Critical Care Nursing

Nursing Responsibilities in Critical Care

Historical Overview ,First Organization, Research Intensive Discipline, Five Areas ,Critical Care Environment ,Characteristics of ICU Environment ,Effects And Concerns ,Critical Care Development ,Physiological Monitoring ,Current Research Priorities Include the Following

Historical Overview 

    In the history of nursing the development of the specialty of critical care is fairly recent, paralleling the growth and development of intensive care units (ICUs) in the 1960s and 1970s. 

    The first ICUS were areas in the hospital designated for the care of patients recovering from anesthesia who required close monitoring during a period of physiological instability.

     Recognition of the efficiency and effectiveness gained from segregating any patients who required intensive nursing care for a short period of time was spurred by experiences in managing groups of critically ill patients, such as those injured in the Boston Coconut Grove fire of 1942 and victims of the polio epidemics of the 1950s. 

    The development of the mechanical ventilator and advances in coronary care led to recognition of the need for specialized skills and knowledge bases among nurses caring for these patients.

First Organization

    The first specialty organization was formed by nurses working in coronary care. As electrocardiographic monitoring became a routine tool in the care of many patients and critical care broadened to include the care of patients other than post anesthesia and those with cardiac disease.

    The American Association of Critical Care Nurses (AACN), originally named the American Association of Cardiovascular Nurses, was formed in 1969 (Lynbaugh & Fairman, 1992). 

    This step was rapidly followed by the development of continuing education programs, formal recommendations for critical care curricular content in undergraduate programs, and a certification program. Today, AACN is the largest specialty nursing organization in the world, with more than 65,000 nurses in the U.S. and 45 other countries.

    Heitkemper and Bond (2003) reviewed major advances in nursing research in critical care. Domains of nursing science predicted to emerge as important contenders for research priorities include genetic therapeutics and counseling, infection and emerging infectious epidemics, the aging population, high-risk neonates, health disparities, man-made and natural disasters, and the impact of gender on the mechanism, detection, and management of disease.

Research Intensive Discipline

    From the outset, critical care has been a research intensive discipline, both in medicine and in nursing. The initial narrow focus on maintaining physiological stability of the cardiopulmonary system undoubtedly contributed to the early commitment to research- based practice. 

    Dracup and Bryan-Brown (2003) observed an unprecedented change in the pace of critical care research and practice. Critical care researchers are venturing into multiple areas, including the impact of genomics and molecular biology on disease states. 

    At the same time, there is an increasingly vast amount of published research, coupled with a trend toward specialization. Yet critical care nurse scientists have been extraordinarily productive, creative, and sophisticated in their investigations. 

    A search of grants funded in 2003 by the National Institute of Nursing Research (NINR) yielded 24 federally funded studies of pediatric and adult patients with cardiac problems, four genetically-based studies, and more specifically, critical care research focusing on complex subjects such as heart-rate.

    Variability, prone positioning in pediatric patients with acute lung injury, gene expression in cerebral ischemia, the use of acute-care nurse practitioners in improving outcome in patients receiving long-term mechanical ventilation, and an ethnographic study of dying patients in surgical intensive care unit, examining family interactions with clinicians as the goal of care shifts from cure to comfort.

Five Areas 

    Phenomena of interest can be described as falling into five broad areas: 

(a) the critical care environment

(b) critical care nurses

(c) monitoring techniques

(d) interventions

(e) outcomes of critical care

    Journal articles published since 2003 in American Journal of Critical Care, Critical Care Nurse, Heart and Lung, Nursing Research, and Biological Re- search for Nursing were reviewed for evidence of significant trends and changing par- terns of inquiry.

Critical Care Environment 

    Interest in studying the critical care environment began with observation of post cardiotomy delirium in open heart surgery patients in the 1960s. Efforts to describe this phenomenon and identify causative factors soon broadened to include all forms of delirium and disorientation, grouped under the heading "ICU psychosis." 

    This syndrome is now called delirium, described as a disturbance of consciousness, characterized by in attention and a change in cognition or perceptual disturbance that develop rapidly (Truman & Ely, 2003). 

    Delirium, one of the most common complications in the ICU, has been found to be an independent risk factor for prolonged ICU and hospital stay, and higher mortality rates 6 months after discharge. 

    Delirium may be associated with visual and auditory hallucinations, and sometimes paranoid ideation. It is thought to be related to a variety of physiological, psychological, and environmental factors.

Characteristics of ICU Environment 

    Characteristics of the ICU environment that have been consistently implicated in studies and have been the target of changes in environment and care routines include sleep deprivation, social isolation, and multiple sources of unusual sensory stimulation, such as lighting and noise (Noble, 1982). 

    Predisposing risk factors that are present prior to hospital admission may trigger delirium's on- set, including age over 70 years, recent history of alcohol abuse, and transfer from a nursing home (Truman & Ely, 2003). 

    Precipitating risk factors occurring following patient ad- mission have been found to be any noxious stimuli initiated in the ICU setting, such as the administration of benzodiazepines, opiates, the performance of invasive procedures, and the emergence of electrolyte and fluid imbalance. 

    Severe metabolic changes causing imbalances in neurotransmitter concentrations are thought to act as the basic mechanism for delirium, although environmental factors are known to play a role in its development and symptomatic escalation.

Effects And Concerns 

    Another growing environmental concern is the potentially deleterious effects of light and noise in the neonatal intensive care unit on the growth and development of neonates, a subject that has received increasing attention from nurse scientists and greater funding for nursing research. 

    A third recurring theme in the scientific literature is the need for the ICU environment to appear less threatening to patient family members and to meet family needs. Thus, the subject of ICU visitation has been examined by many investigators, particularly as it affects attitudes of family members and staff nurses alike. 

    The emergency department as an environment of care has also been showcased as an important context of care, as the issue of family presence during patient resuscitation has received considerable attention by nurse researchers over the past several years. 

    The boundaries between the sheltered ICU environment and the rest of the world, however, have become more permeable, given the recent turmoil and changing nature of world events. 

    In response to these changes, Heitkemper and Bond (2003) recommend that nursing broaden its definition of environment to capture the threats of infectious dis- ease, disasters, and health disparities as environmental factors in need of further research.

Critical Care Development 

    During the first decade of critical care development, there was considerable interest in studying the practitioners of this new specialty. In general, research projects were aimed at describing characteristics of nurses who chose this area of practice, comparing them with non-ICU nurses. 

    In addition to looking for demographic differences, there was particular interest in the effects of working in the ICU environment on stress levels and the effects of stress, such as burnout and rapid turnover.

    Currently, the focus of research on critical care nursing has shifted to a broader recognition of the importance of collaborative, interdisciplinary care and appropriate levels of staffing in order to ensure patient safety, improve patient outcomes, and address the growing nursing shortage due to dissatisfaction with working conditions. 

    In a landmark study of more than 10,000 nurses and. 230,000 surgical patients, Aiken and col- leagues (2002) reported that when the safe patient-staff ratio exceeded 4 to 1 on a surgical floor, the frequency of patient deaths increased by 7% for each additional patient assignment added to the nurse's workload. 

    This problem is particularly salient in the highly complex critical care environment, where Cullen and colleagues (as cited in Dracup & Bryan-Brown, 2003) found that preventable adverse drug events are twice as frequent when compared with the incidence of medication related errors outside of the ICU, and where the risk of an adverse event rises by 6% for each day of ICU stay. 

    Proposed solutions evident in the literature include nursing interventions using a teamwork model to improve patient outcomes and the use of acute care nurse practitioners to over- see continuity of patient care.

Physiological Monitoring 

    Physiological monitoring has been the hallmark of critical care since its inception. Until the recent emphasis on reducing the cost of expensive services, the most common reason for ICU admission was either for frequent and close physical assessment by nurses or for monitoring of some physiological parameter that required specialized technology not available on the general hospital ward, such as electrocardiography or intracranial pressure monitoring. 

    It is understandable, then, that studies of monitoring techniques have been so prevalent. In a review of critical care practice research conducted in the decade 1979 to 1988 (VanCott, Tittle, Moody, & Wilson, 1991), the most common content areas were the effect of patient position on hemodynamic parameters (11%), cardiac output measurement (6%), and coagulation studies (5%). 

    In the past decade, the usefulness of physiologic monitoring continues to receive attention, especially in the continuing interest in the accuracy of measurement of cardiac output with position change, temperature, oxygen consumption, work of breathing, neuromuscular blockade, as well as the determination of novel biomarkers of inflammation, rejection of organ transplantation, and sepsis. 

    Greater numbers of critical care nurse researchers are receiving genetic training as well as federal funding for con- ducting basic laboratory and animal investigations, including such topics as diaphragmatic fatigue, cytokine response to inflammation, and genetic susceptibility to cerebral ischemia following brain injury.

    Interventional studies have become more frequent in the recent past. The majority of these studies have focused either on psychosocial interventions, such as teaching. communication techniques, or family support, or on specific nursing procedures, such as suctioning or chest tube drainage procedures. 

    Like much of nursing research in general, many ICU intervention studies have been limited by small sample sizes. In addition, earlier studies have typically used investigator-designed instruments, making comparisons across studies difficult; however, the use of standardized acuity rating systems, such as APACHE or TISS, to describe study populations and control for acuity have be- come more common. 

    In her year-end review of nursing intervention research, Naylor (2003) noted that between 1999 and 2002, there were 78 nurse-led studies funded by the NINR: several of these projects focused on the critically ill patient, such as measuring changes in cerebral blow flow during suctioning, determination of proper feeding tube placement and detection of aspiration, the provision of ventilator care in patients with Acute Respiratory Distress Syndrome, and meeting the psychosocial needs of the patient following acute myocardial infarction. 

    One very promising approach to the problem of small sample sizes is the AACN research program of large, multi-site studies coordinated by an AACN research team. These investigations, termed "Thunder Projects," have enabled researchers to conduct large, tightly controlled studies of nursing problems specific to critical care. 

    For example, Thunder Project I was a comparison of the effectiveness of heparinized versus non- heparinized flush solutions for maintaining patency of arterial catheters. This study, which supported the practice of heparinizing flush solutions, had a sample of 5,024 sub- jects (AACN, 1993). 

    The objectives of Thun- der Project II were to describe and compare patients' perceptions of pain and their responses to turning, wound drain removal, tracheal suctioning, femoral line removal, central line insertion, and nonburn wound dressing change (Puntillo, 2003). The sample size consisted of 91 children (ages 4 to 12), 151 adolescents (ages 13 to 17), and 5,959 adults (over 18 years of age). 

    Procedural pain intensity and its associated distress were found to vary depending on the specific procedure performed. Overall, adults and children (ages 4 to 7) reported turning to be the most painful and distressing procedure, while children (8 to 12 years old) rated tracheal suctioning as the worst, and adolescents found wound care to be the most painful and distressing. 

    More than 75% of children did not receive medication prior to and during a painful procedure, and more than 63% of adults did not receive any medication for procedural events. How patients were prepared for the procedure was found to be a key factor; anticipatory preparation should include analgesic administration and information about expected sensations that might occur.

    As is occurring in other disciplines, there has been a recent trend toward emphasizing outcomes research in critical care focused particularly on use of quality management tools such as critical pathways; systems of care, such as case management; and alternative environments of care, such as special care units and observation units. 

    It has been estimated that critical care accounts for 15% to 20% of total hospital costs (Berenson, 1984; Rudy & Grenvik, 1992). The high cost of critical care in the context of a national commitment to reducing health care spending will continue to make testing of more cost-effective approaches to care a research priority.

    The emphasis for research efforts has also been directed toward establishing best practices for nursing care. It is in this area of research that one can find numerous nursing studies in the scientific literature. 

    Nursing bedside practices of interest have included testing different methods for providing oral care for intubated patients, endotracheal suctioning with saline lavage, skin breakdown in open-heart patients, the beneficial effects of tight glycemic control of preoperative patients, and the success of a weaning protocol for patients receiving mechanical ventilation. 

    Qualitative approaches in research methodologies have flourished, such as focusing on patients living with heart failure, prolonged mechanical ventilation, nurse decision making about hemodynamic status, patient anxiety following cardiac surgery, and end-of-life care. 

    Predictive studies of risk factors have focused on long-term disability post head in- jury, transient myocardial ischemia, atrial fibrillation following open-heart surgery, delay in seeking treatment for chest pain, heart failure readmission, heart transplantation, and functional and cognitive status after cardiac surgery and cardiac rehabilitation. 

    Educational nurse-led interventions have targeted compliance as a primary goal in patients with heart failure using telephone counseling and a web-based approach, as well as supporting patients undergoing cardiac rehabilitation,

    Critical care research is expected to continue to concentrate in the areas of monitoring techniques, specific procedural interventions, and outcomes research. AACN's research priorities for the 1990s included ventilator weaning procedures, hemodynamic monitoring techniques, measurement of tissue oxygenation, and nutritional support modalities (Lindquist et al., 1993).

Current Research Priorities Include the Following

1. Effective and appropriate use of technology to achieve optimal patient assessment, management, and/or outcomes

 2. Creation of a healing, humane environment

3. Processes and systems that foster the optimal contribution of critical care nurses

4. Effective approaches to symptom management

5. Prevention and management of complications.

    In addition to the need for more multi-site studies in order to generate adequate sample sizes, there continues to be a need for the development of valid and reliable instruments that can measure outcomes, other than physiological parameters, that are sensitive to nursing interventions. 

    In addition, many of the previously reported intervention studies should be replicated and tested with varying populations. 

    Naylor (2003) pointed out that given the complex nature of effective interventions, the science underlying these interventions often spans knowledge derived from multiple disciplines, requiring the expertise and collaboration of scientists working in the basic, clinical, social, and behavioral sciences. 

    For nurse scientists to succeed in the implementation of programs of research and dissemination of findings, they will need to utilize interdisciplinary collaboration and, ultimately, find ways to effectively transcend traditional disciplinary boundaries for the sake of addressing fundamental health issues and improving the health of individuals, families, communities, and society.