The intensive care unit (ICU) is a nursing unit involving patients with life-threatening multi-organ failure, sophisticated, invasive monitoring devices, frequent administration of cardiac and vasoactive medications, and a highly-charged, stressful psychological environment (Figure 1). Care within this crucible is provided by nurses who have received specialized training and advanced education in the technical, medical, pharmaceutical, and emotional aspects of critical care, in a ratio of one nurse to one, or at most, two patients. The very principles which define specialized critical care nursing are currently at risk, and constitute the fundamental safety concerns in the ICU from a nursing perspective. The first concern is inadequate nursing staff to provide appropriate levels of patient care and monitoring. Nursing shortages often require ICU staffing be stretched to ratios of 1:3, sometimes reaching 1:4 during periods of exceptional urgency or other periods of rapidly increasing ICU patient census. The second concern is errors related to the orientation, application, and interpretation of technically-advanced equipment.
The Nursing Shortage
The United States is experiencing a shortage of nurses trained for areas such as critical care, emergency departments, and the operating room. Projections foretell an even bleaker future. The average age of a critical care nurse is 45, indicating that the number of trained and experienced nurses retiring within the next decade will mushroom. Within 15 years, approximately 50% of today’s nursing work force will retire. By the year 2006, this will result in an absolute shortfall of over 400,000 nurses across the nation. The following year, the largest cohort of registered nurses will begin retiring. Thus, by 2020, the United States will chronically experience a 20% shortfall in the number of required nurses.1 This will be at the same time that about 80 million baby boomers become eligible for Social Security and Medicare.1 The American Association of Critical Care Nurses (AACN) reports that enrollment of entry-level bachelor’s degree students in the nation’s nursing schools fell by 5.5% in the fall of 1998, making it the fourth consecutive year nursing enrollment declined. Thus, one major factor for the increasing age of our current nursing workforce is the decline in young people choosing nursing as a career.1 In addition, the Institute of Medicine (IOM) recently noted that older nurses are restricted or unable to perform certain physical tasks often expected of registered nurses (RNs). Such limitations decrease retention of experienced nurses.2 Without question, the dwindling supply of nurses will not keep up with demand, particularly in specialty areas such as critical care.
Many additional factors contribute to the nursing labor shortage. Specific (and overly enthusiastic) efforts during the last decade at re-engineering nursing duties and care have contributed. Furthermore, new and financially more lucrative career opportunities are available to women today. Sadly, the public perception of nursing has not kept pace with the true changes within the profession. Respect is lacking. Lastly, the medical and economic climate changed dramatically for nursing in the 1990s, as well. Capitation and managed care produced a dramatic increase in acuity of hospitalized patients. Despite this, fewer clinical dollars were reimbursed to hospitals to care for these patients. Perhaps most disruptive to academic medical centers (AMCs) was the Balanced Budget Act of 1997, which reduced Medicare reimbursement 10% or more. As a consequence, personnel budgets were often targeted as a mechanism to balance medical center budgets, and nursing staffs were “streamlined” through downsizing, reorganization, and reassignments. One of the groups especially hard hit was nursing supervisors, and, consequently the responsibility of one Nurse Manager expanded to multiple nursing units 24 hours per day. Advanced practice nurses needed to support the nursing staff were also cut, just when their advanced skills and teaching were most needed. In many situations, clinical nurse specialists, nurse educators, and nurse researchers have seen their role reduced or eliminated. Their efforts have been redirected to bedside patient care, so that the effectiveness of their advanced education is diluted.3 One example of this dilution is the lack of appropriate orientation for newly hired personnel. The time frame for nursing orientation to multiple specialty areas and cross-training has decreased, while there is a simultaneous expectation for nurses to routinely function in multiple patient care areas. Also, hospital time and financial support for continuing education of nurses has decreased. Many local educational programs have been minimized or cut.4 There have been alarming increases in mandatory overtime. In some states, the only significant relief has come from legislative mandates specifying nurse-to-patient ratios, designed to ensure safe patient care.5
The rapidity of these changes has put the nation’s hospitals under enormous pressure, often triggering disorganized and inadequate responses. One of the unfortunate consequences is the large number of serious medical errors during the care of critically ill patients.6 The recent Institute of Medicine (IOM) report focused concern on medical mishaps which may be responsible for between 44,000 and 98,000 patients deaths per year in the United States.7 Examples abound. For instance, a hospital in Wichita, KS, recently agreed to a $2.7 million settlement in a lawsuit which alleged a woman suffered permanent brain damage from hypoxemia ultimately resulting from inadequate levels of nursing staff.6 A recent series in the Chicago Tribune reported their analysis of 3 million state and federal computer medical records of Illinois citizens. They suggest that since 1995 up to 1,720 hospitalized patients have been killed, and 9,584 additional patients injured from misdirected actions, or the lack of appropriate action of registered nurses. The Tribune attributed the accidental deaths to overwhelmed and inadequately trained nurses, particularly in hospitals squeezed hard from budget shortfalls.6 The AACN response stated that valid concerns were raised, and that this article should be a “wake up call” for hospitals to assess their own practices and staffing policies, so as not to compromise patient safety and care.
Nurses working in understaffed ICUs experience enormous stress. Coordinating medical care, vasoactive drug administration, monitoring patient ventilation and cardiovascular status, while addressing the emotional needs of a bereaved family requires knowledge, maturity, experience, and insight. Nurses currently report increasing fatigue and stress when demands for this level of multitasking exceed their physical ability and professional standards of safe patient care. Excessive work pressures create at-risk conditions in which errors are more likely to occur. These events may occur while assessing the causes of a ventilator alarm, calculating or programming complex infusion regimens on infusion pumps, checking correct doses and medications for multiple patients, and assessing subtle changes in a patient’s condition. Thus, nursing quality declines, patients and families become dissatisfied with their care, and professional pride and satisfaction are eroded.
Medical Equipment Mishaps
Although preventable adverse drug events (ADE) occur in about one of every 50 admissions, errors related to medical devices and equipment are also an enormous concern to critical care nurses. The number and sophistication of ICU devices currently used in the average ICU patient increases the odds of an untoward event. Furthermore, the pace of change for ICU equipment and technology is rapid, requiring a constant assimilation of new information. Compounding these problems is the lack of standardized equipment, which increases the likelihood of operator errors.7 Nurses must be familiar with many models of the same device. For example, lack of standardization and physician preference may result in a hospital carrying as many as five or more models of pulmonary artery catheters. Furthermore, in an effort to market their product as unique, manufacturers often introduce new terminology for features that currently exist on a competitor’s product. Misinterpretation of conflicting terminology and changes in equipment configuration, not accompanied by appropriate education, may lead to misuse of medical equipment. Nurses, the end-users of many hospital supplies, should be involved early in equipment product selection to help identify and avoid potential patient safety issues.
As a general principle, nurses who are not properly trained in use of a medical device should not be assigned to a patient care area where use of such equipment is required. Errors are more likely in application and interpretation of the equipment and data. Such errors occur most commonly as nurses from one specialty area are temporarily assigned (“floated”) to another specialized nursing unit where the patient population, techniques, and medical devices are unfamiliar.5 For example an ICU nurse specializing in burn care may be inappropriately assigned to a patient in a neurosurgical ICU where a ventriculostomy catheter and drainage system is in place. Specialized hospital units were historically developed for the efficiency of physicians; however, they have also resulted in the opportunity for nurses to specialize. Nurses gain increased competency via this care model. It has been shown that patients cared for on specialized nursing units have improved outcomes.8 Specialized nurses cannot optimally practice in “territory” unfamiliar to them, nor deal with new equipment without appropriate education and training.
A Model for Maintaining Medical Device Competency
Equipment manufacturers and medical leaders must work together to creatively engineer systems that reduce the probability of errors. ICU nurses must be properly educated when using new medical equipment, and understand the capabilities, limitations, and special applications of the device. Knowing how to properly apply the device interface and being familiar with basic troubleshooting guidelines, as well as emergency procedures is crucial.9 Of special note, equipment associated with either high-risk or infrequent use, such as defibrillators, pacemakers, intracranial pressure monitors, and so forth, should require annual competency verification. This validation should contain both a knowledge and interpretation component, as well as a technical proficiency component. Such a process is ideally suited for the modern patient simulation laboratories. Hospitals administrators should recognize the value of such personnel as clinical nurse specialists and nurse educators in training and maintaining staff proficiency with medical equipment.
A Culture Change
The old medical culture often sought to identify and blame a “bad apple” when medical errors occurred. Most experts encourage a culture shift which acknowledges that providers don’t fail alone. Organizations and systems have vulnerabilities, as do individuals, and the ingredients of many accidents are present long before a specific incident occurs. These latent factors, combined with an inexperienced or fatigued caregiver, may produce equipment failure or a medical mishap. We think such mishaps most often represent systems failure. A positive culture change is one where the existence of risk and human error is acknowledged and everyone is engaged in injury prevention and redesign of the system to make errors difficult to commit.10 The organizational culture must encourage learning from errors and effective patient safety programs.7
The shortage of critical care nurses has exacerbated concerns for patient safety in this country and abroad.11 Nursing leaders and hospitals administrators must effect plans which fully utilize the skills and talents of increasingly scarce critical care nurses to optimize patient care. Programs must retain experienced critical care nurses and maintain nursing staff competency with medical equipment and procedures. These continuing education efforts must not be forsaken because the nurse supposedly cannot be spared from active clinical duty—a short-sighted savings propagating unsafe practices in the long term. Retaining skilled nurses and supporting their continuing education needs will help hospital administrators create a healing environment in which health care providers can deliver comprehensive patient care that is professionally rewarding.
Ms. Pierce is Clinical Nurse Specialist in Critical Care at the University of Kansas Hospital in Kansas City.
- Buerhaus PI, Staiger DO, Auerbach DI. Implications of an aging registered nurse workforce. JAMA 2000;283:2948-2954.
- Wunderlich GS, Sloan FA, Davis CK. Nursing staff in hospitals and nursing homes: is it adequate? Committee on the adequacy of nurse staffing in hospitals and nursing homes, Institute of Medicine: Division of Health Care Services. Washington, DC: National Academy Press, 1996.
- Dracup K, Bryan-Brown CW. Diminishing supplies: How will nursing cope? Am J Crit Care 2000;9:370-372.
- Berens MJ. Training often takes a back seat: budget pressures, lack of state laws aggravate trend. Chicago: Chicago Tribune. September 11, 2000.
- Trossman S. Nurses fight short staffing on several major fronts. Am Nurse 2000;32:1-2.
- Berens MJ. Nursing mistakes kill, injure thousands: cost-cutting exacts toll on patients, hospital staffs. Chicago: Chicago Tribune. September 10, 2000.
- Kohn LT, Corrigan JM, Donaldson MS (eds). To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America. Institute of Medicine. Available at: http://www.nap.edu/books/0309068371
- Czaplinski C, Diers D. The effect of staff nursing on length of stay and mortality. Med Care 1998; 36:1626-1638.
- Joint Commission on Accreditation of Healthcare Organizations. Management of the environment of care. In Hospital Accreditation Standards. 1999, pp 163-186.
- Leape LL, et al. Promoting patient safety by preventing medical error (editorial). JAMA 1998;280:1444-1447.
- Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 2000;356:185-189.