Relationship for true collaboration to grow.

If the rela- tionship between the key professionals

caring for the critical care patient is unhealthy, this leads to increas errors, decreased quality,
and decreased staff retention/satisfaction. To establish true collaboration, the nurse-physician
relationship must be addressed, yet this is a difficult relationship to understand.
Mutual respect between all disciplines is one of the fundamental elements that must be
present in order to foster a collaborative work environment. The nurse and physician must
demonstrate mutual respect surrounding each other's unique knowledge and competence. Lack
of respect for one's colleagues leads disharmony in the workplace, ultimately leading to
decreased quality of care provided to patients.
Possessing the mutual respect of our physician leagues has been cited as one of the top
reasons nurse retention within an organization. However, it is essential to recognize that true
collaboration will not occur overnight, nor will it be sustained if it is not given constant
attention and resources.

Nurse-to-Nurse Collaboration. The ability to collaborate with other nurses before making
both clinical and nonclinical decisions has been shown to prevent errors, increase nurse
confidence, and increase nurse retention. As the complexity of the critical care patient
increases, the need for the critical care nurses to collaborate on decisions increases as well.
Bucknall determined that critical care nurses had an increased confidence level and
looked more confi- dent when making decisions when they had the opportunity to collaborate
with other nurses. Synergy is built as nurses collaborate together on complex patient ssues.
That same synergy can be experienced when urses work together on other issues.
Nurses need to work collaboratively among themselves and with the nursing leadership
to resolve ssues on the unit. Nurses' ability to collaborate with he nurse administrator on more
than just clinical ecisions positively impacts employee satisfaction. To increase nurse
satisfaction and retention, the bedside critical care nurse must be actively involved in perational
issues. Such operational issues include cheduling, quality improvement processes, policy
evelopment, and participation in organizational decisions that impact professional nursing
practice.
The nursing shortage is predicted to reach an RN acancy rate of 23% by 2008. There
continues to be oncern throughout the nursing profession about e ability of experienced nurses
to mentor graduate urses entering the nursing profession. Therefore entoring programs must
focus on both the new aduate and the preceptor. Another concern sur unds the fact that the
number of experienced bedside clinicians is diminishing As the new graduate nurse begins a
career focused on the bedside care clinically complex critical care patients, there are lewer
experienced nurses to provide key mentoring, and collaboration.

Nurse-to-Family Collaboration. When collaboration is discussed, the immediate thought is

the collaboration between the healthcare team. There is a critical elemment of collaboration
that must not be forgotten-the collaborative relationship between the nurse and the
patient/family. Research indicates that when there is a harmonious relationship among staff,
patient, and family, the patient will experience a decreased of stay, increased patient
satisfaction, and incre overall collaboration. Chapter 8 of this textbook addresses Families in
Critical Care; it is essential to not overlook their important role in collaboration patient care.

Effective Decision Making

Nurses must be valued and committed partners in making policy, directing and evaluating
clinical care and leading organizational operations (Box 1-3). The line between collaboration
and effective decision making is exceedingly blurred. To make effective decisions nurses
carnot stand alone. The complexity of the critical care environment continues to grow, which
necessitates that all practitioners collaboratively engage in dinical decision making. All
decisions made surrounding patient care must be sound in reasoning and grounded in the
institution's mission, vision, and values as well as available evidence and industry standards of
care Therefore the bedside clinician, ancillary personnel, the physician, and administration
personnel all must work together in effective decision making.

Collaborative Interdisciplinary Decision Making. In addition to seeking the opinions of

nursing colleagues, the complexity of the critical care patient demands that all disciplines
collaborate to make the most effective and efficient decisions. The interdisciplinary critical
care team includes, but is not limited to, the staff nurse the clinical nurse specialist (CNS), and
the physician as well as personnel specializing in the following areas: social work, physical
therapy, occupational therapy, speech therapy, diet, pharmacy, pastoral care and anesthesia.
Interdisciplinary decision making take many forms, including clinical pathways, protocols
team meetings, and face-to-face comnmunications.
As reviewed earlier, face-to-face communication cause most practitioners the greatest
problems, yet it is essential that focus is given to the further development on this skill.

Box 1-3
Critical Elements of Effective Decision Making
 The healthcare organization provides team mem- bers with support for and access to
ongoing educa- tion and development programs focusing on strategies that ensure
collaborative decision making Program content includes mutual goal setting, nego-
tiation, facilitation, conflict management, systems thinking, and performance
improvement.
 The healthcare organization clearly articulates organizational values, and team
members incorporate these values when making decisions.
 The healthcare organization has operational structures in place that ensure the
perspectives of patients and their families are incorporated into every decision
affecting patient care.
 Individual team members share accountability for effective decision making by
acquiring necessary skills, mastering relevant content, assessing situations
accurately, sharing fact-based information, communicating professional opinions
cearly, and inquiring actively
 The healthcare organization establishes systems, such as structured forums involving
all depart ments and healthcare disciplines, to facilitate data driven decisions The
 healthcare organization establishes deliberate decision-making processes that enaure
rspect for the rights of every individual, incorporate all key perspectives, and
designate clear accountability.
 The healthcare organization has fair and effective processes in place at all levels to
dbjectively eval uate the results of decisions, including delayed decisions and
indecision.

Nurses who have the ability to participate in deci- sion making on their unit are more
likely to demon- strate highe. job satisfaction.237 When nurses are involved in the decision-
making process both of unit operations and of patient care, their job satisfaction and retention
will increase. Research has demonstrated a clear relationship between nurse retention and the
level in which the registered nurse has a voice in organ- izational and clinical decision making
237 There are many opportunities for the staff nurse to participate in decision making. Some
of the most successful mod- els include staff nurse councils, quality improvement projects, and
interdisciplinary team rounds.
Information Systems. The healthcare industry is in a constant state of evolution. Patients in
the critical care unit today would never have survived in years past, mostly because of the
wealth of knowledge and new treatments that are now available. The current amount of
knowledge present in healthcare is humanly impos- sible to manage. Therefore the healthcare
industry is partnering with the information technology industry to provide the most efficient
and safe care delivery possible. By partnering with the information systems industry, decision
making is becoming more efficient and safer. Clinical pathways and protocols allow the
healthcare team to intervene and monitor a patient's progress based on current evidence-based
research To holistically care for the patient, there must be con- tinuous collaboration on
decisions for optimal patient outcomes and patient safety. There are numerous examples of
how clinical pathways increase the safety of care provided. Clinical pathways guide
practitioners hroughout the decision-making process, ensuring care s provided consistently
research.
The strength of clinical pathways is their provision of "checks and balances" within
patient care deliv- ery.624 The effectiveness of clinical pathways is linked directly to their
consistency of use and the efficiency of use. Many organizations have found that the most
effective way to ensure consistency and efficiency with clinical protocols is to link the protocol
to a computerized information system. Computerized informa tion systems increase efficiency
by providing prompts for care providers regarding needed interventions and can also increase
the number of automatic reierrals to ancillary departments. The reliability of computerized
systems can approach 100 %, whereas human inspection will have far more variance in their
processes. Computerized clinical decision models guide the practitioner through the decision-
making process, providing alerts when a practitioner chooses an intervention that might be
contraindicated in the patient's particular situation. Through automated clinical path- ways,
patients are more effectively and efficiently cared for by providing evidencebased protocols
guide all disciplines.
One key advantage of using computerized protocols to guide care for patients is the ease
with which the protocol can be updated when new evidence is discovered. Many robust
computerized systems are directly linking clinical pathways to practice alerts from national
healthcare associations. When new evidece be presented, it is efficiently updated to reflect this
change in practice.
A second and equally important advantage is most computerized clinical protocols are
directly linked to the patient care documentation record. Therefore the protocol is implemented,
the documentation is completed. This increases compliance with key documentation
requirements from regulatory agencies and legal requirements.
As a result of the everchanging healthcare envi ronment, clinical decision making will
continue to be a challenge. The vast amount of new information released in healthcare makes
it impossible for health care professionals to maintain a current knowledge base. Therefore as
critical care clinicians, we must look for ways to make the best decisions to care for our patients
in the safest and most efficient ways possible. As discussed, collaboration is a hallmark in
effective decision making. Without collaboration from all healthcare disciplines, patient safety
will be jeopar- dized. As information continues to stream into the healthcare field, the use of
clinical pathways and computerized automation will be very important. The computer systems
can assist clinicians in effective decision making.

Appropriate Staffing
Staffing must ensure an effective match between patient needs and nurse competencies
(Box 1-4). When looking to build and maintain a healthy work environ-ment, there is little
debate on the impact of appropriate staffing levels. The bedside registered nurse has been
referred to as the "front line" in providing patient surveillance, assessing the patient, and
interveningwhen problems devélöp ready to rescue patients when they are in trouble. The
registered and also is the highest expense in the acute care hos- pital budget. Therefore it is
essential for organizations to ensure safe staffing levels with competent practi- tioners while
monitoring expenses. Because of the complexity of this issue, there are several ways nurses
and organizations can work together to ens appropriate staffing.
Nursing Shortage. Historically, the nursing shortage has had peaks and valleys. What makes
this nursing shortage any different from those in the past? Predic- tions currently estimate a
nursing shortage of 400,000 nurses by the year 2020; therefore it is the largest shortage ever
recorded.
Staffing levels and patient outcomes. Many regulatory agencies are concerned with
patient safety it relates to nurse staffing levels. As of March 2002 The Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) found that staffing levels were a factor in
24% of reported sentinel events. In addition to patient safety, there have been numerous studies
directly linking patient outcomes and nurse satisfaction to nurse staffing levels.
In a hallmark study, Needleman and colleagues found a direct link between the number
of registered nurse hours per patient day and six patient outcomes. These outcomes were length
of stay and rates of urinary tract infections, upper gastrointestinal bleed- ing, hospital-acquired
pneumonia, shock or cardiac arrest, and failure to rescue." Shortly after the release of this study,
Aiken and colleagues demonstrated sim- ilar findings. Aiken et al2 found that in hospitals with
 Box 1-4
Critical Elements of Appropriate Staffing
 The healthcare organization has staffing policies in place that are solidly grounded
in ethical principles and support the professional obligation of nurses to provide high-
quality care.
 Nurses participate in all organizational phases of the staffing process from education
and planning- ncluding matching nurses' competencies with patients' assessed needs-
through evaluation.
 The healthcare organization has formal processes in place to evaluate the effect of
staffing decisions on patient outcomes. The evaluation includes analysis of both
patient and system outcomes. This evaluation includes analysis of when patient needs
and nurse competencies are mismatched and how often contingency plans are
implemented.
 The healthcare organization has a system in place that facilitates team members' use
of staffing and outcome data to develop more effective staffing models
 The healthcare organization provides support services at every level of activity to
ensure nurses can optimally focus on the priorities and require ments of patient and
family care.
 The healthcare organization adopts technologie that increase the effectiveness of
nursing care delivery. Nurses are engaged in the selection, adaptation, and evolution
of these technologies

high patient to nurse ratios, the surgical patients experienced higher risk-adjusted 30-day
mortality and failure to rescue rates, and nurses were more to experience burnout and job
dissatisfaction. These studies were very powerful and helped to demonstrate the value of the
bedside registered nurse to the entire likely healthcare team.
Staffing requirements. These studies along with California's ground-breaking mandated
staffing ratios have encouraged regulatory agencies to begin to evalu- ate staffing levels and
their relationship to patient safety. TJC has recently released staffing effec- tiveness standards
for all acute care hospital settings. Each patient has his/her own unique characteristics. These
characteristics, along with the nurse's unique competencies and experience, must guide the
staffing requirements for the critical care unit (Box 1-5). There- fore the critical care nurse must
work with the nursing leadership team to provide appropriate nurse staffing to meet patient
needs and regulatory requirements.
The critical care unit is a dynamic envirenment, with patient acuity and patient voiume
changing drastically within a given shift. Therefore flexibility has to be pres- ent in determining
the number of nurses required per shift. Staffing requirements are built on the basis of average
census and average acuity of a unit. The role of the charge nurse becomes crucial in monitoring
adequate staffing. With more and more critical care units having to depend on new graduate
nurses and agency/temporary staff, the charge nurse must take a leadership role within the unit
to ensure appropriate staffing. The charge nurse must be given the flexibility to staff
appropriately to meet patient demands.
Not only is the bedside nurse concerned about the provision of appropriate staffing levels,
but many
 Box 1-5
Considerations for Staffing Requirements
 Acuity of patient
 Availability of assistive personnel (e.g, health unit secretary, monitor technician,
patient care technician)
 Availability of other nursing personnel (eg., CNS, educator)
 Physical facilities
 Presence of a shift supervisor Skill competency required Skill levels of the
interdisciplinary team (eg. physicians, NP)
 Years of experience of practitioners.

nursing labor unions have advocated for mandated nurse-to-patient ratios. In 1999 California
became the first state to mandate nurse-to-patient ratios Effective July 2003, Califonia
mandated a critical care nurse-to- patient ratio as one nurse for every two critical care patients.
Many people commended this effort, but there have been a large number of opponents
as well. The number of RNs needed to meet the mandates increases the number of RNs at the
bedside. With the current nursing shortage, these nurses are difficult to locate leading to
increases in overtime, use of agency nurses, and frustration when there are no nurses to be
provided. The California Healthcare Association estimated that it would cost a minimum of
$400 million a year in wages and benefits to provide the mandated staffing level. Mandated
staffing ratios also negatively impact the ability of the nursing staff to practice flexibility in
staffing. Mandated ratios treat every patient and nurse the same and do not allow for variation
in either. Some states have followed California's lead, but many states continue to search for a
better answear.
TJC requires every acute care höspital Efectiveness of its staffing ratios. Each hospital
must nonitor patient outcomes and compare those out- omes to the staffing levels of the unit.
There are a variety of nurse-driven patient outcomes that an institution an choose to monitor.
These include, but are not lim- ted to, patient falls, skin breakdown, and adverse drug vents.
These outcomes are compared to human esource outcomes such as, but not limited to, vacancy
ate, nursing hours per patient day, and RN nursing ours per patient day. Each hospital
determines which outcomes and which human resource data will be monitored based on typical
problems and high-risk issues for the healthcare institution.
Nurse competency. Several years ago, AACN defined a vision of a healthcare system
driven by the patient's needs where the critical care nurse makes an optimal contribution. As
AACN put this vision into operation, it revealed that the blueprint for the credentialing
examinations followed a systems ap proach to thinking versus being patient centered. To that
end, AACN introduced the Synergy Model as discussed earlier in this chapter. According to
the Synergy Model, when one links patient characteristics to nurse competencies, optimal
patient outcomes will result The patient is the priority within the Synergy Model and the
competencies of the nurse must link directly to the patient.
New graduate nurses. To meet the demand for the number of needed bedside nurses,
critical care units face the challenge of hiring new graduate registered.