership
between nursing and medical clinicians
the collective experience of a steep learning curve for
nursing and medical staff
the courage to work in an unfamiliar setting, caring
for patients who were extremely sick – a role that
required development of higher levels of competence
and practice
a high demand for education speciﬁc to critical care
practice, which was initially difﬁcult to meet owing to
the absence of experienced nurses in the specialty
the development of technology such as mechanical
ventilators, cardiac monitors, pacemakers deﬁbrillators, dialysers, intra-aortic balloon pumps and cardiac
assist devices, which prompted development of additional knowledge and skills.
There was also recognition that improving patient outcomes through optimal use of this technology was linked
to nurses’ skills and stafﬁng levels.12 The role of adequately educated and experienced nurses in these units
was recognised as essential from an early stage,8 and led
to the development of the nursing specialty of critical care.
Although not initially accepted, nursing expertise, ability
to observe patients and appropriate nursing intensity are
now considered essential elements of critical care.12
As the practice of critical care nursing evolved, so did
the associated areas of critical care nursing education
and specialty professional organisations such as the
Australian College of Critical Care Nurses (ACCCN). The
combination of adequate nurse stafﬁng, observation of
the patient and the expertise of nurses to consider the
complete needs of patients and their families is essential
to optimise the outcomes of critical care. As critical care
continues to evolve, the challenge remains to combine
excellence in nursing care with judicious use of technology to optimise patient and family outcomes.
CRITICAL CARE NURSING EDUCATION
Appropriate preparation of specialist critical care nurses
is a vital component in providing quality care to patients
and their families.5 A central tenet within this framework
of preparation is the formalised education of nurses
to practise in critical care areas.13 Formal education –
in conjunction with experiential learning, continuing
professional development and training, and reﬂective
clinical practice – is required to develop competence in
critical care nursing. The knowledge, skills and attitude
necessary for quality critical care nursing practice have
been articulated in competency statements in many
countries.14-16
Critical care nursing education developed in unison with
the advent of specialist critical care units. Initially, this
consisted of ad-hoc training developed and delivered in
the work setting, with nurses and medical ofﬁcers learning together. For example, medical staff brought expertise
in physiology, pathophysiology and interpretation of
electrocardiographic rhythm strips, while nurses brought
expertise in patient care and how patients behaved and
responded to treatment.12,17 Training was, however, fragmented and ‘ﬁtted in’ around ward stafﬁng needs. Postregistration critical care nursing courses were subsequently
developed from the early 1960s in both Australasia and
the UK.4,8 Courses ranged in length from 6 to 12 months
and generally incorporated employment as well as speciﬁc days for lectures and class work. Given the local
nature of these courses developed for the local needs of
individual hospitals and regions, differences in content
and practice therefore developed between hospitals,
regions and countries.18-20
During the 1990s the majority of these hospital-based
courses in Australasia were discontinued as universities
developed postgraduate curricula to extend the knowledge and skills gained in pre-registration undergraduate
courses. A signiﬁcant proportion of critical care nurses
now undertake specialty education in the tertiary sector,
often in a collaborative relationship with one or more
hospitals.4 One early study of students enrolled in
university-based critical care courses in Australia21 identiﬁed a number of burdens (workload, ﬁnancial, study–
work conﬂicts), but also a number of beneﬁts (e.g. better
job prospects, job security).
Within Australia and New Zealand, most tertiary institutions currently offer postgraduate critical care nursing
education at a Graduate Certiﬁcate or Graduate Diploma
level as preparation for specialty practice, although this
is often provided as a Master’s degree.22 In the UK, similar
provisions for postgraduate critical care nursing education at multiple levels are available, although some
universities also offer critical care specialisation at the
undergraduate level (for example, King’s College,
London). Education throughout Europe has undergone
signiﬁcant change in the past 10 years as the framework
articulated under the Bologna Process has been implemented.23 In relation to critical care nursing, this has led
to the expansion of programs, primarily at the postgraduate level, for specialist nursing education. Critical care
nursing education in the USA maintains a slightly different focus, with most postgraduate studies being generic
in nature, including a focus on advanced practice roles
such as clinical nurse specialists and nurse practitioners,
while specialty education for critical care nurses is undertaken as continuing education.24 Employment in critical
care, with associated assessment of clinical competence,
remains an essential component of many universitybased critical care nursing courses.22,25
Both the impact of post-registration education on practice and the most appropriate level of education that is
required to underpin specialty practice remain controversial, with no universal acceptance internationally.26-29
Globally, the Declaration of Madrid, which was endorsed
Scope of Critical Care Practice
‘beginner’
Induction/
orientation
to critical
care
nursing
Postgraduate
education
‘competent’
‘specialist’
‘expert’
continuing experience/experiential learning
Practice
Training
short courses/skills updates/in-service education
initial competencies
increasing complexity of competencies
Graduate
Certificate
Graduate
Diploma
Education
Masters
FIGURE 1.1 Critical care nursing practice: training and education continuum.
by the World Federation of Critical Care Nurses, provides
a baseline for critical care nursing education (see Appendix A for the position statement).5
A range of factors continue to inﬂuence critical care
nursing education provision, including government policies at national and state levels, funding mechanisms and
resource implications for organisations and individual
students, education provider and healthcare sector partnership arrangements, and tensions between workforce
and professional development needs.13 Recruitment, orientation, training and education of critical care nurses
can be viewed as a continuum of learning, experience and
professional development.5 The relationships between
the various components related to practice, training and
education are illustrated in Figure 1.1, on a continuum
from ‘beginner’ to ‘expert’ and incorporating increasing
complexities of competency. All elements are equally
important in promoting quality critical care nursing
practice. Practice- or skills-based continuing education
sessions support clinical practice at the unit level.30
(Orientation and continuing education issues are discussed further in the context of stafﬁng levels and skills
mix in Chapter 2.)
Many countries now incorporate requirements for continuing professional development into their annual
licensing processes. Speciﬁc requirements include elements such as minimum hours of required professional
development and/or ongoing demonstration of competence against predeﬁned competency standards.31,32
SPECIALIST CRITICAL CARE COMPETENCIES
Critical care nursing involves a range of skills, classiﬁed
as psychomotor (or technical), cognitive or interpersonal.
Performance of speciﬁc skills requires special training and
practice to enable proﬁciency. Clinical competence is
a combination of skills, behaviours and knowledge,
demonstrated by performance within a practice situation33 and speciﬁc to the context in which it is demonstrated.34 A nurse who learns a skill and is assessed as
performing that skill within the clinical environment is
deemed competent. As noted above, a set of competency
statements for specialist critical care practice comprises
20 competency standards grouped into six domains:
professional practice, reﬂective practice, enabling, clinical
problem solving, teamwork and leadership14 (see
Appendix B). The validity of this structure of six domains
has been questioned, however, as a number of competency statements are linked to several domains.35 Further
research is therefore required to reﬁne the structure of a
competency model with improved construct validity.35
Other competency domains and assessment tools have
also been developed.25 Although articulated slightly differently, the American Association of Critical-Care Nurses
(AACN) provides ‘Standards of Practice and Performance
for the Acute and Critical Care Clinical Nurse Specialist’,36
which outlines six standards of practice (assessment,
diagnosis, outcome identiﬁcation, planning, implementation and evaluation) and eight standards of professional performance (quality of care, individual practice
evaluation, education, collegiality, ethics, collaboration,
research and resource utilisation) (see Online resources).
CRITICAL CARE NURSING PROFESSIONAL
ORGANISATIONS
Professional leadership of critical care nursing has undergone considerable development in the past three decades.
Within Australia, the ACCCN (formerly the Confederation of Australian Critical Care Nurses) was formed from
a number of preceding state-based specialty nursing
bodies (e.g. Australian Society of Critical Care Nurses,
Clinical Nurse Specialists Association) that provided professional leadership for critical care nurses since the early
1970s. In New Zealand, the professional interests of critical care nurses are represented by the New Zealand Nurses
Organisation, Critical Care Nurses Section, as well as
afﬁliation with the ACCCN. The ACCCN has strong professional relationships with other national peak nursing
bodies, the Australian and New Zealand Intensive Care
Society (ANZICS), government agencies and individuals,
and healthcare companies.
Professional organisations representing critical care
nurses were formed as early as the 1960s in the USA with
the formation of the American Association of Critical
Care Nurses (AACN).37 Other organisations have developed around the world, with critical care nursing bodies
now operating in countries from Australasia, Asia, North
America, South America, Africa and Europe. In 2001 the
inaugural meeting of the World Federation of Critical
Care Nurses (WFCCN) was formed to provide professional leadership at an international level.38,39 The ACCCN
5
6 SCOPE OF CRITICAL CARE
was a foundation member of the WFCCN and a member
association of the World Federation of Societies of Intensive Care and Critical Care Medicine, and maintains a
representative on the councils of both these international
bodies. (See the ACCCN website, listed in Online resources,
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 care
nurses.40,41 The continuum of critical illness (see Chapter
4) includes pre-crisis/proactive care, management of the
critical illness, and follow-up care in hospital, clinic and
home settings.42 This continuum also includes the practice of palliative care in the ICU environment.43 Clinical
(bedside) roles and nurse-to-patient ratios for various
levels of critical care unit, as well as the roles of unit
manager and clinical nurse educator, are discussed in
Chapter 2. Practice issues for critical care clinicians are
detailed in the remaining chapters of this book. Roles
that apply to all nursing professionals are speciﬁcally
highlighted; for example:
●
●
●
carer, in Chapters 6, 7 and 8, all practice-related
chapters in Section 2, and the specialty chapters in
Section 3
patient and family advocate, in Chapters 5 and 8
educator, in Chapter 3.
This section focuses on the scope of critical care nurses’
roles inside and external to the critical care area, and
provides links to other speciﬁc chapters.44 These roles
include:
●
●
●
consultant45-47
advanced practice48/nurse practitioner roles in ICU,46
trauma,49 emergency50 (Chapter 22), critical care outreach51/ICU liaison52-54 (Chapter 2)
research/quality coordinator (Chapter 3).
Developing a body of knowledge and the integral role of
research and nurse researchers in that process is described
in a later section of this chapter.
CONSULTANT
Expert clinicians in one of the subspecialties of critical
care – emergency, general ICU, cardiology, cardiothoracic,
neurosciences – play important roles in facilitating
improvements in clinical practice for both critical care and
non-critical care patients. The consultant’s role involves
clinical practice, education, quality improvement and
research activities.55 Within these work portfolios, leadership and the development and dissemination of knowledge45,46 within a multidisciplinary team are integral to
effective practice.47 Practice includes role-modelling of
expected behaviours, policy and clinical guideline development to support clinical care, and facilitating professional development of colleagues in collaboration with
the nurse educator role. The beneﬁts that this role brought
to the critical care area led to the introduction of a similar
service for non-critical care areas, particularly in the
context of clinical deterioration of patients or for patients
recently discharged from the ICU, with the development
of critical care outreach or ICU liaison nurse roles (see
Chapter 2 for further discussion of these services).
In practice, the role of clinical consultant and that of an
advanced practice nurse or nurse practitioner can become
blurred, with hospital administrators believing that one
role can replace the other. Clearly, however, the consultant’s role has a broader portfolio, with a focus on
supporting clinical colleagues in providing safe, quality
patient care, while the role of advanced practice nurse or
nurse practitioner has a direct patient care focus (see
below).
ADVANCED PRACTICE NURSE/NURSE
PRACTITIONER
Processes for authorisation to practise as a nurse practitioner (NP) have been introduced by professional registration agencies in Australia and New Zealand, with
similar roles present in the UK and USA prior to this.48
Nurse practitioner roles in ‘critical care’ (or high dependency) range from emergency department practitioners
through to community-based cardiac failure specialists,
and, as noted above for the nurse consultant’s role, often
lack clarity regarding their scope of practice.56,57 Factors
inﬂuencing the establishment of these roles include the
accrediting process, deﬁning the scope of practice through
speciﬁc clinical practice guideline development, prescribing rights and the prevailing medical views, and the level
of support provided by health service administrators for
the implementation, development and evaluation of the
role.48,56 Advanced practice roles in the emergency department are the most well-established in the critical care
domain (see Chapter 22).
CLINICAL DECISION MAKING
Clinical decision making is integral to critical care nursing
practice and forms part of the clinical reasoning process.
Clinical reasoning is
the cognitive processes and strategies that nurses use to understand the signiﬁcance of patient data, to identify and diagnose
actual or potential patient problems, and to make clinical decisions to assist in problem resolution and to achieve positive
patient outcomes.58
Clinical information and prior knowledge are therefore
used to inform a decision. This section focuses on the
decision-making component of clinical reasoning. A brief
overview of the theoretical perspectives that have been
used to understand clinical decision making is provided
and then studies that focus on critical care nursing
are reviewed. Finally, strategies for developing clinical
decision-making skills are provided.
THEORETICAL PERSPECTIVES ON
DECISION MAKING
There are numerous theoretical perspectives on decision
making, but they can be grouped into two main
categories:
1. analytical or rationalist
2. intuitive or humanistic.
Scope of Critical Care Practice
The analytical approaches arise from a positivist or rationalist perspective and focus on analysing behaviours
and the steps involved in problem solving. Some of the
speciﬁc theories that fall into this category include information-processing theory (IPT)59 and decision analysis
theory (DAT).60
Fundamental to IPT is the premise that reasoning consists
of a relationship between the problem solver and the
context within which the problem occurs. This theory
asserts that relevant information is stored in one’s memory
and that problem solving occurs when the problem solver
retrieves information from both short- and long-term
memory. Additionally, IPT claims that there are limits to
the amount of information that can be processed at any
given time. Thus, IPT focuses on understanding how
information is gathered, stored and retrieved. DAT focuses
on the use of decision trees, mathematical formulas and
other techniques to determine the likelihood of meaningful clinical data. These rationalist approaches focus on
diagnosing a problem, intervening and evaluating the
outcome.61
Contrary to the analytical approaches, intuitive approaches
(also termed humanistic, hermeneutic or phenomenological) focus on the importance of intuitive knowledge
and context in clinical decision making.40,62,63 That is,
expert intuition develops with experience and can be
used to make complex decisions. Both intuitive knowledge and analytical reasoning contribute to clinical decisions.63 Intuitive approaches to decision making therefore
focus on understanding the development of intuition, the
role of experience and articulating how nurses use intuition to make a decision. In addition, Australian authors64
have described a naturalistic framework to examine critical care nurses’ decision making, describing it as a way
of considering how people use their experience when
making real-life decisions.
RESEARCH ON DECISION MAKING IN
CRITICAL CARE NURSING
Critical care nursing practice has been the focus of many
studies on decision making. As multiple, complex decisions are made in rapid succession in critical care, it is an
ideal setting for studying clinical decision making.61 The
seminal work by Benner and colleagues40,63,65 focused on
critical care nurses. Table 1.1 summarises 10 studies (11
publications) conducted on critical care nurses’ decision
making over the past decade.
Of note, 7 of the 10 studies were conducted in Australia,
with two multinational studies also including Australia.
All but two studies66,67 used qualitative approaches such
as observation, interviewing and thinking aloud. Two
studies reported the types and frequency of decisions
made during the time period and identiﬁed that critical
care nurses’ decisions were related to interventions and
communication,61,68 evaluation,61 assessment, organisation and education.68 A further study demonstrated that
critical care nurses generate one or more hypotheses
about a situation prior to decision making.69 All three
studies highlighted the importance of enabling expert
nurses to provide a narrative account of their practice.
Other studies indicated that experienced and inexperienced nurses differ in their decision making skills,67,70,71
and that role models or mentors are important in assisting to develop decision making skills.72
RECOMMENDATIONS FOR DEVELOPING
CLINICAL DECISION MAKING SKILLS
Several strategies can be used to help critical care nurses
to develop their clinical decision-making abilities (Table
1.2).73-75 These strategies can be used by nurses at any
level to develop their own decision-making skills, or by
educators in planning educational sessions.
In summary, clinical decision making is a component of
the clinical reasoning process that is part of everyday critical care nursing practice. It involves gathering and analysing information in order to arrive at a decision about a
particular course of action. The analytical or rationalist
perspective of clinical decision making focuses on analysing behaviours and the steps in solving a problem, while
the intuitive or humanistic approach centres on intuitive
knowledge and the context of the decision. In this specialty area nurses are making clinical decisions at a rate
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 case
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 essential 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 given
time and in any speciﬁc setting is a reﬂection of the surrounding environment. Regardless of the setting, effective
leadership involves having and communicating a clear
vision, motivating a team to achieve a common goal,
communicating effectively with others, role modelling,
creating and sustaining the critical elements of a healthy
work environment and implementing change and innovation.76-79 Leadership at the unit and hospital levels is
essential to ensure excellence in practice, as well as adequate clinical governance. In addition to the generic strategies described above, it is essential for leaders in critical
care units and hospitals to demonstrate a patient focus,
establish and maintain standards of practice and collaborate with other members of the multi-disciplinary healthcare team.76
Leadership is essential to achieve the growth and development in our specialty and is demonstrated through such
activities as conducting research, producing publications,
making conference presentations, representation on
relevant government and healthcare councils and committees, and participation in organisations such as the
ACCCN and the WFCCN. As outlined earlier in this
chapter, we have seen the ﬁeld of critical care grow from
early ideas and makeshift units to a well-developed and
7
8 SCOPE OF CRITICAL CARE
TABLE 1.1 Australian and international critical care nurses decision-making research
Author [Country]
Sample
Data collection
18 CC nurses (range of
levels and experiences;
all had completed a CC
course)
Observation (2-hour periods)
Currey & Worrall-Carter,
200168 [Australia]
12 CC nurses with 2+ years’
CC experience from 3
units
Clinical decision record (of
2-hour periods) and focus
groups
Aitken, 200369 [Australia]
8 expert CC nurses with 5+
years’ CC experience
Thinking aloud (2-hour periods)
and follow-up interview
Hypotheses developed as a framework for decision
making
A combination of strategies used to gather data
Currey & Botti, 200670
[Australia]
CC nurses from 2
metropolitan hospitals;
18 inexperienced
(≤3 years) and 20
experienced CC nurses
(>3 years).
Observation followed by
semi-structured interview
Clinical processes that affected decision making
following the settling in phase post cardiac
surgery were:
● handover from anaesthetists
● settling in procedures
● 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
(2006)70 [Same study
as above] [Australia]
Same as above
Observation in 2 phases:
1st phase comprised
unstructured, narrative
observational data; 2nd
phase comprised a 2-page
structured observation
checklist. Followed up by
interview.
Quality of haemodynamic decision making in the 2
hours post cardiac surgery was influenced by
decision complexity, nurses’ level of experience,
and forms of decision support provided by
nursing colleagues.
Experience was a dominant influence in recognising
patterns of haemodynamic cues that were
suggestive of complications.
Adherence to evidence-based practice also
influenced quality of decision making.
Aitken, 2008102 [Australia]
7 CC nurses with a CC
qualification, >5 years
CC experience, and
working ≥2 days/week
Observation and/or thinking
aloud, along with follow-up
interviews
A range of concepts related to the assessment and
management of sedation needs. Assessment
included:
● patient’s condition
● response to therapy
● multiple sources of information during
assessment
● consideration of relevant history
● consideration of the impact on physiology and
pathophysiology
● implications of treatment
● options in treatment.
Hough, 2008103 [USA]
15 CC nurses from 4 units,
with varied experience
and education levels
In-depth, semi-structured
interviews
The presence of a role model or mentor to help
guide the ethical decision-making process,
through reflection-in-action, was critical for
focused ethical discourse and the decision
making.
Enhanced ethical decision making occurred
through experiential learning.
Thompson, 200867
[various countries]
245 Dutch, UK, Canadian
and Australian
registered nurses
working in surgical,
medical, ICU or HDU
Vignettes with decision
whether or not to contact a
senior nurse/doctor. The
proportion of true positives
(the patient is at risk of a
critical event and the nurse
takes action) and false
positives (the nurse takes
action when it was not
warranted) was calculated.
Time pressure significantly reduced the nurses’
decision tendency to intervene.
There were no statistically significant differences in
decision-making ability between years of generic
clinical experience.
There were statistically significant differences in
decision-making ability between years of critical
care experience when participants were not
under time pressure: those with greater critical
care experience performed better.
Under time pressure, there were no differences in
decision-making ability between years of critical
care experience.
Bucknall, 2000
[Australia]
61
Findings
Three types of decision:
evaluation (51%)
● communication (30%)
● intervention (19%)
Average: 238 decisions/2 hours (i.e. 2.0/min)
●
Five types of decision:
intervention (40%)
● communication (26%)
● assessment (19%)
● organisation (13%)
● education (2%)
Average: 395 decisions/2 hours (i.e. 3.3/min)
●
Scope of Critical Care Practice
TABLE 1.1, Continued
Author [Country]
Sample
Data collection
Findings
8 CC nurses: 4 novice and
4 expert
Thinking aloud (during 2-hour
period of care); interview
●
Ramezani-Badr, 2009104
[Iran]
14 CC nurses from 4
hospitals, currently
working in the CCU,
with ≥3 years CC
experience and holding
at least a bachelor of
nursing.
In-depth, semi-structured
interviews
●
Thompson, 200966
[Various countries]
245 Dutch, UK, Canadian
and Australian
registered nurses
working in surgical,
medical, ICU or HDU.
Judgement classification
systems, Continuous (0–100)
ratings or dichotomous
ratings on 3 nursing
judgements were used
Hoffman, 2009
[Australia]
71
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 patient’s
haemodynamic status.
● Expert nurses were more proactive in collecting
relevant cues to anticipate problems and make
decisions.
3 themes were involved in reasoning strategies:
intuition
● recognising similar situations
● hypothesis testing.
3 other themes regarding participants’ criteria to
make decisions:
● patient’s 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).
Critical care experience was associated with
estimates of risk, but not with the decision to
intervene.
Nurses varied considerably in their risk assessments,
this being partly explained by variability in
weightings given to information.
Information was synthesised in non-linear ways that
contributed little to decisional accuracy.
TABLE 1.2 Strategies to develop clinical decision-making skills
Strategy
Description
Iterative hypothesis
testing74
Description of a clinical situation for which the clinician has to generate questions and develop hypotheses; with
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 model74
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
action74
Clinicians are asked to reflect on their actions after a particular event. Reflection focuses on clinical judgments made,
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 aloud74
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 of
half a generation. Such development would not have
been possible without the vision, enthusiasm and commitment of many critical care leaders throughout the
world.
Leadership styles vary and are inﬂuenced by the mission
and values of the organisation as well as the values
and beliefs of individual leaders. These styles of leadership are described in many different ways, sometimes
using theoretical underpinnings such as ‘transactional’
9
10 S C O P E O F C R I T I C A L C A R E
and ‘transformational’ and sometimes by using leadership characteristics. Regardless of the terminology in use,
some common principles can be expressed. Desired
leadership characteristics include the ability to:
●
●
●
●
●
●
●
●
articulate a personal vision and expectations
act as a catalyst for change
establish and implement organisational standards
model effective leadership behaviours through both
change processes and stable contexts
monitor practice in relation to standards and take corrective action when necessary
recognise the characteristics and strengths of individuals, and stimulate individual development and
commitment
empower staff to act independently and
interdependently
inspire team members to achieve excellence.80-85
Personal characteristics of an effective leader, regardless
of the style, include honesty, integrity, commitment and
credibility, as well as the ability to develop an open, trusting environment.85 Effective leaders inspire their team
members to take the extra step towards achieving the
goals articulated by the leader and to feel that they are
valued, independent, responsible and autonomous individuals within the organisation.85 Members of teams with
effective leaders are not satisﬁed with maintaining the
status quo, but believe in the vision and goals articulated
by the leader and are prepared to work towards achieving
a higher standard of practice.
Although all leaders share common characteristics, some
elements vary according to leadership style. Different
styles – for example, transactional, transformational,
authoritative or laissez faire – incorporate different characteristics and activities. Having leaders with different
styles ensures that there is leadership for all stages of an
organisation’s operation or a profession’s development.
A combination of leadership styles also helps to overcome team member preferences and problems experienced when a particularly visionary leader leaves. The
challenges often associated with the departure of a leader
from a healthcare organisation are generally reduced in
the clinical critical care environment, where a nursing
leader is usually part of a multidisciplinary team, with
resultant shared values and objectives.
CLINICAL LEADERSHIP
Effective critical care nurses demonstrate leadership characteristics regardless of their role or level of practice. Leadership in the clinical environment incorporates the
general characteristics listed above, but has the added
challenges of working within the boundaries created by
the requirements of providing safe patient care 24 hours
a day, 7 days a week. It is therefore essential that clinical
leaders work within an effective interdisciplinary model,
so that all aspects of patient care and family support, as
well as the needs of all staff, are met. Effective clinical
leadership of critical care is essential in achieving:
●
●
effective and safe patient care
evidence-based healthcare
●
●
satisﬁed staff, with a high level of retention
development of staff through an effective coaching
and mentoring process.81,86
Effective clinical leaders build cohesive and adaptive
work teams.84 They also promote the intellectual stimulation of individual staff members, which encourages the
analysis and exploration of practice that is essential for
evidence-based nursing.85
Clinical leadership is particularly important in contemporary critical care environments in times of dynamic
change and development. We are currently witnessing
signiﬁcant changes in the organisation and delivery of
care, with the development of new roles such as nurse
practitioner (see this chapter) and liaison nurse (see
Chapter 3), the introduction of services such as rapid
response systems, including medical emergency teams
(see Chapter 3), and the extension of activities across the
care continuum (see Chapter 4). Effective clinical leadership ensures that:
●
●
●
critical care personnel are aware of, and willing to
fulﬁl, their changing roles
personnel in other areas of the hospital or outside the
hospital recognise the beneﬁts and limitations of
developments, are not threatened by the developments and are enthusiastic to use the new or reﬁned
services
patients receive optimal quality of care.
The need to provide educational opportunities to develop
effective clinical leadership skills is recognised.80 Although
not numerous in number or variety, programs are beginning to be available internationally that are designed to
develop clinical leaders.79,87 Factors that inﬂuence leadership ability include the external and internal environment, demographic characteristics such as age, experience,
understanding, stage of personal development including
self-awareness capability, and communication skills.80,82,87
In relation to clinical leadership, these factors can be
developed only in a clinical setting, so development of
clinical leaders must be based in that environment.
Development programs based on mentorship are superbly
suited to developing those that demonstrate potential for
such capabilities.80
Mentorship has received signiﬁcant attention in the
healthcare literature and has been speciﬁcally identiﬁed
as a strategy for clinical leadership development.88-90
Although many different deﬁnitions of mentoring exist,
common principles include a relationship between two
people with the primary purpose of one person in the
relationship developing new skills related to their
career.91,92 Mentoring programs can be either formal or
informal and either internal or external to the work
setting. Mentorship involves a variety of activities directed
towards facilitating new learning experiences for the
mentee, guiding professional development and career
decisions, providing emotional and psychological support
and assisting the mentee in the socialisation process both
within and outside the work organisation to build professional networks.89,91 Role modelling of occupational and
professional skills and characteristics is an important
Scope of Critical Care Practice
1. randomly allocating patients to receive either a
new intervention (the experimental or intervention group) or an alternative or standard intervention (the control group)
2. delivering the intervention or alternative
treatment
3. measuring an a priori identiﬁed patient outcome.
component of mentoring that helps develop future clinical leaders.89,92
DEVELOPING A BODY OF
KNOWLEDGE
Development of a body of knowledge is a key characteristic of both professions93-95 and the specialties within
professions. One criterion for a specialty identiﬁed over
two decades ago by the International Council of Nurses
(ICN)96 is that it is based on a core body of nursing
knowledge that is being continually expanded and reﬁned
by research. Importantly, the ICN acknowledges that
mechanisms are needed to support, review and disseminate research.
RESEARCH
As noted above, research is fundamental in the development of nursing knowledge and practice. Research is a
systematic inquiry using structured methods to understand an issue, solve a problem or reﬁne existing knowledge. Qualitative research involves in-depth examination
of a phenomenon of interest, typically using interviews,
observation or document analysis to build knowledge
and enable depth of understanding. Qualitative data
analysis is in narrative (text) form and involves some form
of content or thematic analysis, with ﬁndings generally
reported as narrative (where words rather than numbers
describe the research ﬁndings). In contrast, quantitative
research involves the measurement (in numeric form) of
variables and the use of statistics to test hypotheses.
Results of quantitative research are often reported in
tables and ﬁgures, identifying statistically signiﬁcant ﬁndings. One particular type of quantitative research, the
clinical trial (randomised controlled trial, or RCT), is used
to test the effect of a new nursing intervention on patient
outcomes. In essence, clinical trials involve:
Statistical analyses are used to determine if the new
intervention is better for patients than the alternative
treatment.
Mixed methods research have now emerged as an
approach that integrates data from qualitative and quantitative research at some stage in the research process.97
In mixed methods approaches, researchers decide on
both priority and sequence of qualitative and quantitative
methods. In terms of priority, equal status may be given
to both approaches. Priority is indicated by using capital
letters for the dominant approach, followed by the
symbols + and → to indicate either concurrent or sequential data collection. For example:
●
●
●
QUAL + QUANT: both approaches are given equal
status and data collection occurs concurrently.
QUAL + quant: qualitative methods are the dominant
approach and data collection occurs concurrently.
QUAL → quant: the qualitative study is given priority
and qualitative data collection will occur before quantitative data collection.
Irrespective of which type of research design is used, there
are a number of common steps in the research process
(Table 1.3), consisting of three phases: planning for the
research, undertaking the research and analysing and
reporting on the research ﬁndings.
Clinical research and the related activities of unit-based
quality improvement are integral components in the
practice, education and research triad.98 Partnerships
TABLE 1.3 Steps in the research process
Step
Description
Identify a clinical
problem or issue.
Clinical experience and practice audits are two ways that clinical issues or problems are identified.
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
question.
A concise question includes both the phenomenon of interest and the patient population.
Write a research
proposal.
Clear description of the proposed research design and sample and a plan for data collection and analysis. Ethical
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 approvals.
Approval of the proposed research by a human research ethics committee (HREC) is required before the study can
commence.
Conduct the research.
Adequate time for recruitment of participants and data collection are crucial to ensure that accurate data are
obtained.
Disseminate the
research findings.
Conference presentations and journal publications are two common ways that research findings are disseminated
and are vital to ensure that both nursing practice and nursing knowledge continue to be developed.
11
12 S C O P E O F C R I T I C A L C A R E
Research program
Practice
issues
Patient
outcomes
Practice
development
Health status/
HRQOL
Clinical information
systems
Competencies
Commonwealth &
state policies
Evidencebased practice
Patient/family
experiences
Product
evaluation
Credentialling
Impact of
international factors
Resource
utilisation
Economic
evaluation
Impact of
technology on
patient care
Program
evaluation
Ethical &
legal issues
Technology
assessment
Education
& training
Policy
issues
FIGURE 1.2 Example of critical care nursing research program.
between clinicians and academics, and the implementation of clinical academic positions, including at the professorial level,99 provide the necessary infrastructure and
organisation for sustainable clinical nursing and multidisciplinary research. A strong research culture in critical
care nursing is evident in Australasia, transcending geographical, epistemological and disciplinary boundaries to
focus on the core business of improving care for critically
ill patients. Our collective aim is to develop a sustainable
research culture that incorporates strategies that facilitate
communication, cooperation, collaboration and coordination both between researchers with common interests
and with clinicians who seek to use research ﬁndings in
their practice. A sample of a guiding structure for a coherent research program that highlights the major issues
affecting critical care nursing practice is illustrated in
Figure 1.2, with identiﬁed themes and topic exemplars.
A number of resources are available to critical care nurses
interested in undertaking research. For example, the
ACCCN provides funding for research on a competitive
basis, with its Research Advisory Panel assessing grant
applications and providing feedback to applicants. The
Intensive Care Foundation, whose members are drawn
from the Australia and New Zealand Intensive Care
Society (ANZICS), the College of Intensive Care Medicine
(CICM) and ACCCN, also has a research funding scheme.
Additionally, the ANZICS Clinical Trials Group (CTG)
holds regular meetings where potential research can be
discussed and research proposals reﬁned. There is great
value in receiving a critical review of proposed research
before the study is undertaken, as assessors’ comments
help to reﬁne the research plan.
Over the years, various groups have identiﬁed priorities
for critical care research. A review of this literature identiﬁed the following research priorities: nutrition support,
infection control, other patient care issues, nursing roles,
stafﬁng and end-of-life decision making.100
While not all nurses are expected to conduct research, it
is a professional responsibility to use research in practice.101 Chapter 3 provides a detailed description of
research utilisation approaches, with a description of
evidence-based practice and the use of evidence-based
clinical practice guidelines. In addition, each chapter in
this text contains a research critique to assist nurses in
developing critical appraisal skills, which will help to
determine whether research evidence should change
practice.
SUMMARY
This chapter has provided a context for subsequent chapters, outlining some key issues, principles and concepts
for studying and practising nursing in a range of critical
care areas. Critical care nursing now encompasses a wide
and ever-expanding scope of practice. The previous focus
on patients in ICU only has given way to a broader
concept of caring for an individual located in a variety 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
today’s healthcare environment. Critical care clinicians
also continue their professional development individually, focusing on clinical practice development, education
and training, and on quality improvement and research
activities, to facilitate quality patient and family care
during a time of acute physiological derangement and
emotional turmoil. The principles of decision making
and clinical leadership at all levels of practice serve to
enhance patient safety in the critical care environment.
ONLINE RESOURCES
American Association of Critical-Care Nurses, www.aacn.org
Annual Scientiﬁc Meeting on Intensive Care, www.intensivecareasm.com.au
Australian College of Critical Care Nurses, www.acccn.com.au
Australia and New Zealand Intensive Care Society, www.anzics.com.au
British Association of Critical Care Nurses, www.baccn.org.uk
College of Intensive Care Medicine, www.cicm.org.au
Intensive Care Foundation (Australia and New Zealand),
www.intensivecareappeal.com
King’s College, London, www.kcl.ac.uk/schools/nursing
World Federation of Critical Care Nurses, http://en.wfccn.org
Scope of Critical Care Practice
Research vignette
Aitken L, Marshall AP, Elliott R, McKinley S. Critical care nurses’ decision making: sedation assessment and management in intensive
care. Journal of Clinical Nursing 2008; 18: 36–45.
Abstract
Aims
This study was designed to examine the decision-making processes that nurses use when assessing and managing sedation for
a critically ill patient, specifically the attributes and concepts used
to determine sedation needs and the influence of a sedation
guideline on the decision-making processes.
Background
Sedation management forms an integral component of the care of
critical care patients. Despite this, there is little understanding of
how nurses make decisions regarding assessment and management of intensive care patients’ sedation requirements. Appropriate nursing assessment and management of sedation therapy is
essential to quality patient care.
Design
Observational study.
Methods
Nurses providing sedation management for a critically ill patient
were observed and asked to think aloud during two separate occasions for two hours of care. Follow-up interviews were conducted
to collect data from five expert critical care nurses pre- and postimplementation of a sedation guideline. Data from all sources were
integrated, with data analysis identifying the type and number of
attributes and concepts used to form decisions.
Results
Attributes and concepts most frequently used related to sedation
and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes
related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes
related to assessment (pre, 58%; post, 65%), physiology (pre, 10%;
post, 9%) and treatment (pre, 31%; post, 26%) aspects of care.
Conclusions
Decision making in this setting is highly complex, incorporating a
wide range of attributes that concentrate primarily on assessment
aspects of care.
Relevance to clinical practice
Clinical guidelines should provide support for strategies known to
positively influence practice. Further, the education of nurses to
use such guidelines optimally must take into account the highly
complex iterative process and wide range of data sources used to
make decisions.
Critique
The study aim was to identify the concepts and attributes used by
Australian critical care nurses in their decision making before and
after the implementation of a nurse-initiated sedation protocol. A
number of educational strategies were used to support implementation of the sedation protocol including: individual and group
education; protocol and its supporting evidence placed on the
intranet; laminated copies of the protocol available in the patient
care areas; poster reminders; and audit and feedback. The aims
of the study were easy to identify and clearly stated, but the inclusion of definitions of attributes and concepts would have been
helpful, because some phrases (such as level of sedation, comfort
and level of consciousness) were labelled as both attribute and
concept.
Three methods of data collection were used: ‘think aloud’, observation and interviews. Specifically, during the think-aloud approach,
nurses wore a collar-mounted microphone attached to an audiorecorder and were asked to verbalise their thought processes
during the data collection period. At the same time, an observer
recorded the activities that the nurses were undertaking while
thinking aloud. A follow-up interview was then undertaken to help
clarify the activities that were observed. Two observers were used
to collect the data. The qualitative nature of the study and the data
collection methods are accepted methods to examine decisionmaking processes. The researchers are to be commended for training the participants in the think-aloud method and for piloting
various forms of observational data collection.
The data from the think-aloud method and the observations
were analysed independently by the data collector who had
collected the data for that particular nurse. As part of this analysis,
the think-aloud, observation and interview data were integrated
for each nurse. The actual analysis involved identifying concepts
and attributes related to three predefined categories: assessment,
physiology and treatment. All analyses were assessed by the chief
investigator and any differences were resolved by consensus.
The sample size – five nurses observed twice each (i.e. before and
after implementation of the sedation protocol) and two nurses
observed once in the pilot study – is appropriate. It is obvious that
a very large amount of data was generated. While selection criteria
were described to identify ‘expert’ nurses, and included the need
to have critical care qualifications and more than five years experience, the fact that they self-nominated as expert means that it is
always possible that some would not have been judged to be
‘expert’ by their peers and superiors. It was not clear, however, how
the data of the two pilot nurses was actually incorporated into the
findings. That is, as their data was only pre-protocol, the reported
number of attributes after protocol was implemented could be
expected to be influenced by two fewer participants. This issue was
not addressed in the report.
The fact that a number of strategies were used to educate the
nurses about the sedation protocol should be applauded, as it is
generally recognised that didactic education is not effective in
getting clinicians to use guidelines with multi-mode strategies, as
in this study. The method used for analysing data – that is, having
the observers analyse the data they collected, and the investigator
also assessing the analysis – is a strength of the study. The researchers note that they integrated the think-aloud, observation and
interview data but do not elaborate how this was done, possibly
because of the word limit imposed by the journal. Anyone interested in how this actually occurred would have to contact the
researchers. In their discussion, the researchers note that they were
not able to determine the path between attributes and concepts
(i.e. which came first) or the actual decision-making methods used.
They note, however, that that they were able to identify relationships between attributes and concepts. They suggest that their
findings can be used by educators when designing educational
activities such as concept mapping to help to develop decisionmaking skills in nurses. The findings were clearly reported, the
table was easy to understand and the discussion considered the
implications of the main findings. Overall, this study provides additional evidence about the concepts and attributes that critical care
nurses draw on when they are making decisions about sedation.
13
14 S C O P E O F C R I T I C A L C A R E
Learning activities
1. Consider the leaders to whom you are exposed in your
work environment and identify the characteristics they
display that influence patient care. Reflect on whether
these are characteristics that you possess or how you might
develop them.
2. Mentors are generally individuals who have excelled in
their chosen profession and who are willing to share their
experiences and expertise with others. Think about your
aspirations in your career as a critical care nurse. With the
help of others, try to identify a potential mentor. Consider
asking this person to meet you on a regular basis to discuss
your professional goals and your strategies to meet these
goals and to provide you with advice.
3. Review the strategies outlined in Table 1.2 and develop
a plan of how you might improve your clinical decisionmaking skills. Approach a mentor in your clinical environment and ask him/her to provide feedback over a period of
months on any changes observed in your clinical decisionmaking skills.
4. Consider the role that you have within critical care and
examine the influence that research has on that role. How
might you use research to inform your practice more effectively? Are there strategies that you could implement to
influence the research that is undertaken so that it meets
your needs?
5. Reflect on your practice in terms of the ACCCN competency
domains14 of professional practice; reflective practice;
enabling; clinical problem solving; teamwork; and leadership. To what extent does your current practice address
these domains? What strategies can you implement to
enhance your practice in these domains?
FURTHER READING
Andrew S, Halcomb EJ. Mixed methods research for nursing and the health sciences.
Oxford: Wiley-Blackwell; 2009.
Thompson C, Dowding D. Essential decision making and clinical judgment for nurses.
Edinburgh: Churchill Livingstone; 2010.
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