Page 49 - ACCCN's Critical Care Nursing

26 S C O P E O F C R I T I C A L C A R E

The nursing workload at the individual patient level, registered nurses possessing a formal specialist critical
however, is also reflective of patient acuity, the complexity care qualification. The ACCCN recommends an optimum
of care required and both the physical and the psycho- qualified critical care nurse to unqualified critical care
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logical status of the patient. Strict adherence to the nurse ratio of 75% (see Appendix B2). In Australia and
patient census model leads to the inflexibility of match- New Zealand, approximately 50% of the nurses employed
ing nursing resources to demand. For example, some ICU in critical care units currently have some form of critical
patients receive care that is so complex that more than care qualification. 34
one nurse is required, and an HDU patient may require Debate continues in an attempt to determine the
less medical care than an ICU patient, but conversely may optimum skill mix required to provide safe, effective
require more than 1 : 2 nursing care level secondary to nursing care to patients. 42–48 Much of the research fuelling
such factors as physical care requirements, patient confu- this debate has been undertaken in the general ward
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sion, anxiety, pain or hallucinations. A patient census setting, and still predominantly in the USA. However, it
approach therefore does not allow for the varying nursing has provided the starting point for specialty fields of
hours required for individual patients over a shift, nor nursing to begin to examine this issue. The use of nurses
does it allow for unpredicted peaks and troughs in activ- other than registered nurses in the critical care setting has
ity, such as multiple admissions or multiple discharges.
been discussed as one potential solution to the current
There are many varied patient dependency/classification critical care nursing shortage. Projects in Australia trial-
tools available, with their prime purpose being to classify ling the use of EENs in the critical care environment have
patients into groups requiring similar nursing care and to largely proved inconclusive. 49
attribute a numerical score that indicates the amount of Published research on skill mix has examined the substi-
nursing care required. Patients may also be classified tution of one grade of staff with a lesser skilled, trained
according to the severity of their illness. These scoring or experienced grade of staff and has utilised adverse
systems are generally based on physiological variables, such events as the outcome measure. A significant proportion
as the acute physiological and chronic health evaluation of research suggests that a rich registered nurse skill mix
(APACHE) and simplified acute physiology score (SAPS) reduces the occurrence of adverse events. 42–48 A compre-
systems. Although these scoring systems have value in deter- hensive review of hospital nurse staffing and patient out-
mining the probability of in-hospital mortality, they are not comes noted that existing research findings with regard
good predictors of nursing dependency or workload. 38
to staffing levels and patient outcomes should be used to
The therapeutic intervention scoring system (TISS) was better understand the effects of skill mix dilution, and
developed to determine severity of illness, to establish justify the need for greater numbers of skilled profession-
nurse-to-patient ratios and to assess current bed utilisa- als at the bedside. 50
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tion. This system attributes a score to each procedure/ While there has not been a formal examination of skill
intervention performed on a patient, with the premise mix in the critical care setting in Australia and New
that the greater the number of procedures performed, the Zealand, two publications 51,52 informing this debate
higher the score, the higher the severity of illness, the emerged from the Australian Incident Monitoring Study–
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higher the intensity of nursing care required. Since its ICU (AIMS–ICU). Of note, 81% of the reported adverse
development in the mid-1970s, TISS has undergone mul- events resulted from inappropriate numbers of nursing
tiple revisions, but this scoring system, like APACHE and staff or inappropriate skill mix. Furthermore, nursing
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SAPS, still captures the therapeutic requirements of the care without expertise could be considered a potentially
patient. It does not, however, capture the entirety of the harmful intrusion for the patient, as the rate of errors by
nursing role. Therefore, while these scoring systems may experienced critical care nurses was likely to rise during
provide valuable information on the acuity of the patients periods of staffing shortages, when inexperienced nurses
within the ICU, it must be remembered that they are not required supervision and assistance. These important
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accurate indicators of total nursing workload. Other spe- findings provide some insight into the issues surrounding
cific nursing measures have been developed, but have not skill mix.
gained widespread clinical acceptance in Australia or New
Zealand. (For further discussion of nursing workload In Australia and New Zealand, an annual review of inten-
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measures, see Measures of Nursing Workload or Activity in sive care resources reported that there were 6633.7 FTE
this chapter.) registered nurses currently employed in the critical care
nursing workforce (5587.2 in the public sector and
While not strictly workload tools, various early warning 1046.5 in the private sector). More recently, in 2005,
scoring systems are increasingly being used to facilitate categories of nurses in the workforce other than registered
the early detection of the deteriorating patient. These nurses were captured and reported for the first time,
early warning systems generally take the format of a stan- showing that there were 53.9 FTE enrolled nurses cur-
dardised observation chart with an in-built ‘track and rently employed in the critical care setting in Australia
trigger’ process. 39–41
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(44.6 in the public sector and 9.3 in the private sector).
Enrolled nurse training has not occurred in New Zealand
SKILL MIX since 1993, and those who are currently employed in the
Skill mix refers to the ratio of caregivers with varying healthcare system are restricted to a scope of practice that
levels of skill, training and experience in a clinical unit. does not call for complex nursing judgements. Thus, no
In critical care, skill mix also refers to the proportion of enrolled nurses were reported to be working in critical