Critical care nursing is a requirement for senior baccalaureate nursing students atThe College at Brockport. The critical care nursing curriculum is 1 semester andincludes 2 concurrent 3-credit courses, “Critical Care Nursing Class” and “CriticalCare Nursing Clinical.” The clinical settings used include many units within 2 largeteaching hospitals. Each student’s clinical training during the semester includes weekly

clinical practice on 2 different critical care and/or step-down nursing units.The instructors in this course strongly emphasize the importance of safety and the use of best prac-

tices. Best practices are introduced at the beginning of the critical care nursing courses and are continu-ously reinforced throughout the semester in both the class and clinical settings. Also introduced in thefirst class is the final assignment of the semester in which students apply principles of leadership to theuse of best practices in clinical settings. In this article, we describe how best practices are assimilatedthroughout the semester and highlight a participative leadership assignment centered on best practices.Students discuss their leadership assignment and experience on the last day of class.

Incorporating Best Practices Into Undergraduate CriticalCare Nursing EducationZARA R. BRENNER, RN-BC, MS, ACNS-BC

NANCY S. IAFRATI, RN, MS, FNP-BC

©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014174

Academic Education

Incorporation of best clinical practices into the baccalaureate critical care nursing curriculum is important.At The College at Brockport, best clinical practices are introduced early in the semester and are reinforcedthroughout the semester in both class and clinical settings. Among the best clinical practices included arethose recommended by the American Association of Critical-Care Nurses, The Centers for Medicare andMedicaid Services, the Institute for Healthcare Improvement, The Joint Commission, Quality and Safety Edu-cation for Nurses, the Surviving Sepsis Campaign, and the Institute for Safe Medication Practices. The culmi-nating assignment of the semester requires students to focus on patient safety. Students describe the use ofthe National Patient Safety Goals and other best practices in the critical care setting. The role of the nurseleader and exploration of near-miss and work-around events also are described. Nursing students need toprovide safe competent nursing care by incorporating best practices into their clinical practice now and inthe future when they become registered professional nurses. (Critical Care Nurse. 2014;34[1]:61-65)

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Best PracticesBest practices is a term that incorporates “the use

of care concepts, interventions and techniques that aregrounded in research and known to promote higherquality of care.”1 Hospital settings use best practices tosupport their clinical protocols and standards of care.Our students have previously learned about nursingresearch and evidence-based practice in the nursingprogram. The critical care nursing courses take the stu-dents’ education to the next level with the translationof evidence-based practice into best practices.

The American Association of Critical-Care Nurses(AACN) website often uses the terms clinical practiceand evidence-based resources together, often in thecontext of best practices. Throughout the semester,students are referred to the AACN website section ofclinical practice, where nurses can find “evidence-basedclinical practice resources.”2

Local chapters also recognize the importance of bestpractices. The Greater Rochester Areas Finger LakesChapter (GRAFL), which is our local chapter of AACN,has an annual meeting titled “Best Practices SharingSession.” Through podium and poster presentations,local nurses showcase how best practices are implemented

at theirplace ofwork. Facultymembersstrongly

encourage students to attend this meeting. Studentsreceive a week off from their required written clinicalassignment in exchange for the time and energy used toattend the meeting.

Best Practices in Class and Clinical Settings

To begin the semester, students have a class titled“Overview of Critical Care Nursing.” This class intro-duces or reintroduces students to some of the mostimportant national best practices in nursing and incritical care. These include Quality and Safety Educa-tion for Nurses competencies,3 National Patient SafetyGoals (NPSGs),4 Institute for Healthcare Improvementcare bundles,5 AACN practice alerts,6 the SurvivingSepsis Campaign,7 Centers for Medicare and MedicaidServices quality indicators and Surgical Care Improve-ment Project indicators,8 and Institute for Safe Medica-tion Practices.9

As part of the introductory class, students receivelaminated pocket cards on NPSGs and the SurvivingSepsis Campaign to which they can refer throughoutthe semester. These documents are also available in theonline course management system in case they aremisplaced. Students are encouraged to bring the hand-outs to the clinical sites and to use them in the clinicalsetting. A digital copy of “Look-Alike Drug Names withRecommended Tall Man Letters” from the Food andDrug Administration and the Institute for Safe Medica-tion Practices is also made available for students to use.9

Students are not required to download this 5-pagehandout, but they need to be aware of Tall Man Letters,and they see this concept used throughout the semesterin class and in clinical settings.

Best practices are continually reinforced throughoutthe entire semester in class, clinical settings, assign-ments, and examinations. The Table provides examplesof how and where best practices are incorporated intothe critical care nursing courses.

Best Practices in the Leadership Assignment

The concluding requirement for critical care nursingis a leadership assignment in which students identifyand analyze best practices in a clinical setting. Studentsare asked to describe best practices that they observedwhile working with critical care nurses and during theirshadowing experiences with a nurse leader. This leaderis most often a nurse manager, an assistant nurse man-ager, or a charge nurse. Although this is an analysis ofclinical encounters, the final discussion takes place in aclassroom at the end of the semester.

Care concepts, interventions, and techniques that are grounded in researchand known to promote higher quality ofcare are called best practices.

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Authors

Zara R. Brenner teaches undergraduate critical care nursing at TheCollege at Brockport, State University of New York, Brockport, New York,and is a care manager and clinical nurse specialist in the surgicalintensive care unit at Rochester General Hospital, Rochester, New York.

Nancy Iafrati teaches undergraduate critical care nursing at TheCollege at Brockport and works as a nurse practitioner at the Student Health Center.Corresponding author: Nancy Iafrati, RN, MS, FNP-BC, The College at Brockport, 350New Campus Dr, Brockport, NY 14420 (e-mail: niafrati@brockport.edu).

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

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The first component of the leadership assignmentasks students to describe nurse leaders in the clinicalsetting. Students frequently start the discussion by list-ing tasks such as giving report, running “huddle,” and

helping nurses with daily care. With the help of the nurs-ing faculty, the dialogue expands to an exploration of theroles and responsibilities of the nurse leader. Studentsdiscuss leadership skills such as managing patient flow,

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Best clinical practices

Quality and Safety Education for Nurses (QSEN)Patient-centered careTeamwork and collaborationEvidence-based practiceQuality improvementSafetyInformatics

National Patient Safety Goals (NPSGs)Patient identification Effective communicationMedication safetyMedication reconciliationReduced health care–associated infectionPrevent wrong procedure, wrong site, wrong person surgery/procedure

Suicide risk assessment

Institute for Healthcare Improvement bundlesVentilator bundlePressure ulcer preventionMedication reconciliationCatheter-associated urinary tract infectionsCentral catheter bundle

American Association of Critical-Care Nurses(AACN) practice alertsList of all practice alerts can be found on AACN website

Surviving Sepsis CampaignSepsis management bundleSepsis resuscitation bundle

Centers for Medicare and MedicaidServices quality indicatorsAcute myocardial infarction

Surgical Care Improvement Project indicatorsCardiac surgery

Institute for Safe Medication Practices, TALL ManletteringMedications

Learning strategies for class, clinical, and leadership assignment

Presented/reviewed on the first day of classEach clinical write-up includes the question: “What did you do to keep your patient safe today?”

Perioperative/procedure clinical assignment requires students to: “Select 1 of the6 QSEN competencies and describe how you observed this competency in practice during your clinical day in this setting.”

Clinical performance evaluation tool is focused on the 6 QSEN competencies.

Laminated handout given/reviewed on the first day of classIncorporated in subsequent classes and on examinationsIncluded in mandatory hospital orientation packet Reinforced in clinical settings Reinforced in leadership assignment where students identify how best practiceswere implemented in their clinical setting by using NPSGs

Presented/reviewed on the first day of classDetailed in online downloadable clinical course packet for use in clinical settingsIntegrated in classes (eg, class on ventilator bundle in acute respiratory failure)and on examinations

Used in clinical settingsReinforced in leadership assignment where students identify how best practiceswere implemented in their clinical setting by using care bundles

Showcased at best-practices sharing session, which is attended by many criticalcare students even before their first class

Practice alerts discussed in the overview classIncluded in classes as appropriate (eg, class on ventilator-associated pneumoniain acute respiratory failure)

Students required to cite appropriate practice alert in their ethics paper if applicable (eg, family visitation)

Each student is required to explore an AACN practice alert and to present it totheir clinical group in postconference

Reinforced in leadership assignment where students identify how best practicesand AACN practice alerts were implemented in their clinical setting

Laminated handout is distributed and discussed in overview class Sepsis is detailed in classroom presentation on shock and on examinationsHandout used in the clinical settingStudents encouraged to bring handout to examinations and to apply the knowledgeon the card

Included in online, downloadable notes Detailed in classroom presentation and on examinationsReinforced in clinical setting

Included in online, downloadable notes Detailed in classroom presentation and on examinationsReinforced in clinical setting

Included in all course materials and on examinationsUsed in clinical setting on the electronic medical recordStudents starting to use TALL Man lettering on assignments

Table Incorporating best practices into critical care nursing education

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supporting staff, facilitating communication, effectivelyusing resources, and implementing best practices. Lead-ership functions are then grouped in terms of the nurseleader’s responsibilities to patients and their families,nursing staff, and the health care team. By identifyingtasks and then roles, students are able to identify thenurse leader as a respected figure who supports thehealth care team in its ongoing effort to provide the bestpossible patient care.

In the next section of the assignment, students exam-ine best practices from several vantage points. Studentsare instructed to refer to the NPSGs and to explainstrategies used by the nurse leader to implement bestpractices in order to attain and maintain patient safetyand satisfaction. Students typically provide many exam-ples under the NPSG headings of patient identification,effective communication, medication safety, reductionof health care–associated infections, and preventing mis-takes in surgery. When giving examples of ways to pre-vent health-care–associated infections, students oftenrefer back to AACN practice alerts. Students are less

likely toprovideexamplesunder theheadings

of identification of patient safety risk (suicide) but canprovide examples when prompted. In the discussion,students are able to identify many successful strategiesused by nurse leaders to improve patient care throughthe use of NPSGs. In this discussion, students are alsoencouraged to develop alternative ways to provide carewhen best practices have not been incorporated.

As part of their first critical care class, students arerequired to read an article by Henneman10 that identifiesthe challenges of reporting medical errors and highlightsways to incorporate system reporting strategies into clin-ical practice. In the last part of the best-practices leader-ship assignment, students are asked to use the salientpoints from this article by identifying errors, near misses,and work-arounds that they observed in their clinicalsettings. During the discussion, students provide exam-ples and are prompted to go a step further by offeringsuggestions so that overt and/or covert mistakes wouldbe less likely to happen in the future. Students are able torecognize that communication or the lack thereof is respon-sible for most mistakes that happen in the clinical setting.10

Throughout this class discussion, students are ableto consistently verbalize a multitude of ways in whichsafety is maintained in the clinical setting through theuse of best practices. Readers interested in getting a copyof the assignment may request one by e-mailing the cor-responding author.

Thoughts on Incorporating Best PracticesWe have been incorporating best practices throughout

our critical care curriculum for several years. Because thisprocess was designed as a key component of our baccalau-reate curriculum rather than a research study, we can offeronly anecdotal comments on its effectiveness. Exampleshave been cited in the article and in the accompanyingtable, but additional observations can be provided.

In January 2013, many of our students attendedGRAFL’s “Best Practices Sharing Session,” where theysaw examples of best practices being implemented atlocal hospitals even before they started their clinicaltraining for the upcoming semester. GRAFL memberswere excited that students were becoming involved intheir organization. The critical care nurses at this meet-ing were also pleased that these students and future col-leagues were learning to embrace best practices. Two ofour students presented a poster at this meeting, whichwas very well received. With the encouragement andhelp of the faculty, these students went on to presenttheir work on best practices at the college’s Scholars Daylater in the semester. As part of their presentation, thestudents were able to use a video on safe practices thatwas developed and presented by several GRAFL mem-bers at the January 2013 meeting.

We will continue to incorporate best practices in ourcritical care curriculum. One of the most rewarding partsof teaching critical care nursing is being present at the lastclass when the students discuss how they saw best prac-tices implemented in the clinical setting and how theyplan on using them in their future practice of nursing.

SummaryWhen preparing nurses for the future, goals go

beyond students passing the course, graduating, andbecoming registered professional nurses. It is essentialthat all nursing students learn to provide safe, competentnursing care by incorporating best practices. It is alsoof the utmost importance that students become lifelonglearners, critical thinkers, and leaders. Incorporation of

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Students recognize that communication orthe lack thereof is responsible for mostmistakes that occur in clinical settings.

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best practices throughout an entire semester in both thecritical care class and the clinical setting enables studentsto learn to provide safe and competent nursing care.Students’ incorporation of quality and safety into theirprofessional learning is evidenced in a culminatingassignment focused on best practices. Our goal is thatour student nurses go on to become registered profes-sional nurses who can provide leadership skills to bene-fit both patients and the nursing profession through theuse of best practices. CCN

AcknowledgmentsThe success of this course is enhanced by adjunct faculty including ZinaSciortino, RN, MS, CCRN, FNP-BC.

Financial DisclosuresNone reported.

References1. HCGNE—Best Practices for Healthcare Professionals. The University of

Iowa College of Nursing website. http://www.nursing.uiowa.edu/hartford/best-practices-for-healthcare-professionals. Accessed November 12,2013.

2. Clinical Practice. American Association of Critical-Care Nurses website.http://www.aacn.org/DM/MainPages/PracticeHome.aspx. AccessedNovember 12, 2013.

3. Quality and Safety Education for Nurses. www.qsen.org. AccessedNovember 12, 2013.

4. The Joint Commission. 2013 National Patient Safety Goals. http://www.jointcommission.org/assets/1/6/2013_HAP_NPSG_final_10-23.pdf.Updated 2013. Accessed November 12, 2013.

5. Institute for Healthcare Improvement. www.ihi.org. Updated 2013.Accessed November 12, 2013.

6. Practice Alerts. American Association of Critical-Care Nurses website.http://www.aacn.org/WD/Practice/Content/practicealerts.content?menu=Practice. Updated August 2013. Accessed November 12, 2013.

7. Surviving Sepsis Campaign website. http://www.survivingsepsis.org/Pages/default.aspx. Accessed November 12, 2013.

8. Quality initiatives—general information. The Centers for Medicare andMedicaid Services. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html. Updated August 14, 2013. Accessed November 12, 2013.

9. Institute for Safe Medication Practices. FDA and ISMP List of Look-AlikeDrug Names With Recommended TALL Man Letters. http://www.ismp.org/Tools/tallmanletters.pdf. Update 2011. Accessed November 12, 2013.

10. Henneman EA. Unreported errors in the intensive care unit: a casestudy of the way we work. Crit Care Nurse. 2007;27(5):27-35.

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Now that you’ve read the article, create or contribute to an online discussionabout this topic using eLetters. Just visit www.ccnonline.org and select the arti-cle you want to comment on. In the full-text or PDF view of the article, click“Responses” in the middle column and then “Submit a response.”

To learn more about nursing education, read “Repeated ScenarioSimulation to Improve Competency in Critical Care: A NewApproach for Nursing Education” by Abe et al in the AmericanJournal of Critical Care, January 2013;22:33-40. Available atwww.ajcconline.org.

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Zara R. Brenner and Nancy S. IafratiIncorporating Best Practices Into Undergraduate Critical Care Nursing Education

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