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ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
ACCCN's Critical Care Nursing 2e - Elliott
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ACCCN's Critical Care Nursing 2e - Elliott

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Critical care nurses in Australia and New Zealand assume responsibility for total patient management and care across a wide range of acute life-threatening medical and surgical conditions. …

Critical care nurses in Australia and New Zealand assume responsibility for total patient management and care across a wide range of acute life-threatening medical and surgical conditions.

ACCCN's Critical Care Nursing 2e has been fully revised and updated to provide detailed coverage of the specialty areas within critical care nursing including intensive care, emergency nursing, cardiac nursing, neuroscience nursing and acute care. The second edition reflects current clinical practice, policies, procedures and guidelines and encourages students to be reflective practitioners, ethical decision-makers and providers of evidence-based care.

Developed in conjunction with the Australian College of Critical Care Nurses (ACCCN), the text has been revised and edited by the most senior and experienced critical care nursing clinicians and academics across Australia and New Zealand.

http://www.elsevierhealth.com.au/au/product.jsp?sid=&isbn=9780729540681&lid=EHS_ANZ_BS-DIS-4&iid=

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  • 1. ACCCN’s 2nd editionCritical Care Nursing Doug Elliott Q Leanne Aitken Q Wendy Chaboyer
  • 2. ACCCN’S CRITICAL CARE NURSING
  • 3. ACCCN’S CRITICAL CARE NURSING SECOND EDITIONDoug Elliott Leanne Aitken Wendy ChaboyerRN, PhD BAppSc(Nurs), RN, PhD, BHSc(Nurs)Hons, RN, PhD, MN, BSc(Nurs)Hons,MAppSc(Nurs), ICCert, Professor GradCertMgt, CritCareCert Professor & Director,of Nursing, Faculty of Nursing, GradDipScMed(ClinEpi), ICCert, NHMRC Centre of ResearchMidwifery and Health University FRCNA Professor of Critical Care Excellence in Nursing Interventionsof Technology, Sydney, New South Nursing Griffith University & Princess for Hospitalised Patients, GriffithWales Alexandra Hospital Brisbane, Health Institute, Griffith University Queensland Gold Coast, Queensland
  • 4. 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 AustraliaThis publication is copyright. Except as expressly provided in the Copyright Act 1968 andthe Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may bereproduced, stored in any retrieval system or transmitted by any means (includingelectronic, mechanical, microcopying, photocopying, recording or otherwise) without priorwritten permission from the publisher.Every attempt has been made to trace and acknowledge copyright, but in some cases thismay not have been possible. The publisher apologises for any accidental infringement andwould welcome any information to redress the situation.This publication has been carefully reviewed and checked to ensure that the content is asaccurate and current as possible at time of publication. We would recommend, however,that the reader verify any procedures, treatments, drug dosages or legal content describedin this book. Neither the author, the contributors, nor the publisher assume any liabilityfor injury and/or damage to persons or property arising from any error in or omissionfrom this publication.National Library of Australia Cataloguing-in-Publication DataTitle: ACCCN’s critical care nursing / [editors] Doug Elliott, Leanne Aitken and WendyChaboyer.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: 616.028Publisher: Libby HoustonDevelopmental Editor: Elizabeth CoadyPublishing Services Manager: Helena KlijnEditorial Coordinator: Geraldine MintoEdited by Melissa ReadProofread by Tim LearnerIndexed by Cynthia SwansonCover design by Lamond Art & DesignTypeset by Toppan Best-set Premedia LimitedPrinted by ••
  • 5. ContentsForeword vi 12 Cardiac Surgery and Transplantation 291Preface vii Judy Currey, Michael GraanAbout the Australian College of Critical Care Nurses 13 Respiratory Assessment and Monitoring 325 (ACCCN) ix Amanda Corley, Mona RingdalAbout the Editors x 14 Respiratory Alterations and Management 352Contributors xi Maria Murphy, Sharon Wetzig, Judy CurreyReviewers xiiiAcknowledgements xiv 15 Ventilation and Oxygenation Management 381Detailed Contents xv Louise Rose, Gabrielle HanlonAbbreviations xviii 16 Neurological Assessment and Monitoring 414 Di Chamberlain, Leila Kuzmiuk 17 Neurological Alterations and Management 446Section 1 Scope of Critical Care 1 Di Chamberlain, Wendy Corkill 1 Scope of Critical Care Practice 3 18 Support of Renal Function 480 Leanne Aitken, Wendy Chaboyer, Doug Elliott Ian Baldwin, Gavin Leslie 2 Resourcing Critical Care 17 19 Gastrointestinal, Liver and Nutritional Denise Harris, Ged Williams Alterations 507 3 Quality and Safety 38 Andrea Marshall, Teresa Williams, Wendy Chaboyer, Karena Hewson-Conroy Christopher Gordon 4 Recovery and Rehabilitation 57 20 Management of Shock 540 Doug Elliott, Janice Rattray Margherita Murgo, Gavin Leslie 5 Ethical Issues in Critical Care 78 21 Multiple Organ Dysfunction Sydrome 563 Amanda Rischbieth, Julie Benbenishty Melanie Greenwood, Alison Juers Section 3 Specialty Practice in Critical Care 579Section 2 Principles and Practice of Critical Care 103 22 Emergency Presentations 581 David Johnson, Mark Wilson 6 Essential Nursing Care of the Critically Ill Patient 105 23 Trauma Management 623 Bernadette Grealy, Wendy Chaboyer Louise Niggemeyer, Paul Thurman 7 Psychological Care 133 24 Resuscitation 654 Leanne Aitken, Rosalind Elliott Trudy Dwyer, Jennifer Dennett 8 Family and Cultural Care of the Critically 25 Paediatric Considerations in Critical Care 679 Ill Patient 156 Tina Kendrick, Anne-Sylvie Ramelet Marion Mitchell, Denise Wilson, Vicki Wade 26 Pregnancy and Postpartum Considerations 710 9 Cardiovascular Assessment and Monitoring 180 Wendy Pollock, Clare Fitzpatrick Thomas Buckley, Frances Lin 27 Organ Donation and Transplantation 74610 Cardiovascular Alterations and Management 215 Debbie Austen, Elizabeth Skewes Robyn Gallagher, Andrea Driscoll Appendices 76311 Cardiac Rhythm Assessment and Glossary 783 Management 251 Picture Credits 790 Malcolm Dennis, David Glanville Index 793 v
  • 6. Foreword As a specialty area of nursing practice, critical care nursing book reviews essential content related to critical care is focused on the care of patients who are experiencing nursing knowledge and skills to provide care to acutely life-threatening illness. Globally, critical care nurses ill patients and their families. provide care to ensure that critically ill patients and their Internationally, there are more than 500,000 critical care families receive optimal care. This second edition of the nurses, representing one of the largest specialty areas of Australian College of Critical Care Nurses (ACCCN’s) nursing practice. The importance of maintaining knowl- Critical Care Nursing is a valuable resource for critical care edge of best practices, utilising evidence-based approaches, nursing practice. The editors, who are acknowledged and applying research to clinical practice for critical expert practitioners, educators, and researchers in critical care patients remain essential components of critical care, have organised the book into topics covering the care nursing. This second edition of ACCCN’s Critical Care scope of critical care, principles and practice of critical Nursing is a comprehensive resource for critical care care, and specialty practice in critical care. The content nurses seeking to further develop their knowledge and covered in this book, written by established experts in the enhance their clinical practice expertise. field of critical care, provide a comprehensive overview of critical care nursing concepts and practices. The Ruth Kleinpell PhD RN FAAN FCCM book provides up-to-date information on evidence-based Director, Center for Clinical Research and Scholarship practices and the chapters incorporate a variety of educa- Rush University Medical Center; tional resources including website links, case studies and Professor, Rush University College of Nursing; practice tips. Nurse Practitioner, Mercy Hospital & Medical Center ACCCN’s Critical Care Nursing is a beneficial resource for Chicago Illinois, USA critical care nurses, regardless of practice setting. In seeking to provide complex high intensity care, therapies President of World Federation of Critical Care Nurses and interventions, critical care nurses will find that the http://www.wfccn.orgvi
  • 7. PrefaceCritical care as a clinical specialty is over half a century have been included in each chapter to facilitate thisold. With every successive decade, advances in the educa- process.tion and practices of critical care nurses have been made.Today, critical care nurses are some of the most knowl- This second edition is again organised in three broadedgeable and highly skilled nurses in the world, and sections: the scope of critical care nursing, core com-ongoing professional development and education are ponents of critical care nursing, and specialty aspectsfundamental elements in ensuring we deliver the highest of critical care nursing. Inclusion of new chapters andquality care to our patients and their families. significant revisions to existing chapters were based on our reflections and suggestions from colleagues andThis book is intended to encourage and challenge nurses reviewers as well as on evolving and emerging practicesto further develop their critical care nursing practice. Our in critical care.vision for the first edition was for an original text fromAustralasian authors, not an adaptation of texts produced Section 1 introduces a broad range of professional issuesin other parts of the world. This writing approach more related to practice that are relevant across critical care.accurately captures the uniquely local elements that form Initial chapters provide contemporary information oncontemporary critical care nursing in Australia and New the scope of practice, systems and resources, quality andZealand and help to answer the myriad of questions safety, recovery and rehabilitation, and ethical issues.posed by critical care nurses as they practise in the localenvironment, while still allowing the universal core ele- Content presented in the second section is relevant to thements that represent critical care practice internationally. majority of critical care nurses, with a focus on conceptsThis second edition of ACCCN’s Critical Care Nursing has that underpin practice such as essential physical, psycho-27 chapters that reflect the collective talent and expertise logical, social and cultural care. Remaining chapters inof 50 contributors – a strong mix of academics and clini- this section present a systems approach in supportingcians with a passion for critical care nursing – in showcas- physiological function for a critically ill individual. Thising the practice of critical care nursing in Australia, New edition now has multiple linked chapters for some of theZealand, Asia and the Pacific. We also engaged contribu- major physiological systems – 4 chapters for cardiovas-tors beyond Australasia to reflect global practices and to cular, 3 for respiratory, and 2 for neurological. Chaptersextend the applicability of out text to a wider geographic on support of renal function, gastrointestinal, liver andaudience. All contributors were carefully chosen for their nutritional alterations, management of shock, and multi-current knowledge, clinical expertise and strong profes- organ dysfunction complete this section.sional reputations. The third section presents specific clinical conditionsThe book has been developed primarily for use by prac- such as emergency presentations, trauma, resuscitation,tising critical care clinicians, managers, researchers and paediatric considerations, pregnancy and post-partumgraduate students undertaking a specialty critical care considerations, and organ donation, by building on thequalification. In addition, senior undergraduate students principles outlined in Section 2. This section enablesstudying high acuity nursing subjects will find this book readers to explore some of the more complex or uniquea valuable reference tool, although it goes beyond the aspects of specialty critical care nursing practice.learning needs of these students. The aim of the bookis to be a comprehensive resource, as well as a portal Chapters have been organised in a consistent format toto an array of other important resources, for critical ease identification of relevant material. Where appropri-care nurses. The nature and timeline of book publishing ate, each chapter commences with an overview of relevantdictates that the information contained in this book anatomy and physiology, and the epidemiology of thereflects a snapshot in time of our knowledge and under- clinical states in the Australian and New Zealand setting.standing of the complex world of critical care nursing. Nursing care of the patient, both delivered independentlyWe therefore encourage our readers to continue to also or provided collaboratively with other members of thesearch for the most contemporary sources of knowledge healthcare team, is then presented. Pedagogical featuresto guide their clinical practice. A range of website links include a case study that elaborates relevant care issues, vii
  • 8. viii P R E F A C E a critique of a research publication that explores a related The delivery of effective, high-quality critical care nursing topic, and learning activities to assist both the reader and practice is a challenge in contemporary health care. those in educational roles to assess knowledge acquisi- We trust that this book will be a valuable resource in tion. Extensive use of tables, figures and practice tips are supporting your care of critically ill patients and their located throughout each chapter to identify areas of care loved ones. that are particularly pertinent for readers. It is not our intention that readers progress sequentially through the Doug Elliott book, but rather explore chapters or sections that are Leanne Aitken relevant for different episodes of learning or practice. Wendy Chaboyer
  • 9. About the Australian College of Critical Care Nurses (ACCCN)The Australian College of Critical Care Nurses, with over committees. The panel has also developed position2400 members, is the peak professional organisation statements on nurse staffing for intensive care andrepresenting critical care nurses in Australia. Member- high-dependency units in Australia, and annuallyship types include standard membership, international reviews the dataset design for national workforce datamembers, life members, honorary members and corpo- collection in conjunction with ANZICS;rate members. All individual members are eligible and Organ & Tissue Donation & Transplantation Advi-are encouraged to participate in the activities of the sory Panel: advises the board and developed a posi-College; to receive the College journal and Critical Times tion statement on organ donation and transplantationpublication, in addition to discounts for ACCCN confer- as it relates to intensive care. It disseminates relatedence registration and for ACCCN publications. Life and information to critical care nurses regarding the pro-honorary memberships are awarded to individuals in motion and national reform objectives of organ andrecognition of their outstanding contribution to ACCCN tissue donation in Australia;and/or to critical care nursing excellence in Australia. Quality Advisory Panel: provides expert knowledge, advice and information to ACCCN on matters rele-ACCCN is a company limited by guarantee and has vant to critical care nursing practice relating specifi-branches in each state of Australia, with two members cally to patient management.from each state branch management committee forming Paediatric Advisory Panel: provides expert knowl-the ACCCN National Board of Directors. Each committee edge, advice and information to ACCCN on mattersfacilitates the activities of the college at a local/state level relevant to paediatric critical care nursing in additionand provides local and at times national representation. to recommending content and speakers for the annualThe ACCCN Editorial Committee and Editorial Board, ACCCN conferences.under the leadership of the editor of the Australian Critical The ICU Liaison Special Interest Group: is a collec-Care (ACC) journal, are responsible for the College pub- tive group of ACCCN members who have an interestlications including the journal Australian Critical Care and in ICU liaison/outreach and work together to discussnewspaper Critical Times. matters relevant to this increasing area of critical careThere are a number of national advisory panels and nursing focus.special interest groups dedicated to providing the organi- In addition to branch educational events and sympo-sation with expert opinion on issues relating to critical siums, ACCCN conducts three national conferences eachcare nursing. These include: year: ACCCN Institute of Continuing Education (ICE); Resuscitation Advisory Panel: consists of eight and, in conjunction with our medical colleagues from members representing each branch of ACCCN, plus a The Australian and New Zealand Intensive Care Society paediatric nurse representative. It has developed a (ANZICS), the ANZICS/ACCCN Annual Scientific Meeting complete suite of contemporary advanced life support on Intensive Care and the Australian and New Zealand and resuscitation educational material and offers its Paediatric & Neonatal Intensive Care Conference. ACCCN National ALS Courses throughout Australia; ACCCN has a representative on the Australian Resuscita- Research Advisory Panel: in addition to providing tion Council (ARC), and has representation at a federal expert advice to ACCCN, the panel is responsible for government advisory level through the Nursing and Mid- evaluating and making recommendations on research wifery Stakeholder Reference Group (NMSRG) chaired by strategy and grant submissions to ACCCN, and for the Chief Nurse of Australia, and is also a member of the evaluating abstracts submitted to the ANZICS/ACCCN Coalition of National Nursing Organisations (CoNNO). Annual Scientific Meeting on Intensive Care; The founding Chairperson of the World Federation of Education Advisory Panel: advises ACCCN on all Critical Care Nurses (WFCCN) continues to represent matters relating to education specific to critical care ACCCN on the WFCCN Council, and the College also nursing. This panel has developed a position paper on has representatives on the World Federation of Paediatric critical care nursing education and written submis- Intensive and Critical Care Societies, and is a member of sions on behalf of ACCCN to national reviews of the Intensive Care Foundation. nursing education; Workforce Advisory Panel: has represented ACCCN More information can be found on the ACCCN website: on a number of national health workforce and nursing www.acccn.com.au ix
  • 10. About the Editors Doug Elliott decision-making practices of critical care nurses and a Doug Elliott is Professor of Nursing in the Faculty of range of clinical practice issues within critical care and Nursing, Midwifery and Health at the University of Tech- trauma. nology, Sydney. During his 25 years as a nurse academic, Leanne has been active in ACCCN for more than 20 years Doug has been a faculty Director of Research, Clinical and was made a Life Member of the College in 2006 after Professor, Head of Department and a conjoint hospital having held positions on state and national boards, coor- appointment as Assistant Director of Nursing – Research. dinated the Advanced Life Support course in Western Prior to this, he worked as a clinician in acute and critical Australia in its early years, chaired the Education Advisory care areas in tertiary hospitals in Sydney and Perth. Panel and been an Associate Editor with Australian Critical Doug’s clinical and health services research focuses on Care. In addition, she is a peer reviewer for a number of the health-related quality of life (HRQOL) and illness national and international journals and reviews grant experiences of individuals with critical and acute ill- applications for a range of organisations including the nesses, and the use of technologies to improve patient National Health and Medical Research Council (NHMRC) outcomes. Doug has received research funding from the and Intensive Care Foundation. She is the World Federa- NHMRC and the Australian Commission on Safety and tion of Critical Care Nurses’ representative on a number Quality in Health Care, as well as competitive funding of sepsis related working groups including an interna- from other national organisations, health service and uni- tional group who authored a companion paper to the versity funding sources. He has published over 80 peer- Surviving Sepsis Campaign guidelines to summarise the reviewed articles and book chapters, and is co-editor for evidence underpinning nursing care of the septic patient, two additional books, on nursing and midwifery research, the revision of the Surviving Sepsis Campaign Guidelines and pathophysiology and nursing practice. and the Global Sepsis Alliance. Doug became a Life Member of the Australian College of Wendy Chaboyer Critical Care Nurses in 2006 in recognition of over 20 Wendy Chaboyer is a Professor of Nursing at Griffith years of service to critical care. He has previously been an University and the Director of the Centre of Research Associate Editor and on the Editorial Board for Australian Excellence in Nursing Interventions for Hospitalised Critical Care, was the inaugural Chair of the Research Patients, funded by the National Health and Medical Advisory Panel, a member of the Education Advisory Research Council (NHMRC) (2010–2015). Wendy has 30 Panel, and also served on the NSW committee. He is cur- years experience in the critical care area, as a clinician, rently on the Editorial Board for the American Journal of educator and researcher and she is passionate about the Critical Care, and peer-reviews for several critical care contribution nurses can make to a patient’s, and their medicine and nursing journals, and a range of competi- family’s, hospital experience. Her research has focused on tive funding bodies. Doug has been an invited speaker to ICU patients’ transitions and on continuity of care for international and national multi-disciplinary critical care ICU patients. More recently, she has focused on patient meetings on numerous occasions. safety, undertaking research into adverse events after ICU, clinical handover and ‘transforming care at the bedside’. Leanne Aitken Leanne Aitken is Professor of Critical Care Nursing at Wendy has been active in ACCCN since her arrival in Griffith University and Princess Alexandra Hospital, Australia in the early 1990s. She has been a National Queensland. She has a long career in critical care nursing, Board member and member of the Queensland Branch including practice, education and research roles. In all Management Committee. Wendy is a past Chair of the her roles in nursing, Leanne has been inspired by a sense Research Advisory Panel and past Chair of the Quality of enquiry, pride in the value of expert nursing and a Advisory Panel of the ACCCN. Wendy played a role in belief that improvement in practice and resultant patient the formation of the World Federation of Critical Care outcomes is always possible. Research interests include Nurses and continues to support their activities. Wendy developing and refining interventions to improve long reviews for a number of journals and funding bodies suchx term recovery of critically ill and injured patients, as the NHMRC and the Australian Research Council.
  • 11. ContributorsLeanne Aitken RN, PhD, BHSc(Nurs)Hons, Amanda Corley BN, ICU Cert, GradCert Clare FitzpatrickGradCertMgt, GradDipScMed(ClinEpi), HealthSci, M AdvPrac (candidate) Registered Nurse, Registered MidwifeICCert, FRCNA Nurse Researcher BA (Hons)Professor of Critical Care Nursing Critical Care Research Group, The Prince Lead for Critical CareGriffith University & Princess Charles Hospital Liverpool Women’s NHS Foundation TrustAlexandra Hospital Queensland Liverpool, United KingdomBrisbane, Queensland Judy Currey RN BN BN(Hons) Crit Care Robyn Gallagher RN, BA (Psych), MN, PhDDebbie Austen RN, BaHSc, Grad Cert Cert Grad Cert Higher Ed Grad Cert Sc Associate Professor Chronic andCritical Care, Grad Cert Management, (App Stats) PhD Complex CareJP (Qual) Associate Professor in Nursing Faculty of Nursing, Midwifery and HealthRegistered Nurse, Capricorn Coast Hospital Deakin University University of Technology, Sydneyand Health Service Victoria New South WalesQueensland Jennifer Dennett RN, MN, BAppSc David Glanville RN, BN, Grad Dip Crit CareIan Baldwin RN, PhD (Nursing), CritCareCert, Dip Management, Nursing, MNPost Graduate Educator MRCNA Nurse EducatorIntensive Care Unit, Austin Health Nurse Unit Manager Intensive Care UnitVictoria Critical Care, Oncology, Cardiology, Renal Epworth Freemasons Hospital Dialysis, Central Gippsland Health Service East Melbourne, VictoriaJulie Benbenishty MNS VictoriaAcademic Consultant Surgical Division Christopher Gordon RN, MExSc, PhDHadassah Hebrew University Medical Center Malcolm Dennis RN, Bed, CritCareCert(ICU) Senior LecturerJerusalem, Israel Bed Field Technical Specialist Director of Postgraduate Advanced Studies Cardiac Rhythm Management Division, Sydney Nursing School, The UniversityTom Buckley RN(UK), PhD MNRes, BScHlth St Jude Medical of SydneyCertICU, CertTeaching&Assessing New South Wales New South WalesSenior Lecturer and Co-ordinator Masterof Nursing (Clinical Nursing & Nurse Andrea Driscoll RN, CCC, BN, MN, MEd, PhD Michael Graan RN, GradDip CritCarePractitioner) Senior Research Fellow Clinical Nurse Educator (ICU)Sydney Nursing School, The University Monash University, Melbourne Epworth HealthCareof Sydney Victoria Richmond, VictoriaNew South Wales Trudy Dwyer RN, ICU Cert, BHlth, GCert Bernadette Grealy RN, RM, CritCareCert,Wendy Chaboyer RN, BSc (Nu) Hon, FlexLrn, MClinEd, PhD BN, MNMN, PhD Associate Professor Clinical Services Coordinator IntensiveDirector School of Nursing and Midwifery, Faculty of Care UnitNHMRC Centre of Research Excellence in Sciences, Engineering & Health Queen Elizabeth HospitalNursing Interventions for Hospitalised Central Queensland University South AustraliaPatients (NCREN), Research Centre for QueenslandClinical and Community Practice Innovation Melanie Greenwood MN, Grad Cert.(RCCCPI) Doug Elliott RN, PhD BAppSc(Nurs), UniTeach&Learn, ICCert, NeurosciCertGriffith Health Institute MAppSc(Nurs), ICCert Senior Lecturer,Queensland Professor of Nursing School of Nursing and Midwifery Faculty of Nursing, Midwifery and Health University of TasmaniaDiane Chamberlain RN BN BSc MNSc University of Technology Tasmania(Critical Care) MPH PhD Sydney, New South WalesSenior Lecturer Gabrielle Hanlon RN, Crit Care Cert, BN,Flinders University Rosalind Elliott RN, BSc (Hons), PG Dip GDBL, MRCNASouth Australia (Crit Care), MN Project Manager PhD candidate Australian Commission on Safety & QualityWendy Corkill RN University of Technology Sydney in Health CareClinical Nurse Specialist New South Wales New South WalesAlice Springs HospitalNorthern Territory xi
  • 12. xii C O N T R I B U T O R S Denise Harris RN, BHSc(Nurs), Marion Mitchell RN, BN (Hon), Grad Cert Louise Rose BN, MN, PhD, ICU Cert GradDipHlthAdmin& InfoSys, (Higher Educ), Ph.D. Assistant Professor MN(Res), ICCert Senior Research Fellow Critical Care Lawrence S. Bloomberg Faculty of Nursing, Assistant Director of Nursing—Medicine & Griffith University and Princess University of Toronto Critical Care Alexandra Hospital Research Director and Advanced Practice The Tweed Hospital Queensland Nurse, Prolonged-ventilation Weaning Tweed Heads, New South Wales Centre, Toronto East General Hospital, Margherita Murgo BN, MN (Crit Care) Toronto Karena Hewson-Conroy BSocSci(Hons), Project Officer Ontario, Canada PhD candidate Clinical Excellence Commission Research & Quality Manager, Intensive Care New South Wales Elizabeth Skewes DAppSc(Nursing), CCRN Co-ordination & Monitoring Unit Senior Nurse of Organ and Tissue Donation Honorary Associate, Faculty of Nursing, Maria Murphy RN PhD, Grad Dip Crit Care, St Vincent’s Hospital Midwifery & Health, University of Grad Cert Tert Ed, BN, Dip App Sci (Nursing) Victoria Technology Lecturer New South Wales LaTrobe University Paul Thurman RN, MS, ACNPC, CCNS, Clinical Nurse Specialist CCRN, CNRN David Johnson RN, Grad Dip (Acute Care Austin Health Clinical Nurse Specialist Nurs), MHealth Sci Ed, A&E Cert, MCN Victoria R Adams Cowley Shock Trauma Center Director of Nursing University of Maryland Medical Center Caloundra Health Service Louise E Niggemeyer RN, MEd, BEdSt, Baltimore, Maryland, USA Sunshine Coast Wide Bay Health IC Cert, MRCNA Service District Trauma Program Manager Vicki Wade Dip Nsg, BHSc, MN Queensland The Alfred Hospital Leader Senior Researcher National Aboriginal Health Unit Alison Juers RN, BN (Dist), MN (Crit Care) Trauma Systems & Education Consultant Heart Foundation Australia Nurse Educator National Trauma Research Institute Brisbane Private Hospital Alfred Health Sharon Wetzig RN, BN, Grad Cert Queensland Victoria (Critical Care), MEd Clinical Nurse Consultant Tina Kendrick RN, PIC Cert, BNurs(Hons), Wendy Pollock RN, RM, Grad Dip Crit Princess Alexandra Hospital MNurs, FCN, FRCNA Care Nsg, Grad Dip Ed, Grad Cert Adv Queensland Clinical Nurse Consultant – Paediatrics Learn & Leadership, NSW Newborn and Paediatric Emergency PhD Research Fellow Ged Williams RN, RM, CritCareCert, MHA, Transport Service La Trobe University/Mercy Hospital LLM, FACHSM, FRCNA, FAAN New South Wales for Women Executive Director of Nursing and Midwifery Victoria Gold Coast Health Service District Leila Kuzmuik RN, BN, DipAdvClinNurs, MN, Professor of Nursing, Griffith University Grad Cert HlthServMgt Anne-Sylvie Ramelet RN, ICU Cert, PhD Founding President, World Federation of Nurse Educator Senior Lecturer Critical Care Nurses Intensive Care Services Institute of Higher Education and Queensland John Hunter Hospital, Hunter New Nursing Research England Health Lausanne University-Centre Hospitalier Teresa Williams RN, ICUCert, BN, MHlthSci New South Wales Universitaire Vaudois, Switzerland (Res), GradDipClinEpi, PhD Professor, HECVSanté Research Assistant Professor and NH&MRC Gavin D Leslie RN, IC Cert, PhD, BAppSc, University of Applied Sciences Clinical Research Postdoctoral Fellow Post Grad Dip (Clin Nurs), FRCNA Western Switzerland Discipline of Emergency Medicine (SPARHC) Professor Critical Care Nursing Switzerland The University of Western Australia Royal Perth Hospital Western Australia Director Research & Development Janice Rattray PhD, MN, DipN (CT), School of Nursing & Midwifery, RGN, SCM Denise Wilson PhD, RN, FCNA(NZ) Curtin University Reader Associate Professor Māori Health Western Australia School of Nursing and Midwifery Auckland University of Technology University of Dundee Auckland, New Zealand Frances Lin RN, BMN, MN (Hons), PhD United Kingdom Lecturer & Program Convenor (Master of Mark Wilson DipAppSc (Nursing), Nursing – Critical Care) Mona Ringdal RN, PhD, MSc GDipClPrac (Emergency Nursing), MHScEd School of Nursing and Midwifery Senior Lecturer Emergency Department Nurse Educator Griffith University Institute of Health and Care Sciences Illawarra Shoalhaven Local Health District Queensland The Sahlgrenska Academy, University New South Wales of Gothenburg Andrea Marshall RN PhD Sweden Sesqui Senior Lecturer Critical Care Nursing Sydney Nursing School Amanda Rischbieth RN, Grad Dip (Intens University of Sydney Care), MNSc, PhD New South Wales School of Nursing University of Adelaide South Australia
  • 13. ReviewersSteven Frost RN, MPH Holly Northam RN, RM, M Critical Care NursingLecturer, School of Nursing and Midwifery Assistant Professor of Critical Care NursingUniversity of Western Sydney University of CanberraNew South Wales Australian Capital TerritoryMelanie Greenwood MN, Grad Cert. UniTeach&Learn, Jon Mould PhD candidate, MSc, RGN, RSCN, RMN, Adult Cert EdICCert, NeurosciCert Senior LecturerSenior Lecturer Edith Cowan UniversitySchool of Nursing and Midwifery Western AustraliaUniversity of TasmaniaTasmania Helena Sanderson RN, BHSc, ICU Cert, MN(Advanced Clinical Education)Nichole Harvey RN, EM, CritCareCert, BN (Post Reg), MNSt, Lecturer in NursingGradCertEd (TT), PhD Candidate School of HealthSenior Lecturer University of New EnglandSchool of Medicine and Dentistry Armidale, New South WalesJames Cook UniversityQueensland Natashia Scully RN, BA, BN, PGDipNSc(Critical Care), MPH(Candidate)Ann Kuypers RN, Med Grad Dip(Clin Ed), Grad Cert (Periop) Lecturer in NursingLecturer Nursing School of HealthAcademic Language and Learning Unit University of New EnglandLaTrobe University, Albury Wodonga Campus Armidale, New South WalesVictoria Kerry Southerland RN, ICCert, BSc, MCN, GCTT, MRCNARenee McGill MN, Grad Cert Crit Care, BS(Nurs) LecturerLecturer in Nursing, Academic Advisor School of Nursing & MidwiferySchool of Nursing, Midwifery and Indigenous Health Curtin UniversityCharles Sturt University Western AustraliaNew South Wales Peter Thomas RN, BSc, GradDipEd, PhDStephen McNally RN, BApp Sc (Nursing), PhD LecturerLecturer, Head of Program School of Nursing, Midwifery & Indigenous HealthUniversity of Western Sydney University of WollongongNew South Wales New South Wales xiii
  • 14. Acknowledgements A project of this nature and scope requires many talented the staff at Elsevier Australia, our publishing partner. and committed people to see it to completion. The deci- Thanks to our Publishing Editor Libby Houston, for sion to publish this second edition was supported enthu- guiding this major project; our Developmental Editors siastically by the Board of the Australian College of – initially Larissa Norrie, and then Elizabeth Coady for Critical Care Nurses (ACCCN) and Elsevier Australia. To the majority of the project; and to Melissa Read our our chapter contributors for this edition, both those editor. In Publishing Services, Geraldine Minto, thanks returning from the first edition and our new collabora- for your work with typesetting issues. To others who pro- tors – thank you for accepting our offer to write, for duced the high quality figures, developed and executed having the courage and confidence in yourselves and us the marketing plan, and the myriad of other activities, to be involved in the text, and for being committed in without which a text such as this would never come to meeting writing deadlines while developing the depth fruition, thank you. We acknowledge our external review- and quality of content that we had planned. We also ers who devoted their time to provide insightful sugges- acknowledge the work of chapter contributors from tions in improving the text and contributed to the quality our first edition – Harriet Adamson, Susan Bailey, of the finished product. Martin Boyle, Sidney Cuthbertson, Suzana Dimovski, Finally, and most importantly, to our respective loved Bruce Dowd, Ruth Endacott, Paul Fulbrook, ones – Maureen, Kate, Nick and Josh; Steve; and Michael Michelle Kelly, Bridie Kent, Anne Morrison, Wendy – thanks for your belief in us, and your understanding Swope and Jane Treloggen. and commitment in supporting our careers. Continued encouragement and support from the Board and members of ACCCN, for having the belief in us as Doug Elliott editors and authors to uphold the values of the College, Leanne Aitken is much appreciated. We also acknowledge support from Wendy Chaboyerxiv
  • 15. Detailed ContentsSection 1 Scope of Critical Care 1 Section 2 Principles and Practice of Critical Care 103 1 Scope of Critical Care Practice 3 Development of critical care nursing 3 6 Essential Nursing Care of the Critically Ill Roles of critical care nurses 6 Patient 105 Clinical decision making 6 Personal hygiene 105 Leadership in critical care nursing 7 Eye care 107 Developing a body of knowledge 11 Oral hygiene 109 Summary 12 Patient positioning and mobilisation 110 Bowel management 115 2 Resourcing Critical Care 17 Urinary catheter care 116 Ethical allocation and utilisation of Bariatric considerations 117 resources 17 Infection control in the critical care unit: Historical influences 18 general principles 118 Economic considerations and principles 19 Transport of critically Ill patients: general Budget 20 principles 123 Critical care environment 22 Summary 125 Equipment 22 Staff 23 7 Psychological Care 133 Risk management 28 Anxiety 133 Measures of nursing workload or activity 30 Delirium 136 Management of pandemics 33 Sedation 138 Summary 34 Pain 141 Sleep 145 3 Quality and Safety 38 Summary 149 Quality and safety monitoring 42 8 Family and Cultural Care of the Critically Ill Patient safety 49 Patient 156 Summary 52 Overview of models of care 157 Cultural care 161 4 Recovery and Rehabilitation 57 Religious considerations 170 ICU-acquired weakness 58 End-of-life issues and bereavement 172 Patient outcomes following a critical illness 59 Summary 173 Psychological recovery 61 9 Cardiovascular Assessment and Monitoring 180 Rehabilitation and mobility in ICU 66 Related anatomy and physiology 180 Ward-based post-ICU recovery 68 Assessment 190 Recovery after hospital discharge 68 Haemodynamic monitoring 195 Summary 72 Diagnostics 206 5 Ethical Issues in Critical Care 78 Summary 210 Principles, rights and the link with law 78 10 Cardiovascular Alterations and Management 215 End-of-life decision making 83 Coronary heart disease 215 Brain death 88 Heart failure 227 Organ donation 89 Selected cases: Ethics in research 91 Cardiomyopathy 241 Summary 96 Hypertensive emergencies 242 xv
  • 16. xvi D E T A I L E D C O N T E N T S Infective endocarditis 243 17 Neurological Alterations and Management 446 Aortic aneurysm 244 Neurological therapeutic management 450 Ventricular aneurysm 245 Central nervous system disorders 456 Summary 245 Selected neurological cases 471 11 Cardiac Rhythm Assessment and Summary 473 Management 251 18 Support of Renal Function 480 The cardiac conduction system 251 Related anatomy and physiology 481 Arrhythmias and arrhythmia management 252 Pathophysiology and classification of renal Cardiac pacing 265 failure 484 Cardioversion 280 Acute renal failure: clinical and diagnostic Ablation 285 criteria for classification and management 487 Summary 285 Renal dialysis 489 12 Cardiac Surgery and Transplantation 291 Approaches to renal replacement therapy 492 Cardiac surgery 291 Summary 502 Intra-aortic balloon pumping 302 19 Gastrointestinal, Liver and Nutritional Heart transplantation 308 Alterations 507 Summary 319 Gastrointestinal physiology 507 13 Respiratory Assessment and Nutrition 509 Measurement 325 Nutrition support 510 Related anatomy and physiology 325 Stress-related mucosal disease 514 Pathophysiology 333 Liver dysfunction 517 Assessment 335 Liver transplantation 523 Respiratory monitoring 338 Glycaemic control in critical illness 526 Bedside and laboratory investigations 341 Incidence of diabetes in Australasia 527 Diagnostic procedures 344 Summary 529 Summary 347 20 Management of Shock 540 Pathophysiology 540 14 Respiratory Alterations and Management 352 Patient assessment 542 Incidence of respiratory alterations 352 Hypovolaemic shock 543 Respiratory failure 353 Cardiogenic shock 546 Pneumonia 357 Distributive shock states 552 Respiratory pandemics 360 Anaphylaxis 555 Acute lung injury 362 Neurogenic/spinal shock 557 Asthma and chronic obstructive pulmonary Summary 558 disease 364 Pneumothorax 366 21 Multiple Organ Dysfunction Syndrome 563 Pulmonary embolism 367 Pathophysiology 564 Lung transplantation 369 Systemic response 565 Summary 374 Organ dysfunction 568 Multiorgan dysfunction 570 15 Ventilation and Oxygenation Management 381 Summary 573 Oxygen therapy 381 Airway support 383 Intubation 384 Section 3 Specialty Practice in Tracheostomy 386 Critical Care 579 Complications of endotracheal intubation and 22 Emergency Presentations 581 tracheostomy 387 Triage 582 Tracheal suction 387 Extended roles 586 Extubation 387 Retrievals and transport of critically ill patients 587 Mechanical ventilation 388 Multiple patient triage/disaster 588 Non-invasive ventilation 389 Respiratory presentations 589 Invasive mechanical ventilation 392 Chest pain presentations 591 Summary 404 Abdominal symptom presentations 593 16 Neurological Assessment and Monitoring 414 Acute stroke 594 Neurological anatomy and physiology 414 Overdose and poisoning 596 Neurological assessment and monitoring 431 Near-drowning 612 Summary 440 Hypothermia 614
  • 17. D E TA I L E D C O N T E N T S xvii Hyperthermia and heat illness 615 Exacerbation of medical disease associated Summary 615 with pregnancy 726 Special considerations 72923 Trauma Management 623 Caring for pregnant women in ICU 731 Trauma systems and processes 623 Caring for postpartum women in ICU 735 Common clinical presentations 626 Summary 738 Summary 649 27 Organ Donation and Transplantation 74624 Resuscitation 654 ‘Opt-in’ system of donation in Australia and Pathophysiology 655 New Zealand 746 Resuscitation systems and processes 655 Types of donor and donation 747 Management 655 Organ donation and transplant networks in Roles during cardiac arrest 670 Australasia 0 747 Family presence during an arrest 670 Identification of organ and tissue donors 749 Ceasing CPR 671 Organ donor care 755 Postresuscitation phase 671 Donation after cardiac death 757 Near-death experiences 671 Tissue-only donor 758 Legal and ethical considerations 672 Summary 758 Summary 672 APPENDIX A1 Declaration of Madrid: Education 76325 Paediatric Considerations in Critical Care 679 APPENDIX A2 Declaration of Buenos Aires: Anatomical and physiological considerations Workforce 765 in children 680 APPENDIX A3 Declaration of Vienna 767 Developmental considerations 684 Comfort measures 685 APPENDIX B1 ACCCN Position Statement (2006) Family issues and consent 686 on the Provision of Critical Care Nursing The child experiencing upper airway Education 773 obstruction 686 APPENDIX B2 ACCCN ICU Staffing Position The child experiencing lower airway disease 691 Statement (2003) on Intensive Care Nursing Nursing the ventilated child 693 Staffing 775 The child experiencing shock 695 APPENDIX B3 Position Statement (2006) on the The child experiencing acute neurological Use of Healthcare Workers other than Division dysfunction 696 1* Registered Nurses in Intensive Care 777 Gastrointestinal and renal considerations in APPENDIX B4 ACCCN Resuscitation Position children 698 Statement (2006) – Adult & Paediatric Paediatric trauma 700 Resuscitation by Nurses 779 Summary 702 APPENDIX C Normal Values 78026 Pregnancy and Postpartum Considerations 710 GLOSSARY 783 Epidemiology of critical illness in pregnancy 710 Adapted physiology of pregnancy 711 LIST OF FIGURES 790 Diseases and conditions unique to pregnancy 716 INDEX 799
  • 18. Abbreviations 2-PAM pralidoxime AORTIC Australasian Outcomes Research Tool for 6MWT six-minute walk test Intensive Care A/C assist control APACHE acute physiology and chronic health evaluation A/C MV assist-controlled mechanical ventilation APC activated protein C AACN American Association of Critical-care Nurses APRV airway pressure release ventilation AATT aseptic non-touch technique aPTT activated partial thromboplastin time ABG arterial blood gas ARAS ascending reticular activating system ACCCN Australian College of Critical Care Nurses ARC Australian Resuscitation Council ACD active compression–decompression ARDS acute respiratory distress syndrome ACE angiotensin-converting enzyme ARF acute renal failure ACEM Australasian College of Emergency Medicine ASL arterial spin labelling ACh acetylcholine AST aspartate aminotransferase AChE acetylcholinesterase ATC automatic tube compensation ACN advanced clinical nurse ATCA Australasian Transplant Coordinators Association ACNP acute care nurse practitioner ATN acute tubular necrosis ACS acute coronary syndrome ATP adenosine triphosphate ACS abdominal compartment syndrome ATS Australasian Triage Scale ACT activated clotting time AV arteriovenous ACTH adrenocorticotrophic hormone AV atrioventricular ADAPT Australasian Donor Awareness Program Training AVDO 2 arteriovenous difference in oxygen ADE adverse drug event AVM arteriovenous malformation ADH antidiuretic hormone AVPU Alert/response to Voice/only responds to Pain/ ADL activities of daily living Unconscious ADP adenosine diphosphate BBB blood–brain barrier AE adverse event BDI Beck Depression Inventory AED automatic external defibrillator BiPAP bilevel positive airway pressure AHA American Heart Association BiVAD biventricular assist device AHEC Australian Health Ethics Committee BIS bispectral index AIS abbreviated injury score BLS basic life support AKI acute kidney infection BMV Bag/mask ventilation ALF acute liver failure BP blood pressure ALI acute lung injury BPS Behavioural Pain Scale ALP alkaline phosphatase BSA body surface area ALS advanced life support BSLTx bilateral sequential lung transplantation ALT alanine aminotransferase BTF Brain Trauma Foundation AMI acute myocardial infarction BURP Backwards, upwards, rightward pressure AND autonomic nerve dysfunction BVM bag–valve–mask ANP atrial natriuretic peptide CaO2 content of arterial oxygen in the blood ANZBA Australian and New Zealand Burn Association CABG Coronary artery bypass graft ANZICS Australian and New Zealand Intensive Care CAM-ICU Confusion Assessment Method – Intensive Care Society Unit ANZOD Australia and New Zealand Organ Donation CAP community-acquired pneumonia Registry CAUTI Catheter associated urinary tract infection AoCLF acute-on-chronic liver failure CAV cardiac allograft vasculopathyxviii AODR Australian Organ Donor Register CAVH continuous arteriovenous haemofiltration
  • 19. A B B R E V I AT I O N S xixCBF cerebral blood flow CVC central venous catheterCBG corticosteroid-binding globulin CVD cardiovascular diseaseCCF chronic cardiac failure CvO2 central venous oxygenationCCU critical care unit—may be intensive care, coronary CVP central venous pressure care, high dependency or a combination of these CVVH continuous veno-venous haemofiltrationCCU coronary care unit CVVHDf continuous veno-venous haemodiafiltrationCDSS clinical decision support system CXR chest X-rayCEO2 cerebral oxygen extraction DAI diffuse axonal injuryCES–D Center for Epidemiologic Studies–Depression DASS Depression Anxiety and Stress ScaleCFI cardiac function index DAT decision analysis theoryCFM cerebral function monitoring DCD donor after cardiac deathCHD coronary heart disease DCM dilated cardiomyopathyCHF chronic heart failure DDAVP 1-deamino-8-D-arginine vasopressin (Vasopressin)CI cardiac index DKA diabetic ketoacidosisCI critical illness DO2 oxygen deliveryCIM critical illness myopathy DPL diagnostic peritoneal lavageCINM critical illness neuromyopathy DRG diagnosis-related groupCIP critical illness polyneuropathy DSC (MRI) dynamic susceptibility contrastCIPNP critical illness polyneuropathy DVT deep venous thrombosisCIS clinical information system EBI electrical burn injuryCK creatine kinase EBN evidence based nursingCLAB Central line associated bacteremia EBP evidence based practiceCLD chronic liver disease EC ethics committeeCLF chronic liver failure EC extracorporeal circuitcLMA classic laryngeal mask airway ECC external cardiac compressionCLRT continuous lateral rotation therapy ECG electrocardiograph/yCMV controlled mechanical ventilation ECMO extracorporeal membrane oxygenationCMV cytomegalovirus ED emergency departmentCNE clinical nurse educator EDD extended daily diafiltrationCNPI checklist of nonverbal pain Indicators EDD-f extended daily dialysis filtrationCNS central nervous system EDIS Emergency Department Information SystemCO carbon monoxide EEG electroencephalogramCO cardiac output EGDT early goal-directed therapyCO2 carbon dioxide EMD electromechanical dissociationCOAD chronic obstructive airways disease EMS emergency medical systemCOPD Chronic Obstructive pulmonary disease EN enteral nutritionCPAP continuous positive airway pressure ENID emerging novel infectious diseaseCPB cardiopulmonary bypass EPAP expiratory positive airway pressureCPDU clinical practice development unit ePD emancipatory practice developmentCPG clinical practice guideline EQ-5D Euroquol 5DCPM cuff pressure monitoring ERC European Resuscitation CouncilCPOE computerised physician (provider) order entry ESBL-E extended-spectrum beta-lactamase-producingCPOT Critical Care Pain Observation Tool EnterobacteriaceaeCPP cerebral perfusion pressure ESLD end stage liver diseaseCPP coronary perfusion pressure ESLF end-stage liver failureCPR cardiopulmonary resuscitation ETC (o)esophageal–tracheal CombitubeCRASH corticosteroid randomisation after significant head ETCO2 end-tidal carbon dioxide injury ETIC-7 experience after treatment in intensive careCRF chronic renal failure ETT endotracheal tubeCRH corticotrophin-releasing hormone EVLW extravascular lung waterCRP c-reactive protein FAED fully automatic external defibrillatorCRRT continuous renal replacement therapy FAST focused assessment with sonography for traumaCSF cerebrospinal fluid FBC full blood countCSSU central sterile supply unit FDA (US) Food and Drug AdministrationCSWS cerebral salt-wasting syndrome FES fat embolism syndromeCT computerised tomography FEV1 forced expiratory volume in 1 secondCTG clinical trials group (of ANZICS) FFA free fatty acid
  • 20. xx A B B R E V I A T I O N S FFP fresh frozen plasma IES impact of events scale FI fear index IgE immunoglobulin E FiO2 fraction of inspired oxygen IHD intermittent haemodialysis fMRI functional magnetic resonance imaging IL interleukin FRC functional residual capacity ILCOR International Liaison Committee on Resuscitation FTE full-time equivalent (equivalent to 76-hour fortnight) IMA internal mammary artery FVC forced vital capacity INR International Normalized Ratio FWR family witness resuscitation IO intraosseous GABA gamma-aminobutyric acid IPP information privacy principles GAS general adaptation syndrome IPPV intermittent positive pressure ventilation GCS Glasgow Coma Scale IPT information-processing theory GEDV global end-diastolic volume ISS injury severity score GGT gamma-glutamyl transpeptidase ITBV intrathoracic total blood volume GI gastrointestinal IVC inferior vena cava GIT gastrointestinal tract IVIg intravenous immunoglobulin GM1 monosialoganglioside JE Japanese B encephalitis GTN glyceryl trinitrate LAD left anterior descending coronary artery HCO3− sodium bicarbonate LAP left atrial pressure H2CO3 carbonic acid LDL low-density lipoprotein H+ hydrogen LDLT living donor liver transplantation HADS hospital anxiety and depression scale LFTs liver function tests HAI Healthcare acquired infection LMA laryngeal mask airway Hb haemoglobin LN liaison nurse HbF fetal haemoglobin LOC level of consciousness HCM hypertrophic cardiomyopathy LOC loss of consciousness HDU high-dependency unit LP lumbar puncture HE hepatic encephalopathy LVAD left ventricular assist device HFA Heart Foundation Australia LVEDV left ventricular end-diastolic volume HFNC high flow nasal cannuala(e) LVEF left ventricular ejection fraction HFOV high-frequency oscillatory ventilation LVF left ventricular failure HH heated humidification LVP left ventricular pressure HHNS hyperglycaemic hyperosmolar non-ketotic state LVSWI left ventricular stroke work index Hib Haemophilus influenzae type b MAP mean arterial pressure HIT Heparin-induced thrombocytopenia MARS molecular adsorbent(s) recirculating system HME heat–moisture exchanger MASS Motor Activity Assessment Scale HPA hypothalamic–pituitary–adrenal MCA middle cerebral artery HRC Health Research Council (New Zealand) MED manual external defibrillator HRQOL health-related quality of life MET medical emergency team HRS hepatorenal syndrome MET(s) metabolic equivalent(s) HSV herpes simplex virus MEWS medical early-warning system HTLV human T-lymphotropic virus MIDCAB minimally invasive direct coronary artery bypass I:E inspiratory:expiratory (ratio) MIDCM minimally invasive direct cardiac massage IABP intra-aortic balloon pump mmHg millimetres of mercury IAC interposed abdominal compression MODS multiple organ dysfunction syndrome IAP intra-abdominal pressure MRI magnetic resonance imaging ICC intercostal catheter MRO Multi-resistant organisms ICD implantable cardioverter defibrillator MRS magnetic resonance spectroscopy ICDSC Intensive Care Delirium Screening Checklist MRSA methicillin-resistant Staphylococcus aureus ICG indocyanine green MVC motor vehicle collision ICH intracranial haemorrhage MVE Murray Valley encephalitis ICP intracranial pressure NAC N-acetylcysteine ICT information and communications technologies NAS nursing activities scale ICU intensive care unit NASCIS National Acute Spinal Cord Injury Study ICU-AW intensive care unit acquired weakness NAT nucleic acid testing ICU LN intensive care unit liaison nurse NDE near-death experience IDC indwelling catheter NDU nursing development unit I:E inspiratory:expiratory (ratio) NE norepinephrine
  • 21. A B B R E V I AT I O N S xxiNFκB nuclear factor kappa B PEFR peak expired flow rateNGT nasogastric tube PET positron emission tomographyNHBD non-heart-beating donation PETCO2 positive end-tidal carbon dioxideNHMRC National Health and Medical Research Council pH acid–alkaline logarithmic scaleNHP Nottingham Health Profile PI pulsatility indexNIBP non-invasive blood pressure PICC peripherally inserted central catheterNIRS near-infrared spectroscopy PiCCO pulse-induced contour cardiac outputNIV non-invasive ventilation PICU paediatric intensive care unitNMB neuromuscular blocking PN parenteral nutritionNMDA N-methyl-d-aspartate PND paroxysmal nocturnal dyspnoeaNMJ neuromuscular junction PNS peripheral nervous systemNO nitrous oxide Pplat plateau pressureNO2 nitric oxide PPE personal protective equipmentNOC Nurse observation checklist PROWESS (recombinant human-activated) protein CNOK next of kin worldwide evaluation in severe sepsisNP nurse practitioner PRVC pressure-regulated volume controlNPA nasopharyngeal aspirate PSG PolysomnographyNPP national privacy principles PT prothrombin timeNPY neuropeptide Y PTA posttraumatic amnesiaNSAIDS Non-steroidal anti-inflammatory drugs PTCA percutaneous transluminal coronary angioplastyNTS national triage scale PTSD posttraumatic stress disorderNTT nasotracheal tube PTSS posttraumatic stress symptomsNYHA New York Heart Association PTT partial thromboplastin timeO2 oxygen Pv venous pressureODIN organ dysfunction and/or infection PvO2 mixed venous oxygen pressureOEF oxygen extraction fraction PVR peripheral vascular resistanceOHCA out-of-hospital cardiac arrest QI quality improvementOLTx orthotopic liver transplantation QOL quality of lifeOSA Obstructive sleep apnoea QOL–IT quality of life–Italian versionOTDA Organ and Tissue Donation Agency QOL–SP quality of life–Spanish versionPA alveolar pressure QUM quality use of medicinesPa arterial pressure QWB quality of wellbeingPaCO2 partial pressure of carbon dioxide in arterial blood RAAS renin–angiotensin–aldosterone systemPaO2 partial pressure of oxygen in arterial blood RASS Richmond Agitation–Sedation ScalePaw peak airway pressure RAS reticular activating systemPv venous pressure RBC red blood cellPAC pulmonary artery catheter RCA root cause analysisPAF platelet-activating factor RCA right coronary arteryPALS paediatric advanced life support RCSQ Richards-Campbell Sleep QuestionnairePaO2 partial pressure of arterial oxygen REM Rapid eye movementPAOP pulmonary artery occlusion pressure RICA Right Internal Carotid ArteryPAP pulmonary artery pressure ROSC return of spontaneous circulationPART patient-at-risk team RRS rapid response systemPAWP pulmonary artery wedge pressure RR respiratory ratePbtO2 brain tissue oxygen RRT rapid response teamsPCI percutaneous coronary intervention RRT renal replacement therapyPCT dynamic perfusion computed tomography RTS revised trauma scorePCV pressure-controlled ventilation RVF right ventricular failurePCWP pulmonary capillary wedge pressure RVP right ventricular pressurePD peritoneal dialysis RVSWI right ventricular stroke work indexPDH pulmonary dynamic hyperinflation SaO2 saturation of oxygen in arterial bloodPDR plasma disappearance rate SpO2 saturation of oxygen in peripheral tissuesPDSA plan, do, study, act SvO2 venous oxygen saturationPDU practice development unit SA sinoatrialPE pulmonary embolism SAC safety assessment codingPEA pulseless electrical activity SAED semiautomatic external defibrillatorPEEP positive end-expiratory pressure SAFE Saline versus Albumin Fluid Evaluation (trial)
  • 22. xxii A B B R E V I A T I O N S SAH subarachnoid haemorrhage TLC total lung capacity SAI State Anxiety Inventory TNF[alpha] tumour necrosis factor alpha SAPS simplified acute physiology score TNS Tumour Necrosis Factor SARS severe acute respiratory syndrome TOE transoesophageal echocardiograph/y SARS-CoV severe acute respiratory syndrome coronavirus tPA tissue plasminogen activator SAS Sedation Agitation Scale tPD technical practice development SBE serum base excess TPN total parenteral nutrition SBP systolic blood pressure TPR temperature, pulse, respirations SCA sudden cardiac arrest TSANZ Transplant Society of Australia and SCI spinal cord injury New Zealand SCUF slow continuous ultrafiltration TSC trauma symptom checklist SE status epilepticus TSH thyroid-stimulating hormone SEI sleep efficiency index TST Total sleep time SF-36 Short Form 36 TT thrombin time SGRQ St George’s Respiratory Questionnaire TV tidal volume SIADH syndrome of inappropriate antidiuretic hormone TVI time velocity interval secretion UEC urea, electrolytes, creatinine SICQ Sleep in Intensive Care Questionnaire UO urine output SIG strong ion gap URTI upper respiratory tract infection SIMV synchronised intermittent mandatory ventilation V ventilation SIP sickness impact profile V/Q ventilation/perfusion SIRS systemic inflammatory response syndrome V T tidal volume SjvO2 jugular venous oxygen saturation VALI ventilator-associated lung injury SLTx single lung transplantation VAP ventilator-acquired pneumonia SOFA sepsis-related/sequential organ failure assessment VAS Visual analogue scale SPECT single photon emission computed tomography VAS-A Visual analogue scale – Anxiety SR systematic review VC Vital capacity SSG surviving sepsis guidelines VC volume-controlled (ventilation) STAI State Trait Anxiety Inventory VCV volume controlled ventilation STEMI ST-elevation myocardial infarction VE minute ventilation SVDK snake venom detection kit VF ventricular fibrillation SVG saphenous vein graft VICS Vancouver Interaction and Calmness Scale SVR systemic vascular resistance VO2 oxygen consumption SVT supraventricular tachycardia VRE vancomycin-resistant Enterococcus SVV stroke volume variation VT ventricular tachycardia SWS Slow wave sleep VTE venous thromboembolism TAFI thrombin-activatable fibrinolysis inhibitor VV veno-venous TB tuberculosis WBC white blood cell TBI traumatic brain injury WCC white cell count TCD transcranial Doppler WFCCN World Federation of Critical Care Nurses TEG thromboelastograph WHO World Health Organization TIPS transjugular intrahepatic portosystemic shunt/stent WOB work of breathing TISS therapeutic intervention scoring system XeCT xenon-enhanced computed tomography
  • 23. SECTION 1Scope of Critical Care
  • 24. Scope of Critical Care Practice 1 Leanne Aitken Wendy Chaboyer Doug Elliott consumables and the rest to clinical support and capital Learning objectives expenditure.2 Critical care as a specialty in nursing has developed over After reading this chapter, you should be able to: the last 30 years.3,4 Importantly, development of our spe- ● describe the history and development of critical care cialty in Australia and New Zealand has been in concert nursing practice, education and professional activities with development of intensive care medicine as a defined ● discuss the influences on the development of critical care clinical specialty. Critical care nursing is defined by the nursing as a discipline and the professional development of World Federation of Critical Care Nurses as: individual nurses ● outline the various roles available to nurses within critical Specialised nursing care of critically ill patients who have mani- care areas or in outreach services fest or potential disturbances of vital organ functions. Critical care nursing means assisting, supporting and restoring the ● discuss the potential impact of clinical decision-making patient towards health, or to ease the patient’s pain and to processes on patient outcomes prepare them for a dignified death. The aim of critical care ● consider processes in the work and professional nursing is to establish a therapeutic relationship with patients environment that are influenced by local leadership styles. 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 Key words potential life-threatening health problems.6 Care of the critically ill can occur in a number of different locations critical care nursing in hospitals. In Australia and New Zealand, critical care roles of critical care nurses is generally considered a broad term, incorporating clinical decision making subspecialty areas of emergency, coronary care, high- clinical leadership dependency, cardiothoracic, paediatric and general inten- sive care units.7 This chapter provides a context for subsequent chapters, outlining some key principles and concepts for studyingINTRODUCTION and practising nursing in a range of critical care areas. TheThere is unprecedented demand for critical care services scope of critical care nursing is described in the Australianglobally. In our region, there are approximately 119,000 and New Zealand contexts, which in turn have someadmissions to 141 general intensive care units (ICUs) influence on clinical practice in Southeast Asia and thein Australia per year; this includes 5500 patient re- Pacific. Development of the specialty is discussed, alongadmissions during the same hospital episode. In New with the professional development and evolving roles ofZealand, there are 18,000 admissions per year to 26 ICUs, critical care nurses in contemporary health care, includingincluding 500 re-admissions.1 Patients admitted to coro- clinical decision making and leadership.nary care, paediatric or other specialty units not classifiedas a general ICU are not included in these figures, so theoverall clinical activity for ‘critical care’ is much higher DEVELOPMENT OF CRITICAL(e.g. there were also 5500 paediatric admissions toPICUs).1 Importantly, critical care treatment is a high- CARE NURSINGexpense component of hospital care; one conservative Critical care as a specialty emerged in the 1950s andestimate of cost exceeded $A2600 per day, with more 1960s in Australasia, North America, Europe and Souththan two-thirds going to staff costs, one fifth to clinical Africa.4,8-11 During these early stages, critical care consisted 3
  • 25. 4 SCOPE OF CRITICAL CARE primarily of coronary care units for the care of cardiology Critical care nursing education developed in unison with patients, cardiothoracic units for the care of postoperative the advent of specialist critical care units. Initially, this patients, and general intensive care units for the care of consisted of ad-hoc training developed and delivered in patients with respiratory compromise. Later develop- the work setting, with nurses and medical officers learn- ments in renal, metabolic and neurological management ing together. For example, medical staff brought expertise led to the principles and context of critical care that exist in physiology, pathophysiology and interpretation of today. electrocardiographic rhythm strips, while nurses brought expertise in patient care and how patients behaved and Development of critical care nursing was characterised by responded to treatment.12,17 Training was, however, frag- a number of features,4 including: mented and ‘fitted in’ around ward staffing needs. Post- ● the development of a new, comprehensive partnership registration critical care nursing courses were subsequently between nursing and medical clinicians developed from the early 1960s in both Australasia and ● the collective experience of a steep learning curve for the UK.4,8 Courses ranged in length from 6 to 12 months nursing and medical staff and generally incorporated employment as well as spe- ● the courage to work in an unfamiliar setting, caring cific days for lectures and class work. Given the local for patients who were extremely sick – a role that nature of these courses developed for the local needs of required development of higher levels of competence individual hospitals and regions, differences in content and practice and practice therefore developed between hospitals, ● a high demand for education specific to critical care regions and countries.18-20 practice, which was initially difficult to meet owing to the absence of experienced nurses in the specialty During the 1990s the majority of these hospital-based ● the development of technology such as mechanical courses in Australasia were discontinued as universities ventilators, cardiac monitors, pacemakers defibrilla- developed postgraduate curricula to extend the knowl- tors, dialysers, intra-aortic balloon pumps and cardiac edge and skills gained in pre-registration undergraduate assist devices, which prompted development of addi- courses. A significant proportion of critical care nurses tional knowledge and skills. now undertake specialty education in the tertiary sector, often in a collaborative relationship with one or more There was also recognition that improving patient out- hospitals.4 One early study of students enrolled in comes through optimal use of this technology was linked university-based critical care courses in Australia21 identi- to nurses’ skills and staffing levels.12 The role of ade- fied a number of burdens (workload, financial, study– quately educated and experienced nurses in these units work conflicts), but also a number of benefits (e.g. better was recognised as essential from an early stage,8 and led job prospects, job security). to the development of the nursing specialty of critical care. Although not initially accepted, nursing expertise, ability Within Australia and New Zealand, most tertiary institu- to observe patients and appropriate nursing intensity are tions currently offer postgraduate critical care nursing now considered essential elements of critical care.12 education at a Graduate Certificate or Graduate Diploma level as preparation for specialty practice, although this As the practice of critical care nursing evolved, so did is often provided as a Master’s degree.22 In the UK, similar the associated areas of critical care nursing education provisions for postgraduate critical care nursing edu- and specialty professional organisations such as the cation at multiple levels are available, although some Australian College of Critical Care Nurses (ACCCN). The universities also offer critical care specialisation at the combination of adequate nurse staffing, observation of undergraduate level (for example, King’s College, the patient and the expertise of nurses to consider the London). Education throughout Europe has undergone complete needs of patients and their families is essential significant change in the past 10 years as the framework to optimise the outcomes of critical care. As critical care articulated under the Bologna Process has been imple- continues to evolve, the challenge remains to combine mented.23 In relation to critical care nursing, this has led excellence in nursing care with judicious use of techno- to the expansion of programs, primarily at the postgradu- logy to optimise patient and family outcomes. ate level, for specialist nursing education. Critical care nursing education in the USA maintains a slightly differ- CRITICAL CARE NURSING EDUCATION ent focus, with most postgraduate studies being generic in nature, including a focus on advanced practice roles Appropriate preparation of specialist critical care nurses such as clinical nurse specialists and nurse practitioners, is a vital component in providing quality care to patients while specialty education for critical care nurses is under- and their families.5 A central tenet within this framework taken as continuing education.24 Employment in critical of preparation is the formalised education of nurses care, with associated assessment of clinical competence, to practise in critical care areas.13 Formal education – remains an essential component of many university- in conjunction with experiential learning, continuing based critical care nursing courses.22,25 professional development and training, and reflective clinical practice – is required to develop competence in Both the impact of post-registration education on prac- critical care nursing. The knowledge, skills and attitude tice and the most appropriate level of education that is necessary for quality critical care nursing practice have required to underpin specialty practice remain controver- been articulated in competency statements in many sial, with no universal acceptance internationally.26-29 countries.14-16 Globally, the Declaration of Madrid, which was endorsed
  • 26. Scope of Critical Care Practice 5 ‘beginner’ ‘competent’ ‘specialist’ ‘expert’ continuing experience/experiential learning Practice Induction/ orientation to critical short courses/skills updates/in-service education Training care nursing initial competencies increasing complexity of competencies Education Postgraduate Graduate Graduate Masters education Certificate Diploma FIGURE 1.1 Critical care nursing practice: training and education continuum.by the World Federation of Critical Care Nurses, provides Appendix B). The validity of this structure of six domainsa baseline for critical care nursing education (see Appen- has been questioned, however, as a number of compe-dix A for the position statement).5 tency statements are linked to several domains.35 Further research is therefore required to refine the structure of aA range of factors continue to influence critical care competency model with improved construct validity.35nursing education provision, including government poli- Other competency domains and assessment tools havecies at national and state levels, funding mechanisms and also been developed.25 Although articulated slightly dif-resource implications for organisations and individual ferently, the American Association of Critical-Care Nursesstudents, education provider and healthcare sector part- (AACN) provides ‘Standards of Practice and Performancenership arrangements, and tensions between workforce for the Acute and Critical Care Clinical Nurse Specialist’,36and professional development needs.13 Recruitment, ori- which outlines six standards of practice (assessment,entation, training and education of critical care nurses diagnosis, outcome identification, planning, implemen-can be viewed as a continuum of learning, experience and tation and evaluation) and eight standards of profes-professional development.5 The relationships between sional performance (quality of care, individual practicethe various components related to practice, training and evaluation, education, collegiality, ethics, collaboration,education are illustrated in Figure 1.1, on a continuum research and resource utilisation) (see Online resources).from ‘beginner’ to ‘expert’ and incorporating increasingcomplexities of competency. All elements are equallyimportant in promoting quality critical care nursing CRITICAL CARE NURSING PROFESSIONALpractice. Practice- or skills-based continuing education ORGANISATIONSsessions support clinical practice at the unit level.30 Professional leadership of critical care nursing has under-(Orientation and continuing education issues are dis- gone considerable development in the past three decades.cussed further in the context of staffing levels and skills Within Australia, the ACCCN (formerly the Confedera-mix in Chapter 2.) tion of Australian Critical Care Nurses) was formed fromMany countries now incorporate requirements for con- a number of preceding state-based specialty nursingtinuing professional development into their annual bodies (e.g. Australian Society of Critical Care Nurses,licensing processes. Specific requirements include ele- Clinical Nurse Specialists Association) that provided pro-ments such as minimum hours of required professional fessional leadership for critical care nurses since the earlydevelopment and/or ongoing demonstration of compe- 1970s. In New Zealand, the professional interests of criti-tence against predefined competency standards.31,32 cal care nurses are represented by the New Zealand Nurses Organisation, Critical Care Nurses Section, as well asSPECIALIST CRITICAL CARE COMPETENCIES affiliation with the ACCCN. The ACCCN has strong pro- fessional relationships with other national peak nursingCritical care nursing involves a range of skills, classified bodies, the Australian and New Zealand Intensive Careas psychomotor (or technical), cognitive or interpersonal. Society (ANZICS), government agencies and individuals,Performance of specific skills requires special training and and healthcare companies.practice to enable proficiency. Clinical competence isa combination of skills, behaviours and knowledge, Professional organisations representing critical caredemonstrated by performance within a practice situa- nurses were formed as early as the 1960s in the USA withtion33 and specific to the context in which it is demon- the formation of the American Association of Criticalstrated.34 A nurse who learns a skill and is assessed as Care Nurses (AACN).37 Other organisations have devel-performing that skill within the clinical environment is oped around the world, with critical care nursing bodiesdeemed competent. As noted above, a set of competency now operating in countries from Australasia, Asia, Northstatements for specialist critical care practice comprises America, South America, Africa and Europe. In 2001 the20 competency standards grouped into six domains: inaugural meeting of the World Federation of Criticalprofessional practice, reflective practice, enabling, clinical Care Nurses (WFCCN) was formed to provide profes-problem solving, teamwork and leadership14 (see sional leadership at an international level.38,39 The ACCCN
  • 27. 6 SCOPE OF CRITICAL CARE was a foundation member of the WFCCN and a member of critical care outreach or ICU liaison nurse roles (see association of the World Federation of Societies of Inten- Chapter 2 for further discussion of these services). sive Care and Critical Care Medicine, and maintains a In practice, the role of clinical consultant and that of an representative on the councils of both these international advanced practice nurse or nurse practitioner can become bodies. (See the ACCCN website, listed in Online resources, blurred, with hospital administrators believing that one for further details about professional activities.) role can replace the other. Clearly, however, the con- sultant’s role has a broader portfolio, with a focus on ROLES OF CRITICAL CARE NURSES supporting clinical colleagues in providing safe, quality As the discipline of critical care has developed, so too has patient care, while the role of advanced practice nurse or the range of roles performed by specialty critical care nurse practitioner has a direct patient care focus (see nurses.40,41 The continuum of critical illness (see Chapter below). 4) includes pre-crisis/proactive care, management of the critical illness, and follow-up care in hospital, clinic and ADVANCED PRACTICE NURSE/NURSE home settings.42 This continuum also includes the prac- PRACTITIONER tice of palliative care in the ICU environment.43 Clinical Processes for authorisation to practise as a nurse practi- (bedside) roles and nurse-to-patient ratios for various tioner (NP) have been introduced by professional regi- levels of critical care unit, as well as the roles of unit stration agencies in Australia and New Zealand, with manager and clinical nurse educator, are discussed in similar roles present in the UK and USA prior to this.48 Chapter 2. Practice issues for critical care clinicians are Nurse practitioner roles in ‘critical care’ (or high depen- detailed in the remaining chapters of this book. Roles dency) range from emergency department practitioners that apply to all nursing professionals are specifically through to community-based cardiac failure specialists, highlighted; for example: and, as noted above for the nurse consultant’s role, often ● carer, in Chapters 6, 7 and 8, all practice-related lack clarity regarding their scope of practice.56,57 Factors chapters in Section 2, and the specialty chapters in influencing the establishment of these roles include the Section 3 accrediting process, defining the scope of practice through ● patient and family advocate, in Chapters 5 and 8 specific clinical practice guideline development, prescrib- ● educator, in Chapter 3. ing rights and the prevailing medical views, and the level of support provided by health service administrators for This section focuses on the scope of critical care nurses’ the implementation, development and evaluation of the roles inside and external to the critical care area, and role.48,56 Advanced practice roles in the emergency depart- provides links to other specific chapters.44 These roles ment are the most well-established in the critical care include: domain (see Chapter 22). ● consultant45-47 ● advanced practice48/nurse practitioner roles in ICU,46 CLINICAL DECISION MAKING trauma,49 emergency50 (Chapter 22), critical care out- Clinical decision making is integral to critical care nursing reach51/ICU liaison52-54 (Chapter 2) practice and forms part of the clinical reasoning process. ● research/quality coordinator (Chapter 3). Clinical reasoning is Developing a body of knowledge and the integral role of the cognitive processes and strategies that nurses use to under- research and nurse researchers in that process is described stand the significance of patient data, to identify and diagnose in a later section of this chapter. actual or potential patient problems, and to make clinical deci- CONSULTANT sions to assist in problem resolution and to achieve positive patient outcomes.58 Expert clinicians in one of the subspecialties of critical care – emergency, general ICU, cardiology, cardiothoracic, Clinical information and prior knowledge are therefore neurosciences – play important roles in facilitating used to inform a decision. This section focuses on the improvements in clinical practice for both critical care and decision-making component of clinical reasoning. A brief non-critical care patients. The consultant’s role involves overview of the theoretical perspectives that have been clinical practice, education, quality improvement and used to understand clinical decision making is provided research activities.55 Within these work portfolios, leader- and then studies that focus on critical care nursing ship and the development and dissemination of knowl- are reviewed. Finally, strategies for developing clinical edge45,46 within a multidisciplinary team are integral to decision-making skills are provided. effective practice.47 Practice includes role-modelling of expected behaviours, policy and clinical guideline devel- THEORETICAL PERSPECTIVES ON opment to support clinical care, and facilitating profes- DECISION MAKING sional development of colleagues in collaboration with There are numerous theoretical perspectives on decision the nurse educator role. The benefits that this role brought making, but they can be grouped into two main to the critical care area led to the introduction of a similar categories: service for non-critical care areas, particularly in the context of clinical deterioration of patients or for patients 1. analytical or rationalist recently discharged from the ICU, with the development 2. intuitive or humanistic.
  • 28. Scope of Critical Care Practice 7The analytical approaches arise from a positivist or ratio- Other studies indicated that experienced and inexperi-nalist perspective and focus on analysing behaviours enced nurses differ in their decision making skills,67,70,71and the steps involved in problem solving. Some of the and that role models or mentors are important in assist-specific theories that fall into this category include infor- ing to develop decision making skills.72mation-processing theory (IPT)59 and decision analysistheory (DAT).60 RECOMMENDATIONS FOR DEVELOPINGFundamental to IPT is the premise that reasoning consists CLINICAL DECISION MAKING SKILLSof a relationship between the problem solver and the Several strategies can be used to help critical care nursescontext within which the problem occurs. This theory to develop their clinical decision-making abilities (Tableasserts that relevant information is stored in one’s memory 1.2).73-75 These strategies can be used by nurses at anyand that problem solving occurs when the problem solver level to develop their own decision-making skills, or byretrieves information from both short- and long-term educators in planning educational sessions.memory. Additionally, IPT claims that there are limits tothe amount of information that can be processed at any In summary, clinical decision making is a component ofgiven time. Thus, IPT focuses on understanding how the clinical reasoning process that is part of everyday criti-information is gathered, stored and retrieved. DAT focuses cal care nursing practice. It involves gathering and analys-on the use of decision trees, mathematical formulas and ing information in order to arrive at a decision about aother techniques to determine the likelihood of meaning- particular course of action. The analytical or rationalistful clinical data. These rationalist approaches focus on perspective of clinical decision making focuses on analys-diagnosing a problem, intervening and evaluating the ing behaviours and the steps in solving a problem, whileoutcome.61 the intuitive or humanistic approach centres on intuitive knowledge and the context of the decision. In this spe-Contrary to the analytical approaches, intuitive approaches cialty area nurses are making clinical decisions at a rate(also termed humanistic, hermeneutic or phenomeno- of two to three per minute.61,68 Given this, it is importantlogical) focus on the importance of intuitive knowledge that clinical decision-making skills be developed throughand context in clinical decision making.40,62,63 That is, experience, training and education. Previous research hasexpert intuition develops with experience and can be demonstrated that a number of strategies, such as caseused to make complex decisions. Both intuitive knowl- studies and reflection on action, can be used to assistedge and analytical reasoning contribute to clinical deci- nurses in developing these important skills.sions.63 Intuitive approaches to decision making thereforefocus on understanding the development of intuition, therole of experience and articulating how nurses use intu- LEADERSHIP IN CRITICALition to make a decision. In addition, Australian authors64 CARE NURSINGhave described a naturalistic framework to examine criti- Effective leadership within critical care nursing is essen-cal care nurses’ decision making, describing it as a way tial at several organisational levels, including the unit andof considering how people use their experience when hospital levels, as well as within the specialty on a broadermaking real-life decisions. professional scale. The leadership required at any given time and in any specific setting is a reflection of the sur-RESEARCH ON DECISION MAKING IN rounding environment. Regardless of the setting, effectiveCRITICAL CARE NURSING leadership involves having and communicating a clearCritical care nursing practice has been the focus of many vision, motivating a team to achieve a common goal,studies on decision making. As multiple, complex deci- communicating effectively with others, role modelling,sions are made in rapid succession in critical care, it is an creating and sustaining the critical elements of a healthyideal setting for studying clinical decision making.61 The work environment and implementing change and inno-seminal work by Benner and colleagues40,63,65 focused on vation.76-79 Leadership at the unit and hospital levels iscritical care nurses. Table 1.1 summarises 10 studies (11 essential to ensure excellence in practice, as well as ade-publications) conducted on critical care nurses’ decision quate clinical governance. In addition to the generic strat-making over the past decade. egies described above, it is essential for leaders in critical care units and hospitals to demonstrate a patient focus,Of note, 7 of the 10 studies were conducted in Australia, establish and maintain standards of practice and collabo-with two multinational studies also including Australia. rate with other members of the multi-disciplinary health-All but two studies66,67 used qualitative approaches such care team.76as observation, interviewing and thinking aloud. Twostudies reported the types and frequency of decisions Leadership is essential to achieve the growth and develop-made during the time period and identified that critical ment in our specialty and is demonstrated through suchcare nurses’ decisions were related to interventions and activities as conducting research, producing publications,communication,61,68 evaluation,61 assessment, organisa- making conference presentations, representation ontion and education.68 A further study demonstrated that relevant government and healthcare councils and com-critical care nurses generate one or more hypotheses mittees, and participation in organisations such as theabout a situation prior to decision making.69 All three ACCCN and the WFCCN. As outlined earlier in thisstudies highlighted the importance of enabling expert chapter, we have seen the field of critical care grow fromnurses to provide a narrative account of their practice. early ideas and makeshift units to a well-developed and
  • 29. 8 SCOPE OF CRITICAL CARE TABLE 1.1 Australian and international critical care nurses decision-making research Author [Country] Sample Data collection Findings 61 Bucknall, 2000 18 CC nurses (range of Observation (2-hour periods) Three types of decision: [Australia] levels and experiences; ● evaluation (51%) all had completed a CC ● communication (30%) course) ● intervention (19%) Average: 238 decisions/2 hours (i.e. 2.0/min) Currey & Worrall-Carter, 12 CC nurses with 2+ years’ Clinical decision record (of Five types of decision: 200168 [Australia] CC experience from 3 2-hour periods) and focus ● intervention (40%) units groups ● communication (26%) ● assessment (19%) ● organisation (13%) ● education (2%) Average: 395 decisions/2 hours (i.e. 3.3/min) Aitken, 200369 [Australia] 8 expert CC nurses with 5+ Thinking aloud (2-hour periods) Hypotheses developed as a framework for decision years’ CC experience and follow-up interview making A combination of strategies used to gather data Currey & Botti, 200670 CC nurses from 2 Observation followed by Clinical processes that affected decision making [Australia] metropolitan hospitals; semi-structured interview following the settling in phase post cardiac 18 inexperienced surgery were: (≤3 years) and 20 ● handover from anaesthetists experienced CC nurses ● settling in procedures (>3 years). ● collegial assistance. 15 nurses (13 inexperienced) felt daunted by decision making while 7 nurses (1 inexperienced) felt challenged with a sense of being stimulated, excited and positive. Currey, Browne & Botti Same as above Observation in 2 phases: Quality of haemodynamic decision making in the 2 (2006)70 [Same study 1st phase comprised hours post cardiac surgery was influenced by as above] [Australia] unstructured, narrative decision complexity, nurses’ level of experience, observational data; 2nd and forms of decision support provided by phase comprised a 2-page nursing colleagues. structured observation Experience was a dominant influence in recognising checklist. Followed up by patterns of haemodynamic cues that were interview. suggestive of complications. Adherence to evidence-based practice also influenced quality of decision making. Aitken, 2008102 [Australia] 7 CC nurses with a CC Observation and/or thinking A range of concepts related to the assessment and qualification, >5 years aloud, along with follow-up management of sedation needs. Assessment CC experience, and interviews included: working ≥2 days/week ● 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, In-depth, semi-structured The presence of a role model or mentor to help with varied experience interviews guide the ethical decision-making process, and education levels through reflection-in-action, was critical for focused ethical discourse and the decision making. Enhanced ethical decision making occurred through experiential learning. Thompson, 200867 245 Dutch, UK, Canadian Vignettes with decision Time pressure significantly reduced the nurses’ [various countries] and Australian whether or not to contact a decision tendency to intervene. registered nurses senior nurse/doctor. The There were no statistically significant differences in working in surgical, proportion of true positives decision-making ability between years of generic medical, ICU or HDU (the patient is at risk of a clinical experience. critical event and the nurse There were statistically significant differences in takes action) and false decision-making ability between years of critical positives (the nurse takes care experience when participants were not action when it was not under time pressure: those with greater critical warranted) was calculated. care experience performed better. Under time pressure, there were no differences in decision-making ability between years of critical care experience.
  • 30. Scope of Critical Care Practice 9 TABLE 1.1, Continued Author [Country] Sample Data collection Findings 71 Hoffman, 2009 8 CC nurses: 4 novice and Thinking aloud (during 2-hour Cue usage and clustering during decision making: [Australia] 4 expert period of care); interview ● 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. Ramezani-Badr, 2009104 14 CC nurses from 4 In-depth, semi-structured 3 themes were involved in reasoning strategies: [Iran] hospitals, currently interviews ● intuition working in the CCU, ● recognising similar situations with ≥3 years CC ● hypothesis testing. experience and holding 3 other themes regarding participants’ criteria to at least a bachelor of make decisions: nursing. ● 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). Thompson, 200966 245 Dutch, UK, Canadian Judgement classification Critical care experience was associated with [Various countries] and Australian systems, Continuous (0–100) estimates of risk, but not with the decision to registered nurses ratings or dichotomous intervene. working in surgical, ratings on 3 nursing Nurses varied considerably in their risk assessments, medical, ICU or HDU. judgements were used this being partly explained by variability in weightings given to information. Information was synthesised in non-linear ways that contributed little to decisional accuracy. TABLE 1.2 Strategies to develop clinical decision-making skills Strategy Description Iterative hypothesis Description of a clinical situation for which the clinician has to generate questions and develop hypotheses; with testing74 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 Clinicians are asked to reflect on their actions after a particular event. Reflection focuses on clinical judgments made, action74 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 Leadership styles vary and are influenced by the missionhalf a generation. Such development would not have and values of the organisation as well as the valuesbeen possible without the vision, enthusiasm and com- and beliefs of individual leaders. These styles of leader-mitment of many critical care leaders throughout the ship are described in many different ways, sometimesworld. using theoretical underpinnings such as ‘transactional’
  • 31. 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 leader- ● satisfied staff, with a high level of retention ship characteristics. Regardless of the terminology in use, ● development of staff through an effective coaching some common principles can be expressed. Desired and mentoring process.81,86 leadership characteristics include the ability to: Effective clinical leaders build cohesive and adaptive ● articulate a personal vision and expectations work teams.84 They also promote the intellectual stimula- ● act as a catalyst for change tion of individual staff members, which encourages the ● establish and implement organisational standards analysis and exploration of practice that is essential for ● model effective leadership behaviours through both evidence-based nursing.85 change processes and stable contexts ● monitor practice in relation to standards and take cor- Clinical leadership is particularly important in contem- rective action when necessary porary critical care environments in times of dynamic ● recognise the characteristics and strengths of indivi- change and development. We are currently witnessing duals, and stimulate individual development and significant changes in the organisation and delivery of commitment care, with the development of new roles such as nurse ● empower staff to act independently and practitioner (see this chapter) and liaison nurse (see interdependently Chapter 3), the introduction of services such as rapid ● inspire team members to achieve excellence.80-85 response systems, including medical emergency teams (see Chapter 3), and the extension of activities across the Personal characteristics of an effective leader, regardless care continuum (see Chapter 4). Effective clinical leader- of the style, include honesty, integrity, commitment and ship ensures that: credibility, as well as the ability to develop an open, trust- ● critical care personnel are aware of, and willing to ing environment.85 Effective leaders inspire their team members to take the extra step towards achieving the fulfil, their changing roles ● personnel in other areas of the hospital or outside the goals articulated by the leader and to feel that they are valued, independent, responsible and autonomous indi- hospital recognise the benefits and limitations of viduals within the organisation.85 Members of teams with developments, are not threatened by the develop- effective leaders are not satisfied with maintaining the ments and are enthusiastic to use the new or refined status quo, but believe in the vision and goals articulated services ● patients receive optimal quality of care. by the leader and are prepared to work towards achieving a higher standard of practice. The need to provide educational opportunities to develop Although all leaders share common characteristics, some effective clinical leadership skills is recognised.80 Although elements vary according to leadership style. Different not numerous in number or variety, programs are begin- styles – for example, transactional, transformational, ning to be available internationally that are designed to authoritative or laissez faire – incorporate different char- develop clinical leaders.79,87 Factors that influence leader- acteristics and activities. Having leaders with different ship ability include the external and internal environ- styles ensures that there is leadership for all stages of an ment, demographic characteristics such as age, experience, organisation’s operation or a profession’s development. understanding, stage of personal development including A combination of leadership styles also helps to over- self-awareness capability, and communication skills.80,82,87 come team member preferences and problems experi- In relation to clinical leadership, these factors can be enced when a particularly visionary leader leaves. The developed only in a clinical setting, so development of challenges often associated with the departure of a leader clinical leaders must be based in that environment. from a healthcare organisation are generally reduced in Development programs based on mentorship are superbly the clinical critical care environment, where a nursing suited to developing those that demonstrate potential for leader is usually part of a multidisciplinary team, with such capabilities.80 resultant shared values and objectives. Mentorship has received significant attention in the healthcare literature and has been specifically identified CLINICAL LEADERSHIP as a strategy for clinical leadership development.88-90 Although many different definitions of mentoring exist, Effective critical care nurses demonstrate leadership char- common principles include a relationship between two acteristics regardless of their role or level of practice. Lead- people with the primary purpose of one person in the ership in the clinical environment incorporates the relationship developing new skills related to their general characteristics listed above, but has the added career.91,92 Mentoring programs can be either formal or challenges of working within the boundaries created by informal and either internal or external to the work the requirements of providing safe patient care 24 hours setting. Mentorship involves a variety of activities directed a day, 7 days a week. It is therefore essential that clinical towards facilitating new learning experiences for the leaders work within an effective interdisciplinary model, mentee, guiding professional development and career so that all aspects of patient care and family support, as decisions, providing emotional and psychological support well as the needs of all staff, are met. Effective clinical and assisting the mentee in the socialisation process both leadership of critical care is essential in achieving: within and outside the work organisation to build profes- ● effective and safe patient care sional networks.89,91 Role modelling of occupational and ● evidence-based healthcare professional skills and characteristics is an important
  • 32. Scope of Critical Care Practice 11component of mentoring that helps develop future clini- 1. randomly allocating patients to receive either acal leaders.89,92 new intervention (the experimental or interven- tion group) or an alternative or standard interven-DEVELOPING A BODY OF tion (the control group) 2. delivering the intervention or alternativeKNOWLEDGE treatmentDevelopment of a body of knowledge is a key character- 3. measuring an a priori identified patient outcome.istic of both professions93-95 and the specialties within Statistical analyses are used to determine if the newprofessions. One criterion for a specialty identified over intervention is better for patients than the alternativetwo decades ago by the International Council of Nurses treatment.(ICN)96 is that it is based on a core body of nursingknowledge that is being continually expanded and refined Mixed methods research have now emerged as anby research. Importantly, the ICN acknowledges that approach that integrates data from qualitative and quan-mechanisms are needed to support, review and dissemi- titative research at some stage in the research process.97nate research. In mixed methods approaches, researchers decide on both priority and sequence of qualitative and quantitativeRESEARCH methods. In terms of priority, equal status may be given to both approaches. Priority is indicated by using capitalAs noted above, research is fundamental in the develop- letters for the dominant approach, followed by thement of nursing knowledge and practice. Research is a symbols + and → to indicate either concurrent or sequen-systematic inquiry using structured methods to under- tial data collection. For example:stand an issue, solve a problem or refine existing knowl-edge. Qualitative research involves in-depth examination ● QUAL + QUANT: both approaches are given equalof a phenomenon of interest, typically using interviews, status and data collection occurs concurrently.observation or document analysis to build knowledge ● QUAL + quant: qualitative methods are the dominantand enable depth of understanding. Qualitative data approach and data collection occurs concurrently.analysis is in narrative (text) form and involves some form ● QUAL → quant: the qualitative study is given priorityof content or thematic analysis, with findings generally and qualitative data collection will occur before quan-reported as narrative (where words rather than numbers titative data collection.describe the research findings). In contrast, quantitative Irrespective of which type of research design is used, thereresearch involves the measurement (in numeric form) of are a number of common steps in the research processvariables and the use of statistics to test hypotheses. (Table 1.3), consisting of three phases: planning for theResults of quantitative research are often reported in research, undertaking the research and analysing andtables and figures, identifying statistically significant find- reporting on the research findings.ings. One particular type of quantitative research, theclinical trial (randomised controlled trial, or RCT), is used Clinical research and the related activities of unit-basedto test the effect of a new nursing intervention on patient quality improvement are integral components in theoutcomes. In essence, clinical trials involve: practice, education and research triad.98 Partnerships TABLE 1.3 Steps in the research process Step Description Identify a clinical Clinical experience and practice audits are two ways that clinical issues or problems are identified. problem or issue. 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 A concise question includes both the phenomenon of interest and the patient population. question. Write a research Clear description of the proposed research design and sample and a plan for data collection and analysis. Ethical proposal. 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 Conference presentations and journal publications are two common ways that research findings are disseminated research findings. and are vital to ensure that both nursing practice and nursing knowledge continue to be developed.
  • 33. 12 S C O P E O F C R I T I C A L C A R E Research program Practice Patient Technology Education Policy issues outcomes assessment & training issues Practice Health status/ Clinical information Commonwealth & Competencies development HRQOL systems state policies Evidence- Patient/family Product Impact of Credentialling based practice experiences evaluation international factors Impact of Resource Economic Program Ethical & technology on utilisation evaluation evaluation legal issues patient care FIGURE 1.2 Example of critical care nursing research program. between clinicians and academics, and the implementa- research utilisation approaches, with a description of tion of clinical academic positions, including at the pro- evidence-based practice and the use of evidence-based fessorial level,99 provide the necessary infrastructure and clinical practice guidelines. In addition, each chapter in organisation for sustainable clinical nursing and multi- this text contains a research critique to assist nurses in disciplinary research. A strong research culture in critical developing critical appraisal skills, which will help to care nursing is evident in Australasia, transcending geo- determine whether research evidence should change graphical, epistemological and disciplinary boundaries to practice. focus on the core business of improving care for critically ill patients. Our collective aim is to develop a sustainable SUMMARY research culture that incorporates strategies that facilitate communication, cooperation, collaboration and coordi- This chapter has provided a context for subsequent chap- nation both between researchers with common interests ters, outlining some key issues, principles and concepts and with clinicians who seek to use research findings in for studying and practising nursing in a range of critical their practice. A sample of a guiding structure for a coher- care areas. Critical care nursing now encompasses a wide ent research program that highlights the major issues and ever-expanding scope of practice. The previous focus affecting critical care nursing practice is illustrated in on patients in ICU only has given way to a broader Figure 1.2, with identified themes and topic exemplars. concept of caring for an individual located in a variety of clinical locations across a continuum of critical illness. A number of resources are available to critical care nurses interested in undertaking research. For example, the The discipline of critical care nursing, in collaboration ACCCN provides funding for research on a competitive with multidisciplinary colleagues, continues to develop basis, with its Research Advisory Panel assessing grant to meet the expanding challenges of clinical practice in applications and providing feedback to applicants. The today’s healthcare environment. Critical care clinicians Intensive Care Foundation, whose members are drawn also continue their professional development individu- from the Australia and New Zealand Intensive Care ally, focusing on clinical practice development, education Society (ANZICS), the College of Intensive Care Medicine and training, and on quality improvement and research (CICM) and ACCCN, also has a research funding scheme. activities, to facilitate quality patient and family care Additionally, the ANZICS Clinical Trials Group (CTG) during a time of acute physiological derangement and holds regular meetings where potential research can be emotional turmoil. The principles of decision making discussed and research proposals refined. There is great and clinical leadership at all levels of practice serve to value in receiving a critical review of proposed research enhance patient safety in the critical care environment. before the study is undertaken, as assessors’ comments help to refine the research plan. ONLINE RESOURCES Over the years, various groups have identified priorities American Association of Critical-Care Nurses, www.aacn.org for critical care research. A review of this literature identi- Annual Scientific Meeting on Intensive Care, www.intensivecareasm.com.au fied the following research priorities: nutrition support, Australian College of Critical Care Nurses, www.acccn.com.au Australia and New Zealand Intensive Care Society, www.anzics.com.au infection control, other patient care issues, nursing roles, British Association of Critical Care Nurses, www.baccn.org.uk staffing and end-of-life decision making.100 College of Intensive Care Medicine, www.cicm.org.au Intensive Care Foundation (Australia and New Zealand), While not all nurses are expected to conduct research, it www.intensivecareappeal.com is a professional responsibility to use research in prac- King’s College, London, www.kcl.ac.uk/schools/nursing tice.101 Chapter 3 provides a detailed description of World Federation of Critical Care Nurses, http://en.wfccn.org
  • 34. Scope of Critical Care Practice 13Research vignetteAitken L, Marshall AP, Elliott R, McKinley S. Critical care nurses’ deci- and level of consciousness) were labelled as both attribute andsion making: sedation assessment and management in intensive concept.care. Journal of Clinical Nursing 2008; 18: 36–45. Three methods of data collection were used: ‘think aloud’, observa-Abstract tion and interviews. Specifically, during the think-aloud approach,Aims nurses wore a collar-mounted microphone attached to an audio-This study was designed to examine the decision-making pro- recorder and were asked to verbalise their thought processescesses that nurses use when assessing and managing sedation for during the data collection period. At the same time, an observera critically ill patient, specifically the attributes and concepts used recorded the activities that the nurses were undertaking whileto determine sedation needs and the influence of a sedation thinking aloud. A follow-up interview was then undertaken to helpguideline on the decision-making processes. clarify the activities that were observed. Two observers were used to collect the data. The qualitative nature of the study and the dataBackground collection methods are accepted methods to examine decision-Sedation management forms an integral component of the care of making processes. The researchers are to be commended for train-critical care patients. Despite this, there is little understanding of ing the participants in the think-aloud method and for pilotinghow nurses make decisions regarding assessment and manage- various forms of observational data collection.ment of intensive care patients’ sedation requirements. Appropri- The data from the think-aloud method and the observationsate nursing assessment and management of sedation therapy is were analysed independently by the data collector who hadessential to quality patient care. collected the data for that particular nurse. As part of this analysis,Design the think-aloud, observation and interview data were integratedObservational study. for each nurse. The actual analysis involved identifying conceptsMethods and attributes related to three predefined categories: assessment,Nurses providing sedation management for a critically ill patient physiology and treatment. All analyses were assessed by the chiefwere observed and asked to think aloud during two separate occa- investigator and any differences were resolved by consensus.sions for two hours of care. Follow-up interviews were conducted The sample size – five nurses observed twice each (i.e. before andto collect data from five expert critical care nurses pre- and post- after implementation of the sedation protocol) and two nursesimplementation of a sedation guideline. Data from all sources were observed once in the pilot study – is appropriate. It is obvious thatintegrated, with data analysis identifying the type and number of a very large amount of data was generated. While selection criteriaattributes and concepts used to form decisions. were described to identify ‘expert’ nurses, and included the need to have critical care qualifications and more than five years experi-Results ence, the fact that they self-nominated as expert means that it isAttributes and concepts most frequently used related to sedation always possible that some would not have been judged to beand sedatives, anxiety and agitation, pain and comfort and neuro- ‘expert’ by their peers and superiors. It was not clear, however, howlogical status. On average each participant raised 48 attributes the data of the two pilot nurses was actually incorporated into therelated to sedation assessment and management in the preinter- findings. That is, as their data was only pre-protocol, the reportedvention phase and 57 attributes postintervention. These attributes number of attributes after protocol was implemented could berelated to assessment (pre, 58%; post, 65%), physiology (pre, 10%; expected to be influenced by two fewer participants. This issue waspost, 9%) and treatment (pre, 31%; post, 26%) aspects of care. not addressed in the report.Conclusions The fact that a number of strategies were used to educate theDecision making in this setting is highly complex, incorporating a nurses about the sedation protocol should be applauded, as it iswide range of attributes that concentrate primarily on assessment generally recognised that didactic education is not effective inaspects of care. getting clinicians to use guidelines with multi-mode strategies, as in this study. The method used for analysing data – that is, havingRelevance to clinical practice the observers analyse the data they collected, and the investigatorClinical guidelines should provide support for strategies known to also assessing the analysis – is a strength of the study. The research-positively influence practice. Further, the education of nurses to ers note that they integrated the think-aloud, observation anduse such guidelines optimally must take into account the highly interview data but do not elaborate how this was done, possiblycomplex iterative process and wide range of data sources used to because of the word limit imposed by the journal. Anyone inter-make decisions. ested in how this actually occurred would have to contact theCritique researchers. In their discussion, the researchers note that they wereThe study aim was to identify the concepts and attributes used by not able to determine the path between attributes and conceptsAustralian critical care nurses in their decision making before and (i.e. which came first) or the actual decision-making methods used.after the implementation of a nurse-initiated sedation protocol. A They note, however, that that they were able to identify relation-number of educational strategies were used to support implemen- ships between attributes and concepts. They suggest that theirtation of the sedation protocol including: individual and group findings can be used by educators when designing educationaleducation; protocol and its supporting evidence placed on the activities such as concept mapping to help to develop decision-intranet; laminated copies of the protocol available in the patient making skills in nurses. The findings were clearly reported, thecare areas; poster reminders; and audit and feedback. The aims table was easy to understand and the discussion considered theof the study were easy to identify and clearly stated, but the inclu- implications of the main findings. Overall, this study provides addi-sion of definitions of attributes and concepts would have been tional evidence about the concepts and attributes that critical carehelpful, because some phrases (such as level of sedation, comfort nurses draw on when they are making decisions about sedation.
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