Page 51 - ACCCN's Critical Care Nursing

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

preparation and education of critical care nurses are avail- points have often been required to support continued
able 31,57,58 that present frameworks to ensure that the cur- registration. This concept has subsequently been imple-
ricula of courses provide adequate content to prepare mented in the UK and Europe. 64
nurses for this specialist nursing role (see Appendices A1
and B2). RISK MANAGEMENT
Nursing has always been a profession that has required
currency of knowledge and clinical skills through con- Managing risk is a high priority in health, and critical care
tinuing education input, because of the rapidly changing is an important risk-laden environment in which the
knowledge base and innovative treatment regimens. manager needs to be on the lookout for potential error,
These changes are occurring at an increasingly rapid rate, harm and medico-legal vulnerability. The recent Sentinel
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particularly in critical care. The need for critical care Events Evaluation (SEE) study has given an indication
nurses to maintain current, up-to-date knowledge across of this risk for critical care patients. The SEE study was a
a broad range of clinical states has therefore never been 24-hour observational study of 1913 patients in 205 ICUs
more important. Specific issues related to orientation and worldwide, which identified 584 errors causing harm or
continuing education programs are briefly discussed potential harm to 391 patients. The SEE authors con-
below. cluded there was an urgent need for development and
implementation of strategies for prevention and early
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detection of errors. A second study by the same team
Orientation specifically targeted errors in administration of parenteral
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The term orientation reflects a range of activities, from a drugs in ICUs. In this study 1328 patients in 113 ICUs
comprehensive unit-based program, attendance at a worldwide were studied for 24 hours; 861 errors affecting
hospital induction program covering the mandatory edu- 441 patients occurred, or 74.5 parenteral drug admini-
cational requirements of that facility, through to familia- stration errors per 100 patient days. The authors con-
risation with the layout of a department. The aim of an cluded that organisational factors such as error reporting
orientation program is the development of safe and effec- systems and routine checks can reduce the risk of such
tive practitioners. 59 errors. 66
Unit-specific orientation should be a formal, structured What is more alarming is that many health practitioners
program of assessment, demonstration of competence do not acknowledge their own vulnerability to error. One
and identification of ongoing educational needs, and study asked airline flight crews (30,000) and health pro-
should be developed to meet the needs of all staff who fessionals (1033 ICU/operating room doctors and nurses,
are new to the unit. Competency-based orientation is of whom 446 were nurses) from five different countries
learner-focused and based on the achievement of core a simple question, ‘Does fatigue affect your (work) per-
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competencies that reflect unit needs and enable new formance?’, with fascinating results. Of those respond-
employees to function in their role at the completion of ing, the following replied in the affirmative to the
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the orientation period. The ACCCN Competency Stan- question: pilots and flight crew, 74%; anaesthetists, 53%;
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dards for Specialist Critical Care Nurses may be used as surgeons, 30% (a figure for nurses’ responses to this ques-
a framework on which to build competency-based orien- tion was not provided in the study). The study also found
tation programs. that only 33% of hospital staff thought errors were
handled appropriately in their hospital and that over
Continuing Education 50% of ICU staff found it hard to discuss errors. 67
In 2003, both the Royal College of Nursing Australia and Governance and management of the critical care environ-
the College of Nursing implemented systems of formally ment requires a multidisciplinary team of senior clinician
recognising professional development, with the awarding managers who understand both the clinical risk and the
of continuing education (CE) points. While professional quality cycles of the environment as well as the executive
development has always been a requirement of continuing requirements for financial and organisational viability.
practice, this process is becoming more formalised. On 1 An astute and careful balance between good clinical gov-
July 2010 the Australian Health Practitioner Regulation ernance and good corporate governance is required to
Agency came into being as a national health practitioner ensure sustainable and appropriate healthcare for all
body. With this, a formal requirement for continuing users. The take-home message in all this is that managers
education or professional development was mandated. in hospitals manage enormous risks with patients, staff
The Nursing and Midwifery Board of Australia, a subgroup and visitors but often do not appreciate their own level
of the above agency, clearly identifies the standard for of vulnerability to error and risk. Yet claims of negligence
continuing professional development of nurses and mid- and charges of incompetence can be as threatening to the
wives. In New Zealand there is an expectation that a manager as they are to the clinician.
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minimum of 60 hours professional development and 450
hours of clinical practice will be undertaken over a three- NEGLIGENCE
year period for the purposes of registration renewal. 63
The above studies do not necessarily mean that health
Conversely, North American nursing associations have professionals are negligent. Negligence is a legal term that
for many years had formal programs for recognising con- can be proven only in a court. There are four aspects to
tinuing education and awarding CE points. These CE the charge of negligence: