Nursing care does make a difference to the patient, to the families, to the healthcare team and in determining patient outcomes. Functions of nursing in the critical care environment include: ongoing assessment of the patient, therapeutic interaction with the family, facilitation of communication across multiple healthcare disciplines, and engaging in activities directly impacting the patient clinical outcome. A critical care nurse is a registered nurse who has been specially oriented and educated concerning the needs and acute physiology of a critically ill patient. Through the application of scientific knowledge, the critical care nurse reacts to the full range of human experiences, within the context of a caring relationship. One focus of nursing care in the ICU is the concept of quality. Quality includes the promotion of safe, efficient, and effective care based on scientific principles demonstrated through evidence that culminates in satisfaction for the patient, family, and the nurse.

The scope of practice for a nurse is determined by the level of formal education or preparation, area of clinical practice, competency validation, hospital or facility policy, and education or training as part of or required for a particular job. Scope of practice may also be mandated by the individual State Board of Nursing or through legislation. Critical care nurses receive more intensive orientation in preparation for patient care, and may be required to hold certifications in areas such as advanced life support. The American Association of Critical Care Nurses has developed a set of standards of care (Table 203.1) and defines the scope of practice for the critical care nurse, using the principles developed by the American Nurses Association (ANA) [1]. Utilization of these standards provides a framework for the delivery of comprehensive, high quality care.

In 1854, Florence Nightingale was the first to identify the need to segregate the sickest patients needing the most intensive care in an area she referred to as her Monitoring Unit. Here, patients wounded in battle were able to receive nursing care with greater regularity, from women she had trained specifically. Through delivery of more consistent care from better trained nurses, she was able to demonstrate significantly decreased battlefield mortality, from 40% to 2% [2].

Caring for the most critically ill patients separate from other patients allows nurses to meet the complex needs of patients and families. This is accomplished through application of specific training and education with regard to disease process, treatment modalities, and the psychology of devastating injury or illness. Additionally, sequestering critically ill patients for care facilitates changes in nurse-to-patient ratio. A critical care nurse is commonly responsible for the nursing care of one or two patients.

Critical care nursing, as we know it today, emerged after World War II. The increase in medical specialization and improvement of technology influenced the development of this specialty [3]. The first intensive care or critical care units were established in the 1960s. Preparation to care for these patients resulted in development of curricula addressing nurses as well as intensivists, physicians specifically trained in critical care.

Nurses are the largest group of healthcare providers caring for patients daily in the critical care unit. As members of the healthcare team, nurses are responsible to provide nursing and medical interventions, as ordered, and evaluate the effect of those interventions on patients. An enormous part of the demand of patient care is the work of nurses, based on standards of care supported by appropriate resource allocation, enhanced nursing knowledge, accountability, and institutional policies and procedures. Clinical decision making is grounded in evidence-based practice that grows from the nurse’s commitment to lifelong learning. Developing and implementing a plan of care allows interventions to be provided in a safe, systematic way, tailored to the condition of each individual patient. As a result of a holistic approach and long periods of time at the bedside in critical care, it is the nurse who gives voice to the patient and family, including them in planning for care. Communication and collaboration among healthcare professionals are essential in planning and delivering care, as well as in maintaining a healthy work environment, one that promotes safe, efficient, effective care for patients. Interdisciplinary communication and collaboration are critical to prevent errors and omissions in the plan of care. The American Association of Critical Care Nurses, in a 2005 study [4], described the consequences of poor communication behaviors among healthcare professionals. These consequences include medication errors, infections, falls, increasing complications of both disease and treatment, and death. Seven areas were specified to be contributing to poor outcome: broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement. Participants in this study described a resistance to communicating with others regarding these areas. Only through promotion of enhanced communication can patient safety and improved outcomes be expected. The Joint Commission on Accreditation of Healthcare Organizations identifies poor communication as a primary factor in sentinel events [5]. The Institute of Medicine described communication as a contributor to the harm patients experience in the course of their care [6].

The result of poor nursing care in relation to poor patient outcomes has been evaluated. These poor outcomes result in higher overall cost, low rates of nursing job satisfaction,
decreased patient and family satisfaction, accreditation issues, and lower rates of reimbursement [7]. For example, cost per case will increase in medical patients with urinary tract infection and pressure ulcers and in surgical patients with urinary tract infection and pneumonia. Provision of safe, high quality patient care is motivated by both professional accountability and growing financial pressure. By evaluating the quality of patient care, opportunities for poor patient outcomes can be eliminated or prevented. Use of Nursing-Sensitive Quality Indicators (NSQI) provides an opportunity to evaluate and improve care in the critical care unit. Quality and Nurse sensitive indicators are defined as measures and indicators that reflect the impact of nursing actions on outcomes. Although the entire scope of nursing-sensitive indicators includes structure, process, and outcome of nursing, nursing-sensitive indicators in critical care are primarily outcome driven.

Nursing-sensitive quality indicators identify and allow measurement of structures of nurse-specific patient care, the processes by which this care is accomplished, and the outcomes of that care. They are performance measures that quantify the work of nursing and the outcomes of that work. These indicators are particularly useful in the critical care setting, where intensive nursing care directly influences patient safety and outcome. In addition to measurement, the use of NSQI promotes identification of best practice and accountability for practice, and points out gaps in research, education, and practice within the discipline of nursing and in interdisciplinary patient care. NSQI, as they measure nursing’s impact on the quality of patient care, are instrumental in helping hospitals to reduce misdirection of nursing time to nonproductive or non-patient care tasks or activities. By allowing nurses to engage in the work of nursing, patient outcomes are improved, appropriate staffing decisions are made, and nurse job-satisfaction is enhanced [8].

The American Nurses Association (ANA) Nursing Safety and Quality Initiative began in 1994, aimed at the development of hospital quality indicators. Data from this initiative was stored in the National Database of Nursing Quality Indicators (NDNQI), at the Midwest Research Institute and University of Kansas School of Nursing in 1998. The initial outcome measures included nosocomial infection rate (bacteremia), rate of patient falls with injury, patient satisfaction with nursing care, patient satisfaction with pain management, patient satisfaction with educational information, and patient satisfaction with care. Process measures included maintenance of skin integrity. The NDNQI has developed nationally accepted measures to assess quality of nursing care, identifying and promoting best practice around specific indicators. The database provides members the transparency of quality outcomes, motivating nursing leaders to implement practice that can maintain or improve those outcomes. Current NDNQI indicators can be found in Table 203.2.

Infection is one complication critical care patients are particularly at risk for, as the result of invasive procedures, disease process, and exposure to multiple infective organisms. Specific NSQI address behaviors aimed at avoiding this risk. The most common potential infections in the ICU are catheter-associated urinary tract infection, central line related blood stream infection (BSI), and ventilator-associated pneumonia.