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The Concept of Holism Applied to Critical Care Nursing Practice 1 Critical Care Nursing Practice: An Integration of Caring, Competence, and Commitment to Excellence 2 The Patient’s Experience With Critical Illness 3 The Family’s Experience With Critical Illness 4 Impact of the Critical Care Environment on the Patient 5 Relieving Pain and Providing Comfort 6 Patient and Family Education in Critical Care

one two three four five six seven eight nine ten eleven twelve

INTERNET RESOURCES Topic

Web Page Address

Agency for Healthcare Research and Quality (AHRQ)

www.ahrq.gov

American Association of Critical Care Nurses

www.aacn.org

American Chronic Pain Association

www.theacpa.org

American Holistic Nurses Association (AHNA)

www.ahna.org

American Pain Foundation

www.painfoundation.org

American Society of Pain Management Nurses

www.aspmn.org

Center for Medical Ethics and Mediation

www.wh.com/cmem/

Cochrane Collaboration (evidence-based practice)

www.cochrane.org

End of Life Nursing Education Center

www.aacn.nche.edu/elnec

Hospice and Palliative Nurses Association

www.hpna.org

Institute for Family Centered Care

www.familycenteredcare.org

International Center for Control of Pain in Children

www.pedspain.nursing.uiowa.edu

National Center for Complementary and Alternative Medicine

www.nccam.nih.gov

National Center for Cultural Competence

http://gucchd.georgetown.edu/nccc/cultural.html

National Guideline Clearinghouse

www.guidelines.gov

National Hospice and Palliative Care Organization

www.nhpco.org

The Patient Education Institute

www.patient-education.com

Promoting Excellence in End-of-Life Care

www.promotingexcellence.org

Transcultural Nursing Society

www.tcns.org

US Preventive Services Task Force

www.ahcpr.gov/clinic/uspstfix.htm

chapter

Critical Care Nursing Practice: An Integration of Caring, Competence, and Commitment to Excellence MICHAEL RELF

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ROBERTA KAPLOW

Evidence-Based Critical Care Nursing Practice Critical Thinking Is Essential to Critical Care Certification and Critical Care Nursing Practice The Synergy Model Collaboration The Family, Critical Illness, and Current Evidence Spirituality and Caring During Critical Illness and at the End of Life Professional Organizations and Resources American Association of CriticalCare Nurses: A Commitment to Excellence The Future of Critical Care Nursing

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objectives Based on the content in this chapter, the reader should be able to: ■ Describe the value of evidence-based practice in caring for critically ill patients. ■ Discuss the value of critical thinking in critical care. ■ Describe the value of certification. ■ Provide examples of how the Synergy Model can promote positive patient outcomes. ■ Discuss the value of collaborative practice in critical care. ■ List benefits of membership in the American Association of Critical-Care Nurses. ■ Discuss future issues facing critical care nursing practice.

s the health care delivery system continues to evolve, so too does nursing and critical care. Today, the care of critically ill patients occurs not only in the “traditional” setting of the hospital intensive care unit (ICU), but also on the progressive care unit, the medical unit, and the surgical unit as well as in the subacute facility, the community, and the home. Since the first critical care unit (CCU) opened in the late 1960s, significant technological advances have occurred, accompanied by a knowledge explosion in critical care nursing. Consequently, critical care nurses of the 21st century are routinely caring for the complex, critically ill patient. This is accomplished by integrating sophisticated technology with the psychosocial challenges and ethical conflicts associated with critical illness, while at the same time addressing the needs

and concerns of family members and other significant people in the patient’s life. In response to the ever-changing delivery system, critical care nurses are championing the needs of the patient and the family or significant others. During the last several decades, critical care nurses have experienced firsthand what nurse researchers have consistently demonstrated—however it is comprised, critical illness is not only a physiological alteration, but a psychosocial, developmental, and spiritual process. Critical illness is also a threat to the individual and his or her family constellation. As health care becomes increasingly technological, the concurrent need for humanization has become even more essential. Compatible with the need for “humanized” health care is the need to provide effective 3

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interventions that are based on evidence instead of being steeped in tradition.

EVIDENCE-BASED CRITICAL CARE NURSING PRACTICE Today’s health care system has become increasingly more costly and complex. Consequently, in this market-driven delivery system, there is a greater emphasis on outcomes, cost-effectiveness, and consumer satisfaction. These pressures operate in an environment of rapid information exchange, technological advancements, and an increasing nursing workload. Nurses are challenged to maintain clinical competence, to demonstrate how their care positively affects patient outcomes, and to participate actively in clinical decision making and practice improvements. Furthermore, nurses are now mandated to demonstrate cost-effectiveness and efficiency with the use of time and resources, while continuing to demonstrate their valueadded impact on outcomes. These mandates provide a strong rationale for adopting an evidence-based model of practice. As reported by the President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry in 1998, “improving the quality of healthcare requires a commitment to delivering healthcare based on sound scientific evidence and continuously innovating new, effective healthcare practices and preventive approaches.”1 Payers advocate the use of an evidenced-based practice model (EBP) in an effort to identify health care costs that are not beneficial.2 There are many instances in critical care nursing, and in nursing overall, when nurses wonder if they are providing the best possible intervention or using the best product to attain optimal patient outcomes. Too frequently, the responses may be “We’ve always done it that way,” “That’s what I learned in my undergraduate nursing program,” or “I prefer to do it this way.” Unfortunately, these common comments do not reflect the sophisticated knowledge base or experiential practice base that nurses use on a daily basis. Evidence-based practice (EBP) has been defined as the use of the best clinical evidence from systemic research in making patient care decisions.3 It is a process used by nurses to integrate the best and most timely scientific evidence with clinical expertise when making health care decisions. The methods are derived from evidence-based medicine developed as a paradigm and method in Canada.4,5 EBP is a framework in which to determine the best means to care for patients and make informed decisions concerning nursing policies and procedures in order to influence patient outcomes. It is not intended to take the place of clinical nursing judgment and expertise. Rather, EBP combines evidence with clinical expertise and patient preferences to promote positive patient outcomes and excellence in nursing practice. EBP is a method used by nurses as a basis for clinical decision making in an effort to optimize patient care and outcomes. It is predicated on the notion that clinical practice, guidelines, standards, and protocols should be derived from evidence from randomized clinical trials, which

allows nurses to confirm or challenge the ways they provide and evaluate care.6 Results of a meta-analysis have demonstrated that patients who receive research-based interventions and care have better outcomes than patients who receive traditional care.7 In addition, nurses are legally responsible for the care provided in EBP. They are therefore also responsible for knowing the research foundation for practice and for determining the best interventions based on critique and application of the research.8 Box 1-1 provides an overview of the essential steps to evidencebased critical care nursing practice.

CRITICAL THINKING IS ESSENTIAL TO CRITICAL CARE In addition to using evidenced-based critical care nursing interventions to deliver optimal care to critically ill patients and families, critical care nurses need a strong knowledge base and critical thinking skills. Critical thinking skills

box 1-1 Steps to Evidence-Based Critical Care Nursing Practice 1. Accept the fact that health care is evolving, with the consequent need to base nursing care on evidence, rather than on tradition or previous education. 2. Identify a need for change in practice by examining less-than-favorable patient outcomes; causes of patient, family/significant other, or staff dissatisfaction; or situations in which compelling new evidence exists in an aspect of care. Targets for changing practice may include high-risk, high-volume, or high-cost procedures and interventions. 3. Frame a clinical question and search the literature for evidence regarding the topic. 4. Once current research data and evidence have been collected, evaluate the evidence for scientific merit, quality, and applicability. Inherent in this process is the need to determine if findings have been replicated and that they are relevant (applicable) to the clinical question posed, and whether the data identified constitute the best evidence. 5. Synthesize to determine the strength of the evidence to support a change in practice. 6. Conduct a comparison between current practice recommendations and current research. 7. If there is sufficient evidence to suggest a change in practice and the change in practice is practical in respect to costs, staff skill, and resources required, application of the evidence into practice can occur. Implicit in the implementation of evidence are the issues associated with change, including fear of change and the need for information, staff training, leadership, and ongoing evaluation of the change. 8. Continue to evaluate the evidence through an ongoing and systematic review to promote stateof-the-science nursing care.

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allow the nurse to see the patient’s “big picture” through the analysis of patient data, the evaluation of problems that emerge in the clinical setting, and the determination of appropriate interventions to solve the clinical issue. Critical thinking allows the nurse to conduct a cost–benefit analysis for any and all therapies indicated, while delving into the viability of alternative strategies to care. Although national organizations and nurses in the clinical arena identify critical thinking skills as pivotal to competent nursing practice, education often focuses on the memorization of facts regarding clinical care rather than on critical thinking as a process essential to care.9 Between 1995 and 1998, an international panel of expert nurses representing nine countries and the United States identified and defined 10 affective components (habits of the mind) and 7 cognitive skills of critical thinking. The affective components include confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual ability, intuition, open-mindedness, perseverance, and reflection. The cognitive skills comprising critical thinking include analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge.10 All of these components are essential for providing quality care to critically ill patients. Nurses must be able to use these comprehensive skills to perform clinical decision making and problem solving as they care for patients with complex, multisystemic problems. The value of critical thinking skills has become increasingly important in the face of rapid changes in the health care environment, including procedural changes and technological advances.11 The development of critical thinking skills in nursing students and new critical care nurses is a major challenge confronting nurse educators in the academic and clinical settings.12 Traditional teaching methods such as lecture, handouts, and observation do not stimulate critical thinking skills. Consequently, complementary teaching methods are essential to facilitate the application of theoretical knowledge to the bedside, particularly during the transition of the new graduate or experienced nurse into the critical care environment. There are several strategies that may be used to enhance critical thinking skills. These include the use of case studies, simulation, videotaped vignettes, role playing, games, and clinical questioning. Clinical preceptors, managers, clinical educators, and clinical nurse specialists, along with staff nurse colleagues, need to create environments conducive to critical thinking for the new critical care nurse. By mentoring and role modeling, experienced critical care nurses can encourage creative problem solving, facilitate open dialogues, and discuss clinical issues, while at the same time facilitating the transition from novice to expert.13 Simultaneously, new as well as experienced critical care nurses need to challenge underlying beliefs related to their practice and evaluate alternative strategies for care.14 Critical thinking skills are required to evaluate practice and use an EBP model, which results in optimal patient outcomes. Similar to EBP, the application of critical thinking skills has been shown to improve clinical outcomes and is associated with a decrease in errors and sentinel events.15 Through the development and application of critical thinking, the level of competence of the critical care nurse will be

Critical Care Nursing Practice

5

increased, producing quality patient outcomes. Time, experience in the clinical arena, and the critical thinking skills themselves contribute to the development of a critical thinker. In addition, it is essential to establish a unit culture of openness, respect, and trust, which allows the novice as well as the experienced critical care nurse to ask questions, seek information, and critically analyze practice.

CERTIFICATION AND CRITICAL CARE NURSING PRACTICE Certification is a process by which a nongovernmental agency validates, based on predetermined standards, the qualifications and knowledge of an individual nurse that are necessary for practice in a defined functional or clinical area of nursing.16 In 1975, the American Association of Critical-Care Nurses (AACN) established the Certification Corporation. The purpose of the Certification Corporation was to develop the critical care registered nurse (CCRN) certification examination program. The purpose of the certification process, consistent with the definition of certification, is to have a means for developing, maintaining, and promoting high standards of critical care nursing practice.17 The ultimate goal is to provide optimal care to critically ill patients and their families in a dynamic health care environment. The CCRN credential acknowledges that the nurse has attained a knowledge base that is essential to critical care nursing practice, as well as the ability to synthesize, interpret, and apply this knowledge to the care of the patient.18 To date, 50,000 nurses worldwide have received the CCRN credential in adult, pediatric, and neonatal critical care nursing. This credential validates to patients, peers, and hospital administrators the nurse’s competence and commitment to excellence in critical care nursing. Because the standards for the examination are high, certification is well respected throughout the health care community.18 In May 2002, Terry Richmond19 described the value of critical care certification in her address to the attendees of the CCRN luncheon at the National Teaching Institute. She described certified nurses as “the heroes of critical care” and noted three gifts that certified nurses give their patients. The first gift is the “gift of knowledge.” The specialty of critical care requires high levels of preparation and the in-depth knowledge necessary for providing optimal care. CCRN certification is a powerful external validation of this critical knowledge and a gift that critical care nurses give themselves and their patients. The second gift is the “gift of caring.” Once a critical care nurse has attained the necessary breadth, depth, and currency of knowledge, energy can be put into other foci of care. A patient can be seen as not merely a diagnosis, but as a person with a family or significant other who likewise has needs. According to Richmond, the gift of caring is essential to being a hero. Knowledge and caring go hand in hand; one without the other does not translate into quality care. The third gift is the “invitation into lives.” A certified nurse can walk into a patient’s life with knowledge and caring during the most vulnerable period in that person’s life. Critical illness will never be ordinary for a patient and family. Nor should critical illness ever become ordinary for a

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nurse. A certified practice that uses these gifts promotes optimal patient outcomes and is nothing less than extraordinary. The process of certification enhances the profession and practice of nursing by encouraging nurses to attain the breadth and depth of knowledge required for successful completion. This is essential to the practice of giving quality nursing care to critically ill patients and their families.19

THE SYNERGY MODEL In August 1999, the AACN implemented the Synergy Model to link certified practice to clinical outcomes. Synergy is an evolving phenomenon that occurs when individuals work together in mutually enhancing ways toward a common goal. The Synergy Model describes nursing practice on the basis of the needs and characteristics of patients rather than in terms of diseases and treatment modalities. The underlying premise of the Synergy Model is that the characteristics of patients and families influence and drive the characteristics and competencies of nurses. Because each patient brings a set of unique characteristics to the clinical situation, nurses must possess their own unique characteristics and competencies. When patient characteristics and nurse competencies match and synergize, optimal patient outcomes can be attained.20

Two major tenets of the Synergy Model are that the characteristics of the patient are of concern to nurses and that the competencies of the nurse are important to patients. Although each patient and family is unique, all patients have similar needs and experience these needs across a continuum, from low to high. The more compromised the patients are, the more complex are their needs. Nursing practice is determined by the needs of patients and their families. Nursing care reflects an integration of the knowledge, skills, and experience necessary to meet the needs of patients and their families. The Synergy Model focuses on the unique contributions of nursing to patient care and emphasizes the role of the professional nurse. The eight patient characteristics and nurse competencies are listed and defined in Box 1-2. The eight nurse competencies also exist on a continuum, from competent to expert. Figure 1-1 provides a schematic representation of the Synergy Model and the interrelationships between the patient and family, and the patient and nurse characteristics. There are three perspectives from which to evaluate outcomes using the Synergy Model. These are outcomes derived from the patient, the nurse, and the health care system.20 Optimal outcomes are based on what patients define as important. These may include functional change, behavioral change, trust, satisfaction, comfort, and quality of life.

box 1-2 Patient Characteristics and Nurse Competencies as Described by the Synergy Model Patient Characteristics ■

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Resiliency: The capacity to return to a restorative level of function using compensatory coping mechanisms; the ability to bounce back quickly after an insult Vulnerability: Susceptibility to actual or potential stressors that may adversely affect patient outcomes Stability: The ability to maintain a steady-state equilibrium Complexity: The intricate entanglement of two or more systems (e.g., body, family, therapies) Resource availability: Extent of resources (e.g., technical, fiscal, personal, psychological, social) the patient, family, and community bring to the situation Participation in care: Extent to which the patient and family engage in aspects of care Participation in decision making: Extent to which the patient and family engage in decision making Predictability: A summative characteristic that allows one to expect a certain trajectory of illness

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Nurse Competencies ■

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Clinical judgment: Clinical reasoning, which includes clinical decision making, critical thinking, and a global grasp of a situation, coupled with nursing skills acquired through a process of integrating formal and experiential knowledge Advocacy/moral agency: Working on another’s behalf and representing the concerns of the patient, family, and community; serving as a moral agent in identifying and helping resolve ethical and clinical concerns in the clinical setting

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Caring practices: The constellation of nursing activities that are responsive to the uniqueness of the patient and family and that create a compassionate and therapeutic environment, with the aim of promoting comfort and preventing suffering; these caring practices include, but are not limited to, vigilance, engagement, and responsiveness Collaboration: Working with others (e.g., patients, families, health care providers) in a way that promotes and encourages each person’s contributions toward achieving optimal and realistic patient goals Systems thinking: The body of knowledge and tools that allows the nurse to appreciate the care environment from a perspective that recognizes the holistic interrelationship that exists within and across health care systems Response to diversity: The sensitivity to recognize, appreciate, and incorporate differences in the provision of care; differences may include, but are not limited to, family configuration, lifestyle, socioeconomic status, age values, and alternative medicine involving patients and their families and members of the health care team Clinical inquiry or innovator/evaluator: The ongoing process of questioning and evaluating practice, providing informed practice, and innovating through research and experiential learning; the nurse engages in clinical knowledge development to promote the best patient outcomes Facilitator of learning: The ability to facilitate learning for patients, nursing staff, physicians, and members of other health care disciplines; includes both formal and informal facilitation of learning

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Critical Care Nursing Practice

Cl ini c

Fa c ilita tor

en

Stability

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Resource Availability

Resiliency

Complexity

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s n oratio llab Co

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Outcomes derived from the nurse may include physiological changes, presence or absence of complications, and the extent to which treatment objectives were attained. Outcomes derived from the health care system include recidivism, costs, and resource utilization.20 One manner in which the Synergy Model can be used in clinical practice involves making patient care assignments. Traditionally, in an effort to enhance the continuity of care, patient assignments were made based on the person who cared for the patient the previous day. Using the Synergy Model, the nurse who demonstrates the competencies that match the patient’s needs at that time would be best suited for the assignment. For example, if a patient is in a stable, unpredictable, minimally resilient, and vulnerable condition based on the model’s definitions, the nurse who excelled in clinical judgment and caring practices would be ideal for this patient. If the patient was vulnerable, unable to participate in decision making, and had inadequate resource availability, the primary competencies would focus on advocacy/moral agency, collaboration, and systems thinking. The Synergy Model is currently being evaluated to determine if nurses define their practice based on patient needs, if the patient characteristics accurately describe the full spectrum of those being cared for, and if patients experience optimal outcomes when patient–nurse synergy is achieved.

Pr a

Participation in Care

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Predictability

cacy/Moral Agenc Advo y

Clinical Inquiry

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CRITICALLY ILL PATIENT/ FAMILY

Ca rin g

figure 1-1 The relationship between the patient/family and the nurse in the Synergy Model.

al

em

Vulnerability

Participation in Decision Making

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ARACTERIST SE CH ICS NUR

Collaboration In the Synergy Model, the AACN defines collaboration as “working with others (e.g., physicians, families, healthcare providers) in a way that promotes/encourages each person’s contributions toward achieving optimal/realistic goals. Collaboration involves intra- and interdisciplinary work with colleagues.”21 Since the publication of the Health of the Nation document in 1992, collaborative practice has been at the forefront of health service reform.22 Effective planning of care to meet the needs of critically ill patients and their families who have complex, multisystemic problems requires a multidisciplinary approach to attain timely and optimal outcomes. In addition to meeting health care needs, collaborative practice is further encouraged so that limited federal funds may be used more efficiently.23 Empirical data exist that support the value of a collaborative working relationship between nurses and physicians in the intensive care setting. A collaborative relationship has been linked to higher job satisfaction and retention of nurses, a higher level of patient satisfaction, and lowerthan-expected mortality rates and patient lengths of stay.24 Although leading organizations have put forth recommendations for multidisciplinary efforts and practitioners agree that interdisciplinary collaboration is important to attain optimal patient outcomes, there has been hesitation in adopting collaborative working practices.24,25 One

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reason cited for this problem is the lack of opportunities for medical and nursing students to develop collaborative skills.26,27 Barriers to effective collaboration also include reimbursement, territorialism, and role confusion on the part of the health care team and the general public.28 In one study, nurses reported “too many physicians on the case” and a “power struggle” between the patient’s primary service and specialty physicians as rationales for patient problems not being resolved.24 In the same study, one primary care physician felt that nurses who had medical opinions different from the physician’s were difficult to work with. Another primary care physician felt that nurses would go “doctor shopping” for a physician to give them orders for therapy if they did not receive orders for the interventions they thought were appropriate for their patients.24 One area of specialized nursing in which collaboration is inherent in the job description is that of the nurse practitioner (NP). When NPs accept a position, they are usually given a practice agreement. This collaborative practice agreement is a written statement that defines the joint practice of the physician and NP in a collaborative and complementary working relationship. It delineates the responsibilities of each professional and their respective contributions toward optimal patient outcomes.23 The physician and NP must work together in a successful, complementary, and unified manner to obtain these optimal outcomes. In her Presidential Address at the 31st Congress of the Society of Critical Care Medicine (SCCM), Maureen Harvey described “invisible excellence.” Inherent in this concept is the role of the critical care nurse who is vigilantly monitoring the patient, recognizing subtle changes in the patient’s clinical status, and thwarting critical events through collaboration with the intensivist. Nurse–physician collaboration as well as collaboration with the clinical dietitian, clinical pharmacist, respiratory therapist, physical therapist, occupational therapist, and chaplain are essential for obtaining optimal patient outcomes. These outcomes should reflect the contributions made by all disciplines. Collaboration between researchers and practitioners in both disciplines is essential to provide a scientific basis for that practice.29

The Family, Critical Illness, and Current Evidence Not long ago, the thought of families staying in the CCU and participating in care was almost unimaginable because of restricted and rigid visiting hours in many CCUs.30,31 In addition, the concept that children, animals, or non–legally recognized significant others should not visit a person in the CCU was widespread and went unchallenged.32 Today, patient, family, and significant other advocates have challenged the “status quo” and instituted a change of visitation policies based on consumer dissatisfaction and current evidence.30 Although open visitation is not standard practice in every CCU, many CCUs have modified visiting policies to allow not only immediate family to visit, but significant others, children, friends, and, in some instances, even pets.32–34 Expanded visitation promotes resiliency of the human spirit and allows the vulnerable critically ill patient to connect with significant people that he or she

would encounter in daily life. Simultaneously, the critical care nurse must use clinical judgment to assess the impact of visitation on the physiological and psychological status of the patient and significant others, while promoting involvement in care and decision making.32,33 As CCUs shift from closed to open units, new clinical controversies will develop and be evaluated through clinical inquiry and research. Two of the future challenges confronting critical care nurses and the “traditions” of the CCU are the role and inclusion of families during trauma or cardiopulmonary resuscitation (CPR) and the role of family or significant other as caregivers in assisting or independently providing care in the critical care environment.35–37 Less than a century ago in the United States, families and significant others were the primary caregivers to critically ill persons and persons at the end of life; this remains the case in much of the world today.

Spirituality and Caring During Critical Illness and at the End of Life Despite innovations and advances in technology and other therapeutic interventions, patients still transition from life to death in the CCU. Death, whether expected as a consequence of end-stage cancer or terminal weaning, or unexpected because of trauma or postoperative complications, is viewed as the failure of caring practices for many. During critical illness and at the end of life, issues of spiritual distress, mortality, family dysfunction, grief, hopelessness, helplessness, and many other feelings and emotions may present as part of the coping mechanisms of the individual patient, his or her family or significant others, and members of the health care team.38 Acuity, unplanned hospitalizations, and patient–family and significant other separation are all potential sources of stress during any illness. Regardless of the acuity, the expected outcome, or the availability of interventions, a caring, competent nurse is essential.39 During critical illness where outcomes are uncertain, the nurse competencies described in the Synergy Model are paramount. This is especially true when delivering interventions where the predictability of the outcomes is unknown, the stability of the patient is tenuous or deteriorating, and the complexity of care is ever increasing. Similarly, at the end of life, where helplessness, hopelessness, and spiritual distress may be manifested, caring nursing interventions aimed at alleviating suffering are essential. These interventions must also address patient and family involvement in care and decision making through advocacy, collaboration, and systems thinking.

PROFESSIONAL ORGANIZATIONS AND RESOURCES American Association of Critical-Care Nurses: A Commitment to Excellence The AACN was established in 1969 to help educate nurses working in ICUs. Currently, it is the largest specialty organization in nursing, with over 65,000 members in the

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United States and abroad who care for critically ill patients across the life span. In its mission statement, AACN identifies members as the key to its success. To that end, AACN is committed to providing the highest-quality resources to maximize the nurse’s contribution to caring and improving the health of critically ill patients and their families. AACN is dedicated to providing its members with the knowledge and resources necessary to help them provide optimal patient care.18 Holding membership in professional specialty nursing organizations has several benefits for the “card holder.” It provides members with the opportunity to network with colleagues on the national, regional, and local level, while providing them with a mechanism to obtain current information in their specialty area. In addition, AACN provides members with numerous other benefits that help to enhance professional practice.18

credits. Readers of Critical Care Nurse obtain information on the latest critical care trends. In addition, members receive AACN News, a newsletter that keeps readers apprised of current trends in health care as well as organization, chapter, and certification issues.18

AACN ONLINE AACN Online is a comprehensive critical care Internet website. It provides members with the most recent resources in clinical practice, continuing education, and professional development. AACN Online also allows members to discuss issues and share information with other professional colleagues, obtain clinical practice information, and participate in interactive learning discussions. AACN members have 24-hour access to the website.18

As health care continues to evolve, so too must critical care nursing. As the past few years have demonstrated, critical care nursing will continue to be provided not only in the inpatient specialty critical care units, but on the medical, surgical, oncology, and stepdown units, as well as in the outpatient and home settings. Consequently, the demand for caring, competent, knowledgeable, and skilled critical care nurses will continue. As the “baby boom” generation ages, and with the expansion of CCUs beyond the traditional ICU, the demand for critical care nurses will continue to rise.40 Concurrent with an increased demand for expert critical care nurses is the need for recruiting, developing, and retaining expert clinicians in an era of nursing shortage. The ongoing and cyclical nature of the nursing shortage has had a direct impact on CCUs across the United States.40,41 According to Needleman and colleagues,41 the lack of trained registered nurses to provide direct nursing care has had a direct impact on the quality of patient care and consequently has also affected organizational effectiveness and outcomes. In response to an increased need for nurses, particularly critical care nurses, many organizations continue to use supplemental staffing by caring, competent, knowledgeable critical care nurses. Whether the critical care nurses are part of the organization’s staff or are supplemental staff, consumers and third-party payers alike will continue to mandate competence, proven interventions derived from EBP, cost-effectiveness, and quality outcomes. Simultaneously, the CCUs of tomorrow will be even more technologically challenging. Therefore, critical care nurses of the future must not only be technologically proficient, but competent in the psychosocial, developmental, spiritual, and caring domains to interact successfully with the patient, the family and significant others, and the other members of the health care team. With advances in technology and new interventions discovered through EBP, greater numbers of patients will be afforded interventions that sustain and improve the quality of their lives. However, with the implementation of advances in technology, patients in the CCU will continue to require caring, competent, and knowledgeable critical care nurses. These nurses will serve as patient advocates, facilitate interdisciplinary collaboration, navigate complex delivery

PRACTICE RESOURCE NETWORK The Practice Resource Network (PRN) provides members with the opportunity to network with professional colleagues. Once the PRN network is accessed from the AACN website, members begin by selecting from 1 of 32 topics about which they would like additional information. The topics include all body systems, several acute care specialties, educational content, informatics, administration/ regulatory information, ethical and legal issues, and standards and guidelines for practice, to name a few. The service can be used to help problem-solve clinical dilemmas, access current practice and research information, identify public policy issues as well as resources, and connect with colleagues with similar interests.18 EDUCATIONAL MERCHANDISE All members of AACN can receive educational materials at discounted prices. AACN has educational resources available in several areas, including clinical practice, research, leadership, ethics, and professional development.18 PUBLICATIONS Members of AACN receive two bimonthly journals, The American Journal of Critical Care and Critical Care Nurse. The former is a scientific research journal in which critical care colleagues publish research findings, expanding the current state of the science of critical care nursing. It is an ideal journal to use as a basis for a literature review for an EBP model. Critical Care Nurse is a specialty journal that publishes articles related to current clinical practice topics. For example, a recent issue explored how the Synergy Model is applied in clinical practice by nurses, educators, or management. The journal also offers its readers opportunities for obtaining continuing education

LOCAL CHAPTER AFFILIATION Once nurses have joined the national AACN, they can extend their membership to the local level. Local chapter affiliation provides members with the opportunity to network with peers in their immediate area, become involved with chapter activities, and attend the educational programs offered, thereby enhancing their professional development.

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and reimbursement systems, and facilitate learning, while responding to diverse communities who are vulnerable owing to complex needs. These are the exciting challenges awaiting critical care nurses—challenges, it is hoped, that critical care nurses will surmount with commitment, dedication, and grace!

clinical applicability challenges Self-Challenge: Critical Thinking 1. Describe a patient care situation that exemplifies the use of

the Synergy Model. 2. Identify a problem in your area of practice that needs to be changed, based on evidence in the nursing scientific literature. 3. Describe a situation where collaboration with other members of the health care team enhanced patient outcomes.

Study Questions 1. The first step to evidence-based critical care nursing practice

2.

3.

4.

5.

is to a. frame a clinical question based on clinical observation. b. conduct a literature search and evaluate the evidence. c. implement a needs assessment of critical care nurses. d. accept the fact that health care is continually evolving. According to the Synergy Model, which of the following characterizes the nurse competency of systems thinking? a. The ongoing process of questioning and evaluating practice b. The sensitivity to recognize, appreciate, and incorporate differences in the provision of care c. The ability to appreciate the care environment from a perspective that recognizes holistic interrelationships d. The ability to facilitate learning of others while fostering the work of others in a way that facilitates optimal and realistic patient goals A domestic partner of a critically ill patient expresses an interest in learning how to provide skin care. According to the Synergy Model, this illustrates which of the following patient characteristics and nurse competencies? a. Participation in decision making and caring practices b. Participation in care and response to diversity c. Resource availability and advocacy/moral agency d. Stability and facilitator of learning A new drug has been approved to treat coronary ischemia. Before the introduction of the drug in clinical practice, a critical care nurse conducts a series of in-services about the drug’s dosing and side effects, and related nursing interventions. This is an example of a. caring practices. b. clinical inquiry. c. facilitator of learning. d. collaboration. A certified critical care nurse uses case study analysis and reading clinical journals to maintain a personal practice of clinical excellence. These activities are essential elements of

a. b. c. d.

critical thinking. evidence-based practice. caring practices. advocacy/moral agency.

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CHAPTER 1 27. Dosser DA, Handron DS, McCammon SL, et al: Challenges and strategies for teaching collaborative interdisciplinary practice in children’s mental health care. Fam Syst Health 19(1):65–82, 2001 28. Neale J: Nurse practitioners and physicians: A collaborative practice. Clin Nurse Specialist 13(5):252–258, 1999 29. Harvey M: Invisible excellence. Presidential Message at the Society of Critical Care Medicine 31st Congress, San Diego, CA, Society of Critical Care Medicine, January 2002 30. Roland P, Russell J, Richards KC, et al: Visitation in critical care: Processes and outcomes of performance improvement initiative. J Nurs Care Qual 15(2):18–26, 2001 31. Clarke C, Harrison D: The needs of children visiting on adult intensive care units: A review of the literature and recommendations for practice. J Adv Nurs 34(1):61–68, 2001 32. Simon SK, Phillips K, Badalamenti S, et al: Current practices regarding visitation policies in critical care units. Am J Crit Care 6(3):210–217, 1997 33. Simpson T, Wilson D, Mucken N, et al: Implementation and evaluation of a liberalized visiting policy. Am J Crit Care 5(6):420–426, 1996

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