Critical Care Nursing Research Papers (original) (raw)

Many patients have physiological deterioration prior to cardiac arrest, death and intensive care unit (ICU) admission that are detected and documented by medical and nursing staff. Appropriate early response to detected deterioration is... more

Many patients have physiological deterioration prior to cardiac arrest, death and intensive care unit (ICU) admission that are detected and documented by medical and nursing staff. Appropriate early response to detected deterioration is likely to benefit patients. In a multi-centre, prospective, observational study over three consecutive days, we studied the incidence of antecedents (serious physiological abnormalities) preceding primary events (defined as in-hospital deaths, cardiac arrests and unanticipated ICU admissions) in 90 hospitals [69 UK, 19 Australia and two New Zealand (ANZ)]. Sixty-eight hospitals reported primary events during the 3-day study period (50 UK, 16 Australia and two ANZ). Data on the availability of ICU/high-dependency unit (HDU) beds and cardiac arrest teams and medical emergency teams (METs) were also collected. Of 638 primary events, there were 308 (48.3%) deaths, 141 (22.1%) cardiac arrests and 189 (29.6%) unplanned ICU admissions. There were differences in the pattern of primary events between the UK and ANZ (P < 0.001). There were proportionally more deaths in the UK (52.3% versus 35.3%) and a higher number of unplanned ICU admissions in ANZ (47.3% versus 24.2%). Sixty per cent (383) of primary events had a total of 1032 documented antecedents. The most common antecedents were hypotension and a fall in Glasgow Coma Scale. The proportion of ICU/HDU to general hospital beds was greater in ANZ (0.034 versus 0.016, P < 0.001) and METs were more common in ANZ (70.0% versus 27.5%, P = 0.001). The data confirm antecedents are common before death, cardiac arrest and unanticipated ICU admission. The study also shows differences in patterns of primary events, the provision of ICU/HDU beds and resuscitation teams, between the UK and ANZ. Future research, focusing upon the relationship between service provision and the pattern of primary events, is suggested.

Background: Job satisfaction is an important factor in health care settings. Strong empirical evidence supports a causal relationship between job satisfaction, patient safety and quality of care. However, there have not been any studies... more

Background: Job satisfaction is an important factor in health care settings. Strong empirical evidence supports a causal relationship between job satisfaction, patient safety and quality of care. However, there have not been any studies exploring the job satisfaction of Malaysian nurses. Aim: The main purpose of this qualitative descriptive study was to explore the factors related to feelings of job satisfaction as well as job dissatisfaction experienced by registered nurses in Malaysia. Method: A convenient sample of 46 Malaysian nurses recruited from a large hospital (number of beds = 895) participated in the study. A total of seven focus group discussions were conducted with nurses from surgical, medical and critical care wards. A semi-structured interview guide was used to facilitate the interviews, which were audio-recorded, transcribed verbatim and checked. The transcripts were used as data and were analysed using a thematic approach. Finding: The study identified three main themes that influenced job satisfaction: (1) nurses' personal values and beliefs; (2) work environment factors and (3) motivation factors. Concerning the nurses' personal values and beliefs, the ability to help people made the nurses felt honoured and happy, which indirectly contributed to job satisfaction. For work environment factors, team cohesion, benefit and reward, working conditions play an important role in the nurses' job satisfaction. Motivation factors, namely, professional development and clinical autonomy contributed to job satisfaction. Conclusion: It is important for nurse leaders to provide more rewards, comfortable work environments and to understand issues that affect nurses' job satisfaction. Relevance to clinical practice: Our findings highlight the importance of factors that can improve nurses' job satisfaction. The study provides basic information for hospital administrators in planning effective and efficient policies to improve nursing job satisfaction in order to increase the quality of patient care and decrease nursing turnover.

Background: The word Cardiac Arrhythmia was derived from Latin word "Cardiac'' means heart, "A'' means disturbance, distortion, or without and ``Rhythmia'' means to measure continuous normal rhythm. WHO, estimates about 60% of the total... more

Background: The word Cardiac Arrhythmia was derived from Latin word "Cardiac'' means heart, "A'' means disturbance, distortion, or without and ``Rhythmia'' means to measure continuous normal rhythm. WHO, estimates about 60% of the total worlds cardiac patient will be Indians. Objectives 1. To assess the knowledge regarding Cardiac Arrhythmia and its management among experimental and control group by pre-test. 2. To assess and the effectiveness of STP on knowledge regarding Cardiac Arrhythmia and its management among experimental and control group by post-test. 3. To find out the association between the post-test scores level of knowledge regarding Cardiac Arrhythmia and its management among experimental group with their selected sociodemographic variables. Methods: A quasi experimental one group pre-test and post-test design. Questionnaire was used to collect the data from 50 student nurses, Pre-test was conducted and after the STP was given to the same group and post-test was conducted after 7days of teaching. Result: The results shows a significant difference, calculated p<0.002. STP was highly effective Conclusion: There was no association between knowledge scores with their selected sociodemographic variables.

Aim: This paper reviews descriptive and quasi-experimental studies on the intervention programme developed for school health nurses in order to assist them in different activities which they perform in the school environment. The review... more

Aim: This paper reviews descriptive and quasi-experimental studies on the intervention programme developed for school health nurses in order to assist them in different activities which they perform in the school environment. The review was as a result of the need to conduct an integrative review of intervention programmes developed for school health nurses on guiding adolescents about their reproductive health. However, there is a dearth of studies on this particular area, and this prompted the authors to expand the scope to cover the intervention programme developed for school health nurses in other areas of concern. Methods: Two review questions were raised which prompted the search for articles to provide necessary answers. Computerized database, ancestry and extensive search strategies by titles of research reported in English between 2000 and 2015 located diverse intervention programmes. A total of 1980 articles were retrieved from which 11 were reviewed after series of filtering based on titles, abstracts, full texts, and duplicates had taken place. A broad range of intervention programmes were reported. Results: The most common intervention programme is training programme which is six in number, followed by education and mentoring programmes which are two each while the number of orientation programme is one. The aims of almost all these programmes was to enhance the knowledge and skills of school health nurses in their areas of practice. Common methodological weakness was small sample. Conclusion: Integrative review reveals that school health nurses are subject mainly to a training programme in order to enhance their performance in their roles and responsibilities toward adolescents in the secondary school environment.

A review of the literature was undertaken to determine the existence of any evidence to support cooling strategies used in the ICU • The focus of the review was to examine previous findings on the specific problems of cooling patients... more

A review of the literature was undertaken to determine the existence of any evidence to support cooling strategies used in the ICU • The focus of the review was to examine previous findings on the specific problems of cooling patients with severe cerebral insult • Cooling methods that use external physical cooling strategies as well as the effects of antipyretics and vasoactive drugs were examined • Overall, it would appear that conclusions for practice remain unclear • The findings led to the implementation of a pilot study, the findings of which will be discussed in Part 2

Aims: Heart failure is a major risk factor for erectile dysfunction. This study seeks to investigate the incidence and factors associated with erectile dysfunction in patients with systolic heart failure. Methods: This is a cross... more

Aims: Heart failure is a major risk factor for erectile dysfunction. This study seeks to investigate the incidence and factors associated with erectile dysfunction in patients with systolic heart failure. Methods: This is a cross sectional study that was conducted on 100 male patients with systolic heart failure in 2009. Convenience sampling was used to gather the required data. Data collection instruments included a demographic data form, IIEF-5 (The International Index of Erectile Function, a 5-item version), MLHFQ (Minnesota Living with Heart Failure), and CES-D (Center for Epidemiologic Studies Depression Scale). The data was analyzed by SPSS software and using descriptive statistics, t-test, ANOVA and Pearson correlation coefficient. Findings: The findings indicated that the mean score of erectile dysfunction was 14.02±6.26 and 80% of male patients with systolic heart failure suffered from erectile dysfunction. There was a significant relationship between erectile dysfunction a...

A plan to progress a tracheostomy toward decannulation should be initiated unless the tracheostomy has been placed for irreversible conditions. In most cases, tracheostomy progression can begin once a patient is free from ventilator... more

A plan to progress a tracheostomy toward decannulation should be initiated unless the tracheostomy has been placed for irreversible conditions. In most cases, tracheostomy progression can begin once a patient is free from ventilator dependence. Progression often begins with cuff deflation, which frequently results in the patient’s ability to phonate. A systematic approach to tracheostomy progression involves assessing (1) hemodynamic stability, (2) whether the patient has been free from ventilator support for at least 24 hours, (3) swallowing, cough strength, and aspiration risk, (4) management of secretions, and (5) toleration of cuff deflation, followed by (6) changing to a cuffless tube, (7) capping trials, (8) functional decannulation trials, (9) measuring cough strength, and (10) decannulation. Critical care nurses can facilitate the process and avoid unnecessary delays and complications.

Burnout syndrome is a disorder that seriously affects people who suffer it, the institutions in which they work and the quality of healthcare. It is of great interest to advance in burnout research for its possible prevention. The aim of... more

Burnout syndrome is a disorder that seriously affects people who suffer it, the institutions in which they work and the quality of healthcare. It is of great interest to advance in burnout research for its possible prevention. The aim of this work was to study the levels of burnout syndrome in nurses of emergency department with overtime workdays and to know the relationship between burnout and personality characteristics. Multicenter cross-sectional study with a sample of 1225 emergency nurses from the Andalusian Health Service. Demographic, social and occupational variables were recorded. Burnout was assessed with Maslach Burnout Inventory and personality factors with NEO-Five Factor Inventory. Descriptive analysis of the variables, independent means hypothesis contrast and bayesian analysis were done. 44.1% of nurses who perform overtime workdays have high burnout versus a 38% for those without such overload. These differences have been also found in burnout dimensions, especiall...

Ethical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients' families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes. To... more

Ethical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients' families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes. To examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients. Twenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tool's benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data. Older patients with multiple comorbid conditions and aggressive treatments...

This study tested the effectiveness of a pressure ulcer (PU) prevention bundle in reducing the incidence of PUs in critically ill patients in two Saudi intensive care units (ICUs). A two-arm cluster randomized experimental control trial.... more

This study tested the effectiveness of a pressure ulcer (PU) prevention bundle in reducing the incidence of PUs in critically ill patients in two Saudi intensive care units (ICUs). A two-arm cluster randomized experimental control trial. Participants in the intervention group received the PU prevention bundle, while the control group received standard skin care as per the local ICU policies. Data collected included demographic variables (age, diagnosis, comorbidities, admission trajectory, length of stay) and clinical variables (Braden Scale score, severity of organ function score, mechanical ventilation, PU presence, and staging). All patients were followed every two days from admission through to discharge, death, or up to a maximum of 28 days. Data were analyzed with descriptive correlation statistics, Kaplan-Meier survival analysis, and Poisson regression. The total number of participants recruited was 140: 70 control participants (with a total of 728 days of observation) and 70...

Background: Recovery from critical illness can be prolonged and can result in a number of significant short-and long-term psychological consequences. These may be associated with the patient's perception of the intensive care experience.... more

Background: Recovery from critical illness can be prolonged and can result in a number of significant short-and long-term psychological consequences. These may be associated with the patient's perception of the intensive care experience. Aim: The aims of the study were to assess patients' perceptions of their intensive care unit (ICU) experience and the effect of these on anxiety, depression and post-traumatic stress up to 6 months after discharge. Method: One hundred and three participants were recruited from six ICUs from one Critical Care Network in the United Kingdom. A prospective, longitudinal study was designed to assess anxiety, depression, post-traumatic stress symptomatology and patients' perceptions of their intensive care experience. Data were collected on three occasions: after intensive care discharge and before hospital discharge, and 2 months and 6 months later. Measures included the impact of events scale, hospital anxiety and depression scale and intensive care experience questionnaire. Results: Anxiety, depression, avoidance and intrusion scores did not significantly reduce over time. At hospital discharge there was a significant association between patients' perceptions of their intensive care experience and anxiety, depression, avoidance and intrusion scores at hospital discharge. Conclusion: Standardised assessment of an intensive care experience is important. It provides information about the patient experience which can inform care practice within ICU, following discharge to the ward and, in the longer term, rehabilitation.

Background: Pressure ulcer (PU) risk assessment tools are an important component of good nursing care; however, it is essential that these tools offer a good sensitivity and specificity, in addition to clinical utility in the population... more

Background: Pressure ulcer (PU) risk assessment tools are an important component of good nursing care; however, it is essential that these tools offer a good sensitivity and specificity, in addition to clinical utility in the population being assessed. Objectives: The aim of this study was to examine how the lowest Braden Q score recorded in the first 24 h of paediatric intensive care unit admission related to the risk of PU development in an English PICU (paediatric intensive care unit). Methods: A retrospective cohort study was undertaken over 12 months in a single PICU in the North West of England. 891 critically ill children with a Braden Q score were evaluated. The lowest Braden Q score within the first 24 h of PICU admission was matched to reported PU development and grade. Results: The Braden Q score was found to perform well in children aged 3 weeks to 8 years without congenital heart disease (CHD), which is the population it was validated on. At a cut off score of ≤16 it yielded a sensitivity of 100% specificity of 73.1%, positive predictive value (PPV) 2.56 and a negative predictive value (NPV) of 100 and an area under the curve (AUC) of 0.87(0.75-0.98). When used in other age groups and when it included children with CHD, it performed less well with lower AUC and wider confidence intervals, but it performed moderately well in the group of term to 14 years with a sensitivity of 75% specificity of 72.6%, PPV 1.5 and a NPV of 99.8 and AUC of 0.74 (0.49-0.98). Conclusion: Our results in a heterogeneous UK PICU population found the Braden Q score performed well in the specific population it was validated for (PICU children aged 3 weeks to 8 years without CHD), however, it performed moderately well in the more heterogonous PICU population of term to 14 years including children with CHD.

Background: Job satisfaction is an important factor in health care settings. Strong empirical evidence supports a causal relationship between job satisfaction, patient safety and quality of care. However, there have not been any studies... more

Background: Job satisfaction is an important factor in health care settings. Strong empirical evidence supports a causal relationship between job satisfaction, patient safety and quality of care. However, there have not been any studies exploring the job satisfaction of Malaysian nurses. Aim: The main purpose of this qualitative descriptive study was to explore the factors related to feelings of job satisfaction as well as job dissatisfaction experienced by registered nurses in Malaysia. Method: A convenient sample of 46 Malaysian nurses recruited from a large hospital (number of beds = 895) participated in the study. A total of seven focus group discussions were conducted with nurses from surgical, medical and critical care wards. A semi-structured interview guide was used to facilitate the interviews, which were audio-recorded, transcribed verbatim and checked. The transcripts were used as data and were analysed using a thematic approach. Finding: The study identified three main themes that influenced job satisfaction: (1) nurses' personal values and beliefs; (2) work environment factors and (3) motivation factors. Concerning the nurses' personal values and beliefs, the ability to help people made the nurses felt honoured and happy, which indirectly contributed to job satisfaction. For work environment factors, team cohesion, benefit and reward, working conditions play an important role in the nurses' job satisfaction. Motivation factors, namely, professional development and clinical autonomy contributed to job satisfaction. Conclusion: It is important for nurse leaders to provide more rewards, comfortable work environments and to understand issues that affect nurses' job satisfaction. Relevance to clinical practice: Our findings highlight the importance of factors that can improve nurses' job satisfaction. The study provides basic information for hospital administrators in planning effective and efficient policies to improve nursing job satisfaction in order to increase the quality of patient care and decrease nursing turnover.

Background: With the goal of optimizing tissue perfusion and maintaining adequate oxygen delivery, nurses play an important role in monitoring oxygenation and ventilation. Nursing practices may affect oxygen saturation in critically ill... more

Background: With the goal of optimizing tissue perfusion and maintaining adequate oxygen delivery, nurses play an important role in monitoring oxygenation and ventilation. Nursing practices may affect oxygen saturation in critically ill patients. Aim of study was to determine the relationship between nursing practices and oxygen desaturation in critically ill patients. A descriptive research design was used in this study. Setting: The study was conducted at the Critical Care Units (CCUs) of two selected Hospitals at Makah Al-Mukaramah, KSA. Subjects; a convenience sample of 100 newly admitted critically ill patients were included in the study. Tool of data collection was the relationship between nursing practices and oxygen desaturation in critically ill patients' tool. It consists of two parts: Part 1; nursing practices observation checklists and part 2; oxygen saturation monitoring record. Results: It was noted that in 67% of observations, patients had their position changed by nurses once per shift, no patients had oxygen during suctioning. In addition, there were significant correlation between oxygen saturation during, and after bathing (r .403, p.000, r .342, p .000). From the results of this study it can be concluded that the nursing practices mainly suctioning, positioning and bathing affect oxygen desaturation in critically ill patients. There were significant relationships between oxygen desaturation and the procedures performed as oxygen saturation decreased during and after certain performed procedures especially suctioning. Recommendations: Protocols should be developed regarding oxygen desaturation in critically ill patients. Adequate supervision should be provided on nurses during their practice.

Aims and objectives: To evaluate the concurrent validity and reliability of the behavioural COMFORT and a modified version of the FLACC scale for assessment of pain and sedation in intubated and ventilated children and to evaluate the... more

Aims and objectives: To evaluate the concurrent validity and reliability of the behavioural COMFORT and a modified version of the FLACC scale for assessment of pain and sedation in intubated and ventilated children and to evaluate the construct validity of the FLACC scale for assessment of pain. Background: Few instruments are available for assessment of pain/sedation in paediatric intensive care. Design: A prospective observational study was performed postoperatively in 40 children aged 0-10 years. Methods: Two trained nurses observed the child simultaneously and assessing COMFORT behavioural (COMFORT-B) and FLACC scores. In comparison, two bedside nurses concurrently scored pain using an observational visual analogue scale (VAS obs ) and sedation using the Nurse Interpretation of Sedation (NIS) score: oversedated, adequately or insufficient sedated. In 20 additional patients, one nurse assessed FLACC scores before and after analgesics. Results: The majority of patients were <1 year. A moderate but significant correlation was found between each scale and both sedation and VAS obs . COMFORT-B differentiated better than FLACC between the three sedation levels. For those assessed to be in pain (VAS obs > 3), both COMFORT-B and FLACC scores were significantly different compared with VAS obs < 3. The interrater reliability was high for COMFORT-B and FLACC (kappa 0Á71 and 0Á63, respectively). For bedside nurses' assessment of pain, the interrater reliability was high (kappa 0Á63) but low for the level of sedation (kappa 0Á20). After administration of analgesics, the FLACC median score decreased significantly from 5 to 0. Conclusions: The COMFORT-B scale was a more reliable measure of children's sedation than bedside subjective assessment and gives more substantial information about sedation than the FLACC scale. Concurrent validity for assessment of pain was supported for both scales. The modified FLACC showed construct validity for measuring pain. Relevance to clinical practice: The use of validated scales may improve the assessment and management of pain and sedation in intubated children.

The care bundle is a new concept in critical care, which is currently being promoted by the National Health Service Modernisation Agency for Critical Care. Care bundles originated in North America and are described best as groups of... more

The care bundle is a new concept in critical care, which is currently being promoted by the National Health Service Modernisation Agency for Critical Care. Care bundles originated in North America and are described best as groups of evidence-based practice interventions. The theory behind care bundles is that when several evidence-based interventions are grouped together in a single protocol, it will improve patient outcome. Care bundles are relatively easy to develop, implement and audit, and provide practitioners with a practical method for implementing evidence-based practice. This article describes the care bundle and offers practical suggestions about how to develop, implement and audit them in practice.

This article reviews the current evidence, benefits and drawbacks for the use of continuous lateral replacement therapy in the treatment and prevention of nosocomial infections in the ventilated patient. Relevant to Practice: The... more

This article reviews the current evidence, benefits and drawbacks for the use of continuous lateral replacement therapy in the treatment and prevention of nosocomial infections in the ventilated patient. Relevant to Practice: The acquisition of nosocomial infections and the development of pressure sores continue to be major issues in the care of the critically ill, ventilated patient. The use of continuous lateral rotation therapy (CLRT) as an adjunct in the prevention and treatment of pneumonia has increased in popularity in recent years. A number of institutions routinely advocate the use of CLRT in critically ill patients. Conclusion: While there is some data to suggest that CLRT may have an impact on prevention of and treatment for nosocomial infections acquired by ventilated patients, there still remains insufficient evidence to its inclusion as a fully validated treatment. Clearly, there is a requirement for more robust, in-depth research into the efficacy of this proposed treatment.

Background: upper respiratory tract infections are the major causes for mortality and morbidity under 3 years of children. in worldwide statistics when we take every year 3.9 million deaths of toddler due to upper respiratory tract... more

Background: upper respiratory tract infections are the major causes for mortality and morbidity under 3 years of children. in worldwide statistics when we take every year 3.9 million deaths of toddler due to upper respiratory tract infections where as in India 15-20% of toddler admission to the hospital is due to upper respiratory tract infection the aim of the present study is to assess the effectiveness of structured teaching programme for mothers of toddler on prevention of upper respiratory tract infection. Objectives of the study is to assess the knowledge of the mothers in prevention of upper respiratory tract infection, to determine the effectiveness of structured teaching program regarding upper respiratory tract infection and to find out the association between selected demographic variable with knowledge regarding prevention of upper respiratory tract infection. Method: one group pretest posttest quasi experimental design was selected for the study. The participants were 60 mothers of toddler were included using simple random sampling from a selected hospital at Bangalore. Questionnaire is used to collect data from the subjects and the obtained data was analyzed using descriptive, inferential statistics and interpreted in terms of objectives of the study. The level of significance was set at 0.05 levels. Results: In the pre-test the subjects had inadequate knowledge with a mean of 29.25% and standard deviation of 2.26 where as in posttest there was a significant mean knowledge gain of 77.77% and standard deviation of 1.68. The chi-square test revealed that there was a significant association of knowledge with selected demographic variables such as occupation, family income and any previous exposure to the knowledge on URT infection. Conclusion: The present study proved that the structured teaching program was significantly effective in improving the knowledge of mothers of toddler on prevention of upper respiratory tract infection. Hence the study concluded that improve the knowledge on management of upper respiratory tract infection helps to provide care, to safeguard the children and to prevent further complication.

Aim: To explore variability in perceptions of nurse managers and physician directors regarding roles, responsibilities and clinical-decision making related to mechanical ventilator weaning in Norwegian intensive care units (ICUs).... more

Aim: To explore variability in perceptions of nurse managers and physician directors regarding roles, responsibilities and clinical-decision making related to mechanical ventilator weaning in Norwegian intensive care units (ICUs). Background: Effective teamwork is crucial for providing optimal patient care in ICU. More knowledge on nurses' and physicians' perceptions of responsibility in clinical decision-making for mechanical ventilation is needed. Methods: Self-administered survey of mechanical ventilation and weaning responsibilities was sent to nurse managers and physician directors of Norwegian adult ICUs. Nurses' decisional influence and autonomy were estimated on a numeric rating scale (NRS) from 0 to 10 (least to most). Results: Response rate was 38/60 (63%) nurses and 38/52 (73%) physicians. On the NRS nurse managers perceived the autonomy and influence of nurses' ventilator decisions higher than physician directors: median of 7 (IQR 5-8) (nurses) versus 5 (3-6) (physicians), (p < 0·01), and 8 (7-9) (nurses) versus 7 (5-8) (physicians), (p < 0·01) respectively. Respondents agreed that nurses collaborated in assessment of patient response to ventilator changes and titrating ventilator settings: 92% of nurses and 87% of physicians, (p = 0·46), and recognizing weaning failure 84% of nurses and 84% of physicians, (p = 0·96). Physician directors perceived significantly less collaborative decision-making on weaning method (p = 0·01), weaning readiness (p = 0·04) and readiness to extubate (p < 0·01) than nurse managers. Both groups acknowledged the importance of 'knowing the patient' for weaning success, and agreed that the assessment of work of breathing, well-being, and clinical deterioration were important for determining weaning tolerance. Conclusions: Nurse managers perceived nurses to have greater autonomy, influence and collaborative interaction regarding decisions on mechanical ventilation than physician directors. Greater awareness and acknowledgment of nurses' role may promote interprofessional collaboration and improve patient care.

Aims and objectives: Aims of this article were (a) to explore how parents of premature infants experience guided family-centred care (GFCC), and (b) to compare how parents receiving GFCC versus standard care (SC) describe nurse-parent... more

Aims and objectives: Aims of this article were (a) to explore how parents of premature infants experience guided family-centred care (GFCC), and (b) to compare how parents receiving GFCC versus standard care (SC) describe nurse-parent communication in the neonatal intensive care unit. Background: Family-centred care (FCC) is acknowledged as fundamental to supporting parents of premature infants, and communication is central to this practice. Accordingly, nurses need good communication skills. GFCC is an intervention developed to improve nurse-parent communication in the neonatal intensive care unit. This intervention helps nurses to realize person-centred communication as an approach to optimize contemporary practice. Design: Our qualitative study had a descriptive and comparative design using semi-structured interviews to explore the parent's experience of GFCC. Methods: We conducted 10 dyad interviews with parents (n = 20) and two individual interviews with mothers of premature infants (n = 2). Parents in the intervention group versus SC group were 13 versus 9. Thematic analysis was applied. Findings: GFCC was generally experienced as supportive. Three interrelated themes were identified that illustrated how the intervention helped parents cope as persons, parents and couples: (a) discovering and expressing emotions, (b) reaching a deeper level of communication, and (c) obtaining mutual understanding. In contrast, SC communication was more superficial and less structured. Factors such as inaccessibility of nurses, inability to ask for assistance and parent popularity impaired successful communication.

Background: The environment of an intensive care unit (ICU) is, in general, stressful and has an impact on quality of care in terms of patient outcomes and safety. Little is known about nurses' experiences, however, from a... more

Background: The environment of an intensive care unit (ICU) is, in general, stressful and has an impact on quality of care in terms of patient outcomes and safety. Little is known about nurses' experiences, however, from a phenomenological perspective with regard to the critical care settings as a place for the provision of care for the most critically ill patients and their families. Aim: The aim of this study was to explore nurses' lived experiences of ICU bed spaces as a place of care for the critically ill. Design and methods: A combination of qualitative lifeworld interviews and photos -photovoice methodology -was used when collecting data. Fourteen nurses from three different ICUs participated. Data were analysed using a phenomenological reflective lifeworld approach. Findings: An outer spatial dimension and an inner existential dimension constitute ICU bed spaces. Caring here means being uncompromisingly on call and a commitment to promoting recovery and well-being. The meanings of ICU bed spaces as a place of care comprise observing and being observed, a broken promise, cherishing life, ethical predicament and creating a caring atmosphere. Conclusions and relevance to clinical practice: The architectural design of the ICU has a great impact on nurses' well-being, work satisfaction and the provision of humanistic care. Nurses need to be involved in the process of planning and building new ICU settings. There is a need for further research to highlight the quality of physical environment and its impact on caring practice.

In nursing education, physiological concepts are typically presented within a body 'systems' framework yet learners are often challenged to apply this knowledge in the holistic and functional manner needed for effective clinical... more

In nursing education, physiological concepts are typically presented within a body 'systems' framework yet learners are often challenged to apply this knowledge in the holistic and functional manner needed for effective clinical decision-making and safe patient care. A nursing faculty addressed this learning challenge by developing an advanced organizer as a conceptual and integrative learning tool to support learners in diverse learning environments and practice settings. A mixed methods research study was conducted that explored the effectiveness of the Oxygen Supply and Demand Framework as a learning tool in undergraduate nursing education. A pretest/post-test assessment and reflective journal were used to gather data. Findings indicated the Oxygen Supply and Demand Framework guided the development of pattern recognition and thinking processes and supported knowledge development, knowledge application and clinical decision-making. The Oxygen Supply and Demand Framework supports undergraduate students learning to provide safe and effective nursing care.

Aim: The aim of the research was to understand how nurses used technology to wean patients from mechanical ventilation. Background: The literature concerned with the development of critical care centres on the role of technology with... more

Aim: The aim of the research was to understand how nurses used technology to wean patients from mechanical ventilation. Background: The literature concerned with the development of critical care centres on the role of technology with little emphasis on the nursing contribution. Design: An ethnographic approach was used to understand how nurses used technology to wean patients from mechanical ventilation. Methods: Data were gathered by participant observation and interviewing over a 6-month period. In total, 250 h of field notes were recorded. Results: Data were analysed by the content analysis method. Knowing the patient was a central theme identified. Three sub-themes were identified: ways of knowing, continuity of care and the role of the patient in the weaning trajectory. Conclusion: 'Knowing the patient' was implied during the interviews as essential to the delivery of patient-centred care. There were two main factors that needed to be present in order for nurses to know their patients: continuity of care and expertise. 'Ways of knowing' was reliant on gaining information about the patient. The role of the patient was a passive recipient of treatment. Implications for practice: Knowing the patient has been defined as a characteristic of expert nursing. To be truly patient-centred nursing needs to address the barriers that prevent nurses from getting to 'know' their patients.

Aims: To critically review the literature in order to describe the themes associated with the experience of critical illness and consider how these inform the patients understanding. Background: Critical illness requires life-saving... more

Aims: To critically review the literature in order to describe the themes associated with the experience of critical illness and consider how these inform the patients understanding. Background: Critical illness requires life-saving intervention and application of high technology medicine and intensive nursing within a specialist critical care unit. Whilst an extensive and rapidly advancing knowledge of the physiological basis for treating critical illness exists, understanding how critical illness is experienced by the patient is less well understood. Data sources: Literature was retrieved through systematic searching of electronic databases, hand searches of journals and incremental searching. Review methods: 26 qualitative studies of firsthand experiences of adult patients who had been in a critical care unit were reviewed. Key, common, explicit themes between the studies were identified as well as implicit themes that emerged through preliminary synthesis. Results: Eight common explicit themes were identified. These included: Transformations of perception: Unreal experiences and dreams; Proximity to death; Transformation and perception of the body in illness; Transformation and perception of time; The critical care environment: technology and dependence; Care, communication and relationships with healthcare professionals; The support of family and friends and desire for contact; Transfer from critical care and recovery from critical illness. A further two implicit themes related to the primacy of the critical care unit within the studies; and the focus of recall or personal meaning which divided the literature. Conclusion: The explicit themes highlight the steps taken by researchers to understand what is salient about the critical care experience for those who have been critically ill. Future research exploring the whole illness-recovery trajectory and the way personal meaning contributes to understanding life experiences is justified.

Aims and objectives. To describe and evaluate the basic competence of graduating nursing students in intensive and critical care nursing. Background. Intensive and critical care nursing is focused on severely ill patients who benefit from... more

Aims and objectives. To describe and evaluate the basic competence of graduating nursing students in intensive and critical care nursing. Background. Intensive and critical care nursing is focused on severely ill patients who benefit from the attention of skilled personnel. More intensive and critical care nurses are needed in Europe. Critical care nursing education is generally postqualification education that builds upon initial generalist nursing education. However, in Europe, new graduates practise in intensive care units. Empirical research on nursing students' competence in intensive and critical care nursing is scarce. Design. A cross-sectional survey design. Methods. A basic competence scale (Intensive and Critical Care Nursing Competence Scale, version 1) and a knowledge test (Basic Knowledge Assessment Tool, version 7) were employed among graduating nursing students (n = 139).

Aims and objectives. To develop a scale to assess basic competence in intensive and critical care nursing. In this study, basic competence denotes preliminary competence to practice in an intensive care unit. Background. There is a need... more

Aims and objectives. To develop a scale to assess basic competence in intensive and critical care nursing. In this study, basic competence denotes preliminary competence to practice in an intensive care unit. Background. There is a need for competence assessment scales in intensive care nursing practice and education. The nursing care performed in the intensive care unit is special by its nature and needs to be assessed as such. At this moment, however, there is no tested, reliable and valid scale in this field. Design. A multi-phase, multi-method development and psychometric testing of the scale was conducted. Methods. The scale was developed in three phases. First, following a literature review and Delphi study, the items were created. Second, the scale was pilot tested twice by nursing students (n 1 = 18, n 2 = 56) and intensive care nurses (n 1 = 12, n 2 = 54), and revisions were made. Third, reliability and construct validity were tested by graduating nursing students (n = 139) and intensive care nurses (n = 431). Results. The Intensive and Critical Care Nursing Competence Scale (ICCN-CS-1) is a self-assessment test consisting of 144 items. Basic competence is divided into patient-related clinical competence and general professional competence. In addition, basic competence is comprised of knowledge base, skill base, attitude and value base and experience base. ICCN-CS-1 is a reliable and tolerably valid scale. Conclusions. The ICCN-CS-1 is a promising scale for use among nursing students and nurses. Future research is needed to evaluate its construct validity further and to assess its suitability for completion during intensive care unit's orientation programmes and nursing students' clinical practice in an intensive care unit. Relevance to clinical practice. The ICCN-CS-1 can be used for basic competence assessment in professional development discussions in intensive care units, in mentor evaluation situations during nursing students' clinical practice and in intensive care nursing education.

Aims: To describe crucial information needs of ICU charge nurses, and to compare these needs in two countries in Europe. Background: ICU charge nurses are on the front line for ensuring that the activities of their units are running... more

Aims: To describe crucial information needs of ICU charge nurses, and to compare these needs in two countries in Europe. Background: ICU charge nurses are on the front line for ensuring that the activities of their units are running smoothly. They are accountable for making sure that the right tasks are performed under the right circumstances, with the right people, at the right time. Design and participants: An online survey based on a previous observation study regarding the ad hoc decision-making of ICU shift leaders. A total of 257 Finnish and 50 Greek ICU charge nurses participated in this study, from 17 Finnish and 16 Greece ICUs for adults. Methods: Our survey incorporated 122 statements divided into six dimensions (patient admission, organization and management of work, allocation of staff, allocation of material, special treatments and patient discharge) with a rating scale from 0 to 10. Analysis involved descriptive statistics. Mann-Whitney U and Kruskal-Wallis tests were used to compare the answers of the two countries. Validity was verified with confirmatory factor analysis and the reliability was tested with Cronbach's α values. Results: The most crucial information needs of ICU charge nurses concerned the overall organization and management of work. Both staff-related and individual patient-related information was needed. Information needs of Finnish and Greek charge nurses concerned similar kinds of situations in ICUs. However, there were some differences that might depend on the cultural differences between the countries. Conclusions: Accurate and real-time information is a prerequisite for ICU charge nurses' ad hoc decision-making during daily care management. Identification of the most crucial information is needed when tools for information management are developed. Relevance to clinical practice: The results of this study indicated that a major portion of immediate information needs of ICU charge nurses are internationally common in similar settings.

Up to 85% of nurses have reported exposure to incivility in the workplace (Hunt & Marini, 2012). The often-subtle nature of incivility toward nurses in a minority population may partially explain why it remains a problem. Healthcare... more

Up to 85% of nurses have reported exposure to incivility in the workplace (Hunt & Marini, 2012). The often-subtle nature of incivility toward nurses in a minority population may partially explain why it remains a problem. Healthcare organizations realize the need for civility to counter the high turnover rate, staff shortages, and low job satisfaction reported by nurses, but lack understanding of how nurses of a minority population perceive incivility and bullying. This study aimed to answer the research question how do nurses with minority representation experience incivility and bullying versus empowerment in the workplace? A descriptive phenomenological design used a purposeful sample of minority registered nurses to explore how they experience these phenomena in the workplace. The participants were recruited through electronic communications with leaders of national healthcare and nursing organizations, minority nurses’ associations, and word of mouth via social media in the Uni...

To identify and prioritize research questions of concern to the practice of pediatric critical care nursing practice. One-day consensus conference. By using a conceptual framework by Benner et al describing domains of practice in critical... more

To identify and prioritize research questions of concern to the practice of pediatric critical care nursing practice. One-day consensus conference. By using a conceptual framework by Benner et al describing domains of practice in critical care nursing, nine international nurse researchers presented state-of-the-art lectures. Each identified knowledge gaps in their assigned practice domain and then poised three research questions to fill that gap. Then, meeting participants prioritized the proposed research questions using an interactive multivoting process. Seventh World Congress on Pediatric Intensive and Critical Care in Istanbul, Turkey. Pediatric critical care nurses and nurse scientists attending the open consensus meeting. Systematic review, gap analysis, and interactive multivoting. The participants prioritized 27 nursing research questions in nine content domains. The top four research questions were 1) identifying nursing interventions that directly impact the child and fam...

Purpose: The aim of the study was to describe the Jordanian patients' experience during their stay in intensive care units (ICUs) and to explore factors that contribute to positive and negative experiences. Materials and methods: A... more

Purpose: The aim of the study was to describe the Jordanian patients' experience during their stay in intensive
care units (ICUs) and to explore factors that contribute to positive and negative experiences.
Materials and methods: A descriptive, exploratory design was used. The study was conducted at 3 hospitals in
Jordan. Patients were selected from surgical and medical ICUs within 72 hours after transfer to the floor. Data
were collected through structured interviews using the Intensive Care Experience Questionnaire with 98 patients.
Results: Data showed high level of awareness among patients to surrounding persons (82.2%) and relatives
(90.3%). Although 58% of patients perceived pain as a problem during their stay, patients' perception of the care
as good as it should be was generally high (82%). Male and female patients differed significantly in their frightening
experiences (t=−2.559, P = .01).
Conclusion: Understanding patients’ experiences in the ICU would increase nurses' awareness to patients’ stressors.
It would help policy makers in designing structural and process-related care activities in a manner that promotes
positive patient experiences, which would improve quality of care in general and specifically ICU patients’
outcome. The ICU environment was found to adversely affect patients in many aspects. In addition,most patients
were able to recall their ICU experience.

Shahin, M., Mohamed, W., & Sayed, M. (2012). Nurses’ Knowledge and Practices Regarding Enteral Nutrition at the Critical Care Department of Al-Manial University Hospital in Egypt: Impact of A Designed Instructional Program. Journal of... more

Shahin, M., Mohamed, W., & Sayed, M. (2012). Nurses’ Knowledge and Practices Regarding Enteral Nutrition at the Critical Care Department of Al-Manial University Hospital in Egypt: Impact of A Designed Instructional Program. Journal of American Science, 8(9), 397-405. http://www.jofamericanscience.org/journals/am-sci/am0811/061_12121am0811_397_405.pdf
doi: 10.7537/marsjas081112.61

The spectrum of critical care begins outside the ICU setting. The nature of the illness rather than the space of the patient defines the need for critical care; therefore, critical care patients are best defined physiologically rather... more

The spectrum of critical care begins outside the ICU setting. The nature of the illness rather than the space of the patient defines the need for critical care; therefore, critical care patients are best defined physiologically rather than geographically. Outside the ICU and postoperative recovery rooms, critical care is most commonly provided in the emergency department (ED)

I n 2001, the Institute of Medicine challenged all health care professionals to decrease variation in practice through adoption of practice interventions based on best evidence to improve patients' outcomes. 1 Current reviews of clinical... more

I n 2001, the Institute of Medicine challenged all health care professionals to decrease variation in practice through adoption of practice interventions based on best evidence to improve patients' outcomes. 1 Current reviews of clinical practice suggest that only 10% to 15% of clinicians consistently implement evidence-based care 2 and indicate that it may take up to 2 decades for original research to be put into routine clinical practice. 3 It is well established that evidence-based practice (EBP) is associated with higher quality care and better outcomes for patients than care that is steeped in tradition. 4 Yet at times, clinicians continue to practice on the basis of tradition. 5

Increased intracranial pressure (ICP) that not treated immediately can lead to serious, life-threatening conditions. As nurses we need to ensure we are assessing and monitoring our patients for any potential changes to ICP and reporting... more

Increased intracranial pressure (ICP) that not treated immediately can lead to serious, life-threatening conditions.
As nurses we need to ensure we are assessing and monitoring our patients for any potential changes to ICP and reporting these changes promptly for early interventions to be implemented and to improve patient outcomes.

A valid nursing diagnosis is very important in nursing care. Accurate clinical indicators are required to validate nursing diagnoses established to reduce the risk of misdiagnosis. The accuracy of clinical indicators is determined by the... more

A valid nursing diagnosis is very important in nursing care. Accurate clinical indicators are required to validate nursing diagnoses established to reduce the risk of misdiagnosis. The accuracy of clinical indicators is determined by the limitations of characteristics and related factors. This study aimed to describe the limitations of characteristics of nursing diagnosis of ineffective cerebral tissue perfusion among stroke patients. This research was a descriptive study (documentation study) with retrospective approach with assessment through direct observation. There were 20 records of stroke patient documentation used in this study. The results showed that the limitations of the main characteristics that emerged in stroke patients were changes in motor responses and extremity weakness (100%), while changes in pupillary reaction did not occur (0%), behavioral changes (85%), difficulty swallowing (80%), speech abnormalities (70%), and altered mental status (45%). Nurses are expected to focus on the limitations of the main characteristics that arise during the assessment of stroke patients with nursing diagnosis of ineffective cerebral tissue perfusion in order to plan effective nursing actions.

Ketamine has been rarely described for use in critically ill patients. We describe our institutional experience using continuous infusion ketamine for sedation. This was a retrospective chart review of patients admitted to the medical... more

Ketamine has been rarely described for use in critically ill patients. We describe our institutional experience using continuous infusion ketamine for sedation. This was a retrospective chart review of patients admitted to the medical intensive care units (MICUs). An informatics query of patients who received continuous infusion ketamine between 1/1/2010 and 7/1/2012 was conducted. Mechanically ventilated patients in the MICU who received continuous infusion ketamine were included. Twelve patients met criteria. Mean age was 41; 60% were Caucasian and 60% were female. Six patients were admitted for pneumonia, three for asthma exacerbation. Median duration of ketamine therapy was 1.57 days. Median minimum and maximum rates were 0.24mg/kg/hr and 0.83mg/kg/hr. The maximum documented dose used was 2.8mg/kg/hr. The ketamine infusion was discontinued secondary to tachycardia or hypertension in two patients. No patient who received concomitant benzodiazepines experienced hemodynamic changes prompting ketamine cessation. Median maximum SBP, DBP, and HR while on ketamine were 154, 96 and 121, respectively. No further adverse events were identified. Five of the patients had decreases in concomitant sedative and analgesic doses while five had increases. Continuous infusion ketamine can safely be used for adjunctive sedation/analgesia in mechanically ventilated MICU patients. Larger trials are needed to further define optimal dosing and confirm safety.

Wolff-Parkinson-White (WPW) syndrome is a cardiac disorder having abnormal electrical communication between atria and ventricles. It is an uncommon disorder may be asymptomatic or present with symptoms like palpitation. Intraoperatively... more

Wolff-Parkinson-White (WPW) syndrome is a cardiac disorder having abnormal electrical communication between atria and ventricles. It is an uncommon disorder may be asymptomatic or present with symptoms like palpitation. Intraoperatively these patients may present with serious cardiac emergencies like paroxysmal supraventricular tachyarrythmias (PSVT) and atrial fibrillation (AF). We report a case of 35 years old female posted for elective laparoscopic cholecystectomy under general anesthesia with the use of dexmedetomidine in the perioperative period. Perioperative management of these patients under general anesthesia is a real challenge for the anesthesiologists particularly under general anesthesia.

El trauma craneoencefálico es un problema de salud pública. La lesión traumática cerebral severa es la primera causa de mortal-idad. En el contexto de un trauma craneoencefálico severo, las estrategias de monitorización, nos brindan la... more

El trauma craneoencefálico es un problema de salud pública. La lesión traumática cerebral severa es la primera causa de mortal-idad. En el contexto de un trauma craneoencefálico severo, las estrategias de monitorización, nos brindan la opción de conocer las alteraciones intracraneales posterior a la lesión primaria. 

Background: Australian critical care nurses generally undertake assessment of resuscitation competencies on an annual or biannual basis. International resuscitation evidence and guidelines released in 2010 do not support this practice,... more

Background: Australian critical care nurses generally undertake assessment of resuscitation competencies on an annual or biannual basis. International resuscitation evidence and guidelines released in 2010 do not support this practice, instead advocating more frequent retraining. Aim: To review the evidence for annual assessment of resuscitation knowledge and skills, and for the efficacy of resuscitation training practices. Methods: A search of the Medline and CINAHL databases was conducted using the key search words/terms 'resuscitation' 'advanced life support' 'advanced cardiac life support' 'assessment' 'cardiac arrest', 'inhospital cardiac arrest', 'competence', 'training', 'ALS', 'ACLS' 'course' and 'competency'. The search was limited to English language publications produced during the last 10 years. The International Liaison Committee On Resuscitation worksheets were reviewed for key references, as were the reference lists of articles from the initial search. Results: There is little evidence to support the current practice of annual resuscitation competency assessments. Theoretical knowledge has no correlation with resuscitation performance, and current practical assessment methods are problematic. Both knowledge and skills decline well before the 12-month mark. There is emerging support in the literature for frequent practice sessions using simulation technology. Conclusion: The current practice of annual assessments is not supported by evidence. Emerging evidence for regular resuscitation practice is not conclusive, but it is likely to produce better outcomes. Changing practice in Australia also represents an opportunity to generate data to inform practice further.

Background: Patients hospitalized in critical care units are at risk for developing different health problems such as sleep disorders. Detection of sleep disorders is very important and needs the appropriate tools. This study was aimed to... more

Background: Patients hospitalized in critical care units are at risk for developing different health problems such as sleep disorders. Detection of sleep disorders is very important and needs the appropriate tools. This study was aimed to determine the psychometric properties of Richard Campbell sleep questionnaire. Methods: This methodological study was conducted in the cardiac surgery intensive care unit (CICU) of Military Hospital of Tehran in 2016. A standard translation of the questionnaire was provided, and face and content validity of the questionnaire were qualitatively evaluated by the main users (patients) and experts, respectively. Reliability of the questionnaire was determined using Inter-rater reliability and internal consistency. In this study, 100 patients who met the inclusion criteria were selected using convenience sampling method. On the 2nd and 3rd day after the hospitalization, quality of their past night's sleep was measured using the questionnaire. Results: The face and content validity of the questionnaire were qualitatively at desired level. The reliability of the questionnaire through inter-rater correlation coefficient and the Cronbach's alpha value were 0.714 (P < 0.0001) and 0.906, respectively. Conclusions: According to the results, Richard Campbell sleep questionnaire is a simple validated instrument that can be used by health care providers such as nurses to measure the quality of sleep in patients in cardiac surgery intensive care unit (CICU).

Background: All nurses entering intensive care unit (ICU) for the first time are required to master many critical nursing skills. Providing a clinical learning environment that is, conducive to mastering these essential skills is a key... more

Background: All nurses entering intensive care unit (ICU) for the first time are required to master many critical nursing skills. Providing a clinical learning environment that is, conducive to mastering these essential skills is a key component of ensuring clinical competence. Yet there are few publications worldwide that focus on clinical learning for qualified nurses entering ICU for the first time. Factors that affect clinical learning in ward environments have been clearly identified. It remains unclear if these factors are applicable to the ICU environment. Aims and Objectives: (1) To describe how registered nurses new to ICU environment perceive their clinical learning environment; (2) to identify the factors that influence these perceptions. Design: Descriptive quantitative survey design. Method: Sixty-four nurses were recruited from five Irish teaching hospitals. The participants completed a modified version of Dunn and Burnett's clinical learning environment scale, with five subscales, that measures perceived factors that influence clinical learning. Results and conclusions: Nurses new to ICU perceived the environment as conducive to clinical learning. Factors positively affecting clinical learning include: educational staff and clinical nurse managers' commitment to supporting learning and good interpersonal relationships. Non-European qualified nurses who did not do an induction course and those with longest experience on the unit were more satisfied with ICU as a clinical learning. Relevance to clinical practice: These findings will provide nurse educationalists with some further insight as to the factors that promote optimal learning in ICU.

Background: Moral distress has been identified as a major factor influencing the physical and emotional well being of the nurses. It is a serious problem among critical care nurses, it my make the nurses avoid the patient and do not act... more

Background: Moral distress has been identified as a major factor influencing the physical and emotional well being of the nurses. It is a serious problem among critical care nurses, it my make the nurses avoid the patient and do not act as an advocate. While its impact on the nurses themselves is burnout , resignation from their position, or abandonment of nursing. The impact that moral distress has on the institution is high nurse turnover, low patient satisfaction, and decreased quality of care. The aim of this study was to identify the moral distress related factors affecting the critical care nurses. Method: the study was conducted in six intensive care units (ICUs) of kafr-Elsheikh hospitals. Subjects: All of the critical care nurses providing direct patient's care and working in the mentioned ICUs included in the study (70 nurses). Tool: Moral distress intensity scale was used for data collection, it was adopted from Corely. Results: The physician practice category is found to be the highest moral distress factor followed by the nursing practice category and then the institutional category. Conclusion: Moral distress including several factors is a critical problem that affects the critical care nurses and it needs more attention. [Maysa Abdalla Hassan, Hayam Ibrahim Asfourand Nagwa Ahmad Reda. Moral Distress Related Factors Affecting Critical Care Nurses.