Realizing the contribution of critical care nurses

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Realizing the contribution of critical care nurses

• Dr Carol Ball
• Consultant Nurse Critical Care
• Royal Free Hospital, London
• Senior Research Fellow
• City University, London

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strives to capture the contribution made by
nurses and midwives to the care of
patients/clients through their interventions and
the extent of measurement of their
interventions p12
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(No Transcript)
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Why is nursing contribution a subject of debate
in critical care?

• NursePatient Ratios
• Not comparable
• Increased need for flexibility
• Technological advancement
• Increasing shortage of nurses
• Largest proportion of cost is associated with
  Nursing

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TISS
GRASP
System of Patient Related Activity
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Flaws in the measurement of nursing workload

• Emphasis placed on what nurses do, rather than
  what they might achieve
• Measure patients need for technology rather than
  their need for a nurse
• Relies on nurses to care plan effectively
• Fail to address need for supervision and training
• Lack definition in terms of what they are trying
  to measure and why

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What is the risk associated with less nurses?
FAILURE TO RESCUE

• Increase in catheter related infections (Robert
  et al 2000, Fridkin et al 1996)
• ? risk of mortality (Tarnow-Mordi 2000)
• ? risk of pulmonary and infectious complications
• Abdominal Aortic Aneurysm (Provonost et al, 2001)
• Hepatectomy (Dimick et al, 2001)
• Oesophagectomy (Amaravadi, et al 2000)

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Hospitalised patients who die following the
development of one or more of six complications
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• DVT / PE
• Acute Renal Failure
• Pneumonia
• Sepsis
• GI haemorrhage
• Cardiac Arrest

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Study 1 Nursing Contribution

• What difference do nurses make to the recovery of
  critically ill patients, the support of relatives
  and how do they prevent deterioration?

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The Scope of the Study

• January April 2002
• Six Acute Trusts London Region
• 5 Teaching Hospitals
• 1 District General Hospital
• Ten Critical Care Units
• Seven Level 3 Units
• Three Level 2 Units

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Methods

• Four data collection tools
• 33 Observation Participation episodes
• 390 hours
• Interview Sample
• 231 nurses
• 51 relatives
• Analysis Burnard (1991)

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Results
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Contextual Issues

• Geographical Disposition
• Not purpose built so ? Fit for purpose!
• Overall Activity
• Transfers, Admissions
• Patient Dependency
• Patients need for nursing
• Skill Mix
• A nurse is not a nurse is not a nurse!

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Results
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Nurse Attributes

• Knowledge
• Theoretical
• Patient related
• Experience
• Clinical
• Exposure
• Critical events

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Results
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The Nursing Contribution

• Patient Centred Task Orientated
• Proactive Progress Hindered
• Vigilance Fail to Appreciate Cues
• Coping Unpredictable Ineffective Coping
• Emotional Support Emotional Tension

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Patient Centred

• Personalising Patient Space
• Maintaining the humanity of the patient
• Encouragement
• Task Orientated
• Uncaring

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Proactive

• Care pathway determined by nurses
• Medical Plan and Nursing Plan
• Nursing Intervention to achieve progress
• Autonomy and Negotiation
• Physical and Technical Appraisal
• Progress Hindered
• Unable to give full attention patient at risk
• Lack of knowledge

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Vigilance

• Looking Ahead
• Aware of Potential Complications
• Maintaining Patient Safety
• Failure to Appreciate Cues
• Knowledge, Experience, Exposure
• Increased Ratios
• Poor Communication

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Coping with the Unpredictable

• Completely Unpredictable
• Reasonably Anticipated
• Knowledge, Experience, Exposure
• Reprioritising
• Ineffective Coping
• Knowledge, experience, exposure
• Geography, activity, skill mix, patient dependency

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Emotional Support

• Relatives, Patients, Colleagues
• Relatives Information and explanation
• Patients Patient centred
• Colleagues out of depth, struggling
• Emotional Tension
• Nurses
• not being able to give fundamental care
• poor communication

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What is the contribution nurses make?

• Knowledge
• Experience
• Exposure

• Patient Centred
• Proactive
• Vigilant
• Effective Coping with the Unpredictable
• Emotional Support

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What is the potential contribution nurses make to
outcome?

• Decrease Risk to Patients
• Timely Patient Progression
• Increase the Potential for Patients to Recover

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Inhibiting Factors

• Geography
• Increased, Unexpected Activity
• Increased Patient Dependency
• Poor Skill Mix

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If there is an imbalance

• Task orientated
• Progress is hindered
• Failure to Appreciate Cues
• Ineffective Coping
• ? Emotional Tension

• Increased Risk to Patients
• Delayed Progression
• Potential for Deterioration

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The Nursing ContributionNever forget you have a
choice!!
FAILURE TO RESCUE

• Patient Centred Task Orientated
• Proactive Reactive
• Vigilance Fail to Appreciate Cues
• Coping Unpredictable Ineffective Coping
• Emotional Support Emotional Tension