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Intensive care is a young speciality. The first purpose-built intensive care unit (ICU) in the UK opened in 1964

ICUs offer potentially life-saving intervention during acute physiological crises, with emphasis on medical need and availability of technology

ICU nurses should develop therapeutic and humanistic environments which help the patient as a whole person towards their recovery

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Patients are admitted to intensive care because a physiological crisis threatens one or more Body systems, and their life. Care therefore needs to focus primarily on supporting failed systems.

Extrinsic needs for dignity privacy psychological support spiritual support

nurses are with the patient throughout their hospital stay. A fundamental role of nurses is therefore to be with and be for the patient, as a whole person

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Relatives, including friends and significant others, are an important part of each person's life, giving patients courage to struggle for survival

In contrast of the often high-tech focus of staff, families of intensive care patients often focus on fundamental aspects of physiological needs, such as shaving , pain relief and communication

Rather than ruminate by bedsides, afraid to touch their loved ones incase they interfere with some machine

relatives should be offered opportunities to be actively involved in care without being made to feel guilty or becoming physically exhausted. Letting relatives participate in care can help them psychologically

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Physiological crises of patients often create psychological crises for their relatives. Holistic patient care should include caring for their families and other significant people in their life

Relatives may be angry. They are usually angry at the disease, but it is difficult to take anger out on a disease. Instead, anger, complaints or passive withdrawal may be directed at those nearby, who are usually nurses .

Relatives often experience unnecessary suffering. They may blame themselves, however illogically, for their loved one's illness

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Feeling guilty and distressed, they neglecting their own physical needs, such as rest and food.

Facilities for relatives should include a waiting room near the unit, some where to stay overnight and facilities to make refreshments

Relatives need information, both to cope with their own psychological crisis and to make decisions. They often have a psychological need for hope, but with one quarter of patients dying on the unit, and additional post discharge mortality and morbidity, there may be little hope to offer

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If death seems likely, relatives need to know so they can start grieving

Families may experience information overload, at a time they are least able to cope with it

Communication by staff is often ineffective. Printed information can provide useful reminders but should not be a substitute for discussion relatives need human support and contact.

Information given should be consistent and should be recorded in multidisciplinary notes

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nurses should be sensitive to both their own and relatives' non-verbal cues, such as posture, eye-contact and tone of voice

Of all staff, nurses are best placed to meet relatives' needs, yet the needs are not always met

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Nurses monitor and assess patients, but they also provide care. Assessment is fundamental to providing care, but sometimes a excess of paperwork prevents care.

Nurses should collaborate with doctors (and other

members of the healthcare team). Traditional nurse to patient ratios of 1:1 for UK ICUs are higher than in most other countries, but UK ICU patients are also sicker .

The Department of Health (2000) recommends the flexible use of beds for level 2 and level 3 patients. Widely accepted nurse-patient ratios for high dependency are 1:2, which identifies should be the maximum number of patients per nurse.

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Psychological stress caused or accentuated by intensive care

dehumanizing nursing can become when machines, rather than people, become the focus of attention.

A pragmatic solution to both economic and recruitment limitations has been to develop support worker roles. Most units employing support workers have found they provide valuable contributions to teamwork, provided skill mix of nurses is not reduced inappropriately

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Patients, their relatives and nurses all suffer stress.

Stress is both a psychological and physiological phenomenon. Psychology and physiology interact.

Critically ill patients suffer physiological stress from their illness, and psychological stress from negative emotions such as fear

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ICU staff often have to break the bad news to relatives and friends. Changes may be rapid and unpredictable, but if patients are dying their family need to be aware of the future grief to begin grieving

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Many principles of industrial management or managing other healthcare areas are applicable to the ICU.

Vaughan and Pilmoor (1989) suggest that management is getting the work done through people. A good shift leader is a good team leader, enabling other people to do their work.

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Drucker (1974) identifies five roles for managers:

setting objectives organizing motivating and communicating measuring targets developing people

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The shift leader should establish constructive working conditions at the start of each shift, enabling development of staffs' individual strengths and skills, while recognizing individual needs and limitations.

Managers should individually assess and proactively plan and respond to needs for each shift, rather than seek to impose their own schedules on staff.

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Managers rely on their staff to achieve the work, so staff are the shift leader's most important resource.

Staff numbers are important. are there enough staff for patients already on the unit and expected/potential admissions?

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abilities and qualities of staff are also important.

‘Skill mix' is more than simply counting numbers of staff at each grade.

Some staff need more support than others; each has different experience, knowledge and skills to draw on

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Specific allocation should consider:

maintaining patient safety optimizing patient treatment developing and supporting staff

Nurses unable to safely care for a patient should not be allocated to their care. Each nurse is individually accountable for their actions, and should acknowledge their limitations

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without gaining experience of nursing very sick patients, junior staff will be denied opportunities to develop their skills.

If continually denied developmental experience, they may become demotivated and leave or be unable to care safely for sicker patients when more experienced staff are not available

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two junior nurses may safely manage adjacent patients when both are present, but become unsafe if caring for two patients through covering each other's breaks.

Nurse managers remain accountable for their actions; unsafe allocation breaches

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the shift leader also has wider moral responsibilities for health and safety of their staff and patients.

Fire exits should remain clear and accessible at all times and safety and emergency equipment should be in complete and in working order.

Emergency equipment varies between units, but may include the resuscitation trolley, emergency intubation trolley and (on cardiothoracic units) thoracotomy pack. Any environmental hazards should be minimized, and where possible removed.

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The shift leader may have to assume direct patient care, but this causes role conflict between responsibility to the whole unit as shift leader and individual responsibility to your patient, and limits your availability to other members

It is recommend that the shift leader should not provide direct patient care

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Endacott (1999) identifies four key aspects of shift leadership:

presence (availability) information gathering (from bedside nurses) supportive involvement (e.g. attractive

equipment, checking drugs, reassuring staff) direct involvement (taking over from

bedside nurses when they are away or unable to cope).

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Shift leaders are responsible for enabling others to achieve their work, so should motivate and communicate

Maintaining staff and unit morale is therefore a management priority

loyal staff are more likely to support shift leaders during crises.

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Democratic or authoritarian leaders use their power and authority to achieve goals and objectives

But healthcare is challenged with an philosophy of 'blame' culture, which should be replaced by one of 'safety‘

A safety culture recognizes that errors will occur, and so an openness about reporting errors allows potential causes to be identified and rectified.

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An alternative approach to management is 'Transformational' leadership, which seeks to transform the culture of care through

staff empowerment practice development developing other workplace

characteristics

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Shift leaders therefore need good interpersonal skills and respect for their staff.

Shift leaders seeing unsatisfactory practices should approach staff constructively, identifying why staff are acting that way (rationale, knowledge base)

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Breaks from work provide a psychological coping mechanism. European working time regulations are prescriptive about working time, including the right to breaks every four hours.

Delayed, compromised or missed breaks often cause dissatisfaction

Possible conflicts with managerial duties (earlier) should be considered, especially if relieving for breaks in inaccessible areas (e.g. side rooms).

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The ICU work is unpredictable; workload will sometimes exceed resources, so shift leaders and staff should identify priorities, accepting that some lesser priorities are not always achieved

Ideally, staff should take breaks away from their workspace, but busy shifts may sometimes prevent this. If full breaks cannot be taken, providing refreshments at bedsides (this task could be dele- gated) may help staff function safely, and maintain morale

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Staff levels should be individualized to patient/unit needs .

If shift leaders consider unit, patient or staff safety is compromised through inadequate staff (or any other problem they are unable to resolve), they should inform senior managers, who have (higher) responsibility for the unit.

 

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Staff need to feel confidence in their shiftleader.

While shift leaders usually have more experience and knowledge than their staff, each member of staff has potential to contribute knowledge, experience or values, and shift leaders should be prepared to learn from, as well as guide and teach, their staff.

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Shift leaders may be pressurized to accept patients 'because there is an empty bed, there appear to be enough staff or because' patients need the ICU.

the pressure cannot always be relieved by admission to other wards. While medical staff must decide whether patients require ICU admission, shift leaders must decide whether patients can be safely nursed on the unit. This decision includes

imminent shifts dependency of patients already on the unit skills of staff available

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Good shiftleaders may inspire loyalty in their staff, but being in charge can isolate shiftleaders from other support mechanisms.

Shiftleaders also need their breaks: a stressed shift leader is less likely to be able to support their staff.

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Triage (pronounced /ˈtriɑʒ/) is a process of prioritizing patients based on the severity of their condition.

This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate, sort, sift or select.

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There are two types of triage: simple and advanced. The outcome may result in determining the order and priority of emergency treatment, the order and priority of emergency transport, or the transport destination for the patient, based upon the special needs of the patient or the balancing of patient distribution in a mass-casualty setting.

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Simple triage is usually used in a scene of a "mass-casualty incident" (MCI), in order to sort patients into those who need critical attention and immediate transport to the hospital and those with less serious injuries. This step can be started before transportation becomes available. The categorization of patients based on the severity of their injuries can be aided with the use of printed triage tags or colored flagging

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Triage separates the injured into four groups:

0 The deceased who are beyond help 1 The injured who can be helped by

immediate transportation 2 The injured whose transport can be

delayed 3 Those with minor injuries, who

need help less urgently

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In advanced triage, doctors may decide that some seriously injured people should not receive advanced care because they are unlikely to survive. Advanced care will be used on patients with less severe injuries.

Because treatment is intentionally withheld from patients with certain injuries, advanced triage has ethical implications. It is used to divert scarce resources away from patients with little chance of survival in order to increase the chances of survival of others who are more likely to survive.

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Immediate: The casualty requires immediate medical attention and will not survive if not seen soon. Any compromise to the casualty's respiration, hemorrhage control, or shock control could be fatal.

Delayed: The casualty requires medical attention within 6 hours. Injuries are potentially life-threatening, but can wait until the Immediate casualties are stabilized and evacuated.

Minimal: "Walking wounded," the casualty requires medical attention when all higher priority patients have been evacuated, and may not require stabilization or monitoring.

Expectant: The casualty is expected not to reach higher medical support alive without compromising the treatment of higher priority patients. Care should not be neglected, spare any remaining time and resources after Immediate and Delayed patients have been treated

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