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Overview of Critical Care
Nursing
Chapter 1
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Learning Objectives
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Define critical care nursing.
Describe standards of professional practice for critical care nursing.
Discuss trends, issues and stressors related to critical care nursing.
Describe common family needs and family-centered nursing
interventions.
Discuss challenges experienced by nurses working in critical care
settings.
Describe the American Association of Critical-Care Nurses Synergy
Model that guides critical care nursing practice.
Discuss ethical principles and legal concepts related to critical care
nursing.
Discuss ethical and legal issues that arise in the critical care setting.
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Key Terms
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AACN
ACNP
ANCC
CCRN
CCNS
Critical care nursing
Critical pathways
Evidence-based practice
Multidisciplinary rounds
Patient safety goals
SBAR communication
SCCM
Standards
Telemedicine
Synergy model
Advance directive
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Advocacy
Autonomy
Beneficence
Brain death
Confidentiality
Fidelity
Health care surrogate
Informed consent
Justice
Life support
Living will
Malpractice
Negligence
Nonmaleficence
Persistent vegetative state
Veracity
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Critical Care Nursing
• Deals with human responses to critical illness
or injury
– Physiological
– Psychological
• Focus on both the patient’s and family’s
responses
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Nurse as Patient Advocate
• Support autonomous decision making and decisions
made; respect values; represent patient based on these
choices
• Intervene in patient’s best interests; intercede for those
who cannot advocate for selves; help patients get care
• Educate patient and family members
• Ensure safe, quality care
• Serve as liaison between patient, family, and providers
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Critical Thinking Challenge
• What comes to your mind when you hear
the following terms?
• Intensive Care
• Critical Care
• ICU and CCU
• Trauma
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Historical overview
• Critical care units have evolved over the last four
decades in response to medical advances.
• Florence nightingale recognized the need to consider
the severity of illness in bed allocation of patients and
placed the seriously ill patients near the nurses’ station.
• 1923, John Hopkins University Hospital developed a
special care unit for neurosurgical patients .
• Modern medicines boomed to its higher ladder after
world war 2
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Historical overview (continued)
• As surgical techniques advanced it
became necessary that post operative
patient required careful monitoring
and this came about the recovery room.
• In 1950, the epidemic of poliomyelitis
necessitated thousands of patients
requiring respiratory assist devices
and intensive nursing care.
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Historical overview (continued)
• At the same time came about newer horizons in
cardiothoracic
surgery,
with
refinements
in
intraoperative membrane oxygen techniques.
• In 1953, Manchester Memorial Hospital opened a four
bedded unit at Philadelphia was started.
• By 1957, there were 20 units in USA and
• In 1958,the number increased to 150.
• During 1970’s,the term critical care unit came into
existence which covered all types of special care.
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Past
Present
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Critical Care in 21st Century
• Specialization
• Practice in a variety of settings
– Inpatient
– Outpatient
– Home care
• Various roles for nurses who work with
critically ill
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Professional Organizations
• Support critical care nurses and practice
• Key organizations
– American Association of Critical-Care Nurses
– Society of Critical Care Medicine
– The Saudi Critical Care Society
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American Association of Critical-Care
Nurses (AACN)
• Founded in 1969
• Largest specialty organization in world
• Mission
– Provide leadership to establish work and patient care
environments that are respectful, healing, and humane
• Website
– www.aacn.org
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AACN’s Vision
Create a healthcare system
driven by patient’s and
family’s needs in which
critical care nurses make
their
optimum
contributions
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AACN Synergy Model for Patient Care
• Developed by American
Association of Critical-Care
Nurses to guide practice
– Needs of the patient and
families
drive
the
competencies of the nurse
– Matching needs of the patient
with the nurse
– Working together creates
synergy
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AACN Synergy Model Nurse Competencies
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Clinical judgment
Advocacy and moral agency
Caring practices
Collaboration
Systems thinking
Response to diversity
Facilitation of learning
Clinical inquiry
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AACN Synergy Model Patient Characteristics
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Resiliency
Vulnerability
Stability
Complexity
Resource availability
Participation in care
Participation in decision making
Predictability
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AACN Membership Benefits
• Professional journals and continuing education offerings
– Critical Care Nurse
– American Journal of Critical Care
– AACN Advanced Critical Care (reduced rate)
• Practice Alerts
– Evidence-based interventions
• Continuing education
– National Teaching Institute (NTI)
• Support from local chapters
• Scholarships
• Research grants
• Student rate for membership
• Discounted rate for certification exams
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Society of Critical Care Medicine (SCCM)
• Founded in 1970
• Multidisciplinary membership
– Physicians
– Nursing section
– Other critical care team members
• Website
– www.sccm.org
• Journal—Critical Care Medicine
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SCCM Vision
• Health care system in which all critically ill and
injured persons receive care
– Multiprofessional health care team
– Directed by physician specializing in critical care—
intensivist
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Critical Care Certification
• Purpose
• Validate knowledge
• Promote professional excellence
• Help nurses to maintain up-to-date knowledge
• AACN Certification Corporation oversees process
• Based on AACN Synergy Model for Patient Care
• Needs of patients and families drive practice
• Bedside practice
• CCRN: Adult, Neonatal, and Pediatric
• PCCN for those working in step-down units
• Advanced practice
• CCNS Critical Care Clinical Nurse Specialist
• ACNPC™ Acute Care Nurse Practitioner
• Subspecialty certification
• Cardiac medicine
• Cardiac surgery
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The Saudi Critical Care Society (SCCS)
• Founded in January 2007.
• It is under the umbrella of Saudi Council for health
Specialties.
• Multidisciplinary membership
– Physicians
– Nursing section
– Other critical care team member
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The Saudi Critical Care Society (SCCS)
• Website
– http://www.sccs-sa.org/
• Journal—Saudi Critical Care
– http://www.sccj-sa.org/
• SCCS
just recently joined Middle-East Critical
Care Assembly (MCCA) and now a partner for
promoting the highest standard of care for ICU
patients.
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Standards
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Guide clinical practice
Establish goals for patient care
Provide assessment of outcomes
AACN Standards for Acute and Critical Care Nursing Practice
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Describe level of performance
Describe expected roles and responsibilities of critical care nurses
Evaluate nursing practice
Reflect on standards, laws, and regulations
Acquire knowledge
Interact and contribute to peers
Serve as patient advocate
Collaborate with health care team
Use clinical inquiry
Consider factors related to safety, effectiveness, and cost
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Trends and Issues
• Critical care patients more complex
– Multi-system organ dysfunction
– Complicated by aging population
• Increasing costs for care
– Challenged to reduce costs and length of stay
– Transfer of higher acuity patient from the critical care unit to other units or
home
• Quality and safety focus
• The Joint Commission National Patient Safety Goals (See Box 1-4)
– Examples relative to critical care nursing
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Communication
Medication safety
Reduce infections
Prevent pressure ulcers
Family involvement in care
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Trends and Issues (continued)
• Communication important to reduce errors
• SBAR communication strategy
– Situation: State what is happening at the present time that has warranted the SBAR
communication.
– Background: Explain circumstances leading up to this situation. Put the situation into
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context for the reader/listener.
Assessment: State what you think is the problem.
Recommendation: State your recommendation to correct the problem.
• Other safety initiatives
– Rapid response team (RRT)
– Institute for Healthcare Improvement
• www.ihi.org
– Clinical practice guidelines
• www.guideline.gov
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Trends and Issues (continued)
• Daily rounds with multidisciplinary team (See Box 1-6)
• Implementation of “bundles” of care to promote evidence-based
practices and prevent complications
• Advances in technology
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Advanced monitoring devices
Point-of-care testing
Computerized physician order entry (CPOE)
Telemedicine
• Improved design of critical care units (Video)
• Shortage of critical care nurses
– Importance of recruitment, orientation, and retention
– Ongoing debate of hiring new graduates to work in critical care units
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Trends and Issues (continued)
• EVIDENCE-BASED PRACTICE:
• Clinical practice guidelines are being implemented to ensure that
care is appropriate and based on research.
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Patient and Family Response to the
Critical Care Experience
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Critical Care Nursing
• Deals with human responses to critical illness
or injury
– Physiological
– Psychological
• Focus on both the patient’s and family’s
responses
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(continued)
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Critical Thinking challenge
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Ethical and Legal Issues in
Critical Care Nursing
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Ethical Issues
• Critical care nurses confront in everyday practice
– Informed consent and confidentiality
– Withholding or withdrawal of treatment
– Organ and tissue transplantation
– Distribution of health care resources
• Impact of advanced technology
• Greater frequency in critical care
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Nurse Advocacy
• Obligation to protect patients
– Serve as patient advocates
• Professional organizations promote ethics
and advocacy
– American Nurses Association
• Code of ethics for nurses with interpretive statements
– American Association of Critical-Care Nurses
• An ethic of care
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Ethical Dilemmas
• Warning signs
– Emotionally charged
– Significant change in patient’s condition
– Confusion about facts
– Hesitancy about what is right
– Deviation from customary practice
– Need for secrecy regarding proposed actions
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Ethical Decision Making Process
(See Figure 3-1)
1. Assess
– Contextual factors
– Physiologic factors
– Personal factors
2. Consider options
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Patient wishes
Burden versus benefit
Ethical principles
Potential outcomes
3. Develop plan with patient,
surrogate, family, and team
4. Act on plan
5. Evaluate plan
– Short-term outcomes
– Long-term outcomes
– Apply to other cases
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Table. The 4A’S to Rise Above Moral Distress
ASK
Ask appropriate questions.
“Am I feeling distressed“ or showing signs of suffering? Is
the source of my distress work related?
Goal: You become
aware that moral
distress is present.
AFFIRM Affirm your distress and your commitment to take care
Goal: You make a
of yourself.
commitment to address
Validate feelings and perceptions with others.
moral distress
Affirm professional obligation to act.
ASSESS
ACT
Identify sources of your distress.
Recognize there is an issue but may be ambivalent about
taking action to change it.
Analyze risks and benefits.
Take Action
Implement strategies to initiate the changes you desire.
Maintain Desired Change
Goal: You are ready to
make an action plan
Goal: You preserve
your integrity and
authenticity
Reprinted with permission American Association of Critical Care Nurses
(AACN) from AACN Work Group. (2004)
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• Autonomy
Ethical Principles
– Right of self-determination concerning medical care
• Beneficence
– Duty to prevent harm, remove harm, and promote the good of another person
• Nonmaleficence
– Not to intentionally inflict harm
• Justice
– Fair distribution of health care resources
• Veracity
– Truthfulness
• Fidelity
– Be faithful to commitment
• Confidentiality
– Respect for right to control information
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Moral Theories
• Deontology (‫)علم األخالق‬
– Ethical decisions made according to principles
• Utilitarianism (‫)مذهب المنفعة‬
– Ethical decisions made considering the greatest good
• Casuistry (‫)قضايا الضمير‬
– Ethical decisions made by examining similar cases
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Nurse Involvement in Ethical Decision Making
• Advocacy
– Open communication of patient’s wishes and ethical concerns
– True collaboration with health care team members
• Dilemmas can result in moral distress
• Formal mechanisms (The Joint Commission)
– Bioethics committees
– Ethics consultation
• Opportunities for critical care nurses
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Ethics forums and rounds
Peer review
Institutional review boards (research)
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Legal Accountability
(‫)المسألة القانونية‬
• Legal responsibilities to patients
• Benchmark for defining nurses’ responsibilities
• Preventing situations that compromise patients is
preferred to court hearings
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Licensure/Continuing Education
• Nurses must be aware of licensure requirements
– Continuing education
• Hospital requirements
– Varied to ensure competence
– May mandate certification
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Criminal Lawsuits
• Defined by country law
– Battery: touching patient against will
– Assault: threatening to batter a patient
– False imprisonment: preventing the patient from leaving the
hospital
• Prevention
– Consistent job performance
– Promoting satisfaction of patients and family members
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Medical Malpractice
• Negligence or incompetence:
– Nurse had duty to patient
– Nurse did not carry out duty
– Nurse caused injury
– Patient suffered injury
• What are examples of medical malpractice cases that
involve nurses?
• Preventing Malpractice:
– Act according to standards of care
– Documentation
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Selected Issues
for your Reading and Discussion
on the Class and Blackboard
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Elements of Informed Consent
• Competence: ability to understand
• Voluntariness: consent without coercion
• Disclosure of information
– Diagnosis
– Proposed treatment
– Probable outcome
– Benefits and risks
– Alternative treatments
– Prognoses if treatment not provided
• What is the role of the nurse?
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Informed Consent of Adolescents
• Parents/guardians required to give consent
• Emancipated minors give own consent
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Life-Sustaining Treatment
• Factors to consider
– Constitutional rights
– Quality of life
– Impact of advanced technology
– Ordinary versus extraordinary care
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CPR Issues
• Should a patient be “coded?”
– A do not resuscitate (DNR) is needed to not initiate a
code
• Advance directives useful in guiding decision
making PRIOR to code
• When do resuscitation efforts stop?
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Life Support
• Definitions
– Withholding: not initiating
– Withdrawal: weaning or removing
• Comfort measures maintained
• Debate views on withholding and withdrawal of life
support
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Helping Families Make Decisions About
Life Support
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Communicate frequently
Consistent, honest communication
Base on patient’s wishes
Provide psychological support to the family
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Patient Self-Determination Act
• Patient’s right to initiate advance directive
• Patient’s right to consent for or refuse treatment
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Advance Directive
• Communication about
preferences for treatments if
patient is incapacitated
• Living will
– Treatment desired and what should
be withheld
• Durable power of attorney for
health care
– Determines who makes decisions
– Health care surrogate or proxy
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Organ and Tissue Transplantation
• Patients who are brain dead are often candidates for
organ donation
• Brain death criteria
• Everyone has the right to donate organs
• Conflict of patient’s designation versus family
members’ views on donation
• Designated requestors seek consent
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Critical Thinking Challenge
• What are some examples of situations in which a
nurse might have moral or religious convictions that
would interfere with the duty to treat?
• What actions are required of the nurse when conflict
exists?
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Critical Thinking Challenge
Suggested Answer
• Nurses might have conflicts with a variety of situations,
including:
– Participating in procedures such as abortion, withdrawing life
support, and organ donation/transplantation.
– They may disagree with decisions made by the patient and family
member, such as the decision NOT to receive blood transfusions.
• Actions are to notify the manager and supervisor regarding
situations that are truly conflicting to avoid abandoning the
patient.
• If many situations are encountered on a regular basis, the
nurse should consider alternative nursing units.
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Case
• You are taking care of Mr. J., a 23-year-old man
with a closed head injury. During your shift, you
note a change in the level of consciousness at 3:00
am. You call the physician, who tells you to watch
Mr. J. until the physician attends rounds the next
morning. He tells you not to call him back. Mr. J.’s
neurological status continues to deteriorate.
• What actions do you take?
• What is the rationale for your actions?
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Answer
• As a nurse caring for a patient with a deteriorating physiologic
condition, there are ethical and legal obligations to request medical
assistance.
• Actions include going up the hospital and medical “chain of
command.”
• This includes calling back the physician one more time, notifying him of
the continued deterioration in patient status.
• If the physician does not acknowledge that he or she will come in and
evaluate the patient (or have another on-call physician evaluate the
patient),
• The next step is to notify the nursing supervisor and/or administrator on
call, and the medical department chair or chief of the medical staff.
• The rationales for these actions are related to the ethical principles of
fidelity and beneficence.
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Critical Thinking Challenge (continued)
• Discuss
– Who has:
• Living will?
• Durable power of attorney for health care?
– Do your family members know your wishes?
• Identify strategies that can be implemented to get
more people to complete advance directives?
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Questions?
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Blackboard Journal Club Discussion
Critical Thinking Challenge
• What are issues related to organ donation?
• What are strategies to increase donation, especially
among ethnic minority populations?
• If you have a signed organ donor card, can your
family members overrule your wishes?
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Reference
Sole, M. L., Klein, D. G., & Moseley, M. J.
(2017). Introduction to critical care nursing.
(7th ed.,), St. Louis, Mo: Elsevier/Saunders.
ISBN: 9780323375528. Chapter 1 (2-13),
Chapter 2 (14-25) & Chapter 3 (26-36)
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Thank You
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