Volume 23, Issue 6 , Pages 309-312, December 2007
Australian intensive care nursing
Article Outline
- Intensive care services in the Australian health care system
- ICU nurse staffing and responsibilities
- Intensive care nursing education
- Intensive care nursing research
- Issues facing nurses and patients
- Summary
- References
- Copyright
Keywords: Intensive care, Nursing, Australia
Intensive care services in the Australian health care system
The Commonwealth of Australia is a federation of six states – New South Wales, Queensland, South Australia, Tasmania, Victoria and Western Australia – plus two territories, the Australian Capital Territory and the Northern Territory. Health care services provided to acute and critically ill patients are jointly funded by the Commonwealth Government and the state governments. Nationally, we all are covered by the universal health insurance scheme, Medicare, funded by Federal taxes. Medicare was designed to cover the costs of acute hospitalisation, including intensive care, amongst other services, especially general practitioner visits that are paid directly by the Commonwealth Government to the patient or primary provider. Hospital services are administered by the state governments with funds provided by the Commonwealth in periodically negotiated Health Care Agreements, plus funds that the states are able to provide. The result is availability in the public health care system of a high standard of health care for seriously ill patients, despite shortfalls and political tension between the state and Commonwealth governments over which is failing to fund services adequately. There is also an expanding provision of intensive care services in the private sector, with many of the big tertiary public hospitals having co-located private hospitals with sophisticated intensive care services.
There is continual argument within public sector hospitals, with governments and often in the media about underfunding of ICU services and lack of access to ICU for patients who would appropriately be admitted, because of too few available funded beds in ICU and ‘bed block’, that is the inability to transfer patients who no longer need intensive care to acute wards because there are no beds available. The perception of nurses, doctors and others working in the public hospital system is that there often are insufficient resources available to provide the care that patients need and deserve. These are real issues that ICU staff face daily. They are cause for tension and personal stress because staff feel under pressure to provide more care with existing resources, while at the same time feeling that they are not providing care patients need because there are not enough resources.
In practice though, the standard, cost and accessibility of intensive care in Australia are good and compare favourably to those of other developed countries. There are 167 ICUs in Australia, with 1859 available beds (i.e. fully equipped, staffed and funded such that a patient could be provided with intensive care). This number of beds is around 2.8% of all hospital beds and 9.4 beds per 100,000 people (Higlett et al., 2005). The overall in-hospital mortality of adult patients who are cared for in Australian ICUs is 14.5% (Stow et al., 2006). Patient outcomes from usual care in Australian ICUs contrast favourably to the intervention arms of several studies from other countries, especially North America where many of the other studies have been conducted (Bellomo et al., 2007).
Australian ICUs in public and large private hospitals are mostly all what are now called ‘closed units’ (Judson and Fisher, 2006). This means that the medical management of patients is under the direction of an Intensivist, a doctor who has qualified as a Fellow of the Faculty of Intensive Care Medicine. The patients’ surgeons and physicians provide their specialist input into decisions about diagnosis and treatments/procedures and the ICU medical staff order the treatment that patients are to be given. This has significant implications for the practice of intensive care nurses. It means that nurses caring for the patients communicate predominantly with one medical team about the care and treatment of the patients and interactions with the patients’ families, rather that different medical teams for each patient. Despite occasional glitches it usually works very well.
ICU nurse staffing and responsibilities
Arguably even more significant for the quality of care in Australian ICUs (Bellomo et al., 2007) is the standard of a ratio of one registered nurse to one mechanically ventilated patient (ACCCN, 2003, JFICM, 2003). There are also usually additional resource RNs who are ‘team leaders’ or ‘in charge’ of a shift, plus managers, educators and clinical nurse consultants in many ICUs during regular hours, with availability depending largely on the size of the ICU; the nurse to patient ratio will often be 1:2 for nonventilated or high dependency patients (ACCCN, 2003). Registered nurses have extensive responsibilities such as monitoring of patients’ haemodynamic and respiratory status and adjustment of vasocative drugs and ventilatory support, weaning of mechanical ventilation, titration of sedative and analgesic therapies and operation of continuous renal replacement treatment (Bellomo et al., 2007).
Occasionally there are other ICU personnel who have the designation of ‘nurse’ involved in patient care in ICU. In most acute care settings there are ‘Enrolled Nurses’ (or Second Division Nurses in Victoria) who are on the registers of their respective state nursing boards. Enrolled Nurses have undertaken fewer years of education and clinical training than RNs, somewhat like Licensed Practical Nurses in the United States. They are authorised to carry out some of the responsibilities of nurses in ICUs, such as noninvasive monitoring, routine hygiene and wound care, but other care can be done only under direct RN supervision. In Australia there are also nursing personnel designated ‘Assistants in Nursing’ or by similar titles. AINs have minimal training in patient care and are not employed in ICUs in Australia in direct patient care roles.
In addition to nurses, Australian ICUs usually have Allied Health professionals as part of the team – physiotherapists, social workers, pharmacists and dieticians. There are often professional scientific and technical staff who are responsible for the selection and maintenance of equipment used in the monitoring and support of patient care. Other support personnel include ward clerks, and ancillary staff such as patient services assistants who help with patient care activities such as repositioning.
Intensive care nursing education
Education for entry to practice as an RN throughout Australia was transferred from the hospital-based apprenticeship system to the university-based Bachelor of Nursing degree in the 1980–90s. Since then, what were formerly hospital-based specialty courses in intensive/critical care nursing have progressively been converted into postgraduate university courses at Graduate Certificate, Graduate Diploma or Masters levels (McKinley and Aitken, 2007). The postgraduate courses often are run jointly by universities and hospitals/health services. Generally the courses are intended to meet the professional practice needs of critical nurses and their patients, the service needs for sufficient numbers of ‘trained’ staff in critical care areas, and university requirements for the award of postgraduate academic qualifications. Some of these desired outcomes compete against others, for example the need and desire of RNs to learn specialist clinical nursing skills and the RN achieving a postgraduate qualification that requires academic scholarship in which she or he may have no primary interest. There appears to be an evolving balance in meeting university standards as well as the needs of nurses, patients and ICU service managers. The number of RNs enrolling in the university courses is increasing, as well as the numbers of those continuing to practice in intensive care after qualifying. An increase in the numbers of critical care coursework graduates going on to undertake higher degrees suggests that the introduction to tertiary study may lead to an interest in pursuing further study, including research degrees.
Intensive care nursing research
The growth in intensive care nursing research is best evidenced by presentations selected by competitive abstract submission for presentation at the Annual Scientific Meeting (ASM) on Intensive Care, jointly run by the Australian and New Zealand critical care nursing and intensive care medicine organisations. The first time I was involved in selecting abstracts of papers for presentation at this meeting in 1983, six abstracts were submitted by nurses and most were not based on research. In 2007, there were 90 abstracts submitted and most were reporting research. As well as a growth in the number of intensive care nurses conducting research, two other encouraging trends are evident. Firstly, more of the research reported at scientific meetings is appearing in peer reviewed journal publications, which is essential for research findings to make a difference to patient care beyond the local level. Secondly, more of the abstracts submitted for the ASM are from recent graduates of masters or doctoral research programmes, as evidenced by the number of nurses who nominate for the Nursing Scholarship Prize for the best presentation on research leading to a research degree. Over this time the nature of intensive and critical care nursing research in Australia predominantly has been clinical research, and increasingly the focus has been on research that investigates the effect of nursing care on patient outcomes. The development of intensive care nursing research in Australia over three decades is considerable, but there remain many opportunities to improve the quality and impact of our research for the benefit of patients cared for in ICU and for the sustainability of nursing education within universities.
Issues facing nurses and patients
The most prominent, and perennial, issue in intensive care nursing in Australia is the availability of sufficient nurses to provide care for patients who need intensive care – staffing shortages. The two biggest factors in this are funding of hospitals and the availability of enough nurses to care for patients. There are ‘supply side’ issues of having enough nurses to fill available employment places, but it is also perceived that there needs to be more funding for hospitals to have the positions to employ more nurses in ICUs, and that this would improve job satisfaction and retain more RNs in direct patient care roles. Funding of universities to educate enough RN graduates is also perceived by many to be insufficient, viz. there are too few university places for undergraduate and postgraduate nursing students, leading to an undersupply of RNs and too few RNs who undertake specialty courses such as critical care. These truly are issues in the local context. The funding for these places is largely determined by the Commonwealth Government, which has reduced its funding of places for students in universities and increased the contribution that students have to pay to undertake postgraduate university courses, such that the fees are seen as prohibitive by many prospective students. In response to this some hospital and local area health service administrations have collaborative arrangements with universities in which they subsidise students undertaking specialty postgraduate critical care courses.
Despite such arrangements, there are still shortages of RNs generally, as well as in intensive care and other critical care units. There have been numerous governmental enquiries and working parties on staffing shortages that have made numerous recommendations relating to university training places, pay, working conditions, career development opportunities and many other recruitment and retention strategies. Some of these have been implemented with some success. However, as in almost every other developed country, one of the main strategies has been recruitment of RNs from abroad. This occurs even though our peak national professional body, the Royal College of Nursing Australia (RCNA, 2003) supports the position of the International Council of Nurses that, while nurses who wish to migrate to other countries should not be hindered, there should not be active recruitment of nurses from other countries that also have shortages of RNs while factors contributing to shortages of nurses in the recruiting country have not been adequately addressed (ICN, 2001).
Another possible strategy to increase nurse staffing availability and increase the number of available ICU beds is to introduce more Enrolled Nurses into ICUs, and to extend the role they undertake to fully utilise the scope of practise for which they are authorised. The stated position of the national critical care nursing professional organisation is that ENs carrying out activities involving direct patient contact “…must always be performed in the immediate presence of the Registered Nurse” (ACCCN, 2006). In the states of Victoria and New South Wales, trials are underway to evaluate the use of ENs in the provision of more of the direct patient care that until now has been carried out only by RNs. There could be an RN and an EN allocated to care for two ‘stable’ mechanically ventilated patients, for example, with the RN supervising care the EN gives that would normally be done by an RN. How such a change in the skill mix of ICU nurse staffing will effect patient outcomes, staff recruitment and retention, and the availability of ICU beds is yet to be reported.
An increasing trend in Australian intensive care is the extension of nursing responsibility to roles beyond the ICU, often called ‘liaison nurses’, with the aim of averting admission of patients to ICU and reducing readmissions (Caffin et al., 2007), and in Medical Emergency Teams (Hillman et al., 2005). The liaison nurse role is similar to the outreach team in Britain (Ball et al., 2003) and appears to be gaining increased acceptance by demonstrating better outcomes for patients. Medical Emergency Teams are intended to be called when patients’ vital signs indicate pre-arrest deterioration, to avoid cardiac arrest. These teams are less well accepted because of their potential to reduce the skill of the general ward staff in recognising and responding to deteriorating patients, and because the results of a large randomised controlled trial showed no benefit to patient outcomes (Hillman et al., 2005).
There are also issues in education and research that are removed from the day-to-day practice and concerns of nurses currently caring for patients in our ICUs, but which are highly relevant to future intensive and critical care nursing practice in Australia. In particular, the Federal Government is introducing the Research Quality Framework, in which the research carried out in universities is assessed. The RQF assesses the amount, the quality and the impact on the Australian population of the research of the disciplines educated in universities, which includes nursing for about the last 20 years. Research productivity and impact will be compared between institutions and across disciplines. If nursing is assessed as having too little good quality research that makes a difference to patients, the continuation of Government funding for nursing education in universities, together with the opportunity for nurses to undertake Masters and Doctoral research degrees could be negatively affected.
Summary
Intensive care services and intensive care nursing in Australia are strong, in spite of issues and challenges that must be dealt with both locally on a day-to-day basis and with longer-term strategies. Many of the challenges are shared with intensive care nurses throughout the world. We must use the pages of international journals such as Intensive and Critical Care Nursing to share our strategies and solutions, and to learn from each other to provide the best possible care we can for critically ill patients.
References
- . ACCCN ICU staffing position statement on intensive care nurse staffing. Melbourne: ACCCN; 2003;
- . ACCCN ICU position statement on the use of healthcare workers other than division 1 registered nurses in intensive care. Melbourne: ACCCN; 2006;
- . Effect of the critical care outreach team on patient survival to discharge from hospital and readmission to critical care: non-randomised population based study. BMJ. 2003;327:1015–1017
- . Why is there such a difference in outcome between Australian intensive care units and others?. Curr Opin Anaesthesiol. 2007;20:100–105
- . Introduction of a liaison nurse role in a tertiary paediatric ICU. Intensive Crit Care Nurs. 2007;23:226–233
- . Review of intensive care resources and activity 2002/2003. Melbourne: Australian and New Zealand Intensive Care Society; 2005;
- MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365(9477):2091–2097
- . Position statement: ethical nurse recruitment. Geneva: International Council of Nurses; 2001;http://www.icn.ch/psrecruit01.htm
- . Minimum standards for intensive care units IC-1. Melbourne: JFICM; 2003;http://www.jficm.anzca.edu.au/pdfdocs/ic1_2003.pdf
- . Intensive care in Australia and New Zealand. Crit Care Clin. 2006;22:407–423
- . Securing the future of critical care nursing in Australia. Aust Crit Care. 2007;20:3–5
- . Ethical nurse recruitment. Canberra: RCNA; 2003;http://www.rcna.org.au/UserFiles/communique_on_ethical_nurse_recruitment_oct_03.doc
- Development and implementation of a high-quality clinical database: the Australian and New Zealand Intensive Care Society Adult Patient Database. J Crit Care. 2006;21:133–141
PII: S0964-3397(07)00099-7
doi:10.1016/j.iccn.2007.08.007
© 2007 Elsevier Ltd. All rights reserved.
Volume 23, Issue 6 , Pages 309-312, December 2007
