High-Acuity Nursing, 6th Edition

High-Acuity Nursing Objectives: 1. Discuss the various health care environments in which high-acuity patients receive care. 2. Identify the need for resource allocation and staffing strategies for high-acuity patients. 3. Examine the use of technology in high-acuity environments. 4. Identify the components of a healthy work environment. 5. Discuss the importance of patient safety in the high-acuity environment. I. High-Acuity Environment A. Historical perspective 1. Intensive care units (ICUs) were developed in the 1960s. Medical advances resulted in the initiation of these units. a) The implementation of CPR b) Improved management of patients experiencing hypovolemia and shock c) The implementation of emergency medical services d) Technological advances e) The advancement of renal transplant services B. Determining the level of care needed 1. Systematic triage approach for high-acuity patients aids in giving the most efficient and cost-effective care. a) ICU b) Intermediate-care unit (IMC) (1) Developed to manage those patients who did not require life-saving, critical-care functions (2) Ability to manage the potentially serious health care needs of the patient whose condition is too complex for the traditional medical-surgical floor c) Medical-surgical acute care unit. 2. Nurses should use a prioritization model to triage and determine the level of care needed by acutely ill patients. The model divides patient needs into four categories: a) Priority 1: The patient is acutely ill, requiring intensive treatments not available outside of the intensive care unit. b) Priority 2: The patient is seriously ill and has the potential to require immediate medical interventions to prevent complications. c) Priority 3: The patient is critically ill but has a limited chance for recovery. There might be limits placed on the amount of life-saving interventions that may be implemented. d) Priority 4: This is a large category of patients. Their inclusion into the ICU will depend on an individualized decision based on the appropriate use of resources and current patient status. C. Levels of intensive care units 1. The American College of Critical Care Medicine has identified three levels of ICUs as determined by resources available to the hospital: a) Level I: Hospitals with ICUs that provide comprehensive care for patients with a wide range of disorders. Sophisticated equipment, specialized nurses and comprehensive support services. b) Level II: Hospitals with ICUs that provide comprehensive care to most critically ill patients. c) Level III: Hospitals with ICUs that provide initial stabilization of critically ill patients. D. Profile of the high-acuity nurse 1. Able to analyze clinical situations. 2. Make decisions based on analysis. 3. Rapidly intervene to ensure optimal patient outcomes. 4. Competent in detecting early signs of an impending complication. 5. Role of the nurse in the management of the high-acuity environment: a) Review the patient’s clinical condition and implement a plan of care. (1) Studies show that constant surveillance of patients by nurses reduces mortality and complications. PowerPoint Slides 1. Intensive Care Units (ICU) Developed in 1960 Why initiated 2. Intermediate Medical Care (IMC) Units Intended for patients needing close observation but not in need of life-saving, critical interventions Able to manage those patients too complex for the traditional medical surgical unit 3. Triage Prioritization Model Priority 1: acutely ill patients requiring life-saving, critical interventions Priority 2: seriously ill patients possibly in need of immediate medical interventions Priority 3: critically ill patients who will not likely recover from their disorders Priority 4: patients who might be terminally ill 4. The Registered Nurse in High-Acuity Settings Continual assessment of the patient’s status Implementation of the plan of care Studies link to reduced mortality and complications II. Resource Allocation A. Nurse staffing 1. Nurse-patient ratios a) Many interrelated factors have led to a shortage of nurses able and willing to work with acutely ill patients. Factors linked to the nursing shortage include: (1) Reduced job satisfaction, resulting in nurses leaving the workforce (2) Aging of the registered nurse workforce (3) Limited number of young adults choosing nursing as a career (4) Increasing number of aging persons, resulting in an increase in persons requiring acute care health services b) The reduction in the number of professional nurses has resulted in an increase in the nurse–patient ratio. c) The Academy of Medical Surgical Nurses (AMSN) does not support the development of exact patient–nurse ratios. 2. Magnet Status: Recruiting and Retaining Nurses a) Magnet designation is a status awarded to hospitals that demonstrate success in recruiting and retaining professional nurses. b) Magnet hospitals promote environments that are attractive to the retention of professional nurses. 3. Unlicensed assistive personnel (UAP) can be used to provide direct care. a) The UAP provides care under the direction of the professional nurse. B. Decreasing resources, increasing care needs 1. Who Belongs in an ICU? a) The health care needs of the patient and the skill mix available must be the deciding factors. b) The assignment of patients to units requires a close review of available resources. c) A goal is to ensure that those patients requiring the greatest level of care will be cared for in the intensive care unit. d) Age and seriousness of illness can be controversial variables in the assignment of intensive care beds. Severity scales are models used to determine which patients will benefit most from intensive care services. e) Additional considerations must be given to ethical, economic, and legal concerns. PowerPoint Slides 1. Nursing Shortage The nursing shortage has resulted in a scarcity of nurses available to work with acutely ill patients. Factors linked to the nursing shortage include: Reduced job satisfaction Aging of the nursing workforce Limited numbers of young adults choosing nursing as a career The increasing number of aging persons leading to an increase in persons requiring acute care health services 2. Nurse–Patient Ratios Linked to a reduction of professional nurses Academy of Medical Surgical Nurses does not support exact ratios 3. Magnet Status Awarded to hospitals demonstrating success with recruitment and retention of professional nurses Promotes environments favorable to professional nurses 4. Unlicensed Assistive Personnel Used to provide direct care Work under the direct supervision of the professional nurse 5. Allocation of Resources and Patient Bed Assignments Goals involve ensuring the most favorable use of resources Resource allocation must include ethical, economic, and legal concerns III. Use of Technology in High-Acuity Environments A. Benefits 1. The use of technology in the intensive care unit allows for close monitoring of the patient. 2. The technology is a primary incentive for placement in the intensive care unit. 3. The use of computers can provide a programmed approach to guide decision making by providing decision-making trees. 4. Programs are available to diagnose patient conditions. Handheld devices can be used to provide bedside reference guides. B. Patient depersonalization 1. Difficulties arise when machines become the focus of care of the high-acuity patient. 2. Technical devices present mechanical impediments to touching the patient. 3. Little surface area may be available for physical contact, and this may lead to a feeling of depersonalization. 4. Technology may evoke fear in patients and contribute to their anxiety about their recovery process. C. Overload and overreliance issues 1. The potential for increased stress on the nurse as a result of information overload. 2. A potential overreliance on technology by the nurse. D. Finding a Balance 1. The skilled nurse who practices in a high-acuity setting must be able to bridge the gap between complex technology and the art of caring. PowerPoint Slides 1. Advantages of Technology in the ICU Allows for close monitoring of the patient Provides a programmed approach to decision making Provides programs to diagnose patient disorders Source of readily available reference information 2. Disadvantages of Technology Depersonalization of the patient Overload Over-reliance IV. Healthy Work Environment A. Healthy work environment 1. The American Association of Critical Care Nurses (AACN) has identified six standards needed to sustain a healthy work environment. These standards are: a) Skilled communication b) True collaboration c) Effective decision making d) Appropriate staffing e) Meaningful recognition f) Authentic leadership B. Stress and burnout 1. Burnout is a term used to describe feelings of personal and professional frustration, dissatisfaction, job insecurities, and emotional and physical exertion. 2. Causes for burnout: a) Nursing shortages, long work hours, and a loss of concentration b) Stress caused by exposure to patients experiencing pain and suffering c) Feelings of powerlessness d) Repeated exposure to pain and traumatic loss C. Coping with stress and burnout 1. Factors that improve a nurse’s ability to cope with stress are a positive social climate, managerial support, and staff cohesiveness. 2. Debriefings help to promote coping with special situations. 3. A sense of community allows the nurse the ability to share both stresses and joys. PowerPoint Slides 1. AACN Standards for Healthy Work Environments Skilled communication True collaboration Effective decision making Appropriate staffing Meaningful recognition Authentic leadership 2. Burnout Describes feelings of personal and professional frustration, dissatisfaction, job insecurities, and emotional and physical exertion 3. Causes of Nursing Burnout Nursing shortages Long work hours Loss of concentration Repeated exposure to patients during suffering Feelings of powerlessness Exposure to pain and traumatic loss 4. Work-related factors that improve the ability of the nurse to manage stress: Positive social climate Managerial support Staff cohesiveness Availability of debriefings V. Ensuring Patient Safety in High-Acuity Environments A. The culture 1. Studies have linked a relationship among work conditions, teamwork, and patient outcomes: a) High levels of teamwork have been associated with a decreased length of stay and decreased mortality. 2. The current culture is supportive of reporting health care errors. B. Patient safety 1. The Joint Commission (TJC) is an accrediting organization that seeks to improve patient safety through an accreditation process. a) TJC developed National Patient Safety Goals for acute care hospitals. b) To receive accreditation, the applying organization must develop and provide evidence that it is meeting the outlined safety goals. C. Technology and patient safety 1. Computerized systems are used to prevent errors a) The computerized provider order entry (CPOE) systems (1) Used to block incorrect medication orders; warn of drug interactions, allergies, and overdoses; provide current drug information; and alert one to similar drug names b) The barcode point-of-care (BPOC) (1) Allows nurses to scan their badges and then the patient wristbands to access medications c) Personal digital assistants (PDAs) provide helpful reference information D. Other factors contributing to patient safety 1. Patient safety can be promoted with factors other than technology. 2. A strong educational foundation and solid orientation will help the high-acuity nurse provide a safe environment. 3. Strong physician–nurse relationships and responsible management are key. PowerPoint Slide 1. Error Reporting Culture in health care is supportive of error reporting. Error reporting has been accompanied by systems improvement. 2. The Joint Commission (TJC) Accrediting organization seeking to improve patient safety. Developed National Patient Safety Goals. Acute care facilities seeking accreditation must provide evidence of meeting safety goals. 3. Computerized Systems Used to Prevent Errors Computerized provider order entry (CPOE) systems Barcode point-of-care (BPOC) Personal digital assistants (PDAs) 4. Non-Technological Elements That Promote Patient Safety Strong educational foundation Solid orientation Specialty certification Strong physician–nurse relationships VI. Chapter Summary VII. Clinical Reasoning Checkpoint VIII. Post-Test IX. References Suggestions for Classroom Activities Develop three to four patient scenarios. Lead a class discussion as to whether the patients being referenced are suitable to the ICU, IMC, or general medical–surgical unit. Determine the students’ interest level. Ask the students if they are considering a nursing career in an ICU, an IMC, or a generalized medical–surgical care unit. What factors do the students cite as the reasons behind their choices? Contact a local clinical facility. Ask to have a copy of its policies concerning the steps taken when the intensive care units are filled to capacity. Suggestions for Clinical Activities During the clinical post conference, ask the students to evaluate whether their assigned patients were appropriate for the ICU, IMC, or general medical–surgical care unit. Lead a class discussion to determine potential factors that would lead to a patient’s being considered a Priority 4 patient. Provide the clinical group rotation opportunities to the ICU and the IMC. Ask the students to develop a listing of the noted differences between the units. Wagner et al., Instructor’s Resource Manual for High-Acuity Nursing, 6th Edition ©2014 by Education, Inc.