A review of intensive care nurse staffing practices overseas: what lessons for Australia?

State of the Science

Over a decade of research on the relationship between nurse staffing and patient outcomes has demonstrated the important role of nurses in the provision of high-quality, safe care, yet currently, no evidence-based nurse staffing guidelines exist. A systematic review of reviews was conducted to explore reasons why this is the case and recommend directions for future research to improve upon this gap. Authors of the 29 included reviews reported variability in methods and measurement approaches, lack of incorporation of nurse processes and system factors that potentially affect relationships among variables, and overall inconsistencies in results across primary studies. We propose use of an Integrated Framework for a Systems Approach to Nurse Staffing Research to inform the development of applicable conceptual models. Future studies that use a systems approach and focus on establishing causal relationships among variables will potentially strengthen the evidence and advance the science in this area.

Professional challenges of bedside rationing in intensive care

As the pressure on available health care resources grows, an increasing moral challenge in intensive care is to secure a fair distribution of nursing care and medical treatment. The aim of this article is to explore how limited resources influence nursing care and medical treatment in intensive care, and to explore whether intensive care unit clinicians use national prioritization criteria in clinical deliberations. The study used a qualitative approach including participant observation and in-depth interviews with intensive care unit physicians and nurses working at the bedside. Scarcity of resources regularly led to suboptimal professional standards of medical treatment and nursing care. The clinicians experienced a rising dilemma in that very ill patients with a low likelihood of survival were given advanced and expensive treatment. The clinicians rarely referred to national priority criteria as a rationale for bedside priorities. Because prioritization was carried out implicitly, and most likely partly without the clinician's conscious awareness, central patient rights such as justice and equality could be at risk.

Critical care nursing education and practice in Canada and Australia: a comparative review

Critical care nursing is an area of policy concern with respect to staffing projections, skill mix and educational preparation in both Canada and Australia. Despite many similarities between the health systems of these two countries, differences exist in both undergraduate and graduate specialty nursing education. In Australia, specialist education is primarily delivered via the tertiary sector as a formalised qualification, whereas the current Canadian model displays significant variation in duration, content, and mode of delivery. This paper provides a comparative perspective on the educational preparation of critical care nurses in these two countries. Consideration of alternative models of specialty nursing education may provide a method to improve recruitment and retention of staff while maintaining quality of care.

Consensus forum: worldwide guidelines on the critical care nursing workforce and education standards

This article explores the key themes, evidence, and arguments that inform the current position statements. It is acknowledged that future research, evidence, and practice experience may create the need to review and change these guidelines. Reform and refinement of the guidelines are inevitable; however, the current guidelines represent the best attempt yet to reach international consensus on what are appropriate standards to guide critical care nursing education and workforce requirements.

Matching nurse skill with patient acuity in the intensive care units: a risk management mandate

AIM

This paper aims to highlight the need for the traditional concept of nursing skill mix to be reconfigured within a new concept of skill matching.

BACKGROUND

Substantive literature describes staff deployment and patient-dependency models. However, limited information exists as to what informs decision making regarding nurse skill assessment and subsequent patient allocation in intensive care units.

KEY ISSUES

In intensive care units, nurse numbers, available nursing skills and patient allocation decisions, impact directly on care provision and outcomes. This paper argues that staffing decisions that are based on insufficient knowledge which lack consideration of all pertinent factors result in poor 'skill matching', potential adverse events and poor outcomes. A critical inextricable link exists between staffing decisions, patient safety and risk in the intensive care unit. Use of a multifactorial skill-matching approach within a dedicated staffing decision-support system is recommended.

CONCLUSION

This commentary paper adds a new perspective to nurse-staffing decision practices and their relationship to risk management in the intensive care unit and offers a new research direction.

Issues in weaning from mechanical ventilation: literature review

AIM

The aim of this paper is to raise questions on the effect of skill mix and organizational structure on weaning from mechanical ventilation.

BACKGROUND

Mechanical ventilation is an essential life-saving technology. There are, however, numerous associated complications that influence the morbidity and mortality of patients receiving intensive care. Therefore, it was essential to use the safest and most effective form of ventilation for the shortest possible duration. Because of the potential complications and costs of mechanical ventilation, research to date have focused on accurate weaning readiness assessment, methods and organizational aspects that influence the weaning process.

METHOD

In early 2005, the literature was reviewed from 1986 to 2004 by accessing the following databases: Medline, Proquest, Science Direct, CINAHL, and Blackwell Science. The keywords mechanical ventilation, weaning, protocols, critical care, nursing role, decision-making and weaning readiness were used separately and combinations.

DISCUSSION

Controversy exists in weaning practices about appropriate and efficacious weaning readiness assessment indicators, the best method of weaning and the use of weaning protocols. Arguably, the implementation of weaning protocols may have little effect in an environment that favours collaboration between nursing and medical staff, autonomous nursing decision-making in relation to weaning practices, and high numbers of nurses qualified at postgraduate level.

CONCLUSION

Further research is required that better quantifies critical care nurses' role in weaning practices and the contextual issues that influence both the nursing role and the process of weaning from mechanical ventilation.

Evaluating and planning ICUs: methods and approaches to differentiate between need and demand

OBJECTIVE

In all western countries the demand for ICU-services is increasing and complaints about a lack of ICU-beds arise--independent of the actual density of ICU-services. The demand for more ICU-beds triggered a debate on whether it is possible to define an "objective" need. It was the aim of the assessment to analyze conventional as well as innovative approaches to plan and to evaluate ICU-services.

METHOD

Systematic review, multistep searches in Medline, EmBase, Cochrane, HTA-Database, websearches, informal searches through planning and HTA-networks.

INTRODUCTION

The differences between the density of intensive care in Europe and other parts of the western world is enormous. At a first superficial glance, Austria and Germany--in absolute figures--have many more ICU-beds than any other European country. In relative figures, taken into consideration that Austria and Germany have also many more acute care beds, the number of ICU-beds is among European average. It is therefore, impossible to analyze the need for ICU-beds without taking into account the national context of delivered acute hospital services. Although ICU-services take about 15-20% of the hospital budgets, there are still more questions than answers.

RESULTS

Recent planning-documents: a review of trends in recent planning shows that all planners calculate on the basis of existing style of practice within their countries; the figures change only marginally. But while planners in countries with a relatively low ICU-bed density (Great Britan, Australia, Canada) certify a certain need for an increase, planners in countries with high density (USA, Germany, Austria) state a "satisfied need" and an over-provision of ICU-services. Innovative planners apply an "appropriateness of ICU-use" approach with analysing the actual utilisation by interpreting scores (especially TISS) and by identifying "low-risk" groups and propose a more flexible organisation of ICUs and a higher proportion of (intermediate care unit) IMCU-beds. Clinical and ICU-management tools, such as admission and discharge guidelines, strategies to reduce treatment-variations, certain organisational changes (leadership, horizontal hierarchy) and costing methods gain importance for better, more efficient and co-ordinated use of ICU-resources.

CONCLUSION

In countries with a high density of ICU-services--such as Austria and Germany--not an expanding of the capacities, but a better use of the existing resources is recommended. For a fair comparison, participation in national databases, in registers as well as benchmarking and quality-assurance programs should be enforced.

Use of Physical Restraints in Adult Critical Care: A Bicultural Study

• Background Although controversial, physical restraints are commonly used in adult critical care units in the United States to prevent treatment interference and self-inflicted harm. Use of physical restraints in Norwegian hospitals is very limited. In the United States, an experimental design for research on use of restraints has not seemed feasible. However, international research provides an opportunity to compare and contrast practices.

• Objectives To describe the relationship between patients’ characteristics, environment, and use of physical restraints in the United States and Norway.

• Methods Observations of patients and chart data were collected from 2 intensive care units (n = 50 patients) in Norway and 3 (n = 50 patients) in the United States. Sedation was measured by using the Sedation-Agitation Scale. The Nine Equivalents of Nursing Manpower Use Score was used to indicate patients’ acuity level.

• Results Restraints were in use in 39 of 100 observations in the United States and not at all in Norway (P = .001). Categories of patients were balanced. In the Norwegian sample, the median Nine Equivalents of Nursing Manpower Use Score was higher (37 vs 27 points, P < .001), patients were more sedated (P < .001), and nurse-to-patient ratios were higher (1.05:1 vs 0.65:1, P < .001). Seven incidents of unplanned device removal were reported in the US sample.

• Conclusions Critical care units with similar technology and characteristics of patients vary between nations in restraint practices, levels of sedation, and nurse-to-patient ratios. Restraint-free care was, in this sample, safe in terms of treatment interference.

A consensus driven method to measure the required number of intensive care nurses in Australia

This paper describes a methodology for determining the number of nurses required to staff Australia's intensive care unit (ICU) beds. The evidence used is level IV, that is the use of expert panel opinion, and it is the strongest and most accurate attempt yet to describe how Australia's ICU beds should be staffed with nurses. The researchers provide ratios of staffing applicable to a variety of situations that should be of use to ICU managers and hospital administrators. Equally, the broader calculations explaining the national supply and demand needs provide an easy to use approach and explanation suitable to health professionals, health administrators, policy advisors, governments, politicians and the broader community. Limitations of the approach and further recommendations are made to encourage future work in this area. Finally, a strong correlation between the number of available 'open' ICU beds in Australia and the number of nurses actually working in ICU at any given time is well demonstrated using the methodology outlined in this paper. Clarification of scope and terminology: This paper focuses on the nursing requirements of ICUs only; occasionally we use the word critical care nurse--this generally refers to those nurses who have completed a generic critical care nursing course but who, for the purposes of our study, are working in ICUs. Critical care units encompass ICUs but may also encompass recovery room, cardiothoracic units, coronary care, emergency departments and many other environments where critically ill patients are cared for and treated. This paper does not cover the broader scope of critical care units, only ICUs.

The effects of nursing staff inexperience (NSI) on the occurrence of adverse patient experiences in ICUs

Although many studies have attempted to define levels of staff experience appropriate for the care of critically ill patients, minimal data is available on the effect of nursing staff inexperience (NSI) on the occurrence of incidents in the intensive care environment. The Australian Incident Monitoring Study in Intensive Care Units (AIMS-ICU), an anonymous, voluntary incident reporting system, can help to identify problems in which NSI may be implicated. NSI may be an incident in itself or contribute to the occurrence of other incidents. The objective of this paper was to identify incidents associated with NSI and estimate their effect on the quality of patient care. Incidents related to NSI were extracted from the AIMS-ICU database and analysed using descriptive methodology. Seven hundred and thirty five reports covering 1,472 incidents were identified as relating to NSI. Of these, 282 were described in the narrative section and 453 were selected as a contributing factor by the reporter. Major categories for the 1,472 incidents included airway and ventilation (317) drugs and therapeutics (468), procedures, lines and equipment (219), patient environment (234) and unit management (234). An undesirable major adverse patient outcome was selected in 20 per cent of reports. NSI associated incidents reported to AIMS-ICU suggest that NSI can have a negative impact on the quality of care delivered to critically ill patients as shown by the occurrence and outcome of incidents related to such inexperience. Errors are more likely to occur when NSI is combined with staff shortage, inadequate supervision and high unit activity. When rostering or employing staff, nurse managers and educators must consider the special requirements of inexperienced nurses. Safe patient care requires these issues be included in discussions about ICU resource allocation.