Partners in critical care.

Patient- and family-centred care (PFCC) concepts are increasingly cited in the critical care literature and are a welcome addition to the vernacular of the intensive care unit (ICU). The implementation and maintenance of a supportive PFCC environment is challenging, however, and usual strategies for knowledge translation using guidelines and policies, no matter how articulate, have not yet resulted in sustained practice change at the point of care delivery. In this article, co-authored by community partners, the physician director and nurse leader of one tertiary care ICU, we describe an initiative in which patient and family representatives were included in the ICU interdisciplinary team membership. After two years and now, at the conclusion of the assignment, options for community partner participation in various activities related to unit governance are shared.

A multicenter survey of Ontario intensive care unit nurses regarding the use of sedatives and analgesics for adults receiving mechanical ventilation.

BACKGROUND: Nursing-directed sedation protocols have been shown to reduce the duration of mechanical ventilation and shorten the length of intensive care unit (ICU) stay among critically ill adult patients. METHODS: We designed a self-administered questionnaire to understand nurses' satisfaction with current sedation and analgesia practices as well as drug therapies in the ICU setting and the perceived relevance of sedation protocols to patient care and nursing autonomy. We surveyed nurses from 3 academic medical-surgical ICUs that were not using a sedation protocol or a sedation scale. Responses were based on a 5-point Likert scale and on text responses to open-ended questions. RESULTS: Of the 88 respondents, only 52.7% were satisfied (score, > or =4) overall with their local ICU's approach to sedation and analgesia. Nurses favored the use of morphine (85.0%), midazolam (71.2%), and fentanyl (59.6%) over that of lorazepam (38.6%) and haloperidol (15.4%). Some nurses (39.3%) were satisfied with the subjective methods used in their ICU to evaluate sedation adequacy. Almost all respondents believed that a nursing-directed sedation protocol combined with a sedation/agitation scoring system would be valuable to patient care (84.3%) as well as professional nursing practice (85.3%) and that a standardized approach by nurses and physicians was important (81.6%). CONCLUSIONS: In this survey of ICU nurses, we identified a perceived need for improvement in sedation and analgesia practices. Most respondents believed that the use of a nursing-directed sedation protocol in combination with a sedation scoring system would provide greater practice consistency among nurses and physicians and thus improve the care of critically ill patients.

The standardization of critical care nursing education and training: strategies for advancing clinical practice in Ontario's adult ICUs.

In 2004/2005, the Ontario Ministry of Health and Long-Term Care (MOHLTC) launched a critical care transformation strategy with a goal to enhance service delivery through improved access, quality and system resource management. Health human resources planning was seen as essential to the success of the strategy, particularly recruitment, education/training and retention of critical care nurses. A nursing task group was invited to articulate core competencies and practice standards that can be applied across Ontario's adult ICUs and to make recommendations for implementation and the training needed to encourage compliance with the initiative. In this article, the opportunity to position nursing within the Ontario MOHLTC vision is described, as well as the work undertaken to prepare for a province-wide approach to critical care nursing education and training.

Dealing with aggressive behavior within the health care team: a leadership challenge.

During an interdisciplinary Canadian leadership forum [ (click on the Conferences icon)], participants were challenged to develop an approach to a difficult leadership/management situation. In a scenario involving aggressive behavior among health care providers, participants identified that, before responding, an appropriate leader should collect additional information to identify the core problem(s) causing such behavior. Possibilities include stress; lack of clear roles, responsibilities, and standard operating procedures; and, finally, lack of training on important leadership/management skills. As a result of these core problems, several potential solutions are possible, all with potential obstacles to implementation. Additional education around communication and team interaction was felt to be a priority. In summary, clinical leaders probably have a great deal to gain from augmenting their leadership/management skills.

Reflections on critical care emergency preparedness: the necessity of planned education and leadership training for nurses.

ICU nurses who are involved in pandemic planning must advocate for the education and training they need to assume clinical leadership roles in emergency situations such as an infectious disease outbreak. Although many ICU nurses do advance to become clinical leaders, preparation is often inadequate and sometimes absent. This article focuses on two aspects of preparedness: the further development and integration of leadership competencies into day-to-day practice, and education and training using a computerized simulator.

Developing leadership skills in critical care nurses: a case scenario--part one.

During a recent CACCN board meeting, directors were challenged with developing an approach to a difficult case scenario. In a situation where inappropriate communication toward a new nurse was observed and reported directly to the charge nurse, participants identified that before responding, the charge nurse should seek out additional information to identify the problems causing the behaviour. Possible core problems included lack of clarity around the roles and responsibilities, plus the lack of training on preceptorship and the principles of effective communication. Solutions are proposed, along with associated strengths, weaknesses and barriers to implementation. In summary, nurses have much to gain from augmenting their leadership skills.

About critical thinking.

Although a universally accepted definition of critical thinking has yet to be determined, there is much discussion in the literature about its meaning and, in particular, how it can be expressed in professional nursing practice. The simultaneous use of related terms such as reflective thinking, problem solving and clinical decision-making contributes to the lack of clarity around exactly what critical thinking is and, subsequently, how it can be taught and evaluated in the clinical setting. The purpose of this article is to provide an overview of the various components of critical thinking and to discuss barriers, facilitators and strategies that can enhance nurses' attainment of this core competency. Few would argue that registered nurses today must be able to think critically in order to effectively communicate a nursing perspective that reflects a meaningful clinical grasp and preparedness to act.

Analgesic and sedative pharmacology in the intensive care unit.

Sedation and analgesia are central elements in the care of critically ill, mechanically-ventilated patients. The goal of analgesic therapy is to provide relief from pain and physical discomfort which may lead to poor sleep, agitation, or a stress response. Opioids, such as morphine, fentanyl, and hydromorphone, are considered first-line agents for treating pain. All of these agents are equally effective at equipotent doses and the choice of an agent depends on both drug and patient characteristics. Sedatives with amnestic properties are desirable to prevent or relieve anxiety and agitation. The benzodiazepines and propofol are the primary sedative agents used in the intensive care unit (ICU). Agents such as clonidine and haloperidol may have a role in the ICU when used concomitantly with sedatives and analgesics. An understanding of the pharmacotherapy of sedation and analgesia in the ICU will help support appropriate usage of these agents and improve patient care.