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to provide resources, education and leadership. Regis- helpful for new units to contact a unit of similar size and
tered nurses within the unit are generally nurses with service profile to ascertain their experiences.
formal critical care postgraduate qualifications and
varying levels of critical care experience. NURSE-TO-PATIENT RATIOS
Prior to the mid-1990s, when specialist critical care nurse Nurse-to-patient ratios refer to the number of nursing
education moved into the tertiary education sector, criti- hours required to care for a patient with a particular set
cal care education took the form of hospital-based certifi- of needs. With approximately 30% of Australian and New
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cates. Since this move, postgraduate, university-based Zealand units identified as combined units incorporating
programs at the graduate certificate or postgraduate intensive care, coronary care and high-dependency
diploma level are now available, although some hospital- patients, different nurse-to-patient ratios are required
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based courses that articulate to formal university pro- for these often diverse groups of patients. It is important
grams continue to be accessible. The ACCCN (see to note that nurse-to-patient ratios are provided
Appendix B1) and the WFCCN (see Appendix A1) have merely as a guide to staffing levels, and implementation
developed position statements on the provision of critical should depend on patient acuity, local knowledge and
care nursing education. Various support staff are also expertise.
required to ensure the efficient functioning of the depart-
ment, including, but not limited to, administrative/ Within the intensive care environment in Australia and
clerical staff, domestic/ward assistant staff and biomedi- New Zealand, there are several documents that guide
cal engineering staff. nurse-to-patient ratios (Table 2.4). The ACCCN has devel-
oped and endorsed two position statements that identify
STAFFING LEVELS the need for a minimum nurse-to-patient ratio of 1 : 1 for
intensive care patients and 1 : 2 for high-dependency
A staff establishment refers to the number of nurses patients. 30,35 In New Zealand, the Critical Care Nurses
required to provide safe, efficient, quality care to Section of the New Zealand Nursing Organisation
patients. Staffing levels are influenced by many factors, (NZNO) also determines that critically ill or ventilated
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including the economic, political and individual char- patients require a minimum 1 : 1 nurse-to-patient ratio.
acteristics of the unit in question. Other factors, such Both of these nursing bodies state that this ratio is clini-
as the population served, the services provided by the cally determined. The WFCCN states that critically ill
hospital and by its neighbouring hospitals, and the sub- patients require one registered nurse to be allocated at all
specialties of medical staff working at each hospital also times. The College of Intensive Care Medicine (CICM)
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influence staffing. Specific issues to be considered also identifies the need for a minimum nurse-to-patient
include nurse-to-patient ratios, nursing competencies ratio of 1 : 1 for intensive care patients and 1 : 2 for high-
and skill mix. dependency patients. 27,37
The starting point for most units in the establishment of The ACCCN and the NZNO Critical Care Nurses
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minimum, or base, staffing levels is the patient census Section have outlined the appropriate nurse staffing
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approach. This approach uses the number and classifica- standards in Australia and New Zealand for ICUs within
tion (ICU or HDU) of patients within the unit to deter- the context of accepted minimum national standards and
mine the number of nurses required to be rostered on evidence that supports best practice. The ACCCN state-
duty on any given shift. In Australia and New Zealand a ment identified 10 key principles to meet the expected
registered nurse-to-patient ratio of 1 : 1 for ICU patients standards of critical care nursing (Table 2.5).
and 1 : 2 for high-dependency unit (HDU) patients has
been accepted for many years. Recently in Australia there These recommendations serve merely to guide nurse-to-
have been several projects examining the use of endorsed patient ratios, as extraneous factors such as the clinical
enrolled nurses (EEN) in the critical care setting. The New practice setting, patient acuity and the knowledge and
South Wales project identified difficulties with EENs expertise of available staff will influence final staffing pat-
undertaking direct patient care, but determined that there terns. In particular, patient dependency scoring tools are
may be a role for them in providing support and assis- designed to guide these staffing decisions and are dis-
tance to the RN. 27,30,32 Other countries, such as the USA, cussed below.
have lower nurse staffing levels, but in those countries
nursing staff is augmented by other types of clinical or PATIENT DEPENDENCY
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support staff, such as respiratory technicians. The limi-
tations of this staffing approach are discussed later in this Patient dependency refers to an approach to quantify the
chapter. Once the base staffing numbers per shift have care needs of individual patients, so as to match these
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been established, the unit manager is required to calcu- needs to the nursing staff workload and skill mix. For
late the number of full-time equivalents that are required many years, patient census was the commonest method
to implement the roster. In Australia, one FTE is equal to for determining the nursing workload within an ICU.
a 38-hour working week. That is, the number of patients dictated the number of
nurses required to care for them, based on the accepted
The development of the nursing establishment is depen- nurse-to-patient ratios of 1 : 1 for ICU patients and 1 : 2
dent on many variables. Historical data from previous for HDU patients. This reflects the unit-based workload,
years of patient throughput and patient acuity assist in and is also the common funding approach for ICU
the determination of future requirements. It is often bed-day costs.