PART

The Concept
of Holism Applied
to Critical Care
Nursing Practice
1 Critical Care Nursing Practice:
An Integration of Caring, Competence,
and Commitment to Excellence
2 The Patients Experience With Critical Illness
3 The Familys Experience With Critical Illness
4 Impact of the Critical Care Environment
on the Patient
5 Relieving Pain and Providing Comfort
6 Patient and Family Education in Critical Care

one
two
three
four
five
six
seven
eight
nine
ten
eleven
twelve

INTERNET RESOURCES
Topic

Web Page Address

Agency for Healthcare Research

and Quality (AHRQ)

www.ahrq.gov

American Association
of Critical Care Nurses

www.aacn.org

American Chronic Pain Association

www.theacpa.org

American Holistic Nurses

Association (AHNA)

www.ahna.org

American Pain Foundation

www.painfoundation.org

American Society
of Pain Management Nurses

www.aspmn.org

Center for Medical Ethics

and Mediation

www.wh.com/cmem/

Cochrane Collaboration
(evidence-based practice)

www.cochrane.org

End of Life Nursing Education Center

www.aacn.nche.edu/elnec

Hospice and Palliative

Nurses Association

www.hpna.org

Institute for Family Centered Care

www.familycenteredcare.org

International Center for Control

of Pain in Children

www.pedspain.nursing.uiowa.edu

National Center for Complementary

and Alternative Medicine

www.nccam.nih.gov

National Center
for Cultural Competence

http://gucchd.georgetown.edu/nccc/cultural.html

National Guideline Clearinghouse

www.guidelines.gov

National Hospice
and Palliative Care Organization

www.nhpco.org

The Patient Education Institute

www.patient-education.com

Promoting Excellence
in End-of-Life Care

www.promotingexcellence.org

Transcultural Nursing Society

www.tcns.org

US Preventive Services Task Force

www.ahcpr.gov/clinic/uspstfix.htm

chapter

Critical Care Nursing Practice:

An Integration of Caring,
Competence, and
Commitment to Excellence
MICHAEL RELF

ROBERTA KAPLOW

Evidence-Based Critical Care

Nursing Practice
Critical Thinking Is Essential
to Critical Care
Certification and Critical Care
Nursing Practice
The Synergy Model
Collaboration
The Family, Critical Illness,
and Current Evidence
Spirituality and Caring During
Critical Illness and at the End
of Life
Professional Organizations and
Resources
American Association of CriticalCare Nurses: A Commitment
to Excellence
The Future of Critical Care Nursing

objectives
Based on the content in this chapter, the reader should be able to:
Describe the value of evidence-based practice in caring for critically ill patients.
Discuss the value of critical thinking in critical care.
Describe the value of certication.
Provide examples of how the Synergy Model can promote positive patient outcomes.
Discuss the value of collaborative practice in critical care.
List benets of membership in the American Association of
Critical-Care Nurses.
Discuss future issues facing critical care nursing practice.

s the health care delivery system continues to

evolve, so too does nursing and critical care. Today,
the care of critically ill patients occurs not only in
the traditional setting of the hospital intensive care unit
(ICU), but also on the progressive care unit, the medical
unit, and the surgical unit as well as in the subacute facility,
the community, and the home. Since the rst critical care
unit (CCU) opened in the late 1960s, significant technological advances have occurred, accompanied by a knowledge explosion in critical care nursing. Consequently,
critical care nurses of the 21st century are routinely caring
for the complex, critically ill patient. This is accomplished
by integrating sophisticated technology with the psychosocial challenges and ethical conicts associated with
critical illness, while at the same time addressing the needs

and concerns of family members and other signicant

people in the patients life.
In response to the ever-changing delivery system,
critical care nurses are championing the needs of the
patient and the family or significant others. During the
last several decades, critical care nurses have experienced firsthand what nurse researchers have consistently
demonstratedhowever it is comprised, critical illness
is not only a physiological alteration, but a psychosocial,
developmental, and spiritual process. Critical illness is
also a threat to the individual and his or her family constellation. As health care becomes increasingly technological, the concurrent need for humanization has become
even more essential. Compatible with the need for
humanized health care is the need to provide effective
3

PART 1

THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE

interventions that are based on evidence instead of being

steeped in tradition.

EVIDENCE-BASED CRITICAL
CARE NURSING PRACTICE
Todays health care system has become increasingly more
costly and complex. Consequently, in this market-driven
delivery system, there is a greater emphasis on outcomes,
cost-effectiveness, and consumer satisfaction. These pressures operate in an environment of rapid information
exchange, technological advancements, and an increasing
nursing workload. Nurses are challenged to maintain clinical competence, to demonstrate how their care positively
affects patient outcomes, and to participate actively in
clinical decision making and practice improvements.
Furthermore, nurses are now mandated to demonstrate
cost-effectiveness and efciency with the use of time and
resources, while continuing to demonstrate their valueadded impact on outcomes. These mandates provide a
strong rationale for adopting an evidence-based model of
practice.
As reported by the Presidents Advisory Commission on
Consumer Protection and Quality in the Healthcare Industry in 1998, improving the quality of healthcare requires a
commitment to delivering healthcare based on sound scientic evidence and continuously innovating new, effective
healthcare practices and preventive approaches.1 Payers
advocate the use of an evidenced-based practice model
(EBP) in an effort to identify health care costs that are not
benecial.2
There are many instances in critical care nursing, and
in nursing overall, when nurses wonder if they are providing the best possible intervention or using the best product to attain optimal patient outcomes. Too frequently,
the responses may be Weve always done it that way,
Thats what I learned in my undergraduate nursing program, or I prefer to do it this way. Unfortunately, these
common comments do not reect the sophisticated
knowledge base or experiential practice base that nurses
use on a daily basis.
Evidence-based practice (EBP) has been dened as the
use of the best clinical evidence from systemic research in
making patient care decisions.3 It is a process used by nurses
to integrate the best and most timely scientic evidence
with clinical expertise when making health care decisions.
The methods are derived from evidence-based medicine
developed as a paradigm and method in Canada.4,5 EBP is a
framework in which to determine the best means to care for
patients and make informed decisions concerning nursing policies and procedures in order to influence patient
outcomes. It is not intended to take the place of clinical
nursing judgment and expertise. Rather, EBP combines
evidence with clinical expertise and patient preferences
to promote positive patient outcomes and excellence in
nursing practice.
EBP is a method used by nurses as a basis for clinical
decision making in an effort to optimize patient care and
outcomes. It is predicated on the notion that clinical practice, guidelines, standards, and protocols should be derived
from evidence from randomized clinical trials, which

allows nurses to conrm or challenge the ways they provide and evaluate care.6 Results of a meta-analysis have
demonstrated that patients who receive research-based
interventions and care have better outcomes than patients
who receive traditional care.7 In addition, nurses are legally
responsible for the care provided in EBP. They are therefore also responsible for knowing the research foundation
for practice and for determining the best interventions
based on critique and application of the research.8 Box 1-1
provides an overview of the essential steps to evidencebased critical care nursing practice.

CRITICAL THINKING IS
ESSENTIAL TO CRITICAL CARE
In addition to using evidenced-based critical care nursing
interventions to deliver optimal care to critically ill patients
and families, critical care nurses need a strong knowledge
base and critical thinking skills. Critical thinking skills

box 1-1
Steps to Evidence-Based Critical Care
Nursing Practice
1. Accept the fact that health care is evolving, with the
consequent need to base nursing care on evidence,
rather than on tradition or previous education.
2. Identify a need for change in practice by examining
less-than-favorable patient outcomes; causes of
patient, family/significant other, or staff dissatisfaction;
or situations in which compelling new evidence exists
in an aspect of care. Targets for changing practice may
include high-risk, high-volume, or high-cost procedures
and interventions.
3. Frame a clinical question and search the literature for
evidence regarding the topic.
4. Once current research data and evidence have been
collected, evaluate the evidence for scientific merit,
quality, and applicability. Inherent in this process is
the need to determine if findings have been replicated
and that they are relevant (applicable) to the clinical
question posed, and whether the data identified constitute the best evidence.
5. Synthesize to determine the strength of the evidence
to support a change in practice.
6. Conduct a comparison between current practice recommendations and current research.
7. If there is sufficient evidence to suggest a change in
practice and the change in practice is practical in
respect to costs, staff skill, and resources required,
application of the evidence into practice can occur.
Implicit in the implementation of evidence are the
issues associated with change, including fear of
change and the need for information, staff training,
leadership, and ongoing evaluation of the change.
8. Continue to evaluate the evidence through an
ongoing and systematic review to promote stateof-the-science nursing care.

CHAPTER 1

allow the nurse to see the patients big picture through

the analysis of patient data, the evaluation of problems that
emerge in the clinical setting, and the determination of
appropriate interventions to solve the clinical issue. Critical thinking allows the nurse to conduct a costbenet
analysis for any and all therapies indicated, while delving
into the viability of alternative strategies to care. Although
national organizations and nurses in the clinical arena
identify critical thinking skills as pivotal to competent
nursing practice, education often focuses on the memorization of facts regarding clinical care rather than on critical thinking as a process essential to care.9
Between 1995 and 1998, an international panel of expert
nurses representing nine countries and the United States
identied and dened 10 affective components (habits of
the mind) and 7 cognitive skills of critical thinking. The
affective components include condence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual ability, intuition, open-mindedness, perseverance, and
reflection. The cognitive skills comprising critical thinking include analyzing, applying standards, discriminating,
information seeking, logical reasoning, predicting, and
transforming knowledge.10
All of these components are essential for providing quality care to critically ill patients. Nurses must be able to use
these comprehensive skills to perform clinical decision
making and problem solving as they care for patients with
complex, multisystemic problems. The value of critical
thinking skills has become increasingly important in the
face of rapid changes in the health care environment,
including procedural changes and technological advances.11
The development of critical thinking skills in nursing
students and new critical care nurses is a major challenge
confronting nurse educators in the academic and clinical
settings.12 Traditional teaching methods such as lecture,
handouts, and observation do not stimulate critical thinking skills. Consequently, complementary teaching methods are essential to facilitate the application of theoretical
knowledge to the bedside, particularly during the transition of the new graduate or experienced nurse into the
critical care environment.
There are several strategies that may be used to enhance
critical thinking skills. These include the use of case studies,
simulation, videotaped vignettes, role playing, games, and
clinical questioning. Clinical preceptors, managers, clinical
educators, and clinical nurse specialists, along with staff
nurse colleagues, need to create environments conducive to
critical thinking for the new critical care nurse. By mentoring and role modeling, experienced critical care nurses can
encourage creative problem solving, facilitate open dialogues, and discuss clinical issues, while at the same time
facilitating the transition from novice to expert.13 Simultaneously, new as well as experienced critical care nurses need
to challenge underlying beliefs related to their practice and
evaluate alternative strategies for care.14 Critical thinking
skills are required to evaluate practice and use an EBP
model, which results in optimal patient outcomes.
Similar to EBP, the application of critical thinking skills
has been shown to improve clinical outcomes and is associated with a decrease in errors and sentinel events.15
Through the development and application of critical thinking, the level of competence of the critical care nurse will be

Critical Care Nursing Practice

increased, producing quality patient outcomes. Time, experience in the clinical arena, and the critical thinking skills
themselves contribute to the development of a critical
thinker. In addition, it is essential to establish a unit culture
of openness, respect, and trust, which allows the novice as
well as the experienced critical care nurse to ask questions,
seek information, and critically analyze practice.

CERTIFICATION AND CRITICAL

CARE NURSING PRACTICE
Certication is a process by which a nongovernmental
agency validates, based on predetermined standards, the
qualications and knowledge of an individual nurse that
are necessary for practice in a dened functional or clinical area of nursing.16 In 1975, the American Association of
Critical-Care Nurses (AACN) established the Certication Corporation. The purpose of the Certication Corporation was to develop the critical care registered nurse
(CCRN) certication examination program. The purpose
of the certication process, consistent with the denition
of certication, is to have a means for developing, maintaining, and promoting high standards of critical care
nursing practice.17 The ultimate goal is to provide optimal
care to critically ill patients and their families in a dynamic
health care environment.
The CCRN credential acknowledges that the nurse has
attained a knowledge base that is essential to critical care
nursing practice, as well as the ability to synthesize, interpret, and apply this knowledge to the care of the patient.18
To date, 50,000 nurses worldwide have received the
CCRN credential in adult, pediatric, and neonatal critical
care nursing. This credential validates to patients, peers,
and hospital administrators the nurses competence and
commitment to excellence in critical care nursing. Because
the standards for the examination are high, certication is
well respected throughout the health care community.18
In May 2002, Terry Richmond19 described the value of
critical care certication in her address to the attendees of
the CCRN luncheon at the National Teaching Institute.
She described certied nurses as the heroes of critical
care and noted three gifts that certied nurses give their
patients. The rst gift is the gift of knowledge. The specialty of critical care requires high levels of preparation
and the in-depth knowledge necessary for providing optimal care. CCRN certication is a powerful external validation of this critical knowledge and a gift that critical care
nurses give themselves and their patients.
The second gift is the gift of caring. Once a critical
care nurse has attained the necessary breadth, depth, and
currency of knowledge, energy can be put into other foci of
care. A patient can be seen as not merely a diagnosis, but as
a person with a family or signicant other who likewise has
needs. According to Richmond, the gift of caring is essential to being a hero. Knowledge and caring go hand in hand;
one without the other does not translate into quality care.
The third gift is the invitation into lives. A certied
nurse can walk into a patients life with knowledge and caring during the most vulnerable period in that persons life.
Critical illness will never be ordinary for a patient and family. Nor should critical illness ever become ordinary for a

PART 1

THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE

nurse. A certied practice that uses these gifts promotes

optimal patient outcomes and is nothing less than extraordinary. The process of certication enhances the profession and practice of nursing by encouraging nurses to attain
the breadth and depth of knowledge required for successful
completion. This is essential to the practice of giving quality nursing care to critically ill patients and their families.19

THE SYNERGY MODEL

In August 1999, the AACN implemented the Synergy
Model to link certied practice to clinical outcomes. Synergy is an evolving phenomenon that occurs when individuals work together in mutually enhancing ways toward
a common goal. The Synergy Model describes nursing
practice on the basis of the needs and characteristics of
patients rather than in terms of diseases and treatment
modalities. The underlying premise of the Synergy Model
is that the characteristics of patients and families inuence
and drive the characteristics and competencies of nurses.
Because each patient brings a set of unique characteristics
to the clinical situation, nurses must possess their own
unique characteristics and competencies. When patient
characteristics and nurse competencies match and synergize, optimal patient outcomes can be attained.20

Two major tenets of the Synergy Model are that the

characteristics of the patient are of concern to nurses and
that the competencies of the nurse are important to
patients. Although each patient and family is unique, all
patients have similar needs and experience these needs
across a continuum, from low to high. The more compromised the patients are, the more complex are their needs.
Nursing practice is determined by the needs of patients
and their families. Nursing care reects an integration of
the knowledge, skills, and experience necessary to meet
the needs of patients and their families. The Synergy
Model focuses on the unique contributions of nursing to
patient care and emphasizes the role of the professional
nurse. The eight patient characteristics and nurse competencies are listed and defined in Box 1-2. The eight
nurse competencies also exist on a continuum, from competent to expert. Figure 1-1 provides a schematic representation of the Synergy Model and the interrelationships
between the patient and family, and the patient and nurse
characteristics.
There are three perspectives from which to evaluate
outcomes using the Synergy Model. These are outcomes
derived from the patient, the nurse, and the health care system.20 Optimal outcomes are based on what patients dene
as important. These may include functional change, behavioral change, trust, satisfaction, comfort, and quality of life.

box 1-2
Patient Characteristics and Nurse Competencies as Described by the Synergy Model
Patient Characteristics

Resiliency: The capacity to return to a restorative level of

function using compensatory coping mechanisms; the
ability to bounce back quickly after an insult
Vulnerability: Susceptibility to actual or potential stressors that may adversely affect patient outcomes
Stability: The ability to maintain a steady-state equilibrium
Complexity: The intricate entanglement of two or more
systems (e.g., body, family, therapies)
Resource availability: Extent of resources (e.g., technical, fiscal, personal, psychological, social) the patient,
family, and community bring to the situation
Participation in care: Extent to which the patient and
family engage in aspects of care
Participation in decision making: Extent to which the
patient and family engage in decision making
Predictability: A summative characteristic that allows
one to expect a certain trajectory of illness

Nurse Competencies

Clinical judgment: Clinical reasoning, which includes

clinical decision making, critical thinking, and a global
grasp of a situation, coupled with nursing skills acquired
through a process of integrating formal and experiential
knowledge
Advocacy/moral agency: Working on anothers behalf
and representing the concerns of the patient, family, and
community; serving as a moral agent in identifying and
helping resolve ethical and clinical concerns in the clinical
setting

Caring practices: The constellation of nursing activities

that are responsive to the uniqueness of the patient and
family and that create a compassionate and therapeutic
environment, with the aim of promoting comfort and preventing suffering; these caring practices include, but are
not limited to, vigilance, engagement, and responsiveness
Collaboration: Working with others (e.g., patients, families, health care providers) in a way that promotes and
encourages each persons contributions toward achieving
optimal and realistic patient goals
Systems thinking: The body of knowledge and tools that
allows the nurse to appreciate the care environment from
a perspective that recognizes the holistic interrelationship
that exists within and across health care systems
Response to diversity: The sensitivity to recognize,
appreciate, and incorporate differences in the provision
of care; differences may include, but are not limited to,
family configuration, lifestyle, socioeconomic status, age
values, and alternative medicine involving patients and
their families and members of the health care team
Clinical inquiry or innovator/evaluator: The ongoing
process of questioning and evaluating practice, providing
informed practice, and innovating through research and
experiential learning; the nurse engages in clinical knowledge development to promote the best patient outcomes
Facilitator of learning: The ability to facilitate learning
for patients, nursing staff, physicians, and members of
other health care disciplines; includes both formal and
informal facilitation of learning

CHAPTER 1

Critical Care Nursing Practice

Cl
ini
c

Fa c
ilita
tor

en

Stability

ity
ers

Div
to

Resource
Availability

Resiliency

Complexity

e
ic

e
s
on

Re
s

s
n
oratio
llab
Co

Systems
T
h
inki
ng

Outcomes derived from the nurse may include physiological changes, presence or absence of complications, and the
extent to which treatment objectives were attained. Outcomes derived from the health care system include recidivism, costs, and resource utilization.20
One manner in which the Synergy Model can be used
in clinical practice involves making patient care assignments. Traditionally, in an effort to enhance the continuity of care, patient assignments were made based on the
person who cared for the patient the previous day. Using
the Synergy Model, the nurse who demonstrates the competencies that match the patients needs at that time would
be best suited for the assignment. For example, if a patient
is in a stable, unpredictable, minimally resilient, and vulnerable condition based on the models denitions, the
nurse who excelled in clinical judgment and caring practices would be ideal for this patient. If the patient was vulnerable, unable to participate in decision making, and had
inadequate resource availability, the primary competencies would focus on advocacy/moral agency, collaboration, and systems thinking.
The Synergy Model is currently being evaluated to
determine if nurses dene their practice based on patient
needs, if the patient characteristics accurately describe the
full spectrum of those being cared for, and if patients experience optimal outcomes when patientnurse synergy is
achieved.

Pr
a

Participation
in
Care

ct

Predictability

cacy/Moral Agenc
Advo
y

Clinical Inquiry

CRITICALLY
ILL
PATIENT/
FAMILY

Ca
rin
g

figure 1-1 The relationship between the patient/family and the

nurse in the Synergy Model.

al

em

Vulnerability

Participation
in
Decision
Making

dg

of
L

ng
ni
ar

Ju

ARACTERIST
SE CH
ICS
NUR

Collaboration
In the Synergy Model, the AACN denes collaboration as
working with others (e.g., physicians, families, healthcare
providers) in a way that promotes/encourages each persons
contributions toward achieving optimal/realistic goals. Collaboration involves intra- and interdisciplinary work with
colleagues.21 Since the publication of the Health of the
Nation document in 1992, collaborative practice has been
at the forefront of health service reform.22 Effective planning of care to meet the needs of critically ill patients and
their families who have complex, multisystemic problems
requires a multidisciplinary approach to attain timely and
optimal outcomes. In addition to meeting health care needs,
collaborative practice is further encouraged so that limited
federal funds may be used more efciently.23
Empirical data exist that support the value of a collaborative working relationship between nurses and physicians
in the intensive care setting. A collaborative relationship
has been linked to higher job satisfaction and retention of
nurses, a higher level of patient satisfaction, and lowerthan-expected mortality rates and patient lengths of stay.24
Although leading organizations have put forth recommendations for multidisciplinary efforts and practitioners
agree that interdisciplinary collaboration is important to
attain optimal patient outcomes, there has been hesitation in adopting collaborative working practices.24,25 One

PART 1

THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE

reason cited for this problem is the lack of opportunities

for medical and nursing students to develop collaborative
skills.26,27 Barriers to effective collaboration also include
reimbursement, territorialism, and role confusion on the
part of the health care team and the general public.28
In one study, nurses reported too many physicians on
the case and a power struggle between the patients primary service and specialty physicians as rationales for
patient problems not being resolved.24 In the same study,
one primary care physician felt that nurses who had medical opinions different from the physicians were difcult to
work with. Another primary care physician felt that nurses
would go doctor shopping for a physician to give them
orders for therapy if they did not receive orders for the interventions they thought were appropriate for their patients.24
One area of specialized nursing in which collaboration is inherent in the job description is that of the nurse
practitioner (NP). When NPs accept a position, they are
usually given a practice agreement. This collaborative
practice agreement is a written statement that defines
the joint practice of the physician and NP in a collaborative and complementary working relationship. It delineates the responsibilities of each professional and their
respective contributions toward optimal patient outcomes.23 The physician and NP must work together in a
successful, complementary, and unified manner to obtain
these optimal outcomes.
In her Presidential Address at the 31st Congress of
the Society of Critical Care Medicine (SCCM), Maureen
Harvey described invisible excellence. Inherent in this
concept is the role of the critical care nurse who is vigilantly
monitoring the patient, recognizing subtle changes in
the patients clinical status, and thwarting critical events
through collaboration with the intensivist. Nursephysician
collaboration as well as collaboration with the clinical
dietitian, clinical pharmacist, respiratory therapist, physical
therapist, occupational therapist, and chaplain are essential for obtaining optimal patient outcomes. These outcomes should reflect the contributions made by all
disciplines. Collaboration between researchers and practitioners in both disciplines is essential to provide a scientic
basis for that practice.29

The Family, Critical Illness,

and Current Evidence
Not long ago, the thought of families staying in the CCU
and participating in care was almost unimaginable because
of restricted and rigid visiting hours in many CCUs.30,31 In
addition, the concept that children, animals, or nonlegally
recognized signicant others should not visit a person in
the CCU was widespread and went unchallenged.32 Today,
patient, family, and signicant other advocates have challenged the status quo and instituted a change of visitation policies based on consumer dissatisfaction and current
evidence.30 Although open visitation is not standard practice in every CCU, many CCUs have modied visiting
policies to allow not only immediate family to visit, but signicant others, children, friends, and, in some instances,
even pets.3234 Expanded visitation promotes resiliency of
the human spirit and allows the vulnerable critically ill
patient to connect with signicant people that he or she

would encounter in daily life. Simultaneously, the critical

care nurse must use clinical judgment to assess the impact
of visitation on the physiological and psychological status
of the patient and signicant others, while promoting
involvement in care and decision making.32,33
As CCUs shift from closed to open units, new clinical
controversies will develop and be evaluated through clinical inquiry and research. Two of the future challenges
confronting critical care nurses and the traditions of the
CCU are the role and inclusion of families during trauma
or cardiopulmonary resuscitation (CPR) and the role of
family or signicant other as caregivers in assisting or
independently providing care in the critical care environment.3537 Less than a century ago in the United States,
families and signicant others were the primary caregivers
to critically ill persons and persons at the end of life; this
remains the case in much of the world today.

Spirituality and Caring During Critical

Illness and at the End of Life
Despite innovations and advances in technology and
other therapeutic interventions, patients still transition
from life to death in the CCU. Death, whether expected
as a consequence of end-stage cancer or terminal weaning, or unexpected because of trauma or postoperative
complications, is viewed as the failure of caring practices
for many. During critical illness and at the end of life,
issues of spiritual distress, mortality, family dysfunction,
grief, hopelessness, helplessness, and many other feelings
and emotions may present as part of the coping mechanisms of the individual patient, his or her family or signicant others, and members of the health care team.38
Acuity, unplanned hospitalizations, and patientfamily
and signicant other separation are all potential sources of
stress during any illness. Regardless of the acuity, the
expected outcome, or the availability of interventions, a
caring, competent nurse is essential.39 During critical illness where outcomes are uncertain, the nurse competencies described in the Synergy Model are paramount. This
is especially true when delivering interventions where the
predictability of the outcomes is unknown, the stability of
the patient is tenuous or deteriorating, and the complexity of care is ever increasing. Similarly, at the end of life,
where helplessness, hopelessness, and spiritual distress
may be manifested, caring nursing interventions aimed at
alleviating suffering are essential. These interventions
must also address patient and family involvement in care
and decision making through advocacy, collaboration, and
systems thinking.

PROFESSIONAL
ORGANIZATIONS
AND RESOURCES
American Association of Critical-Care
Nurses: A Commitment to Excellence
The AACN was established in 1969 to help educate nurses
working in ICUs. Currently, it is the largest specialty
organization in nursing, with over 65,000 members in the

CHAPTER 1

Critical Care Nursing Practice

United States and abroad who care for critically ill patients
across the life span. In its mission statement, AACN identies members as the key to its success. To that end,
AACN is committed to providing the highest-quality
resources to maximize the nurses contribution to caring
and improving the health of critically ill patients and their
families. AACN is dedicated to providing its members
with the knowledge and resources necessary to help them
provide optimal patient care.18
Holding membership in professional specialty nursing
organizations has several benets for the card holder. It
provides members with the opportunity to network with
colleagues on the national, regional, and local level, while
providing them with a mechanism to obtain current information in their specialty area. In addition, AACN provides
members with numerous other benets that help to
enhance professional practice.18

credits. Readers of Critical Care Nurse obtain information

on the latest critical care trends. In addition, members
receive AACN News, a newsletter that keeps readers
apprised of current trends in health care as well as organization, chapter, and certication issues.18

AACN ONLINE
AACN Online is a comprehensive critical care Internet website. It provides members with the most recent
resources in clinical practice, continuing education, and
professional development. AACN Online also allows members to discuss issues and share information with other professional colleagues, obtain clinical practice information,
and participate in interactive learning discussions. AACN
members have 24-hour access to the website.18

As health care continues to evolve, so too must critical care

nursing. As the past few years have demonstrated, critical
care nursing will continue to be provided not only in the
inpatient specialty critical care units, but on the medical,
surgical, oncology, and stepdown units, as well as in the
outpatient and home settings. Consequently, the demand
for caring, competent, knowledgeable, and skilled critical
care nurses will continue.
As the baby boom generation ages, and with the
expansion of CCUs beyond the traditional ICU, the
demand for critical care nurses will continue to rise.40 Concurrent with an increased demand for expert critical care
nurses is the need for recruiting, developing, and retaining
expert clinicians in an era of nursing shortage. The ongoing and cyclical nature of the nursing shortage has had a
direct impact on CCUs across the United States.40,41
According to Needleman and colleagues,41 the lack of
trained registered nurses to provide direct nursing care
has had a direct impact on the quality of patient care and
consequently has also affected organizational effectiveness
and outcomes. In response to an increased need for nurses,
particularly critical care nurses, many organizations continue to use supplemental stafng by caring, competent,
knowledgeable critical care nurses. Whether the critical
care nurses are part of the organizations staff or are supplemental staff, consumers and third-party payers alike
will continue to mandate competence, proven interventions derived from EBP, cost-effectiveness, and quality
outcomes.
Simultaneously, the CCUs of tomorrow will be even
more technologically challenging. Therefore, critical care
nurses of the future must not only be technologically procient, but competent in the psychosocial, developmental,
spiritual, and caring domains to interact successfully with
the patient, the family and signicant others, and the other
members of the health care team. With advances in technology and new interventions discovered through EBP,
greater numbers of patients will be afforded interventions
that sustain and improve the quality of their lives.
However, with the implementation of advances in
technology, patients in the CCU will continue to require
caring, competent, and knowledgeable critical care nurses.
These nurses will serve as patient advocates, facilitate
interdisciplinary collaboration, navigate complex delivery

PRACTICE RESOURCE NETWORK

The Practice Resource Network (PRN) provides members
with the opportunity to network with professional colleagues. Once the PRN network is accessed from the
AACN website, members begin by selecting from 1 of
32 topics about which they would like additional information. The topics include all body systems, several acute care
specialties, educational content, informatics, administration/
regulatory information, ethical and legal issues, and standards and guidelines for practice, to name a few. The service can be used to help problem-solve clinical dilemmas,
access current practice and research information, identify
public policy issues as well as resources, and connect with
colleagues with similar interests.18
EDUCATIONAL MERCHANDISE
All members of AACN can receive educational materials at
discounted prices. AACN has educational resources available in several areas, including clinical practice, research,
leadership, ethics, and professional development.18
PUBLICATIONS
Members of AACN receive two bimonthly journals, The
American Journal of Critical Care and Critical Care Nurse.
The former is a scientic research journal in which critical care colleagues publish research ndings, expanding
the current state of the science of critical care nursing. It
is an ideal journal to use as a basis for a literature review
for an EBP model. Critical Care Nurse is a specialty journal that publishes articles related to current clinical practice topics. For example, a recent issue explored how the
Synergy Model is applied in clinical practice by nurses,
educators, or management. The journal also offers its
readers opportunities for obtaining continuing education

LOCAL CHAPTER AFFILIATION

Once nurses have joined the national AACN, they can
extend their membership to the local level. Local chapter
afliation provides members with the opportunity to network with peers in their immediate area, become involved
with chapter activities, and attend the educational programs
offered, thereby enhancing their professional development.

THE FUTURE OF
CRITICAL CARE NURSING

10

PART 1

THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE

and reimbursement systems, and facilitate learning, while

responding to diverse communities who are vulnerable
owing to complex needs. These are the exciting challenges
awaiting critical care nurseschallenges, it is hoped, that
critical care nurses will surmount with commitment, dedication, and grace!

clinical applicability challenges

Self-Challenge: Critical Thinking
1. Describe a patient care situation that exemplies the use of

the Synergy Model.

2. Identify a problem in your area of practice that needs to
be changed, based on evidence in the nursing scientific
literature.
3. Describe a situation where collaboration with other members
of the health care team enhanced patient outcomes.

Study Questions
1. The rst step to evidence-based critical care nursing practice

2.

3.

4.

5.

is to
a. frame a clinical question based on clinical observation.
b. conduct a literature search and evaluate the evidence.
c. implement a needs assessment of critical care nurses.
d. accept the fact that health care is continually evolving.
According to the Synergy Model, which of the following
characterizes the nurse competency of systems thinking?
a. The ongoing process of questioning and evaluating
practice
b. The sensitivity to recognize, appreciate, and incorporate
differences in the provision of care
c. The ability to appreciate the care environment from a
perspective that recognizes holistic interrelationships
d. The ability to facilitate learning of others while fostering
the work of others in a way that facilitates optimal and
realistic patient goals
A domestic partner of a critically ill patient expresses an
interest in learning how to provide skin care. According to
the Synergy Model, this illustrates which of the following
patient characteristics and nurse competencies?
a. Participation in decision making and caring practices
b. Participation in care and response to diversity
c. Resource availability and advocacy/moral agency
d. Stability and facilitator of learning
A new drug has been approved to treat coronary ischemia.
Before the introduction of the drug in clinical practice, a critical care nurse conducts a series of in-services about the
drugs dosing and side effects, and related nursing interventions. This is an example of
a. caring practices.
b. clinical inquiry.
c. facilitator of learning.
d. collaboration.
A certified critical care nurse uses case study analysis
and reading clinical journals to maintain a personal practice
of clinical excellence. These activities are essential elements of

a.
b.
c.
d.

critical thinking.
evidence-based practice.
caring practices.
advocacy/moral agency.

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CHAPTER 1
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