Pulmonary critical care in the United States of America: A complex issue
Article Outline
Critical care nursing practice has long required that nurses be both skilled and knowledgeable in the care of patients with pulmonary conditions, specifically those requiring mechanical ventilation. Because mechanical ventilators are ubiquitous to critical care units, it is reasonable to assume that nurses, who care directly for the patients on the technology, are experts in the application and function of the ventilators. Unfortunately this is not the case in the United States (US). To a large degree this element of assessment and care has been gradually relegated to respiratory care practitioners (RCPs).
RCPs are well trained to manage ventilators; they are wonderful resources for physicians and nurses. We who work with these talented professionals can barely imagine doing without them! Unlike countries like Australia, mechanical ventilation does not assure a one-to-one nurse patient ratio (Mckinley, 2007). Thus we have welcomed these professionals in part because they help assure the safety of patients on ventilators. Yet it may be that in our efforts to assure consistency and safety in the care of ventilated patients, we have allowed artificial and unsafe limits to be put in place by these and other health care providers. The limits are directly related to how nurses assess and intervene in the care of the ventilated patients. Statements such as: “only therapists can make changes in the ventilator” or “don’t touch the controls” exemplify the limits that are commonly defined in US hospitals. While these dictates are intended to protect the patient from uneducated and erroneous “control twisting”, the unintended consequences go far beyond the “controls”.
In some institutions, critical care nurses are not taught essential content related to mechanical ventilation because “the therapists do that” or it “is not in nursing's scope of practice”. These statements are truly disturbing since the risk of nurses not understanding the ventilators, and/or being responsible for how the patient tolerates the technology, is that when needed, the nurse can only wait for the therapist to arrive. Stories abound about nurses who had to “bag the patient” for extended periods of time because “adjusting the controls” was not “allowed”; even when the adjustment was only to increase the fraction of inspired oxygen (FiO2). In one case a nurse (who had been trained in ventilator management) adjusted the settings on a patient who was dyssynchronous and uncomfortable on the ventilator. The nurse had attempted to contact the therapist first but was told that she was busy in a code and he should just “bag the patient” until she got there. He felt he needed to further assess the etiology of the problem and adjusted the ventilator so that he could work directly with the patient (which he did) without being tied to the bedside bagging the patient. Hours later the therapist arrived and despite the fact that the settings were fine and more importantly so was the patient, the therapist “submitted a complaint” for adjusting the ventilator. His hospital took the side of the therapist and the nurse was reprimanded (personal communications with author).
Unfortunately when we allow such illogical decisions to stand, the unintended consequences are serious. Nurses, even those who are qualified to intervene, will be afraid to do so if such limits to their practice exist. It is important that we consider how they emerged and proactively work to prevent such interpretations.
Scope of practice
Nursing's scope of practice is defined by academic preparation, experience and training. In the case of critical care nursing, the scope of nursing practice, of necessity, requires that nurses assume responsibility for a wide variety of skills and knowledge specific to critical care. In fact it is essential that they do so. Examples include reading and interpreting electrocardiograms, performing cardioversion and defibrillation, and managing mechanical ventilation.
While some argue that undergraduate nursing programs do not provide enough of an educational base upon which to build specialty skills such as ventilator management, this is incorrect. Undergraduate nurses receive education on pulmonary physiology and pathophysiology, a variety of pulmonary diseases and conditions and finally therapies and treatments; in many cases the content includes mechanical ventilation. Regardless, critical care training provided following graduation may indeed provide the commensurate skills and knowledge that constitute the nurse's extended scope of practice in many areas of specialty such as care of the mechanically ventilated patient.
Professional organizations such as the American Association of Critical-Care Nurses (AACN) have set standards for the education and practice of critical care nursing In addition they have developed multiple resources for critical care nurse training and certification at both staff nurse and advanced practice levels. The resources are widely used and include procedures, protocols for practice and critical care orientation materials (i.e., Essentials of Critical Care Orientation: ECCO). These resources all provide evidence-based information on the skills and knowledge related to the management of the ventilated patient (AACN web sites 2008). USA hospital orientation programs use these resources to assure the mastery of associated competencies.
Selected certifications test and recognize attainment of specialty knowledge such as ventilator management. The certifications are available for adult, paediatric and neonatal populations (Critical Care Registered Nurse: CCRN and Critical Care Nurse Specialist: CCNS) as well as those just for the adult patient populations (Progressive Critical-Care Nurse: PCCN and the Acute Care Nurse Practitioner Certification: ACNPC) (AACN web sites 2008). In fact, nurses can be trained in ventilator management and may then assume the commensurate responsibilities for doing so.
The RCP as the sole ventilator manager
A major flaw in the premise that RCPs should be the sole individuals responsible for the ventilator is that unlike the critical care nurse they are not available at the patient's bedside but instead cover numerous patients (whole units or even multiple service lines). Many hospitals have very few of these individuals; making the nurse “wait for the therapist” to assess and intervene is simply not a tenable position. Legally, given the importance of ventilation and oxygenation to survival, it seems that a nurse who does not have the commensurate knowledge and training to assess and intervene is derelict in his/her responsibility to the patient. An institution that allows such a practice or condones it is culpable as well.
In many countries such as Australia, New Zealand, Denmark, England, and Ireland, nurses manage the ventilators (RCPs are uncommon or non-existent). Even in the US, in institutions where RCPs are scarce, nurses of necessity must manage the ventilators. To assume that only one type of caregiver should have sole responsibility for managing these patients is illogical and not in the best interest of the patient or nurse.
RCPs are physician extenders and as such really work from physician orders. They do not define nursing's scope of practice, nor do physicians. It is remarkable that nursing has to a large degree allowed these specialties to attempt to define nursing's scope of practice in this area. It is even more remarkable that in many cases physicians are also told they may not adjust the ventilators. The frequently stated rationale for this is that the physician doesn’t understand the ventilator. If true, this is of concern given that then they too are unable to assess the patient on the very therapy that they “prescribed”. If we believe and understand the analogy of the co-pilot's role in partnering with the captain to assure safety, this premise of only one person being the owner of the knowledge and skills related to ventilator management is indeed a concerning one.
Complexity
Some may argue that nurses are unlikely to be able to be able to “keep up” with the wide variety of complex, sophisticated, microprocessor ventilator mode options. There is no question that ventilators are becoming increasingly complex and education of clinicians is indeed a challenge. However this is true for nurses, therapists and physicians alike.
Unfortunately the superiority of the new sophisticated modes has not been demonstrated in ventilated critically ill or weaning patients. Our use of them is often because we can, even though perhaps we should not. Simple and familiar may indeed be best as there is less room for variability and subsequent error. Complexity in care does not improve outcomes and “trying out” a new mode is experimentation and puts the patient at risk. This is especially true since the harder they are to understand the more likely accurate patient assessment will be lacking. New modes that are only understood by the therapist obviate the nurse's ability to accurately assess and intervene if necessary.
Regardless, it is clear that we need to increase our efforts to regularly update critical care nurses in this sophisticated technology. If our philosophy is that ventilator management is an essential practice element, then continuing education is our professional responsibility.
Conclusion
It is the opinion of this author that nursing must reassume responsibility for learning the skills and knowledge necessary to manage ventilated patients. Before the advent of the discipline of respiratory care, nurses were responsible for the care of ventilated patients and did it well. Schools of nursing and hospitals must develop partnerships to assure that the education of nurses in pulmonary critical care is not neglected but instead recognized and addressed.
We are fortunate to have RCPs to work with in critical care but the two disciplines must work collaboratively together to manage the ventilated patient. The RCP's knowledge and skills are extremely valuable in managing these patients and they certainly, when available, should be considered the experts in how the ventilator functions. But, unless nurses also understand how the ventilator functions, the RCT is flying solo, without the benefit of the co-pilot to assure that the patient is safe.
References
- AACN standards. Web site accessed 10/08. http://www.aacn.org/DM/MainPages/AACNHomePage.aspx?enc=9RdxXufgiNKQ0ZMRg/3r90mSvrht9L2wflGxl7gLJsM=.
- AACN Resources. Web site accessed 10/08. http://www.aacn.org/DM/MainPages/MarketplaceHome.aspx.
- . Australian intensive care nursing. Intensive Crit Care Nurs. 2007;23:309–312
- Respiratory Care Practitioners Scope of Practice. Web site accessed 10/08. http://www.dsd.state.md.us/comar/10/10.32.11.09.htm.
PII: S0964-3397(08)00114-6
doi:10.1016/j.iccn.2008.11.001
© 2008 Elsevier Ltd. All rights reserved.