Page 800 - ACCCN's Critical Care Nursing

A P P E N D I X B A U S T R A L I A N C O L L E G E O F C R I T I C A L C A R E N U R S E S ( A C C C N ) P O S I T I O N S TAT E M E N T S 777

APPENDIX B3 healthcare worker. This concept fails to recognise the
POSITION STATEMENT (2006) expertise and knowledge of the Division 1* RN (espe-
ON THE USE OF HEALTHCARE cially those with a postgraduate qualification) that has
been demonstrated to decrease the risk of adverse patient
WORKERS OTHER THAN outcomes. 4,5
DIVISION 1* REGISTERED NURSES The use of Division 2 RNs/ENs** and unlicensed health-
IN INTENSIVE CARE care workers in the intensive care setting has been exam-
ined in North America and the United Kingdom, with a
ACCCN acknowledges the important contribution of number of studies identifying a relationship between low
Enrolled Nurses (ENs) (Division 2 RN)** in many roles Division 1* RN staffing levels, higher patient mortality
and settings, and is supportive of all nurses who wish to rates and increased adverse events. 6-12 Other studies
enhance their skills and knowledge to enable them provide evidence that the number of Division 1* RN
to work in specialist areas. ACCCN believes the best way hours per patient per day influences the quality of
to achieve the appropriate skill level for specialist areas patient care. 13-15
is through a formal postgraduate program in that
specialty. The British Association of Critical Care Nurses (BACCN)
performed a critical appraisal of the literature to inform
This position statement is based on current evidence their position statement on nurse : patient ratios within
regarding the effect of healthcare workers other than Divi- intensive care16; included in this review was an examina-
sion 1* Registered Nurses on patient outcomes in the tion of the use of staff other than (Division 1*) Registered
intensive care environment. It is also supported by the Nurses. The BACCN position statement states that it is
ACCCN ‘Position Statement on Intensive Care Nurse the right of intensive care patients to be cared for by a
1
Staffing’ , the Joint Faculty of Intensive Care Medicine (Division 1*) Registered Nurse, and that the acuity of the
2
(JFICM) ‘Minimum Standards for Intensive Care Units’ , intensive care patient should be the determining factor
and the Australian Council of Healthcare Standards when matching their needs with the knowledge and skills
3
‘Guidelines for Intensive Care Units’ . 16
of the Registered Nurse delivering their care.
l All intensive care patients must have a Division 1*
Registered Nurse allocated exclusively for their care The Canadian Association of Critical Care Nurses
17
l High-dependency or stepdown patients (within inten- (CACCN) position statement on the use of non-
sive care) who require a nurse to patient ratio of 1 : 2, regulated health personnel in intensive care areas identi-
should have a Division 1* Registered Nurse allocated fies how critical-thinking is both invaluable and essential
exclusively to their care in the provision of care to critically ill patients. They also
l Enrolled Nurses (Division 2 RNs**) may be allocated assert the process involved in the delivery of nursing care
duties to assist the Division 1* Registered Nurse; to this specific population of patients represents a com-
however, any activities which involve direct contact plex integration of knowledge, judgement, organisation
with the patient, must always be performed in the and evaluation. While CACCN do not unequivocally rule
immediate presence of the Division 1* Registered out the use of these personnel in this setting, they believe
Nurse the quality of patient care would be compromised with
l Unlicensed personnel should only be used to assist their use, and they do not endorse the use of non-regu-
the Division 1* Registered Nurse perform direct lated personnel in direct patient care roles in intensive
15
patient care for specific duties such as manual han- care areas.
dling. Otherwise their duties should be confined to In Australia, while there has not been a formal examina-
non-nursing duties, housekeeping, etc. tion of the use of Division 2 RNs/ENs** within the inten-
sive care setting, two publications that inform this debate
Discussion come from the Australian Incident Monitoring Survey.
Many factors that result in decreased recruitment and The first paper examined 3600 reports which identified
retention are causing the current worldwide nursing 89 incidents related to nursing staff shortages; 373 inci-
shortage. One idea that has been promulgated as a poten- dents related to nursing staff shortages being a contribut-
tial solution to the shortage of nurses in intensive care is ing factor in the incident, and 81% of the adverse events
the use of personnel other than Division 1* Registered reported resulted from inappropriate numbers of nursing
Nurses. This idea suggests the issue is one of ‘workload’, staff or inappropriate skill mix. 18
i.e. a group of tasks that can easily be delegated to any
The second paper from this group examined 735 reports
which identified 1472 incidents relating to nursing staff
inexperience. Of the 1472 incidents, 20% led to adverse
*Division 1 Registered Nurse is the term used in Victoria for nurses who are
referred to as Registered Nurses in all other states of Australia. RNs in all states outcomes for the patient. The authors believe that nursing
must undertake a 3 year undergraduate degree. care without appropriate expertise poses a potential
increased risk of harm to the patient. They concluded that
**Division 2 Registered Nurse is the term used in Victoria for nurses who are
referred to as Enrolled Nurses in other states of Australia. The educational prepara- the rate of errors made by experienced intensive care
tion varies between states, but is primarily conducted in the vocational sector; it nurses was likely to increase during periods of staffing
ranges from a 12-month certificate to an 18-month diploma. One of the most shortages, when inexperienced nurses required super-
contentious differences between jurisdictions and educational preparation is the 15
inclusion of medication administration. vision and assistance. Another Australian study also